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I can’t believe these 4 weeks have flown by so fast! Working with wonderful physicians every day, learning how to manage common, and not so common, illnesses with limited resources, and living on this beautiful island has been an experience I will never forget.  During my time in the clinics and ERs at Port Maria, Annotto Bay and Port Antonio hospitals, I have seen much of the same problems as in the US: colds (which can be any number of symptoms), rashes, eczema, asthma, URIs, sickle cell complications, failure to thrive, etc. However, being the only pediatrician at times, I felt I could offer a sometimes more appropriate approach to the children. Yet, at other times, I needed the assistance of my more experience colleagues in improvising and using clinical judgment without the luxury of readily available tests and imaging I have grown accustomed to.  This month also gave me a chance to make independent decisions (with support available) and build up my confidence as I get ready to leave residency and enter the pediatric world on my own. Nearly every day, I had the chance to put in IVs, or suture or splint – all important skills of course.  Parents appreciated the chance to see a pediatrician and get explanations from a doctor. I remember my very first day when I had to admit a little girl with pneumonia and the father thanked me, saying they had been in the ER all night and no one had diagnosed her or explained anything. Though most of the time it was rewarding, there is is one case in particular I would like to highlight as it was extremely humbling and emotional for me and points out some of the challenges of working with fewer resources and without trained pediatricians in all hospitals.  A couple weeks ago, a mother brought in her 8mo infant complaining of continued fever for at least 1 week and parotid swelling. She had brought the child in to the same ER twice in the previous week with the same complaint and though lymphadenitis and different descriptions of the swelling were noted in the chart, she went home each time with antibiotics. This time, however, she was fussier, in and out of sleep in her mother’s arms, and I must admit the parotid swelling was incredibly impressive and unusual for me. She also had very large non-mobile sub-mandibular lymph nodes. Her mom said was continued to take fluids, though appetite poor. My first thought was mumps – which others confirmed has not been seen in Jamaica in many years – or another viral illness. However, her weakness, ongoing fever for more than a week and such large nodes and swelling bothered me. I got an xray to ensure the masses were not compressing her airway , then decided to draw labs and admit on IV antibiotics. Once we starting sticking her for labs, we noticed she was not clotting well. After getting an IV in her foot, we decided to get a culture. Here, cultures are often obtained through the femoral vein. I did feel uncomfortable with it but a colleague insisted. At this point, we noticed the child stopped struggling against our phlebotomy sticks and was more lethargic. WE placed pressure for several minutes and wrapped the leg tightly. However, with ongoing bleeding and hematoma forming, we were sure this child had a coagulopathy and perhaps in DIC. Though she initially denied any bleeding or bruising in the child, she later noted some gum bleeding at home.  Her HR at been 150 with a fever, a NS bolus was started and soon after, we noticed wheezing and on closer examination, hepatosplenomegaly.  Two melena stools were noted while in the ER as well. Malignancy was now at the top of our differential with the possibility of pulmonary hemorrhage vs leukocyte infiltrate. We were preparing FFP when labs returned comfirming our diagnosis of leukemia: WBC 225K, Hb 4.7, Plts 44K. This was an extremely hyper-leukocytosis and likely already meant she was  having tumor lysis.  As we awaited her type and screen, we tried to get O- FFP and pRBCs but this was unavailable. So we had to wait for the appropriate type – FFP was given ASAP though.   After this, her HR plummeted as well as her respiratory effort and her O2 sats. CPR was initiated and continued for 35min before she was pronounced dead. There is much to learn from this case. Though childhood leukemia has incredibly high cure rates in the US, this is not the case in most low and middle income countries largely due to late diagnosis.  This can often be due to lack of knowledge amongst providers on how children present with cancer as it can be different than adults. I don’t blame anyone in particular, but clearly a few things were missed along the way and there was likely a poor prognosis at this point. However, in a setting where blood is not always readily available, I believe we need to be extremely cautious in how we take blood and how much we take from a child. This was something I discussed with my colleagues there in our debriefings after the case.  I know that we may not have had much a chance to save her, but I will never forget her and will undoubtedly take lessons from this case as I move through my career. It was not all work and sad cases of course and truly had a blast in Jamaica! The resort was incredible – food, beach, entertainment and amazing staff. On the weekends, I explored all over the island. I highly recommend spending a weekend near Port Antonio, the most beautiful part of the island and with famous jerk chicken. Thank you ISSA Trust for this opportunity and I’ll definitely be coming back!    

