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July

Week 1 in Jamaica

After just my first week in Jamaica, I’m starting to realize how different everything is here. I went to Port Antonia yesterday, where I assisted with inpatient rounds and saw a few clinic patients as well. After an hour of waiting for the doctor to arrive on the Pediatric Ward, I was told he was actually not coming. Someone from the Emergency Department was asked to round in his place, and with neither of us knowing any of the children in the unit, the morning started off a little hectic. There were some very sick patients– a child with posterior urethral valves with now overlying pyelonephritis was there for IV antibiotics and ultrasound imaging. Looking through his chart, however, notes were written as “patient with unknown kidney disease with left flank pain” or “??kidney disease, rule out pyelonephritis”. There apparently isn’t a consistent doctor who works in the unit, so information is poorly relayed, and treatment reflected likewise. As the covering doc flipped through the boy’s chart, he informed me his ultrasound showed hydronephrosis. “What grade?” I asked. “A bad one,” he replied, moving on to the next patient.

Rounds continued on in this way until I was sent off to clinic. Sitting in an air-conditioned room, I felt a little guilty. Most of the patients here were follow ups after discharge from the hospital. I was seeing a boy after multiple episodes of febrile seizures, now with 1 week history of penis pain. During the physical exam, he became very upset, and slapped his mother, who was holding him down. Appalled, I asked him to apologize, but he refused. I thought to myself about all the clinic visits I spent talking about behavior management, and positive/negative reinforcement. It seemed like such a luxury now..! I reluctantly gave up my behavior talk, as the boy would not be overcome in one clinic visit, and continued to counsel the mother on other issues.

In Iowa, parents come in with a list of problems to discuss, and residents usually limit them to their top 3. Here, parents come in with just one problem to discuss, but watching them, and listening to them, you see hundreds of issues. You sleep with your baby and she sleeps on her tummy? Why are you starting solids at 2 months? Leaving your baby in the sun is different from phototherapy… I guess when I go back home, I will sympathize with them more now; it is hard to choose just 3.

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July

First (real) day at Port Maria

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Hello everyone! I am one of the pediatric residents from University of Iowa, and I just arrived to Jamaica 2 days ago. This is my first time in Jamaica, and hopefully I can share the experiences I have here with you.

I was scheduled to start today at Port Maria, a small rural hospital up a hill with unpaved roads; however, due to some mix ups with the driver, I was unexpectedly taken there yesterday morning. I saw maybe 7-8 patients within a short 2 hr period in the middle of the day, and then none for the rest of the day. Apparently, patients here are seen by their number in line, so even though I was free most of the morning, since it was not yet their turn, I waited in my room, until 1pm, when they all came through at once. During my waiting time, though, I did learn a few things: there are no alcohol wipes, no hand sanitizers, no gloves, let alone any otoscope attachments. It was stressful working in conditions you knew were far from acceptable, and as I desperately rubbed my stethoscope with my personal pink rose scented hand sanitizer, I understood how different everything would be here.

Today, I came prepared. After some rummaging in my room at the resort (which did stock a few of these supplies), I was able to bring my own mini travelling sanitation center. Life was so much better when I was able to properly clean everything between patients! The morning started out with 3 siblings, and from there, charts were brought in by the handful every 30 minutes. By 12pm, I had seen about 10 patients, but still had a stack of charts on my desk. With all these patients with their mothers, siblings, cousins, and friends waiting outside, all I could think about was how low our “patient satisfaction scores” would be if we were in the States…

I started getting stressed at 2pm, when it seemed like there would be no end to the day, and I lost track as to whether I was sweating (glistening) from the heat or from the pressure. I went out at 2:30 to call the next patient in, but saw that somehow, the herds of people had disappeared, and there were now only a few people left in the clinic. Although relieved, I knew most of them were probably sent home as it came near the end of the day. It was a sad thing, because most of these children didnt require long visits, and with a quick prescription, could have become better much faster. There was one boy with severe eczema all over his arms, and a history of secondary cellulitis due to skin breakdown during his last flare. One look, and I started searching through the formularly for steroids available at the clinic while his father told me the history. They had been waiting there for 6 hrs but only needed 10 minutes for a triamcinalone script and some quick reprimanding for a habit of hot showers and aggressive drying techniques. I felt bad there was nothing more to offer for their wait, so I unsatisfyingly handed the boy 3 packets of neosporin to use in case there is again any skin breakdown. It’s weird how giving people something (a script, medicine, food) is so gratifying…I’ll be running out of supplies fast at this rate.

