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Today was another clinic day in Port Maria (roughly 30 minute drive). It seemed slower but that was because there was a heart screening going on at the same time. This made the patients flow more steady instead of a huge rush.
I saw 19 patients today.
Found out that they don’t carry Claritin/Loratadine in the pharmacy (I’ve probably written 10 scripts for it and today was the first time someone came back in to tell me the pharmacy didn’t carry it).
The very last patient I saw was a bit frustrating. She had viral pharyngitis. I spent awhile explaining the difference between a virus and bacteria and how we do not treat viruses with antibiotics. Mom and 12 year old seemed ok with this but then they came out and told the lady that had asked me to see them about my diagnosis/treatment plan. I had to leave my room to walk to the pharmacy. When I came back they had taken the chart (which they call a docket) and put her in line to see the nurse practitioner!
This is a common battle we fight in the US as well. Viruses are not treated with antibiotics but families sometimes get upset when you explain this. Studies have supposedly shown that if the doctor explains the nature of the illness that they family is ok with not getting a prescription. I have not found this to be very true (here or at home). Also, we are not supposed to give cough and cold medicine to anyone under the age of 6 years. I had a mother last week tell me that she wanted a prescription for their local cold medicine for her 9 month old baby. I explained why we don’t give the medicine (risk is greater than benefit). She demanded 2 more times for me to write it and I finally had to say “you can leave now because I will not write you a prescription.”
Please don’t get me wrong. The vast majority of my patient encounters are pleasant and the families accept what I tell them. I just needed to vent about those.
Today I admitted a child to the Annotto Bay hospital. I hope he is still there on Wednesday when I do hospital rounds there. He is not growing and developing and has frequent infections (this is not a good combination).
Tip of the day: Don’t travel with black luggage.
Time for Jamaican fun:
They report time like this: 1 day= 1/7, 1 week = 1/52, 1 month = 1/12
$1 US = $84 Jamaican
Their version of Sprite is called Ting
Kids here do not think of Santa Claus like we do. He is a figure at Christmas but he doesn’t come down the chimney (they don’t have them) and bring all of the presents. He rides on a donkey that pulls a cart with some toys in it. On Christmas Eve kids dress up in their finest clothing and walk around the town with their parents. They buy toys and candy that night as their gifts.

Friday was my first trip to Port Antonio. As with any first day it started a bit rocky. I called the day before and confirmed a driver, apparently the staff knew I was coming but nobody told the driver 🙁 I finally made it to the clinic around 1:30 and there was a whole waiting room of babies. There were 5 scheduled but word spread and a few extras showed up (I think there were only about 10 total but the waiting area seemed packed). After I saw clinic patients they took me to the inpatient area where I saw the 3 admitted babies, all 3 wks or younger. I actually had a wonderful day it just started late. My driver was really nice and he navigated the windy, pothole stricken road with grace. The nurse that helped during the clinic was fantastic. She actually stayed in the room with me to learn and to help with any language issues (we didn’t have any).
Packing tip: Harriet Lane!!! I am using it frequently (for those that don’t know it is just a reference text that fits in your pocket, well your very large pocket).
I had been told that flexibility is needed to do well at mission work. I understand what they mean now. We frequently stop at the gas station. We make stops at hospitals along the way to trade supplies. I have traveled with patients that are being transported to other hospitals (when you transfer to a higher level of care they do not go by ambulance but they just sit in the back of the car with a nurse). I don’t mind any of it because this stuff has to happen anyway so conserve in your trips from here to there.
Fun Jamaican stuff: Almost half the cars here are Toyota. Originally I thought they must be the best then but I learned that the parts are the cheapest and easiest to get. By the way if you own a Toyota I can tell you that one of the first things to go out is the speedometer followed by the passenger windshield wiper. The horn though seems everlasting.
Many Jamaicans opt not to get officially married and just do the common law thing. Even if they do get married rings are not always involved.
You will commonly see an infant with a red hair tie on their wrist. Apparently they are supposed to have something red on so that they are watched over.
They dislike the cable companies as much as we do!
I mentioned before most of the buildings are concrete. They have metal roofs. Mostly concrete flooring. No air conditioning (mainly only for businesses) and of course no heater (no need). Instead of billboards and free standing signs they mostly paint on the concrete wall to advertise.
People do with what they have. Unlike Americans if a sister passes down a pink backpack or a purple bike the Jamaican boys will use it. Keep this in mind when examining babies because sometimes boys will have on pink and purple striped socks.
You can’t get a license until you’re 18. You can also drink at 18.

