Part 2 of Learning through seeing and doing

2/21/12

Posted by Amy Westman, MD (a third year pediatric resident from Kaiser Permanente Oakland in preparation for a global health elective in Ocho Rios, Jamaica with Issa Trust Foundation.

One piece of advice for anyone else going there to work, is to really brush up on your IV placement and blood drawing skills if it’s not one of your strongest areas. I have never really been very good at placing IVs in small children. While my pediatric program of course has requirements and time built into our training so that we learn how to do this, there has never been much pressure to get really good at it, since there is always a nurse or phlebotomist to do these things for you. Since I don’t naturally love putting in IVs like some other residents, I haven’t perfected the skill. In Jamaica, however, the doctors draw all of the blood and place all the IVs, so I’ve actually gotten much better by necessity! I was also surprised to learn, that the GPs here, although I knew they saw all ages, actually do some surgeries as well. One doctor at Port Maria said he will do “simple” procedures like appendectomies or inguinal hernia repairs himself, but prefers to only assist on more difficult operations like a biliary atresia repair. He has of course received specific training in surgery as part of his medical training, but I was impressed. At least I can do my own I&Ds and laceration repairs!

The rotation was challenging at times, and looking back it seems that the first and last weeks were the toughest. The first week, of course, because I was getting used to how to treat patients in a different medical system. The last partly because I was, by that time, feeling homesick. The other difficulty was brought on by a discussion I had the end of my 3rd week with Dr. Ramos and I had some realizations about things I had been experiencing that for a while made me feel somewhat depressed. I had grown used to patients and their parents answering everything I said with “Yes Miss.” I tried my best to give education and explanations at the end of each visit and always ended with, “Do you have any questions?” Very rarely would anyone actually ask a question, and most times they would respond with a little giggle or chuckle, followed by “No.” I told this to Dr. Ramos, and he replied, “Well how can they ask a question when they didn’t understand anything you just said.” Excellent point. Even at home, at times it is difficult to explain to a parent what is going on with their child in terms they fully understand, trying to find the words in lay terms while trying to provide necessary education. But in Jamaica, one also has to deal with a language barrier. Even though I had gotten better at understanding the mix of usually broken English and Patwa that most people speak, I also had to ask them when I don’t understand. Could they repeat, or tell me in a different way. But rarely would a parent ask me to do the same. I shouldn’t have assumed they could understand my English. I came to realize that just because they did not have questions or nodded their heads and said, “Yes Miss,” in a lot of cases it probably had nothing to do with whether they actually understood or not. What a doctor says goes, and most Jamaicans would never speak up to say they couldn’t understand me. There is also another aspect, it seems that a lot of time the people just don’t listen to what you say. I would be asked a question, and then as I proceeded to answer they would either start talking about something else, or a few times even got up to leave the office. Anyway, after I realized all this about 3 weeks into my time here, I felt a bit helpless, wondered how much good I had been doing besides just writing a prescription when needed. When a mother comes in with her baby worried because that baby is having reflux (that is not in need of medication), the whole key is helping her to understand what is happening to her baby and why and when it will get better. That is whole point of reassurance, education is the biggest part of it, knowing what is “normal” and what is cause for concern. But after a couple days, I just accepted that this is part of learning and part of working in an unfamiliar culture. It has been an amazing learning opportunity. I hope I can take this experience and become a better listener and a better educator for all people. It has been a very important lesson for me.

Overall, I hope that this whole experience will make me a better clinician in all aspects, as well as improve my cultural competence. I am truly grateful for the opportunity!

I encourage other physicians to take advantage of this opportunity as well. The Issa Trust Foundation has room for 2 physicians here all year round! It would so wonderful if there were always pediatricians there, a consistent presence to serve the children here so they receive appropriate follow-up and care. You will be challenged, you will have fun, and you will leave feeling rewarded. The accommodations here are out of this world! When you have off time, which is every night and the weekends, it is wonderful to be at Tower Isle where you always have great food and entertainment, and can always relax on the beach and read a book, as I so often did after work. There are many opportunities for trips outside the resort if you wish to join them. Please, take advantage of this exciting opportunity to become a better clinician while helping the children of St. Mary and Portland!

So a HUGE thank you to everyone at the Issa Trust Foundation, all the many physicians and nurses I had the pleasure of working with in Jamaica, and to Kaiser Permanente for allowing me the time to have this experience! I plan on returning soon . . .

