Observations and recommendations

 
I am now at the end of my rotation, and it has been a good one. I have worked in many countries before, in many different contexts and capacities, and they are all different. What stands out about this particular site is the commitment from Issa Trust and Diane, and importantly from the Jamaican Ministry of Health to fill in the gaps of quality pediatric care. Ideally, of course, the rotation of doctors is a temporary measure, with the real goal of increasing the cadre of local medical personnel knowledgeable about pediatric care. The foundation attempts to do this through their lecture series, and I have heard the medical officers formulate plans based on what was learned from the most recent lecture. And while this is an amazing resource for those who can attend, the majority of children continue to be seen by medical officers who have not attended these sessions. In the absence of trained pediatricians, the medical officers working at the health centers and in the A/E would benefit from a “pediatrics for the general medical officer” curriculum. So for those to come, I highly recommend imbedding quick presentations for the A/E and health center staff on a regular basis. What has surprised me tremendously is the degree of medico-legal fear among practioners here. While we often think of resource limited settings being ones in which diagnostics are curtailed and clinical judgement emphasized, what I have found is that it is a bit of the opposite. I have ordered more labs here than I have in almost any other country in which I have worked. Of course, this only stands true for the routine patient. What is clearly lacking is the ability to make more complicated diagnoses. For instance, I admitted a 14 y/o girl last week who most probably has autoimmune hepatitis. I was able to get an Ultrasound, monitor her LFTs, but getting an ANA or other rheumatologic markers is nearly impossible. OK, now for the nitty-gritty: Resources I used most  over the month include Medscape, Harriet Lane, though mostly for the growth charts, and epocrates. A dermatology reference would have been helpful. I didn’t find a great need for any books dedicated to low-resource settings, for most resources are available in Jamaica (though the distance for travel is great, the cost is free). Nor did I find the need for any tropical medicine books. There is a canister of urine dipsticks at the villa that check for leukocytes and nitrites. The ones I’ve seen at the clinic are the ones used for pregnancy, focusing on glucose and protein. All the  places in which Issa works have on-site labs and so can always send the kid to the lab for a formal u/a as well. Turnaround time on x-rays is great, usually within the hour, or even half-hour, during the day. Most commonly encountered conditions: viral URI/ AGE, impetigo, eczema, seb derm, scabies. asthma, obesity in children (getting to be a big problem, and more commonly encountered than underweight), anemia. I’ve been treating everyone for worms per WHO guidelines. I have not seen anyone dispense zinc for diarrhea, and when I asked about it, I was given a blank stare. So again, think US practices and guidelines over WHO ones. Overall, it’s been great here, and I look forward to returning sometime soon.    

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