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Today was ward rounds at Annotto Bay, which was an excellent learning experience. Typically the morning on the ward is a combination of “ward reviews” which is a brief follow up visit for (mostly) recently discharged patients who need a sooner follow up than the next available clinic date. I was able to see a baby that I had admitted for dehydration and failure to regain birthweight on my very first day of work. He was discharged a few days ago and is doing great now, has surpassed birthweight and is feeding well – I’m so happy about that! The remainder of the morning is spent discussing patients currently admitted to the ward. I never realized how much I enjoyed the whole process of reviewing management and differential diagnoses and now I realize how much more important this process becomes in a setting such as this where management decisions are largely based on your clinical judgment and a limited number of available tests.  There are quite a few patients currently admitted, most of them neonates, and quite a few admitted for jaundice.  The management of neonatal jaundice here is an interesting mix of some quite familiar therapies mixed in with some (such as giving phenobarbital and albumin) that I had never heard of, but when explained, made intuitive sense.  There is no universal bilirubin screening for newborns here and so only babies with clinical concern for jaundice end up getting a level. Even with mild jaundice, mothers are sometimes encouraged to expose the babies to sunlight and advised to return to care if jaundice does not improve. Here in Annotto Bay there is the capability for phototherapy as well as exchange transfusion if the need arises. Overall a great day, and definitely the most “academic” day so far, which is a nice contrast to the constant buzz of the clinic setting. RH
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Today was my first day of work, which was at Annotto Bay Hospital. To say I got thrown right in would be nothing short of a gross understatement, but I somehow managed to get a handle on what I was supposed to be doing by the end of the day. Today was a chronic disease follow up clinic, so I saw a mix of patients with asthma, sickle cell, epilepsy,G6PD deficiency, Trisomy 21 and a few ex-premies  – quite an impressive range, actually. I was pretty excited to see the sickle cell patients, particularly because I plan to pursue subspecialty training in pediatric hematology/oncology.  (Not so) fun fact: there are no pediatric heme/onc physicians in the entire island of Jamaica. As hard as it is to imagine there being zero, it is equally difficult for me to imagine what it would be like to be the only one. Peds heme/onc was certainly not designed to be practiced in isolation, and the extremely cooperative culture is one of the reasons I am drawn to it. So what exactly happens here?  Turns out oncology patients are treated at Bustamante Children’s Hospital in consultation with physicians from St. Jude’s for protocols and such. Hematology wise, there is a Sickle Cell Unit at the University Hospital of the West Indies that will see patients for initial consultations, for vaccines such as Pneumovax, and for management of complicated cases. However both of these institutions are in Kingston, which means often significant transportation costs for patients’ families.  So the majority of heme care takes place in clinics like the one at Annotto Bay. The patients I saw with sickle cell today brought several issues to my mind, the foremost being the lack of universal newborn screening for the disease. Given the prevalence of the sickle trait in Jamaica (1 in 10 persons), about  1 in 150 newborns will have some form of sickle cell disease.* From what I can gather, only babies born at the University Hospital of the West Indies, Victoria Jubilee and Spanish Town Hospitals get their cord blood screened for SCD. All patients that I saw today were diagnosed after some acute illness that unveiled their SCD. The first was an 11 year old boy carrying a presumptive diagnosis of SCD (in addition to his diagnosis of asthma) after CBC on an admission for respiratory distress showed Hb 5.8 and subsequent sickle screen was positive. Another was a 3 year old girl diagnosed after an episode of splenic sequestration and yet another was an 8 year old boy who presented with abdominal pain, and had an appendectomy.  His appendix was not inflamed after removal  and subsequent testing showed HbSS, so it was likely abdominal VOC all along! Overall it was a tough but exhilarating first day.  I think my favorite moment was when the dad of the 3 year old (the only dad I saw in clinic today) showed me how he palpates his daughter’s spleen, and he was spot on!  Yes, yes, yes – for so many reasons! RH *  Info from  http://www.sicklecelltrustjamaica.com/
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It has been just over 24 hours since I arrived in Jamaica. Though it seems so distant, it truly was just yesterday that I was rushing to JFK airport, struggling with my bags (how have I not realized the beauty of curbside check in until now?!).  After that, there was only the unending line to security, 3 gate changes and a 1 hour flight time delay before finally we were off.  It was only once I was suspended above NY on my way to Jamaica that I allowed myself to grasp what was happening.  And what was happening was the opportunity of a lifetime. 10 years after graduating high school and leaving Jamaica for college I was coming back as a doctor to hopefully in some small way be able to give back to the country that had given me so much. I am still in disbelief that an organization like the Issa Trust Foundation even exists and so humbled by the work they have been doing in my home country over the past several years. When I heard of the opportunity I immediately started thinking of ways to make it possible for me to be here.  And now I’m here. This month will be a curious mixture of the foreign and the familiar. The culture, as well as the actual communities I will be working in, are familiar.  In fact one of the hospitals I will work at (Port Antonio) is about a 5 minute walk from the house where I grew up and where my parents still live. So I will literally be in my own backyard.  At the same time I am acutely aware of my lack of involvement with the Jamaican medical system to date. My entire medical training has taken place in New York, and I have no doubt that the differences will be stark, and at times jarring. Despite the challenges that may arise in the work setting, the most important thing is that I am home. It feels like home, looks like home, tastes like home and there’s no place in the world like it. RH
