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You will find that there will be many opportunities for procedures, some as simple as drawing blood and placing IV’s.  The physicians are responsible for collecting all blood specimens for urgent lab testing and for placing IV’s in those patients who are to be admitted.  I found this a bit daunting at first as I do not get much opportunity to perform such procedures at my home institution.    As when performing any procedure, I would recommend familiarizing yourself with the equipment first.  I had to remove a perfectly placed IV simply because I did not know how to secure it once it had been placed.

There is also quite a bit of obstructive uropathy secondary to benign prostatic hypertrophy.  This has given me the opportunity to replace several urinary and suprapubic catheters while I have been here.  While they have all of the supplies you will need, they are not all assembled in an organized kit.  It can be quite difficult to get everything together without the help of a nurse, and on a busy day in the A&E the help of a nurse is not always available.

I have also had the opportunity to do some suturing.  In both cases it was man versus machete, and the machete won.  Most cannot remember the last time they got a tetanus shot, so they all get one for good measure.  Most are not familiar with the term Tetanus but rather know of the disease by “Lock Jaw.”  In both cases the patients were very cooperative and the suturing went quick and easy.  I understand that sutures can be in short supply at times, so I found myself being very conservative with my thread so as not to waste.  In any case I can’t even imagine how difficult it would be to perform any of these procedures on kids, like my wife had to do!

Drew

Over the past month I have had the opportunity to participate in Ward rounds at Annotto Bay Hospital, Port Antonio Hospital and at St. Anne’s Bay Hospital.  Each had their unique challenges.  Port Antonio Hospital is a local hospital in a fairly remote location.  The “house officer” on duty is in charge of both the male and female medical wards.  A lot of the cases are similar to those that I have seen in the states including Hypertensive Emergency, Hyperosmotic Hyperglycemia State, Exacerbation of Congestive Heart Failure, and Stroke.  The resources are limited, and as I have shared in previous blogs many of the diagnostic tests have to be done privately as the hospital does not own a CT scanner, Echo machine, or Ultrasound.  The “house officer” that I worked with was very kind and sought advice on how he could improve in caring for his patients.  Given the tough circumstances I think he is doing an outstanding job.

Annotto Bay hospital is a referral hospital of sorts.  The female medical ward is currently undergoing repairs after it was damaged by Hurricane Sandy.  This has required intermingling of male and female patients on the male medical ward.  There is also overflow of patients onto the male and female surgical wards.  The construction is almost done and they should be moving the patients in the coming month.  Here two “house officers” and two “interns” manage both the male and female medical wards with input from a “consultant” who is board certified in Internal Medicine.  I would equate this to the attending, senior resident, and intern model.  However, the consultant is not their everyday, and may only physically round on patients 2 or 3 times a week.  He is always available by telephone if needed.  When he is there he is quick to teach and share his experience.  Annotto Bay has similar limitations and most of the diagnostic work-up must be done privately.  They do have the ability to perform basic x-ray and laboratory tests.  The morning is filled with pre-rounding and then rounding with the consultant.  The afternoon is consumed with coordination of care and phone conferencing with specialists in Kingston.  Discharges are performed in the afternoon, and their seems to be a disconnect between the hospital and the primary care physicians at the health centers.  There really is not good way to communicate hospital details to the physicians in the community.

I have spent the last week at St. Anne’s Bay Hospital which is the regional referral center.  The hospital is about twice as large as Annotto Bay hospital which is about twice as big as Port Antonio.  The hierarchy is similar with consultants, house officers, and interns.  Annotto Bay hospital is equipped with ultrasound and fluoroscopy, however, I understand that the ultrasound machine has been over heating and they are currently limited on the number of ultrasounds that they can perform each day.  Major testing such as CT scans and echocardiograms still have to be performed privately.  They do have two beds in a “High Dependency Unit,” which would be equivalent to our ICU without ventilators.  They have telemetry, continuous pulse oximetry, and they have one nurse that cares for the two patients.  I find that the cases are a little more severe at St. Anne’s Bay.  For example, a young many with Ackee poisoning, known to cause hypoglycemia and anion gap metabolic acidosis, had to be transferred from one of the smaller local hospitals to St. Anne’s as they lacked the resources to complete his work-up and give him adequate treatment.  Even with his transfer the patient did not do well and subsequently expired.  I can’t help but wonder if his outcome would be different if the proper resources were available.  The physicians are well trained and are as efficient as the system allows.

