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My first day of work started with an hour long drive up narrow, winding roads pockmarked with deep potholes every hundred meters or so. Thankfully, my driver was very familiar with said potholes and showed no sign of fear or hesitation when rounding tight corners at high speeds while simultaneously passing another car in the one and only lane. The views of the mountainous jungles were beautifully distracting as were the colourful shanty towns that dot the way. Stray dogs, chickens, and humans could often be found wandering dangerously close to our vehicle’s path.

The clinic I was headed for was actually a last minute change as the previously assigned clinic had been shut down because of crumbling infrastructure and “infestation” (I still don’t know what that really means). When we finally arrived at 9am, I was greeted by a group of lovely clinic workers who promptly told me that we couldn’t start seeing patients yet because there was no water. Apparently, there has been a nation-wide drought for months. The government deems it too expensive to pump water into these areas so the people (and the clinic) rely on “water trucks” to sporadically fill their reservoirs. Of course, the Jamaican “soon” turned out to be a four-hour wait. But, eventually, I did start seeing patients by 1:30pm.

Based on my first afternoon of clinic, I can confidently say that there is currently an outbreak of bullous impetigo in the area. Fortunately, the pharmacy’s large selection of exactly three different antibiotics (sarcasm intended) is sufficient to treat this condition. After a packed afternoon of not understanding what my patients were saying (I swear we’re not always speaking the same language) and realizing the only investigations I could reliably perform was basic blood work (50/50 chance for culture results, don’t even think about a chest X-ray), I finally managed to see all of the registered patients by 4pm.

Despite a crazy, sweaty (35 degrees Celsius without air conditioning), and slightly confusing first day, it was blissful to come “home” to an air-conditioned room and a cold shower. I finished my day in true tropical island style: cocktail party with live music, sumptuous dinner on the beach, and a fantastic acrobatic show complete with fire dancers!

Not a bad first day. Now if only I could figure out how to set free the tiny lizard that is trapped in the living room…

Favourite Food of the Day: fried plantain!

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Gleaner From August 13, 2015 Jamaica Gleaner

The United States Agency for International Development (USAID), along with the Government of Jamaica and the Jamaica diaspora, recently hosted a five-week Camp Summer Plus programme in Jamaica. Participants were instructed in reading and mathematics and the arts. Careful thought was given to the medical, dietary, social behavioural and academic fortification of students.

The Issa Trust Foundation, chaired by Paul Issa, who is also the deputy chairman of Couples Resorts, facilitated medical clinics at Sam Sharpe Teachers’ College in Montego Bay, Cedar Grove Academy in St Catherine, and the College of Agriculture, Science and Education in Portland, from July 13-15.

Dr Jeff Segar led the team which gave 362 children a physical examination, basic blood tests, hearing and vision screening, pharmacy medications, when needed, and fluoride treatments. Eyeglasses were provided through a partnership with Michigan Lions Club to one in four of the children seen.

A questionnaire was developed to assist the team to identify risk factors for impaired learning, and also to assist in identifying potential future interventional measures designed to promote learning in this population. If parents had to pay out of their pockets for the medical care, eye examination and glasses, it would cost them approximately $75,000 each.
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The Issa Trust Foundation was formed to make a measurable & sustainable difference for the children in Jamaica. You can help children in school by giving them the tools they need to succeed. Our goal is to raise the funding necessary to purchase 4,000 backpacks and school supplies.

Click here to support this campaign:

