medical commentary on the maternity ward

I still can’t get over the blood-drawing differences. In fact, one of the residents commented that she’s never seen a tourniquet. I have trouble tying the glove in the right conformation to form a tourniquet, but they’re experts at it. I’m getting pretty good at phlebotomy, even though drawing up blood into the syringe while holding the needle steady is still something I’m struggling with on occasion. I miss the technology we have in the states.

Speaking of technology, have we ever considered the convenience of the tube system for blood delivery to the lab? And to continue with the general lack of resources, the pleasant use of biohazard bags in which to put the tubes of blood?

Behold the box for blood samples! After drawing up a tube of blood, you fill out the paper slip to order the labs, wrap it around the tube, fold down the ends, and put it in the box. Hope you mixed the preservatives in the tube well with the blood—it could sit there ALL day. If you really want something ‘stat,’ be prepared to walk it to the lab yourself and you still might not get the results in a timely fashion.

The lack of resources extends beyond the lack of tourniquets and tube systems. There are no op-sites to tape down IVs with, but just tape. Even that can be in short supply (in fact, we ran out of tape and purple top tubes for CBCs today!). There is no sharps box, but just a cardboard box. Which then adds to the fun because to put a needle in it, you have to recap it—and that puts you at risk for a needlestick injury. (For those of you who aren't aware, health care workers are NOT supposed to recap needles AT ALL. EVER. It's drilled into you. We still do it. Not so much in America, but situations do arise. Regardless, it's the time you're most likely to stick yourself with a used needle and thus, get a needlestick injury.)

Also lacking is a Pyxis system (the fancy term we have for the computerized system on every floor in every hospital in America, where the meds are locked in drawers and only the med drawer you key in for one particular patient opens when you key in your password and the patient's information), or any kind of secured medicine container. 

We have a cabinet.

It doesn’t even close all the way. It doesn’t really matter too much because there are no narcotics or anything particularly frightening in there, there is a small box with more dangerous medicines locked up (misoprostol is about it, though, no morphine here!).

Here’s another of my favorites.

This could be harder to figure out, but there’s a stack of notebooks on the counter. Those would be the booking diaries. You need a c-section? Open the calendar to the day you want to book it! Someone need to be induced? Check the diary to see if we have room! I went down to the OT (it’s a theatre here, not a room!) today to book someone for an emergency c-section; all I needed was her name, age, registration number, ward, and why we’re doing surgery. No signatures, no phone calls, nothing else. The orderlies came and got her later in the day.

There are no computers on the maternity ward (or anywhere else). You generally ask the patient their name while you’re doing rounds, then you go find their ‘docket,’ or chart. In fact, the patient brings their own supplies—receiving blankets and hats for the baby (West Wing aside--babies apparently do NOT come with hats!), pillows, sheet, rags, clothes, etc. There is a refrigerator where they can come to the nurses to buy juice or soda. Food delivery is common, though they do get food trays—not nearly so well stocked as American hospital trays.

This may be my favorite thing that happened today (besides getting all my blood draws)—finding the fetal heart rate with this thing.

I believe it’s called a pinhole, but I’m not sure. The resident actually handed it to me and I just had to say that I had no idea what to do with it. She kindly demonstrated while shaking her head at the thought of dopplers. (Her reaction when I told her that EVERY hospital has electronic medical records was priceless). I will tell you—it works. It belongs in a museum, to me, but it works.

new start in maternity

New week, new placement—this time on the maternity ward. It’s supposed to be OB/gyn, but there’s a separate ward for gynecology stuff, and I don’t think I’ll really end up there much but we’ll see.

It’s rather awkward here starting a new placement because the culture is different than what I’m used to in America. I’m trying so hard to not offend anyone that it makes me nervous to go somewhere new where I may inadvertently do something wrong, sit in someone’s seat, etc.

So the day didn’t get off to an auspicious start. Going into the hospital, your bags are searched by security guards. Mine are not, because I am clearly not Jamaican and also because I wear a Projects Abroad ID badge protecting me. Some of the guards like to talk to me and ask about America, but most just wave me through. To get to maternity, there were different guards who weren’t as friendly, but I found the ward and told the charge nurse why I was there and was directed to wait. Multiple nurses asked me if I needed help, which is always nice. Overall, these nurses are nicer than the surgical nurses. A lot of what is considering nursing care in the US is doctor-level care here, so I never really saw the surgical nurses doing much business nursing, but the maternity nurses visibly do work. I watched them while I waited around for my doctor for about an hour, which isn’t too bad in Jamaica. In fact, the maternity ward has a TV locked away in its small waiting area, so I was entertained. Even more so entertained considering it was a program on food allergies, something I know a lot about (I have charmed Ingrid with the idea of cooking without eggs—she was exclaiming to her friends in the grocery store about it yesterday!).

