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Wa’gwa! (We’re working on our Patwa).

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Steph and I rounded out last week at Annotto Bay hospital. On our way to the hospital we made a stop at Port Maria Hospital for a quick pit stop and I was able to run up to the pediatrics ward and check on a couple patients. There was one young girl who had right sided facial swelling in the previous post who I was worried about. Her swelling was unchanged with the antibiotics. The doctors were unable to bring in a dentist to pull the infected tooth so they were going to send her out the next day for extraction. I was just glad that the infection had not spread and become preorbital or orbital cellulitis! She was not very thrilled to see me as I had put her in the hospital, but I was just glad she didn’t get worse! The other child I checked on was an 11 year old boy who had lost his mother and the teachers brought him to the emergency department for an asthma attack. He actually likely had a panic attack at school then on the the way to the emergency department attempted to jump out of the teacher’s car. This case broke my heart! He needed to be admitted as he was not safe to be discharged and actually had no place to go. I was happy to hear that there is a special grieving team made up of social workers and counselors. He was able to work with them and was in a better place even a couple days later. Again he was hesitant to speak with me again but I was just relieved that he was in a safe place. photo(6) At Annotto Bay we were able to see quite a few children in the clinic primarily for follow-up of seizures and asthma. It was nice to be the ones managing seizure medications and when to stop them as this is primarily handled by specialists at home. We saw quite a few patients. We also spent some time in the emergency department where we were quickly handed multiple charts. One young girl needed casting for a left tibia/fibula fracture and another child needed sutures for a chin laceration. I was glad to have local anesthetic even though the only sutures available were much larger than what I would normally use. Always a little creative in whatever we do!     The weekend was amazing and extra special as my sister and brother-in-law, Maria and Dan came to visit. We spent the time relaxing, playing beach volleyball, paddle boarding and reading. They were very happy to get out of the cold Chicago winter and we were more than happy to show them around our home! Steph attempted to learn wind surfing which would have worked well if there was more wind ūüôā On Saturday we climbed Dunn’s River Waterfalls which was more challenging than expected and we each have a few scrapes to prove it. Our guide at one point wanted us to climb blindly through a vertical slope of the waterfall…needless to say we did not successfully complete that challenge. Regardless it was a great time and I would recommend it! We even shared a special Valentine’s Day dinner at Eight Rivers where we were serenaded by a Jamaican acapella men’s group! Can’t beat that!¬†photo(8)photo 2(3) photo 1(1)photo 3(1)

Gearing up for our last full week here in Jamaica!

With respect and love.

– S & D

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Sunday we participated in our first excursion away from the resort when we went to Dolphin Cove and had a chance to swim with dolphins!! ¬†Neither D nor I had ever done this and it was amazing!!! I highly recommend it for anyone coming to Jamaica!! Dolphin cove is beautiful. ¬†At the cove we swam with Mitch (the alpha male dolphin who in his early 20s is already a dad to multiple baby dolphins at Dolphin Cove), watched 2 shark shows, held a sting ray and hung out with multiple parrots!! ¬†And hey, I don’t want to brag but apparently Mitch thought I was the best kisser because he brought me the ring to throw for him after getting a kiss from everyone!! ¬†We got back to the resort that afternoon and had a late lunch before relaxing and catching up with friends and family back home. ¬†We then had mango sorbet for dinner. ¬†I know an interesting choice for 2 adults but hey it’s true, in Jamaica no problems!! ¬†All in all a great day!!

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Monday and Tuesday we were back at Port Maria Hospital but we switched it up this week with me going to clinic and D going to the A&E. ¬†Of all the hospitals we go to, Port Maria is by far the one with the greatest need for pediatricians and we are always busiest here but it’s our favorite!! ¬†On Monday I saw a large kerion and even made a diagnosis of Gionati-Crosti!! ¬†I have to pause here to thank Dr Brown for hammering home this viral exanthem to Stevie and I after our last month in Jamaica!! ¬†You’re the best, Dr Brown! ¬†In the A&E, D diagnosed several fractures and is becoming a pro at plaster casting–don’t worry guys, she still refers to Ortho once the cast is on!!