Part 1 of Learning through doing and seeing

2/13/12

Posted by Amy Westman, MD (a third year pediatric resident from Kaiser Permanente Oakland in preparation for a global health elective in Ocho Rios, Jamaica with Issa Trust Foundation.

I spent a month in Jamaica, parish of St. Mary, working in several hospital clinics. It was hard coming from working in the American medical system to working in the Jamaican medical system, but it got easier everyday. I had the opportunity to see many patients and work with many wonderful physicians. Our goals as physicians both there in Jamaica and here in America are the same, to do what is best for our patients, we just get there in different ways sometimes. 

My weeks began at Port Maria Hospital. The kids that generally showed up for regular clinic that day got funneled to me, or were sent from A&E (the ED), lots of general complaints. The first patient the A&E doc sent me was a consult to rule out leishmaniasis. What do I know about leishmaniasis? I work in California! So I said, “Give me a minute,” got out my atlas of tropical diseases, and read up quickly. Then I was able to say with some certainty that the child did not have leishmaniasis. But that’s how a lot of my experiences were, learning through doing and seeing. I saw the typical childhood problems that I see so often here at home: asthma, eczema, otitis, pharyngitis, and cellulitis. I also saw things that I have never seen before, but now have seen several times and feel confident in my diagnosis, such as miliaria crystallina. So many babies at their well checks seem to have developed it, and at first I wasn’t sure what I was seeing, but after looking it up on the internet (at night after clinic – no wifi or computers there) and seeing it over and over again, I can now confidently tell parents what it is and offer reassurance. 

I am also visiting Annotto Bay Hospital in the middle of my weeks. There I see patients and participate in ward rounds, as well as being in the pediatric clinic where I see kids with problems that are followed by the pediatrician there, Dr. Ramos. More asthma, anemia, and some follow-ups post discharge from the hospital. On the inpatient side the majority of the patients I saw were neonates with suspected sepsis or risk factors. Since it is very difficult to get cultures here (they must be sent to Kingston and most of the time never make it there due to transportation problems or make it there too late to be useful for making treatment decisions), most babies with any suspicion, those who would be a 48 hours rule out in the states, get a full 5 day course of IV antibiotics and then are sent home on orals. 

On Fridays I make the 2+ hour ride (thanks meclizine!) to Port Anotonio Hospital in the parish of Portland, where I visit the wards and then go to clinic. Here they do not have a pediatrician at all, but the general physicians round on the patients on the ward. 

There were so many interesting cultural things to be learned as well. I quickly heard about black dressing, which is tar based, an all-purpose salve for infections and the like. It took me a while to figure out what the mothers were talking about when they said the baby had “coal” (not sure how they spell it!) in his emesis or diarrhea, but I realized they meant mucus. I asked my patient’s parents a lot of questions about things like this as you can learn so much from them about attitudes toward health and nutrition and home remedies used. 

One thing I had to get used to there is that I am always “Dr. Westman,” not “Amy,” at least at the hospital. Here at Kaiser I am on a first name basis with everyone in my program, from interns to attendings and administrators. But in Jamaica, it is more formal. A doctor is always “Dr. . .” and a nurse is always “Nurse . . .” The other doctors and even the interns introduce themselves as “Dr . . .” and I’ve noticed that even when they drop the doctor part, others refer to them by their last name only. 

Another thing that just goes with the territory here, and I presume for all global health rotations or missions, is that you just need to relax and go with the flow. Things are not as tightly regimented and scheduled there as in America, but everything gets taken care of in the end. The patients show up at 8am and register first come, first serve, but will wait all day to be seen, no appointment times. You, as a volunteer there, will always have someone to drive you to and from the hospitals and clinics, but it may not be the same person and they may not pick you up at the expected time. But you will get there and back safely! The doctors mentioned in the orientation packets may not be around, but there is always someone there to help with any questions. Even if there aren’t many clinic patients one day (my wide range has been from 2 to 30, but on average about 20), you can always find other ways to help out like seeing patients in A&E. Just go with the flow, and everything will work out. One of the big things I’ve learned in my time there!