Collette, from Projects Abroad, came to check on me this morning and how things were going and she started to agitate more to find me something to do besides waiting around. As she is more au courant with the Jamaican culture, I went along with this. We tracked down the doctor to which I was assigned, who happened to be in clinic that day so it’s a good thing I didn’t wait around, and they sent me back to the wards with the doctor who was on wards today. I ended up being introduced to the residents and from there, things went swimmingly!

First off was watching one of the residents write her progress notes. It was fascinating, not only because OB notes are generally different than the traditional SOAP note, but because they use different abbreviation and phrasing here! NAD in America is no acute distress, a general observation or something put next to respiratory findings. Here is means no abnormality detected and can be written next to any system. For respiratory, we would write “CTAB,” clear to auscultation bilaterally, here there’s commentary on the vesicular air flow and something else I didn’t quite catch.

Ward rounds came next, and they’re not that exciting, although I enjoyed the attending playing a joke on the resident regarding the recently delivered mother—she’s not G2P1 anymore, she’s G2P2. They didn’t think it all the way through. (G=gravida, or pregnant, P=parity, or how many children--so she was pregnant twice and had one child, but now that she delivered she's been pregnant twice and has two children).

Then the going got interesting. I mentioned earlier about how some nursing care in the US is doctor-level care here. As such, I got to play phlebotomist and drew blood on four different patients. Never done on a real patient in America and in fact, I haven’t drawn blood since the lab where we had to learn it during second year, practicing on each other. They also do it differently here—in the US, we have rubber tourniquets, and the needles we place in the vein have a place where you put the blood tubes right onto the catheter drawing up the blood. Here there’s a latex glove tied for a tourniquet, and a beveled needle attached to a 10cc syringe to draw up the blood. I wear gloves, but the residents do not. You wipe the site down with alcohol swabs drawn out a jar that the orderly prepared earlier, and the same swab will be place on the site after you draw the blood—no band-aids here. Also, I’m used to my easily visible veins in my pale white skin, and it’s more difficult to see the veins in some of the very dark skinned Jamaicans. But I was proud of myself, I only struggled on the radial draw on a woman for whom we couldn’t find anything in the antecubital fossa. (in English, wrist...elbow crease)

The main part of the day was preoccupied with general admissions and notes and boring things like that, but then the resident asked me give the post-surgical patients their IV Augmentin. There is no such thing as locked up medicines/Pyxis, but you go over to the cabinet and take out what you need. I had to be shown how to mix up the medicine, but that was interesting. Also, there’s no sterile water like I’m used to, in jars or containers. I was drawing sterile water out of an IV bag, adding it to the powdered Augmentin in the vials, and pulling it back up into syringes and administering it to the patients. No IV flush afterwards, and apparently it burned a lot and I wished I could have flushed the lines.

There were then two emergency c-sections, which was interesting. It’s actually the first time I haven’t scrubbed in on c-sections, and it’s a surgery I had seen five times previously, so one with which I’m rather familiar. They suture the uterus together differently here and I was rather fascinated by the suture technique, which apparently doesn’t really have a name and is one of those things that is passed from surgeon to surgeon.

All in all, it was a long day by Jamaican standards, but a standard American one. I left some of the residents on the 24 hour shift, which I’m so glad we don’t do in America anymore.

big week in Jamaica

It’s been a long week in the Projects Abroad world, and the end of my time in surgery. So there’s a lot to recount. I’ll tackle it chronologically.

Monday was a visit to the custos rotulorum, an official here in Jamaica. I had to look up what it meant, but it boils down to the fact that is similar to the concept of a local magistrate. In Mandeville, or the parish of St. Elizabeth, it’s a post held by the Hon. Sally Porteous. She’s a very nice lady, engaging and fun to talk to. It was an interesting visit from start to finish. We weren’t really sure where her office was located, so we were wandering around the plaza looking for no. 14. In Jamaica, number 14 may be near 13 and 15, or could be randomly somewhere else. We were peeking around a corner and found 14 and the custos sitting at her desk; we were spotted. She was sitting at this desk that was totally bare of anything—no computer, no papers, nothing!

Regardless of how she spotted us trying to find her office, we got off to a good start. The Projects Abroad staff members who had come with us had spent the walk over practicing the German names and as always, the pure Englishness of mine was appreciated. I also confessed to the Germans that there are certain sounds English speakers will never be able to make and they think this is funny—no, I cannot reach back in my pharynx and produce those glottal noises!

Lucas, me, and Fabio--an American sandwiched between two tall Germans

It was a productive conversation, sharing with her what PA does in Mandeville in particular, and the future roles being planned. As always, she liked hearing why we’re here and it’s a rather awkward conversation because I know I don’t need any praise for saying that I wanted to experience medicine in another country. It gives me perspective on what I have and how blessed we are in the US, so no thanks are necessary.

The Jamaicans also like to hear the differences in our cultures, and somehow we ended up on how everyone you walk past will say hello or good morning. The custos mentioned that she had been watching Piers Morgan the night before, and he had a feature on about how lonely many people in developed countries are because we lack human connection—things as simple as saying hello and making eye contact with your fellow human beings. How many of us have stood in an elevator with other people and not said anything to them? That kind of thing would never happen here (not that I’ve seen an elevator).

