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14
March

Another great week!

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This opportunity continues to be amazing and eye-opening. We spent Tuesday at Port Maria and Steph and I switched it up…her going to clinic and me in the A&E. Stephanie was referred many patients from the Matron for complaints found during their well checks. Common things being common, she diagnosed pneumonia, otitis media, and many rashes. She was able to follow up with a patient I had seen the day prior who had fever without a source and was given IM Ceftriaxone and asked to come back. The great news is that he looked much better and was smiling and playful. It’s amazing that we’re able to have continuity here as the moms often have to walk long distances to the hospital. The people here continue to put smiles on our faces and it’s very apparent how much the mothers care for their children.




My time in the A&E at Port Maria was eventful to say the least. With the recent rain and “cold front” as the Jamaicans call it, I saw lots of asthma exacerbations. I did my best to educate each family and even found handouts about asthma in the clinic room. I sent two of them home with asthma action plans! The most exciting and challenging part of the day was a precious 3 year-old boy who needed his finger sutured. With no anxiolytic and only myself and Steph to hold him the process was extremely difficult but we got it done. Plus he is coming back next week for follow up.


Wednesday we returned to Annotto Bay Hospital and started the morning with rounds. We had extremely interesting patients and there was lots of good discussion not only about each patient’s treatment plan but about medicine in general. A little boy had been admitted the night before with 4 days of cold and cough symptoms along with 2 days of alternating lethargy and irritability. The interesting part of his history was that he had been given “bush tea” over the past 2 days. He’d received IVFs overnight and the leading diagnosis had been intoxication from “bush tea”. We learned on rounds that it’s customary, especially in the rural areas of Jamaica, for mothers to make tea from various bushes as a cold remedy. But similar to being in the US,  we have no idea how safe these herbal remedies are. We ultimately determined after much discussion, that “bush tea” intoxication is truly a diagnosis of exclusion given the lack of reported cases. With that being said an encephalopathy/encephalitis needed to be ruled out with an LP.  Soooo…if there’s a take home message to this story, it’s don’t give bush tea to your child!!!  We then finished up the day with Dr. Yandav doing procedures. We each performed an LP and drew blood for the lab. It was a wonderful day spent with sweet patients and great physicians.


We returned to the resort Wednesday night and rested a bit before having dinner at the Bayside restaurant (Asian cuisine). We had a delicious dinner and then we stayed up waaaaay too late to enjoy the steel band. They were amazing and full of energy. They played versions of popular songs like gangnam style and tons of Michael Jackson, my favorite. They had dance routines, outfit changes, and even did this crazy balancing stunt. It was incredible to say the least.





Today we spent the morning in clinic at Annotto Bay Hospital. Last week was filled with 2 week-old infants coming for hospital follow-up and weight checks but today we saw many older patients. Stephanie and I both saw many children with seizures, some with epilepsy on AEDs and others with febrile seizures. We both gave a lot of education to the families with children having febrile seizures, emphasizing that controlling the fever could prevent the seizure. Dr. Yandav joined in and made the very valid point that the seizures typically occur just prior to the fever or sometimes afterwards. His point was that parents should treat their child with either panadol (acetaminophen) or cataflam (diclofenac) at the first sign of warmth to touch. Interspersed between these patients was an asthma follow-up, phimosis, UTI, and well checks. The most exciting part of the day for me was following up with an infant I had seen just last week on the wards. The mom remembered me which made the visit all that more enjoyable. It’s amazing that here in Jamaica we are able to have continuity. While the morning was bustling, the afternoon was rather slow in the A&E which is proving to be the trend. I think with all the damage from Hurricane Sandy there is limited knowledge that the A&E is up and running and ready for kids. This did give us the chance though to follow up on our patients from the wards and it was really rewarding to know that all of the LPs performed yesterday were normal. It was also nice to see all the precious patients again too. We ended the afternoon with a snack from the Tuck Shop, the local eatery here at the Hospital. We had beef and cheese patties, curtesy of Dr. Marshall, one of the A&E physicians. We were warned that Jamaicans have heartier stomachs so we can only blame ourselves if there are negative repercussions from our eating adventure. It was totally worth it though…patties are delicious!







We’re heading back to the resort. It’s cloudy and cool here…maybe another cold from is moving in. After our late night watching the steel band we’re planning on naps and an early dinner. I say that but the idea of kayaking is being thrown around because even through our exhaustion we want to take advantage of the amazing opportunity we’ve been given. Well see 🙂

S&S

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11
March

It stopped raining!!