Me (center) at Annotto Bay Hospital meeting with the doctors

Weeks 3 & 4 – Port Maria and Port Antonio

Posted by Chung Lee, MD (a third year pediatric resident from Kaiser Permanente, Oakland serving a global health elective at Issa Trust Foundation in Ocho Rios, Jamaica).

5/31/11

Port Antonio

My last week of Port Antonio Hospital was a slow day on the ward as well as clinic, having only 2 patients to be seen in clinic which was a contrast to the previous week which had us working with no breaks up until the moment we left. One was a young girl I diagnosed with inguinal hernia and referred to the Surgeon down the hall and the other was a 7 month old baby who was unable to make it to the appointment but had been referred for evaluation for achondroplasia. I listened to the social worker who was there representing the mother and she explained how the mother had come several weeks to see a pediatrician but that the weeks she had come, there were no pediatricians available and today both were unable to make it due to a complicated social situation. The baby was apparently disproportionate in size with short extremities and a description that fit but had not been formally seen or diagnosed with a genetic condition. Of note, there are also no medical geneticists on the island in addition to other pediatric subspecialties.

On the way back from Port Antonio, the Ministry of Health employee who was kind enough to drive me back the two hours back to the resort explained to me all of the different type of plants and fruit trees lining the road ranging from banana trees, breadfruit trees, mango trees, and ackee trees. I expressed my interest in trying ackee and saltfish which is a national Jamaican dish. He stated the dish was delicious with breadfruit, but he warned me that ackee that is picked too early can be poisonous. Other people who call this dish the Jamaican Rundown, told me that one has to be careful about who you buy your ackee from but that the dish is very delicious. I asked one of the doctors at Annotto Bay about this, and she told me there was recently an outbreak in ackee poisonings this past year with a spike in the number of cases. Due to ingestion of ackee that has not fully matured, the toxin Hypoglycin will lead to hypoglycemia and symptoms of vomiting, stomach cramps, and diarrhea and in severe rare cases, coma or death. I found this useful information to know and has somewhat dampened my curiosity in trying this fruit.

Ackee fruit

The next two weeks at Port Maria were busy and a week after the departure of my wonderful colleague Dr. Hack, I found myself incredibly busy seeing 26 patients in clinic one day from 9 AM to 4PM. I realized how just like at the end of any rotation, you start feeling comfortable with how things are run right when it’s about time to leave. One of my more complicated cases was a preadolescent boy diagnosed several months ago with HIV but who was not aware about his diagnosis. He came in with 3 weeks of cough and a rash which looked like tinea versicolor. I obtained a chest xray which revealed an infiltrate, keeping in mind that the mother stated he had been on several weeks of an antibiotic which finished a week ago, but now was not on any medications and that his first appointment to discuss his condition was next month. None of this information was located in my paper chart and without any previous labs or other information about which antibiotic he previously was on, I discussed a plan of care with the ER doctor who knew him well and sent him to the A&E for further work-up including a CBC, viral load, CD4 count and initiation of antibiotics.

The rest of my clinic visits at Port Maria in the last two weeks were the same ranging from well checks, scabies, deworming, a variety of skin rashes and referrals to other hospitals for conditions requiring surgical intervention. Three medications that I felt helpful to know were Tropovite Vitamin Drops which contain Vitamin D, Hemafed which contains iron, and Rid Cream for scabies and lice. I would ask to peruse the pharmacy counters before clinic on days I had time because knowing which medications were available in the pharmacy is invaluable to avoid having families paying out of pocket for medications at private pharmacies when alternatives can be easily picked up at no cost here.

Another thing I take for granted in the states are scheduled appointments. I find it hard to take breaks knowing that patients arrive at 9 or 10 in the morning for an appointment. Once a parent even pretended his son was another patient so that he could be seen earlier and I only discovered this after the parent of the actual child asked why they had not been seen yet. Due to this, I have made it a habit of asking the parent the child’s birthdate before starting the visit. I’ve also gotten used to adults randomly walking into my room, even in the middle of a child well check, and start telling me their ailments. I always have to gently cut them off and explain to them that the family practitioner across the hall can aid them and that they have to wait for their turn.

Long lines

Here are a couple of photos of 2 adorable children seen in the clinic: (written consent obtained from parents).

Week 2 – Annotto Bay and Port Antonio

Posted by Chung Lee, MD (a third year pediatric resident from Kaiser Permanente, Oakland serving a global health elective at Issa Trust Foundation in Ocho Rios, Jamaica).