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My name is Kelsey Bayliss. I am a fourth year pharmacy student at the University of Iowa, College of Pharmacy. I am very fortunate for the opportunity to have participated as part of the 2013 medical mission team for the Issa Trust Foundation in Jamaica. I spent close to two weeks in Jamaica as part of my elective pharmacy rotation and it has been the most influential time spent on my journey to become a pharmacist. Not only did it strengthen my love for international healthcare and the pediatric population, but it really introduced me to a love of mission work and helping others that are less fortunate. Truly, it has been a life-changing experience. I was first introduced to the Issa Trust Foundation as a third year pharmacy student. My preceptor, on an experiential pharmacy rotation, was a pharmacist who has been a medical mission trip volunteer in Jamaica for many years. I helped package albendazole tablets for the 2012 mission and after learning about the Issa Trust Foundation and what they do for children in Jamaica, I knew I wanted to become more involved. A year later, I contacted the preceptor asking permission to join her as part of the 2013 medical mission team, and the rest is history. I was so excited to become part of the team and participate in my first mission, and now that it is over, I am even more excited for next year’s mission to be here! The experience I had while on the medical mission is very hard to express in words. I have never felt as empowered and fulfilled as what I did during my time with the children in Jamaica. They do not have the access to proper healthcare and medical resources and it was a very touching experience to be able to help provide that. Being able to counsel a parent on a medication, knowing that you giving them a chance to improve the life of their child is truly life-changing. The patients were always so grateful for our time spent and the resources we gave them. Children were just as grateful when you shared a smile, hug, or gave them a high-five. Just thinking of the time I was able to spend with the children brings a smile to my face. While on the mission, not every moment deserved a smile. Many of the children are in dire need of our help. Many of the children lack a safe and stable home-life and some children were reported to be eating only every other day due to lack of access to food. This is heart-shattering. My husband, Austin, had a little boy ask him if he could go home with us. After Austin sadly told him that he could not, he asked again with a serious, straight-face, “Are you sure I can’t go home with you?”  Hearing this, broke my heart. A request like this, from someone this young, showed us that he was one of those children that lacked a good home-life. Children like this, are the reason my husband and I have a strong desire to continue mission work with the Issa Trust Foundation in Jamaica. I saw examples everyday on how the Issa Trust Foundation has enriched the lives of children in Jamaica. Not only did this mission provide children with medical care that they needed and deserve, but the team was also able to provide eye glasses to those with need as well.  The children were very shy when approached about their new glasses, but after a well-deserved compliment, a heart-warming smile was generally the response the children gave. I will never forget my experience as part of the medical mission trip team in Jamaica. I had the opportunity to help change the lives of close to 900 children in five days on my pharmacy rotation. Keeping everything I have shared in mind, I would highly recommend fellow pharmacy students, health care professionals, or those with a love of children or international healthcare to strongly consider contributing and/or donating their time to the Issa Trust Foundation. I am for certain that I want to continue enriching the lives of children in Jamaica through the Issa Trust Foundation and I cannot wait for next year’s mission to arrive. What an amazing experience!    
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So I have to make a correction/retraction for Dr. Ramos. We had the discussion during ward rounds at Annotto Bay regarding my post about peds patients being transferred to Bustamante being “very sick”. In fact many of the very sick patients stay at Annotto Bay (such as the 30 week premie on CPAP or the new-onset diabetic, among others that are currently there.) Usually the reason for transfer to Bustamante is because the patient requires Pediatric specialty care, such as surgery or oncology. And as I think on it – the care we give back home in our rural non-pediatric hospital is very similar. We are 5 hours away from pediatrics specialists and care for a very similar level of sick patients. I stand corrected! Dr. Jeff
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ventilatorDid you know in Jamaica there is Universal healthcare coverage?
•Hospitals run by government
•Governments spend $125/person vs $5000/person in USA
•Doctors ratio – 8.5:10,000 people
•Dentist 1:17,000 people
•Pediatricians are subspecialists (children < 12 yo)
•Medical transport is limited
•Healthcare centers provide free vaccines
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My first day (8/5) was at Port Maria Hospital. We had a substitute driver named Justin. Steve was not available – never heard why… Justin is actually the X-ray tech at the hospital but became the driver for the morning as the X-ray machine was down for the day. (Didn’t hear if it was fixed) Had a tour of the facility from Dr. Brown, the Parish Manager. (equivalent to a County Health Officer?) Then they put me right to work.I saw Urgent Care type cases – first come, first served. It was right next to the ED – Which they call A&E here (I believe it’s for accidents and emergencies).  Saw a total of 6 patients only – I guess it was a slow day as the A&E was not busy when I arrived and the Peds Ward was rather quiet.Two of the patients were infants w/ constipation but otherwise healthy (they say “Can’t du du” here) and a young man with a cellulitis from nail puncture on his foot. The last patient I saw had a second occurrence of fever w/ bad leg pain – so bad he had trouble walking. Otherwise healthy kid. We got some blood work (one of the Jamaican doctors helped me – I haven’t drawn blood in 15 years!) which should elevated CK. I think it’s a viralmyositis because I had 2 patients in the past with something similar. The rest of the day was very slow – no more patients. On Tuesday (8/6) I am actually sitting here writing this beside the pool. Apparently it’s Jamaican Independence Day and a holiday. We were told not to come in today and wouldn’t have a driver anyways.  Tomorrow I am scheduled to go to Annotto Bay Hospital, a little further to the east from Port Maria.
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I finished my last day of work, and it was bittersweet. According to my patient logs, I have helped many children here in Jamaica (135 to be exact), while enjoying the beauty of lush rainforest and gorgeous beaches.