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D also saw one of my patients from the week prior. ¬†Last week I had seen a 17 year old male who was febrile, diaphoretic, complaining of pain on urination, bilateral CVA tenderness and that morning had noted blood in his urine. ¬†His u/a showed 3+ blood and 1+ protein (unfortunately at Port Maria the dipsticks aren’t able to tell you if LE or nitrites are present and there are not sterile containers for sending urine cultures). ¬†I was confident this teenager had a UTI but I was worried that he may have had pyelonephritis or an infection caused by an STI (although he denied sexual activity repeatedly). ¬†As his vitals were stable and he did not want either a GU exam or admission, I decided to treat him with a 7 day course of augmentin and told him he had to return in 1 week for a repeat u/a. ¬†My plan was to obtain labs and imaging at that time if he had any blood or protein in his urine. ¬†When D saw him on Tuesday he looked and felt great! ¬†He’d completed his antibiotics and his repeat u/a was completely clean!! ¬†Look at that continuity of care even in Jamaica!!! ¬†That same day in the A&E D saw an interesting patient with a tooth abscess that had progressed to facial swelling and edema. ¬†We spent a long time trying to decide what antibiotics we should use based on availability and how we would be able to get this child to a dentist for tooth extraction. ¬† ¬†Ultimately, we decided on clindamycin and CTX and she was admitted in order to find a dentist who would be willing to come to the hospital. ¬†Prior to antibiotics and admission, D started an IV and drew both labs and a blood culture — in Jamaica all lab work is performed by physicians not the nursing staff!! It’s a great opportunity for D and I to work on our procedural skills!!

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Monday night was our first time that we attended the “Returners Dinner”. ¬†The dinner was possibly the best one I’ve had at Couples– amazing soup and salad followed by an entree of lobster and steak and then a wonderful dessert. ¬†At the end of the dinner, the manager of Couples stood up to thank people for coming back and even spoke about the Issa Trust Foundation. ¬†It’s great how much Couples is doing to help raise awareness and money for pediatric care!! photo 3 (1) On Wednesday we were back at Anotto Bay. ¬†It was a slow morning on the wards but things really picked up when we went to the A&E. ¬†Within 5 minutes of being there, we were handed 3 pediatric X-rays for review! ¬† One child had a distal tib-fib fracture that needed casting and another had a chin laceration that needed repair. ¬†We quickly got to work seeing as many kids as we could. photo 1 (5) photo 2 (3) photo 1 (3) The ambulance provided our ride home that afternoon! ¬†Our driver was great and convinced us that we had to stop for “real Jamaican food”. ¬†We stopped at one of his favorite restaurants for jerk chicken and red stripes. ¬†Last year we were told that Jamaicans have heartier stomachs than we do so we have no one to blame but ourselves if there are negative repercussions from our eating adventures!!! ¬†But local jerk chicken is fabulous! photo 2 (4) photo 1 (4) Back at the resort and the weather is gorgeous!! ¬†We have dinner reservations at bayside tonight but are first going to enjoy a cocktail on the rooftop bar before we go!! Crazy that our friends and colleagues are dealing with snow at home while we are soaking up as much sunshine as possible here!! photo 2 (5) Still feeling so blessed, S&D
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Our first week has flown by! Stephanie and I are grateful to be surrounded by such warm people that continue to help us become oriented to all the clinics we are working at! On Wednesday and Thursday we were at Annotto Bay Hospital. Our first day we were able to join the residents on the inpatient service. The pediatric ward struck me immediately as it is one open room with children of all ages from 3 days to 11 years old with the sickest patients closest to the nurses‚Äô station. We were surprised to learn that if you are over 12 years old you go to the medicine unit! At home we have a hard time transitioning our 18 year olds to the adult units so that struck us by surprise. That continues to point how valuable and needed pediatricians are in Jamaica! We were able to join in on work rounds with Dr. Ramos and found a teaching point with every patient. It was nice to contribute and discuss pathophysiology and management on each disease process. There was a 3 day old infant with hypoxic ischemic encephalopathy who was continuing to have seizures despite being started on phenytoin. This led to a lively discussion of what else was available and prognosis as one of the medicine interns wanted to obtain a CT scan of the patient’s head. We talked about both cost efficient and responsible healthcare as we tried to stress that this imaging modality would not give us additional information and increases the patient’s risk for cancer in the future. Currently in Jamaica no hospital is capable of doing body cooling but an interesting teaching point that we were able to share. One of the residents then gave a presentation on shock. This reminded me of the many talks we have had with the intensivists both at noon conference and in the PICU. Stephanie and I stressed to them the importance of early recognition and quick action. Overall the day was great as we were able to share a lot of teaching points that our teachers and mentors have successfully stressed to us! On Thursday we were in well baby clinic where we each saw about 10-12 newborns. We fell in love with the infants and most were doing well and healthy. We had a couple of patients one with a new murmur that we sent to obtain echocardiogram and another that Stephanie was the one managing diuretics as the last echocardiogram showed a closed VSD with good function. In the afternoon we spent time in the A&E where we immediately admitted two patients. Stephanie saw a young boy with sickle cell disease who presented with pain crisis who was admitted for pain control. I saw a 14 year old boy with an asthma exacerbation that had failed 6 nebulized treatments in the A&E with Salbutamol and Atrovent. We had another lively debate about dosaging as he had been under-treated. Some of the generalist doctors had wanted me to obtain basic labwork to see if the white count was elevated which led to a debate of not ordering labwork when it will not change our management. We stuck to our guns and I like to think it was beneficial to all to think about these things before ordering labwork or imaging. photo(1) On Friday we traveled to St. Antonio Hospital with Mr. Campbell, the CEO of the hospital. He was so gracious to drive us the almost 2 hours each way. There weren‚Äôt any patients in the outpatient clinic so we spent the day in Accident & Emergency. We saw a variety of conditions and have a knack for starting the day off with an admission. Stephanie saw a child with a hot water burn on the top of his foot. With good supplies there could‚Äôve been the possibility of sending him home but as we didn‚Äôt even have appropriate wraps the patient was admitted to help prevent infection in this very vulnerable area. After seeing all the patients we were able to spend about an hour playing with the kids on the inpatient side. We read them books, colored and even told some scary (or not so scary) stories! We had a blast! photo(4)IMG_2440photo(5)photo 2(2)       This weekend we are enjoying everything that Jamaica has to offer! Sailing, kayaking and tomorrow we are off to swim with the dolphins! We are definitely feeling blessed! Until next time, Steph and Diana
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We were privileged to be able to start our day in Port Antonio with a brief presentation about febrile seizures to the doctors and nurses on staff at the hospital. While febrile seizures are quite a common issue for us as pediatricians, they can be daunting for doctors who are not as familiar with kids. A lively discussion followed the presentation (as are most discussions in Jamaica) and we all walked away with a deeper understanding of practicing medicine effectively with the resources available.