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I’m not sure I had truly considered that Jamaica was a mountainous island, and what that meant for the landscape, until the drive to Annotto Bay hospital on my first day at work. To my left was beautiful bright blue sea and to my right, forested hills. Coming from Miami, this view even beat my 15th floor bay/city view balconies. At the hospital, there was more of the new familiar- a modestly equipped open air style British colonial style hospital with friendly nurses and patients. I was greeted with a stream of “good morning”s and “good day”s and the smiles seem to be brighter once I mention that I am with Issa Trust, the Foundation clearly has a solid track record with the hospitals. In terms of work, rounding at Annotto Bay, and even clinic, is very independent. As the Issa trust pediatrician, I pre round on the patient (along with the general practitioner “medical officers” and present to Dr. Ramos, the attending pediatrician. He does fantastic teaching for the residents and  specialist, he usually invites me to chip in to teach. In clinic we function completely independently but can still ask Dr. Ramos or one of the house officers if we have questions on procedure, available medications, referrals etc. While all the charting in clinic is handwritten and often not too legible,most of these visits are well newborn checks and the infants have their health booklets with all pertinent antenatal and peripartum information on the baby. This serves as a very helpful portable medical record for the child and even has growth charts, vaccination records and slots to input information for all of their well child visits through to the school-age years! While the rooms are not as fully stocked as they would be in the states (otoscopes etc), with some effort, it’s possible to maintain the same standard of care/screening as we would have stateside. It’s mostly about remembering your basic history and anticipatory guidance skills and making sure to bring with you what you can (oto/ophthalmoscopes, tiips etc) from the states or from the villa. By nature, and training at Jackson Memorial, I try not to assume anything on behalf of the patients or the follow up system so when I doubt anything at all, I ask one of the other doctors to be sure that what I am doing will actually get them their referral, follow up, medication etc. Overall, it’s relatively easy to settle in and the other doctors and staff are very helpful and welcoming.
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Hello readers, I am a new addition to the Issa Trust this month, your doctor du mois. I am visiting from Boston Children’s Hospital where I am a senior resident in Pediatrics. For supporters and future volunteers, I hope that this glimpse into the journey is enlightening and entertaining.

For the past near decade, I have wanted to get back out into the field. I first wanted to be a physician as a child, but I fell in love with medicine in Sierra Leone. I lived in Freetown and on the border with Liberia for 3 months, working and living in various hospitals as a non-medical professional, before starting medical school. What I saw there propelled me through school, from a nonchalant undergrad to a ravenous medical student. Fast forwarding through the next 7 years of training, the Issa Trust has given me an opportunity to be the person I wanted when I set out on this journey. I am ever grateful for the logistical help, transportation support, and incredible accommodations. It is was you expect–a wonderful place to stay.

Before coming down here, I was the senior on service on a busy ward in Boston’s urban medical center in January. In fact, the weekend before I left, I admitted a child returning from Jamaica (we don’t have a large Jamaican population in Boston) with typhoid fever. I didn’t have much time to plan ahead or go to a travel clinic due to the season and service, and I hadn’t planned to take the typhoid vaccine… needless to say, that changed about 2 days before leaving and I scrambled to find a way to transport a refrigerated vaccine in my luggage. I tell that story to say that, I was very nervous about the tropical medicine component of this month. How was I going to recognize dengue from mono, gastro from typhoid? I started reading the Oxford Handbook for tropical medicine on the way down, and that made me even more anxious! Not only is it recommending management of dehydration that is way different than my training, the meds and abbreviations are different! What’s co-trimoxazole and why are they recommending it for everything I would use bactrim for (which isn’t much, honestly).

Then I started at Annotto Bay. It was newborn day, the day where every baby born there gets to see a pediatrician, and I decide if they need to be seen by Pediatrics (or Paediatrics here) or can by followed by the generalist in the community. This is a relatively new program brought about by Dr. Ramos (the community pediatrician). But, gee, I don’t know. How do I know what they shouldn’t follow when I’ve never met them? Well, my first patient of the month wasn’t any of the things that I feared–he wasn’t a baby with a subtle defect, or a child with a tropical disease that I might miss. He was a child with Trisomy 21, a seizure disorder, FTT, likely autism, developmental delay and a surgically repaired VSD who came for hospital follow up after starting valproic acid for seizures. Now we’re in my wheel-house! As complicated as the patient could have been (and all the rehab services and other medicines I wanted to start for him), it really was quite simple. He was tolerating the valproic acid well, and he should be seen by Pediatrics (Dr. Ramos or YOU future Issa Trust rotators) in 3 months.

What an initiation! But, it was freeing to know that I know things, and that the medicine is the same.

It turns out that the problem is learning how to navigate the system. At Port Maria, I staff the A&E (accidents and emergency), functionally as a pediatrician working in a general ED. I see the all the kids, and I consult to the emergency physicians if there is a toxic child. I have been really impressed by some of the Jamaican physicians at Port Maria. They have been very helpful, and are knowledgeable about pediatrics. Of course, they are also very busy, and there are times where decisions just need to be made. The tricky part to me right now is knowing who needs to be admitted and who can go home. It’s a challenge for any pediatrician, but it seems extra difficult here. Do I admit the asthmatic who I think will space to every 2.5 hours? I would in Boston, but I know that they will probably be fine even if I sent them home. It turns out that the hospital stays for asthmatics are days long (not the 24-48 hour turnout I am used to), and that’s quite a stay to commit a child to just because that’s what I do back home. Plus, the beds on the wards are side by side, exposing this asthmatic to all the gastro and other viruses on the floor, and their parents can only visit during visiting hours (they can’t stay overnight). Do I REALLY need to admit this asthmatic? Also, standard protocol is that all admitted asthmatics need an IV–and docs put in all IVs. Talk about making me appreciate my IV team back home.

