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I rode to work in the ambulance today. Cameron arrived bright and early. He said the usual MOH van was out, but the ambulance was free. I asked him, what happens when the ambulance is needed? he said it’s mainly used for transporting patients from one hospital to another, not for emergency response. He then launched into a discussion of the lack of EMT services in Jamaica. When a road accident happens, people just toss the victims into the nearest vehicle and make a run for the hospital — there’s no emergency services, no spine boards, etc. I did point out that he himself was not wearing his seat belt –to which he replied with an anecdote about someone who was severely injured by a seat belt — the proverbial smoker who lives to be 100. I said, pick your risks, I like my brain. When we drove into the gate of the hospital a funeral home van was coming out. Cameron told me someone was shot this morning. Jamaicans accept the risk of no seat belts. Both our countries accept the risk of too many guns. How do we change perceptions of risk? On a cheerier note, it was well babies in the pediatric clinic all morning. What’s more delightful than a nonstop stream of one to two month olds?

As a family physician with mostly outpatient pediatric experience, I found the first patient of the day a little daunting — a 4 year old with congestive heart failure due to rheumatic heart disease, AND sickle cell disease. Where I live this kid would inhabit multiple subspecialty clinics at a university hospital. However, she looked great after her Lasix adjustment and was ready for discharge. A referral from the local health center of a kid with a fever and rash later in the day reminded me that outpatient experience counts for a lot. A sandpapery rash….and a red throat to go with it. I’ve seen enough scarlet fever over the years to recognize it immediately. And I’d had a reminder just this morning of how important it is to treat strep! I’m celebrating my birthday today….let’s see, with a sunset from my balcony, a stroll on the beach, and dinner with an ocean view. Guess I’m celebrating my birthday month! because I get to do that every day in July.    

Almost every child has a “cold.” The symptoms are as follows: swollen eyes, fever, abdominal pain, and joint pain. Then you have to figure out what they have — the kid with pneumonia had the exact same chief complaint as everyone else (the difference being her respiratory rate of 44). The trick, wherever you are, is to figure out what your patient means and how to translate it into what you mean.(It took me the longest time to figure out that when my US patients say they’re “dehydrated,” they mean their mouth feels dry. Not dehydration as I understand it, any more than Jamaican kids have a cold as I understand it.) Moms are really on it. They have got the protocol on using oral rehydration solution when their kids have gastroenteritis. “DPH” seems to be quite a popular remedy for the ubiquitous cold. It took me a bit to figure out that this is diphenhydramine, aka Benadryl. Perhaps moms like it because it puts the kid to sleep while they get over whichever cold they have! On day two, I remembered to ask an important question — has your child had worm medication in the last 6 months?

are the same the world over. They run and tussle push each other and fall and break things. I saw two of them today — a distal humerus fracture and a radius/ulna fracture. Both got placed in posterior splints and send to the ortho clinic at St Ann’s Bay. Week one, day one. Medicine — it’s the same the world over. Nurses are helpful, colleagues answer questions, moms have lots of concerns about their kids. Oh wait…I haven’t had any moms in California ask (about pink eye and allergic rashes) “could it be Zika?”

Friday I returned to Port Antonio. I alternate Friday’s working between the Hospital (top of the hill) and Health Centre (bottom of the hill). Since its a 2 hour drive from my base in Tower Isle, Fridays involve a lot of commuting. It’s a beautiful hilly winding drive, though, especially in eastern Portland Parish where Port Antonio is. “Lush” is the word that comes to mind. The “bush” as it is called here, is filled with palms, orchids, wild bananas, and huge flowering tropical trees. Portland Parish is called “the Garden Parish” and is decidedly less developed than the western end of the north coast. The bush itself is very dense and wild feeling. I’ve read that Port Antonio was THE tourist center in the 1940s and 50s . The actor Errol Flynn ran his yacht ashore off of Port Antonio and liked it so much he ended up staying. His Hollywood friends followed and Port Antonio became THE destination of the rich and famous. Today its pretty quiet though a yacht harbor here bears his name. The town itself has become somewhat of a backwater despite its natural beauty. There are no pediatricians here that I”m aware of. I function as a consultant while here rotating between the local health centre and the hospital/ED. Sicker kids are referred to Annotto Bay or Bustamante Children’s Hospital in Kingston. Finally, I was asked a question this week by a concerned Mom (Mummy) in Jamaica. I had just finished seeing her daughter who had a very obvious case of impetigo on her face and arms. I had completed her prescription and talked about treatment with Mummy. “But wait, doctor, what about her sugar medicine”. Whoa! did I miss something important? She sure didn’t look like a new diabetic, there had been no history of diabetes, she sure wasn’t ketotic….. As I started to ask Mummy about symptoms and diabetes, she replied “no doctor, every time she eats sugar this comes”. Her favorite food? Sweets of course…..problem solved!! No more medicines needed, Mummy, just stop the sweets!! and Mummy smiled

