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Hello from Jamaica~
We are loving our time in Jamaica. Here is a run down of a normal week as a pediatrician.

Monday and Tuesday are at Port Maria Hospital. It is about 30 minutes away and is very rewarding. I have been working in the A&E (Jamaican ER) and have loved it. I have a room in the back and all of the children 12 and under wait on benches to be seen. The pediatricians in Jamaica only see children under 12 years old once they are 12 they have to go to adult medicine. Also, there are not a lot of pediatricians at the hospitals that we visit and it is very rewarding to see the patients and be able to explain the diagnosis. I have seen multiple different illness but URI is the most common diagnosis. Because the patients wait so long to be seen (they can wait a full day to be seen at the A&E) they always want to go home with a script for medication in their hand. I do a lot of counseling on cough physiology and what viruses are. Many patients think they need antibiotics and the cough will get better. Most of the patients understand once I explain why they do not need an antibiotic. If a patient needs an antibiotic they usually don’t get the prescription that day. The pharmacy only takes a certain number of scripts a day and once they have that number they won’t fill any more scripts. The patient can go to a private pharmacy but they will have to pay for the medication and many patients don’t have the money for the prescription. If a child needs antibiotics, steroids, or nebs then it is usually best if they get the first dose in the A&E that way if they don’t get there script right away they have at least one dose.

Wednesday and Thursday are at Anotto Bay which is about 1 hour from the resort. Here there is a pediatrician named Dr. Ramos . The days that I have been at Anotto Bay I have been in clinic or in the A&E. The census has been low so I haven’t done any inpatient medicine. The 1st and 3rd Thursday on the month are well baby checks. They get their weights checked at 4-6 weeks and if they are growing well they are discharged to be follow up with their local health clinic. I love the well baby check days. I find that the majority of the mothers breast feed and the babies gain weight well. For the babies that aren’t growing as well formula is expensive. A drug rep from Enfamil found me and gave me 5 large samples that I have been giving out which always helps. At Anotto Bay there are pediatric residents and medical officers who have worked with children for years and are knowledgeable. I had to ask lots of questions on my first day as the medications they use in Jamaica are different from the ones I am used to. They also have different protocols and I found it helpful to ask about admission criteria, asthma protocol, and dehydration protocol. There was a cricket match that we got to watch one afternoon which was a lot of fun. Our driver had to transport a patient and was 3 hours late to pick us up (patient care always comes first. Thank heavens there was a cricket match to watch.)

Friday is at Port Antonio which is 2 hours away. I started in the wards then went to clinic then the A&E. I enjoyed getting to see some inpatient children. The clinic at Port Antonio is also wonderful. I have seen scabies in a 4 week old with FTT, constipation, viral induced asthma, seizure disorder, sickle cell, G6PD, fracture, ITP ect… The patients are referred to see a pediatrician on Friday (and I am the only pediatrician available.) Thankfully I feel comfortable with the complaints and treatments and the patients are happy to wait if they can be seen by a pediatrician.

Medicine is different in Jamaica than in the United States and one of the medical officers put it best by saying, “just do the best you can for the patient with the resources available.” I have learned that the people will listen to your advise if you take the time to explain the diagnosis and treatment. Next week I will write about the wonderful Couples Tower Isle Resort.

Hello to all from Jamaica!

Katie and I have been in the country for a little over a week and are absolutely loving it.  As you can expect it takes a little time to get acclimated to the way things are done here.  For those coming from a large university with an electronic medical record, all of the paper work comes as a little bit of a shock.  We have found that the handwriting of those that have come before us isn’t always the best.  We try to keep our notes suscinct but legible in order to help those that come after us better treat the patients.  The people are the most appreciative and patient you will ever meet.  They line up early and wait patiently to be seen, although, in those cases where only reassurance is needed, they feel better if they have a script for something in hand.  At Port Maria and Port Antonio most of our work centers in the Accident and Emergency Department.  The days go by quickly and the work is fulfilling.  The great part about the end of the day is the adventurous ride home and the great food that awaits us at the resort!

Drew & Katie

I am writing this a little late..but better late than never 🙂 I wrote about the medical part, now my recommendations about Jamaica and the resort.

