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On my first day in Port Antonio last week, I had seen a child in clinic who was referred to me because he was “malnourished”. While he didn’t meet a clinical diagnosis of marasmus or kwarshiokor (two different types of severe malnutrution, sadly common in some parts of the developing world) he was certainly not hitting his goal weights. To translate, as I told the mom, while he was as tall as more than half of the children his age, he weighed what the average child should weigh at 8 months of age…and he was nearly 15 months old. Not having any evidence of chronic infection, illness or heart disease, from the history and physical I was reasonably comfortable in my assessment that it was a problem of inadequate nutrition….but mom was young and it nagged my internal (“ain’t right”) barometer that she insisted she was giving him 4 cups of milk a day, sardines and porridge and he was eating it with no problem. That day being my first day as a clinician in Jamaica, I wasn’t too sure what to do with him not being severely malnourished and stunted, but not well enough to send out the door without me feeling at all concerned. After writing for multivitamin supplements, I referred him to the Child Guidance Clinic to find assistance obtaining nutritional milk-based supplements (that mom couldn’t afford herself) and asked mom to follow up every two weeks for weight reassessment. But something about the kid has been gnawing at me for the entire week I’ve been here and after discussing with Dr. Ramos, the local pediatrician, in clinic yesterday, he reassured me that it would be appropriate practice to admit the kid for high-calorie diet and social work consultation. Just like I would in the US for a kid who was failure to thrive.

In my time here, frankly, I’ve been trying to grasp, as a clinician, what is common practice, what would be overly conservative, what is appropriate utilization of resources. I didn’t (and still don’t) have a good sense of the epidemiology of moderate malnutrition here or it’s management and I wrongly assumed that since I was Jamaica, maybe this problem was seen too often to admit all the kids who walked up with growth problems; that outpatient management was a necessity of constraints in available resources–even in the setting of a positive “ain’t right” test. I’ve been trained that when the “ain’t right” test is positive, a good clinician should step back and reassess, questioning a diagnosis until the “ain’t right” feeling is gone. Also, in my short time here, from my perspective as one new to practicing pediatrics in a developing country, I’ve actually appreciated the notion that it is important to manage conservatively at times. Frankly, the odds of seeing a “bad case” is considerably higher here than at home in the States.

Anyway, I made a call to a friend I’d made in administration at Port Antonio –Mr. C.–in the late afternoon yesterday, telling him about the child. And miraculously, this morning the child was waiting with his mom at the clinic to see me. I explained to the mom my plan to admit him and draw labs, she seemed fine and I felt so much better knowing that he would be under close observation for at least the next 3 days for a calorie count. I’m grateful to my Jamaican doctors-colleagues and other hospital employees for their graciousness and cooperative spirits along this brief journey of mine.

Ah, and a funny story. So I had another frustrated mom presenting with a child with tinea versicolor today. (You know, if anyone wants to make his fortune in the tropics, they would invent a potion that eradicates this fungus in days). By this time, after a week, I’ve already gotten used to my Jamaican patients with their lyrical histories and colorful interpretations of the natural world. So as I was going through my third iteration of why I wasn’t going to prescribe her child an oral medication, these words popped out of my mouth: in my best Jamaican accent, I said, “Miss, it’s like trying to shave a goat by having him swallow the razor….it just don’t work like that.” Any other patient in the States would probably have looked at me like I had gone crazy. But this woman looked at me like she was satisfied with that answer…and stopped harrassing me about the orals.

LOL.

Apart from missing my family tremendously, I’ve been having a great time volunteering in Jamaica so far. On Friday was my first day going to Port Antonio and I’ve spent the last two days in Port Maria.

The patients and their parents have been very polite and grateful to me in general. I did see a mom today in Port Maria though who was frustrated at the tinea versicolor on her son’s chest and back which seemed to keep coming back despite her treatments and visits to the clinic. Her son had a classic rash. After giving her some selenium sulfide and some clotrimazole, she wanted oral medication which I didn’t feel was indicated. I did my best to explain that it can be a very frustrating problem in Jamaica as well as in the US. She was the exception though. Another parent totally made my day when he returned with his daughter today to bring me a bag full of ripe ackee fruit, freshly picked green bananas and plantain. I had seen his daughter in clinic the day before and she looked much better (OK, so she had a viral illness and got better on her own…fine). I was so happy, thanked him profusely. Unfortunately since I’m staying at the resort without any kitchen facilities, I had to give away my fruit to the nurses who were working with me.

Practicing medicine in a foreign country has its many rewards but also quite a few challenges that one can’t readily appreciate. There are different home remedies, different names of body parts, different perceived etiologies of disease and conditions that can totally throw you off while you’re talking to a patient. For instance, who knew that toilet paper can cause a vaginal infection or that a rubber band can give a child fungus in the hair? Plus, I’ve been totally inundated with all sorts of rashes that I would have been quick to refer to a dermatologist at home in the US. On top of that, there’ve been cases of measles in the area so I’ve been on the lookout for those potential cases as well. Luckily, the health department here has a rockin immunization program and parents are serious about giving their children shots.

Even as I say this, there is one similarity that I was surprised to find here in my rural clinic experience—pharm reps! Yes, I actually got approached with gifts and flatteries by a Jamaican pharm rep who handed me a printed bag, a pen, and a little speech on some new cough syrup for children…I was quite tickled about it. I actually would have appreciated a good ol’ Pharm lunch though—I was getting hungry. Too hungry and not enough energy to go into how I will be following my AAP recommendations and not prescribing cough syrup to children under 6, thanks very much.