More Jamaica...

April 17, 2011

We are halfway done with the first mission stop in Jamaica.  We got here on Wednesday morning and I spent the last 2 days at the Northside Arena clinic in Kingston.  What an experience.

When we arrived into port, I was so excited to get off the ship (after 5 long days at sea with nothing to do).  This excitement was tempered somewhat when I discovered I’d have to be ready to board a “hospitality boat” at 5:20 am.  This meant a 4-something o'clock alarm in order to get dressed, eat breakfast, pick up my MRE (meal “ready-to-eat” – as unappetizing as it sounds), and muster up.  There’s a lot of mustering in the Navy.  I forced down some coffee (suffice it to say, I really miss my Keurig), knowing it would be a long day, and was ready to go by the appointed time.  Turns out the Navy is just like the Air Force in its HUAW mentality – that’s hurry-up-and-wait.  We finally left on our hospitality boat at 6:15 or so.  As I mentioned previously, the Comfort is not docked in Kingston, but actually anchored several hundred yards offshore, so it was a quick ride.  Once we arrived on land, we boarded buses which took us to one of 2 clinic sites.  Like many places in the Caribbean, driving in Jamaica is terrifying – narrow roads, fast cars, opposite-side-of-the-street driving.  On top of that, we had a police escort with sirens and lights, and didn’t stop at a single stop sign or traffic light.  Not sure if this was for safety or celebrity status – I’m choosing to think the latter. 

After being driven through countless poverty-ridden neighborhoods, we arrived at the clinic site a little after 7am, with maybe a hundred patients already waiting in line.  My clinic site was actually not a clinic at all, but the city’s sports arena – a large indoor building with lights, some air-conditioning, and fixed plumbing – all luxuries that we were told not to expect.  Of course, the tradeoff was that there were no actual medical facilities, so everything we needed we had to bring ourselves.  There were several privacy screens, that we set up between long tables, kind of like this:

Hmm.  It took me a really long time to make that little drawing, and it doesn't appear to have copied into blogger.  Damn.  Actually, looking at it now, I’m pretty sure you would have had no idea what it was supposed to be anyway.  I’ll post pictures if I can.  Basically, there were 5 rectangles next to each other at the top of the drawing, and 5 rectangles next to each other at the bottom, with little lines in between.  There were 3 other rectangles on the far right of the drawing.  Each rectangle on the left 2/3 of the picture represents a table.  The top row was for adults, and the bottom row was pediatrics.  The three rectangles to the left were our Physical Therapy/ Back pain station, our mobile lab, and our pharmacy staff.  I put an X on my table, which you can't see.  That clarified things, right?  There were 2 providers at each table, and we each saw patients on our side of the table.  There was one private exam area set up outside this picture, under a staircase, with a privacy screen surrounding, but detailed physical exams were the exception, not the norm.

The only equipment we had at our table was a blood pressure cuff, an ear/eye scope, a stethoscope, and prescription forms.  We also had Purell at our table and a hand washing station close by.  It didn’t take long to familiarize ourselves with the “clinic,” and we started seeing patients shortly after we arrived.  The next 8-9 hours are kind of a blur.  Prior to seeing the medical provider (physician, nurse practitioner, or physician’s assistant), the patients were screened outside to determine their chief complaint.  They were given a wrist band with one of 4 categories – medical, dental, optometry, or pediatrics.  The hard-and-fast rule was ONE CATEGORY PER PATIENT PER DAY.  This was very difficult to explain and enforce.  I saw, obviously, patients who requested adult medical care.  We had a limited number of medications we could dispense.  We could also check a very small number of labs – Hemoglobin (only), iStat, fingerstick glucose, urine dipstick, and pregnancy tests, along with tests for malaria and HIV.  Labs in general were discouraged.  The first day I was there, we had no radiology capabilities, but the second day, we had plain films and ultrasound.  Radiology studies were generally discouraged too.  At first I didn’t really understand why, but after seeing a few patients, it quickly became clear.  There was really no way to follow these patients up.  I’ll get to that more later.