♫ Until the philosophy which hold one race superior and another inferior is finally and permanently discredited and abandoned ..Until there’s no longer first class and second class citizens of any nation.. Until the color of a man’s skin is of no more significance than the color of his.. eyes ..Until the basic human rights are equally guaranteed to all, without regard to race.. ♫        

Another interesting and busy day at Port Antonio Acute Care. Steady patient flow, until closing… Many patients with cold symptoms/ URI.  But one patient had acute onset facial rash and conjunctivitis (pictured below) treated for impetigo and bacterial conjunctivitis. Then I had another patient with presumed viral AGE, mother was giving coconut water and he was now well hydrated and active!!! Tried coconut water at the resort and it is delicious!! The nurses where great! For my first patient the nurse gathered much of the history before bringing the patient to me. Port Antonio had more resources than Annotto Bay.  There was an otoscope and ophthalmoscope in the room, gloves and tongue depressors. Also, I found the vaccination schedule… BCG at birth and a lot less shots than in the US. Great way to end the week.  Monday Port Maria for the first time, so I’m excited to see what’s it like there.                                                                                                                                                                                                                                                                                                                                                             ~      

There is plenty of variety this week-gingivostomatitis, possible appy, scabies, and a nursemaid’s elbow. I was able to call an Orthopedist on his cell for a consult and follow up with a few patients from previous visits. For the possible appy, I made sure I had an updated contact number to follow the patient’s symptoms, arranged follow up, and provided  a surgery consult referral in case her symptoms worsened. There’s a better workflow between the nurses and myself now that we’re familiar with each other’s expectations and I certainly pitch in and vitalize my patients when triage gets backed up. I also feel more at ease with documentation, accessing records, ordering films, and selecting appropriate referral centers.   Unfortunately, this was a short week for me due to a viral illness (flu season), but I’m feeling much better now and ready to get back to work.

My first week went better than expected. The first few days were a bit rough working with little guidance or orientation but I figured things out soon enough. Once you figure out the system at one site, it’s pretty similar to others, so I didn’t need much orienting afterwards. Surprisingly, the resources weren’t as limited as I had been preparing for. I ordered and reviewed chest radiographs within one shift, selected several different antibiotics from the formulary to treat cellulitis, made a timely referral for a urologic emergency, and there was an otoscope at every site. I saw ~50 patients-plenty of asthma, URIs, cellulitis, and fungal infections. The communication between the nurses and myself varied from site to site. Most of the time, I had to request to keep a steady flow of patients and not assume I needed scheduled breaks. Nurses triage adults and children so getting orders filled in a timely manner, urgent or not, varied day to day. I surprised to see how much autonomy the nurses took in caring for the asthmatics, treating them with duonebs and steroids for 1-1.5hrs before I every laid eyes on them. By the time I listened to the patients, their mild exacerbations had been cleared. The patients and their families seemed grateful to be evaluated by a pediatrician. I spent a lot of time educating patients on inhaler+spacer use, controller vs rescue inhalers, monitoring for dehydration signs, and SIDs precautions. We’ll see how next week goes…

4 weeks in Jamaica has flown by!  This rotation has been one of the highlights of the year, and we are a day away from heading back to 5 degree weather and rain.  I will miss the people of Jamaica – their friendly smiles, greetings, and the adorable babies with full heads of hair!  The variety of clinical settings we have worked in has been a great.  We worked in 3 different community sites – Port Maria Hospital on Mondays and Tuesdays, Annotto Bay Hospital on Wednesday and Thursdays, and Port Antonio on Fridays. We worked on the inpatient wards, the A&E (accident and emergency) department, the hospital clinic, and a health clinic. This elective has been a great opportunity to solidify 4 years of pediatric training, and work autonomously within a medical system with limited resources. Though we may have had the most dedicated pediatric training in the A&Es and health clinic, medical knowledge is only one part of patient care, and learning to navigate the medical system, choosing the most appropriate (and available) investigations and treatment, and accessing interdisciplinary resources was a challenge that pushed me to better refine my critical thinking and clinical skills.   The medicine here is great for a general pediatrician. There was some common pathology here that I rarely saw at home (scabies, tinea capitus and kerion, furuncles, tinea corporis, extranumerary digit, large abdominal hernias, infected styes). There was pathology I was very familiar with (asthma, eczema, viral illness, AOM, gastroenteritis, concussion, bronchiolitis, Coxsackie virus, febrile seizures etc), and there were some interesting cases (gasoline burn, vitamin ingestion, motor vehicle accident). Having come during “winter time” in Jamaica, there were many viruses going around. While many patients presented with viral symptoms, some had convincing history and physical exams suggestive of bacterial infections. Choosing the most appropriate antibiotic based on what was available at the pharmacy, or what the parents could afford at the private pharmacy had challenges, and often times, second line or third line antibiotics would be prescribed due to these limitations. Getting cultures done were often futile as samples (if not lost) and results are shipped out to and back from Kingston, and could take weeks. Without an EMR system, bloodwork is labelled by hand, paper blood results are physically transported, X-rays are printed on films, and all patient information is recorded by hand. I learned to actively ask myself why I was ordering specific investigations and how results would change my management, something I will take home with me, especially in my future career as a pediatric emergency physician.   The most enjoyable part of the elective has been interacting with the Jamaican people – they are friendly, kind, and genuine. They appreciate the work that we do, and ask us when we will be back. Parents who came from areas more than an hour away came to clinics before 7am in the morning to register, and waited patiently until physicians were able to see their child. Parents were only grateful and appreciative to have a physician see them, despite sometimes waiting for more than 8 hours. One of the biggest impacts we can have on the patients we see is education – teaching parents about their child’s condition, explaining what we think their child may have, and what the medications we prescribe do and how to take them.   I am also fortunate to have had a colleague and great friend come work beside me over the last 4 weeks. The benefits of having his clinical perspective and expertise in discussing cases where the diagnosis or treatment plan was not straight forward helped me feel more comfortable in my final management.  I am grateful we were able to support each other in learning around our cumulative interesting cases, and navigating an unfamiliar medical system.   Lastly, I would like to acknowledge the great work that the Issa Foundation does to help improve the health and quality of life for young Jamaicans. During my time here, we saw grass roots progress being made: sustainable equipment delivered to hospitals with in-service teaching provided, and vision screening at schools with glasses given out to children who needed them. For me, working within a fantastic organization was important in participating in an elective to ensure that there was continuity with the work we do.