Things to do:
#1. The steel drum band on Wednesdays is amazing, I went to see it twice. The second time they had a group of break dancers that were incredible!
#2 The acoustic artist that plays his guitar on the beach on Tuesday night is also amazing. It starts late but worth it
#3 We went biking in the mountains one Saturday using the Chukka tour…it was my favorite activity in Jamaica
#4. Climbing Dunns River is really fun and a short little free trip
#5  If you mix the light beer with Ting (the grapefruit juice) it makes an awesome little drink that tastes a little like Summer Shandy
#6  The Catameran ride is fun and worth the trip to get out into the ocean and swim a bit
#7  The spa treatments are excellent and worth the money
#8  They serve lattes and cappucino in the shop by the beach from 10-6
#9. Love their sorbet and ice cream
#10 Fridays are lobster day..take advantage of that 🙂

Hi everyone! I wish I would have kept up with this as the weeks went by but I was having such a great time it was hard to sit down and write. Like the most recent entry I will try to cover each hospital I went to and the resort.

Annotto Bay:  This hospital is currently under reconstruction due to hurricane Sandy so the pediatric ward was located in the old administration section. I’ve seen pics of the new pediatric ward and it looks amazing! Hopefully by the time the next docs arrive they will have moved into the new section and will be again taking pediatric transfers from other hospitals. We only had about 5-8 inpatients at a time due to the limited space but I felt like the experience in the inpatient setting, directly working with the Jamaican pediatric specialists here was very helpful to me. Wednesdays I would show up around 9 am and pick a few patients to see and then we would round with Dr. Ramos and Dr. Fischer around 11 am. There are other general doctors covering the pediatric section available to answer any questions you have and divide up the patients with you. After rounds on Wednesdays I would often head over to A&E (ED) to see any pediatric patients they had there. By that time, there usually aren’t too many children so I would head out around 2pm Wednesdays when there is a driver available. The administration is really helpful in finding someone to take you back so I would just ask for their help each day when I was ready.

Thursdays are clinic days at Annotto Bay. Sometimes there were 16 patients scheduled and sometimes 65. This is a pretty fast paced clinic and they would call the next patient up to see me as soon as the other patient walked out the door, so I found it helpful to jot down a few notes in the chart and do the rest of my charting at the end. I worked again with a general physician and sometimes Dr. Ramos so there is always someone available to answer questions regarding how to refer someone, how to write a script, what is available, etc.

The inpatient unit had a wide variety of types of patients, for example, I saw children with post strep glomerulonephritis, ill asthmatics, meconium aspiration syndrome infants, and osteomyolitis in a sickle cell kid to mention a few.

In clinic, we mostly saw children for asthma check ups and well baby checks. However every once in a while there would be a weird rash, or something more unusual. I actually saw a first time mother who likely had ectopic breast tissue with a nipple in her armpit that was lactating out of her armpit!!!

Port Maria:

At Port Maria, they would send me patients from A&E that they normally would either see in A&E or send to the clinic. The only physicians I had contact with here were the docs assigned to A&E that day. Make sure you let both the nurses in the back and in the front, AND the doc know you are there. They will clean the room for you and send you patients. You are kind of off in a corner outside of the ED, so if you need to ask questions or need more supplies it is more difficult. Try to anticipate what you will need at the beginning of the day and they will grab it for you. Especially because you can’t leave your things in the room. I would grab my computer and bring it with me when I needed to go into the ED for something, and I never left the patients in the room when I wasn’t there with my things. Mondays are pretty busy, I saw anywhere from 15-20 patients on Monday, Tuesdays were much more low key and I saw about 10. So, bring a good book on Tuesdays especially, because Steve (your driver to Port Maria) can’t always bring you back when you are ready. He is usually there by 4pm, but I finished by 2 or 3 most days.

I saw more ED type patients here and often had to make a splint, read xrays on my own, and even admit people. The A&E physicans are willing to do anything you don’t feel comfortable doing, you just need to tell them you can’t or don’t know how to do something and they will take care of it, but usually the patient has to wait much longer then. I had to refer a few people to orthopedics, which is in St. Anne’s Bay (about 1 hour away), they can be seen the next day.

I also ran into problems with meds being available at this hospital that usually are available, such as prednisone, salambuterol, cephalexin etc. It helps to ask your patients to come back and let you know if something wasn’t available. Some of them are willing to go into town and buy the meds, but those pharmacies close early also so if a child really needs something right away try to write for it in A&E. I would send children in to get neb treatments and prednisone before they could go home. You can usually get xrays within an hour and I would just ask the patients to come back with the film that day. Cultures get lost all the time, so I rarely ordered these…If I thought a kid looked classic strep I just gave them amox. I would never do that in the US but cultures take a month sometimes to get back here.

