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April

Pimping at Annotto Bay

I’ll explain the blog title in a moment…

The past two Wednesdays I’ve had the opportunity of rounding with the pediatric attendings and residents on the inpatient ward at the Annotto Bay Hospital. The wards here are separate smaller buildings spread throughout the hospital compound connected by a breezeway. The “Pedi” ward houses both neonates and children in one modest, open room. Lately the census has been about 8, but they can accommodate many more. Although they accept referrals from outlying hospitals, the resources at Annotto Bay are limited as well. For example, they do not have mechanical ventilators. Neonates born in respiratory distress are placed on oxygen by CPAP. One of the residents explained that this is accomplished by placing an endotracheal tube into the nose (but not into the lower airway) and then attaching tubing that on one end is hooked to oxygen and on another end to a plastic bottle of water to humidify the air. I observed a baby on “CPAP” and it seemed to work quite well. If the baby’s respiratory status worsens, then it’s the resident’s job to call around to other “higher level” facilities to see if any ventilators are available. Most of the time, unfortunately, there are none or the other hospitals can’t accept the transfer. “So we hope for the best here,” the resident said. Occasionally, critically ill patients are airlifted to the children’s hospital in Kingston if arrangements can be made. I can only imagine being the resident on a 50 minute helicopter flight hoping that the aminophylline you’ve given is stimulating the baby’s respiratory drive enough to keep him alive until you get there.

Rounding with the team was helpful in gaining insight to how they manage care in the face of limited resources. Another example: microbiology labs are not available at any of the 3 hospitals that we visit. Cultures are sent out to other remote labs but only on limited, certain days…if transit is available. The process, however, is very unreliable and often the specimen is rejected when, or rather, if it reaches the lab due to it being “out-dated.” Urine cultures seem rarely possible unless the family can afford to pay for the test at a local private lab. Neonates admitted for concerns of sepsis receive empiric IV amoxicillin (this is not a typo) and gentamicin and if the baby does well the antibiotics are stopped after a few days, usually without any culture results.

Rounds were also helpful to observe how doctors are trained here. Doctor Fisher led rounds the first week and Dr. Ramos this past week. The patient presentations and the teaching style were almost identical to rounds back home. If a neonate had poor feeding or jaundice the residents were asked for all of the possible causes or a “differential diagnosis.” The questioning did not end until a list of all possibilities was exhausted. Other topics that required in-depth questioning included the signs and symptoms of congenital hypothyroidism, causes of failure to thrive, causes of newborn hypoglycemia, and all of the possible causes of low APGAR scores, that’s right, all of them. We discussed the expected pathological findings of a cranial ultrasound in different patient circumstances. Then it was on to the next patient (seriously). Another topic discussed at length was neonatal resuscitation drugs. Residents were not only expected to know the drug and when to use it, for example, nalaxone for respiratory depression from opiate intoxication, but also for dosages, route of administration, inappropriate routes of administration, preparations of the medication and even what the vials of the medications looked like. None of what was asked seemed malignant but rather important for the trainees to know because here the doctors and residents are the ones starting all lines, obtaining all lab work, and responsible for these medications in code situations. In our U.S. training, we often rely on others such as pharmacists or nurses to be responsible for some of these things. I was impressed with the fund of knowledge of both the pediatric attendings and residents.

I asked one of the residents if they had a name for when the attending asks questions during rounds to teach and to see what they know. He did not know of a name for this. I also asked Dr. Ramos, who trained outside of Jamaica, if he knew of an expression for this. He also did not know of one.

At U.S. medical schools and residency programs this teaching style is universally known as “pimping.” The attending will ask questions or “pimp” the residents and students to evaluate their fund of knowledge and to teach where deficiencies are exposed. The use of this word in this context is usually limited to the verb tenses (i.e. the attending is not a “pimp” during rounds). I asked both of them if they had heard of this term before. They had not. Well, I must say that here in Jamaica that I participated in one of the most intense pimping sessions that I’ve ever witnessed. Who knows, maybe in Jamaica the term will catch on.

I better do some more reading before next Wednesday.

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April

The Start of Week 2

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So we had our last 2 days in Port Maria. Since it is 2 of us we usually split up with one going to A&E and one in the clinic. However, on Monday the medical records department are striking (this was a surprise to everyone working there) and so we both were asked to go to the clinic since they were short staffed in A&E.

We saw alot of rashes including a pityriasis and likely lichen striatus that David saw (he got the cool stuff).