Drew

Our last few days in Jamaica have been spent at St. Ann’s Bay Regional Hospital. It has been wonderful to see the referral hospital. The pediatric unit is large and attached in a small room is the special nursery. The nursery has 2 ventilators and the physicians and nurses are very proud that the ISSA foundation donated the ventilators. While asking about the ventilators and how they monitor the neonates on the ventilators I was shocked to learn that the portable x-ray machine broke down months ago so the neonates never get a CXR. They also have a difficult time obtaining blood gasses. They don’t have CVN and the physician told me that the babies just get D5 0.2NS and starve. It was also interesting to note that they don’t have central line kits and many times use a foley catheter for a UVC. They are very innovative in the nursery and on the wards. They have learned to rely on physical exam findings instead of labs and images.

On the pediatric ward I see lots of asthma, bronchiolitis, and URI’s. The turn around rate is fast. Most of the children stay the night and get to leave the next morning. The beds are very close together and there is only room for a small chair (like a school room chair not a nice recliner.) Many of the parents sleep in the chair overnight so they can be close to their children. The parents that have been there a long time even sleep during the day in the chair because they are so tired. The children usually just sit in there beds and color or read but, I noticed a small playroom attached that has books, a TV and some games for the kids to use. I noticed that no one ever used the playroom. This morning I arrived at the pediatric unit early and asked why none of the kids are ever in the playroom. The nurse said it was because they needed a supervisor and the nurses are usually to busy. I told them that I would supervise the children and they gave me the key to the room. The kids were excited and after breakfast came to play. They loved the room and were sad to leave when rounds started. I was sad I couldn’t play more but was sweating profoundly after pushing children in carts and entertaining them.

The resort is AMAZING. Everyone has been so wonderful to us and they call doc wherever we go. The food is amazing and there is a large variety of food. The activities are wonderful and Drew even got scuba certified so we can go diving together. I couldn’t ask for better service or a nicer place to stay. It truly has been wonderful.

So this is our first blog of the trip and Stephanie and I couldn’t of had a better first few days. I’ll admit the rain hasn’t been our favorite part but the country of Jamaica is so beautiful it makes up for it. I’ll start with our lodging which is too good to be true. Staying at the Couples Tower Isle Resort is amazing. It’s gorgeous, well-kept, and staff treats you like old friends. They all knew our names by the first evening and we were often referred to as “S&S” for Stephanie and Stevie. The food is plentiful and there is so much variety. The entertainment is full of flare and the music has tempted both of us to get up and make fools of ourselves after dinner every night. From crab racing to the steel band you won’t be bored.


Now to the reason were really here. The kiddos. Our first day of work was spent at Port Maria. Stephanie worked in a room off of the A&E (Accident & Emergency) and saw a good number of kids. She saw everything from ear infections, pneumonia, seborrheic dermatitis, and and chest pain. We should of brought an otoscope but they have one there and you can easily walk patients into the A&E to use it. I was in the clinic at Port Maria which was bustling with well child visits and vaccinations. I acted as the referring pediatrician and was sent any child with a medical complaint during their well check. I saw many URIs, pneumonia, eczema, tinea corporis, and even a septic hip which was referred for admission. They have basic lab work and radiology there which is wonderful because you can send a patient over and have them return with the image or results in real time. There are limitations especially with the pharmacy, for example they have no oral third generation cephalosporin but you can give IM Rocephin. Another challenge we faced was a common one in pediatrics, parental desires and concerns. For example, the child with the suspected septic hip had been see just 2 days prior and referred for hospitalization but the mom refused because she wasn’t allowed to stay. We resolved that concern by referring to St. Ann’s Hospital because parents can stay but the mom could not travel there until morning. Luckily we were able to give a dose of Rocephin along with a referral form stating everything we wanted done. The mothers in Jamaica are very attentive and great historians (which helps because you often can’t make out anything from the charts). They can tell you the exact age of their infant down to 8 months, 13 days. They can also list medications and dates of previous appointments with other physicians…all wonderfully helpful.