5/27/11

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.

Hello again from Jamaica!

Posted by Chung Lee, MD (a third year pediatric resident from Kaiser Permanente, Oakland serving a global health elective at Issa Trust Foundation in Ocho Rios, Jamaica).

5/15/11

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.

Week 1 Welcome to Jamaica

Posted by Chung Lee, MD (a third year pediatric resident from Kaiser Permanente, Oakland serving a global health elective at Issa Trust Foundation in Ocho Rios, Jamaica).

5/5/11

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!

Saddened to say goodbye

Posted by Thao Nguyen, MD (a third year pediatric resident from Kaiser Permanente Oakland serving a global health elective at Issa Trust Foundation in Ocho Rios, Jamaica).

9/28/10

It did not really hit me that I just finished my one month pediatric rotation in Jamaica until now when I’m packing my suitcases to head back to the States. What an INCREDIBLE month it has been! I think one month is an adequate amount of time to learn about the culture of medicine here in Jamaica and to become comfortable with it to apply to the daily clinic and hospital work.

The one most important things that I learned after working here for a month is FLEXIBILITY. One needs to be flexible and ready to adapt to work in a less than optimal clinical setting, but still be able to provide the best of care.

There are several things in Jamaica that will always be dear in my heart. Jamaicans are some of the nicest people you’ll ever meet in your life. People are always greeting you with a smile and passing around the vibe of “no problem” on this island. The food is inarguably delicious, especially the jerk pork at Scotchies (and I’m not even a pork fan). The children here are so adorable in their crisp and colorful uniforms, holding hands and walking to school together (there is something so endearing about this), always politely addressing you as “yes, miss”, “no, miss”. The lush green vegetations of the mountains and the aqua blue of the Caribbean Sea provide the best scenery that I never get bored of while looking out of the window on my daily ride to the hospitals.

I HIGHLY encourage third-year pediatric residents to embark on this awesome journey. I am thankful to the ISSA Trust Foundation and Couples Resort for its sponsorship, to Diane and Stacey who gave me this golden international opportunity, and to Oakland Kaiser Permanente (my residency program) for supporting me with this brand new rotation. I would definitely do this rotation again in a heart beat.

Below is another cutie patient of mine that I won’t forget (permission obtained from mother).

Week 3: Cruise Control

Posted by Thao Nguyen, MD (a third year pediatric resident from Kaiser Permanente Oakland serving a global health elective at Issa Trust Foundation in Ocho Rios, Jamaica).

9/25/10

I remember my first day of work here in Jamaica, there were a lot of things that I was not familiar with. Now that I am more than half way thru this month, I have established a routine and I am comfortable with it. I am more confident now about my clinical diagnoses, which is the predominant tool that one has here, when there is a lack of resources such as Xray, exotic labs and cultures, CT, MRI.

The diagnosis themes for this week are dengue fever, asthma exacerbation, and fungal infection. Dengue fever is real! The outbreak currently reported to have one associated death and 4 confirmed cases of hemorrhagic dengue fever. This week in clinic on one morning, I saw 5 children back to back who ALL came in with complaints of fever, headache, eye pain, and leg pain. These are classic symptoms of dengue fever. The children looked well and there was low concern for hemorrhagic or shock. I sent them to the lab for dengue fever screening which includes dengue, malaria, hepatitis, leptospirosis. I discussed with the parents that there is no specific treatment for dengue, just mostly supportive care with Paracetamol (that is what Tylenol is called here) for fever and/or pain, avoid use of Ibuprofen and aspirin as there is increase risk of bleeding, and to return if there are any signs of bleeding or changes in mental status.

This time of the year with rain and quick changes in weather, asthma exacerbation is quite common here in Jamaica. I actually admitted 2 children this week from clinic to the pediatric ward for management since they failed to improve after Salbutamol nebulizer treatment in the ED. Salbutamol (international nonproprietary name) is just another name for Albuterol (the United States adopted name). The children on the ward get nebulizer treatment every 4 hours. Often they are not hooked up to any monitor such as pulse oximetry. They walk around on the ward and play with other children. I was thinking to myself when I rounded on my patients on the ward the next morning about how do we know if they desat when they sleep at night? I guess we just have to rely on lungs exam and how they look clinically. I am happy to report that my 2 children did well, likely to go home after being transitioned to Salbutamol MDI and prescription for Beclomethasone MDI.

