Archive for May, 2011
During the second week of our stay, I enjoyed rounding with Dr. Fisher and the ward team on the inpatient service. There were several interesting cases ranging from rule out kawasaki disease, seizure disorders, and asthma exacerbations. There was one case where a parent believed that bad spirits were causing the medical disorder, and did not believe giving the anti-epileptic medications recommended to treat the disorder would help, asking instead to take her child out of the hospital to see a medicine man that day. One of the doctors and an ambulance worker explained to me that there are people with voodoo beliefs and they can be suspicious of medical treatment, preferring to go instead to those they believe can make the bad spirits go away. This can present as a challenge for medical doctors who are trying to give a child the medical treatment they need and to educate a parent about the condition.
The following day, we had a short clinic day where I saw several well checks, a follow-up for sickle-cell disease, and a girl diagnosed and treated for kawasaki disease whose coronary aneurysm had resolved and was getting ready to graduate the clinic. I was surprised to hear that there was no clinic in the afternoon, and then was informed of a special event that afternoon where the ISSA Trust Foundation was donating incubators and a combination incubator and ventilator to Annotto Bay! Everyone was very excited because this equipment would help improve the care of premature babies in keeping them warm instead of having to improvise by wrapping them in cotton which is not as effective in maintaining their temperature. It was a very exciting day for Annotto Bay!
Here is a link to an article about the event ~ Incubators for Annotto Bay.
The following day, we headed towards Port Antonio, which was a 2 hour drive. We were very thankful for the kind employees who drove us back and forth to this hospital where there are no pediatricians. We helped run rounds where we saw a sick baby with abnormal electrolytes and a boy with sickle-cell pain crisis and acute chest syndrome. We made recommendations to get a CBC, BCx, CXR, and give oxygen and were concerned enough about the progression of one of the children that we called over to Annotto Bay for a possible transfer. I was informed later that the baby’s electrolytes normalized, but the patient with sickle-cell ended up having to be transferred to Bustamante. It is nice to know that we can easily call the ward team or Dr. Ramos with any questions about patients who give us reason to be concerned. One thing that struck me after having rounded on the patient with sickle-cell was that there are no pediatric subspecialists on the island particularly hematologist-oncologists. That is still a fact that I am trying to digest.
Afterwards, we attended to clinic and did not eat lunch in order to see all the patients there. We ended up having to split one room which felt chaotic but were able to see everyone by the time we had to leave. Overall, we agreed that there seems to be a great need for pediatricians at Port Antonio and were thankful for the experience to participate in the care of children there.
Port Antonio Ward
That weekend, we had the pleasure of having dinner with Diane Pollard, Dr. McConkey, her husband, and two Biomed volunteers. It was such an inspiration to hear their ideas and new developments coming in the future for the hospitals and the rotation that will make a positive impact by improving pediatric care. During my experience here, I have had times where I initially felt powerless as a physician when certain resources were not available, but after these weeks, I realize it is empowering to know that one can help out by donating needed resources, spreading awareness, or volunteering.
After a long busy week, we were able to enjoy Jamaica by going bobsledding and ziplining through the Jamaican Rainforest at Magic Mountain in Ocho Rios. Here is a beautiful view from a sky lift showing the coast.
This week began with two days in Port Maria, with my colleague spending time in the A&E while I worked in the clinic. Here’s a photo of the front of the clinic. Each day we arrived to a line of people who have been there since 8 am waiting for clinic to open. It seems to be first come, first served with the clinic starting at 9 am.
It was Child’s Day on Tuesday so we got to see the children for their well checks. While seeing babies, I found a measuring tape useful to have since we measure the length and head circumference of each baby ourselves. I looked up each growth percentile in my Harriet Lane Handbook to ensure that the babies were growing well. There aren’t growth charts in all of the paper chart files due to resources, so we document everything by percentile in the paper charts, which is helpful for the next person who sees them in terms of following a growth trend. Also, if you think a baby is jaundiced and you want a bilirubin level, after 11 AM you would have to draw it yourself in clinic and have it dropped off at the lab. I was really surprised to hear from the lab how much blood is actually needed for a bili draw as the lab or nurses usually draw it at my home institution. Dr. San and Dr. Win have been a great help in asking questions about what is available in the pharmacy here and what is used to treat patients for certain diseases. The cases we saw ranged from scabies to viral gastroenteritis to parental concerns about worms.
One thing I take for granted in the states are strep swabs. In the states, if you hear a complaint of sore throat and suspect strep, you can get a strep screen and if it’s a positive treat, which is important to prevent the complication of rheumatic fever. Here, there is no rapid strep screen so if you suspect, you treat. Dr. Win told us that there have been cases of rheumatic fever this past year and it reminded me of the child I saw last week who was being treated with month shots of penicillin for the past year after being diagnosed with rheumatic fever. I have only seen one case in the states of Rheumatic Fever and here it is definitely more prevalent.