The view from the bridge of Annotto Bay


On the way between Ochos Rios and Annotto Bay


Typical bar in Jamaica

On my last day, I saw a patient for the second time at Port Antonio Hospital.  She was a 12 year old girl who had come last week  concerned because she was always thirsty, and always urinating, even at night.  In fact, mom was concerned because this wonderful, active 12 year old had never had a dry night in her life.  The mother had brought up this issue in the past with previous doctors, but no one had quite figured it out.  I had them obtain some basic labwork and a urine sample.  She had normal kidney function, her urine was negative for protein or blood or sugar, and she could properly concentrate her urine (ruling out a hormonal problem that could cause this issue).  The last test that we did was to check her hemoglobin A1c, which reflects the amount of sugar in the blood present over the past three months.  Normal is less than 6.3%.  Hers was 8.1%, indicating that she had diabetes (likely type 1).  I explained what happens in diabetes, warning signs to look out for, and referred her to an endocrinology specialist at Bastamante Bay. 

What I will remember most is the gratitude on the mother’s face because she finally knew what was wrong with her daughter.  The relief on my patient’s face was even more gratifying.  When I first saw her last week, she was so embarrassed because she was twelve and was still wetting the bed at night.  She wouldn’t make eye contact, and she barely said a word.  After she knew that it wasn’t her fault, that a disease was why she couldn’t keep dry at night, and that this problem was fixable once her diabetes was under control, she started smiling.