Finally, it’s good to know that I am doing more good than bad (I hope). Today, I admitted a child to the wards with the most classic orbital cellulitis I have ever seen. By every guideline I know, she would have had a CT scan, ophtho consult, and admitted on IV antibiotics with possible drainage in the OR. Well, I know what antibiotics I should start, and what labs I should order. CT scan? $150 US dollars out of pocket for the family, which they can’t afford. Ophtho? Four hours away in Kingston at Bastamante Children’s Hospital. How do I know what Ophtho wants to do? Well, after talking the case over with the senior medical officer, Dr. Sloley, I found the phone number for the eye clinic at Bastamante. I even had a cell phone (provided by the Issa Trust), and gave them a call. We talked over the case and came up with a treatment plan and transfer criteria. I obtained labs, placed the IV (I’m getting better! I think) and admitted to the wards with everything laboriously hand written in the paper chart.

It’s a learning curve. But the medicine is good! It’s a great experience. It can be scary in all the ways that it should be functioning with minimal/no oversight. Considering that I will be attending in 5 months, this is extraordinary preparation. So far, I highly recommend this to any senior resident who wants to stretch their clinical boundaries, enjoy the sunshine (I recommend the winter in Jamaica), and make some friends along the way.

Ya mon.    
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LloydOn Wednesday October 1, 2014, My wife Gillian and I had the pleasure to travel to Free Hill Primary School with some other guests and Diane Pollard, CEO of the Issa Trust Foundation. The school is located up in the hills of St. Mary’s Parrish, and is very remote. Upon pulling into the driveway, I wasn’t sure that this was actually a school, as it looked more like a factory, not a place of education as we in Canada and the US are used to. First thing I noticed was there are no windows, only shutters and cinder blocks with decorative holes for ventilation. The principal, Mr. Murphy, greeted us with a warm smile and a handshake, and led us into the center courtyard. The school is basically “U” shaped, with an inner open area where the students play, have recess, snacks, and lunch. We did get to enter a couple of classes to observe, where we were greeted extremely politely by the teachers and students. Some students even sang for us, which was quite a treat. This is a school with very limited resources, but filled with caring teachers and students who are eager to learn. I could probably describe all the things that they do have, but I think describing what they don’t have may give a better sense of the conditions there. Windows.  As I said before, there are no windows, just shutters and cinder blocks with decorative openings on the exterior. There is no air conditioning. There are no walls between some of the classrooms. Only blackboards on stands used to divide the classes. The rooms are small, and not well lit.  There is no playground, just a couple of rusted basketball nets with no webbing and no backboards. There is a swing set without any swings. There is no soccer field, baseball field, monkey bars, or climbing sets. They have nothing of the sort. All things that we take for granted. This school’s students range in age from 4 to 12 years old, and it is certainly not a place that any of us would ever send our own kids to. Alas they do get by, even with the limited supplies and facilities they have.  In compared to what we have though, they have nothing. Thanks to the hard work and dedication of the Issa Trust and it’s staff, the school does have a new classroom, separate from the others for those student who need a more quiet area for learning, without the distraction of having to hear whats being taught in the next classroom. But they do need more. This 2 hour trip was a learning experience for both of us, to actually see how others live in this world. We have been humbled.   I urge all guests to take the trip and see for yourselves,  get an appreciation for what we take for granted. Bring some school supplies of pens and pencils, crayons and paper, books, and craft paper. Donate to the Issa Trust. If we all pitch in, even just a few dollars, we, as a group who travel from far and wide to enjoy our vacations in paradise, who have fallen in love with this little island and the people of Jamaica, will make a difference in a child’s life. We are all of this world, so please, support our world.    
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Jamaica! I can easily say that the Pediatrics rotation here was one of the best months during my residency. Looking back on my short time on the island, the one thing I remember and miss the most is the friendliness of the people. Issa Trust does an incredible job in coordinating and organizing these volunteer opportunities, which is no small feat when we cross country lines. The places we work at appreciate having assistance from the volunteer physicians and also guide us when needed about how to work in a completely different and new environment. When I first started thinking of packing for my Jamaica trip, I was worried about how the rotation will go. I am the first person from my residency program to have opted for this elective, and hence had no peer guidance available. If you find yourself in a similar situation, I would say that the guide that Ms Pollard sends you is pretty accurate about what to expect. Start planning a few months in advance. Go through the guide at one go, make mental or paper notes for yourself. If you are in a time crunch, use a notepad-like app on your smart phone – this keeps a packing and reminder list handy to add on to whenever you are inspired. I found this to be the most convenient way. Make sure you read the PDF again 1-2 weeks prior to departure, to go through the travel tips. The blog also offers a wealth of information. Once I started reading it, I could not stop. I wanted to know more, as most of it is practical and gives a good idea of what to expect in the clinical realm.
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We had the privilege of joining a small Issa Trust Foundation sponsored mission in March, 2014.   This was our 3rd trip to the island.  Our first 2 trips were busy working in the pediatric clinics that the Issa Trust has sponsored for the past 10 years.  This trip was different.  We had an opportunity to see more of the beautiful island, visit multiple hospitals and meet with dignitaries. But most importantly, we gained a new appreciation into the depth and value of the work that has been carried out by the Foundation and Diane Pollard. Picture from top floor of the Port Antonio Hospital Our first day we traveled to St Ann’s Bay and returned to a hospital we had visited last September. We were again escorted through the hospital, weaving through seemingly endless lines of seriously ill people, waiting all too patiently to be seen by a care provider.   The pediatric unit bares no resemblance to the hospitals we’ve worked in, but one is immediately struck by the dedication and caring nature of the staff, working with severely limited resources.   We carried a variety of Welch Allen equipment that was being donated. Thermometers, blood pressure cuffs – tools we take for granted are received with overwhelming gratitude.
Donations By WelchAllyn