On the second day of clinic, I saw this adorable 2 year old boy who had right periorbital cellulitis with bilateral bacterial conjunctivitis. I had the child admitted for IV antibiotics and observation and found out from the other ER doctors to refer him to A&E for admission. Port Maria also has a ward which we haven’t seen yet and I assume he went there since I did not see him the following day at Annoto Bay. One of the benefits of having electronic medical records back at home is being able to follow up on kids to ensure that they are seen and admitted.
After a busy day at the clinic, we have our 30 minute drive back to the resort. Here is a view of driving through Port Maria where you can see different stores and daily life.
At the end of the day, it is always so nice to come back to the resort. We have been welcomed by such friendly people and my colleague and I are always amazed of the beauty of this country.
Hello from Jamaica! It has been a wonderful first week and after getting settled in, we started our first day of clinic this Tuesday at Port Maria’s clinic and A&E department. We split up our time between the A&E and clinic but the ED was slow with not much pediatric cases so we both ended up working the clinic which was busy with pediatric patients. I ended up seeing 9 patients or so the first day and it was pretty busy in the morning! One difference I noticed was the lab is open in the morning for several hours and if you miss that window, you have to draw your own labs which we ended up having to do. A CBC is fast to run with results in 10 minutes, but we sent for coags which ended up being a send out and can take 3-4 days and cultures even longer. It makes you really think about whether you really need those labs and how to manage your patient, given your clinical judgement, knowing that it may take a while for labs to come back. I saw several gastroenteritis cases, a primary herpes gingivostomatitis, asthma exacerbations, and well checks. It all seemed similar to urgent care clinic that I see back in the States. In the beginning of the day, there was a long line outside of the clinic but by the afternoon we were able to finish seeing everyone. Week 1 – welcome to Jamaica
The next day we went to Annoto Bay Health Center and participated in rounds on the ward. The set up had all the beds and cribs in one room with a mixture of pediatric ward, NICU, and well baby! I was really impressed by the rounding, the residents, and Dr. Ramos whose teaching was thorough and engaging. There were interesting cases from r/o sepsis, r/o ITP, RDS, IDM to discuss and it was basically sit down rounds. There is also a need for certain medical equipment including neonatal blood pressure cuffs which the physicians are working on getting and hopefully will come soon.
Today we had clinic at Annoto Bay Clinic and again saw a huge line of patients until everyone was seen. I saw a kid for a well check with a h/o rheumatic fever which is more prevalent here in Jamaica, as well as newborn well checks and urgent care visits. I did spend time making sure to give dental education for my patients during their well checks since there is not as much access to dentists here. It has so far been an amazing experience thus far and we have been so grateful for this opportunity!
Posted by Rachel Ng, MD (a third year Internal Medicine resident from Kaiser Permanente, San Francisco who served, in Spring 2010, a global health elective at John F. Kennedy Memorial Medical Center in Monrovia, Liberia through the Yale/Stanford Johnson & Johnson Global Health Scholars Program).
It’s been over a year since my return from Liberia. As I approach the end of my residency training, my Liberia trip will definitely be one of the unforgettable highlights of the past 3 years. Again, I am so thankful for the incredible opportunity and support from the Kaiser Global Health Program and Yale/Stanford Johnson and Johnson Global Health Scholars Program. I hope that the medical students and residents reading this blog (and even non medical readers) will seriously consider doing an international elective, medical missions, or some kind of volunteering trip abroad that will truly enrich your practice as a clinician. Thank you also to other current KP residents for sharing all of your memorable stories and experiences of times abroad.
|Aerial view of Liberia|
This will be my last official blog about my Liberia trip that took place during Spring 2010. In my last entry, I left off at the part of my trip where my teammates and I had the honor to meet with Liberia President Ellen Johnson-Sirleaf. Thereafter, we also briefly traveled off the beaten track to marvel at the beautiful land and seascape of Robertsport.
The final 2 weeks
So it was, energized and ready to head back to the hospital for the final 2 weeks of my trip. Knowing that the remaining time will pass quickly, I treasured, even more so, each moment of working with the staff I have come to know dearly and of seeing the patients whose conditions were now more familiar to me despite not having the diagnostic tools so easily at my disposal as I would have back at home. My patient panel had grown to become a TB service with pleural effusion +/- chest tubes, advance liver disease, pneumonia, cellulitis, and HIV w/ a few presenting with kaposi’s…seemingly not a very good outlook. And some patients inevitably died. However by that time, I had come to terms with the limitations of what the system could provide. And systems issues take time to change. Thus in a setting of what I have termed “medical poverty” (vs. “medical abundance” whereby there is more than enough of the basic medical support in infrastructure, persons, and supplies to treat all general medical conditions)—and similar to what many other residents on the KP Global Health Blog have already noted on the theme of limitations and humility—there is the realization that the art of medicine goes so much more beyond simply offering curative treatment. How much more can be offered by compassion, a listening ear, and the human touch. Below are a few more anecdotes.
