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26
March

Last day….

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After a good nights rest and some medication both myself and Stephanie felt much better. It took awhile to get going on Friday but the Jamaica sunshine is a great motivator.We were unable to go to Port Antonio on Friday which made us both sad because we’ve seen so many great cases there and their need for Pediatricians is perhaps the greatest. Dr. Ramos only sees pediatric patients on Tuesdays and he has to limit the number to 15 given his other duties. Now that the community of Port Antonio is catching wind that we are present on Fridays the patients come in good number.

I have to say we took our last weekend by storm. We first decided to lay in the sun and relax as both of us had not felt well for the pat 24 hours but after watching everyone else on the resort participate in activities we were both itching to do something. We decided on snorkeling and had a blast. We saw tons of fish, my favorite were these amazing light blue ones that reminded me of Dori on ‘Finding Nemo’ and Stephanie loved the yellow fish with black stripes which she thought kind of resembled Nemo 🙂 She was also lucky enough to see a sting ray! I was soooojealous!! We were pretty exhausted after this one little excursion so we returned to the room for some rest and nearly slept through our dinner reservations made over a week ago. But no worries, we rallied and got ready in no time. After all…you can’t pass up the amazing food here on Couples resorts.





Saturday we awoke to go train for scuba diving. We had been looking forward to this the entire trip but typically they only do classes on weekdays. We first did a swim test (you have no idea how hard 4 laps
in pool can be) and luckily we both passed! We then watched a 30 minute video about the equipment and safety instructions for scuba diving. Then we were off to the pool in our gear. We like to think we looked fashionable but our wet suits were a little awkward fitting to say the least. We practiced in the pool for about 45 minutes but unfortunately I had a cold and was unable to clear my ears at just 6 feet (the depth of the pool) and that’s not safe for scuba diving. Steph and I had a blast practicing in the pool and our instructor was phenomenal. I guess I’ve just been loving up on too many sick Jamaican children in the A&E 🙂 Since scuba was out and we were feeling adventurous we decided to go skiing behind the boat. We’ve both have been water skiing behind boats in the lake but never the ocean so we were beyond excited. It was late morning and the water was a little choppy but we both managed to get up twice and had a blast. Our boat driver Kenneth was so nice and knew exactly how to pull skiers out of the water.
















 Later that afternoon we went on the Catamaran cruise (our 4th time…we know, a little excessive) but we love the crew and the peacefulness off being out on the ocean. Plus we met some great people this time who were spending their anniversary here and had some great conversation. The waves were a little crazy and Stephanie and I had a few scares sitting on the front of the boat (I lost my prized blue aviator sunglasses!!) but all in all it was a great time. I found myself in a back flipping competition off the boat with one of the staff, Odain, and I like to think I won. He was much more fearless than me though and his one foot back flip was a crowd pleaser. After returning back to the resort, we participated in a Reggae Dance class on the beach. I’m sure we provided great entertainment and a lot of laughing for those watching. We again had a great dinner and ended our night by skyping our fellow 2nd year residents. This weekend was our annual retreat and we were sad to miss it but we like to think we were there in spirit. After much laughing and telling them about our experiences here we hit the sack looking forward to our last weekend day on the resort.
We woke up Sunday and climbed Dunn’s River. We had both done this before, Stephanie 6 years ago on a cruise and me on my honeymoon 4 years ago, but we were up for a 2nd trip. The sun was out and we again
were feeling adventurous. Our bus driver, Gary, had to be one of the funniest people I’ve ever encountered. He gave us a full tour of Jamaica on our way to the falls telling us about everything we passed from an Electric Store with the motto “stronger for longer” (you can imagine the jokes made) to the only radio station on this side of the island called ‘Irie’ which plays only reggae music. He then gave us a run down of the geography of Jamaica, explaining that we had passed through 4 parishes from the airport to the resort which resides in St. Mary (interesting fact is that Port Maria where we work Monday and Tuesday is the capital of St. Mary). We arrived at Dunn’s River and after very strict instructions from Gary regarding vendors and video purchasing we were off. It was a great group of people from the resort and we had an absolute blast. Walking hand in hand with a bunch of strangers up a waterfall doesn’t sound like the safest thing but we were taken care of by our guides and each other. From falling backwards into the water to going down a natural slide made in the rocks we were smiling the entire time. We don’t have pictures because we forgot to bring a waterproof camera but it was beautiful and a great time overall! We got back to the resort and spent the rest of the afternoon relaxing in the sun and making tie-dye shirts!!! I was much more excited than Stephanie as tie-dying has long been a passion of mine, just playing, kind of.  We made late afternoon spa appointments for a facial and pedicure, both of which were wonderful and a must if you get time. By the end we were so relaxed and thankful for the much needed pampering. We then headed to dinner and like always the food was amazing. We also met this great couple who were on their 13th trip to this resort and had a son in his 2nd year of medical school!! We had great conversation with them and ended the dinner stuffed!

