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I’ll explain the blog title in a moment…

The past two Wednesdays I’ve had the opportunity of rounding with the pediatric attendings and residents on the inpatient ward at the Annotto Bay Hospital. The wards here are separate smaller buildings spread throughout the hospital compound connected by a breezeway. The “Pedi” ward houses both neonates and children in one modest, open room. Lately the census has been about 8, but they can accommodate many more. Although they accept referrals from outlying hospitals, the resources at Annotto Bay are limited as well. For example, they do not have mechanical ventilators. Neonates born in respiratory distress are placed on oxygen by CPAP. One of the residents explained that this is accomplished by placing an endotracheal tube into the nose (but not into the lower airway) and then attaching tubing that on one end is hooked to oxygen and on another end to a plastic bottle of water to humidify the air. I observed a baby on “CPAP” and it seemed to work quite well. If the baby’s respiratory status worsens, then it’s the resident’s job to call around to other “higher level” facilities to see if any ventilators are available. Most of the time, unfortunately, there are none or the other hospitals can’t accept the transfer. “So we hope for the best here,” the resident said. Occasionally, critically ill patients are airlifted to the children’s hospital in Kingston if arrangements can be made. I can only imagine being the resident on a 50 minute helicopter flight hoping that the aminophylline you’ve given is stimulating the baby’s respiratory drive enough to keep him alive until you get there.

Rounding with the team was helpful in gaining insight to how they manage care in the face of limited resources. Another example: microbiology labs are not available at any of the 3 hospitals that we visit. Cultures are sent out to other remote labs but only on limited, certain days…if transit is available. The process, however, is very unreliable and often the specimen is rejected when, or rather, if it reaches the lab due to it being “out-dated.” Urine cultures seem rarely possible unless the family can afford to pay for the test at a local private lab. Neonates admitted for concerns of sepsis receive empiric IV amoxicillin (this is not a typo) and gentamicin and if the baby does well the antibiotics are stopped after a few days, usually without any culture results.

Rounds were also helpful to observe how doctors are trained here. Doctor Fisher led rounds the first week and Dr. Ramos this past week. The patient presentations and the teaching style were almost identical to rounds back home. If a neonate had poor feeding or jaundice the residents were asked for all of the possible causes or a “differential diagnosis.” The questioning did not end until a list of all possibilities was exhausted. Other topics that required in-depth questioning included the signs and symptoms of congenital hypothyroidism, causes of failure to thrive, causes of newborn hypoglycemia, and all of the possible causes of low APGAR scores, that’s right, all of them. We discussed the expected pathological findings of a cranial ultrasound in different patient circumstances. Then it was on to the next patient (seriously). Another topic discussed at length was neonatal resuscitation drugs. Residents were not only expected to know the drug and when to use it, for example, nalaxone for respiratory depression from opiate intoxication, but also for dosages, route of administration, inappropriate routes of administration, preparations of the medication and even what the vials of the medications looked like. None of what was asked seemed malignant but rather important for the trainees to know because here the doctors and residents are the ones starting all lines, obtaining all lab work, and responsible for these medications in code situations. In our U.S. training, we often rely on others such as pharmacists or nurses to be responsible for some of these things. I was impressed with the fund of knowledge of both the pediatric attendings and residents.

I asked one of the residents if they had a name for when the attending asks questions during rounds to teach and to see what they know. He did not know of a name for this. I also asked Dr. Ramos, who trained outside of Jamaica, if he knew of an expression for this. He also did not know of one.

At U.S. medical schools and residency programs this teaching style is universally known as “pimping.” The attending will ask questions or “pimp” the residents and students to evaluate their fund of knowledge and to teach where deficiencies are exposed. The use of this word in this context is usually limited to the verb tenses (i.e. the attending is not a “pimp” during rounds). I asked both of them if they had heard of this term before. They had not. Well, I must say that here in Jamaica that I participated in one of the most intense pimping sessions that I’ve ever witnessed. Who knows, maybe in Jamaica the term will catch on.

I better do some more reading before next Wednesday.

I’m a 3rd year pediatric resident from The University of Tennessee in Memphis. A couple of my colleagues have already done this rotation and have really enjoyed the experience and I’m glad to have been given this opportunity as well.