I have learned so much over this past month here in Jamaica, and am so sad that I will be leaving tomorrow. I have learned to be very self reliant, and this experience has shown me that I am ready (even if I didn’t think I was) to take up the mantle of being a full time pediatrician starting in July.  I am comfortable with procedures, and managing sick and not so sick patients at the same time.  I realized how adaptable I can be, and I am able to utilize limited resources to coordinate care of a patient.  I am so much more comfortable now with the idea of striking out on my own. 

Of course, I had wonderful nursing and physician support to help me all along the way.  As I said before, the people here in Jamaica are amazing…especially the parents and patients themselves.  They are so respectful of doctors (everyone takes off heir shoes when laying down on the exam table), and very patient.  They will wait hours to see a doctor in the heat.

Waiting area at PMH in the morning
The waiting area at PMH in the afternoon

Here in Jamaica, they speak both Patois, which is a very lyrical language of shorthand English, slang, and French, and regular English.  During my time here, many parents would speak with thick accents in Patois.  Sometimes I would struggle with understanding them, other times they would struggle with understanding me.  However, they never became frustrated. One of the physicians at PAH (Port Antonio Hospital) even gave me a short half hour lecture on Patois, and some of the rules. Like, never say I, just mi.  Th is pronounced “da”, and er becomes “a” like in “It ova dere”.  Each region of Jamaica has their own dialect of Patois, which makes it even more fun. It was like a puzzle sometimes, as I would do my best to figure out what was said.


So, mi a go home. However, I will always carry this experience with me.   Heading outside to enjoy my last bit of sunshine before I go!

Waving goodbye!



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Yesterday, I worked at Port Maria’s Accident and Emergency Department.  The morning was quiet, the calm before the storm.  I didn’t have a single patient in the morning.  In the course of three hours during the afternoon, I admitted two patients and had to transfer one patient directly to Bastamante Hospital (three hours away) for emergent surgery. 

My first patient to be admitted was a 5 wk old baby boy who came in with fever and cough (likely with a cold).  However, because of his age and his immune system is not strong (and thus he is at risk for a serious bacterial infection), we had to admit him for IV antibiotics and check his blood and urine for infection. I obtained the labwork without problem, but the urine was another story.  In
Jamaica, it is routine to obtain urine specimens from children via suprapubic aspiration as opposed
to catheterization.  While it is the gold standard to obtain urine specimens this way, it is not routinely done in America.  Instead, we do urine catheterizations.  It was fascinating to see how this was done, and it seems surprisingly simple.  All you need is betadine, sterile needle and gloves, and a syringe.  You insert the needle directly into the bladder and draw back on the syringe to get the urine. 



The second patient I admitted was a very active 7 month old boy who had wriggled off his bed while
his mom was trying to change his diaper, and fell three feet onto a hard tiled floor.  He cried immediately, and was otherwise acting normally.  His exam was completely normal for his age except for a large bruise over his left forehead.  I admitted him for observation overnight.

The last patient was a 7 month old girl.  The moment the mom brought her in to the exam room, I knew something was wrong.  She was crying and whining nonstop, and nothing mom was doing was
helping.  Mom told me that she had started throwing up yesterday, and had become increasingly more
fussy overnight.  Yesterday, mom noticed that she had bright red blood in her diaper, and this
morning she noticed scarlet mucousy poop.  Her exam was notable for an increased heart rate, extreme tenderness over her entire belly, and guarding (trying to push my hands away).  Her diaper was filled with poop that looked like currant jelly.  I had never seen that before, but that sign is
pathognomonic for intussussception (the telescoping of one part of your bowel into another that can
cause death of the bowel if not repaired quickly). 





I spoke with the supervising ED doctor, who had never seen intussussception before. One of the
nurses had, and she confirmed that this was consistent with intussussception.  We called over
to Bastamante Bay Hospital, put in an IV and started IV fluids, and transferred her immediately
to the pediatric surgery service there (as there was none available at Port Maria).  Unfortunately,
Bastamante Bay is over 3 hrs from Port Maria Hospital, and is located in Kingston.



My day yesterday was very interesting, if not slightly terrifying.  I am so grateful for the help
that the ED doctor and the nurses here gave me as I was trying to take care of my patients without
knowing the system well or where things were. They patiently helped me out without making me feel
bad for not knowing.  I really appreciated that they did so, but I am not surprised.  Jamaican
people are amazingly warm, welcoming, and hospitable.  

