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Before I get started, a heartfelt apology to my writer friends.  You would be able to convey this experience with much more elegance, and quite probably with more grammatical expertise than I am capable of producing. Work Day 2:  The day really began en route to the hospital.  Imagine driving along a winding road through the Caribbean forest with the shade of the banana and almond trees cooling the humid air to a pleasant morning breeze.  A feeling of familiarity pulls at the fuzzy edges of your still awakening consciousness and you realize that the hokey pokey has insidiously emerged under the cover of a steady reggae beat coming through the car stereo with an overlay of laser sound effects.  Go figure.  The standard small-country driving experience, where the primary and possibly the only rule is, “Do your best not to hit anything, but if you do, oh well,” is not sufficient to wake me up, but reggae laser “Hokey Pokey,” gets my attention.  Now being slightly more awake, I see a few hints of the community I’ll be working with over the next month:  the children walk together dressed in neatly pressed school uniforms, every car full of people, and those that aren’t pulling over to pick up one of the people dotting the shoulder of the road, neighbors calling out and waving to each other on the way to work.  Here at the hospital, everyone helps keep an eye on one of the clinical officer’s children, Shaun, who has come in for the day.  He’s about 3 years old and is happily thumping away on a succession of musical instruments.  First, with rulers repurposed as drumsticks, then with a truck and a table, and now with a reptilian themed Fisher-Price ™ alligator xylophone and an allosaurus figurine. Flashback: After arriving this weekend, I spent the first day sleeping and relaxing at the resort, which was a welcome recovery period after a week of night shifts back home.  I thoroughly enjoyed Monday night performances by a magician, limbo king, and fire breather.  On two occasions, I was a volunteer on stage:  once to assist in the magical appearance of a dove (I still have no idea where it came from!), and once to hold a lighter for the fire breather.  Interestingly, the other two assistants for the fire-breathing performance had 2-foot long torches, which they held extended at arm’s length while the fire breather sputtered kerosene over the flaming end to create a small fireball over the audience.  He performed the same trick with the lighter in my hand.  This was not one of the nice, long, extended lighters, but a standard 3 inch cigarette lighter.  As a result, both the kerosene and the resulting flame were much closer to my person than to the other two volunteers.  Later, I wondered if their hands and arms smelled as much of kerosene as mine did, or if they avoided most of the spray by virtue of lengthier props.  I will likely never know.  The resort is lovely, though I suspect it will be difficult to keep my girlish figure intact given the highly accessible supply of quality food and drink.  Spinning instructor, Mike, may be able to help me stave off the sloth. Thus far, there’s not a lot to report on the medical front.  The clinics provide a dose of reality in contrast to the grounded cruise ship feeling of the resort.  Yesterday afternoon, I saw a few patients at Port Maria, where they’ve recently acquired a wall unit ophthalmoscope and otoscope.  In general, the clinics are well-appointed and the other doctors and staff have been welcoming and supportive.  It’s always a bit of a gear shift to go from “pull out all the stops” medicine in the US to “practical medicine” elsewhere with a sense that my brain is finally coming out of hibernation and that I am indeed capable of setting up my own clinic space, and doing phlebotomy, and reading plain films and all number of useful things which have been lost in the hierarchy back home. Present Day: We rounded this morning with Drs. Ramos and Fisher, who are as thoughtful and enthusiastic as others have described and I look forward to learning from them over the next several weeks.  This afternoon will be my first round in the A&E unit seeing acute patients, which is roughly equivalent to our emergency room (or ‘department’ if a ‘room’ just wasn’t enough).  Wish me luck!

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.    

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.

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!