The second location we’ve visited is Annotto Bay Hospital which is located in a very rural area. We spent our first morning in their pediatric ward and they had 8 patients total, 2 being social cases (you don’t round on those). We saw a patient with epilepsy, one with nephrotic syndrome, and many premature babies. There was a great deal of teaching done on rounds by Dr. Ramos. We then went to their A&E that afternoon which is currently still undergoing revision after damage from Hurricane Sandy but is actively seeing patients. We walked into a physician treating an asthmatic who had already received 3 rescue salbutamol treatments and was still breathless. They were planning for steroids and admission just as we would in America. There were very few children that day so we were able to return to the resort where we participated in the spin class which kicked our butt! We followed the class by relaxing at the poolside grill and having cheeseburgers and delicious onion rings along with some Red Stripes. A little counterintuitive but hey…we’re in Jamaica, no problem man.


Today we returned to Annotto Bay for well child clinic. As we walked in there was a line of mothers and babies as far as we could see and we immediately got to work. We were able to share an exam room and bounce questions off of eachother which was great. As physicians you are constantly learning not only from your patients but your colleagues as well. Our number one goal with each newborn was to ensure adequate weight gain and I don’t think either of us saw any baby that had trouble with this. Jamaican mothers are dedicated to breast feeding and there’s little stigma to openly feeding in public. If the baby was healthy they did not have to follow up but they were reminded to take their infants to the health clinic at 6 weeks of age for their vaccines. We also saw many hospital follow ups and again the mothers were excellent historians in these cases. Our physical exam findings were sharpened today and we saw an infant with an ear tag and pit that we referred to receive an abdominal ultrasound looking for any renal abnormalities. We also saw a baby with ophthalmia neonatorum (aka bacterial conjunctivitis) that we treated with IM Rocephin, PO erythromycin and tetracycline eye ointment. We also saw a lot of umbilical hernias of varying sizes and spent a lot of time counseling moms about when they would resolve and signs of incarcerated bowel. We then finished up the day in the A&E and saw a child with 3 days of cough who one week ago was put under general anesthesia for circumcision. After a detailed history of no fever, URI symptoms, or history of asthma along with a benign physical exam we were left with possible post-extubation irritation of the larynx and treated him with a one time dose of decadron, like we would for croup back at home. We also saw a little boy with new onset enuresis and increased urinary frequency x 1 day who had a UTI. We did the urine dipstick ouselves after having him urinate in an old medicine container and then interpreted the results from colors on the urine dipstick. It was interesting. We also had to convert mmmol/L to mg/dL when interpreting his blood glucose. We left today as a transfer came in from Port Antonio which was a newborn with hypoxia who was grunting and retracting. History included meconium stained fluid, Apgars of 7 and 7, and SpO2 of 87% at 10 minutes. We would have loved to help admit the patient and wrote orders but they were already on their way to the ward. Our differential included TTNB (transient tachypnea of the newborn), meconium aspiration, congenital heart defect, or sepsis.


It’s raining here but were enjoying the inside of our resort and the wonderful food and beverages it provides. It’s been a great first few days and we can’t wait for more.


Tanless but happy 🙂 S&S

Hello from Jamaica!

My name is Drew Behunin and I am an Internal Medicine Resident at the University of Iowa.  It has been my great privilege to be the first Internal Medicine doctor to volunteer with the Issa Trust.  Honestly, I was quite nervous before starting.  The Issa Trust is a well established entity when it comes to the Pediatric world in Jamaica, but up until now has not been involved in promoting care for adults. I have been in country for just over 2 weeks and have to say that my experience has been unforgettable.

