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Packing List: I traveled in June, which is rainy season and also has humid temperatures. My list is not in any particular order except how I remember it. Umbrella or thin waterproof jacket: This is useful to get around, although you never travel in an open jeep. Get an umbrella that is small sized as your daily bag will otherwise get heavier. Gloves: Get a few boxes. Most places have gloves but may sometimes run out depending on supply. If you have left over, like I did, you can either give to the hospital or leave back in the Villa at Couples for the next volunteers to use. Ophthalmoscope and otoscope: Get small, lightweight portable ones. This is easily a must, if you want to get through clinic more efficiently. I used these nearly every day. There are a lot of versions available online, buy something which gives you a good deal with a sizeable stock of disposable ear nozzles. Most importantly it has to be extremely lightweight. Cross-body small purse: I used this to put my clinical equipment in – the eye and ear scopes, measuring tapes, extra nozzles, antibacterial gel, handkerchief and phone or other personal item. This was useful as one of the blog posts says don’t leave anything in the room as it may disappear. This method kept my hands free and my clinical tools available. Tourniquets: if you are used to them to do lab draws, most places don’t have any. They just tie a glove instead to obtain IV access. Easy tear surgical tape – they are in short supply occasionally. Most places are well stocked. Stethoscope(s), toys to attach to stethoscope or bubbles to pacify children. Laptop bag: I found my own laptop bag more convenient to use as it had more capacity to hold the books, water and lunch. Notebook: It is easier to keep a written running list as you complete charts, to send to Diane about patients seen every day. This does not need identifiers. I did not generally have time to log the patients in the laptop. I would do that after going back to the hotel. CDC and WHO growth charts – take them with you as you may need them Harriet Lane: There is one copy in the Villa. If you have more than one person going that month then better to have your own latest copy to use. I had data roaming on my cell phone but it only gave me 2G coverage, so the book was very important for me. Flu masks: keep a few if you may ever need them. Respiratory illnesses are prevalent. Small flashlight: To walk to and from the Villa after dark.

Today will be one of my less cheerful, slightly frustrated blogs. The reason is that today I felt like a burden. I must preface this with saying that one of the things I am very much looking forward to going back to is the ability to get in my car and go where I want on my own timetable and power. With that background, I felt very strongly like we were a thorn in people’s side today as our driver was late to pick us up, and then there did not seem to be a place for me to work today. I started my day like usual when I work in the A&E, but due to space constraints I was moved to another part of the hospital. Moving around does not bother me in the least as I would work out of a corner if I had to, but I felt like my presence was more of a nuisance than a benefit today. I want my work here to be a positive experience for my patients and for the people I work alongside. I know wishing that was the case every moment sounds very idealistic, but what else am I doing here if not to foster relationships and learn. I do not want to be an annoyance or any kind of bother and feeling even remotely like that has given me a definite case of the Mondays. On a more positive note (because I can never stay gloomy for long), we had a great time at the ISSA/CHUKKA Trust polo match. When Diane told me of the event, I had to chuckle because we started having a similar affair back in St. Louis. Starting last year we have an annual “Glennon Gallop” to benefit our primary care clinic at Cardinal Glennon. The patient population there is mainly Medicaid and reimbursement is not great, so fund-raising can benefit the clinic and patient population a great deal. The overall feel and goals were the same at both events, so experiencing this Jamaican version was a great treat. We also got to spend some time with one of the doctors from Annotto Bay outside of the hospital and that was a delight as well. That leads me to my overwhelming favorite part of this entire experience- the people. I have found Jamaica as a whole to be a friendly and welcoming place that has embraced our visit. We are often asked if this is our first time to Jamaica and then warmly welcomed. This question has come from resort staff, MOH drivers, other health care workers, and even the patients. There is a pride here that permeates much of the culture and it is truly special. We have also met some very interesting travelers along the way from many parts of the states and the world. I hope someday to be able to come back so I am not a neophyte, but a true Jamaica-phile. Please pardon my grumpy mood earlier. As it often is, writing was cathartic.