Arriving before the start of the work week, I had a couple of days to relax and enjoy Jamaica… 48 hours of rest here felt like a week off. I don’t think I’ve ever felt so rested in all of residency. I was able to SCUBA dive to a coral reef and I saw a variety of aquatic creatures such as a sting ray, sea turtle and lion fish.

The food is delicious and I’ve eaten several things I’ve never heard of before such as naseberry and star apple. The temptation to try all the different types of fresh seafood, fruits and other delicacies offered here resulted in several return trips to the buffet line. Fortunately there is a gym here.

Monday I worked at Port Maria Hospital A&E (accident and emergency) dept. Away from the main patient area inside, a small exam room was prepared for me outside with a door that opened to a walkway. In front of this door, families lined up on a bench partially shaded by a breezeway, awaiting their turn. Without a formal orientation, I was escorted to the room by a nurse and kinda winged it. This week has required some acclimation to their healthcare system, learning what resources & medications are available, as well as how to access those resources.

In just 2 days at A&E, I treated a wide variety of classic pediatric cases such as herpetic gingivostomatitis, radial head subluxation, vitiligo, bacterial cervical neck lymphadenitis, hand, foot & mouth disease, etc.

One young child returned to A&E with a plain film x-ray of his hand. Four days earlier he smashed his finger at school and when he was seen that day at A&E his finger was wrapped up and he was referred for x-rays. His finger looked horrible from the crush injury. The lacerated, necrotic distal end of the finger could be easily separated from the underlying bone. This time he was referred to an orthopedic specialist which will require a trip to another hospital. I’m afraid he may have complications. I wonder if in the sea of patients to be seen, some things don’t get the necessary attention that they really need.

The patient flow was interrupted momentarily when a nurse asked if I would give my “expert opinion” for the staff medical officer on a child admitted in the hospital. Knowing the bench of families was ever-growing, I quickly saw the patient, reviewed the case and wrote a pediatric consult note for the doctor in the chart. The reason for the consult? The doctor was concerned about dextrocardia in a toddler who was admitted for pneumonia and otitis media. But the chest x-ray was shot at a slightly rotated angle giving the illusion of possible dextrocardia. A quick listen to the chest and heart sounds were fortunately on the appropriate side.

After this, the patient flow was again interrupted during a period when I was waiting to discuss an x-ray I had ordered with one family, have a nurse help me cleaned and bandage a wound, and get the weight of an infant so I could prescribe the appropriate dose of antibiotics (mom lost the slip of paper she was given at triage with the weight and vitals). My previously seen patients and the nurses seemed to have vanished. The remainder the bench was becoming restless. I couldn’t figure out where everyone had gone until I found a doctor who informed me that a motor vehicle accident had just occurred in front of the hospital and the curious went out front to look at it. Eventually they all came back.

My last patient at Port Maria was a 4 year old boy that was brought in with lab results to rule out rheumatic fever. I don’t believe he has RF but a CBC did show that he had a normocytic anemia with a hemoglobin of 8 (low). He also had a loud heart murmur that I don’t think can be explained by a simple flow murmur from anemia. His older sister has sickle cell disease and polycystic kidney disease. There are no newborn screens here, so it is very likely the boy has sickle cell anemia also given his lab findings. To test for this, a hemoglobin electrophoresis test must be performed at a private lab. This is a relatively simple blood test but mom will have to pay for this test since it isn’t covered under the national health insurance. I also referred him for an echocardiogram but this has to be done at another hospital which is quite a distance away. Transportation will be an issue as gas is expensive here (almost twice as much to fill up a tank than in the U.S.). She also showed me a referral form from last year for a CT scan of her daughter’s abdomen to image the kidneys. This will cost her roughly $475. It is unlikely that she will have any of the money to pay for these studies since the family has relatively little income. Mom has not given up hope, however. “They will get done somehow,” she said. I hope so too.

Governor General of Jamaica, Sir Patrick Allen, ON, GCMG, CD, Has Been Named Patron of the Issa Trust Foundation – PR.com

So I have been very poor at updating this frequently! My apologies!

I had a very busy week last week. Ended up admitting several children to the hospital, and the parent’s weren’t very happy about it. They tried convincing me that the kids were okay, and I almost relented, but my sixth sense kicked in and I admitted the children.

