I can’t believe these 4 weeks have flown by so fast! Working with wonderful physicians every day, learning how to manage common, and not so common, illnesses with limited resources, and living on this beautiful island has been an experience I will never forget.  During my time in the clinics and ERs at Port Maria, Annotto Bay and Port Antonio hospitals, I have seen much of the same problems as in the US: colds (which can be any number of symptoms), rashes, eczema, asthma, URIs, sickle cell complications, failure to thrive, etc. However, being the only pediatrician at times, I felt I could offer a sometimes more appropriate approach to the children. Yet, at other times, I needed the assistance of my more experience colleagues in improvising and using clinical judgment without the luxury of readily available tests and imaging I have grown accustomed to.  This month also gave me a chance to make independent decisions (with support available) and build up my confidence as I get ready to leave residency and enter the pediatric world on my own. Nearly every day, I had the chance to put in IVs, or suture or splint – all important skills of course.  Parents appreciated the chance to see a pediatrician and get explanations from a doctor. I remember my very first day when I had to admit a little girl with pneumonia and the father thanked me, saying they had been in the ER all night and no one had diagnosed her or explained anything. Though most of the time it was rewarding, there is is one case in particular I would like to highlight as it was extremely humbling and emotional for me and points out some of the challenges of working with fewer resources and without trained pediatricians in all hospitals.  A couple weeks ago, a mother brought in her 8mo infant complaining of continued fever for at least 1 week and parotid swelling. She had brought the child in to the same ER twice in the previous week with the same complaint and though lymphadenitis and different descriptions of the swelling were noted in the chart, she went home each time with antibiotics. This time, however, she was fussier, in and out of sleep in her mother’s arms, and I must admit the parotid swelling was incredibly impressive and unusual for me. She also had very large non-mobile sub-mandibular lymph nodes. Her mom said was continued to take fluids, though appetite poor. My first thought was mumps – which others confirmed has not been seen in Jamaica in many years – or another viral illness. However, her weakness, ongoing fever for more than a week and such large nodes and swelling bothered me. I got an xray to ensure the masses were not compressing her airway , then decided to draw labs and admit on IV antibiotics. Once we starting sticking her for labs, we noticed she was not clotting well. After getting an IV in her foot, we decided to get a culture. Here, cultures are often obtained through the femoral vein. I did feel uncomfortable with it but a colleague insisted. At this point, we noticed the child stopped struggling against our phlebotomy sticks and was more lethargic. WE placed pressure for several minutes and wrapped the leg tightly. However, with ongoing bleeding and hematoma forming, we were sure this child had a coagulopathy and perhaps in DIC. Though she initially denied any bleeding or bruising in the child, she later noted some gum bleeding at home.  Her HR at been 150 with a fever, a NS bolus was started and soon after, we noticed wheezing and on closer examination, hepatosplenomegaly.  Two melena stools were noted while in the ER as well. Malignancy was now at the top of our differential with the possibility of pulmonary hemorrhage vs leukocyte infiltrate. We were preparing FFP when labs returned comfirming our diagnosis of leukemia: WBC 225K, Hb 4.7, Plts 44K. This was an extremely hyper-leukocytosis and likely already meant she was  having tumor lysis.  As we awaited her type and screen, we tried to get O- FFP and pRBCs but this was unavailable. So we had to wait for the appropriate type – FFP was given ASAP though.   After this, her HR plummeted as well as her respiratory effort and her O2 sats. CPR was initiated and continued for 35min before she was pronounced dead. There is much to learn from this case. Though childhood leukemia has incredibly high cure rates in the US, this is not the case in most low and middle income countries largely due to late diagnosis.  This can often be due to lack of knowledge amongst providers on how children present with cancer as it can be different than adults. I don’t blame anyone in particular, but clearly a few things were missed along the way and there was likely a poor prognosis at this point. However, in a setting where blood is not always readily available, I believe we need to be extremely cautious in how we take blood and how much we take from a child. This was something I discussed with my colleagues there in our debriefings after the case.  I know that we may not have had much a chance to save her, but I will never forget her and will undoubtedly take lessons from this case as I move through my career. It was not all work and sad cases of course and truly had a blast in Jamaica! The resort was incredible – food, beach, entertainment and amazing staff. On the weekends, I explored all over the island. I highly recommend spending a weekend near Port Antonio, the most beautiful part of the island and with famous jerk chicken. Thank you ISSA Trust for this opportunity and I’ll definitely be coming back!