Port Antonio:

This was my favorite place to be. It is a really long drive, I was there 3 Fridays, but the drive is beautiful and felt I was the most useful at this hospital. I saw pediatric referral cases from the NP clinics so I would see some pretty interesting problems. Most of the time I just had to refer them to the children’s hospital in Kingston but it was nice to know that they were seen quicker because I was there. I also would help out in the morning on the pediatric inpatient ward, discussing complicated cases with the general medicine doc. I could do some teaching and there were often complicated cases, such as an 11 yr old with hyperbilirubinemia and sick asthmatics. So my first 30 min-hour was spent on the inpatient ward, then I went to clinic and saw anywhere from 3-12 patients (mostly referrals or kids needing refills for asthma, seizure meds, etc), then I would go to A&E and help out with acute sick cases. I saw anywhere from 2-10 patients in A&E also. I left at 4pm each day, so it is also helpful to have a book along in case your case load is less for that day. Mr. Campbell, the hosptial administrator drives you there and back. He is really friendly and always on time.

I gave a presentation the last Friday I was there. I did a talk on acute abdominal pain in children and it went awesome because 10 people showed up including the surgeons and ob/gyn physician, Dr. Davis. We had a great discussion. I recommend bringing a powerpoint you have done before or something you have prepared ahead of time to present, as they really appreciate the presentations at this hospital. In the past, people have talked about bronchiolitis, vomiting and diarrhea, etc. Ok I am publishing this a little late, I left 2 weeks ago but hopefully this will still help. I will write about the resort next.

It’s my last night in Jamaica, and I have had a great two weeks working here!  I have learned a lot about the medical system here in Jamaica and have seen a lot of patients!  I’ll give a quick run down of the way my weeks were set up, followed by some things that I enjoyed most about the resort, and finally some helpful cultural/medical tips that are different from how things typically go at home!

Monday/Tuesday: Port Maria
This is a rural hospital and is the closest of the three locations.  ~ 30minutes by car.  My day typically went from ~8am-4pm, occasionally finishing a little sooner.  I spent a little bit of time up in the ward, but mostly I worked in a room right around the corner from the A&E (Accident and Emergency) seeing patients (mostly patients from the A&E but sometimes also patients that were being seen for immunizations in the outpatient setting that nursing also thought could benefit from seeing a doctor).  Sometimes it was a little slow at the very beginning of the day, but it always picked up and then there was never a lack of patients to be seen before the end of the day.  I probably saw ~10-20 patients per day.  The volume here was definitely a plus.  One of the general doctors was staffing the A&E, which was definitely a benefit because especially at the beginning, I had questions about what medications were available in the pharmacy, how to get someone referred to get a hearing test, get an echo, or see a subspecialist.  I think that is one of the more challenging aspects of the trip– just figuring out how to navigate the healthcare system here.  The general doctors in the A&E were very helpful.  Sometimes with the volume of patients, it would take some time to find someone to get the answer that I needed for the patient.  Here I wouldn’t recommend bringing the computer with to log patients as you are seeing them (if you are by yourself, because when I had a question to be on the safe side i would bring anything valuable with me in my bag into the A&E to find the general doctor to get the answer I needed… the computer is just one extra thing to carry for this).  Other highlights of Port Maria were getting to do blood draws, an I&D of an abscess, and start an IV (as here it is the doctors that do these things rather than nursing/ancillary staff). 

Annotto Bay
I also had a great but different experience at Annotto Bay.  Annotto Bay had a lot of damage from Hurricane Sandy– the roof blew off the pediatric ward and many other buildings.  Currently they are working in a makeshift pediatric ward, while they are working to repair what has been damaged.  Currently, they are working on the building that was the A&E department. There are two general doctors that were working there each morning and then Dr. Ramos (a pediatrician) would come to round.  It was wonderful working with all of them.  Rounds were a great way to gain some education and insight into how things are done here in Jamaica.  Dr. Ramos also highlights some differences between medical practice and the culture here in Jamaica and what we see in the Unites States.  This educational aspect was very helpful in understanding the people here and gave me more guidance in the information I should be giving for anticipatory guidance for well visits and for caring for common medical conditions here.  On Wednesdays, I would see a couple of the inpatient cases then would round with Dr Ramos and the team.  Generally, Wednesdays finished in the early afternoon.  On Thursdays, I would arrive and go straight to the clinic.  Here we would see hospital follow up patients, patients with chronic medical conditions that needed follow up, referrals, and well baby visits (for an initial hospital follow up and anticipatory guidance after being born– usually were ~1-3 weeks old and if they were doing well, they would not require any further visits, just routine follow up with the health centers to get their immunizations).  The clinic would be a steady flow and there were plenty of patients to be seen.  One of the doctors that I had worked with the day before in the ward would be there with me seeing patients (again, a great resource when you need to figure out how to do a referral, navigate the healthcare system here).  Dr Ramos would also be there seeing new patients himself.  The day would finish once we saw all of the patients that had been there waiting (typically mid afternoon).  Annotto bay was ~45min-1 hr drive.

