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01
May

Final thoughts & thanks

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I really enjoyed helping take care of the children down here. I was surprised at the variety of cases that I saw. Of course, there were plenty of cases of asthma, viral URIs, tinea and newborn checks but there was some other real interesting stuff mixed in too. I didn’t see as much tropical diseases as I anticipated. Some days were very busy with numbers seen in the 20s. Other days were a little slower and my last day at Port Antonio only two children were brought to the Friday pediatric clinic but I did get a chance to meet and get to know several people while waiting (Jamaican networking).

I also witnessed a bizarre incident driving into Port Antonio to pick up some others at the health department (usually we aren’t the only ones being driven to and from work). As we were slowly driving toward the town square, an old lady crossing the road reached down, picked up a baseball sized rock, reared back, yelled at us and then threw it at our truck. We all saw what was coming and our driver ducked behind the steering wheel. With a loud thud, the rock bounced off the front windshield. Fortunately, nothing was damaged. The lady continued on but we stopped because there was a police officer on the side walk. I couldn’t understand the animated discussion but I think the officer was telling the driver “What am I going to do? Arrest that mad lady?” I believe she was mentally ill. It’s one of those things that I don’t think I’ll ever forget– a walk-by stoning from a Jamaican elderly lady. And I also don’t think I’ll soon forget talking to all these different drivers on these long drives around the beautiful country side.

Considering a case that was most memorable…I think maybe the 19 month old girl with Down’s syndrome that had some major cardiac defects seen on an ECHO about a year prior. Mom had gone to the Cardiologist appointment in Kingston like she was supposed to but she never got the follow up phone call with instructions that she was told she was going to get. Despite Mom giving the heart failure medications as prescribed, the child had worsening failure to thrive at this visit. The cardiologist was unable to be reached so we tried to refer her again. She may need cardiac surgery but another ECHO and specialist visit first before making that decision. I hope she’s able to be taken care of soon.

Before I leave tropical paradise to go back home to flooding and tornado damage, I just want to thank all who help make this possible and give to help this next generation of Jamaicans. Hopefully, more help to soon follow. Thanks to Diane who was always a phone call or a quick email away to help. Her passion for the children here is so evident. I’m thankful for the help and the teaching from the local doctors especially the two pediatricians, Dr. Ramos and Dr. Fisher. Finally, many thanks to the most hospitable and warm staff for the royal treatment I received here at the hotel the past month.

I wish that I could stay much longer. This has really been a great experience and I hope to return to Jamaica soon.
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30
April

Last thoughts on my extra last day with Issa- April 2011

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Ok, so my flight was cancelled and I got an extra beautiful day in Jamaica. How awesome is that!

So this is likely my last blog. My last week was short but still great. Monday was Easter Monday, a holiday, and Friday I got the day off to finish and do any last minute things before I left.

On Tuesday, I saw about 30 kids. It was like the post holiday/school’s out rush as the week before there were only about 20. Tuesdays at Port Maria clinic has been the busiest days this month. You average about 25 patients. David and I figured out that maybe on those days we should both go to the clinic so that people who are there from 8am aren’t getting too upset when they are still there at 3pm being seen.


The picture above (taken with permission from Mom) is of a little girl I saw twice this month. Initially she came in for recurrent oral thrush and a neck rash that looked like tinea versicolor. She was on the appropriate medications and mom was using it correctly so I was a little curious as to why it hadn’t been getting better. I asked mom about her history (was worried about maybe some immunodeficiency, HIV etc) and sent her to get a CBC. Of course blood work wasn’t being done that day so mom was suppose to come back to see me once she got the results and to continue using the medication.


As is obvious in the picture, this child also had a large head. She had already been sent to have a head ultrasound for hydrocephalus, even though there had been no documented hydrocephalus or even head circumference in the chart…EVER. Mom reported that the ultrasound was normal.


On Tuesday, mom returned with the CBC results and a bottle of medicine that she said the child had been on daily since January for a vaginal discharge. It was Septra. This baby had been on antibiotics since January for what it didn’t sound like was a UTI or any type of VUR; The reason for the continual use was nothing more than a miscommunication. Mom was told to give the medication until it was finished (something we may say to our patients if we wrote a prescription for a specific amount). Unfortunately, she was given a large bottle of the medication and it was not finished. Her CBC was not grossly abnormal except for a slight anemia but I felt I knew the culprit for the recurrent thrush (I hope). So I had mom discontinue the antibiotics and return in 1-2 weeks.