Ok so the title of the post was time for fun. It is Saturday so I didn’t work today. I went to Dunn’s River falls, which was fun. Played 3 games of beach volleyball. Read a book by the pool and now its dinner time! Sorry I can’t post pictures but I forgot the adapter for my camera to load images onto the computer. I am taking plenty though so when I get it I will add them.

I’ve been slacking on my posts!
So I worked Monday and Tuesday in the clinic in Port Maria. Monday 15 patients. Tuesday 22 patients. Most common diagnoses: fungal infections and colds. I did send someone for labs and asked them to come back next week so we will see how this process goes (will the results make it into the chart? will the mom come back?). She was about 18 months old and had fallen pretty drastically off of the growth chart.
Wednesday I went to Annotto Bay and rounded on the inpatients. Attended another Csection delivery. This one was only 32 weeks gestation so I was nervous but he did great. Oh I needed to give Thao an update- I saw one of the triplets, baby #3. He was admitted but for just a bad cold. He is doing good! Today I went back to Annotto and worked in an outpatient clinic. Mostly hospital follow ups. I had a long conversation with one of the other Peds doctors. He takes call overnight at the hospital 3-4 nights a week. It is just him and another doctor to split up the days. This is because of the shortage of doctors (one took a few months maternity leave and I forget why another had to take some time off).
Fun Jamaican stuff- they use a lot of concrete when they build here (houses, fences, etc).
The vast majority of women breastfeed here, which is wonderful. It is normal to breastfeed in public and for children to still be breastfeeding at older ages than in the US.
There is a college in Kingston which services a large area. You go there for almost any degree you want but they will charge you differently based on your intended degree.
Animals I see daily- lots of stray dogs, goats, and chickens.
Kids don’t have to be in carseats but you will get a ticket if someone under 12 years old is in the front seat.
They do not observe daylight savings time so I was on Central time when I first got here and now I’m on Eastern time.

Ok so tomorrow I head to Port Antonio. It is in a different parish (like a state here) so a new driver will pick me up. Called today to confirm this so tomorrow should be smooth (fingers crossed). I didn’t go last week because of the storm and it is pretty far away.

So work was cut short last week due to tropical storm Tomas. Roads flood easily here and with the heavy rains I was stuck at the resort (sounds awful doesn’t it).
I had a wonderful weekend: played pool volleyball, cricket, almost finished my book.
Today my day started out wonderfully because I learned they have peanut butter here!! I made a peanut butter and jelly sandwich to pack for lunch.
Arrived at the clinic, which was packed with kids waiting to be seen. I saw 15 kids again today. Diagnoses included: scabies, tinea, tinea, tinea, scabies, strep, virus, virus, virus.
I asked the ladies in the clinic what they needed and their response: a scale for infants and a bassinet to put infants in if the mom has to leave the room (I think they are called Moses baskets at Babies R Us).
Interesting Jamaica facts: all kids start school at the age of 3yrs.
They write the date starting with the day then month then year. This messed up all of my medical records the first day because I couldn’t get the birthdates right.
Packing tips: you may be here by yourself so spray on sunscreen is a must and check your clothes before you leave- no sense in a dress that you can’t button up by yourself.