This week I saw a girl who was referred to me by the medical mission team from CHOP with random glucose of 430. She has known type 1 DM (diagnosed when she was 6). When I saw her I couldn”t believe how well she looked for someone with a blood sugar of 430. She was very pleasant, conversing with me about her diabetes camp experience (they have diabetes camp here!!!!), her insulin regimen at home, and her glucose normally runs between 100-150, so 430 is definitely not normal for her at all. Luckily, she was not ketotic or acidotic based on her labs. We gave her subcutaneous insulin and her glucose decreased to 288, which was still relatively high, despite her well appearance. She was not very happy when I told her that she had to stay in the hospital overnight. However, when I saw her the next day, she was smiling at me and getting ready to go home.

Photos from my drive to Castleton Clinic. 

I spent one day this week at Castleton clinic. It is another one of those small clinics in the rural mountainous region of Jamaica. The drive there is rough but extremely beautiful! The lush green vegetation is mesmerizing, resembling a tropical forest. Coconut and banana trees are abundant. I was not surprised to arrive at the clinic to find it was already packed with patients sitting in a cramped small room waiting patiently to be seen. I WAS surprised when the nurses informed me that there was no water anywhere in the clinic. Thank god for my hand sanitizer! My first patient came in with complaint of ear pain. I asked the nurse for a plastic ear tip but she told me that there was none. I frantically searched my bag and luckily I came up with 2 ear tips. It would have been a challenge to check the ear without an ear tip when someone is complaining of ear pain. For future docs, it is not a bad idea to stock up on ear tips, ear curettes, and hand sanitizers.

She is such a cutie! Look at that smile! (permission obtained from mother for picture). 

My time here is Jamaica is winding down and so far it has been an AMAZING experience! I have learned so much and met so many wonderful people. This is such a beautiful country.

 

Week 2: Work Hard, Play Harder…

Posted by Thao Nguyen, MD (a third year pediatric resident from Kaiser Permanente Oakland serving a global health elective at Issa Trust Foundation in Ocho Rios, Jamaica).

9/18/10

his past week started out rough with a big storm (at least in my opinion), but the native Jamaicans here called it “heavy rain”….not enough wind to call it a storm….but it was pretty scary nonetheless…heavy pouring rain, lighting, and thunder that literally made you jump out of your seat….I have not seen weather like this in a while. Driving to the clinic was of course more challenging with flooding roads and potholes. The drive to the remote River Rock health clinic (located high up in the mountainous areas of inland Jamaica) was so nauseating from dodging potholes and the width of the road barely enough for two cars to pass. My patient load was somewhat affected on these rainy days, but of course it picked up as soon as the sun came out again. Sometime midweek, I was relieved to learn that Hurricane Igor had diverted away from the Caribbean.

The clinical experience themes for this week are newborn exams and school physicals. Actually, it was somewhat refreshing to see well children after so many acute care visits. I learned that over here all children receive BCG at birth or shortly after birth. Varicella vaccine is not readily available so unfortunately it is still not part of the standard vaccination schedule yet.

I have diagnosed quite a few tinea capitis (a very common fungal infection here in Jamaica). What I found interesting was typically in the States, we would initiate oral Griseofulvin for treatment, but here in Jamaica, often the clinicians will prescribe antifungal shampoo and cream as a first line of treatment before considering Griseofulvin. Often cost and unavailability in the pharmacy are the factors. Also monitoring of hepatic function can be difficult as patients often are lost to follow up.

Despite my vigilance about mosquitoes and constant use of repellant, I still managed to get bitten by these crazy bugs….man and talk about pruritic rash….it drives me crazy! There is currently a dengue fever outbreak in Jamaica. I actually saw a patient in the clinic this week that I suspected of having dengue (fever, headache, eye pain, arthalgia, weakness). Dengue fever is caused by Aedes mosquitoes. It is sometimes also known as “breakbone fever” because of the joint pain. Complications include dengue hemorrhagic fever or dengue shock syndrome. Treatment is supportive care. Luckily, most cases of dengue are either asymptomatic or mild. So far I’m good….crossing my fingers.