Sweet little boy with newly diagnosed Sickle Cell Disease presenting with Acute Chest. (was only playing in wheelchair, but his shirt was fitting)

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♫ Until the philosophy which hold one race superior and another inferior is finally and permanently discredited and abandoned ..Until there’s no longer first class and second class citizens of any nation.. Until the color of a man’s skin is of no more significance than the color of his.. eyes ..Until the basic human rights are equally guaranteed to all, without regard to race.. ♫        
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Monday was very busy last week! I’m not sure if that’s usual for a Monday or if word has spread that there’s a pediatrician that is visiting. I have had plenty of people asking when I’d be returning so it may be a combination of both.

Earlier in the week I had an impressive case of a patient with left sided lymphadenitis and what appears to be a left peritonsilar abscess after trauma. He was punched in the neck the previous day while at school and the swelling had occurred overnight.

I also discussed an interesting patient with Dr. Ravi later in the week! She a young known asthmatic who began having an adverse behavioral reactions whenever given albuterol. According to the chart (called a docket here in Jamaica), the reaction happened both at home as well as at the hospital. The patient wound up being treated with Atrovent in addition to steroids with the plan to be sent home with atrovent for rescue. I’ve never seen a case of albuterol/ventolin allergy.

When it comes to language, while English is the official language, of course many patients speak creole or patois. I’ve been fortunate enough that I’ve been able to understand most people for the most part. Sometimes I need to ask for clarification but it’s relatively uncommon. Of course, even though we may speak English, my accent is obviously different from a Jamaican’s. I’ve had some people think I’m Jamaican and you can usually tell the confusion when I start speaking. So to head it off, I introduce myself as a visiting pediatrician from the US. This week while in clinic in Annotto Bay, I had a fun conversation with a 7 year old girl. While setting her up to go home she turns to her mother and asks in mock whisper: “She’s lives somewhere else?” Her mother responded: “Yes she’s from far away!” The girl paused a second before saying “That’s why she talks like that?” It was so cute I had to laugh. I turned to her and said: “Yes! That’s why I sound funny!” It made me wonder what Americans sounds like to Jamaicans.

My final day in Port Antonio was this past Friday and it was a busy one! At one point I had 7-8 charts waiting for me to be seen. I was able to get some help from the other Doctor in the A&E. I particularly remember two patients. One was an infant present with URI symptoms and wheezing. He overall was well appearing and mother already had an albuterol inhaler. Unfortunately she wasn’t instructed on the proper use of the inhaler and so the child was only getting his medication once a day for the wheezing. I spent the visit breaking down what was causing his wheezing, why he will likely wheeze unlike his sister, the effect of the medication, and the appropriate times and frequency to use it. She was very grateful. Its reminded me of our job to educate our patients and their families about their health so that that can own and improve their lives.

Until my next and final post!
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Completed my first full week here last Thursday. It was pretty amazing! Monday and Tuesday I was at Port Maria working in the A&E. (Accidents and Emergencies, pretty much similar to an American ER.) Since all of my clinic locations are in general hospitals I just help out with the Pediatric patients that present for evaluation.

This active boy tried to be serious for the picture but he couldn’t hold the smile in for long!

