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There is plenty of variety this week-gingivostomatitis, possible appy, scabies, and a nursemaid’s elbow. I was able to call an Orthopedist on his cell for a consult and follow up with a few patients from previous visits. For the possible appy, I made sure I had an updated contact number to follow the patient’s symptoms, arranged follow up, and provided  a surgery consult referral in case her symptoms worsened. There’s a better workflow between the nurses and myself now that we’re familiar with each other’s expectations and I certainly pitch in and vitalize my patients when triage gets backed up. I also feel more at ease with documentation, accessing records, ordering films, and selecting appropriate referral centers.   Unfortunately, this was a short week for me due to a viral illness (flu season), but I’m feeling much better now and ready to get back to work.

My first week went better than expected. The first few days were a bit rough working with little guidance or orientation but I figured things out soon enough. Once you figure out the system at one site, it’s pretty similar to others, so I didn’t need much orienting afterwards. Surprisingly, the resources weren’t as limited as I had been preparing for. I ordered and reviewed chest radiographs within one shift, selected several different antibiotics from the formulary to treat cellulitis, made a timely referral for a urologic emergency, and there was an otoscope at every site. I saw ~50 patients-plenty of asthma, URIs, cellulitis, and fungal infections. The communication between the nurses and myself varied from site to site. Most of the time, I had to request to keep a steady flow of patients and not assume I needed scheduled breaks. Nurses triage adults and children so getting orders filled in a timely manner, urgent or not, varied day to day. I surprised to see how much autonomy the nurses took in caring for the asthmatics, treating them with duonebs and steroids for 1-1.5hrs before I every laid eyes on them. By the time I listened to the patients, their mild exacerbations had been cleared. The patients and their families seemed grateful to be evaluated by a pediatrician. I spent a lot of time educating patients on inhaler+spacer use, controller vs rescue inhalers, monitoring for dehydration signs, and SIDs precautions. We’ll see how next week goes…

Reported by the Jamaica Gleaner Friday | November 25, 2016 | 12:00 AM

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Over the past two weeks, the Issa Trust Foundation – founded as the non-profit arm of Couples Resorts in 2005 – has donated a total of $10.3 million in equipment and supplies to hospitals in St Mary, St Ann and Portland as well as the Savanna-la-Mar Hospital. Twenty autoclaves (valued at $3.4 million), which are medical electronic equipment that sterilise surgical instruments under high temperature and high pressure, were part of the donation, as well as a new Welch Allyn ECG machine valued at $580,000. A crucial element of donations made by the Issa Trust Foundation is the provision of training and maintenance. Ernie Sandona, a biomedical engineer from Michigan, United States, was on hand to conduct a training session to approximately 30 attendees at the Annotto Bay Conference Centre. His training focused on the proper use and maintenance of the equipment to ensure longevity.   A shipment of new cribs, mattresses, IV poles and baby scales, all donated by Direct Relief, a valued partner of the Issa Trust Foundation, was made to the St Ann’s Bay Hospital with a value of $1.9 million.