Hi again- Writing again from the lovely (if not lately rainy in the middle of the night) Jamaica! We have been here for a bit over a week and have now been working for a week. Today was the first day it was not “new”, and there was definitely comfort in that. I have noticed now that we have visited all three hospitals, that each has their own nuance and style that you have to acclimate to. There are two things that specifically prompted this blog tonight. The first was the fun I had working with another physician in the A&E at Port Maria to get creative getting a foreign body out of a nose. As toddler’s do, a little girl had stuck a hair bead in her nose and was too young to understand how to blow it out. Back home we have these nifty tiny catheters that are smaller than spaghetti and we can slide behind objects, then inflate a balloon (like a Foley for a Hamster) and pull the object out. Well the smallest actual Foley was too large, and there were not traditional alligator clamps so the creativity was flowing. First I must say, the other physician did a great job presenting the options to the parents (we try creativity there and either are successful or could push it in further, or we transfer to BCH for possible sedation or possible ENT removal). The family opted for an attempt there so I wrapped the kid in a sheet and we got to work. When the catheter was clearly too large, the other physician fashioned a hook out of a paper-clip and was able to rotate the bead so the hole was visible and get it out. Out came the hair bead and after a few screams and some giant crocodile tears, the child went home with mom and dad. I also enjoy being part of ingenuity, especially when it saves a family a costly trip. The second event that I want to write about is a discussion about allocation of resources we had at Annotto Bay today. There has been discussion that due to budget issues across the board, it has been difficult to transport patients to Kingston for more specialized testing. It was noted that the pediatric patients, especially the babies, seem to get first dibs on transport. There was some talk about why this may be. Is it because everyone has a soft spot for children? Is it because they sometimes seem to have more advocates on their side (vocal care takers both in the medical field and their families)? Or is there another factor we are not evening considering. We see this debate over allocation of public spending dollars on health care at home as well. I do not have an answer, or even a formed opinion, but I was something to think about tonight. The third thing I must say, and I did not include this on the two because it is not medically related, but when I arrived in Jamaica I asked Bob if we could get a goat. He said no (he also vetoed a micro pig earlier this year, apparently three dogs are enough of a menagerie). After the beach party Monday, I now do not want a goat, because if I got attached, how would I later curry it… Having the best time, Becca

There were vary different experiences at the varied hospitals. Port Antonia was the most spectacular of the three locations. The hospital is situated on a bluff overlooking the bay, with the ocean views overlooking the city. The hospital was a journey from the resort with a travel time around 2 hours each way. Our day was much slower at Port Antonio. We spent the entire day in the A&E (Accident and Emergency). We shared a room there. We only had a pediatric patient (birth to 14 yo) about every hour. They highlight of the day was a darling 11 yo girl who just stopped in to our exam room to chat with us while we were waiting to see another patient. She was a fifth grade student who was watching her 2 yo nephew while her sister was being seen. She was a bright and articulate student who was also remarkably polite. She was the highlight of a good day. Port Maria was a crazy first day to say the least. We were divided in the morning, Becca worked in the A&E and I in the clinic. When I arrived at 8:30 there were patients lined up outside the clinic which did not open for another hour. When the clinic started I was handed a stack of eight chart (dockets as they are referred to here). While I was seeing my first few patients the nurse returned with several more stacks of charts. Between 9:30 and 2 I saw 16 patients from asthma follow up, viral illness, well child check, to septic arthritis. I did have one mother refuse to see me, requesting that she see the “black doctor”, none of which were there that day. When I finished clinic, I joined Becca in the A&E. She had been busy as well seeing more than a dozen patient’s in the time I was in clinic. She was seeing a wider variety of patient’s including children as old as 18. She was finishing up charting when I arrived. Several more patients came in while I was there. We only had the one exam room so we rotated patients. By the end of the day on Monday we saw 35 patients between the 2 of us. It was a great but tiring day.