Today, I went to A&E and David managed the peds clinic. I took some toys to the pedi ward and it was like water in a desert! Everyone including some staff wanted to grab toys for their children. All of the ‘play’ areas are devoid of toys or anything for the children to play with and I now can see how appreciative they are. I’m not sure how long those toys will actually last on the ward but at least I know temporarily they have something to play with.

Over the last few days i’ve picked up some lingo I figure I might share. When they say they are rattling in their stomach….stomach actually means chest and belly is stomach.

Today was the first I heard that a child had ‘short wind’ aka rapid respirations or shortness of breath.

Clinic was very busy today…I think there may have been about 30+ patients because David saw I guess around 23-25 and I picked up another 5-7 at the end when I got through with A&E.

Saw a few URIs, overfeeding, scabies, laceration on the face (felt absolutely awful while suturing this kids wound because the sutures available were 0 to 2.0 with HUGE needles!!), pharyngitis and overflow incontinence, more scabies, eczema, constipation, wheezing and asthma follow ups.

Off to Annotto Bay tomorrow.

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April

First Week with Issa

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Hi all,

I am also a resident from the University of Tennessee. I am 4th year Med/Peds. I am SO Blessed to have this opportunity to come and work with the people of Jamaica. It has already been quite a week.

I had a rocky start getting here with delayed flights and lost luggage. It was a good thing I came a few days before starting work. It is absolutely calming and tranquil here and the people at the resort are very welcoming and accommodating. The food is plentiful, to be modest, and I now feel I have to work out twice a day on weekends.

We spent our first 2 days in Port Maria, the next 2 in Annotto Bay and the last day in Port Antonio. At Port Maria for the first 2 days I worked in the Health Clinic.

I saw the general run of the mill cases like viral illnesses, lots of tineas, candidal vulvovaginitis and complaints of worms. Many of the parents expected medications for their children’s ‘chest colds’. Down here cough medicine is DPH and that’s not a brand name. It is actually Diphenhydramine. I spent some time educating the families on the ineffectiveness and detrimental effects of cough medicines. Most were receptive, a few didn’t seem too happy.

The first day I saw about 16 patients, which was hard because I had to stop every minute to ask how things were done and what was available. The second day I saw 25 kids. In our residency, we never get to see that many in our continuity clinics because you have to check out to a superior etc so I was amazed that I could see that many in 6 hrs. I had a few pneumonias and a teenager who came in for many different complaints including vulvovaginitis, anxiety attacks and irregular menses. My interesting case of the day was a set of siblings who came in for generalized itching for 3 weeks after they were swimming in a river. I was SO out of my element because that differential is broader with tropical diseases esp ones transmitted from river water. They do have leptospirosis down here but the symptomology was no where close to that. Could it be schistosomiasis, or some other parasitic infection? I treated them as best I could and recommended they returned if things worsen or did not improve.

At Annotto bay I worked in the A&E department one day and the clinic the next. The clinic was mainly well child visits. It appears that about 3-6 weeks after birth the children are seen by a physician for an examination. After that they receive their “well child checks” at the health clinics with nurses and thereafter see a physician if they are ill. This is unlike our American system where the physicians are the ones doing the Well child visits.

You also are required to draw your own labs and start your own IVs. So far the children here have been spared from me but I do look forward to maybe perfecting those crafts. The most interesting child I saw at the A&E was a referral for a possible glomerulonephritis. The patient had no previous illnesses but was noted to have swollen legs and face prior to admission. I was very excited about working the child up and reaching a diagnosis, however many of the labs such as complement levels, renal ultrasound and maybe urine electrolytes were not available at that hospital.

At Port Antonio, it was a very light day with only 4 children on the ward and 6 total in the clinic (3 seen each by David and I). Two of my 3 cases were referrals for orthopedic issues that I unfortunately could not help. One was a beautiful 4 month old with club feet. The parents do not have the transportation available to get to the referral hospital. I hope they find a way because I am sure with braces she will correct well. In the meantime I tried to recommend a temporary way to get her feet to straighten by recommending buying stiff shoes that ae a direct fit.

While we were on a tour of the facilities (Port Antonio sits on a hill overlooking a lagoon) we got called into A&E to look at a chest xray of an 18month old boy who at a glance looked quite well. The xray looked like he had a whited out R lung with a mediastinal shift to the right and elevation of his right hemidiaphragm…looked like a possible foreign body aspiration. He had to be transferred to Kingston. He was still out in the yard of the hospital playing when we left, definitely in no distress and a little bit of a lady’s man already.