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Stevie and I decided to blog every few days so here is our next update.  This rotation continues to be amazing.  It’s a great opportunity to help people  in need, sharpen your physical exam skills, learn from experienced clinicians and enjoy the beautiful country of Jamaica.  Friday was our first day at Port Antonio.  This hospital is over an hour away but the drive is breathtaking in areas– you can truly see multiple aspects of Jamaican culture en route.  When we got to Port Antonio, I took care of all the kids in the A&E and Stevie went to clinic.   There actually weren’t supposed to be peds patients in clinic on Friday but because Issa Trust has done such a great job of bringing in pediatricians, the community has learned we are now there on Friday.  As soon as word spreads that the pediatrician is there, the patients arrive.   Stevie took care of many interesting rash referrals from simple vaginal candidiasis to disseminated scabies to a complicated rash which was likely super imposed with a staph/strep bacterial infection.  Often times these rashes have progressed past stages we see in the US.  She asked several of the patients to return next week so we could follow up on their progress.  Look at that continuity of care even while we’re in Jamaica!!  In the A&E I saw several typical pediatric emergency patients — asthma exacerbations, gastroenteritis with mild dehydration and an interesting 8 week old with a large lateral neck mass whom I referred for an ultrasound and asked mom to return with the results.  The physicians and the patient families are very appreciative of our being there.  I had two of the physicians I worked with explain to me how helpful it would be to have a pediatrician on staff at all times but unfortunately in Jamaica that’s just not feasible.  All the physicians there are fabulous but they’re not pediatric trained and they are super busy with 3 of them covering almost the entire hospital.  It’s a clear that having an extra set of hands on deck can really help!!  I had one mother tell me that she’s wanted to see an actual pediatrician for so long and was so happy to hear earlier that week that we were coming on Friday!!  One final note about Port Antonio that I don’t want to forget to mention– it’s beautiful and Stevie and I went to explore the city during our lunch break.  It’s bustling with life and unfortunately we didn’t quite make it to the pier (we had to get back to the kiddos) but perhaps we’ll have icecream on the pier next week!!





This past weekend was the best weather we have had in Jamaica yet!!  Although I will admit Stevie and I both got a little too much sun on Saturday!!  Our weekend started Friday night with a lobster dinner at a fabulous restaurant at the resort.  After eating way too much for dinner, we enjoyed live music and delicious wine– the combination definitely had us dancing in our seats!  Saturday we spent the morning laying out on the beach relaxing and then took a catamaran  cruise in the afternoon.  The cruise was perfect– tasty drinks, driving the boat, swimming in the ocean and completing it all with an awesome dance party with all the others on board.  On Sunday we participated in our first excursion away from the resort when we went ZipLining through a mountain rainforest.  This was perhaps the coolest thing I have ever experienced.  We took a sky walker to the top of a mountain, went on 5 zip lines and then went “bobsledding” around the mountain.  This experience was amazing and I recommend it for anyone in Ocho Rios!!  The weekend concluded with an amazing Asian dinner at Bayside restaurant followed by a gorgeous night on the rooftop bar.  I continue to be grateful to Issa Trust for not only allowing us to take care of these adorable kiddos but also to get to experience this country in a way that otherwise would have been impossible during residency.  It’s true in Jamaica, no problems man!!





Now back to the real reason were here, to help the children of Jamaica.    Monday was spent back at Port Maria.  The morning started out much slower then it had the previous Tuesday but by the end it had picked up and we’d seen plenty of rashes, ear infections, respiratory infections and viral gastro.   We also saw several of the follow up patients from the weekend.  The afternoon can be challenging because often the lab closes and the pharmacy closes well before you are done seeing patients.  Sometimes you feel like you are treating patients without all the information.  However, you learn to trust your physical exam and your gut (sick vs not sick).  You also have to educate parents about what to watch for at home and when to bring the child back.  The same is true back home but it sometimes feels magnified here!  All  in all, another great day.





We just got back to the resort and it’s gorgeous today so we’re off to enjoy this weather!!




Sunburned but still happy

S&S
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08
March

Procedures

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You will find that there will be many opportunities for procedures, some as simple as drawing blood and placing IV’s.  The physicians are responsible for collecting all blood specimens for urgent lab testing and for placing IV’s in those patients who are to be admitted.  I found this a bit daunting at first as I do not get much opportunity to perform such procedures at my home institution.    As when performing any procedure, I would recommend familiarizing yourself with the equipment first.  I had to remove a perfectly placed IV simply because I did not know how to secure it once it had been placed.

There is also quite a bit of obstructive uropathy secondary to benign prostatic hypertrophy.  This has given me the opportunity to replace several urinary and suprapubic catheters while I have been here.  While they have all of the supplies you will need, they are not all assembled in an organized kit.  It can be quite difficult to get everything together without the help of a nurse, and on a busy day in the A&E the help of a nurse is not always available.

I have also had the opportunity to do some suturing.  In both cases it was man versus machete, and the machete won.  Most cannot remember the last time they got a tetanus shot, so they all get one for good measure.  Most are not familiar with the term Tetanus but rather know of the disease by “Lock Jaw.”  In both cases the patients were very cooperative and the suturing went quick and easy.  I understand that sutures can be in short supply at times, so I found myself being very conservative with my thread so as not to waste.  In any case I can’t even imagine how difficult it would be to perform any of these procedures on kids, like my wife had to do!

Drew
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08
March

The Medicine Wards!