Hello all, Let me introduce myself (any my co-resident here, the man of few words and my fiancé), my name is Rebecca and Bob is here with me at the lovely Tower Isle Resort in Ocho Rios Jamaica. We arrive here just over 2 days ago after a very uneventful trip down from St. Louis. I have traveled internationally several times in the past and usually the trip down lends itself to some stress and at least a good story or two, but this one was smooth sailing. We were immediately welcomed by the staff and have continued to feel welcome in the 50 some-odd hours that we have been here. The rooms are clean and comfortable and the water is hot so I am a happy camper. I must also mention the food. I am in hog heaven in terms of fresh fruit, seafood, and Jamaican cuisine. Now, more importantly, how did our first day on the job go? All things considered, I think it went well. It was more of a sink or swim situation as orientation was lacking (likely due to our starting mid week) and we had to learn the charting system on the wards on the fly. With that being said, once we figured out what was expected on the inpatient side we dove in as much as we could. I could not say more, however, for the quality of discussion and teaching Dr. Ramos provided on rounds. Bob and I felt right at home as his Socratic style reminded us of some of our favorite mentors back home. The most challenging part of the day was when we ventured down to the Accident and Emergency department to help with Pediatric patients. If we thought getting shown the ropes was limited on the wards, we were sorely mistaken. Placed in a room with two examining spaces and no knowledge of the work flow or charting we got work. Fortunately for us newbies, it was a slower afternoon and the patient load was light, so we were able to figure out how to provided care and not feel like buffoons. When the day was all said and done I must say I again felt very welcomed and appreciated. I was humbled by feeling like a first grader on the first day of school. Most importantly, however, I feel excited about tomorrow. Now off to go eat some BBQ Duck… – Rebecca

The steady whirring of the overhead AC unit at Port Maria is almost hypnotic after the steadily rising cacophony of the morning breakfast buffet at the resort.  Several wedding parties arrived over the weekend, injecting both youthfulness and a certain amount of noise to the system.  While this is good for resort business, I can’t help but be slightly wistful for a beach lined with friendly open lounge chairs, their white cushions warmed by the sunlight, and devoid of the oppressive smoke from a cigarette, or the spicy smoke from other inhaled ignitions.

The pre-crowd beach life

Laughing at my own sense of entitlement, as well as the knowledge that the bustle will slow again in a few days, makes it all right. Flashback:  The ebb and flow of patients continued throughout the week.  Dr. Ravi, who is the more or less the equivalent of a chief resident, was very patient and helpful navigating the system.  We had some excellent discussions regarding differences in admission criteria in and among hospitals in the US, Jamaica, and around the globe, as well as the finer points of “whose patient is this?”

Starting the week at Port Maria A&E (accident and emergency).

In Jamaica, Good Friday and Easter Monday are both public holidays.  The energetic pomp of the marching band was a welcome addition to lunch on Monday.

Yay band!

As such, it was a welcome slow vacation weekend, despite my need to relearn the skill of relaxation, which I hadn’t necessarily lost, but had partially buried under a few layers of dirty scrubs, floor tiling equipment, and board study DVDs.

“Oh, THERE you are, Peter!” (Peter : relaxation)

In rediscovering relaxation, I took advantage of the free scuba lesion here to take my first ever dive.  While the bulk of my attention was focused on diving techniques of “breathing”, “kicking”, and perhaps most importantly, practicing “not touching anything,”  there was enough of my sensorium available to marvel at the towering coral wall to one side and the majesty of the vast blueness to the other.  We explored the shallow shelf of the wall at 40 feet deep.  For those that are absent diving experience, it felt like being hit with a shrink ray and thrown into a tropical aquarium in the role of the plastic diver figurine.  Had we been at the site of the sunken ship (an old WWII ship that the Jamaican government elected to sink off of the north coast for scuba diving tourist purposes), the sensation would have been complete.   The coral caves were marvelous and filled with bright oranges, blues, and purples.  The neon yellow shock of a trumpet fish, the ponderous waggle of the horned, cow-like trunk fish, and the sneaky, sandy camouflage of a puffer fish all made appearances before our steady ascent back into the light world of air. Otherwise, the weekend passed with fine food, good friends, plenty of sun, exercise, and only a little bit of time reserved to read and study.

 

Sunset from the deck of the Bayside Restaurant.

I had a small visitor to the villa (below).  I was suspicious that he was merely freeloading and not volunteering medical services for the foundation, but as I haven’t seen him since, I haven’t been able to confront him.

The freeloader.

Yesterday, I had the unique experience of diagnosing sickle cell disease (correctly!) for the first time since medical school.  The rate in Utah is low owing to a relatively homogenous population to the point that most sickle cell patients become case presentations for our residents. Unwarranted self-congratulatory pride aside, the experience of obtaining the diagnostic test and subsequently establishing appropriate follow up was simple and efficient.  It is this aspect of Jamaican care that I hope others can see.  While the resources are limited, they are largely put to good and effective use by those who see to their management. Present time:  Sticky humidity hangs in the air this morning across the island in the pediatric unit of Annotto Bay as I type and wait for morning rounds to commence.  One of the pediatric surgical patients who last week had his legs tied up above his head has since been cut loose and sits patiently in his crib.  Until rounds start, it seems like good fun to make faces at each other.  And it is.