In Jamaica, most medical graduates begin practicing right after graduation without formal residency training.  Some pursue advanced training through the university and serve as consultants.  While the physicians I have worked with did not complete residency training, they do a commendable job at taking care of patients despite the limited resources available.  I see a lot of the same diagnoses that I would see in the United States, however their management is at times more difficult.  In the United States, any patient presenting to an Emergency Room is almost guaranteed to get at CT scan of the chest, abdomen, and pelvis followed by an MRI of the brain just for good measure! 🙂  Not so here in Jamaica.  Most advanced diagnostic tests including ultrasound, CT scans, echocardiograms, stress testing, spirometry, and even some basic laboratory studies are only available in the private sector.  While these tests are cheaper than they are in the States, they are often outside of the financial capability of the patients.

Hypertension seems to be running rampant among adults.  While many are getting appropriate treatment, I believe there is a greater population that have yet to be diagnosed.  I have spent the majority of my time working in the Accident and Emergency Department and have seen a lot of patients who present for other reasons and also happen to have blood pressures in the 190/100 range.  In these situations it is a no brainer to treat.  However, there are many who come with a blood pressure in the 140/90 range.  I refer these patients back to their local health center for repeat screening, however, there is no great way to relay this need to the health center nor guarantee the patient will follow through.  I am convinced that uncontrolled hypertension is contributing to the rising mortality from cardiovascular disease.  The majority of my time on the Medicine Wards at Anotto Bay Hospital is spent caring for patients suffering from stroke, heart failure, and the consequences of diabetes.  I was relieved to see that all of the major cardiovascular medications are readily available including ACE inhibitors, statins, and diuretics.  Through all of this I have learned to depend on my physical exam skills and clinical intuition, both of which are invaluable tools in the long run.

Hello from Jamaica~
We are loving our time in Jamaica. Here is a run down of a normal week as a pediatrician.

Monday and Tuesday are at Port Maria Hospital. It is about 30 minutes away and is very rewarding. I have been working in the A&E (Jamaican ER) and have loved it. I have a room in the back and all of the children 12 and under wait on benches to be seen. The pediatricians in Jamaica only see children under 12 years old once they are 12 they have to go to adult medicine. Also, there are not a lot of pediatricians at the hospitals that we visit and it is very rewarding to see the patients and be able to explain the diagnosis. I have seen multiple different illness but URI is the most common diagnosis. Because the patients wait so long to be seen (they can wait a full day to be seen at the A&E) they always want to go home with a script for medication in their hand. I do a lot of counseling on cough physiology and what viruses are. Many patients think they need antibiotics and the cough will get better. Most of the patients understand once I explain why they do not need an antibiotic. If a patient needs an antibiotic they usually don’t get the prescription that day. The pharmacy only takes a certain number of scripts a day and once they have that number they won’t fill any more scripts. The patient can go to a private pharmacy but they will have to pay for the medication and many patients don’t have the money for the prescription. If a child needs antibiotics, steroids, or nebs then it is usually best if they get the first dose in the A&E that way if they don’t get there script right away they have at least one dose.

Wednesday and Thursday are at Anotto Bay which is about 1 hour from the resort. Here there is a pediatrician named Dr. Ramos . The days that I have been at Anotto Bay I have been in clinic or in the A&E. The census has been low so I haven’t done any inpatient medicine. The 1st and 3rd Thursday on the month are well baby checks. They get their weights checked at 4-6 weeks and if they are growing well they are discharged to be follow up with their local health clinic. I love the well baby check days. I find that the majority of the mothers breast feed and the babies gain weight well. For the babies that aren’t growing as well formula is expensive. A drug rep from Enfamil found me and gave me 5 large samples that I have been giving out which always helps. At Anotto Bay there are pediatric residents and medical officers who have worked with children for years and are knowledgeable. I had to ask lots of questions on my first day as the medications they use in Jamaica are different from the ones I am used to. They also have different protocols and I found it helpful to ask about admission criteria, asthma protocol, and dehydration protocol. There was a cricket match that we got to watch one afternoon which was a lot of fun. Our driver had to transport a patient and was 3 hours late to pick us up (patient care always comes first. Thank heavens there was a cricket match to watch.)

