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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.

I’m a 3rd year pediatric resident from The University of Tennessee in Memphis. A couple of my colleagues have already done this rotation and have really enjoyed the experience and I’m glad to have been given this opportunity as well.

Arriving before the start of the work week, I had a couple of days to relax and enjoy Jamaica… 48 hours of rest here felt like a week off. I don’t think I’ve ever felt so rested in all of residency. I was able to SCUBA dive to a coral reef and I saw a variety of aquatic creatures such as a sting ray, sea turtle and lion fish.

The food is delicious and I’ve eaten several things I’ve never heard of before such as naseberry and star apple. The temptation to try all the different types of fresh seafood, fruits and other delicacies offered here resulted in several return trips to the buffet line. Fortunately there is a gym here.

Monday I worked at Port Maria Hospital A&E (accident and emergency) dept. Away from the main patient area inside, a small exam room was prepared for me outside with a door that opened to a walkway. In front of this door, families lined up on a bench partially shaded by a breezeway, awaiting their turn. Without a formal orientation, I was escorted to the room by a nurse and kinda winged it. This week has required some acclimation to their healthcare system, learning what resources & medications are available, as well as how to access those resources.

In just 2 days at A&E, I treated a wide variety of classic pediatric cases such as herpetic gingivostomatitis, radial head subluxation, vitiligo, bacterial cervical neck lymphadenitis, hand, foot & mouth disease, etc.

One young child returned to A&E with a plain film x-ray of his hand. Four days earlier he smashed his finger at school and when he was seen that day at A&E his finger was wrapped up and he was referred for x-rays. His finger looked horrible from the crush injury. The lacerated, necrotic distal end of the finger could be easily separated from the underlying bone. This time he was referred to an orthopedic specialist which will require a trip to another hospital. I’m afraid he may have complications. I wonder if in the sea of patients to be seen, some things don’t get the necessary attention that they really need.

The patient flow was interrupted momentarily when a nurse asked if I would give my “expert opinion” for the staff medical officer on a child admitted in the hospital. Knowing the bench of families was ever-growing, I quickly saw the patient, reviewed the case and wrote a pediatric consult note for the doctor in the chart. The reason for the consult? The doctor was concerned about dextrocardia in a toddler who was admitted for pneumonia and otitis media. But the chest x-ray was shot at a slightly rotated angle giving the illusion of possible dextrocardia. A quick listen to the chest and heart sounds were fortunately on the appropriate side.

After this, the patient flow was again interrupted during a period when I was waiting to discuss an x-ray I had ordered with one family, have a nurse help me cleaned and bandage a wound, and get the weight of an infant so I could prescribe the appropriate dose of antibiotics (mom lost the slip of paper she was given at triage with the weight and vitals). My previously seen patients and the nurses seemed to have vanished. The remainder the bench was becoming restless. I couldn’t figure out where everyone had gone until I found a doctor who informed me that a motor vehicle accident had just occurred in front of the hospital and the curious went out front to look at it. Eventually they all came back.

My last patient at Port Maria was a 4 year old boy that was brought in with lab results to rule out rheumatic fever. I don’t believe he has RF but a CBC did show that he had a normocytic anemia with a hemoglobin of 8 (low). He also had a loud heart murmur that I don’t think can be explained by a simple flow murmur from anemia. His older sister has sickle cell disease and polycystic kidney disease. There are no newborn screens here, so it is very likely the boy has sickle cell anemia also given his lab findings. To test for this, a hemoglobin electrophoresis test must be performed at a private lab. This is a relatively simple blood test but mom will have to pay for this test since it isn’t covered under the national health insurance. I also referred him for an echocardiogram but this has to be done at another hospital which is quite a distance away. Transportation will be an issue as gas is expensive here (almost twice as much to fill up a tank than in the U.S.). She also showed me a referral form from last year for a CT scan of her daughter’s abdomen to image the kidneys. This will cost her roughly $475. It is unlikely that she will have any of the money to pay for these studies since the family has relatively little income. Mom has not given up hope, however. “They will get done somehow,” she said. I hope so too.