Port Antonio
I was actually only here on one Friday (as the first week, I had spent an extra day at Port Maria due to transportation arrangements).  Port Antonio is ~1hr40-2hr drive.  One of the administrators from the hospital drives you both ways.  I spent the morning here doing inpatient (seeing the 11 inpatient patients–bronchospasm, rule out sepsis, 2 social cases/holds, a burn patient, dehydration/GE), then in the afternoon saw ~10 outpatients.  The outpatient area was a little further away from the A&E so it was a little further to go to find someone to help you arrange a referral/further care for a patient.  The benefit was that my husband, who is also a physician, was here with me for the second week and he could run up to find what we needed for someone while I kept getting a history, charting, examining a patient.  Again, Port Antonio had a good patient volume.  Seeing patients in the afternoon there was a slight disadvantage because by the lab was then closed so there was no way to send someone for lab results and then have them wait for the results so I could see them before the end of the day.  There were a couple patients that I sent for labs and then had to just have them make the next available appointment in the clinic to follow up.  It was definitely a busy day there though! The people were very patient even though they had been waiting since the early morning to be seen.

The Resort Highlights:
We did the snorkel trip out to the reef and enjoyed getting to see some fish– not as much quantity wise (we didn’t see schools of the same species), but we saw plenty of colorful different fish.
The food is really good with a great amount of variety.  We enjoyed eating at Eight Rivers, which was probably our favorite.  We spent a lot of time eating at The Patio and had some great pasta and snapper.  The staff is really friendly and the service is great!  Everyone in the restaurants, working at the bars, the entertainment team was very friendly and nice!  I have heard great things about the steel drum band that plays on Wednesday nights, but unfortunately we missed it!  Monday nights is a dinner buffet beach party which was really nice as well!
We spent a lot of our down time enjoying some amazing weather on the beach and swimming.  The weather was a little up and down the first week with some rain, but the rain here usually doesn’t last long.  A lot of times it will rain during, the night or early morning hours, but by the time you are leaving to go get some breakfast– it is all sunshine.
We would fill up the couples resort water bottle with ice water for the day to bring with us and brought little sandwich bags and would pack some pastries, cereal or fruit from the breakfast buffet to snack on for lunch at the clinics.

Some helpful things that I learned:

Asthma/Bronchospasm:  They do have spacers available at private pharmacies but the patients do have to pay for them.  I had not really thought about how nebulizer machines wouldn’t be as readily available.  One of the doctors mentioned that she sometimes tells families to do a makeshift spacer if they can’t afford to buy them by having them put an inhaler into the bottom of a paper/styrofoam  and then hold the open part of the cup up to their mouths.

Eczema/Dry Skin (especially in babies):  In Jamaica many families will put chemicals/potential irritants into the bath water (which I initially didn’t know to ask about).  These things include baking soda, blue (which is like a laundry detergent), etc.  They also will often bathe the baby in cold water and frequently will use wet wipes on the babies faces.  I found this information helpful so that I could tell families to avoid these things.  They do carry emulsifying soaps which are mild and unscented here which is what Dr. Ramos told me to recommend to families.

Neonatal conjunctivitis:  I was interested to find out that the vast majority of pregnant women with vaginal discharge do not get tested/treated with antibiotics.  It seems that because of this there is more concern for chlamydia/gonorrhea due to the fact that so many cases go untreated in the mothers.

Sepsis in infants:  Blood cultures aren’t as readily accessible down here so they rely on the clinical status of the patient for treatment.  Many babies will be admitted for concern for sepsis and then receive a total of 3, 5, or 7 days of antibiotics depending on how they do clinically.

We had a great experience, both at the resort and at the hospitals.  It was a wonderful educational experience, and we hope that we were able to help some of the children in Jamaica!  The people here were all very friendly and the patients and their families were appreciative! 