My first hospice patient
In the middle of the night, an old man was admitted onto the hospital ward, accompanied by his young son. The patient had apparently not been eating well for the past week or so and was then very weak and confused. He had also stopped urinating for many days. Long story short, renal failure was suspected with major electrolyte abnormalities. No labs available. Hemodialysis did not exist. Patient was treated under comfort measures only and passed away the next day.
Events are perhaps not as scary when it is expected and not a surprise. And somehow, I felt more at peace with his death than any other I had encountered up until then (though still, any patient’s death is never “easy to deal with”). It led me to think how much good could potentially come out of a palliative care service/hospice at the hospital and community. If we cannot cure them of their diseases, at least we can lessen their suffering and preserve their dignity at the end of life.
The prisoner’s pain
Only a few times in my training have I treated prisoners who were still serving their sentence, sometimes handcuffed, and under the watch of nearby guards as they come into the hospital for treatment. This patient came to the hospital with right upper quadrant abdominal pain and a known history of hepatitis C. He was treated for acute hepatitis. As he clinically improved, he however continued to complain of mild lingering pain despite pain medicines given. Upon further questioning, it turned out he did not want to return to prison and thus had hope to delay his discharge but complaining of pain. Being such a subjective experience, he still very well could have had pain, but likely, it was another sort of pain he had—one related to the trauma and injustice he had experienced—per his account. And thus, what I did offer was a listening ear to hear out his story and offering hope and comfort as best as one human being could offer to another fellow human being while in one of life’s troughs. Unfortunately for this prisoner, because he was clinically improved and his acute abdominal pain was resolved, he had to be discharged back to prison.
The NGO community
Every so often, the NGO community in Monrovia would come together at a chosen restaurant for a game night. A fee is paid by each participating group that ultimately goes to the winner’s charity/NGO of choice. Typical of any city that has undergone unrest requiring UN involvement, the capital city was infiltrated with NGOs. Within a 5 blocks radius around the hospital, there must have been at least over 30 NGO offices dotting every street corner. During my time there, the Spain MSF (doctors without borders) announced their planned withdrawal from the country. Often times, the hardest part after a country crisis is not the acute stabilization but instead, the long term rebuilding of a community/nation whereby it once again becomes self maintaining/self-sufficient. Think of all the attention Haiti received after the earthquake. Where do things stand now?
Somewhat conspicuous in their operation around the hospital, was a group of medical professionals from China. They came during a hospital development phase when medical teams from other countries came to help out. Of the different teams, they stayed behind and opened a clinic in the city offering treatments of acupuncture, moxibustion, and other traditional Chinese medicine remedies. One of the doctors on that team gave an interesting grand rounds presentation on meridians and acupoints. The speaker claimed that there were apparently over 600 diseases of internal medicine, pediatrics, ob/gyn, and ENT (ear, nose, throat) that could be treated with acupuncture! Of all places in the world, what a pleasant surprise to find the use of complementary/alternative medicine when traditional allopathic medicine can only offer so much.
Another off the beaten track activity. My teammates and I ventured through near 2 hours of absurdly rugged dirt roads to the infamous Marshall Island. Our interest in this place was based on a just-as-ridiculous mythical story of the “one arm ape” that lived one of the islands. Scientists use to conduct animal experimentation on these islands. However, during the civil war, the scientists fled and the apes remained. At this point, the story became a bit muddled for me. It was not clear whether the one arm ape came about due to a scientific experiment gone wrong or that the ape unfortunately caught a grenade-having mistaken it for food. Anyhow, fortunately we did not catch sight of any apes missing any limbs. They were quite huge—size of 2.5 to 3 average-sized man put together! I’m glad they were friendly.
And finally, the bittersweet day of my departure from Liberia had arrived.
Some of my final thoughts that day as I remember and looking back at my journal entry that day:
1) Next project: think about how to start an adult chronic condition clinic there (for ongoing hypertension, stroke, diabetes patients)
2) Would love to start an inpatient rehab program
3) Maybe in the future…hospice/palliative care service?
Thank you to my teammates, local colleagues, to the patients and their families, and many new friends met along the way, for making my experience as enriching as it was and for helping me see the beauty, strength, and hope of the land and people despite all challenges.
Hope to see you sometime again, Liberia!