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On our first full day in Jamaica, we climbed the world famous Dunn’s River Falls all the way to the top. It was a great team building exercise to get us mentally ready for the week. The first few days of work have been filled with a mixture of interesting patients, new faces and trying to navigate systems-based practice in a developing country. Each morning, we awaken to melodic sounds from the birds outside of our windows as we prepare to start our day. Prior to reaching the health facilities, we spend 20 minutes to 2 hours traveling along narrow winding roads, but are privy to picturesque ocean views, scenic mountain greenery and the early hustle and bustle for local Jamaicans as they travel to work or school. Rounds on the ward: An ex-29 week preemie who is small yet vigorous laid in an incubator next to an ex-26 week preemie who has apnea and requires continuous resuscitation. Both babies are premature, both in need of ventilators not available, but the latter only survived six hours after we were first introduced to him. He is the fifth child lost for his mother (all born prematurely) and only to think if his life could be saved if the necessary equipment was available – all the incubators were being used at the referring facilities. Two other infants were discharged home having improved after meconium aspiration syndrome and neonatal seizures. The last two patients (4 and 10 years old) were admitted for sickle cell pain crises. The first child had a medical course complicated by a history of rheumatic fever with subsequent heart failure, now improved on aspirin and diuretics. The older intermittently cried out as he awaited his pain medication; no PCA’s are available. We did get to hold plain film radiographs for the first time!!! Accident & Emergency (A&E): The equivalent of the Emergency Room is staffed by non-pediatricians, but they were excited that we saw their pediatric patients (ages 12 and under). Trying to navigate the forms, resources available and medications in stock were the largest challenges. The staff was very friendly and helpful. Chief complaints ranged from upper respiratory tract symptoms to dehydration to imaging follow ups. The biggest concern by parents and health workers was H1N1 or flu as evident by the white masks worn by all the staff.   Annotto Bay Clinic: Thursday morning is typically newborn clinic and chronic disease (i.e. asthma) follow-ups. The day was commenced with torrential rain. A car we passed on the road had slid into the ditch and only a few mothers made it to clinic that day. We were greeted by a sea of infants, tightly bundled and breastfeeding in the waiting area as they awaited their first well baby visit. We were greeted by cooing smiles and their mothers gave us many thank-yous.   Port Antonio A&E: The busiest day of the week!!  After a two –hour commute, we were met with a room full of parents and children who waiting hours to be seen by a Pediatrician. We were directed into a small room (about the size of a standard bathroom) to see our patients. Initially we started with 8 dockets (aka patient charts), as we got settled in the nurse handed us 3 more dockets. It seemed like every few minutes a new patient were being added to the list. In about 3.5 hours we saw 13 patients. To close out the day we had to admit a 13yr old male with a textbook picture of new onset type 1 diabetes. Although we were able to get blood via venipuncture for initial labs, multiple attempts at IV placement were unsuccessful before departing for the day. As pediatricians we both have become accustomed to looking at the patient electronic medical record to follow up patient care even after hand-off, but here it’s more so,” I hope he will be okay” and that what we did was the right thing. It was surely a rough day; thankfully we were able to work as a team. Lessons Learned:

1. Dandelions supposedly help with preventing prostate cancer?
2. The pharmacy can close at any time, leaving patients having to return for medications or not obtain them at all if they have no means to travel back to fill their prescriptions.
3. Remember to ask if your patients have running water, a refrigerator or transportation to return for follow-up. This will play a role in clinical advice, management and decision-making.
4. “Yeh Mon” is used by as a noun, verb, adjective and greeting constantly by all the hotel guests and staff – absolutely hilarious!
5. Keep the patient charts in the correct order or your will corrected swiftly by frustrated parents, fussy children, and nurses.
6. Check in with the pharmacy for each location on the first time going to get a run down on what medications are available.

  Until next week, Nicole & Roxanne