All in all this week identified the biggest obstacle to care in the area….resources. There are few physicians and few resources available to a poorer population that arent able to travel very far for optimal care. I’m looking forward to what the remaining weeks will bring.

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April

April Rotation

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I’m a 3rd year pediatric resident from The University of Tennessee in Memphis. A couple of my colleagues have already done this rotation and have really enjoyed the experience and I’m glad to have been given this opportunity as well.

Arriving before the start of the work week, I had a couple of days to relax and enjoy Jamaica… 48 hours of rest here felt like a week off. I don’t think I’ve ever felt so rested in all of residency. I was able to SCUBA dive to a coral reef and I saw a variety of aquatic creatures such as a sting ray, sea turtle and lion fish.

The food is delicious and I’ve eaten several things I’ve never heard of before such as naseberry and star apple. The temptation to try all the different types of fresh seafood, fruits and other delicacies offered here resulted in several return trips to the buffet line. Fortunately there is a gym here.

Monday I worked at Port Maria Hospital A&E (accident and emergency) dept. Away from the main patient area inside, a small exam room was prepared for me outside with a door that opened to a walkway. In front of this door, families lined up on a bench partially shaded by a breezeway, awaiting their turn. Without a formal orientation, I was escorted to the room by a nurse and kinda winged it. This week has required some acclimation to their healthcare system, learning what resources & medications are available, as well as how to access those resources.

In just 2 days at A&E, I treated a wide variety of classic pediatric cases such as herpetic gingivostomatitis, radial head subluxation, vitiligo, bacterial cervical neck lymphadenitis, hand, foot & mouth disease, etc.

One young child returned to A&E with a plain film x-ray of his hand. Four days earlier he smashed his finger at school and when he was seen that day at A&E his finger was wrapped up and he was referred for x-rays. His finger looked horrible from the crush injury. The lacerated, necrotic distal end of the finger could be easily separated from the underlying bone. This time he was referred to an orthopedic specialist which will require a trip to another hospital. I’m afraid he may have complications. I wonder if in the sea of patients to be seen, some things don’t get the necessary attention that they really need.

The patient flow was interrupted momentarily when a nurse asked if I would give my “expert opinion” for the staff medical officer on a child admitted in the hospital. Knowing the bench of families was ever-growing, I quickly saw the patient, reviewed the case and wrote a pediatric consult note for the doctor in the chart. The reason for the consult? The doctor was concerned about dextrocardia in a toddler who was admitted for pneumonia and otitis media. But the chest x-ray was shot at a slightly rotated angle giving the illusion of possible dextrocardia. A quick listen to the chest and heart sounds were fortunately on the appropriate side.

After this, the patient flow was again interrupted during a period when I was waiting to discuss an x-ray I had ordered with one family, have a nurse help me cleaned and bandage a wound, and get the weight of an infant so I could prescribe the appropriate dose of antibiotics (mom lost the slip of paper she was given at triage with the weight and vitals). My previously seen patients and the nurses seemed to have vanished. The remainder the bench was becoming restless. I couldn’t figure out where everyone had gone until I found a doctor who informed me that a motor vehicle accident had just occurred in front of the hospital and the curious went out front to look at it. Eventually they all came back.

My last patient at Port Maria was a 4 year old boy that was brought in with lab results to rule out rheumatic fever. I don’t believe he has RF but a CBC did show that he had a normocytic anemia with a hemoglobin of 8 (low). He also had a loud heart murmur that I don’t think can be explained by a simple flow murmur from anemia. His older sister has sickle cell disease and polycystic kidney disease. There are no newborn screens here, so it is very likely the boy has sickle cell anemia also given his lab findings. To test for this, a hemoglobin electrophoresis test must be performed at a private lab. This is a relatively simple blood test but mom will have to pay for this test since it isn’t covered under the national health insurance. I also referred him for an echocardiogram but this has to be done at another hospital which is quite a distance away. Transportation will be an issue as gas is expensive here (almost twice as much to fill up a tank than in the U.S.). She also showed me a referral form from last year for a CT scan of her daughter’s abdomen to image the kidneys. This will cost her roughly $475. It is unlikely that she will have any of the money to pay for these studies since the family has relatively little income. Mom has not given up hope, however. “They will get done somehow,” she said. I hope so too.

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April