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22
July

Day 06 – Checking in on the triplets

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This is where I have breakfast every morning. Yes, it’s a tough job but someone has to do it.

Baby A – Note the Zip-Lock bag.
The first thing I did when I arrived to Annotto Bay Hospital is check on the triplets that were born on the day we arrived last week. They are 6 days old today. Dr. Ravi, a pediatric resident, was taking care of them when I arrived and he gave me the update. They can all best be described as stable, but they are having many of the complications that can be expected when they are in an inadequately equipped NICU. Infections are the most worrisome complication at this stage; all the babies had an infection of some sort. Baby A had an eye infection (ophthalmia neonatorum) even though he had reportedly been given preventive antibiotics. Baby B had an infection of his umbilical stump (omphalitis). And Baby C had signs of infection in his intestines (necrotizing enterocolitis) and possibly even signs of a worse infection (sepsis). They were all on adequate antibiotics and have a high chance of cure, however the conditions that set them up for these infections were still there.

Babies B and C sharing a cot – Note the many towels
The temperature irregularities (which actually now may be a reflection of their infections) are being treated by wrapping the babies with nonsterile towels, cotton, and fabric. Last time we were here, we recommended the babies be kept undressed under the warmers, with some plastic wrap covering the cot (acting like a greenhouse). This advice was only temporarily headed, as today they are still wrapped with all sorts of coverings, no doubt havens for bacteria. The use of a Zip-Lock bag in Baby A is ingenious, but clearly it is difficult for the caretakers to stop using additional fabric. Two babies are sharing a cot making it easier for infection to spread. None of the babies are in an incubator. Remember, these babies are sharing a room with other children as old as 13 years old, all of whom have bacterias and/or viruses that are making them sick enough to need hospitalization.

After infection control, nutrition is another top priority in caring for premature infants. However, intravenous total parenteral nutrition is not available. The babies are still receiving simple dextrose water. They will continue receiving this water until they are strong enough to receive formula into their stomach. However, Baby C (who might have NEC) cannot be fed because it could worsen the infection. He will be on sugar water for another week or so. Malnutrition sets him up to be even more easily infected and the cycle continues.

The odds are definitely stacked up against our kiddos, but the doctors are doing the best with what they have. They are using pretty much the same antibiotics we would use in the United States, and everyone is instructed to wash their hands before touching the babies. The bubble CPAP is still working fine. Dr. Ravi told me that he has stayed several late nights at the babies’ bedside.

Last week when these babies were born, I remember telling Stacy and Diane that these babies had a good chance of survival. Infants born at 28-30 weeks routinely survive with minimal or no complications. I neglected to take into account that the many facilities we take for granted in our modern NICUs are absolutely necessary for that survival. I’m learning new lessons about what we can do to help. Sure they need equipment like the warmers we donated a few weeks ago. Those warmers allowed the babies to survive the first few days. But the next few weeks depend on education as much as anything else. Nurses would benefit from learning about warming techniques. And someone who has influence needs to see the value of a separate newborn care unit. In a country where the birth rate is 50% higher than that in the United States, there will obviously be enough babies to keep that room filled.

Walking outside of the pediatric ward, I saw the Adolescent and Child Mental Health Building. I suppose this was God’s way of letting me know that all is not lost. The goat was the perfect accessory to help put a smile on my face.

Lesson learned
I wish we could get an adequately equipped NICU.
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21
July

Day 05 – Nineteen children seen.

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I arrived to the hospital at 8:45AM and I was the first one there. After making my way through the 30-50 families waiting to be seen, I reached the clinic door and it was closed. Not a big deal. I used the time to check out the emergency ward in the next building. It was an air conditioned small building with several rooms that catered to adults and children. The nurses still wear the quintessential nurse’s uniform – white dress and white cap. I saw one teach a mother how to rehydrate her child. It is remarkable that dehydration from diarrheal diseases, considered simply a nuisance in most developed nations, leads to the death of nearly two million children in developing countries every year.

Soon the clinic doors opened and headed to Ms. Grant (I gave her an apple that I brought with me from this morning’s buffet at the resort.) I was told I couldn’t use yesterday’s same room. It was the psychiatrist’s room and today was her clinic day. I instead set up office in the nurse practitioner’s room – she’s the women’s health person and she does not have clinics on Tuesdays. Playing office roulette is a routine that might change when the Issa Trust Foundation’s resident program is in full swing and we have a regular schedule.

I saw 19 patients today. The nurses already knew that I would not see teenagers or do school physicals. A couple of parents knew this too and they registered their children for sick visits, but popped out the school physical form once they were in my office. These actions show the desperate need that these families have for pediatricians in the area. I feel privileged.