                      
 

Today was our last full day in Jamaica and Stephanie and I both woke up sad. We pumped each other up at breakfast and reminded ourselves we were dedicated to returning. The children of Jamaica have a huge piece of our heart and the need for their care is immense. We spent the day at Port Maria, which is perhaps my favorite hospital because we see the most volume there and the nurses are phenomenal and extremely helpful. We learned from our driver this morning that Port Maria serves 66 communities and 8 surrounding towns. No wonder the volume is so great! We also learned that they have no ultrasound machine or tech in the entire hospital. You must be referred to St.Ann’s which only accepts 2 patients a day. We are blessed to have so many resources in America, this trip has taught me never to take that for granted. Stephanie spent the day in A&E and myself in clinic but upon our arrival we were met by a concerned mother. I had seen her 3 year-old boy last Tuesday for an ear infection and possible right-sided inguinal hernia. Mom’s description of a bulge while crying or coughing was consistent and on my exam I could appreciate a bulge during valsalva. I made a referral for pediatric surgery at St. Ann’s which only holds clinic Tuesday and Thursday morning but mom had not gone. I also gave her instructions for seeking immediate medical treatment if the bulge became painful and constant, there was color change over the area, abdominal distention, or uncontrolled fever. She followed those instructions thankfully and today she explained that the bulge had been persistent for 2 days and he was now limping while he walked complaining of pain. Stephanie and I were absolutely concerned for incarceration and after our physical exam and a discussion with the A&E physician the plan was for immediate transfer to St.Ann’s to be evaluated by surgery. What an eventful way to start the morning! Clinic continues to be busy here at Port Maria and I saw many skin infections (a kerion being a new one) and lots of colds and ear infections. I had an especially adorable 1 year-old who was intrigued by my stethoscope. Sadly his newly erupting teeth posed a great threat so I eventually had to take it back but not before some great pictures!


Stephanie was in the A&E and had another appendicitis scare! Once again the lab was down so she only had an abdominal X-ray to help her in addition to her physical exam. And guess what? Constipation strikes again. She also had a little girl brought in by her Aunt for breathing difficulties. On exam she was wheezing with crackles on the right lower base and her vitals on presentation revealed hypoxia. She was placed on oxygen immediately and given a breathing treatment. Unfortunately she didn’t improve and was admitted to the hospital. She was treated with CTX and continued on oxygen with the admission diagnosis of bacterial pneumonia. Most of her labs and CXR will have to be done later since everything had closed down for the day.


Our last drive home from work was gorgeous like always. After you get out of the town of Port Maria it’s just ocean for a few kilometers and it’s breathtaking. Nothing can ever beat it.
Tonight were packing (and maybe crying) as we prepare to leave in the morning. We can’t believe it’s already over. We’re planning on going to the beach party tonight followed by Margaritaville with the rest of the resort-goers 🙂 it should be a great ending to a wonderful trip!






Fully blessed and sad to leave,
S&S
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25
March

Is it really almost over???

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I can’t believe that this experience is almost over.  Stevie and I have been so grateful for this month and are so sad when we realize its coming to an end. 


Wednesday and Thursday were our last days at Annotto Bay Hospital.  On Wednesday, we helped with patients on the pediatric ward.  Per usual, the morning was filled with interesting cases and great discussions led by Dr Ramos.  In the peds ward, there was a 1 day old 26 weeker who was doing surprisingly well.  At 900g the child was doing fabulous, maintaining good oxygen saturation without being intubated and maintaining his temp with an incubator that was duct taped closed!  We had an interesting talk on rounds about fluid management in neonates and the ways that things are done both at home and here.  Although we knew we were returning to Annotto Bay on Thursday, Stevie and I were both a little sad saying goodbye to the doctors we had worked with on the wards.  Dr Blake, Dr Yandav, Dr Fisher and Dr Ramos have all been fabulous to work with here in Jamaica and we hope that our paths cross again at some point!!

 



  
Wednesday afternoon Stevie and I had our first exposure to cricket as we watched a high school match.   Jamaicans take their cricket games very seriously!!  I was amazed at the number of people watching and the loud cheers when the home bowler hit the wicket!!


Thursday was a busy day at Annotto Bay!  Every other Thursday is well baby clinic where any infants born recently return for one follow up with hospital physicians.   After that visit, if they are doing well then they are just followed at the community health centers for immunizations.  When Stevie and I arrived there was a huge line of mothers holding their infants waiting to be seen.  We quickly got to work seeing the adorable newborns.  Fortunately, we did see many healthy newborns who were breast feeding and gaining weight wonderfully.  I also saw 2 patients with supernumerary digits.  Interestingly, when I mentioned removal one of the mothers told me she wanted the extra digits to grow— she had also had supernumerary digits and was angry that her mother had hers removed.  Unfortunately, the extra fingers were already starting to turn purplish so I spent a great deal of time educating the mom about why they would need to be removed and referred her to surgery clinic.   I contemplated tying them off myself but due to lack of equipment and mom’s reluctance I decided the surgery clinic would be a better idea!! 




















I didn’t want to forget to mention about some of the Jamaican culture we have learned about here.  Many of the babies seen here have “ascifnata” placed in their hair.  Stevie and I had no clue what we were looking at the first time we saw it!!  Finally one of the mom’s explained that it’s to keep colds away from the babies.  Apparently it doesn’t work for older people though so don’t go searching for ascifnata at the drug store next year during cold season!!  Also many of the babies have red bracelets on that look like hair bands.  The nurses told us that many of the mom’s will get angry if you take these off the infants because they are placed there for protection and to ward off evil spirits also called dunny’s.  No matter where you are in the world, culture will play a role in your medical care!! 