Today I went to the hospital in Annotto Bay. When I arrived I was greeted very kindly and escorted to the Pediatric Ward of the hospital. The 3 residents were there working. They seem particular about about which year they are (first year=intern, second year=resident, third year=house officer). As an intern I used to get mad when people made the distinction between me and a resident. Residents are residents but that has no point here.
Due to the impending storm (aka Tomas) most patients had been discharged. There were only 6 there today. 3 of them were Once rounds started Dr. Ramos did some teaching and we quickly noted some major differences in our practices. In the US we test every baby’s bilirubin before discharge. We also have a device that will test it without drawing blood (transcutaneous bilimeter). Here they have to stick an artery for blood! This may not sound like a big deal but when we draw blood at home we do what is called a heel stick. Basically we prick the heel and milk out blood. They don’t have equipment to measure capillary blood sample (which is what the heel stick is). They draw all their own blood samples and walk them to the lab!
During rounds we were called to the operating room (which they call the OT or operating theater) for a Csection delivery. I invited myself along. WOW this was different. In the US when a pediatric resident goes to a delivery they are accompanied by a respiratory therapist and a nurse (if it is an intern an upper level resident also goes). Just the intern went (and me)! She had to test all the equipment herself and actually wait at the foot of the bed to take the baby (they bring the baby to us). In the US we are obsessed with keeping the baby warm (put on the hat, use about 5 blankets because as soon as one is wet you throw it off the table, and the baby is not allowed off the warmer for more than a few seconds to get weighed). Now this being said we are in an air conditioned delivery room where there are people who like to turn the temp way down. Here we had 2 blankets and no hat. The first was used the entire time we resuscitated the baby and the second only when we took the baby out of the room (by the way no triple checking identification bracelets and getting footprints- we just took the baby out the door after saying loudly to the room- Baby girl X delivered at 11:48 am). We took the baby to the maternity ward where we took all of the measurements, wrote a note and left the baby with the nurse.
When we got back to the Pediatric ward rounds were over so we headed back to the maternity ward to discharge babies. Here they give the BCG shot (for tuberculosis) which we do not give in the US. They do not however give the hepatitis B vaccine that we give before discharge. Baby boys are not circumcised before leaving the hospital either (most are never done).
This was a long blog today so I am just going to stop babbling.
Take home point: a transcutaneous bilimeter would be awesome here!
Fun Jamaican fact of the day: if you were a car horn you would be very busy
One last random thing I have to tell you about because it blows my mind. They do not have school buses here. When school lets out the kids walk down the side of the road and random people pick them up and drive them down the street! This happens with everyone, not just school kids. People just pull over and pick you up if you are walking. People are just nice to each other. Nobody worries about kidnapping, rape, and all that. Crazy- but in an awesome way.

After a small delay I was off and running this am at the clinic in Port Maria. My exam room was small but sufficient.
Equipment I used today: stethoscope, otoscope and tips, ear curettes, measuring tape, and a pen light. I also used hand sanitizer and sanitizing wipes (out of my awesome fanny pack).
Diagnoses made: well child, fungal infections, seasonal allergies, headache due to poor vision (refer for glasses), tonsillitis (recurrent- refer to ENT), strep, viral gastroenteritis, and foreign body in the eye (sand).
Survival tip: take food. I took a plantain and apple from the breakfast buffet.
Interesting point of the day: my father in law has a saying “drive fast and take chances.” I think the drivers in Jamaica live by that phrase as well.

My trip went smoothly. I checked bags for the first time ever and they made it without any problems. One bag did get searched and I don’t know how the lady got it all back in without sitting on it but she did. My flight went from Memphis to Miami then to Montego Bay. I had a 3 hour layover, which was extended a bit. Luckily I was not one of the unhappy travelers whose flight had been cancelled earlier in the day (hence my short delay because they had to find us a bigger plane to put all of the morning people on too).
When we touched down in Jamaica everyone had to go through customs. This process went smoothly as well. After claiming your luggage you head to the resort’s lounge. It is decorated in bright colors. They offer water or Red Stripe while you wait for the rest of the guests. Then you all board a bus and head to the resort. It was about an hour and a half ride. The driver made it fun though by telling us all about Jamaican foods, words, customs, etc.
I arrived at my room around midnight. It has a courtyard in the front with lounge chairs and a table. You walk in to a large living room. There is also a kitchen area, dining area, and office space. As well as 2 bedrooms each with their own bath. One bedroom door was open but the other had a Do Not Disturb sign on it so I didn’t go in there until this am. I bet the sign was there so the cleaning ladies didn’t bother with that room if only one person was here last month too.
I got up today, had breakfast (the french toast is awesome) and then did the resort orientation with Brenton. He is one of the Entertainment Specialists. This was a helpful 30-45 minutes that I recommend. I rented a book from the library (Wicked) and did some sun bathing. I wish I could bottle up the ocean breeze! Rafael led an awesome aerobics class and then I somehow got sucked into the spinning class that followed. Paula led that. She was fun and helped all of us first timers.
Tonight there is a meet the managers beach party and then a steel drum band playing. I might take my laptop and Skype Doug (my husband) into that! He loves that type of music.
Tomorrow is my first day of work. I have my fanny pack all packed and ready (yes I really do and yes I know I’m a dork). I’ll have breakfast at 7:30 and then get picked up at 8am to start my adventure.