The first was a 1 week old baby with jaundice who was discharged home with jaundice and was supposed to follow up with me. The baby’s blood type was known, but mother’s blood type and Rh factor (rhesus factor, the + or -) were not known. So the baby was potentially set up for problems with having different blood types than mom. Mom was also breastfeeding, and the baby could have had breast feeding jaundice. The third problem was that mom told me that the baby was only breastfeeding about 4 times a day! When asked, the mom said it was because the baby was sleeping the rest of the time. After I raised a stink, the mom started to change her story saying she was feeding more than that… but I just couldn’t risk it. The child was admitted and had labs drawn… better to be cautious than cavalier about that.

The other was a 12 year old asthmatic with an exacerbation. He had several nebulized treatments in the A+E (accident and emergency, our ER) and said he was finally feeling better. However, his mother was not going to be able to fill his prescriptions until the next day, so he would be going home without any albuterol or his needed steroids. I had to draw the line and say that when mom got his meds filled, he’d be able to go home the next day, just didn’t want him getting home and the exacerbation getting worse.

I’ve seen a large portion of run-of-the-mill respiratory infections. Rotavirus has hit Port Antonio, and it looks like it’s spread to Annoto Bay and Port Maria, as I’ve seen an increasing amount of acute gastroenteritis.

Still occasionally have some problems understanding accents, but I think I am getting better.

on Friday I gave a small “lunch and learn” presentation on asthma exacerbations and management of asthma in the acute and chronic settings at Port Antonio. A lot of the doctors and nurses from the peds ward were there. They asked great questions and seemed to enjoy it. I hope it was useful. They did ask that the next group prepare some topic dealing with nephritis/nephritic/nephrotic syndrome, as they’ve seen an increase in those patient’s recently.

I would definitely recommend to future volunteers to get a presentation done before you come down!

Will try to update later this week.

Hello World! My name is Michael, and I am going to try to take a small foray into the blogging world. I am a third year general pediatrics resident from the University of Tennessee (Memphis) and fellow class mate of Audra from November. I have Joined Tayo down here in Jamaica for the month of February.

I’ve been in Jamaica a week now, and so much to say!

I don’t know what I really expected this month to be like. Discussions with Audra had prepared me for some of the things I would experience, but hearing about it and experiencing it are two different things.

This is my first time to Jamaica and really my first time to travel internationally (alone). I lived in El Paso before and would travel across the border to Ciudad Juarez (back when it was still safe to do so), but leaving the States and entering another country for a few hours is not like leaving for a month.

On Thursday the 3rd I got to get acclimated to the weather (that didn’t take long, let me tell you!) and met Tayo. We went off to Annotto Bay on Friday morning and the drive there is beautiful. Very pretty country side with amazing ocean views. This place truly is paradise.

We made it to the Annotto Bay Hospital (ABH) and found our way back to the peds ward. The hospital there is many buildings connected by covered walkways. Each building houses a different subset of patients (peds ward, Male Med/Surg, Female Med/Surg, OB). Walking into the peds ward, there are a few small rooms to the side (one a kitchen, the other a treament room and a few others) and then the ward opens up to house all the patients in a large room. Walking up to the peds ward there is a very cute little patio where alot of the patients were hanging out in the fantastic weather with their families. Very different from what I was used to, where we expect our patients to be in their room, or sign out when they disappear for a bit.

Rounds were fantastic. The attending, Dr. Ramos, is a very intelligent man and I have had great pleasure getting to partake in rounds. We would open with a patient presentation, and he would start asking questions, reviewing physiology, differential diagnoses, treatment options. It’s very thorough and a fantastic learning session/review. After rounds, Tayo and I went down to A&E (accident and emergency) to help out by seeing the peds patients. One of the patients I saw was a teenage girl (16 years) who passed out (or as we call it in Memphis “Done fell out”) after becoming emotional because she lost her cell phone (life’s tough as a teenage girl). The only problem was that as she was passing out, she hit the back of her head on a desk and lost consciousness for more than 20 minutes. If I were back at home, she would have been run through the CT scan to look for a bleed. That wasn’t an option for me down here. She ended up getting admitted to the wards, which was an ordeal for me. I was in charge of drawing her blood and starting her IV… something I’ve never really been responsible for back home. We have phlebotomists and an “IV team” that will handle all that. After torturing the young lady trying for an IV, one of the other doctors helped her (and me) out by showing me what I was doing wrong.