I also wanted to make sure that Stevie and I mentioned our gratitude for Dr Ramos.  Dr Ramos is one of a very small number of pediatric trained physicians here in Jamaica.  After clinic he spent a long time explaining the Jamaican medical training system to us, as well as how the hospitals function on a day to day basis.  He was also curious about the US system and details involving the residency program.  Dr Ramos is an excellent physician who constantly challenges you to push your knowledge base.  He is a great teaching physician who is wonderful for any learning physician to get to work with. 



Our afternoon at Annotto Bay actually brought us back to the peds wards where we helped Dr Yandav with procedures.  We were able to start IVs and perform femoral sticks for necessary labs.  In Jamaica, the physicians, not the nurses, start all IVs and perform all necessary labs.  Stevie and I both love procedures and wish we had more opportunities to perform basic procedures such as starting IVs at home.   This rotation has been a wonderful opportunity to help patients in need while also learning procedural skills from physicians who do these basic procedures day in and day out.  Although Dr Yandav disagrees, he is a wonderful teacher of procedures and Stevie and I both were successful at the procedures because of his advice!!  These hints are things I will continue to use while practicing in the US.  Another advantage to performing procedures in the afternoon was that Stevie and I were able to say goodbye to many of the fabulous nurses we have worked with on the wards!!  These people have huge hearts and we will miss them!


There is a soccer field right by the hospital.  Well a soccer field, cricket field, whatever you want to call it.  I love soccer and some Jamaican kids are amazing.  It’s clear that they’ve grown up with a ball on their foot!!
















Unfortunately, the ride situation home from Annotto Bay can be much more frustrating than at the other hospitals we work at so we are getting back to our resort way later than usual.  Stevie hasn’t felt great today but we’re hoping a relaxing ride home will help her feel better.  Keeping our fingers crossed that later on we’ll be enjoying the great food and live music that we’ve become accustomed too.

Still feeling so blessed,
S&S
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21
March

Only one week left!!

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I can’t believe this is our last full week, it’s flown by. The drive to work is going to be hard to beat when we return home.


We started at Port Maria on Monday and we were busy! Stephanie was in clinic and saw many rashes, infected scabies being the most common.  After consulting with each other and the physicians we learned they treat with a combination of permethrin, augmentin, and mupirocin. Scabies is not that common in our setting at home and seeing it infected is even less common. Once again our physical exam skills are being sharpened. I spent the day in the A&E and felt overwhelmed with the number and variety of things I saw. At one point I had a little girl in the observation area receiving IVFs, 2 children in the lab followed by X-rays, and 5 patients waiting outside. It felt like home and my multi-tasking skills were at their best. Perhaps the most challenging but revealing case was an 8 yo male who presented with complaints of HA, sore throat, anorexia, emesis, and abdominal pain for 1-2 days. He was febrile to 102.4 on arrival and did not appear to feel well. After a detailed history I learned he lacked URI symptoms and combined with my physical exam of cervical lymphadenopathy and an erythematous oropharynx I was leaning towards the diagnosis of strep pharyngitis. I had one hold up though, his abdomen was extremely tender and he demonstrated guarding in the RLQ without rebound. Upon questioning he kept pointing to his umbilicus when I asked where it hurt the most. We all know appendicitis in a child can present atypically but pain that started near his umbilicus, tenderness in the RLQ, high fever, anorexia, and emesis seemed a little too classic to let him go with just a script for amoxicillin. So I started delving into more history asking mom about his bowel habits, desperately looking for another cause of abdominal pain. He did exhibit some signs of constipation so I decided a KUB and a CBC could help me make a decision. A KUB to look for constipation and even free air if he had ruptured his appendix (unlikely given his exam) and an elevated white count, again to help rule out appendicitis. We were unable to get the CBC but the KUB showed constipation!! By that time he was running around outside and I felt very comfortable sending him with a course of amoxicillin for pharyngitis and mineral oil for constipation. Long story for a simple diagnosis but it goes to show that you can’t ignore classic signs of something you can’t afford to miss, appendicitis. It also shows that constipation in children is painful! Always keep it in your differential!








Monday nights at the resort are “Beach nights” and they make this wonderful dinner and have appetizers and drinks and music outside. We haven’t yet participated in this awesome party but we did stop by and sneak a few of the appetizers. Our plan is to enjoy it our last Monday here which is this one upcoming.


On Tuesday we returned to Port Maria and switched our roles, Steph in the A&E and myself in clinic. Unfortunately the clinic had no available rooms for me so Steph and I shared a room. It was a busy day but we made the small space work. We saw over 30 patients together! Along with our ability to be efficient, our physical exams were put to the test. For visualization, we saw classic tinea capitis, diaper dermatitis, and more scabies. For auscultation, we heard many variations of wheezing as we had to frequently assess asthmatics after breathing treatments. For palpation, we assessed for fluctuancy of skin abscesses and I’m fairly certain we felt the “sausage” mass associated with intussusception. Other physical exam findings to note were strabismus and ptosis. It was a great day overall filled with a  huge amount of learning potential we definitely capitalized on. Today also brought continuity which is amazing. Steph and I were able to follow up with our little boy who’s finger was lacerated after a grease pan had fell on it last week. We repaired it and prescribed augmentin and mupirocin along with recommendations to keep the dressing clean and dry. But little boys being boys that dressing came back as dirty and wet as you could imagine. There was pus overlying the lac when we removed the dressing but I like to think our antibiotics and mupirocin helped keep the infection at bay. We ended the afternoon as we had done last Monday but Steph and I switched roles. I tightly held the sweet little boy in a chair while Stephanie removed the sutures and redressed it. It was quite the tear-filled experience for our little guy as he remembered the procedure room from last week but he still liked us afterwards. He’s coming back next Monday and continuing on antibiotics.
                           