On a somewhat unrelated sidenote, it wasn’t until I was taking photos with the Germans that I realized how tall everyone around here it! Obviously Lucas and Fabio are tall, but many of the Jamaicans are too. I did have a pair in clinic the other day that could not have topped 5 foot, but I’ve been finding myself classified as the shorter person in photos!

The visit and some PA paperwork took up most of my Monday morning, but then I got to come home and do laundry. This is notable and worth writing about because I want to point out how lucky I am here to not only have hot water, but to have a washing machine. Hot water isn’t essential around here because of the heat and cold showers can be nice, but it can get chilly here in the mountains so the warm water is nice. Interestingly, it is warmed via a solar panel mechanism! (We spend a lot of time pondering why Jamaica hasn’t spent more time benefited from their major natural resource—sunlight!) But so I didn’t have to hand wash my clothes, hooray! I did still have to hang them out on the line and it was a little eye opening—I’ve spent a lot of time in Jamaica considering the impact that American dollars have, and trying to spend a lot of money in local places. I ended up considering the fortune in clothing I was hanging on the line…like so many things in Jamaica, it puts things in perspective.

Tuesday was April 1^st, International Day. It was Projects Abroad’s six year anniversary in Jamaica. So we had a festival in the park where each country’s volunteers set up a booth and got to share bits about our culture with the Jamaicans. I knew about this before I left, and I’ve previously commented on this—how am I supposed to represent the entire US?! Funnily enough, there are four Americans here right now—all from the East Coast or Midwest. We put together a poster highlighting the Hollywood sign, the Grand Canyon, the White House and President Obama, and then Times Square and the Statue of Liberty.

I spent a good amount of time describing the flag also, with its fifty stars representing fifty states and thirteen stripes representing the original thirteen colonies.

Me and Matt, representing America

I really just stood around and waved my flag and used it as a pointer to gesture to the map. At one point, a huge group of schoolchildren ran up and had notebooks out to take notes on what we had to share. Thank goodness for a history degree, and a childhood in Virginia! I also was interviewed on the radio, and PA took a clip of me talking about America to put in some sort of promotional video. So basically I almost lost my voice, but it was all in good fun.

Wednesday I managed to get back into the hospital for surgical clinic. Clinic…oh my clinic. Fun for me, but also so affecting. First off, you start with a bunch of referrals. The patients are sitting outside waiting to see if they’re going to been seen that day! So you go through that and say yes, no, two weeks, two months. One lucky person got to be scheduled for that day. One man got lucky to get an ultrasound order and an appointment for next week. Then we start in on our queue.

First off, they get an appointment block—for example, 8am or 11am. You show up as early as you can, because they’ll put you in first come first serve. Clinics may not start until much later…in fact, last week the doctor didn’t get there until 10. We started on time this week, and it was just me and Dr. Lloyd. I had one room and he had the other, and we managed very quickly. He didn’t even go in and double check my patients for the most part, which was fine because they were a lot of inguinal hernias—order labs and see them back in the next available appointment (which was June, by the way).

There were two that I will always remember. The first was a 31 year old lady who had fallen out of care six years ago after a breast biopsy. The biopsy was cancer, but she never returned for follow up…until now. Her story is maybe going to turn out okay…her CT scans don’t show any metastases, and her bone scan results are still pending but they didn’t tell her anything scary immediately afterwards. Her breast is unbelievably full of tumor, but good margins should be obtainable. That alone is an affecting story and I will always remember her, but she is also notable because Dr. Lloyd asked me if there was anything I could do for her with osteopathy, and there was! I know from working with my mom’s lymphedema post-mastectomy that I can help this lady. She had lymphedema from enlarged lymph nodes, not post-mastectomy, but the treatment is the same. I was able to teach Dr. Lloyd a little OMT releasing the thoracic inlet and doing some enfleurage. Pretty cool!

Insert medical comment here—I had made a comment about trying to get a PET scan to check for mets and asked if it was available in Kingston and Dr. Lloyd just says, “No, Miami.” Think on that!

The second patient was a lot like a patient I had the week prior. Perfect healthy ladies suddenly having abdominal pain—last week was a likely gastric cancer. This one had already had an ERCP and signs are pointing to cholangiocarcinoma. It’s a type of cancer of the biliary tree (draining bile from the liver into the gallbladder and intestines); it’s incredibly rare and generally fatal. I’d never seen one and I hope to never have to consider that on a patient again.

Cancer awareness is so low here, and it makes me wonder about public health initiatives and just general health awareness. We (PA) try to do outreach and do what we can to supplement in the St. Elizabeth region, but we aren’t miracle workers.

My day on Wednesday did get a little brighter because we were continuing our mission with PA in getting the word out there with what we do in the local community and we took that mission right into Kingston, to the Minister of Local Government and Community.