I also did a head circumference and would like her to have serial head checks because unfortunately mom cannot afford a CT scan right away. I do not feel that this child’s head is normal and fear that it will progress until she starts having sunsetting of her eyes (they are, as is obvious in the pic, already large and somewhat bulging). She is currently developmentally normal and a delightful child. Because this was weighing so heavily on my mind I asked the pediatrician at Annotto Bay on Wednesday what he would do. He recommended just referring her to Neurosurgery in Kingston and letting them sort out imaging. Great advice! I would never do that at home because for a referral to neurosurgery I would likely need imaging to prove that a neurosurgical problem exists and not just a referral for macrosomia. Would like to know that this baby continues to do well.


On Wednesday and Thursday we saw a lot fewer patients at Annotto Bay than usual. We finished both days a little early and were excited that we may get to return to the hotel earlier to do some activities if possible; That didn’t happen. On Wednesday, we had a detour to the garage the hospitals use to work on the vehicle’s brakes (pic above is the garage). On Thursday, our transportation that the hospital arranged for us was in Kingston and we ended up waiting for about 3 hours since they had delays getting back.


My final thought: Many of the problems here in Jamaica with health care stem from lack of resources. As you read blogs you hear about a hospital with no mechanical ventilators, makeshift CPAP, no sub specialists, labs that cannot do urinalyses, clinics not equipped for pelvic exams. They are all needed but aren’t things that we can readily provide. However, there is one area I feel that we can leave an imprint in addition to our service. At Port Maria, the only vital taken is a weight. There are growth charts up to the age of 2 with only weight on SOME of the charts. I did not see them in the charts at Annotto Bay or Port Antonio BUT at Annotto Bay, all vitals incl temp are done and we were provided a copy of full growth charts (birth to 20, females and boys, wt, length and HC).


Maybe we can work to integrate full growth charts in EVERY chart as well as encourage full measurements incl temp, BP (age over 3 and would require they have the appropriate BP cuffs), HC, RR and weight. By doing this we could pick up the infants like the one admitted at Annotto Bay with meningitis at all the centers (the infant was clinically normal, mom came for well infant/newborn check and this was only identified because of a fever documented in clinic). We could avoid things like referral for 2 children who ‘look thin with ribs showing’ when they are growing well (50-75th percentile) and likely having more rapid height gain and from missing children that are failure to thrive because they have not been plotted in their last few visits. This is just my 2 cents and hope that maybe we can accomplish that.


Thanks again to Diane and Couples resort/Issa Trust Foundation for an amazing experience.

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29
April

Last days in April

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So I have somewhat of a potpourri of things to write so I will probably break it down into 2 blogs…one patient related and one not so much.
As I looked back on my month I have been super blessed for this opportunity. I thank Diane and the trust for it.
Things might be helpful for the next group:
1.PLEASE MAKE sure you walk with toilet paper and something to dry your hands. Some of the bathrooms are equipped with toilet paper, most dont have anything to dry your hands.
2. If you are a light sleeper walk with ear plugs….if you are not use to the island sleeping there are crickets and frogs that chirp all night (for most you just drown it out). Also, if you are in the inside room its a little closer to the road so you may hear an 18 wheeler trucking by once in a while (none of these are problems if you arent too light of a sleeper)
3. If you are in the clinic and you want to admit a child you refer them to A&E (ED) department!
4. There are 2 types of referral forms…an interfacility referral white form (form B) and a triplicate copied referral BOOK for outside referrals (i.e all pediatric specialists, most of which will be in Kingston at Bustamante Children’s ; this is referral form A)
5. You can get laundry at the resort done without cost ( I washed many small items in my room
and then big things with the resort)
6. Get familiar with the drugs and their concentrations..Qvar inhaled spray I think is 100mcg, I had never used chloramphenicol eye or ear drops and it was not found in any epocrates so I had no idea the dosage initially. Same goes for their analgesics. DPH cough medicine IS diphenydramine as well as a brand..so plain DPH is benadryl then there is DPH cold that would have an expectorant in addition to benadryl. It is widely used for colds from birth onward.
7. Pediatrics is anything under 13 yrs old. All the children older than that stay on the adult floors/wards.
8. Vitals arent very common at Port Maria. They do a good job at Annotto bay but you only get a weight at Port Maria.
9. If possible do tours outside of the resort. IF you are adventurous the zip line and boblsed ride is fun. There is a blue mountain bicycle tour as well as some rafting tours. I enjoyed Dunn’s River falls.
Hope this is helpful
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29
April

Eye openers

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So I expected certain things traveling to a “third world” country but some things I still found surprising so I thought I would list some of the eye openers on this trip.