When we got back to resort we were exhausted from a full day and we spent an hour sitting by the beach just talking about the patients we saw that day, reviewing their presentations, and running our plans by one another. It’s such a blessing to have time after a long day to really process what you did. The opportunity to process rarely, if ever, comes when working at home. I think most residents would agree with me. By the time you’re off work you’re often so exhausted that the only thing you can do is eat dinner, shower, and go sleep as you prepare for the next day, especially as we’ve switched to shift work.  I cannot convey how wonderful it has been to just sit and talk with Stephanie about medicine. I know from our weekend adventures that medicine may seem to be the last thing on our mind as we return to the resort every evening but that’s honestly not the case. We both feel like we learned so much here and are appreciative for the much need down time.

We concluded the night with an amazing dinner at 8 Rivers and we even got fancy for the occasion. The food was delicious and filling and the waiter was shocked when we turned down desert. We then went to the main dinning area to enjoy some live music and found ourselves out on the dance floor in no time. From ‘We are Family’ to ‘YMCA’ we tore up the dance floor and made many new friends!



 Extremely blessed and thankful…S&S
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18
March

I can’t believe its already been 2 weeks!!

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Friday was spent back at Port Antonio Hospital.  Stevie and I decided to switch it up again– her going to the A&E and me going to clinic.   I was really looking forward to the complex consultant cases Stevie had seen the week prior but unfortunately it started to rain again on Friday as well.  We were told when we first got here that Jamaicans don’t like to leave their houses when it is raining and I think that must be true because I had my first slow morning!!  At home I would kill for a morning like that but with access to care so limited here, I was chomping at the bit for more patients so I joined Stevie in the A&E.  The rain didn’t keep patients out of the A&E!!  Stevie and I both had a busy day seeing several common pediatric complaints– viral processes, strep pharyngitis and a few lacerations as well.  I mentioned earlier how Jamaican physicians learn to rely on their history and physical exams more than anything else– volunteering here is a wonderful opportunity to pick up on these exam skills.  I saw a 6 year old little boy with 2 days of fever, sore throat, headache and vomiting with no cough or respiratory symptoms.  He had large tonsils with exudate noted, a white strawberry tongue and even pastia’s lines in his antecubital fossa— I didn’t need a rapid strep to confirm this was strep pharyngitis!  No lab tests were ordered and I was able to send him home with a 10 day course of amoxicillin and maternal education about keeping him hydrated.  I finished my day by seeing a newborn in the maternity ward that I was asked to evaluate because the mother was VDRL positive and meconium staining was noted at delivery.  In addition to this the infant was noted to be mildly tachypnic with nasal flaring so the nurses in the maternity ward had placed him on oxygen.  There is not pulse oximetry available in the maternity ward so we had no way to document exactly what his O2 sat was.  When I saw the infant (about 1 hour after birth) he looked well.  The differential included congenital syphilis, TTNB, Meconium Aspiration syndrome vs congenital heart defect.  The general physicians asked me how we handled meconium deliveries — although the infant was improving they were planning on a gastric lavage to prevent vomiting.  I explained that we don’t do that back home and explained our process for meconium at deliveries.  The 2 generalist and I then had a great discussion regarding congenital syphilis and what is medically indicated when mom states she was treated but we have no documentation of this.  It was a great learning opportunity for all of us!!!  Ultimately we decided to treat the infant with PCN until lab results returned and admit him to the peds wards for monitoring of his respiratory status.  Oh and we didn’t perform a gastric lavage!!  I’m curious to see what happened with that little one when we return next week!





Friday night was the first night that we ate dinner at 8 Rivers which is the nicest restaurant here at Couples Resort.  We were treated to an amazing 5 course meal and wonderful wine!  We left stuffed but happy and spent the rest of the night enjoying the live music on a beautiful Jamaican night!!



On Saturday we were excited to spend the morning scuba diving but unfortunately the weather did not cooperate and we weren’t able to go this weekend– hopefully we’ll be swimming with the fish next Saturday!  Jamaica is such a beautiful country even on a cloudy, rainy day so we were still able to have wonderful day despite the weather!!  We went back on the catamaran cruise in the afternoon and had another wonderful trip.   It was the same crew as our previous cruise and they all remembered us and treated us like old friends from the start.  We spent the afternoon laughing, dancing and enjoying being out on the ocean.  Even with the occasional rain showers, that is hard day to beat!! 