It’s my last night in Jamaica

Hi Issa blog family!
Week 1 was a very great learning experience. Port Maria was the busiest of the 3 clinics/hospitals.
There were a lot of sick visits during my 2 days at Port Maris, there seems to be a viral illness going around, causing high fevers, uri, and h/a. One boy who was 13yo had h/a, fever and nucchal rigidity on exam and while my gut feeling was that he probably had a viral meningitis, I couldnt be 100% sure so I walked him and his mother over to the ED dept where I was able to draw labs, send off a blood culture, attempt a spinal tap (which was unsuccessful because there were no spinal needles available, I was using 21g angiocaths); but he was admitted and would receive IV ceftriaxone. He will probably be home by the time I go back next week.

Annotto Bay reminds me most of home; Dr Ramos is an excellent Pediatric clinician and functions as a ward attending; he had 2 pediatric residents and I made a 3rd as I pre-rounded on a few patients as well. Once Dr. Ramos arrives we rounded on the patients with him and he does sit down rounds and PIMPs the residents. One case I took care of was an infant with indirect hyperbilirubinemia, likely 2/2 ABO incompatability; he was on phototherapy however I was not able to discern whether he was getting high intensity; one of his treatments was phenobarb, initially i thought is he withdrawing froms drugs because this is a setting i see phenobarb used, but dr. Ramos explained to me that he was on it because phenobarb aids in liver maturation (this baby was 1wk premature as well). That day I also learned to do a femoral arterial stick! The second day is a well baby clinic; most of the infants born at the hospital get seen at 2wks of age; if there is nothing concerning on exam they are d/c from Anotto Bay clinic and f/u at a private doctor or the various health centers in the parish they live in. I saw an infant with ring worm to the forehead and mother’s lesion was on the R forearm; so I had to treat both with topical meds; there was another infant with an ear skin tag; where I am being trained we routinely do not get RUS as majority are wnl; however I confirmed what was standard of care with one of the residents and they do routine RUS so I gave the mother a lab slip to get it done when she could (she will be paying out of pocket ~10-20,000 Jamaican dollars).
Lastly coming home to couples resort is a real treat; for the real authentic jamaican food definitely the monday night beach party is where it is. Also personal trainer Alfred is really great and will customize a work out plan for you!
Till next week; I am going to read up on tinea infections and meconium aspiration syndrome.
~K. Godfrey, MD

Day 1: First day was on a Friday- the day you go to Port Antonio hospital/clinic, which is in the parish of Portland. The ride was very scenic, and while the roads were winding they were very pristine; coming from the Bronx, NY it was nice not having to go over any potholes!
I totally forgot to bring my camera, however next friday I will so that I can catch some pics of the livestock hanging on the road sides; the local pple selling their produce (ackee, bananas, guineps) in addition to getting a great shot of the houses espetially the ones that resemble mini-hotels…I even think I saw one that was in the shape of a ship..Ill be sure to post of pic of that to convince myself!

Anyway; the hospital at Port Antonia has 2 stories, with multiple areas. The pediatric ward is humble, 1 large room for all the patients and directly across is the playroom/sitting area for families that come to visit their children. I worked most of the day in the outpatient wing; there I was in an airconditioned room…was very grateful for that, as I completely forgot I am in Jamaica and brought a lot of polyester tops rather than cotton (lol). The room is partitioned by a curtain, beyond the curtain is the examining table.
The room had hand snaitizer, soap, a sink to wash hands; papertowels and tongue depressors.
All I really needed to bring was my doctoring tools; and maybe my Harriet and Lane.

The pharmacy is on the compound, I asked the pharmacist for a formulary; which was very handy as I was able to pick out the meds I would likely prescribe before seeing patients. So when I did prescribe something, I just placed it on provided Rx pads and patients were able to get what I prescribed w/o a hitch!

Overall the staff is helpful and pleasant to work with…shot out to Nurse Burks! she worked closely with me triaging patients and obtaining vitals.

The staff here also wanted me to discuss some topics, I did 2 of 6 so far. It was well received and interactive. We talked about Bronchiolitis and Fever in baby (0-60days old); overall they manage these patients well but do to some limited resources may not be able to do everything recommended i.e. urine culture/blood culture/csf culture or spinal tap may not be performed on an infant in that age ranges 2/2 cultures going all the way to Kingston (4+ hrs away) and not returning in time…so they just treat empirically with amp and gent. Or rather than treating initially with amoxicillin for an AOM, they jump right to Augmentin….
That’s all for now; Will see how the other two clinics are.
Ciao! going to enjoy a glassbottom boat ride.

Excited about the trip; hope to learn a great deal!