It’s Friday and I confess I am looking forward to the weekend. Today Jamaica celebrates Independence Day, 48 years of Independence from Britain. The pedestrian and vehicular traffic was very light and many people were dressed in the Jamaican colors of green, black and gold; I did the best I could, since I packed light. Er…, well….. light by female standards.

The photos are of Tower Isle Beach, taken from the dining room of The Couples Resort.

On the drive into Annatto Bay, The Jamaica Constabulary Force (that’s the police) were parading in ceremonial uniform near the Annatto Bay town center. The road was closed for the ceremony; Steve the driver seemed to know this and made a detour before I knew what was happenning. I asked about the detour and he pointed out the parade ceremony. Steve is a good person to ask about local information and customs. He has lived all his life in this part of Jamaica.

On the issue of transportation, unlike in the USA , the average person does not own a car. This is also a rural community. Many people use minibuses and taxis to get around; transportation costs are high for the average person. Licensed taxis are cars with red license plates and take multiple passengers. A relatively short trip may cost J$ 80 to J$ 250 (the currency exchange rate is about J$ 85 to US$ 1). Be aware of this as you see patients and make requests that involve travelling for tests, follow up etc. Some patients may not return for follow up if they have don’t the money for the trip and no one to bring them. If they have to buy medications that also adds to the cost of getting care.

The morning was spent at the pediatric ward with Dr Ramos and staff. The sick preterm triplet who was critically ill, was transported by air ( military helicopter)to the Bustamante Hospital for Children in Kingston the previous evening. I thought it was pretty cool that a military helicopter would come for a 1500 gm premie! Made me (neonatologist) feel good. Anyway, the region needs at least 2 transport isolettes with ventilators and monitor, so babies who are critically in need respiratory support can be transported by ground. The cost of the equipment is much less that the resources used for use of a military helicopter and would be a good investment financially and in reducing morbidity and mortality.

On rounds, there were several cases of gastroenteritis and Dr Ramos dicussed the global impact of mortality from gastroenteritis. US pediatric residents need to be aware of the management of gastroenteritis in low resource countries. Dr Ramos gave clear and concise instruction to the mothers on using the oral rehydration salt solution. Other cases on the ward- congenital heart disease with endocarditis, respiratory distress in LGA infant of a diabetic, term baby with neonatl seizures, and a few growing premies. There is a need for isolettes to prevent the environmental temp swings with the babies. It makes for multiple evaluation and treatment for sepsis.

I went to do rounds on the maternity floor to see the normal term newborns. The mothers co-bed with their babies in a shared open ward. No individual private rooms, or even double rooms, no nursery to send the baby for bath, vitals and blood tests, or for mother get some sleep. Mothers provide ALL the the care for the baby, the nurse is there to monitor for any problems. I was only able to see 1 mother and the baby was around 29 hrs old and was for discharge. The mother and baby chart were in the same file. That was soo…… convenient! No searching for maternal records and labs!

This lady had 3 previous children, last delivery 7 yrs before, had prenatal care- 14 visits and told me this was her last child. She used contraception and spaced her pregnancies. She was breastfeeding but said the baby was sleepy. I asked her how she handled this and her response…..”Ah wake her up and force the tittie in her mouth”. Just exactly what a lactation consultant would have advised!