 Sunday was a beautiful tropical Jamaican day!!  After the last Saturday Stevie and I were well prepared with lots of sunscreen and we had a fabulous day playing in the ocean.  We even went kayaking around the island.  It was so much fun that we are already planning our next kayaking trip back home– that or we’re going to be on amazing race.  Do you think they’d give us time off from residency to compete?? 



  

We spent the late afternoon treating ourselves to a massage at the spa here at Couples Resort.   The amenities here really are too good to be true and the massage was one of the best massages I’ve ever had!!  I’d highly recommend it to anyone staying here at the resort.  After the massage we showered and got ready for another fun night with great food, good wine and live music.  Because it was St Patty’s day back home we wore our green out to celebrate.  No green beers here in Jamaica but it was still a great night!!

I can’t believe we’ve already been here 2 weeks.  I can’t wait to see what the rest of this trip has in store…

S&S




 
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14
March

Another great week!

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This opportunity continues to be amazing and eye-opening. We spent Tuesday at Port Maria and Steph and I switched it up…her going to clinic and me in the A&E. Stephanie was referred many patients from the Matron for complaints found during their well checks. Common things being common, she diagnosed pneumonia, otitis media, and many rashes. She was able to follow up with a patient I had seen the day prior who had fever without a source and was given IM Ceftriaxone and asked to come back. The great news is that he looked much better and was smiling and playful. It’s amazing that we’re able to have continuity here as the moms often have to walk long distances to the hospital. The people here continue to put smiles on our faces and it’s very apparent how much the mothers care for their children.




My time in the A&E at Port Maria was eventful to say the least. With the recent rain and “cold front” as the Jamaicans call it, I saw lots of asthma exacerbations. I did my best to educate each family and even found handouts about asthma in the clinic room. I sent two of them home with asthma action plans! The most exciting and challenging part of the day was a precious 3 year-old boy who needed his finger sutured. With no anxiolytic and only myself and Steph to hold him the process was extremely difficult but we got it done. Plus he is coming back next week for follow up.


Wednesday we returned to Annotto Bay Hospital and started the morning with rounds. We had extremely interesting patients and there was lots of good discussion not only about each patient’s treatment plan but about medicine in general. A little boy had been admitted the night before with 4 days of cold and cough symptoms along with 2 days of alternating lethargy and irritability. The interesting part of his history was that he had been given “bush tea” over the past 2 days. He’d received IVFs overnight and the leading diagnosis had been intoxication from “bush tea”. We learned on rounds that it’s customary, especially in the rural areas of Jamaica, for mothers to make tea from various bushes as a cold remedy. But similar to being in the US,  we have no idea how safe these herbal remedies are. We ultimately determined after much discussion, that “bush tea” intoxication is truly a diagnosis of exclusion given the lack of reported cases. With that being said an encephalopathy/encephalitis needed to be ruled out with an LP.  Soooo…if there’s a take home message to this story, it’s don’t give bush tea to your child!!!  We then finished up the day with Dr. Yandav doing procedures. We each performed an LP and drew blood for the lab. It was a wonderful day spent with sweet patients and great physicians.


We returned to the resort Wednesday night and rested a bit before having dinner at the Bayside restaurant (Asian cuisine). We had a delicious dinner and then we stayed up waaaaay too late to enjoy the steel band. They were amazing and full of energy. They played versions of popular songs like gangnam style and tons of Michael Jackson, my favorite. They had dance routines, outfit changes, and even did this crazy balancing stunt. It was incredible to say the least.





Today we spent the morning in clinic at Annotto Bay Hospital. Last week was filled with 2 week-old infants coming for hospital follow-up and weight checks but today we saw many older patients. Stephanie and I both saw many children with seizures, some with epilepsy on AEDs and others with febrile seizures. We both gave a lot of education to the families with children having febrile seizures, emphasizing that controlling the fever could prevent the seizure. Dr. Yandav joined in and made the very valid point that the seizures typically occur just prior to the fever or sometimes afterwards. His point was that parents should treat their child with either panadol (acetaminophen) or cataflam (diclofenac) at the first sign of warmth to touch. Interspersed between these patients was an asthma follow-up, phimosis, UTI, and well checks. The most exciting part of the day for me was following up with an infant I had seen just last week on the wards. The mom remembered me which made the visit all that more enjoyable. It’s amazing that here in Jamaica we are able to have continuity. While the morning was bustling, the afternoon was rather slow in the A&E which is proving to be the trend. I think with all the damage from Hurricane Sandy there is limited knowledge that the A&E is up and running and ready for kids. This did give us the chance though to follow up on our patients from the wards and it was really rewarding to know that all of the LPs performed yesterday were normal. It was also nice to see all the precious patients again too. We ended the afternoon with a snack from the Tuck Shop, the local eatery here at the Hospital. We had beef and cheese patties, curtesy of Dr. Marshall, one of the A&E physicians. We were warned that Jamaicans have heartier stomachs so we can only blame ourselves if there are negative repercussions from our eating adventure. It was totally worth it though…patties are delicious!







We’re heading back to the resort. It’s cloudy and cool here…maybe another cold from is moving in. After our late night watching the steel band we’re planning on naps and an early dinner. I say that but the idea of kayaking is being thrown around because even through our exhaustion we want to take advantage of the amazing opportunity we’ve been given. Well see 🙂

S&S

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11
March

It stopped raining!!

