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03
April

Observations and recommendations

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I am now at the end of my rotation, and it has been a good one. I have worked in many countries before, in many different contexts and capacities, and they are all different. What stands out about this particular site is the commitment from Issa Trust and Diane, and importantly from the Jamaican Ministry of Health to fill in the gaps of quality pediatric care. Ideally, of course, the rotation of doctors is a temporary measure, with the real goal of increasing the cadre of local medical personnel knowledgeable about pediatric care. The foundation attempts to do this through their lecture series, and I have heard the medical officers formulate plans based on what was learned from the most recent lecture. And while this is an amazing resource for those who can attend, the majority of children continue to be seen by medical officers who have not attended these sessions. In the absence of trained pediatricians, the medical officers working at the health centers and in the A/E would benefit from a “pediatrics for the general medical officer” curriculum. So for those to come, I highly recommend imbedding quick presentations for the A/E and health center staff on a regular basis. What has surprised me tremendously is the degree of medico-legal fear among practioners here. While we often think of resource limited settings being ones in which diagnostics are curtailed and clinical judgement emphasized, what I have found is that it is a bit of the opposite. I have ordered more labs here than I have in almost any other country in which I have worked. Of course, this only stands true for the routine patient. What is clearly lacking is the ability to make more complicated diagnoses. For instance, I admitted a 14 y/o girl last week who most probably has autoimmune hepatitis. I was able to get an Ultrasound, monitor her LFTs, but getting an ANA or other rheumatologic markers is nearly impossible. OK, now for the nitty-gritty: Resources I used most  over the month include Medscape, Harriet Lane, though mostly for the growth charts, and epocrates. A dermatology reference would have been helpful. I didn’t find a great need for any books dedicated to low-resource settings, for most resources are available in Jamaica (though the distance for travel is great, the cost is free). Nor did I find the need for any tropical medicine books. There is a canister of urine dipsticks at the villa that check for leukocytes and nitrites. The ones I’ve seen at the clinic are the ones used for pregnancy, focusing on glucose and protein. All the  places in which Issa works have on-site labs and so can always send the kid to the lab for a formal u/a as well. Turnaround time on x-rays is great, usually within the hour, or even half-hour, during the day. Most commonly encountered conditions: viral URI/ AGE, impetigo, eczema, seb derm, scabies. asthma, obesity in children (getting to be a big problem, and more commonly encountered than underweight), anemia. I’ve been treating everyone for worms per WHO guidelines. I have not seen anyone dispense zinc for diarrhea, and when I asked about it, I was given a blank stare. So again, think US practices and guidelines over WHO ones. Overall, it’s been great here, and I look forward to returning sometime soon.    
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28
March

building better pediatric care

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One day I would like to help build systems of pediatric care that are thoughtful and relevant to the people living in the communities where it is scarce. What I’ve loved about being here is meeting people whose lives are examples of this. Yesterday I met a clinical psychologist who is working to build a child and adolescent program for counseling/therapy for people with mood disorders, have been through traumas, and are otherwise victims of abuse and neglect. She was telling us about how the need is huge, how much she loves her work, and how she has gradually been able to show people some methods that they may not be familiar with, but have been helpful to them. She had a career in England for 20 years, is Jamaican born and raised and came back a few years ago to fill this need. Ove the past month I have met many people who have said the words ” we are implementing” or “this is growing”. There are many amazing minds working on building a great system here. I believe Issa Trust has plays a role here precisely because people are hungry for these upgrades and constant ways to improve as we are in the US. This organization can fulfill many needs because so many here have thought about what their needs are and have used what is provided well mostly. There is still a ways t go to get the system to where the people here would like it to be, but that can be said about our system as well. We need more primary care physicians at home, we need better access for the poor, our infant mortality is not acceptable. The spirit of growth that I’ve met here, the push for betterment, has been as familiar as it is at home. I love ward rounds and the type of questions that consultants ask of the medical officers. I gave a presentation last week to a few in Port Antonio and they ate up the information. As long as didactic is strong, we as doctors, will always learn and improve. I’ve seen that poverty is the biggest limiting factor here much as it is back home. The government provides free health care but all that folks need is not readily available in the public sector. I have to send paitnets to Kingston (2 hrs away) for a Ct scan, or they can pay a few hundred USD and get one locally. I have to send cultures to Kingston or the patient can pay up to 50 usd at a private micro lab. some families can’t afford fare to get to the places where the free services exist. Pediatric wards have social cases where the parents never return for the sickly children, or they just can’t afford to keep them well, or give their chronic meds. Some just don’t give them. Some just don’t understand. Same problems I have in Camden. I am so hopeful, though, knowing that the kids here have the great doctors that are always here with Issa to provide those docs with support where they need it. We can’t end the poverty here, but by adding even more thoughtful consistent people to the group of folks already thinking about the children here things have, and will continue to get better.
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24
March