Annatto Bay Hospital’s breastfeeding rate is 100% and they have been designated a Baby Friendly Hospital. They achieive this without lactation consultants, breastfeeding classes, breastpumps and all the other resources of wealthy US hospitals. The co-bedding made it convenient for breastfeeding. The communal atmosphere provides support to the mothers for breastfeeding and I’m sure the experienced mothers give advice to the less experienced. I wonder what would happen to the woman who showed up with formula and a bottle? Probably she would have no friendly looks from the other moms! Formula is very expensive, strongly discouraged and the time and cost to boil water and sterilze bottles is prohibitive

Breastfeeding here is the norm, is natural and women can breasfeed wherever and whenever they need to do so. Fellows, if in the middle of your conversation with a mother, a mammary gland appears, don’t be shocked. Just keep talking, go with the flow. On the maternity ward, there is no detailed scrutiny of urine output or weight loss and there is no multiple lab testing as in the US. Mothers have uninterrupted time to nurse the baby.

I also noticed at all the pediatric wards that I visited, (St Anns Bay,Port Maria, Annatto Bay, Port Antonio) the children who were feeling better were free to roam and play outside ( even if it means rolling around with the IV pole); they were often not in bed- especially the boys! They may be outside somewhere in the vicinity with the mother. The mothers were often there or had recently been there, children wore their own clothes from home, not hospital issued gowns. A nurse may dispense an oral medication and have the mother give it. Mothers are welcomed and feel encourged to stay. I wonder if perhaps all this sense of normalcy contriutes positively to the child’s recovery.

My weekend plans… I’m expecting family to visit and I am looking forward to that cos I’ve been lonely all week!

Port Antonio is one of the most beautiful spots in Jamaica. These photographs were taken from the parking lot of the hospital.

…..Well, today was one of those days, when things just don’t happen as planned. Most of the day was spent on the road driving between Ocho Rios and Port Antonio.

This morning, there was an accident on the main road near Port Maria, so the driver, Steve, was delayed in picking me up. It’s a long drive to Port Antonio, so Steve planned to wait until rounds and clinic were complete, then we would return to Ocho Rios. We expected to be done by 1 or 2 pm.

We were just about approaching the Port Antonio Hospital when he received an urgent call that he was needed at Annatto Bay Hospital. The urgency was related to the need to transport a sick preemie to St Anns Bay Hospital. When I arrived on the pediatric ward, the nurse informed me that rounds were already done and that the registrar ,(Dr Fazul) was in Accident and Emergency Room.

The nurse was very good and she quickly walked me around to every one of the nine patients. Her oral delivery of the history, lab results and management plan- all from memory, was quite impressive. I contacted with the Port Antonio Hosp SMO about the situation (ie the driver needs to leave,)- they had one peds patient scheduled for me, but the patient was a no-show and could not be reached, so I explained I would to leave and return next week. I thought it best to head back to Annatto Bay Hospital; may be I could assist with the preemie.

On the way back, I was on the phone with the Administrator at Annatto Bay Hospital; seems the plans for the baby’s transfer had changed. There was no plan to transfer, since the baby was unstable; they were unable to give any details about the baby.
I later found out the unstable baby was one of the triplets. Drs Fisher and staff were working to stabilize the patient, Dr Ramos, also came to assist. We discussed the problems of prematurity. Sometimes even with the best efforts, some babies do not do well. We are hoping that this little one will respond to treatment and fully recover.


There is a need for compatible BP cuffs to check blood pressure. Neither the Welch-Allyn cuffs and the disposable Critikon cuffs fit the BP machine at Annatto Bay.
Maybe a Dynamap machine would be good, or find a fitting that would adapt the machine for use with current BP cuffs.

Also needed, skin probes for the leads- the kind with the metal snap that are used on many ECG machines. These probes are too large for the preemies- but they work with the machine they have at present.
Also much needed- blood transfusion kits with filter and IV infusion pumps with compatible tubing.