Friday is at Port Antonio which is 2 hours away. I started in the wards then went to clinic then the A&E. I enjoyed getting to see some inpatient children. The clinic at Port Antonio is also wonderful. I have seen scabies in a 4 week old with FTT, constipation, viral induced asthma, seizure disorder, sickle cell, G6PD, fracture, ITP ect… The patients are referred to see a pediatrician on Friday (and I am the only pediatrician available.) Thankfully I feel comfortable with the complaints and treatments and the patients are happy to wait if they can be seen by a pediatrician.

Medicine is different in Jamaica than in the United States and one of the medical officers put it best by saying, “just do the best you can for the patient with the resources available.” I have learned that the people will listen to your advise if you take the time to explain the diagnosis and treatment. Next week I will write about the wonderful Couples Tower Isle Resort.

Hello to all from Jamaica!

Katie and I have been in the country for a little over a week and are absolutely loving it.  As you can expect it takes a little time to get acclimated to the way things are done here.  For those coming from a large university with an electronic medical record, all of the paper work comes as a little bit of a shock.  We have found that the handwriting of those that have come before us isn’t always the best.  We try to keep our notes suscinct but legible in order to help those that come after us better treat the patients.  The people are the most appreciative and patient you will ever meet.  They line up early and wait patiently to be seen, although, in those cases where only reassurance is needed, they feel better if they have a script for something in hand.  At Port Maria and Port Antonio most of our work centers in the Accident and Emergency Department.  The days go by quickly and the work is fulfilling.  The great part about the end of the day is the adventurous ride home and the great food that awaits us at the resort!

Drew & Katie

I am writing this a little late..but better late than never 🙂 I wrote about the medical part, now my recommendations about Jamaica and the resort.

Things to do:
#1. The steel drum band on Wednesdays is amazing, I went to see it twice. The second time they had a group of break dancers that were incredible!
#2 The acoustic artist that plays his guitar on the beach on Tuesday night is also amazing. It starts late but worth it
#3 We went biking in the mountains one Saturday using the Chukka tour…it was my favorite activity in Jamaica
#4. Climbing Dunns River is really fun and a short little free trip
#5  If you mix the light beer with Ting (the grapefruit juice) it makes an awesome little drink that tastes a little like Summer Shandy
#6  The Catameran ride is fun and worth the trip to get out into the ocean and swim a bit
#7  The spa treatments are excellent and worth the money
#8  They serve lattes and cappucino in the shop by the beach from 10-6
#9. Love their sorbet and ice cream
#10 Fridays are lobster day..take advantage of that 🙂

Hi everyone! I wish I would have kept up with this as the weeks went by but I was having such a great time it was hard to sit down and write. Like the most recent entry I will try to cover each hospital I went to and the resort.

Annotto Bay:  This hospital is currently under reconstruction due to hurricane Sandy so the pediatric ward was located in the old administration section. I’ve seen pics of the new pediatric ward and it looks amazing! Hopefully by the time the next docs arrive they will have moved into the new section and will be again taking pediatric transfers from other hospitals. We only had about 5-8 inpatients at a time due to the limited space but I felt like the experience in the inpatient setting, directly working with the Jamaican pediatric specialists here was very helpful to me. Wednesdays I would show up around 9 am and pick a few patients to see and then we would round with Dr. Ramos and Dr. Fischer around 11 am. There are other general doctors covering the pediatric section available to answer any questions you have and divide up the patients with you. After rounds on Wednesdays I would often head over to A&E (ED) to see any pediatric patients they had there. By that time, there usually aren’t too many children so I would head out around 2pm Wednesdays when there is a driver available. The administration is really helpful in finding someone to take you back so I would just ask for their help each day when I was ready.

Thursdays are clinic days at Annotto Bay. Sometimes there were 16 patients scheduled and sometimes 65. This is a pretty fast paced clinic and they would call the next patient up to see me as soon as the other patient walked out the door, so I found it helpful to jot down a few notes in the chart and do the rest of my charting at the end. I worked again with a general physician and sometimes Dr. Ramos so there is always someone available to answer questions regarding how to refer someone, how to write a script, what is available, etc.