I finally met the medical mission team from Children’s Hospital Iowa this past week! What an amazing group of people, so incredibly friendly, caring, and fun. The team went to several of the hospitals that I work at, however it was on different days, so I never actually worked with the team. Every night, after a long day of hard work, we would dine together, share stories, and dance the night away, but of course within a reasonable curfew, so we that we were all ready for the next day of work. Today marked the end of their one-week trip. We were all treated to a wonderfully hosted and delicious dinner as a token for our hard work. I will definitely miss them! We will keep in touch most definitely!

As for me, the weekends have turned out quite well since it is the only time I have off. The excursion to Dunn’s River Fall was incredible. My adventurous side took me sailing, kayaking, beach volleyball, hydraulic biking, and a feeble attempt at water skiing (it turned out my feet were too small to fit into the skiing shoes and I was consider high risk since I cannot swim…still working on that). I also got a chance to eat authentic jerk chicken and pork at one of the best jerk restaurants in Jamaica (Scotchies!).

 

I cannot believe that I only have about 10 days left here in Jamaica. Where did the time go? This upcoming week I will meet the medical mission team from Children’s Hospital Philadelphia.

Until next time….

Week 1: Learning the Ropes

Posted by Thao Nguyen, MD (a third year pediatric resident from Kaiser Permanente Oakland serving a global health elective at Issa Trust Foundation in Ocho Rios, Jamaica).

 9/10/10

 My first week in Jamaica has been extremely BUSY! I worked at three hospitals with adjacent outpatient clinics on different days of the week, saw a ton of patients, befriended many Jamaican medical staffs, picked up quite a few native Jamaican terms, learned to tolerate the humidity, AND already am the victim to mosquito bites despite my repellant. I am very much aware that there is currently a dengue fever outbreak warning in Jamaica.

The diagnosis themes for this week are skin infection, skin infection, AND skin infection. I honestly have never seen so many cases of impetigo and furuncles/carbuncles in my entire life. I’ve written god knows how many prescriptions for Keflex. Skin infection is VERY common here in Jamaica considering its tropical weather that is quite inviting for the mosquitoes. The children play outside a lot and wear short pants and skirts making them more susceptible to mosquitoes. Mosquito bites are incredibly ITCHY (I know!), scratching breaks the skin barrier, and leads to superimposed bacterial infection. Many children have scarring on their arms and legs from recurrent skin infections such as the picture here (I have obtained permission from the patient and her mother for taking the picture).

The clinics are very busy. There is always a long line of patients to been seen way before the clinic even opens. Often, I don’t even have time to eat lunch because as soon as I’m done with one patient, the next one comes in, and I just feel bad that they have been waiting for a long time so I just kept on going. At Port Maria clinic, I’m essentially the ONLY pediatrician there, so I get all the referrals from the main health complex and from the ER. One day I saw as many as 23 patients! It’s insane right? On the contrary, at Annotto Bay clinic, the workload is somewhat lighter since there are one regular pediatrician (Dr. Ramos) and one Jamaican resident working alongside with me.

Here is a picture of my office and exam room in Port Maria.

The biggest adjustment for me has been going back to the paper-style medical record. Deciphering handwritings from previous physicians who documented in the docket (medical chart) can be so tricky. Often the dockets are incomplete or out of order and can take sometime to figure out what has been going on with the child. Writing in the chart and prescriptions also takes time. Sometimes I feel so pressed when I know there is probably a long line of patient waiting outside my exam room. To my fellow residents back home in Oakland, California…we are so blessed with our electronic medical record!

Another challenge for me this week was understanding the native accent. Jamaicans speak English as well as their native dialect called Patois. Sometimes the accent is heavy and I can barely understand, but I’m learning. After I talked to some of the medical staff, here are some things that I’ve picked up… “water bump” means pustule that ruptured, “tonic” means appetite stimulant (mothers keep asking me to prescribe vitamins as “tonic” for their children), “du du” means poop…..

The drive to the hospitals is variably long (anywhere from 30-minute to 2-hour drive). The views of the majestic aqua Caribbean Sea and the lush green coconut and banana trees on the periphery somehow miraculously suppress my car sickness and made the drive quite pleasant.  I have yet to use my Meclizine.

Coconut and banana trees, and the Caribbean Sea (along the drive to Port Antonio).

My plans for this weekend:  hopefully testing out the Caribbean water with some fun water sports finally meeting the medical team from Children’s Hospital Iowa.

Until next week…