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Stevie and I decided to blog every few days so here is our next update.  This rotation continues to be amazing.  It’s a great opportunity to help people  in need, sharpen your physical exam skills, learn from experienced clinicians and enjoy the beautiful country of Jamaica.  Friday was our first day at Port Antonio.  This hospital is over an hour away but the drive is breathtaking in areas– you can truly see multiple aspects of Jamaican culture en route.  When we got to Port Antonio, I took care of all the kids in the A&E and Stevie went to clinic.   There actually weren’t supposed to be peds patients in clinic on Friday but because Issa Trust has done such a great job of bringing in pediatricians, the community has learned we are now there on Friday.  As soon as word spreads that the pediatrician is there, the patients arrive.   Stevie took care of many interesting rash referrals from simple vaginal candidiasis to disseminated scabies to a complicated rash which was likely super imposed with a staph/strep bacterial infection.  Often times these rashes have progressed past stages we see in the US.  She asked several of the patients to return next week so we could follow up on their progress.  Look at that continuity of care even while we’re in Jamaica!!  In the A&E I saw several typical pediatric emergency patients — asthma exacerbations, gastroenteritis with mild dehydration and an interesting 8 week old with a large lateral neck mass whom I referred for an ultrasound and asked mom to return with the results.  The physicians and the patient families are very appreciative of our being there.  I had two of the physicians I worked with explain to me how helpful it would be to have a pediatrician on staff at all times but unfortunately in Jamaica that’s just not feasible.  All the physicians there are fabulous but they’re not pediatric trained and they are super busy with 3 of them covering almost the entire hospital.  It’s a clear that having an extra set of hands on deck can really help!!  I had one mother tell me that she’s wanted to see an actual pediatrician for so long and was so happy to hear earlier that week that we were coming on Friday!!  One final note about Port Antonio that I don’t want to forget to mention– it’s beautiful and Stevie and I went to explore the city during our lunch break.  It’s bustling with life and unfortunately we didn’t quite make it to the pier (we had to get back to the kiddos) but perhaps we’ll have icecream on the pier next week!!





This past weekend was the best weather we have had in Jamaica yet!!  Although I will admit Stevie and I both got a little too much sun on Saturday!!  Our weekend started Friday night with a lobster dinner at a fabulous restaurant at the resort.  After eating way too much for dinner, we enjoyed live music and delicious wine– the combination definitely had us dancing in our seats!  Saturday we spent the morning laying out on the beach relaxing and then took a catamaran  cruise in the afternoon.  The cruise was perfect– tasty drinks, driving the boat, swimming in the ocean and completing it all with an awesome dance party with all the others on board.  On Sunday we participated in our first excursion away from the resort when we went ZipLining through a mountain rainforest.  This was perhaps the coolest thing I have ever experienced.  We took a sky walker to the top of a mountain, went on 5 zip lines and then went “bobsledding” around the mountain.  This experience was amazing and I recommend it for anyone in Ocho Rios!!  The weekend concluded with an amazing Asian dinner at Bayside restaurant followed by a gorgeous night on the rooftop bar.  I continue to be grateful to Issa Trust for not only allowing us to take care of these adorable kiddos but also to get to experience this country in a way that otherwise would have been impossible during residency.  It’s true in Jamaica, no problems man!!





Now back to the real reason were here, to help the children of Jamaica.    Monday was spent back at Port Maria.  The morning started out much slower then it had the previous Tuesday but by the end it had picked up and we’d seen plenty of rashes, ear infections, respiratory infections and viral gastro.   We also saw several of the follow up patients from the weekend.  The afternoon can be challenging because often the lab closes and the pharmacy closes well before you are done seeing patients.  Sometimes you feel like you are treating patients without all the information.  However, you learn to trust your physical exam and your gut (sick vs not sick).  You also have to educate parents about what to watch for at home and when to bring the child back.  The same is true back home but it sometimes feels magnified here!  All  in all, another great day.





We just got back to the resort and it’s gorgeous today so we’re off to enjoy this weather!!




Sunburned but still happy

S&S
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08
March

Procedures

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You will find that there will be many opportunities for procedures, some as simple as drawing blood and placing IV’s.  The physicians are responsible for collecting all blood specimens for urgent lab testing and for placing IV’s in those patients who are to be admitted.  I found this a bit daunting at first as I do not get much opportunity to perform such procedures at my home institution.    As when performing any procedure, I would recommend familiarizing yourself with the equipment first.  I had to remove a perfectly placed IV simply because I did not know how to secure it once it had been placed.

There is also quite a bit of obstructive uropathy secondary to benign prostatic hypertrophy.  This has given me the opportunity to replace several urinary and suprapubic catheters while I have been here.  While they have all of the supplies you will need, they are not all assembled in an organized kit.  It can be quite difficult to get everything together without the help of a nurse, and on a busy day in the A&E the help of a nurse is not always available.

I have also had the opportunity to do some suturing.  In both cases it was man versus machete, and the machete won.  Most cannot remember the last time they got a tetanus shot, so they all get one for good measure.  Most are not familiar with the term Tetanus but rather know of the disease by “Lock Jaw.”  In both cases the patients were very cooperative and the suturing went quick and easy.  I understand that sutures can be in short supply at times, so I found myself being very conservative with my thread so as not to waste.  In any case I can’t even imagine how difficult it would be to perform any of these procedures on kids, like my wife had to do!