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Now that I’ve finally been here greater than a week, I feel I have more to contribute. I think this is an excellent rotation. Diane clearly cares for this work,for the country, for the patients, and to ensure this is a valuable rotation for the visiting pediatricians. There is a great deal of autonomy coupled with adequate local clinical personnel to answer questions. The medical officers are not trained in pediatrics, but most have significant experience working in this environment and are more than happy to assist/ answer questions. Having Dr. Ramos, the senior pediatrician, around greatly helps to bounce ideas off. The clinics themselves are quite busy, speaking to the need for pediatricians in this region. The medical officers are quite adept at caring for the basics of urgent care pediatrics along with well-child visits; however, they are uncomfortable with pathology or deviation from normal, making our role more appreciated. They are also quite eager to learn, so bring any presentations you may done! The living accommodations are superb. Everyone at the resort is friendly, knows us as the “Issa doctors” and goes out of their way to make us feel welcome. I am writing this as I sit along the beach listening to the waves, preparing to have dinner in the fancy Asian restaurant along the water. Can’t beat that!    
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19
March

on pediatrics

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When I first choose medicine, I choose it because I saw the need for medical personnell in the world first hand. Though I consider that as real a reason as any, I was not any less nieve about what it meant to be a physician than any average budding med student. I thought my mere presence would save lives! LOL. I would have this fantasy that I am driving and there is an accident before my eyes. I would spring from my vehicle and magically by my mere presences the mangled would get up and be healed 🙂 I thought I would save the world. As the meaning of doctoring has gone from being fantasy, to tangible, to my real daily existence I have gone through many changes. Primary care has become my passion. But what does it mean? I realized that what I like about my time here with Issa Trust most is that it is very similar to a clinic month back home. I see them, assess as many things as I have time to, introduce interventions, help them navigate the system, see them back. As I would at home I am essentially trying to build some trust and provide the best care I know how to. Im doing that, mostly from the clinic, because I believe in prevention, monitoring for occult disease so it may not cause more significant illness or premature death later in life, and mostly (to be honest about my personal intentions), so that these young folks can have the best quality of life with fewer days of illness or complications. Primary peds is not sexy. Diagnosing a 3 yr old with a urinary tract anomaly and providing interventions to prevent long term kidney damage is not going to wow your grandparents at the dinner table. Preventing a case of rheumatic heart disease by treating a strept throat, or treating a teenager with chlamydia to decrease her odds of having complications that might involve her ability to conceive later in life… those things are not ‘your favorite doctor show exciting’. As I reflect on them it reminds me of why what we do matters and why offering pediatricans to a place where there are so few, is a significant contribution to this and any population where access to a pediatrician is limited.
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17
March

Brain Drain

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I’ve only worked for 2 days, so this may be premature, but here are my very early observations: (1) Even in Ministry of Health hospitals, many of the medical officers are ex-pats, including Cubans, Burmese (!), and South Asians. It seems many Jamaican doctors emigrate to the US whenever the chance presents itself. Additionally, I am told the cost of medical education in Jamaica is quite high, further causing shortages in health providers. (2) I am surprised by how few “tropical” diseases there are here. For the most part, what I’ve encountered is not unlike what I see in the US: lots of viral URIs, AGEs, constipation, asthma, etc. (3) For good or for bad, practicing in Port Antonio or Annotto Bay is not too unlike practicing in low-income areas in the US. Here, limitations revolve around immediate access to diagnostics; in the US, limitations to treatment can be just as severe based on insurance status or ability to pay. (4) A nice change of pace from other parts of the world: Because of national health coverage, patients can actually get diagnostics and treatments, though they may have to travel 2+ hours to Kingston to do so… it’s uplifting to see after working in areas where even if a diagnostic test or treatment is available, unless payment is offered up front, the patient cannot access these. (5) It’s wonderful to have Dr. Ramos’, the pediatrician for the region, experience. He is practical and has a good sense of local epidemiology. So far, this is already proving to be a great experience. Will have more to report as time goes on.
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13
March

balance

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Today I was in Annatto Bay. After being in Port Maria where we see tons of kids and are busy all day Annatto bay is a nice change of pace. There are 2 pediatrics trained folks consulting and a whole team of pediatric focused medical officers. I wasn’t very busy but I learned a lot from rounds and from a presentation one of the interns gave about pediatric UTI. We got to discuss the standard of care for UTI here as far as imaging is concerned and I got to hear how it differs from the US and what kind of studies that have been done to inform the recommendations. I feel like I help the least here because there are so many other amazing people seeing the kids, but I’m sooo glad we come here for my education. I got to run some cases that I saw in clinic yesterday by the pediatricians and learned a lot about hospital care. They were saying they have never had to put a child with asthma on continuos or bipap or anything like that in the 8 yrs since of the peds has been working there. And the kids get better. If I had come here but not had these interactions then I would not be up to speed on the local standards so I’m grateful to have the Annatto Bay experience. I went to the Emergency area after ward rounds and saw a few really good cases. I have seen clinic patients a lone with “attending backup” at home for many months now. But this experience really helps build my confidence when no one is there to just “run things by”. I have been here long enough to have some patients come back and have been pleased by the results I have seen. I’m also getting better at seeing patients faster. I’m still in awe at just how specialized it is to be a pediatrician and how valuable our knowledge base is even among very experienced practitioners. I had a really sick kid in A and E today that myself and 2 other doctors helped stabilize. I felt really good about our efforts. I was nervous but once I calmed down I realized that I know stuff lol and we worked together. There was an ER trained doc there for support and she thought we did great and just added a few recommendations. I’m also really having fun at work. The docs and nurses are just as awesome as they are back home and its been easy to joke and have fun despite working hard. Thats like the icing on the cake.
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