This was a big deal, and they took some of the heavy hitter volunteers—the two medical students (there’s another one here from the UK), two of the teachers who have been here for three months, and one of the very well spoken journalism volunteers. I even put makeup on—the first time I have since being in Jamaica, other than sunscreen!

L-R: Me, Fabio, Lucas, Leeann, Bridgette

This is Bridgette, the country director for Jamaica, trying to identify for us all the VIPs in the pictures on the wall. She got most of them for us, but we were all trying to figure out—what do we address him as? (Minister) What does he look like?

So his advisor showed up first, and he was fun to talk to. Then the Minister showed up, and the advisor stood up so the rest of us did this awkward oh-we-have-to-stand move a few seconds later. Even funnier, Fabio couldn’t get his chair out so his standing was delayed a few more seconds.

We settled in to a good conversation, talking about the role of PA in the local community and all the different things that we achieve. He was astonished at the idea that we pay to come here, and we had to convey to him that we get a lovely experience—staying in a host family, experiencing route taxis, eating the Jamaican dishes, etc.

Once he got over that and we were once again commended for our ‘big hearts,’ we got down to how PA and the Ministry’s work can align. I think it will be a fruitful partnership in the future, as he asked for some specifics that we could do in Mandeville and if they work, implement all over Jamaica! In fact, the meeting last an hour and a half! Who would have ever though a politician would want to meet with US for 1.5 hours?!

Lucas, Sanikia, Leeann, Minister Noel Arscott, Me, Matt, Bridgette, Fabio

Then we paused for pictures. And he got his phone out to make sure he had a picture with all of us! It was funny because I could see the screen, and I could see all the missed calls and texts he had, and I thought that was why he pulled his phone out at the end of the meeting. He’s an important man and has a lot of business to do. No, just wanted to memorialize this himself!

Best of all, after the meeting was over, they took us to Juici Patties. It’s a Jamaican chain restaurant and a patti is the perfect melding of a Hot Pocket and Toaster Strudel. Real fillings and the flaky pastry crust. They have both vegetable and soy fillings for those of us who don’t eat the beef and chicken/cheese filling.

On the trip back to Mandeville, Matt (one of the other Americans) and I spent a lot of time comparing our cultures and how much work we could be doing here and how some little things could make a huge difference here (like actually making the kids attend school, or how important trash cans in public areas could be). It was interesting for me, since we both come from the same American culture and have a lot of the same views on how so very little things could make huge differences here—but it all takes money, and that’s something Jamaica doesn’t have.

It’s the same thing in the hospital, where I finally spotted some computers in the registration area. I did ward rounds on Thursday, and I encountered far more pathology that I was unfamiliar with in this one set of rounds than I have in awhile. It was also interesting because Dr. Lloyd was on a ‘how do they do this in America?’ kick, so I kept getting thrust front and center. I had to admit that the approach to trauma patients, as I described it, could be summed up by Dr. Lloyd as, “So really like they do it in the movies?” I suppose so. I also discovered that in the lack of privacy they have in the wards, there is still some privacy—there’s a code word for HIV. Instead of saying that the patient is positive for HIV, they say that they’re positive for ---- (I’m not giving it away!). It was rather decent, as the six men in the little room all know exactly what is going on with every other man and all the other intimate details of the life they share in that cramped room.

Dr. Lloyd and I have spent a great deal of time talking about American medicine, because he loves it. He dug out an antique central line the other day and made me guess what it was (it took me about thirty seconds of examining a guidewire in a catheter it before I exclaimed, “Is this a central line?”) He is amused by the fact that I hold the camera in laparascopic surgeries in the US, and shows me the lap equipment in Jamaica, complete with an old, glass TV monitor. I tell him we have hi-def monitors back home. The idea of up to date labs and carrying iPads with medical records is beyond his belief. Even physician salaries are incomprehensible to him (even just my poor resident’s salary!). But he assures me he’ll be in the US someday and I hope so because he is oh so smart—they have to be, to get by with the resources that they do have. But he wished me well, and I have to say I thoroughly enjoyed my time in surgery, even though I’ve no desire to go into surgery.

Thursday was a fun evening too, as Ingrid wanted to make a banana bread but didn’t want to bake. She literally caught me coming out of the shower and asked if I would make it, which was fine (but I could I get dressed first?). We had a fun conversation about baking without eggs, I made a banana bread without a recipe, she made dumplings to go with ackee and saltfish, and Josephine (the newest addition to our household—she’s here for three weeks, from Sweden) quizzed me on what I know about Sweden. It was a lovely evening, exactly the family experience we’re supposed to be getting in Jamaica.