That being said, now that we’ve been in Jamaica for almost three weeks, I feel that poverty has become personal. There are now names and faces and images that come to mind when I think about “resource poor settings.” It is the legs of a child with a bacterial superinfection that has been ineffectively treated for months with an antibiotic known to have a high level of resistance because there was nothing else available. It is the back of an ambulance equip with little more than a pair of latex gloves, a bag of expired normal saline, and a small sliver of hope that anything useful would be able to be accomplished should a true emergency arise. It is the mother of an asthmatic who fashioned a spacer out of plastic cups because she couldn’t afford one but acknowledges its importance for her child’s health. And while these disparities become personal, they also become impossible to ignore.

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image Rounding on the inpatients with Dr. Ramos and the residents at Annotto Bay continues to be one of the highlights of our week. One patient in particular has captured our hearts, and we have had the opportunity to watch him improve and become more interactive from week to week. Such an amazing experience!  
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Aspiring Pediatrician from Port Maria (permission granted)

Aspiring Pediatrician from Port Maria (permission granted)

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This Monday and Tuesday we returned to Port Maria, where we are beginning to feel more comfortable with the resources available and how the clinics and the A&E function in general. The matron continues to be our hero and the children have not stopped being irresistible. If there are several Jamaican babies missing from Port Maria, check with us… I saw one 6 week old for a well child check whose mother asked me to look closely at the skin over her anterior fontanelle. When I asked why, she told me that her mother (the child’s grandmother) had poured rum over her soft spot to cure the child’s head cold (which turned out to be likely reflux). Luckily, the child’s scalp was unharmed. I am convinced the family will find other uses for one of Jamaica’s primary exports. Jamie and Alison
 
little one Just¬†like in the U.S., toddlers are a Pediatrician’s biggest critic (permission granted for photo)
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Port Maria!
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We just finished our first week in beautiful Jamaica — what an experience! Each site we visited had it’s own personality and availability of resources but two remain the same no matter where we are. First, Jamaican children are adorable. Second, Jamaican hospitality is second to none. The first day at Port Maria was a bit of a whirlwind. With the help of the staff and a very knowledgeable matron (who is also a Justice of the Peace…and our hero) we found our way to the A and E (accident and emergency) and the Port Maria clinic. We saw a variety of conditions, some familiar to us (asthma, eczema, viral upper respiratory infections) and others that required some guidance for treatment from the local nurses and physicians.¬† We went to Annotto Bay¬†on Tuesday and Wednesday.¬†It is a bigger facility and while it is not a teaching hospital, there are residents who work there and we had an hour long teaching session with them and the head pediatrician, Dr. Ramos.¬†It was fun to see that the experience Jamaican residents have (rounding, being quizzed by the attending, etc) was very similar to our experiencing in the United States.¬† On Friday we traveled to Port Antonio, which is also¬†a larger facility with a beautiful view! Before we started work we were introduced to every (literally, every) hospital employee by Mr. Campbell (the Port Antonio hospital administrator).¬† We’re pretty sure he told everyone to stop by with their children, as we saw the sons and daughters of multiple employees. It is still hard to believe that when we leave work at the end of the day, we come back to the incredibly beautiful Couples Resort.¬† The staff has been amazing and the views are incredible.¬† We feel like we should buy a lottery ticket because we just might be the two luckiest pediatricians in the world right now.
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