4 weeks in Jamaica has flown by!  This rotation has been one of the highlights of the year, and we are a day away from heading back to 5 degree weather and rain.  I will miss the people of Jamaica – their friendly smiles, greetings, and the adorable babies with full heads of hair!  The variety of clinical settings we have worked in has been a great.  We worked in 3 different community sites – Port Maria Hospital on Mondays and Tuesdays, Annotto Bay Hospital on Wednesday and Thursdays, and Port Antonio on Fridays. We worked on the inpatient wards, the A&E (accident and emergency) department, the hospital clinic, and a health clinic. This elective has been a great opportunity to solidify 4 years of pediatric training, and work autonomously within a medical system with limited resources. Though we may have had the most dedicated pediatric training in the A&Es and health clinic, medical knowledge is only one part of patient care, and learning to navigate the medical system, choosing the most appropriate (and available) investigations and treatment, and accessing interdisciplinary resources was a challenge that pushed me to better refine my critical thinking and clinical skills.   The medicine here is great for a general pediatrician. There was some common pathology here that I rarely saw at home (scabies, tinea capitus and kerion, furuncles, tinea corporis, extranumerary digit, large abdominal hernias, infected styes). There was pathology I was very familiar with (asthma, eczema, viral illness, AOM, gastroenteritis, concussion, bronchiolitis, Coxsackie virus, febrile seizures etc), and there were some interesting cases (gasoline burn, vitamin ingestion, motor vehicle accident). Having come during “winter time” in Jamaica, there were many viruses going around. While many patients presented with viral symptoms, some had convincing history and physical exams suggestive of bacterial infections. Choosing the most appropriate antibiotic based on what was available at the pharmacy, or what the parents could afford at the private pharmacy had challenges, and often times, second line or third line antibiotics would be prescribed due to these limitations. Getting cultures done were often futile as samples (if not lost) and results are shipped out to and back from Kingston, and could take weeks. Without an EMR system, bloodwork is labelled by hand, paper blood results are physically transported, X-rays are printed on films, and all patient information is recorded by hand. I learned to actively ask myself why I was ordering specific investigations and how results would change my management, something I will take home with me, especially in my future career as a pediatric emergency physician.   The most enjoyable part of the elective has been interacting with the Jamaican people – they are friendly, kind, and genuine. They appreciate the work that we do, and ask us when we will be back. Parents who came from areas more than an hour away came to clinics before 7am in the morning to register, and waited patiently until physicians were able to see their child. Parents were only grateful and appreciative to have a physician see them, despite sometimes waiting for more than 8 hours. One of the biggest impacts we can have on the patients we see is education – teaching parents about their child’s condition, explaining what we think their child may have, and what the medications we prescribe do and how to take them.   I am also fortunate to have had a colleague and great friend come work beside me over the last 4 weeks. The benefits of having his clinical perspective and expertise in discussing cases where the diagnosis or treatment plan was not straight forward helped me feel more comfortable in my final management.  I am grateful we were able to support each other in learning around our cumulative interesting cases, and navigating an unfamiliar medical system.   Lastly, I would like to acknowledge the great work that the Issa Foundation does to help improve the health and quality of life for young Jamaicans. During my time here, we saw grass roots progress being made: sustainable equipment delivered to hospitals with in-service teaching provided, and vision screening at schools with glasses given out to children who needed them. For me, working within a fantastic organization was important in participating in an elective to ensure that there was continuity with the work we do.

I’ve seen the advertisements with Jamaica’s inviting cyan waters and the lure of a tropical climate, but what to expect in the clinics and hospitals was still a mystery as I arrived in Montego Bay. After all, I didn’t have much international clinical experience before coming to Jamaica. My only previous exposure was an educational opportunity teaching cardiology in Kathmandu. There was, however, no direct patient contact and we were working with students with fluency in English. This time around, I was traveling with a seasoned expert who had spent time in South Africa and Botswana – a very helpful accessory to the adventures ahead! Looking back on the 100 or so cases from the past 4 weeks, there was a whole lot of fever and viral illness floating around. The rainy season has arrived and school is back in session – the perfect recipe for spread of these kinds of infection. I encountered many cases of wheezing and tried to establish children on controller therapy for the first time. I was forced to learn a lot of dermatology with almost half of the cases coming in with some form of chronic or new skin lesions. In our last two weeks, we saw emerging cases of hand, foot, and mouth disease with more limb involvement and larger, angrier lesions than we’re used to seeing at home. With heavy rains and mosquitos on the loose, we came to recognize longstanding, difficult-to-treat cases of pustular urticaria. And the most impressive of all were the cases of tinea capitis with kerion formation. As I’m preparing to write our board exams in the spring, I won’t forget what a kerion looks or feels like and how to manage these fungal infections. And if you asked me for my favourite encounters, I loved seeing adorable newborns for their 6-week wellness check as they were thriving in the first weeks in the world. Besides the adorable babies and interesting cases, my main highlight was how we felt valued by parents. One of the things that we can offer as pediatric doctors is time. While there were many patients to be seen, parents valued having someone spend time hearing about their child and concerns, doing a full head-to-toe physical examination, and explaining what was going on. Parents – sometimes waiting up to 8 hours to be seen – were always thankful for the time that we dedicated to helping their children. I think that reflects how we saw Jamaicans. Whether we were in clinics, hospitals, wandering in cities, or back at our hotel, the staff, parents, and locals were almost universally warm, welcoming, friendly, and laid-back. The other highlight is the collegiality within the Issa team. I was very fortunate to have Alison with me. We traveled to the same sites together. Whenever there was a puzzling rash or an unclear diagnosis, it was helpful to have her weigh in on what was going. When I was unsure about how to navigate the system, she worked with me to find the best way forward. We were also fortunate to meet the Issa team with Diane and her colleagues coming down to Jamaica for other medical missions. Compared to others’ experiences, this elective was easy to “walk into”. Diane organized the details around accommodation, transportation, food, and clinics. And we can’t complain about sleeping in a beautiful location with delicious food, leisure activities, and access to fitness. We will miss Willis’ fruit smoothies and the fresh food that couldn’t possible survive through a Canadian winter. So, here we are on the last day of 4 weeks in Jamaica. While there are always bumps in the road, there lots of highlights that I will remember. The staff and patients keep asking when we are coming back. We haven’t decided just yet, but we will be back for more adventures!