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Over the past month I have had the opportunity to participate in Ward rounds at Annotto Bay Hospital, Port Antonio Hospital and at St. Anne’s Bay Hospital.  Each had their unique challenges.  Port Antonio Hospital is a local hospital in a fairly remote location.  The “house officer” on duty is in charge of both the male and female medical wards.  A lot of the cases are similar to those that I have seen in the states including Hypertensive Emergency, Hyperosmotic Hyperglycemia State, Exacerbation of Congestive Heart Failure, and Stroke.  The resources are limited, and as I have shared in previous blogs many of the diagnostic tests have to be done privately as the hospital does not own a CT scanner, Echo machine, or Ultrasound.  The “house officer” that I worked with was very kind and sought advice on how he could improve in caring for his patients.  Given the tough circumstances I think he is doing an outstanding job.

Annotto Bay hospital is a referral hospital of sorts.  The female medical ward is currently undergoing repairs after it was damaged by Hurricane Sandy.  This has required intermingling of male and female patients on the male medical ward.  There is also overflow of patients onto the male and female surgical wards.  The construction is almost done and they should be moving the patients in the coming month.  Here two “house officers” and two “interns” manage both the male and female medical wards with input from a “consultant” who is board certified in Internal Medicine.  I would equate this to the attending, senior resident, and intern model.  However, the consultant is not their everyday, and may only physically round on patients 2 or 3 times a week.  He is always available by telephone if needed.  When he is there he is quick to teach and share his experience.  Annotto Bay has similar limitations and most of the diagnostic work-up must be done privately.  They do have the ability to perform basic x-ray and laboratory tests.  The morning is filled with pre-rounding and then rounding with the consultant.  The afternoon is consumed with coordination of care and phone conferencing with specialists in Kingston.  Discharges are performed in the afternoon, and their seems to be a disconnect between the hospital and the primary care physicians at the health centers.  There really is not good way to communicate hospital details to the physicians in the community.

I have spent the last week at St. Anne’s Bay Hospital which is the regional referral center.  The hospital is about twice as large as Annotto Bay hospital which is about twice as big as Port Antonio.  The hierarchy is similar with consultants, house officers, and interns.  Annotto Bay hospital is equipped with ultrasound and fluoroscopy, however, I understand that the ultrasound machine has been over heating and they are currently limited on the number of ultrasounds that they can perform each day.  Major testing such as CT scans and echocardiograms still have to be performed privately.  They do have two beds in a “High Dependency Unit,” which would be equivalent to our ICU without ventilators.  They have telemetry, continuous pulse oximetry, and they have one nurse that cares for the two patients.  I find that the cases are a little more severe at St. Anne’s Bay.  For example, a young many with Ackee poisoning, known to cause hypoglycemia and anion gap metabolic acidosis, had to be transferred from one of the smaller local hospitals to St. Anne’s as they lacked the resources to complete his work-up and give him adequate treatment.  Even with his transfer the patient did not do well and subsequently expired.  I can’t help but wonder if his outcome would be different if the proper resources were available.  The physicians are well trained and are as efficient as the system allows.

Drew
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08
March

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Our last few days in Jamaica have been spent at St. Ann’s Bay Regional Hospital. It has been wonderful to see the referral hospital. The pediatric unit is large and attached in a small room is the special nursery. The nursery has 2 ventilators and the physicians and nurses are very proud that the ISSA foundation donated the ventilators. While asking about the ventilators and how they monitor the neonates on the ventilators I was shocked to learn that the portable x-ray machine broke down months ago so the neonates never get a CXR. They also have a difficult time obtaining blood gasses. They don’t have CVN and the physician told me that the babies just get D5 0.2NS and starve. It was also interesting to note that they don’t have central line kits and many times use a foley catheter for a UVC. They are very innovative in the nursery and on the wards. They have learned to rely on physical exam findings instead of labs and images.

On the pediatric ward I see lots of asthma, bronchiolitis, and URI’s. The turn around rate is fast. Most of the children stay the night and get to leave the next morning. The beds are very close together and there is only room for a small chair (like a school room chair not a nice recliner.) Many of the parents sleep in the chair overnight so they can be close to their children. The parents that have been there a long time even sleep during the day in the chair because they are so tired. The children usually just sit in there beds and color or read but, I noticed a small playroom attached that has books, a TV and some games for the kids to use. I noticed that no one ever used the playroom. This morning I arrived at the pediatric unit early and asked why none of the kids are ever in the playroom. The nurse said it was because they needed a supervisor and the nurses are usually to busy. I told them that I would supervise the children and they gave me the key to the room. The kids were excited and after breakfast came to play. They loved the room and were sad to leave when rounds started. I was sad I couldn’t play more but was sweating profoundly after pushing children in carts and entertaining them.

The resort is AMAZING. Everyone has been so wonderful to us and they call doc wherever we go. The food is amazing and there is a large variety of food. The activities are wonderful and Drew even got scuba certified so we can go diving together. I couldn’t ask for better service or a nicer place to stay. It truly has been wonderful.
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