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The clinics are closed and it is time to rest. It is difficult not to enjoy yourself while you are here. The all-inclusive part of the resort includes almost all water sports. Scuba diving lessons and dive are everyday at 9AM. A bus departs everyday but Friday to the beautiful Dunn’s River Falls, Jamaica’s most famous waterfalls. You can go water skiing or knee boarding. Sailboating, kayaking, and pedal boating are all included. Couples’ employees designated as Entertainment Managers arrange for daily activities such as sand and pool volleyball. And there are three different pools to lounge by, one of which has a swim-up bar.

I thought I would feel out of place being here by myself among guests that have all arrived as couples, but the group activities are geared to letting everyone get in on the action. When I sit by myself for meals, almost invariably one of the employees sits with me and we have a nice chat. It’s been a few days and almost all of them know why I am here. They treat me with much respect and are eager to make my stay as comfortable as possible. One favorite greeting, “Respect”, pretty much says it all.

Respect!

Port Antonio is a two-hour ride away from the Couples Resort at Tower Isle. I still love watching the scenery during our ride. But anyone prone to carsickness should definitely premedicate with dramamine. The road is extremely curvy and the long ride is a good setup for some unpleasant feelings.

Port Antonio hospital is designated a type-C hospital – that is the lowest level of care. However, the buildings themselves actually look to be in better shape that both of the other clinics we’ve been to. Dr. Ramos, our partner Jamaican pediatrician, indicated that this location is in the most dire need of pediatric services.

Our contact here was Dr. Davis – she is a gynecologist. She introduced us to two other physicians, one of whom was Dr. Fazul. She called him a resident but he has been at the hospital for 6 or 7 years. I wanted to understand this more, but I figured that is a question I can ask later. Dr. Fazul was going to go to do inpatient rounds and we (Stacy and I) went along. There were 5 patients – two first-time wheezer infants (neither of whom had a pulse oximeter), a 5 year old girl with gastroenteritis (she was getting fluids – D5 0.45%NS – but without an IV pump), and a newborn who had been born at home and was being treated for presumed sepsis. There is no mechanism for local microbiology, so cultures have to be sent to Kingston (two hours away). Cultures are usually bundled to be sent on one particular day. Dr. Fazul expressed his frustration that even on the days the cultures were supposed to be sent out, often weather would impede or even cancel the transport. He therefor rarely obtains cultures, and treats empirically. In this case, the home-born infant who was otherwise doing well was going to be receiving cephalosporins for a week.

The fifth child was a 1 year old who had been admitted a few hours before we arrived. He had been reaching up to a pot of boiling tea and it toppled on him, scalding most of his right side. I estimated his burn at 15-20% of mostly third-degree burns. Needless to say he was in obvious discomfort. They were managing his pain with oral paracetamol, the equivalent of our tylenol. It was woefully inadequate. The child did not have an IV and was not receiving any IV fluids. He was at risk for significant fluid loss. The best way to monitor fluid status is by closely observing the urine output. They had no way of weighing his diapers as a method of monitoring his urine output. A $20 kitchen scale would solve this.

I asked them about morphine, but they were hesitant to use it. I gave them a dose to use and the nurse set about getting it. Since they have no respiratory monitors they were understandable worried about respiratory depression. However, as Stacy quickly pointed out to them, a child in that much discomfort would not likely  fall asleep from a minimal dose of morphine. There was a little “teaching moment” here – infants with burns are more likely to die from fluid loss than they are from infections. I ordered some fluids and let them know that he should have a full wet diaper every two hours.

Stacy and I went to our clinic after rounds. This was by far the most comfortable clinic we’ve had in the past three days. A fully air-conditioned room, with a nearby sink and refrigerator. This clinic sees patient on an appointment basis. I was scheduled to see three patients. We’ve been trying to get the word out that the pediatric clinic would be staffed on Fridays, and with time we will have more patients. Right now, most people are still used to only having the pediatrician, Dr. Ramos, available on Tuesdays.

My first patient was an 8 month old with a VSD/ASD on diuretics awaiting a determination of whether she would need surgical closure. My second patient was a one-year old girl with cognitive and physical developmental delay that we thought had the effects of kernicterus (she would need long-term physical and speech therapy, neither of which were available locally). The final patient was a 1 year old with breathing difficulty that we diagnosed with hypertrophied adenoids (I started her on nasal steroids and asked her to come back in one week to see Dr. Ramos so he could schedule her for surgery). I’m not sure who would do her adenoidectomy. There are no local ENT surgeons, but a general surgeon we met at Annotto Bay yesterday said that he does “some” pediatric surgeries.

Lessons learned:
1. Get kitchen scales to weigh diapers
2. Do teaching rounds with the local resident
3. Talk with Dr. Ramos about long-term availability of physical therapy.