Friday (today) was the end of the PA grand week of festivities, capped with a ‘dirty day’ where we went out into the community and cleaned up a school. We painted, freshened their murals of Mickey Mouse and Big Bird, hung fencing, and cut the grass. The guy who brought the lawnmower didn’t want to cut the grass, and I thought to myself, “I did NOT come to Jamaica just to cut grass!” though the push mower was reminiscent of the one I’ve used at home for years. He buckled down and cut the grass, we cleaned it up, and it was the end of a beautiful Jamaican morning as we got back to Mandeville to head home in the pouring rain.

Taxis do not want to take you home when you’re soaking wet.

I am home, however, listening to the rain, wearing a sweatshirt and smelling of sunscreen, waiting for the odd bits of sunburn to show me where I missed the sunscreen this morning. It has been a long week, and I am grateful for the weekend. Time flies here, even in this relaxed country.

weekend travels: treasure beach

So I finally made it to the beach this weekend! As I'm currently slathered in aloe gel, you should all know it was a successful weekend--and ironically, came back to rain in Mandeville. For future reference, the new lotion + sunscreen combos, like Aveeno, are better than Banana Boat. I have nothing against Banana Boat and have carried a tube of it with me faithfully for years, but the reason I'm sunburned today is because it didn't rub in certain places, so I have stripes where I was less forceful in rubbing it...that doesn't happen with the Aveeno. Plus Aveeno is awesome anyway. Regardless, I'm not that burned and not at all on my face, so it was a good weekend.

The weekend epitomized a lot of American-Jamaican interactions, so I'll go through it in some detail and annotate some lovely photos.

First off, Tora and I were going together. Tora is from Norway and she was looking for the same thing I was for this weekend, relaxation. It was my birthday weekend, so I wanted somewhere I could swim and relax and just enjoy life (away from the party lifestyle to which some of the volunteers adhere).

In grand Jamaican tradition, we took route taxis to get there. Taxis here are uniquely Jamaican, complete with one person in the front seat and AT LEAST four people in the backseat, more if there are children. I will always claim the front if I can, but you generally have to be the first person in to get it. Jamaican routes are set amounts of money, more if you're dropped off at your door, so the more people they can fit, the better. Tora and I hadn't even made it up to the taxi stand when a driver leaned out his window and goes "Treasure Beach?" like we had it written on our foreheads. We have to get to Junction and then switch to Treasure Beach, so he was on the ball. But that's how they make their money.

He was exceptionally nice, as most of the taxi drivers are. His name was Pablo, he put our bags in his trunk and we sat there until the taxi was full. He didn't charge us more, which some of the drivers will do since they know the 'whiteys' don't know the cost of some of the routes. And when we got to Junction, he tried to find us a reputable driver to take us to Treasure Beach. We stand out as two white girls, so we had already had "Treasure Beach!" shouted at us and found one, which makes things easy. This driver wasn't so friendly, so we didn't have to part with a history of our lives to get to TB.

As I've learned in Jamaica, there are universal questions to ask the whiteys--and that's not a derogatory term, it's just cause they don't know your name so they call you whitey. They want to know your name (and Pam doesn't work well here, so it's always Pamela--Pam-ella in the accent), where you're from, and is this your first time from Jamaica. Conversation progresses from there--I usually get where in the US/America are you from, and then what are you doing in Jamaica.

But we made it to our lovely hostel in Treasure Beach and immediately headed down to the beach.

One minute's walk from the hostel.

Just in time for a glorious sunset! There was a cloud across the sun, so it was stripy across the top and bottom, but it progressed too fast for me to get a good picture. This is also the view from the veranda of the restaurant where we got dinner.

My authentically Jamaican birthday dinner--curry goat, festivals, and Red Stripe. I've been enjoying the curry here, spicy but not too much. Festivals are delicious blobs of fried dough. Red Stripe is a fairly decent lager, product of Jamaica. It was a great dinner to eat on the veranda and a good way to end the week. We trekked back along the beach to the hostel, and the stars were incredible. I have never seen so many in my life, just scattered everywhere! Truly beautiful.

We made it to the beach early in the morning, slathered in more sunscreen than many people would use in an entire summer but the sun in burningly hot. It can be relentless, and I would feel burned in certain places and slather even more sunscreen there, but never turned up burned there. It was difficult to keep reapplying sunscreen because the sand gets everywhere and you feel rather exfoliated in a terrible way because of it. The salinity of the Caribbean is also somewhat different than what I'm used to in the Atlantic, so that added to the exfoliative feel.

We were at Frenchman's Bay, protected by two outcroppings of land to either end, which affects the waves in some way I can't remember from physics class. The waves are high and come up without warning, and frequently claim lives. This is not the lifeguard, only swim in protected areas I'm used to from the Jersey Shore, but a wholeheartedly swim at your own risk. I actually ended up keeping an eye on some Germans who were swimming far to close to some rocks. And I'm a strong swimmer, yet was frequently surprised by huge waves coming up on me. They're not incredibly powerful, but they will still knock you over if you're caught in one as it breaks.