Patients came in for a variety of reasons – acute illness, chronic medical problems, second opinions, free medications, “to meet an American doctor,” routine check-up, and a variety of other complaints.  As it turns out, Jamaica actually has a decent health care system – the best of all the countries we’ll be visiting, apparently.  Health care is free to the public, but because of this, the wait list for most specialists or radiology studies is 1-2 years.  Patients who don’t want to (or can’t) wait that long have the option of going to a private clinic, and paying out-of-pocket.  One patient I saw came to me with the diagnosis of “cervical polyps,” and was scheduled for polypectomy in a few days at the local private hospital.  She was wondering if it could be done on the Comfort instead.  When she showed me her paperwork, I understood why: the operation, a relatively minor procedure performed in a same-day surgery clinic, was going to cost her nearly $20,000 Jamaican.  I contacted the ship to see if one of our gynecologists could perform the procedure, but the surgery schedule was already completely full.  Very frustrating to have to tell her that.

Many of the patients I saw came in with relatively minor complaints that were easily fixed with a couple of medications (that we were giving out for free): allergies (Claritin), constipation (Dulcolax), headache (Tylenol), or UTI (Bactrim).  Unfortunately, a lot of patients came in with more complicated problems – abdominal pain, chest pain, cough, shortness of breath, or back pain.  In the US, some of these problems wouldn’t really be considered “complicated,” but would definitely warrant further investigation – either with labs, EKGs, or X-rays or CT scans.  None of that was really available – and even if it was, scheduling follow-up for the results was next to impossible.  We were instructed before we went ashore to try to abandon the practice of “evidence-based medicine” (a concept taught to us since medical school), and instead to practice “empiricism medicine.”  Fever and a cough should be treated as pneumonia – no need to get a chest X-ray.  This was a hard concept to adopt – until we realized there was really no choice.  For a few patients, where I simply couldn’t treat anything without further evaluation, we had local discharge coordinators, who would assist with placing referrals for necessary tests.  However, for these patients, the same wait list or out-of-pocket expense applied, leaving me doubtful that the problem would be managed in a reasonable amount of time, if at all.  I was frustrated that we couldn’t do some of this evaluation on the ship – but then I realized that even if a CT or lab test revealed the diagnosis, the patient would not be able to get necessary follow-up care.  Even for the patients that we could treat, for example, Claritin for allergies, the prescriptions we gave will only last a month at the longest – so our help is only temporary.

We were also told before we went ashore that the “street value” for some of our free medications was fairly high – and that some of the patients would probably not take the medications they were given, but would sell them instead.  For this reason, we were advised to try to limit the prescriptions we gave to 2 per person.  I don’t know about street value, but I definitely had a lot of patients requesting certain medications by name, although they had never taken them before.  The other problem I ran into was that patients would see their friends receiving other prescriptions and would come back requesting those too – they weren’t supposed to be able to come back in, but somehow many of them did.  At first, I tried to help out and give them what they asked for, but eventually I felt like I was being taken advantage of – and for every patient who came back and asked for something else, that was one new patient that had to wait longer or possibly not be seen.  So by the end of the second day, I got good at telling patients, in an apologetic-but-firm way, that they had already received treatment and that they would have to wait in line again if they had other problems they needed addressed.

That was my other problem.  At home, in my oncology clinic, my standard practice is to ask, at the end of every visit, “Anything else?” and to keep asking that until the patient says, “Nope, that’s it.”  Many of my physician friends groan when they hear this, as it is a sure-fire way to extend the visit and run late in clinic, but I’ve found, as the sole oncologist, that it actually serves me well.  If I don’t do this, patients will remember something they forgot to tell me the next day, and will call the clinic to leave me a message.  Or, they’ll come in for chemo (in the middle of another busy clinic day for me), and stop me in the hall (“I forgot to ask you the other day…”).  So I like to try to take care of everything in the scheduled clinic visit.  In Jamaica, asking, “Anything else?” is a HUGE MISTAKE!  There is ALWAYS something else!!  And while we are trying to provide good, personalized care to every patient, there are literally hundreds more patients waiting to be seen.  We are trying to see 40+ patients per day, per provider – that translates to 10-12 minutes per patient.  I quickly realized that “Anything else?” should not be part of my repertoire, but old habits die hard.  I made that mistake several times, to the amusement of my partner provider across the table.

I could write about my patient encounters all day, but this has already been a pretty long post.  Thankfully, I have the next 2 days off, so I’ll continue to regale/ bore you with stories, I promise.

Here's my first attempt at uploading a picture - but I only have 20 minutes before church, so not sure if it will work.  No, I'm not kidding or exaggerating.  Ok, it didn't work.  It was going to be a kind of boring picture anyway, so I'll just show you when I get home. =)