Drew
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08
March

The Medicine Wards!

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Over the past month I have had the opportunity to participate in Ward rounds at Annotto Bay Hospital, Port Antonio Hospital and at St. Anne’s Bay Hospital.  Each had their unique challenges.  Port Antonio Hospital is a local hospital in a fairly remote location.  The “house officer” on duty is in charge of both the male and female medical wards.  A lot of the cases are similar to those that I have seen in the states including Hypertensive Emergency, Hyperosmotic Hyperglycemia State, Exacerbation of Congestive Heart Failure, and Stroke.  The resources are limited, and as I have shared in previous blogs many of the diagnostic tests have to be done privately as the hospital does not own a CT scanner, Echo machine, or Ultrasound.  The “house officer” that I worked with was very kind and sought advice on how he could improve in caring for his patients.  Given the tough circumstances I think he is doing an outstanding job.

Annotto Bay hospital is a referral hospital of sorts.  The female medical ward is currently undergoing repairs after it was damaged by Hurricane Sandy.  This has required intermingling of male and female patients on the male medical ward.  There is also overflow of patients onto the male and female surgical wards.  The construction is almost done and they should be moving the patients in the coming month.  Here two “house officers” and two “interns” manage both the male and female medical wards with input from a “consultant” who is board certified in Internal Medicine.  I would equate this to the attending, senior resident, and intern model.  However, the consultant is not their everyday, and may only physically round on patients 2 or 3 times a week.  He is always available by telephone if needed.  When he is there he is quick to teach and share his experience.  Annotto Bay has similar limitations and most of the diagnostic work-up must be done privately.  They do have the ability to perform basic x-ray and laboratory tests.  The morning is filled with pre-rounding and then rounding with the consultant.  The afternoon is consumed with coordination of care and phone conferencing with specialists in Kingston.  Discharges are performed in the afternoon, and their seems to be a disconnect between the hospital and the primary care physicians at the health centers.  There really is not good way to communicate hospital details to the physicians in the community.

I have spent the last week at St. Anne’s Bay Hospital which is the regional referral center.  The hospital is about twice as large as Annotto Bay hospital which is about twice as big as Port Antonio.  The hierarchy is similar with consultants, house officers, and interns.  Annotto Bay hospital is equipped with ultrasound and fluoroscopy, however, I understand that the ultrasound machine has been over heating and they are currently limited on the number of ultrasounds that they can perform each day.  Major testing such as CT scans and echocardiograms still have to be performed privately.  They do have two beds in a “High Dependency Unit,” which would be equivalent to our ICU without ventilators.  They have telemetry, continuous pulse oximetry, and they have one nurse that cares for the two patients.  I find that the cases are a little more severe at St. Anne’s Bay.  For example, a young many with Ackee poisoning, known to cause hypoglycemia and anion gap metabolic acidosis, had to be transferred from one of the smaller local hospitals to St. Anne’s as they lacked the resources to complete his work-up and give him adequate treatment.  Even with his transfer the patient did not do well and subsequently expired.  I can’t help but wonder if his outcome would be different if the proper resources were available.  The physicians are well trained and are as efficient as the system allows.

Drew
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08
March

Blog, Uncategorized
 
Our last few days in Jamaica have been spent at St. Ann’s Bay Regional Hospital. It has been wonderful to see the referral hospital. The pediatric unit is large and attached in a small room is the special nursery. The nursery has 2 ventilators and the physicians and nurses are very proud that the ISSA foundation donated the ventilators. While asking about the ventilators and how they monitor the neonates on the ventilators I was shocked to learn that the portable x-ray machine broke down months ago so the neonates never get a CXR. They also have a difficult time obtaining blood gasses. They don’t have CVN and the physician told me that the babies just get D5 0.2NS and starve. It was also interesting to note that they don’t have central line kits and many times use a foley catheter for a UVC. They are very innovative in the nursery and on the wards. They have learned to rely on physical exam findings instead of labs and images.

On the pediatric ward I see lots of asthma, bronchiolitis, and URI’s. The turn around rate is fast. Most of the children stay the night and get to leave the next morning. The beds are very close together and there is only room for a small chair (like a school room chair not a nice recliner.) Many of the parents sleep in the chair overnight so they can be close to their children. The parents that have been there a long time even sleep during the day in the chair because they are so tired. The children usually just sit in there beds and color or read but, I noticed a small playroom attached that has books, a TV and some games for the kids to use. I noticed that no one ever used the playroom. This morning I arrived at the pediatric unit early and asked why none of the kids are ever in the playroom. The nurse said it was because they needed a supervisor and the nurses are usually to busy. I told them that I would supervise the children and they gave me the key to the room. The kids were excited and after breakfast came to play. They loved the room and were sad to leave when rounds started. I was sad I couldn’t play more but was sweating profoundly after pushing children in carts and entertaining them.

The resort is AMAZING. Everyone has been so wonderful to us and they call doc wherever we go. The food is amazing and there is a large variety of food. The activities are wonderful and Drew even got scuba certified so we can go diving together. I couldn’t ask for better service or a nicer place to stay. It truly has been wonderful.
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07
March

We are here!!!