The Caribbean is a spectrum of blues and greens, and I am so glad I was able to capture this melding of the blue sky into the more aquamarine ocean. You can use thousands of different words to describe the beauty of this water! (Again, this is the view from the veranda of the restaurant)

We spent the afternoon relaxing indoors, since the sun was so hot. Water bottles are essential around here to those of us not accustomed to the heat, as I know I sweat out probably half of what I take in by mouth. So we reemerged from the hostel to climb these rocks on the eastern end of the bay. A storm was trying to come in, though it never materialized. The surf was pounding against the rocks, and once again, I am pleased to see that the photo captures the swirling colors and intensity of the Caribbean.

It was also really windy, but Tora and I managed. 

The other Jamaican experience that is unique--I mentioned that the taxis drivers always want to know who you are and where you're from, but this happens on the beach too. Particularly to the two 'beautiful white girls'; I acquired a self-professed Jamaican boyfriend, we had a few offers of marijuana, a few men trying to sell us things, requests to go on boat tours, etc etc. I commented to Tora that I've gone to the beach every single year of my life and never has a man ever approached me, regardless of the potential invitation of the bikini. I'm all for light flirtation, but it can be difficult to get the Jamaican men to understand you're not interested and I can't be rude here (though I will be if necessary).

To check out of the hostel, we just had to leave the key in the door. It's a real key, one of those old silver ones that I'd only seen in the movies/books--like in Harry Potter and his room of flying keys. We left behind the glorious Treasure Beach to pouring rain in Mandeville and I was finally able to wash all the sand off.

The other thing about Jamaica--not everywhere has hot water to shower! It's actually a bit refreshing after being on the beach, but even here in Mandeville where it can get chilly, not everyone has hot water. I do here, and it's actually solar powered/warmed. At the beach, it was sun warmed too so it wasn't freezing, but up in Mandeville it can be. Since it's been raining today, the shower wasn't hot but better than lukewarm. Regardless, I'm starting to radiate heat from my splotchy sunburn so it'll be okay. 

Tomorrow I get to meet a local official as an ambassador for Projects Abroad and the USA, then Tuesday is an International Festival, and Wednesday it's off to Kingston to meet the Minister of Local Government and Community. Not so much medicine this week, but the chance to explain why I came here and represent myself, my school, and my country is a rather exceptional opportunity.

it gives you perspective

Almost done with another week...and another time to be reflective on the medicine here.

It's interesting working with the University of the West Indies medical students. First off, their curriculum is five years and they're taking all the final exams now--they haven't taken anything, like we have earlier. So their studying right now is far more rigorous than anything I've encountered. Their exams are also partially oral, in a practical sense; they'll be interpreting x-rays, examining patients with actually pathology, etc.

So 'lectures' are completely different. I was explaining today about the huge lecture halls and projectors, and apparently they have that on campus. Out here in the satellite sites, there's nothing like that. In fact, we have to go get one of the two projectors the hospital owns when a lecturer brings a powerpoint. Usually it's just the socratic method, so you have to know your stuff.

For example, a few days ago, we started talking about peripheral artery disease (PAD). Pathogenesis of PAD? Atherosclerosis, we can all answer that. How does atherosclerosis happen? That was met with pure silence, which didn't make me feel so bad. I could contribute a bit about the foam cells developing from macrophages, but we all struggled to get to that point and to how it contributes to PAD. It's a way to test how well you know your stuff--did you skim the surface or did you actually dig deep and do you know it.

I obviously took to this quite well, since I don't like being all that embarrassed and having to say I don't know...which I really don't like saying as the 'American medical student.' I feel a lot of pride in being an American and representing America here, in addition to my own personal pride. So the next day was aneurysms and I totally showed my stuff, but I didn't hold it over the UWI students. It made the whole lecture more comfortable, and now I know aneurysms really well myself. Win-win.

Oral examinations meant that you have to know what you're talking about, and quite frankly, it points out to me all the things I've forgotten in being on clinical rotations and learning about how the computer system works, and those kind of practical things. It sets up an interesting conundrum for taking step three in the upcoming months (the last of the board exams--you take it after you graduate).

The pathology has changed some too...I evaluated a patient with a goiter today, something you wouldn't see in the US. Particularly not one this big. I knew what it was at once, but it's not something I've seen in person before today. We also had an interesting moment later, when a patient's culture had come back with Pseudomonas, a fairly resistant and hard to treat bacterium. We had to switch the antibiotics, and the residents had no idea about double coverage and also what to switch to give pseudomonal coverage. It was a little hard to cover my surprise, but considering they don't even talk about MRSA here, why should the residents know about pseudomonal double coverage?

I can't get over the wards. This photo is deliberately blurry, but you can see how there are three beds fairly packed in with just the half-hearted attempt at curtains to shield. We had to tell a patient today that we had to amputate below the knee, and she got to cry and try to deal with this information with absolutely no privacy.