Bright, cheerful puffs of sound are the polytonal point and counterpoint of the morning traffic conversation on the way to the hospital.   The tempo is at first a pleasant andante as we pull out of the resort with an occasional “hello” or “coming along side” through the country.  Today, columns of spicy, sweet, hazy smoke rise through the clear morning air at irregular intervals along the road and sometimes back into the hills, a sign that the rubbish collection system is currently down.  As we drive closer to town, the conversation accelerates to a brisk allegretto as the roads become filled with cars, and with bicycles and pedestrians on their way to school or work who ride or step into the street without thought or hesitation, and with goats, which carefully look both ways before venturing into the busy morning traffic.  Owners of the many tiki shops and restaurants are starting to arrange their wares for the day into neat stacks of colorful fruits, or strings of smoked fish, or cloth bags, or t-shirts.  A police car tends to a small altercation between a guilty-looking gray sports car with a large rear spoiler and an unassuming bicycle just before the turn-off to the hospital, which I’m just starting to recognize and expect. Sitting in the office waiting for the morning’s dockets, the other emergency medicine doctors and the chief medical officer pop their heads in to make sure I’m comfortable. (I am).  One brings me up to the pediatric ward to say hello to the few patients up there, one of whom is a toddler who was hospitalized for treatment of a severe skin infection.  She looks quite well, with small dark eyes peering curiously at me underneath the sky blue gauze of the surgical hair net she wears, and I am told that she is well, but being kept for evaluation of neglect.  Her brother, it turns out, was recently hospitalized for a similar infection and his mother received copious education at that time.  Fortunately, his sister is better off as, unlike her brother, she did not have “little people” (maggots) in her infection when she was brought for treatment.  Nonetheless, there is understandable concern regarding the household hygiene.  Her case led to an informative discussion of the local social work system, which is not substantially different from home, though they may be working with even less funding and support. The day was a rush of orthopedic evaluations and skin infections.  By the time I rode back to the resort, the smog from the morning’s rubbish fires had been replaced by majestic afternoon storm clouds billowing above the mountains.  Not a bad way to end the work day.

We had the privilege of joining a small Issa Trust Foundation sponsored mission in March, 2014.   This was our 3^rd trip to the island.  Our first 2 trips were busy working in the pediatric clinics that the Issa Trust has sponsored for the past 10 years.  This trip was different.  We had an opportunity to see more of the beautiful island, visit multiple hospitals and meet with dignitaries. But most importantly, we gained a new appreciation into the depth and value of the work that has been carried out by the Foundation and Diane Pollard. Our first day we traveled to St Ann’s Bay and returned to a hospital we had visited last September. We were again escorted through the hospital, weaving through seemingly endless lines of seriously ill people, waiting all too patiently to be seen by a care provider.   The pediatric unit bares no resemblance to the hospitals we’ve worked in, but one is immediately struck by the dedication and caring nature of the staff, working with severely limited resources.   We carried a variety of Welch Allen equipment that was being donated. Thermometers, blood pressure cuffs – tools we take for granted are received with overwhelming gratitude. The units were busy, the nurses and physicians, including trainees utilizing their strong clinical skills to provide the best care possible.  We were warmly welcomed, a result of the relationships established over a number of years.  This scenario was repeated at the other hospitals we visited.   At the hospital in Annotto Bay, we witnessed a delighted physician overwhelmed with the donation of an exam light.   Previously, his only way to illuminate any assessment or procedure he performed was the light on his phone. Our trip to Kingston included meeting with Lady Allen, the Minister of Health, and visiting Bustamante Children’s Hospital. We came away from this and all hospital visits with a new appreciation for the opportunities for making sustainable contributions to pediatric care.  These include not only resources and equipment, which we had the pleasure of donating during this visit, but also education.  The lack of subspecialty care is striking, the need is vast.  The words that Diane repeated to everyone with whom she interacted echo in our ears – “what can we do to help you?”     We are excited about responding to the answer.