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I thought we should introduce ourselves as the newest, but oldest in age, ISSA volunteers. My name is Richard Pastcan. I am a semi-retired pediatrician, having worked for Kaiser-Permanente in Northern California for 32 years. For the past three years I have been at a community health clinic serving mostly low income and Spanish speakers as a general pediatrician. So unlike the other volunteers who were in their last year of training,  I represent the other end of the career spectrum. I am anxious to experience a different form of health care in a different culture.
I am fortunate to have my wife here with me to share in this experience. Martha is a retired teacher of the deaf, and the ISSA program director Diana Pollard has connected here to a special ed school in Port Maria. Martha has come with a duffle bag full of art supplies and hopefully this will help to engage the students.
We arrive at the Couples Resort two days ago and it is really as nice as all the prior blogs have described. The setting is a tropical paradise, the food is great and the staff is most helpful. It was good to come a few days early to get used to all of this, and get to know the surroundings a little. Yesterday we went to Dunn’s River Falls which was a really memorable experience walking up a picturesque waterfall. I got to take a tennis lesson in the afternoon and this also made me very happy.
We’ll let you know how are first days work .

Richard and Martha

Last week at Port Antonio Peds clinic we were referred a patient from the health center. He was a 6 month old male who was referred to us for concerns of hypotonia. Upon further history, we learned he was a term baby, growing and thriving, and mom had been concerned about his tone for quite some time. The nurse at the health center also noted some nystagmus at rest. On our exam, he was not dysmorphic, HEENT, CV, Lungs, Abd were normal, though neuro was not. He was hypotonic diffusely, though normal muscle bulk. He was also hyporeflexic in all major muscle groups. His Fontanelles were still open, and maybe a bit on the wide side. His eye exam was significant for horizontal nystagmus at rest, and exagerated with eye movement. His pupils responded to light and he blinked to light, though did not focus or react to any visual stimuli.
We had many concerns about this baby, specifically his tone and whether or not he could see, and he obviously needed some further testing, thought where to start? Of course the cell phone server was being worked on that day, so we were limited with our contacts, though I (Chris) did manage to get in touch with Dr. Judy Tapper in Kingston. She agreed that the baby needed to be seen, and didn’t want to suggest any tests until she saw the patient. Mom was very concerned about cost and had very limited resources. Dr. Tapper was very friendly and helpful, though explained that she was the only pediatric neurologist in the country of Jamaica, and therefore was very busy. If the patient wanted to go to the free clinic at Bustamante Children’s Hospital, there was a 6-9 month waiting list. She could go to Dr. Tapper’s private office, though would have to pay out of pocket for the visit (About $9500 Jamaican Dollars – roughly about $120 US) I explained all this to mom, and she understood, I told her to make the appointment at the free clinic, though stressed that if she could go to the private clinic, this would be preferred. As this was not an emergency and I had no true reason to admit the patient, these were the options. Mom understood and said she would try to figure out a way to find the money, and would make the appointment at BCH in the meantime, and would follow monthly at Peds clinic until further testing was done.
This case was interesting, though made us a bit sad, as if this boy and mom had more resources, she may get some answers a bit sooner. Hopefully it all works out and mom gets the answers and help that she needs, though at this point I’m not sure I’ll ever know how it turns out….

4 month old male who was discharged from the ward 2 weeks prior for resolved bronchiolitis. On the day prior to discharge, he developed a rash on his left leg. They were told it was probably a reaction to one of the medications (he was on Azithro and Augmentin) and gave him some diphenhydramine which did not change. The rash then spread to other parts of his body like his other leg (and soles of feet), both arms, left shoulder, and abdomen. The rash was obviously pruritic, though he was otherwise comfortable and non-toxic. The rash appeared to be in clusters, though didn’t seem to follow a dermatome or other pattern that we could identify. The lesions were mixes of papules and vesicles vs pustules? Hard to really say what it was. Mom said it seemed to be spreading slowly over the past two weeks. Any thoughts???? We were between scabies and varicella, though we’re sold on either. Our plan was to treat for scabies and have her follow in a week, or sooner if it got worse.

Well, hard to believe we’ve already been here two weeks and our trip is half way over. The sites are becoming more familiar, the accents are becoming clearer, and we are starting to feel the exhaustion. Though,having said that, we are learning so much about the people, the healthcare system, and the island it is just great! We wanted to hi-light a few of the cases that we thought were interesting over the past week.

“The opportunity of to volunteer with the Issa Trust Foundation in Jamaica was invaluable.
As a physician working in an environment with limited resources, I learned to become more reliant and confident in my clinical skills, and really challenged to order laboratory or r imaging studies which are only absolutely necessary. I developed the utmost respect for the physicians who work in Jamaica, who every day work so hard to treat children without medical equipment we take for granted, such as CT scans, blood tests, blood gasses, cultures, and simple things like growth charts, which now seem like luxuries. Working in a country side by side with natives of
the country is an amazing to learn about a culture and a people. It is fascinating to learn about the healthcare system and the medical training system in another country. This organization is unique in that volunteers are provided with 5-star accommodations at an all inclusive resort, and volunteers have full access to all of the activities at the resort, including scuba diving, horseback riding, water skiing, amazing meals. It is an amazing opportunity from which all pediatricians would benefit.”

In follow up per Dr. Stephanie’s blog, Dr. Ramos in Jamaica shares the following information:

Our recommend treatment for Ophthalmia Neonatorum or Neonatal Conjuctivitis does not differ from what is recommended and practiced elsewhere including many Pediatric hospitals
in North America.