Moms asking me for my number if they liked the care their children got. The minimalist pediatric ward at Port Antonio hospital. The doctors at Annotto Bay keeping a 900 gram 28 weeker alive with CPAP after Bustamante was unable to take him because one of their babies needed the only available ventilator. A road accident outside Port Maria with one of the victims lying in the road. Inep and naceberries. The way the sea turns pink at sunset. Running into the mom of a child I diagnosed with appendicitis in Port Maria, outside the surgical ward in Annotto Bay. Chickens in the courtyard and goats in the parking lot. Too many road accidents — nobody wears seatbelts. Reggae in the morning, reggae in the evening, reggae at nighttime, on Irie radio. A 7 year old yelling “please doctor! I beg of you!” while I was suturing a laceration on her foot, then jumping off the gurney and running screaming through A&E when I was only halfway done. A restaurant in Annotto Bay called “Juss Enuff”. My other favorite Jamaican business — Car Wash and Bar. Dr Ramos’ teaching rounds — What am I thinking of, doctor? Learning to sail the Hobie cat. An 8 year old rasta with his dreads in a tam. Ackee and saltfish. Conversations with the drivers, mostly about food. Seeing things I never see, like hemophilia, and things I always see, like asthma. Who Cook It Betta? Singing along to “Three Little Birds” on the way to Annotto Bay — Cameron, the driver, said we should all listen to it every morning of our lives — I agree. The kids of St Mary’s and Portland parishes. Soon come.

Baby has G6PD deficiency. He’s well, but mom has lots of questions about what medications he should avoid. Can she look on the Internet? (I love being asked whether it’s a good idea to consult the internet, rather than being told what Dr Google has to say). I ask big sister if she knows that girls don’t have G6PD. Mom is fascinated — apparently dad is convinced he’s the one that passed it along to baby. So I launch into a discussion of X linked inheritance, and she asks me to write it out for her to share with dad. OK — mom is a carrier, her sons can have the disease and her daughters can be carriers. If dad has the disease his daughters can be carriers, but he can’t pass it along to his sons. Mom files away this matrix that I’ve written out for her, and she has a new level of understanding of her son’s condition. One more question — should he avoid bush tea? I can’t imagine that anyone has tested the myriad plant alkaloids found in the various bush teas to determine if they induce hemolysis in G6PD… though the natural experiment has probably been done somewhere along the way, given that 10% of the male population of African descent has this condition. So the answer is, no bush tea (I think that’s always the answer no matter what). Do they eat fava beans in Jamaica?

The doctors here know things I don’t know, and vice versa. When was the last time I saw a case of rheumatic fever, or sickle cell, or congenital syphilis? (it’s the joke at Annotto Bay that Dr Ravi is the congenital syphilis expert because he’s had 4 cases this year to date). When did I last do the initial management of a kid with congenital heart disease ? (rural Tennessee, small hospital with level 1 nursery, 1980s). There are lots of things I know, up to date and evidence based. I hope I can offer some of them politely, with appropriate modifications for the local setting. And there are a lot of things they know, practical and hands-on and real-world, that I’m soaking up like a sponge! Dr. Ramos reminded me that just because mom nods her head and says yes when I give her a list of symptoms she should bring the baby back in for doesn’t mean she gets it. “This is a third world country!” he tells me. That doesn’t mean that medical literacy is widely distributed in other parts of the world, though — it behooves us all to make ourselves clear in language our patients understand. For another day, I have a lot to say, not about what’s lacking in low-resource countries, but about American medical bloat. Fortunately I’m between jobs and on sabbatical till September, so I don’t have to experience the reverse medical culture shock of jumping right back in to a US hospital setting. For the moment, I’ll just listen to the tree frogs before falling asleep.