Donations By WelchAllyn

Donations by Welch Allyn The units were busy, the nurses and physicians, including trainees utilizing their strong clinical skills to provide the best care possible.  We were warmly welcomed, a result of the relationships established over a number of years.  This scenario was repeated at the other hospitals we visited.   At the hospital in Annotto Bay, we witnessed a delighted physician overwhelmed with the donation of an exam light.   Previously, his only way to illuminate any assessment or procedure he performed was the light on his phone.
Hospitals in Jamaica

Hospitals in Jamaica

Our trip to Kingston included meeting with Lady Allen, the Minister of Health, and visiting Bustamante Children’s Hospital.
Bustamante Children's Hospital

Bustamante Children’s Hospital

Visit to the Kings House, Kingston Jamaica We came away from this and all hospital visits with a new appreciation for the opportunities for making sustainable contributions to pediatric care.  These include not only resources and equipment, which we had the pleasure of donating during this visit, but also education.  The lack of subspecialty care is striking, the need is vast.  The words that Diane repeated to everyone with whom she interacted echo in our ears – “what can we do to help you?”     We are excited about responding to the answer.
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It is so wonderful to be back in Jamaica!!  Diana and I landed in Jamaica on Friday.  Walking back into Couples resort after 11 months honestly felt like coming home.  The staff at the resort are wonderful and it was so nice to be remembered and hugged by so many of them.  It’s great to walk through the halls and hear “hey doc” and see a familiar face!!  Enough cannot be said about the wonderful lodging that Couples provides to all the doctors volunteering with Issa Trust.  From the beautiful and safe facility to the amazing food and drinks to the countless entertainment, this place cannot be beat!  All the staff also asked about Stevie and were sad she wasn’t joining me this year but were excited to hear she is expecting her first little one and also excited to meet Diana!! photo Diana and I were very excited to get to meet Diane Pollard and Pat Brophy, the CEO and chief medical officer of the Issa Trust Foundation.  I have been talking with Diane for over a year now but it was great to finally put a face to the name!! We have had so much fun hanging out with these two and getting to know them better.  I continue to be amazed at what these two have accomplished for advancing pediatric care in Jamaica.  The need is so great in this beautiful country and the Issa Trust Foundation continues to do everything it can to reach out and help.