The weekend was a nice relaxing time and I felt finally rested after a very long month of January. Tayo and I started back up on Monday where we went to Port Maria. She took the clinic and I was in the A&E there. I had a steady stream of patients and saw 19(!) in a 6 hr period, which was alot more than I have been used too. Most of it was run of the mill diagnoses of colds and tinea capitis. Like my patients at home, the families request antibiotics for viral illnesses. I have been standing strong about not writing for antibiotics when they weren’t needed.

Tuesday was back at Port Maria where I was over in the health clinic. More viral illnesses, fungal disease and a couple of complaints about worms. Wednesday we went back to Annotto Bay where I sat in on rounds again. We had a lengthy discussion about hypoxic-ischemic encephalopathy, the possible causes of hypoxia (broken into maternal causes, placental causes and then baby causes, then further divided into pre-natal, peri-natal and post-natal). We then went on to management once the infant was delivered. We talked about some of the differences between the management in Jamaica and the States. I got to describe the technique of head-cooling which I’ve seen a few times in our NICU. I’m really enjoying sitting for these rounds.

Today we ran the follow up peds clinic at Annotto Bay. I got to do several well babies which are probably my favorite visits. You get to play with the cute 2 week old babies and show off to mom all the baby reflexes.

We head off to Port Antonio tomorrow, that will be my first time there. I am currently working on a lunch and learn presentation about Asthma. Sadly, my new laptop doesn’t have powerpoint on it, so I am having to adjust on the fly.

Overall impressions: I love the island. Everyone here is very friendly and the weather is perfect. The children are wonderful (as expected). I am having a hard time understanding the accents, but I’m getting better. And I am learning that I have a heavy reliance on supporting labs to make diagnoses instead of relying on my clinical skills. I am definitely doing lots of learning and reading while down here! I am excited for the potential that the rest of the month holds.

Having reached home (brrrr, it’s cold), I thought I would summarize the last week as well as give a few thoughts about the last month. My last few days flew by — the 25 wk preemie was holding his own on CPAP, I admitted a child with failure to thrive (less than the third percentile for weight/height/head circumference), went to Ocho Rios for coffee (yum, Jamaican coffee…) and a movie, and wrote a few more referrals to Bustamente. Saturday I soaked up as much sunshine as I could while saying ‘good-byes’. Despite my best effort, I am still ‘white with spots’ (freckles) as one of the children at Annotto Bay described me :)! My return flight was smooth including customs, and I discovered that it is indeed 20 degrees in Iowa as well as Jamaica…unfortunately, one is Fahrenheit and one is Celcius.

It is incredibly hard to believe that the month is over. At the beginning, I was slightly skeptical about what this experience would be like. I have no more doubts now! For those looking into trying this rotation, I definitely recommend it. It is a great chance to ‘try your wings’ before entering fellowship or taking a real-world job, since you get to function a lot by yourself. Also, the rotation exposes you to a few things that you don’t see often here (at least I haven’t — such as lots of versions of fungal infections, worms, rheumatic fever).

Helpful hints: Take something to read or study with you every day…you never know when your driver will stop at the airport, another clinic, or any number of places on the way. Not to mention that during the majority of my stay, I rode with other hospital employees rather than the drivers as the hospital vehicles were often in the shop. Therefore, you may be waiting for he/she to finish work. On the bright side, you can obtain many different perspectives of Jamaican healthcare by talking to the numerous people who provide rides — I learned a lot from the hospital administrator, parish manager, parish accountant, health officer, and a taxi driver in addition to the regular drivers.
Along the same lines, always take something to eat / drink.
Play volleyball at the resort — apparently, I am the 3rd of 3 of us to do so…it would be fun to continue this tradition :).

Most helpful items I brought with me daily: Otoscope/opthalmoscope & tips…could have used curettes. Harriet Lane, hand sanitizer, stethoscope, toilet paper. Needs I encountered: Port Maria clinic could use some Pap Smear swabs, Annotto Bay would love a Red Book…and I don’t know for sure about Port Antonio.

Enjoy! Feel free to email regarding any questions you have. Thanks for following my journey!