1. A pediatric ward with a pediatric attending trained in critical care (ICU) that accepts as a regional referral center having no mechanical ventilators.
2. I heard a report of hospital ERs with no antiepileptic drugs like dilantin to stop a seizure.
3. Residents here are on call nightly for 3 nights or more in a row. (and I thought every 4th or 5th night call is bad as a resident)
4. All the hospitals in the northeast region with laboratories that have no ability to perform microbiology labs/cultures.
5. Send out labs that result by mail sometimes taking 4+ weeks to receive the results.
6. In the settings we were exposed to, a seemingly majority of foreign doctors providing care working long hours for comparatively little.
7. No land-line phones in some hospitals so doctors must use their own cell phone credits to call regarding patient care.
8. Often after making a diagnosis that requires a specialist care, if a specialist is available, obtaining transportation is often not feasible.
9. A hospital with a pediatric ward staffed by medical officers doing shift work with little pediatric training.
10. IV amoxicillin

Also at times I felt like I was taking care of the indigent in the inner city back home so similar problems still remain despite more resources or more health care dollars.
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24
April

Last week of April 2011

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This blog is LONG overdue. As the last week rolls around its only fitting that I write SOMETHING.
For the last 2 weeks I have to say that many of the patients seen have similar ailments as you would see in the US except probably alot more tineas. However, there has been a few cases thrown in that were interesting.
On one of the days we rounded with the pediatric team, we had a 9 year old boy who came in after having his first time seizure the evening before. Per reports the seizure happened during his sleep. Its funny I got a slightly different story from the boy (I’m thinking the way I phrased my questions probably werent the best). Anyway the going diagnosis was possible benign rolandic epilepsy. It’s the right age group and description but of course without the EEG available it is something that will need more occurrences before a firm diagnosis is made.
In the clinic we also saw an infant with diffuse papular lesions on his face and extremities. The infant was very uncomfortable and scratching. Dr Ramos, one of the pediatricians, called us in to see the infant and asked what we thought. It really looked like maybe a scabies type infestation but more papular. He described it as a papular urticaria seen in response to insect bites. It made so much sense as he pointed out that the lesions were only in the areas that were uncovered when the infant slept. I have seen insect bites but never a reaction so widespread before. It was great to have someone show us things that may not be as prevalent at home.
There is one other case, more unfortunate than anything else but may help any one else who encounters a similar case and don’t know how to proceed. I saw a 12 year old girl in the clinic with her mom. Per mom she had been complaining of vaginal itching, foul odor and ‘bumps’ for about 3 days or so. She did tell mom that she had her first sexual encounter with a 16 or 17 year old boy although he didnt ‘go all the way in’. Turns out she had what appeared to be primary herpes outbreak. At home we would call our Child Assessment team and they would get right on it since the girl is a minor (under 16 here). However I was not sure how the system worked or who to inform and it became somewhat frustrating since I did not know the protocol. However, I got in touch with the Child and Mental Health nurse and the matron who assisted me in the protocol—–in essence you refer the child to the A&E department (Emergency room) where the hospital’s social worker and the assault division of the police department can get all the information and deal with the case. Its imperative to get all that information and sometimes even admit the child for observation to obtain these things because most houses dont have addresses like we do in the US and also most families do not have phones. So for fear of the family disappearing (not intentionally) you may have to admit a child just to get all information sorted and proper treatment.
On a lighter note, we were able to have extra time off this week for Easter (both Good Friday and Easter Monday are holidays). I was able to go Mystic Mountain and try the bobsled rides as well as the zip line…it was fun! If anyone comes for Easter, you can show how much you know about Jamaican culture by mentioning ‘bun and cheese’; this is a tradition that involves eating a ‘bun’ (looks like fruit cake) with cheese in the center for Good Friday. The resort had some as desserts so David, my coworker, was able to try it.
I must say that everyone I have encountered have been so warm and welcoming. I feel I have inherited a new family of sorts with the workers here. It saddens me that I soon have to leave.
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Issa Trust Foundation | 7900 Nova Drive | Suite 101 | Davie, FL 33324