Providing that the suspected etiology is infectious, then “triple antibiotic therapy” is
recommended. This consists of:

Topical: Tetracycline
Eye Ointment 1% for 7 days
Oral: Erythromycin,
50mg/kg/day (divided q 6-8 h) for 2-3 weeks.
Paraenteral: Ceftriaxone
50m/kg/ single dose (maximum dose 125mg).

Neonates treated as outpatients should be reviewed within 2 weeks.

Based on my experience (over 10 years) using this “triple antibiotic therapy”, the vast majority of cases (>95%) will resolve.

We do not routinely recommend admission, unless there is an indication for it,
example:

– Signs of systemic involvement (hyper, hypo or unstable body temperature, vomiting, coughing, sick looking baby, etc)
– Severe ocular signs (risk for intraocular complications)
– Concerns about treatment compliance or proper follow up.

If the baby is suspected to have a systemic sepsis in addition to the above outlined treatment regimen, we recommend a combination of Penicillin/ Aminoglycoside for at least 7 days or
until cultures reports are available.

It is to be remembered that cohorts differs from country to country, even from state to
state; therefore we must be aware of this when we approach a population of a different background than the one we are used to attend. Causative agents prevalences, popular practices, and socio-economic status all might also influence the way we approach these conditions.

Yesterday we went to Port Antonio Hospital. This hospital was in Portland Parish, about a 2 hour drive through winding, hilly, jungle roads from our hotel. When we arrived (thanks to our very polite ride and hospital administrator, Mr. Campbell), we were warmly welcomed and put to work. We tried to start in the Peds ward, though the docs had already rounded for the day, so we went to the outpatient clinic.

Yesterday we went to the Annotto Bay Health Center, an outpatient clinic in St. Mary’s Parish that is peacefully located on the water. Although the staff did not know we were coming, they were very welcoming and we knew we would be of use as there were rows of Moms and Children already lined up. Again, we saw a mix of URIs, rashes, Tinea, and constipation, but there was one patient that made us both skip a heartbeat, if only for a minute.

A mom was sent over to us with her 3 month baby from the nurse. She was quiet, though polite. She said that after her baby was born, he had to be admitted for a few days because he was breathing fast. The breathing was improved, though mom reports that he had a chest x-ray and EKG that per mom “showed that one side of his heart was bigger than the other” – cue Oh Crap! She was referred for an echocardiogram, though she could not afford it, and was subsequently referred to a cardiologist in Kingston that had an available appointment in September (7 months from now!). Upon further history, the baby was doing well, feeding and thriving (with occasional sweats), no pallor or cyanosis, and developmentally appropriate. His exam did reveal a very soft mid-systolic murmur at the apex and LLSB, though no signs of heart failure. Our portable pulse ox (Thank God and Dr. Gunkleman from Akron) showed sats of 96%. We were reassured by our findings and planned to look up the Xray and EKG tomorrow when we go to the hospital that the tests were performed. Our thoughts were that this baby was probably fine and maybe had a small VSD, and his EKG probably was just RVH (cue Dr. Bockoven, “RVH in a newborn is normal!” mantra). We told mom that we would check on all this and for her to follow up with us in 1-2 weeks, and to keep her appointment with cardiology in September. In the end we were much more comfortable, but what a scary chief complaint!!

Greetings from Jamaica! Let’s start with introducing ourselves. We are Chris and Stephanie, 3rd
year pediatric residents from Akron Children’s Hospital in Akron, OH. We are so excited to be starting our time
with Issa Trust Foundation, and sharing our experiences with the readers of
this blog. Before we get into the clinical
aspects of our trip, let’s first touch on the AMAZING accommodations at Couples
Tower Isle. The staff here, along with
Diane Pollard, have truly made us feel welcome and have made this a relatively
seamless start to our month.
Today
was our first day at Porto Maria Medical Center. The center is very busy, having inpatient
wards (adult, maternity, and pediatrics), a busy A&E (Accident and
Emergency Room), a busy walk-in health clinic, and a pharmacy. We were warmly greeted by the staff, nurses,
and other physicians there and quickly got to work. We split up right away, with Chris working in
the Outpatient Clinic and Stephanie in the A&E.
At the outpatient clinic, I (Chris)
saw a lot of general pediatrics issues. Main problems I encountered were Tinea
Capitis, other various rashes, URI’s, and GI worms. After only a few patients, my training kicked in and I started to feel more comfortable with the system. Right now my biggest obstacle is learning
what resources are and are not available.
It’s all well and good that I know what the problem is and how to treat
it, though if the pharmacy doesn’t have the treatment I order , then what good
am I doing. As I get more familiar with
our resources, I feel that my nerves will be more settled. Thankfully the staff is very welcoming and
patient, and is very open to questions.
(Thanks to Dr. Hines for the dose of Albendazole – Stephanie had the
formulary in A&E!)
In the A&E, I (Stephanie) was
sent the less acute patients, the ones who did not require nebulized treatments
or IV fluids. As I sat there waiting for
the first patient to arrive, I felt the nerves building up. The first patient had complaints of a
possible seizure, which I am normally comfortable with, but found myself having
a difficult time since I did not what resources were available for testing or
work up. After I had a few patients come in with URI
and asthma complaints I started to get the hang of things and felt more
comfortable. Dr. Facey in the A&E was a great resource
to me, especially when I wasn’t sure what to do with Ventolin Elixir or xray
turn around time. Deworming was a big
complaint which I fully embraced and prescribed mebendazole. The parents seem open to education,
especially on asthma. I even filled out
an asthma action plan (which would make Chris, our future pulmonologist,
proud).
Our first day is over, we are
feeling less nervous, but still getting comfortable with the resources. We can’t wait to see what the rest of the
week brings. We will be blogging again
soon! Ya mon!