Blog

So I expected certain things traveling to a “third world” country but some things I still found surprising so I thought I would list some of the eye openers on this trip.

1. A pediatric ward with a pediatric attending trained in critical care (ICU) that accepts as a regional referral center having no mechanical ventilators.
2. I heard a report of hospital ERs with no antiepileptic drugs like dilantin to stop a seizure.
3. Residents here are on call nightly for 3 nights or more in a row. (and I thought every 4th or 5th night call is bad as a resident)
4. All the hospitals in the northeast region with laboratories that have no ability to perform microbiology labs/cultures.
5. Send out labs that result by mail sometimes taking 4+ weeks to receive the results.
6. In the settings we were exposed to, a seemingly majority of foreign doctors providing care working long hours for comparatively little.
7. No land-line phones in some hospitals so doctors must use their own cell phone credits to call regarding patient care.
8. Often after making a diagnosis that requires a specialist care, if a specialist is available, obtaining transportation is often not feasible.
9. A hospital with a pediatric ward staffed by medical officers doing shift work with little pediatric training.
10. IV amoxicillin

Also at times I felt like I was taking care of the indigent in the inner city back home so similar problems still remain despite more resources or more health care dollars.

On tropical medical mission trips, the use of fans, if available and working, accomplishes at least 3 things:

1. Lessens the distraction to patients caused by sweat dripping from your face.
2. Decreases the diagnosis of asthma because listening for wheezing becomes, well, impossible.
3. Causes the impromptu transformation of nearby objects into paperweights for medical records and other papers blown onto the floor.

So thankful for fans!

I’ll explain the blog title in a moment…

The past two Wednesdays I’ve had the opportunity of rounding with the pediatric attendings and residents on the inpatient ward at the Annotto Bay Hospital. The wards here are separate smaller buildings spread throughout the hospital compound connected by a breezeway. The “Pedi” ward houses both neonates and children in one modest, open room. Lately the census has been about 8, but they can accommodate many more. Although they accept referrals from outlying hospitals, the resources at Annotto Bay are limited as well. For example, they do not have mechanical ventilators. Neonates born in respiratory distress are placed on oxygen by CPAP. One of the residents explained that this is accomplished by placing an endotracheal tube into the nose (but not into the lower airway) and then attaching tubing that on one end is hooked to oxygen and on another end to a plastic bottle of water to humidify the air. I observed a baby on “CPAP” and it seemed to work quite well. If the baby’s respiratory status worsens, then it’s the resident’s job to call around to other “higher level” facilities to see if any ventilators are available. Most of the time, unfortunately, there are none or the other hospitals can’t accept the transfer. “So we hope for the best here,” the resident said. Occasionally, critically ill patients are airlifted to the children’s hospital in Kingston if arrangements can be made. I can only imagine being the resident on a 50 minute helicopter flight hoping that the aminophylline you’ve given is stimulating the baby’s respiratory drive enough to keep him alive until you get there.

Rounding with the team was helpful in gaining insight to how they manage care in the face of limited resources. Another example: microbiology labs are not available at any of the 3 hospitals that we visit. Cultures are sent out to other remote labs but only on limited, certain days…if transit is available. The process, however, is very unreliable and often the specimen is rejected when, or rather, if it reaches the lab due to it being “out-dated.” Urine cultures seem rarely possible unless the family can afford to pay for the test at a local private lab. Neonates admitted for concerns of sepsis receive empiric IV amoxicillin (this is not a typo) and gentamicin and if the baby does well the antibiotics are stopped after a few days, usually without any culture results.

Rounds were also helpful to observe how doctors are trained here. Doctor Fisher led rounds the first week and Dr. Ramos this past week. The patient presentations and the teaching style were almost identical to rounds back home. If a neonate had poor feeding or jaundice the residents were asked for all of the possible causes or a “differential diagnosis.” The questioning did not end until a list of all possibilities was exhausted. Other topics that required in-depth questioning included the signs and symptoms of congenital hypothyroidism, causes of failure to thrive, causes of newborn hypoglycemia, and all of the possible causes of low APGAR scores, that’s right, all of them. We discussed the expected pathological findings of a cranial ultrasound in different patient circumstances. Then it was on to the next patient (seriously). Another topic discussed at length was neonatal resuscitation drugs. Residents were not only expected to know the drug and when to use it, for example, nalaxone for respiratory depression from opiate intoxication, but also for dosages, route of administration, inappropriate routes of administration, preparations of the medication and even what the vials of the medications looked like. None of what was asked seemed malignant but rather important for the trainees to know because here the doctors and residents are the ones starting all lines, obtaining all lab work, and responsible for these medications in code situations. In our U.S. training, we often rely on others such as pharmacists or nurses to be responsible for some of these things. I was impressed with the fund of knowledge of both the pediatric attendings and residents.

I asked one of the residents if they had a name for when the attending asks questions during rounds to teach and to see what they know. He did not know of a name for this. I also asked Dr. Ramos, who trained outside of Jamaica, if he knew of an expression for this. He also did not know of one.

At U.S. medical schools and residency programs this teaching style is universally known as “pimping.” The attending will ask questions or “pimp” the residents and students to evaluate their fund of knowledge and to teach where deficiencies are exposed. The use of this word in this context is usually limited to the verb tenses (i.e. the attending is not a “pimp” during rounds). I asked both of them if they had heard of this term before. They had not. Well, I must say that here in Jamaica that I participated in one of the most intense pimping sessions that I’ve ever witnessed. Who knows, maybe in Jamaica the term will catch on.

I better do some more reading before next Wednesday.