I can’t believe the time here is passing so rapidly!! My second week started with a challenging Monday at Port Maria. On arrival I became immediately involved with an asthmatic boy. He repsonded to treatment but as I was writing up his chart I heard faint labored stridor from the A&ED. Wandering over, I found it was a small 6 month old girl with significant croup…. croup you that may cause airway obstruction. !!!! Again, working with the local A&E doctors, racemic epinephrine eased the symptoms significantly. But with the baby’s age and presentation she was soon on her way to Annotto Bay for admission and more care than could be done at Port Maria. Off to a busy start! Unfortunately the day ended sadly with the stabbing death of a 15 year old boy. He was in an altercation with a classmate at his local high school and arrived dead…..in the back of a pickup truck trying to get him to care in time. He was still in his school uniform….. My experience so far here has been one of warm, caring, friendly people. Not just at the resort that I’m staying at, but with the staff in the A&ED (ER), the parents in my clinics, all the Jamaicans I’ve met. They’re very proud of their country, they’re very concerned about family, and they have gone out of their way to thank me for volunteering. I saw how shaken many were with this boy’s needless death and their concern for their own children. Violence is sadly present in both of our cultures. Perhaps by volunteering we can help, just a little, better lives both in Jamaica and at home.

In general, many of the patients I see in Jamaica have similar issues to my patients in Minnesota. Some things, however, are distinctly different. What did I know about Ackee fruit before coming here…..well, Nothing! Yet I’ve been told that ackee is Jamaica’s national fruit. It’s served with saltfish for breakfast and is probably the most popular dish besides Jerked “fill-in-the-meat”. It’s even frequently on our breakfast buffet here at Couples tower Isle. that’s all well and good until you find out that ackee, if eaten less than fully ripe, causes a rapid and profound hypoglycemic reaction that can be potentially fatal. You sure can’t say that about your morning poached egg or bowl of Wheaties!! As a result Docs here take ackee poisoning very seriously and screen any potential victim very closely. Ackee ingestion is even the leadoff question on the ER’s triage screening form. Hmmmmm, I did have ackee and saltfish this morning………. Another Jamaican custom I’ve been introduced to is Bush Tea. Initially I thought it might be a local brand of tea (why not, they grow great coffee here) or perhaps a type of specialty tea from the more remote inland mountains. Wrong on both counts. Bush tea is a traditional medicinal tea, or I should say teas, made quite literally from a bush. Which bush you may ask? Well from a variety of bushes depending on the illness being treated and the grandmother involved. Some, like peppermint tea, are benign. Others, like “Leaf of Life” buy you a ticket to a Hospital bed. Teas are made from plants like “Dog Blood” (yum) and “Spirit Weed” (you’ll soon be one?). One local doc joked that the stranger the name the more trouble you may be in. It’s a real issue here as bush teas are still commonly given for a wide range of complaints. In kids especially, the “safe” range…if there is one….may be very narrow due to body size. in addition, patients or parents may not know of their bush teas ingredients or may be reluctant to say. That brings up another issue: that of Jamaican culture and traditions……but I’ll save that for another post.

I’ve finished my first week working in Jamaica and all is well. My routine is Monday and Tuesday at Port Maria, Wednesday and Thursday at Port Annotto, and Friday at Port Antonio. The clinics/health services see a range of children from well infants to complicated medical issues for local followup. In addition, I made hospital teaching rounds on Wednesday with Dr Ramos and the junior officers (residents) at Annotto Bay, a real treat. There haven’t been any completely new problems so far, but a real mix of typical and atypical pediatric problems. My most “exotic” patient was a 7 year old otherwise healthy girl who had coughed up an nightcrawler sized (Ascaris lumbricodes) worm. Fortunately, I have seen this before (SE Asia, and Indiana…of all places) and treatment was easy. By the way, Mom said she also had seen these before!! Can you even imagine gagging up something like this????!! The beastie has a very complex life cycle and in this case matures in the lungs to be coughed up and out to start the next generation. Lesson: eat well cooked food and wear sandals!! The resort Issa Trust has put me up at is beautiful with wonderful food and services. Last year at this time I was working with Issa’s US partner (and my co-sponsor) Heart To Heart International on a disaster team in rural Nepal after the Kathmandu earthquake. We were living in tents with limited food and no reliable source of clean water amid ruins. The contrast is stark although when you get down to it, the basic paediatric health needs aren’t that dissimilar. Issa Trust is obviously very well respected among the Jamaicans I’ve worked with and those I’ve seen as patients. I’m very happy to be here and have the chance to work with this exceptional organisation!!