The inpatient unit had a wide variety of types of patients, for example, I saw children with post strep glomerulonephritis, ill asthmatics, meconium aspiration syndrome infants, and osteomyolitis in a sickle cell kid to mention a few.

In clinic, we mostly saw children for asthma check ups and well baby checks. However every once in a while there would be a weird rash, or something more unusual. I actually saw a first time mother who likely had ectopic breast tissue with a nipple in her armpit that was lactating out of her armpit!!!

Port Maria:

At Port Maria, they would send me patients from A&E that they normally would either see in A&E or send to the clinic. The only physicians I had contact with here were the docs assigned to A&E that day. Make sure you let both the nurses in the back and in the front, AND the doc know you are there. They will clean the room for you and send you patients. You are kind of off in a corner outside of the ED, so if you need to ask questions or need more supplies it is more difficult. Try to anticipate what you will need at the beginning of the day and they will grab it for you. Especially because you can’t leave your things in the room. I would grab my computer and bring it with me when I needed to go into the ED for something, and I never left the patients in the room when I wasn’t there with my things. Mondays are pretty busy, I saw anywhere from 15-20 patients on Monday, Tuesdays were much more low key and I saw about 10. So, bring a good book on Tuesdays especially, because Steve (your driver to Port Maria) can’t always bring you back when you are ready. He is usually there by 4pm, but I finished by 2 or 3 most days.

I saw more ED type patients here and often had to make a splint, read xrays on my own, and even admit people. The A&E physicans are willing to do anything you don’t feel comfortable doing, you just need to tell them you can’t or don’t know how to do something and they will take care of it, but usually the patient has to wait much longer then. I had to refer a few people to orthopedics, which is in St. Anne’s Bay (about 1 hour away), they can be seen the next day.

I also ran into problems with meds being available at this hospital that usually are available, such as prednisone, salambuterol, cephalexin etc. It helps to ask your patients to come back and let you know if something wasn’t available. Some of them are willing to go into town and buy the meds, but those pharmacies close early also so if a child really needs something right away try to write for it in A&E. I would send children in to get neb treatments and prednisone before they could go home. You can usually get xrays within an hour and I would just ask the patients to come back with the film that day. Cultures get lost all the time, so I rarely ordered these…If I thought a kid looked classic strep I just gave them amox. I would never do that in the US but cultures take a month sometimes to get back here.

Port Antonio:

This was my favorite place to be. It is a really long drive, I was there 3 Fridays, but the drive is beautiful and felt I was the most useful at this hospital. I saw pediatric referral cases from the NP clinics so I would see some pretty interesting problems. Most of the time I just had to refer them to the children’s hospital in Kingston but it was nice to know that they were seen quicker because I was there. I also would help out in the morning on the pediatric inpatient ward, discussing complicated cases with the general medicine doc. I could do some teaching and there were often complicated cases, such as an 11 yr old with hyperbilirubinemia and sick asthmatics. So my first 30 min-hour was spent on the inpatient ward, then I went to clinic and saw anywhere from 3-12 patients (mostly referrals or kids needing refills for asthma, seizure meds, etc), then I would go to A&E and help out with acute sick cases. I saw anywhere from 2-10 patients in A&E also. I left at 4pm each day, so it is also helpful to have a book along in case your case load is less for that day. Mr. Campbell, the hosptial administrator drives you there and back. He is really friendly and always on time.

I gave a presentation the last Friday I was there. I did a talk on acute abdominal pain in children and it went awesome because 10 people showed up including the surgeons and ob/gyn physician, Dr. Davis. We had a great discussion. I recommend bringing a powerpoint you have done before or something you have prepared ahead of time to present, as they really appreciate the presentations at this hospital. In the past, people have talked about bronchiolitis, vomiting and diarrhea, etc. Ok I am publishing this a little late, I left 2 weeks ago but hopefully this will still help. I will write about the resort next.