I saw a patient with what I thought was leishmaniasis, an infection that is common in tropical countries, and we heard from local doctors that they had been seeing cases here. This is a parasitic infection carried by a fly that thrives in unsanitary environments. After the child is bitten, a painless sore grows slowly and eventually ulcerates (cutaneous leishmaniasis). They can be superinfected, as was the case in my patient, and can spread to involve deeper tissues and possibly even causing death (visceral leishmaniasis). Bad cases of tinea can look similar, but tinea is intensely itchy whereas leishmaniasis is not.. Although the skin sores are ugly and fester for months, they tend to heal on their own albeit leaving behind ugly scars. The treatment is with paromomycin, which provides a cure in more than 90% of kids. The 21-day course costs $10. It is not available in Jamaica. Another treatment is with pentavalent antimony, which costs $60 and was not available either. I prescribed oral and topical ketoconazole and told them to come back in 4 weeks to see if the third-line choice was effective.

The ride home was a little more exciting than usual . I took a cab, and got a lecture from the cab driver about how corrupt the public transport system was. Apparently bus drivers and cab drivers aren’t allowed to drive the same roads – each has a permit for a particular road. He called the bus drivers “big shots” who claim all the “good roads”.

Lessons learned:
1. Everything runs on Jamaican time. Go with the flow and don’t worry, be happy.
2. Learn the second and third-line treatment options for everything. First line therapy may not be available.
3. Make friends with a bus driver. They know all the “top people”.
4. If you want to join in the karaoke fun in the resort, remember that they like to change the words – “Give me the beat, boys, and free my soul. I wanna get lost in the REGGAE world and drift away … “
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20
July

Day 04 – Port Maria Health Center

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Would it be redundant to say it was a beautiful morning in Jamaica? 

This was the first day that I was on my own. Steve picked me up at around 8:15AM and we set off to Port Maria Hospital.  When I arrived, there were at least 50 people waiting to be seen in the clinics. I can see that Mondays in Jamaica are no different from Mondays back home.

I met Ms. Grant as soon as I walked into the clinic (she’s the “female attendant”). She remembered the Issa Trust Foundation and was very helpful in getting me set up in an office. She asked me which age groups I was comfortable seeing and I said up to 18 years. I’d later find out that this was a big mistake. But what better way to learn?

I saw THIRTY-TWO patients today. Out of my first 15 patients, 11 were school physicals for teenagers. That’s when I stepped out to speak with Ms. Grant to tell her that I would no longer see anyone above 13 (as is the norm for pediatricians in Jamaica), and that I would not see school physicals. I felt that they could adequately be seen by one of the three other MDs in the clinic. She rifled through my stack of charts and removed 15 or 20 charts. But before I could breathe a sigh of relief, 5 charts came, then 5 more, etc. I think the word was getting spread that a pediatrician was in the office! Alright!

Most of the sick children I saw were presenting with fungal infections of their skin, scalp, and mouth.When I was examining one 4 year old boy whose came because of ringworm on his forearm, I saw a ring around his iris. The mother had never noticed it. This is called corneal arcus, and can be a common finding in those older than 50 years. However, in a child it can be an indicator of hypercholesterolemia. When I asked his mother she told me that her brother had died at age 27 because of heart disease. I sent this child to have his cholesterol and triglyceride levels checked. He will follow-up in two weeks, on Monday or Tuesday, so he can see one of us!

A seven-year-old girl was brought by her father who wanted to check if she had had sexual intercourse. He said she hadn’t told him anything, but that he heard “talk around the village”. I asked him to step outside and I spoke with the girl alone. She was speaking patois, but I could make out a few key words: “he touch me”, “he say me shut up”, “he lick me”. I wanted to make sure I wasn’t missing anything pertinent so I asked for a nurse to translate. The girl said that this event had happened “a while ago”. I examined her genitalia – the tear I saw was not fresh, but was most likely less than 2 weeks old. After discussion with the head nurse I found out what I had to do: fill out a referral form to the Child Development Agency (the closest one was in Highgate), place the referral in a sealed envelope, and have the father take the little girl to the agency today for a full investigation. If the father had been a suspect, then the head nurse said she would have arranged for someone else to take the girl to the Agency. Before she left, I gave the young girl prophylactic ceftriaxone and azithromycin, and treated a ringworm that I saw during her exam.


Lessons learned:
1. Only see sick patients. School physicals can easily be completed by a non-pediatrician.
2. Review dermal bacterial and fungal infections (I found this article to be very helpful). Study the severe presentations. I saw a child who had such a diffuse infection that he was losing weight! He’s coming back for a repeat visit in 2 weeks too.
3. Child protective service and child abuse service are rolled up into one: the Child Development Agency.

Note: All patient pictures were taken with the written permission of the parent accompanying the child.
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