Looking forward to what today will bring. 
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Just kidding!  Currently, I am very sad that Kasey left Jamaica.  I really did enjoy spending time
with her, not only for her winning personality but because the exchange of ideas was excellent.  Since
we were from different parts of the country, we had our own ways of giving anticipatory guidance, or
managing certain illnesses.  We learned as much from each other as we have from the physicians in
Jamaica.  We also had a ton of fun together. 

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Snorkeling with Kasey
 
This past Monday and Tuesday, I was at Port Maria Hospital, and I worked at their pediatric health care clinic.  Monday was a normal sick clinic, while Tuesday was a shot clinic.  Both days I saw 17 patients by 1:30 pm (approximately 4 patients/hr).  So, to recap, it was busy.  Some cases still stand out though. 

One patient, an 11 year old girl in middle school, came in complaining of pain behind her ankles
bilaterally and wrapping around the front lateral aspect of her foot.  She was an active soccer
player, who had been having this pain intermittently for the past two months (especially
when exercising a lot).  She also had some swelling around the lateral sides of her two feet, and
stated that her dad also had “bony bumps” like hers.  She had already had X rays of her feet, and
those were completely negative for any fracture, or tumor.  Her exam showed that she had tenderness
over the achilles tendon bilaterally and also over the point of insertion of the tendon into the bone
(lateral aspect of feet).  I diagnosed her with achilles tendonitis and accessory navicular bones. 
Treatment for this problem would include rest (minimize activity like soccer and walking) and
NSAIDs (ibuprofen).  However, when I told the mom this, she looked at me with dismay.  “She walks 2 miles to and from school everyday.  There’s no way she can do that.”  

I was reminded anew on how different Jamaica is from America.  Here in Jamaica, all children wear
uniforms to school, and those uniforms must be pressed & cleaned daily.  There is no such thing as
a bus system to take children to and from school, and I frequently see children walking on the side
of the road to school.  Some children even take taxis every day so that they can reach school. 
School here, while paid for by the government, is still a privilege. 

The other surprising patient that I had was an 18 mth old girl with chickenpox.  I had never seen
chickenpox before, and this rash was classic “dewdrops on a rose petal”.  In Jamaica, the goverment provides vaccines for free, but not all vaccines are covered.  All vaccines that are available in the U.S. are available in Jamaica, but families must go to private pediatricians to obtain shots that are not covered by the government. The vaccines that are not covered include vaccines against Hepatitis A, Varicella (chickenpox), Meningococcus (can cause pneumonia and meningitis), Pneumococcus (can cause pneumonia and meningitis), and Human papilloma virus (causes genital warts and anal/cervical cancer). 
 
The chickenpox rash

Thursday, I met a wonderful 4 year old girl whose mom was worried because she was making a “chuffing” or throat clearing sound everyday, multiple times a day, for the past several weeks. Upon further history taking, I also found out that sometimes she would wring her mouth, or she would blink a lot. Each of these behaviors would last just a couple of seconds, and she would be completely aware throughout. She had done these behaviors for the past year. The little girl was otherwise completely normal. I diagnosed this girl with a tic disorder (? early Tourettes), and broke the news to mom that this disorder can unfortunately get worse (she can develop new tics), and that this might not be curable and medicine would not help. Mom was happy to have an answer, but unhappy that there wasn’t much more we could do. Frequently, children who suffer from tic disorders can be taught behavioral techniques to help minimize how frequently they have tics. I don’t know those techniques, and those that would (speech therapists) were not available. Here, speech therapists, along with psychiatrists and physical therapists are concentrated in bigger cities (like Kingston), with
a few scattered throughout the countryside. 

The more I learn about the Jamaican healthcare system, the more impressed I am at the doctors
here.  They truly rely on their clinical judgement, and are trained to be general practioners who can
take care of people from birth to death.  Many of them can also do surgeries like c-sections and
tubal ligations.  I like to think that during my time here, I have learned to be more decisive and
trust my clinical judgement from their example.

 
On the hillside of Annotto Bay Hospital
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