Wednesdays and Thursdays are at Annotto Bay and there I was able to work in the Pediatric clinic seeing patients presenting for their newborn exams and other scheduled patients. It was a busy day and I was able to work and consult with the other Medical Officers who work in the clinic seeing patients. Diagnosed a few murmurs in newborns which required ECHOs prior to being seen by Cardiology. I’m unsure when they will finally be able to have the imaging done (there’s a long scheduling process, especially if patient is overall well appearing.)

She wanted to listen to my heart.

There are many services that are available in my training hospital which we don’t generally have available here in Jamaica. I was consulted for a 3 year old with failure to thrive, which upon prompting I discovered was likely due to suboptimal nutritional intake as the patient had food aversion and would only eat small amounts of rice porridge. Back at my home institution I would get behavioral medicine and our eating specialist involved. In this case, all I could offer is that the patient be started on pediasure and to continue to attempt to feed with new and different foods.

Another service that is dificult would be Rheumatology, which may have been an issue for one of the patients I’d seen on Friday at the Portland Health Department. He was a 10 year old who presented with 1 month of joint pain in elbows and knees. But when prompted would agree that nearly every joint hurts. Yet through history and on physical exam there was no warmth, swelling, or redness to any of the joints. If directly asked he would complain of pain with movement of any joint and would wince as if in pain, but if redirected while I continued examination he didn’t not express or show signs of pain. I do believe he may have some morning stiffness but I didn’t think his symptoms were concerning for a rheumatological problem and so I decided to have the patient come back in 1-2 months if the symptoms continued.

For the most part I’ve seen plenty of the same pathology that I would see back home. The major challenge comes with navigating a different health system and knowing what services and treatments are available. This helps a lot in being judicious in my medical decisions.

I also learn much about Jamaica and the hospitals from the transportation drivers.

PS. On a different topic, after my visit to the Portland Health Dept, I developed hives! That’s a first for me as I’ve never had any allergic reactions before. If you’re wondering, they are not comfortable AT ALL. (I had Benadryl in my emergency kit but wound up having to start steroids since the hives persistently returned every 6 hours.) I’m still unsure of what has cause them and I’m currently still having intermittent break outs but the episodes have been improving.
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Hi All! I’m Iréal Fusco, a pediatric resident training at Nicklaus Children’s Hospital in Miami. I’ve been very excited about participating in the Issa Trust Pediatric rotation as a way to expand my Pediatric training.

My first day was this last Friday, March 10th, 2017 at the A&E in Port Antonio. It was a long drive to the location but there was gorgeous scenery along the way. Mr. Campbell is an administrator at the hospital. He picked me up and drove me to the hospital himself!

Once there, I felt a bit like an intern all over again starting at a new place. I was thrown right in seeing patients so I had to learn how the system worked as I worked. The overall pathology was similar to what I’d see back home at our ER. There was a bronchiolitis that I wound up admitting for further treatment. Some viral URIs, Constipation, Hand, Foot and Mouth disease as well as an AGE.

There was an infant with a new onset fever after several days of URI & diarrhea who looked great but the fevers were high! I was concerned for UTI (especially with the large water stools she was having and I witnessed) but we didn’t have the bags available to get a urine specimen and there were no catheters. I had to make a decision on whether to treat empirically or manage conservatively. That was a tough one.

I had another young lady presented with severe left sided abdominal pain with difficulty ambulating. She was diffusely tender on exam but her pain localized to the left. Urine pregnancy was negative. Urine dipstick was WNL (no blood). No flank pain and denied constipation. She had me very concerned for a surgical emergency and I was unable to obtain ultrasound for diagnosis. After a bit of discussion we got a flat and upright abdominal X ray which showed a large stool burden and after a glycerin suppository she felt much better. She even ran up to hug me and said thank you before she left. It was a reminder that I am helping in some ways (even if I’m not as efficient in the setting I was in.)

Overall, I had a wonderful but busy day! Coupled with the long drive home, I didn’t have the energy to write this post that day, but I’m excited to explore the other two clinical sites!

~ Iréal