This is the most technologically advanced their medical records get. There's also no sort of order--I saw a patient in clinic the other day whose appointment for 24/3/14 (European style dates here!) was shoved in the middle of her records from 2002. There are no tabs for lab results, consultant's notes, or imaging. We're talking about patients who are actively bleeding and the last check of their hemoglobin was three days ago. There's also no blood to give patients right now (and if I were convinced of the sterility of the procedure, I would donate some, but there are about 10 patients on the wards right now who need blood...one donation can't stem that tide).

This is their ER, or A&E as they call it here--accident and emergency. There's a separate section for 'actual' emergencies, this is rather like a holding area. Consultants go see patients down here, and they could be here for days. Beds are just lined up, as many as you can fit in the small space.

On a lighter note, you do have to dress modestly! I can't wear anything less than short sleeves, and if I do, I have to wear my cardigan over it. And remember, it's 80 degrees shortly after sunrise and often will be humid so the heat index is frequently 95ish.

And for the lightest note possible, I was doing blood sugar checks recently on an outreach day and got to find out that they use a different scale than we do in the US! We use a mg/dL scale, so you want a fasting sugar under 100 and somewhere not too much higher for random sugar. I checked mine to make sure the machine was working, and the number popped up 5.2! I was like what the heck! That makes no sense! The girls from the UK and Norway filled me in--it's mmol/L. So 114 on my scale, a number I can interpret.

weekend travels: kingston and the blue mountains

Actually, I should probably start with Friday. As I'm here as a medical volunteer with Projects Abroad, occasionally the PA volunteers get recruited to do other volunteer tasks. As such, on Friday we went to St. Elizabeth to do a beach clean up.

It's a beautiful beach isn't it? Well, imagine what it looked like before we raked up all the trash. In Jamaica, there's no real system of municipal waste such as public trash cans. I've noticed not one since I've started looking. So what happens here is the fishermen just toss their trash out of their boats. It was rather unbelievable how much trash there ended up being in short distances of the beach, but it wasn't too strenuous of work to clean it up and how much better it looks for it!

My first Jamaican beach photo! And yes, I know I have a bit of sand on my face. It's interestingly a mix of dark and lighter sand. Actually, one of the guys was saying that it's so dirty, that's why the sand is dark but I know enough geology to point that out as false. 

Regardless, it was hot and sunny and the beach was beautiful. Onwards, to Kingston!

I went with my friend Helena, from Sweden. She had booked a music tour of Kingston for her only weekend in Jamaica, so I tagged along as the music lover I am. We had a lovely tour guide, and we started off with listening to the music, getting the history of reggae and ska starting with Harry Belafonte (whom many Americans would consider calypso, but the beats develop from there). We headed directly to the Bob Marley Museum, which was really cool.

There's all these great photos of Bob in a mural on the wall, and some great statues too.

Bob was apparently only 5'6", so the statue is life sized. A very interesting life, and I always wonder what would have happened had he amputated the melanomatous toe, instead of keeping it because of his love of soccer. What he could have done! It's amazing what he did in his short life. Also, they have a Grammy in the museum, so I was really quite excited to be in the presence of a real Grammy statue. It's his old house, his wife donated it to make the museum, so there's lots of fun stories to be had and the tour guides here are great too! We had a rousing rendition of "One Love," all six of our group. :)

From there, we headed to National Heroes Park and I got to hear a lovely bit about Jamaican history and its national heroes. Did you know that's where Marcus Garvey ended up? I dredged up some of my Civil Rights history background and got to supply some information for the tour. 

We ended up driving through Kingston and getting to see some of the statues and sights (Hello Port Royal off in the harbor! No pirates or Johnny Depp sightings however...) but then headed to an apparently famous restaurant near the harbor. They served curry, and considering I can't eat beef or chicken...this is curry goat!

It was rather good, even though I don't eat a lot of meat and can't really tell you what texture goat is. The curry was spicy, but not too so overall a lovely win.

After that, we were off to Trench Town to see where Bob Marley grew up and took his first music lessons, and we got it from a genuine Rastafarian man, named Stone Man. There was an undeniable marijuana smell around the house and the people hanging about, but it ended up being atmospheric, considering the culture.

We finished our day with ice cream from Devon House, which is apparently rated the 4th best place in the world to get ice cream (by National Geographic). As a big fan of ice cream, I have some issues with this, but it was still good ice cream.


Onwards to the Blue Mountains on Sunday!

This is Jerome, our tour guide on the coffee plantation we visited. He's pointing out some of the coffee beans, and it's a very interesting culture on the island. He was wonderful--he knew all kinds of dates in the history of coffee, and plenty particular to the coffee industry in Jamaica. ALL the coffee plants are derived from the original plant. This man departed from France (the coffee plant had been brought to Versailles by Louis XV) with six plants, and through storms, attack by pirates, and attack by his fellow shipmates, one plant survived to Jamaica. And a whole industry is grown from that one plant! 

Jamaican now is home to the Blue Mountain coffee, rated the second best coffee in the world. It's a very particular industry, and the elevation at which the coffee is grown determines how good it is, and lots of other things like moisture and acidity and sulphur. Also, it's good coffee because it generates its own sucrose and glucose, and doesn't release bitter acids.