Week in Review

• If you recall the 2 yr old who had a blade of grass stuck I his throat last week, you’ll be surprised to know that he was admitted several days after our meeting for allegedly ingestion Clopidogril ( an anti-platelet medication that can cause bleeding). But you”ll be happy to know that he finally swallowed the grass without needing the ENT referral.
• The x-ray machine was malfunctioning for several days in Annotto Bay, so we really had to put our clinical skills to the test.
• The team at Annotto Bay were able to facilitate a transfer for a newborn term infant to Bustamante Children’s Hospital in Kingston within hours of birth because of impending respiratory failure. The new intern had a look of fear on her face as they left. Our words of advice: you can use bag mask ventilation till the cows come home. Unfortunately the baby passed soon after arrival.
• The interesting cases for the week go to a 7 month of female at Annotto Bay hospital  who was admitted for failure to thrive and dehydration. She has multiple abnormal electrolytes along with pneumonia. At this time the working differentials were Cystic Fibrosis and Bartter’s Syndrome. With hydration she improves clinically but continues have abnormal labs. A nephrologist in Kingston has been consulted to evaluate her. The second case is a 14 yr ol female at Port Maria hospital who had significant right arm pain, limited range of motion at the elbow and severe point tenderness at the joint. Our concern at the time was fracture, septic joint, or osteomyelitis yet there was no history of recent trauma, fever, or joint swelling. An xray of the right elbow had what appears to be an intraossessous bone cyst/abscess. Orthopedics were consulted from the next parish in St. Ann but the patient will have to wait until next week to be seen.
• We have noticed over the course of the month that many newborn infants whether in the A&E or Clinic have a red ribbon or band on their wrist. When asked “what is this for” to the mothers, the common response is “Me nah kno, fi him/her grandmada did put ti pon deh”. After a quick google search we found that this is a Jamaican custom to place the red tie/band on the hand or foot to ward off evil spirits.
• 

  Dr Ravi working on patient transfer to Bustamante Children’s Hospital

  

  Dr. Nicole Davidson taking a brief and much needed break at Port maria A&E

  

  Dr. Roxanne Samuels,
  reviewing arm film of our 14yr old female.

  

  Dr. Hayden-Peart

  
  

  children in infant class at Free Hill Primary school

  

  Mr. Rory Suarez, great driver

  

  Dr. Wilson on our last day at annotto bay

Global Health Rotation in review: Nicole and I are very glad that we decided to do this rotation. We are both of Jamaican heritage , we have a special connection to the island and feed a personal responsibility to keep giving back. We recommend that other residents try to do the rotation in pairs. Working in pairs can be great when trying to manage patient loads and maneuver through the Jamaican health system. We both had the pleasure of meeting with a couple hospital administrator by happenstance but this that these introductions should be standard to provide an introduction to the healthcare system. While to orientation was helpful is seems to be out of date with what labs, ,medications, imaging, and consultations are available at each facility. Having these resources prior to the start would have helped with a smoother start. We recommend that any residents and volunteers visit the Free Hill Primary and Infant School excursion provided by Couples Resort. This gave us the opportunity to see the children you serve in a more natural state, the communities they live and learn about the structure of the education system in Jamaica. Special Thank You to…

• thank you Diane Pollard of the Issa Trust Foundation for assisting use prior to and during our ration. The hotel staff have treated use like family and we truly appreciate all the accommodations made on our behalf.
• Thank you to all the medical and hospital staff at Port Maria Hospital, Annotto Bay Hospital and Port Antonio Hospital.
• Thank you to the hospital administrators, Dr Sloley, Dr. Hayden-Peart and Ms Nunez of Port Maria, Drs. Ramos , Ravi, and Wilson of Annotto Bay, and Mr. Campbell and Dr. Levwok of Port Antonio. All these people have helped us and taught us many lessons for which we are grateful. These service that these people provide to the country of Jamaica s greatly appreciated. Keep trying to change to world.
• Thank you to all our drivers who got us to and from work safely. Special shout out to Mr. Munsie, Mr. Forbes, and Mr Steve.