On the drive back to the resort, I learned about soft Jamaican apples, the “akee fruit poisoning conspiracy”, and the behaviors of the local popo. I was glad to be back in Ocho Rios, but felt a little guilty getting off at a resort. Rural life and Resort life couldnt be more closely juxtaposed. I can already tell this is going to be a very eye-opening trip..!

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May

Week 3&4: Port Maria and Port Antonio

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Port Antonio

My last week of Port Antonio Hospital was a slow day on the ward as well as clinic, having only 2 patients to be seen in clinic which was a contrast to the previous week which had us working with no breaks up until the moment we left. One was a young girl I diagnosed with inguinal hernia and referred to the Surgeon down the hall and the other was a 7 month old baby who was unable to make it to the appointment but had been referred for evaluation for achondroplasia. I listened to the social worker who was there representing the mother and she explained how the mother had come several weeks to see a pediatrician but that the weeks she had come, there were no pediatricians available and today both were unable to make it due to a complicated social situation. The baby was apparently disproportionate in size with short extremities and a description that fit but had not been formally seen or diagnosed with a genetic condition. Of note, there are also no medical geneticists on the island in addition to other pediatric subspecialties.

On the way back from Port Antonio, the Ministry of Health employee who was kind enough to drive me back the two hours back to the resort explained to me all of the different type of plants and fruit trees lining the road ranging from banana trees, breadfruit trees, mango trees, and ackee trees. I expressed my interest in trying ackee and saltfish which is a national Jamaican dish. He stated the dish was delicious with breadfruit, but he warned me that ackee that is picked too early can be poisonous. Other people who call this dish the Jamaican Rundown, told me that one has to be careful about who you buy your ackee from but that the dish is very delicious. I asked one of the doctors at Annotto Bay about this, and she told me there was recently an outbreak in ackee poisonings this past year with a spike in the number of cases. Due to ingestion of ackee that has not fully matured, the toxin Hypoglycin will lead to hypoglycemia and symptoms of vomiting, stomach cramps, and diarrhea and in severe rare cases, coma or death. I found this useful information to know and has somewhat dampened my curiosity in trying this fruit.

Ackee Fruit

The next two weeks at Port Maria were busy and a week after the departure of my wonderful colleague Dr. Hack, I found myself incredibly busy seeing 26 patients in clinic one day from 9 AM to 4PM. I realized how just like at the end of any rotation, you start feeling comfortable with how things are run right when it’s about time to leave. One of my more complicated cases was a preadolescent boy diagnosed several months ago with HIV but who was not aware about his diagnosis. He came in with 3 weeks of cough and a rash which looked like tinea versicolor. I obtained a chest xray which revealed an infiltrate keeping in mind that the mother stated he had been on several weeks of an antibiotic which finished a week ago, but now was not on any medications and that his first appointment to discuss his condition was next month. None of this information was located in my paper chart and without any previous labs or other information about which antibiotic he previously was on, I discussed a plan of care with the ER doctor who knew him well and sent him to the A&E for further work-up including a CBC, viral load, CD4 count and initiation of antibiotics.

The rest of my clinic visits at Port Maria in the last two weeks were the same ranging from well checks, scabies, deworming, a variety of skin rashes and referrals to other hospitals for conditions requiring surgical intervention. Three medications that I felt helpful to know were Tropovite Vitamin Drops which contain Vitamin D, Hemafed which contains iron, and Rid Cream for scabies and lice. I would ask to peruse the pharmacy counters before clinic on days I had time because knowing which medications were available in the pharmacy is invaluable to avoid having families paying out of pocket for medications at private pharmacies when alternatives can be easily picked up at no cost here.

Another thing I take for granted in the states are scheduled appointments. I find it hard to take breaks knowing that patients arrive at 9 or 10 in the morning for an appointment. Once a parent even pretended his son was another patient so that he could be seen earlier and I only discovered this after the parent of the actual child asked why they had not been seen yet. Due to this, I have made it a habit of asking the parent the child’s birthdate before starting the visit. I’ve also gotten used to adults randomly walking into my room, even in the middle of a child well check, and start telling me their ailments. I always have to gently cut them off and explain to them that the family practitioner across the hall can aid them and that they have to wait for their turn.