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So this is our first blog of the trip and Stephanie and I couldn’t of had a better first few days. I’ll admit the rain hasn’t been our favorite part but the country of Jamaica is so beautiful it makes up for it. I’ll start with our lodging which is too good to be true. Staying at the Couples Tower Isle Resort is amazing. It’s gorgeous, well-kept, and staff treats you like old friends. They all knew our names by the first evening and we were often referred to as “S&S” for Stephanie and Stevie. The food is plentiful and there is so much variety. The entertainment is full of flare and the music has tempted both of us to get up and make fools of ourselves after dinner every night. From crab racing to the steel band you won’t be bored.


Now to the reason were really here. The kiddos. Our first day of work was spent at Port Maria. Stephanie worked in a room off of the A&E (Accident & Emergency) and saw a good number of kids. She saw everything from ear infections, pneumonia, seborrheic dermatitis, and and chest pain. We should of brought an otoscope but they have one there and you can easily walk patients into the A&E to use it. I was in the clinic at Port Maria which was bustling with well child visits and vaccinations. I acted as the referring pediatrician and was sent any child with a medical complaint during their well check. I saw many URIs, pneumonia, eczema, tinea corporis, and even a septic hip which was referred for admission. They have basic lab work and radiology there which is wonderful because you can send a patient over and have them return with the image or results in real time. There are limitations especially with the pharmacy, for example they have no oral third generation cephalosporin but you can give IM Rocephin. Another challenge we faced was a common one in pediatrics, parental desires and concerns. For example, the child with the suspected septic hip had been see just 2 days prior and referred for hospitalization but the mom refused because she wasn’t allowed to stay. We resolved that concern by referring to St. Ann’s Hospital because parents can stay but the mom could not travel there until morning. Luckily we were able to give a dose of Rocephin along with a referral form stating everything we wanted done. The mothers in Jamaica are very attentive and great historians (which helps because you often can’t make out anything from the charts). They can tell you the exact age of their infant down to 8 months, 13 days. They can also list medications and dates of previous appointments with other physicians…all wonderfully helpful.



The second location we’ve visited is Annotto Bay Hospital which is located in a very rural area. We spent our first morning in their pediatric ward and they had 8 patients total, 2 being social cases (you don’t round on those). We saw a patient with epilepsy, one with nephrotic syndrome, and many premature babies. There was a great deal of teaching done on rounds by Dr. Ramos. We then went to their A&E that afternoon which is currently still undergoing revision after damage from Hurricane Sandy but is actively seeing patients. We walked into a physician treating an asthmatic who had already received 3 rescue salbutamol treatments and was still breathless. They were planning for steroids and admission just as we would in America. There were very few children that day so we were able to return to the resort where we participated in the spin class which kicked our butt! We followed the class by relaxing at the poolside grill and having cheeseburgers and delicious onion rings along with some Red Stripes. A little counterintuitive but hey…we’re in Jamaica, no problem man.


Today we returned to Annotto Bay for well child clinic. As we walked in there was a line of mothers and babies as far as we could see and we immediately got to work. We were able to share an exam room and bounce questions off of eachother which was great. As physicians you are constantly learning not only from your patients but your colleagues as well. Our number one goal with each newborn was to ensure adequate weight gain and I don’t think either of us saw any baby that had trouble with this. Jamaican mothers are dedicated to breast feeding and there’s little stigma to openly feeding in public. If the baby was healthy they did not have to follow up but they were reminded to take their infants to the health clinic at 6 weeks of age for their vaccines. We also saw many hospital follow ups and again the mothers were excellent historians in these cases. Our physical exam findings were sharpened today and we saw an infant with an ear tag and pit that we referred to receive an abdominal ultrasound looking for any renal abnormalities. We also saw a baby with ophthalmia neonatorum (aka bacterial conjunctivitis) that we treated with IM Rocephin, PO erythromycin and tetracycline eye ointment. We also saw a lot of umbilical hernias of varying sizes and spent a lot of time counseling moms about when they would resolve and signs of incarcerated bowel. We then finished up the day in the A&E and saw a child with 3 days of cough who one week ago was put under general anesthesia for circumcision. After a detailed history of no fever, URI symptoms, or history of asthma along with a benign physical exam we were left with possible post-extubation irritation of the larynx and treated him with a one time dose of decadron, like we would for croup back at home. We also saw a little boy with new onset enuresis and increased urinary frequency x 1 day who had a UTI. We did the urine dipstick ouselves after having him urinate in an old medicine container and then interpreted the results from colors on the urine dipstick. It was interesting. We also had to convert mmmol/L to mg/dL when interpreting his blood glucose. We left today as a transfer came in from Port Antonio which was a newborn with hypoxia who was grunting and retracting. History included meconium stained fluid, Apgars of 7 and 7, and SpO2 of 87% at 10 minutes. We would have loved to help admit the patient and wrote orders but they were already on their way to the ward. Our differential included TTNB (transient tachypnea of the newborn), meconium aspiration, congenital heart defect, or sepsis.


It’s raining here but were enjoying the inside of our resort and the wonderful food and beverages it provides. It’s been a great first few days and we can’t wait for more.


Tanless but happy 🙂 S&S
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