I tried it, and I still don't like coffee, but it's the best of the bunch I've tried!

We climbed all the way up the mountain, viewing the coffee and wonderful vistas throughout the climb (and it was worth the pulled quadriceps I got somewhere along the way).

This is still the vista from the top of the mountain, in the glorious  Blue Mountain range. We spent the rest of the day hiking and enjoying the lovely flowers growing throughout. I took some photos, but this was my favorite of the bunch, crouching amongst the flowers which enclosed the entrance to a waterfall.

It was a glorious day, though misty and rather atmospheric once we were in the mountains. A nice change from the medicine, even with having to read and prepare for lecture the next morning hanging over me on the trip back to Kingston. And it was nice to safely make it back to Mandeville and negotiate the taxi trip home even though twilight had passed and night had definitely fallen.

If anyone is ever in the Blue Mountains or Kingston, they should stay at this lovely B&B called RafJam. The view from our little treehouse:

And despite the problem of stray dogs, there are puppies that go with said stray dogs, and they're just adorable! (Despite the likely profusion of fleas, I couldn't resist!)

medical differences, so far.

So my first week of surgery is done, since tomorrow all the Projects Abroad volunteers are heading out to do a beach clean up (and I will probably take the Jamaican beach photo you've all been anticipating!), and the differences are both stark and reassuringly similar.

(for those of you who aren't medical people, this might not make too much sense...)

One of the residents here asked me that, actually. And the best thing I could tell her was that the pathology and presentation and even some of the treatment is the same. The differential diagnoses may be different, as they have higher rates of malnutrition so things like goiter come to mind more quickly for them than they do for me. Also, they have a much higher incidence of HIV/AIDS, so they have to treat infections more aggressively, so I see more Flagyl/metronidazole being given out to cover a wider variety of bugs.

On the other side, things are vastly different. A reliance on Augmentin and Flagyl because of immunocompromised patients is a far different end of the spectrum than Zosyn and Vancomycin for MRSA. I have YET to hear the word/phrase MRSA while I've been here.

Also, no one wears masks/gowns/gloves. There are isolation rooms, which would be as close to a private room you'd get, and I still think there are 2-3 patients per isolation room. This was a hard sell for me to the Jamaican residents, saying how all of our patients have private rooms and if not private, not with a patient within a foot of your bed.

Speaking of the beds, yes, they are that close. So you're very intimate with everyone around you, and there's nothing like HIPPA to protect your health information. It's all out there--how can you help from hearing what's going around you? We round and share the information right in front of the patients.

Oh, rounding. You know, pre-rounds, getting the printouts, potentially having a laptop, etc with you while rounding? No such luck here! First off, pre-rounds don't exist. (A 7:30 lecture is very early here!) The residents don't seem nearly as prepared as we are in America, but there's a big difference--paper charts! With things just thrown rather haphazardly in them. Labs may be 2 days old and that's the newest information you've got to work with. I have yet to see a computer in use anywhere in the hospital. Nurses work with ledgers of the patients on the floors. Things don't flow as smoothly in rounds because the information isn't all the tips of your fingers, and we actually encountered--twice--patients that no one had seen because it's so easy for them to fall through the cracks.

Patients are often expected to provide and drink their own fluids, rather than to get IV fluids. In fact, patients aren't fed and have to have their family bring them food. They have to walk down the hall by themselves to the bathroom, carrying their own toilet paper. The sheets on the beds are likely donated, as none of them match and a lot of them are floral prints.

There's other differences in the operating theatre also--very few lap sponges or 4x4s are used, and the saline is often squeezed out of IV bags instead of opening new bottles. The instruments are generally the same, but without the variety of retractors you can see/request in the OR back home. Also, no air conditioning in some of the theatres makes it very hot. Also, this is a big hospital, considered the city's hospital. It has four operating theatres. In comparison, many community hospitals have 10-15 and places like VCU have 40.

The scrub technique, as I already commented, is completely different. There's no foaming in/out of patient rooms; first off, there are no patient rooms, and there's no gel/foam/soap. There are NO supplies not locked up.

Lectures are different too; the topics are generally the same, but there are subtle differences in some lectures and huge differences in others--like the cancer lecture I sat through with the University of West Indies medical students yesterday. I was asked a question at one point and responded with how I would treat the patient and informed I was wrong. I wasn't, it's just the difference in the way cancer is treated in the US and the options available here.

That's what it comes down to--in America, we have a surfeit of options and choices while here, there are none.

Or take this for example: a young man with pancreatitis, turns out to have obstructive pancreatitis from gallstones, and sickle cell disease--no big deal in America, right? Easily dealt with on a tele monitor, since he's a little hypoxic from the pain and splinting. Here, he had to be transferred to the University hospital in Kingston because they don't have the ability to take care of him on the floor here.