Challenges and Rewards

I can’t believe these 4 weeks have flown by so fast! Working with wonderful physicians every day, learning how to manage common, and not so common, illnesses with limited resources, and living on this beautiful island has been an experience I will never forget.  During my time in the clinics and ERs at Port Maria, Annotto Bay and Port Antonio hospitals, I have seen much of the same problems as in the US: colds (which can be any number of symptoms), rashes, eczema, asthma, URIs, sickle cell complications, failure to thrive, etc. However, being the only pediatrician at times, I felt I could offer a sometimes more appropriate approach to the children. Yet, at other times, I needed the assistance of my more experience colleagues in improvising and using clinical judgment without the luxury of readily available tests and imaging I have grown accustomed to.  This month also gave me a chance to make independent decisions (with support available) and build up my confidence as I get ready to leave residency and enter the pediatric world on my own. Nearly every day, I had the chance to put in IVs, or suture or splint – all important skills of course.  Parents appreciated the chance to see a pediatrician and get explanations from a doctor. I remember my very first day when I had to admit a little girl with pneumonia and the father thanked me, saying they had been in the ER all night and no one had diagnosed her or explained anything. Though most of the time it was rewarding, there is is one case in particular I would like to highlight as it was extremely humbling and emotional for me and points out some of the challenges of working with fewer resources and without trained pediatricians in all hospitals.  A couple weeks ago, a mother brought in her 8mo infant complaining of continued fever for at least 1 week and parotid swelling. She had brought the child in to the same ER twice in the previous week with the same complaint and though lymphadenitis and different descriptions of the swelling were noted in the chart, she went home each time with antibiotics. This time, however, she was fussier, in and out of sleep in her mother’s arms, and I must admit the parotid swelling was incredibly impressive and unusual for me. She also had very large non-mobile sub-mandibular lymph nodes. Her mom said was continued to take fluids, though appetite poor. My first thought was mumps – which others confirmed has not been seen in Jamaica in many years – or another viral illness. However, her weakness, ongoing fever for more than a week and such large nodes and swelling bothered me. I got an xray to ensure the masses were not compressing her airway , then decided to draw labs and admit on IV antibiotics. Once we starting sticking her for labs, we noticed she was not clotting well. After getting an IV in her foot, we decided to get a culture. Here, cultures are often obtained through the femoral vein. I did feel uncomfortable with it but a colleague insisted. At this point, we noticed the child stopped struggling against our phlebotomy sticks and was more lethargic. WE placed pressure for several minutes and wrapped the leg tightly. However, with ongoing bleeding and hematoma forming, we were sure this child had a coagulopathy and perhaps in DIC. Though she initially denied any bleeding or bruising in the child, she later noted some gum bleeding at home.  Her HR at been 150 with a fever, a NS bolus was started and soon after, we noticed wheezing and on closer examination, hepatosplenomegaly.  Two melena stools were noted while in the ER as well. Malignancy was now at the top of our differential with the possibility of pulmonary hemorrhage vs leukocyte infiltrate. We were preparing FFP when labs returned comfirming our diagnosis of leukemia: WBC 225K, Hb 4.7, Plts 44K. This was an extremely hyper-leukocytosis and likely already meant she was  having tumor lysis.  As we awaited her type and screen, we tried to get O- FFP and pRBCs but this was unavailable. So we had to wait for the appropriate type – FFP was given ASAP though.   After this, her HR plummeted as well as her respiratory effort and her O2 sats. CPR was initiated and continued for 35min before she was pronounced dead. There is much to learn from this case. Though childhood leukemia has incredibly high cure rates in the US, this is not the case in most low and middle income countries largely due to late diagnosis.  This can often be due to lack of knowledge amongst providers on how children present with cancer as it can be different than adults. I don’t blame anyone in particular, but clearly a few things were missed along the way and there was likely a poor prognosis at this point. However, in a setting where blood is not always readily available, I believe we need to be extremely cautious in how we take blood and how much we take from a child. This was something I discussed with my colleagues there in our debriefings after the case.  I know that we may not have had much a chance to save her, but I will never forget her and will undoubtedly take lessons from this case as I move through my career. It was not all work and sad cases of course and truly had a blast in Jamaica! The resort was incredible – food, beach, entertainment and amazing staff. On the weekends, I explored all over the island. I highly recommend spending a weekend near Port Antonio, the most beautiful part of the island and with famous jerk chicken. Thank you ISSA Trust for this opportunity and I’ll definitely be coming back!