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So I have somewhat of a potpourri of things to write so I will probably break it down into 2 blogs…one patient related and one not so much.
As I looked back on my month I have been super blessed for this opportunity. I thank Diane and the trust for it.
Things might be helpful for the next group:
1.PLEASE MAKE sure you walk with toilet paper and something to dry your hands. Some of the bathrooms are equipped with toilet paper, most dont have anything to dry your hands.
2. If you are a light sleeper walk with ear plugs….if you are not use to the island sleeping there are crickets and frogs that chirp all night (for most you just drown it out). Also, if you are in the inside room its a little closer to the road so you may hear an 18 wheeler trucking by once in a while (none of these are problems if you arent too light of a sleeper)
3. If you are in the clinic and you want to admit a child you refer them to A&E (ED) department!
4. There are 2 types of referral forms…an interfacility referral white form (form B) and a triplicate copied referral BOOK for outside referrals (i.e all pediatric specialists, most of which will be in Kingston at Bustamante Children’s ; this is referral form A)
5. You can get laundry at the resort done without cost ( I washed many small items in my room
and then big things with the resort)
6. Get familiar with the drugs and their concentrations..Qvar inhaled spray I think is 100mcg, I had never used chloramphenicol eye or ear drops and it was not found in any epocrates so I had no idea the dosage initially. Same goes for their analgesics. DPH cough medicine IS diphenydramine as well as a brand..so plain DPH is benadryl then there is DPH cold that would have an expectorant in addition to benadryl. It is widely used for colds from birth onward.
7. Pediatrics is anything under 13 yrs old. All the children older than that stay on the adult floors/wards.
8. Vitals arent very common at Port Maria. They do a good job at Annotto bay but you only get a weight at Port Maria.
9. If possible do tours outside of the resort. IF you are adventurous the zip line and boblsed ride is fun. There is a blue mountain bicycle tour as well as some rafting tours. I enjoyed Dunn’s River falls.
Hope this is helpful
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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.
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This blog is LONG overdue. As the last week rolls around its only fitting that I write SOMETHING.
For the last 2 weeks I have to say that many of the patients seen have similar ailments as you would see in the US except probably alot more tineas. However, there has been a few cases thrown in that were interesting.
On one of the days we rounded with the pediatric team, we had a 9 year old boy who came in after having his first time seizure the evening before. Per reports the seizure happened during his sleep. Its funny I got a slightly different story from the boy (I’m thinking the way I phrased my questions probably werent the best). Anyway the going diagnosis was possible benign rolandic epilepsy. It’s the right age group and description but of course without the EEG available it is something that will need more occurrences before a firm diagnosis is made.
In the clinic we also saw an infant with diffuse papular lesions on his face and extremities. The infant was very uncomfortable and scratching. Dr Ramos, one of the pediatricians, called us in to see the infant and asked what we thought. It really looked like maybe a scabies type infestation but more papular. He described it as a papular urticaria seen in response to insect bites. It made so much sense as he pointed out that the lesions were only in the areas that were uncovered when the infant slept. I have seen insect bites but never a reaction so widespread before. It was great to have someone show us things that may not be as prevalent at home.
There is one other case, more unfortunate than anything else but may help any one else who encounters a similar case and don’t know how to proceed. I saw a 12 year old girl in the clinic with her mom. Per mom she had been complaining of vaginal itching, foul odor and ‘bumps’ for about 3 days or so. She did tell mom that she had her first sexual encounter with a 16 or 17 year old boy although he didnt ‘go all the way in’. Turns out she had what appeared to be primary herpes outbreak. At home we would call our Child Assessment team and they would get right on it since the girl is a minor (under 16 here). However I was not sure how the system worked or who to inform and it became somewhat frustrating since I did not know the protocol. However, I got in touch with the Child and Mental Health nurse and the matron who assisted me in the protocol—–in essence you refer the child to the A&E department (Emergency room) where the hospital’s social worker and the assault division of the police department can get all the information and deal with the case. Its imperative to get all that information and sometimes even admit the child for observation to obtain these things because most houses dont have addresses like we do in the US and also most families do not have phones. So for fear of the family disappearing (not intentionally) you may have to admit a child just to get all information sorted and proper treatment.
On a lighter note, we were able to have extra time off this week for Easter (both Good Friday and Easter Monday are holidays). I was able to go Mystic Mountain and try the bobsled rides as well as the zip line…it was fun! If anyone comes for Easter, you can show how much you know about Jamaican culture by mentioning ‘bun and cheese’; this is a tradition that involves eating a ‘bun’ (looks like fruit cake) with cheese in the center for Good Friday. The resort had some as desserts so David, my coworker, was able to try it.
I must say that everyone I have encountered have been so warm and welcoming. I feel I have inherited a new family of sorts with the workers here. It saddens me that I soon have to leave.
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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!
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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.


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