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Our first weekend in Jamaica was spent relaxing and enjoying this beautiful weather!!  It was snowing in NC when we left so I can’t tell you how grateful I was for 80 degrees and sunshine.  Friday night started with an amazing lobster dinner,  great wine and wonderful conversation about the beginning of Issa Trust!!  Saturday we spent the morning laying out on the beach relaxing.  D and I both just completed very busy months working 80 hours per week so I can’t stress how important having a couple of days to decompress was!!  In the afternoon we took the catamaran cruise.  Anyone who red the blog last time knows how much I love the catamaran cruise!!  Again, it was perfect– tasty drinks, catching up with the friendly staff, swimming in the ocean and completing it all with an awesome dance party with all the others on board!!  Saturday night was the weekly gala.  Although D and I were both tired, the entertainment here cannot be beat and we were on our feet dancing in no time!!  Sunday we spent the day on the beach and I must admit we both got a little too much sun.  However it was Super Bowl Sunday so we spent that night eating tailgate food and watching football on a big screen projector on a rooftop bar in the middle of the Caribbean — that my friends, is a tough night to beat!! photo (2)

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On Monday we got to work which is the real reason we came to Jamaica — to take care of these adorable children!!  Monday and Tuesday were spent at Port Maria Hospital which was one of my favorite hospitals we worked at last year because the need is so great.  D was in the clinic and I was in the A&E.  We saw plenty of cases of rashes, viral gastro, fungal infections and asthma exacerbations.  On Tuesday my morning started by seeing a 7 month old female with an incarcerated inguinal hernia.  Mom stated that she’d noticed the mass protruding and getting hard about 15 hours prior.  When I saw the child the inguinal hernia was hard, painful and not reducible.  The child was also vomiting every time mom tried to feed her.  As this was a surgical emergency and Port Maria has no pediatric surgeons, I worked quickly to try to get the child to Bustamante Children’s Hospital in Kingston– the only children’s hospital for all of the English speaking Caribbean countries.  After several attempts I was able to get in touch with a pediatric surgeon who was wonderful and said to get her there as soon as I could.  I made her NPO and placed her on the ambulance.  I am hoping to speak with the surgeon again to see how she did.  Even in Jamaica continuity is great!!!

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After work, D and I had an interesting conversation about vaccines here in Jamaica.  Here oral polio is still used instead of the IPV vaccine we use at home.  She had a 19 month old who was having diarrhea but was due for oral polio.  This led to an interesting conversation about  possible immunocompromised family members, shedding of a live vaccine, multiple concerns regarding oral polio and whether now was the best time to complete the series.  However, there was also concern on whether the mom would actually bring her back and if this could be the only opportunity to vaccinate her.  Just like at home, we have to weigh risks and benefits with every patient we see.  It’s so nice to sit down and talk about patients and medicine.  We are constantly talking about the patients we saw that day, reviewing their presentations, and running our plans by one another.  Especially after coming off of busy months, it is such a blessing to have time after a long day to really process what you did. The opportunity to process rarely, if ever, comes when working at home. I think most residents would agree that in an age where so much of medicine has switched to shift work, by the time you’re off work you’re often so exhausted that the only thing you can do is eat dinner, shower, and go sleep as you prepare for the next day.  It is wonderful to just sit and talk about medicine.  With all that Couples has to offer I’m sure it may seem like medicine is the last thing that would be on our minds but that’s simply not the case.  I continue to be grateful not only for this amazing opportunity but also for the much needed downtime.  This rotation provides a great opportunity to help people in need, sharpen your physical exam skills, and enjoy the beautiful country of Jamaica.

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We’re driving back from Port Maria now and this view is breathtaking.  It’s a beautiful Caribbean day and we want to soak up every second!! Happy and so grateful, D & S
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It’s been an exciting week here in Jamaica — both in clinics and at the resort. We returned to Annotto Bay Tuesday to round with the residents again which was one of the highlights of the week. I was able to see one of the same patients that I took care of last week which provided for some unexpected but welcome continuity. He is a 5 month old with failure to thrive thought to be secondary to congenital heart disease. The team was able to obtain an echo which was reportedly normal; however, the it lacked several key pieces of information. Cost and the availability of echo techs and cardiologists (much less pediatric echo techs and pediatric cardiologists) eliminate the option to repeat the study.  As is the case with much of the medicine we practice here, decisions must be made based more on clinical outcomes that lab results, imaging and other studies. He has been doing quite well on diuretic therapy and having failed a trial without it, he will continue to be treated as a patient with a cardiac anomaly despite his normal echo report.  Add proper nutrition to the mix and he looks like a new (little) man. Last weekend, the Couples Tower Isle celebrated it’s 36th anniversary. There was a celebration Saturday night which, despite the rain, was fantastic. Many new and old employees and guests were in attendance. Alison and I were able to help with some of the decorations. We were quite impressed with ourselves and our abilities to string lights flowered centerpieces. After admiring some of the other decorations Saturday night, I’m pretty sure they gave us the easy jobs.  And I’m convinced that some of our work was later revised…we’ll keep our day jobs for now.