Monday, June 29, 2015

Continuing Promise 2015: Colombia and Dominica

I'll start this off with the disclosure that this blog is about my experiences and is in no way to represent the opinions of the Project HOPE organization as a whole...that being said buckle up...this will be in true Heather Heskett fashion: blunt and often disjointed thoughts, lacking nearly all proper punctuation and hopefully entertaining and informative

Thoughts before I leave…
            I am both anxious and excited for this upcoming rotation. Anxious because you never know what to expect with all new places and people (that dreaded 1st day of school feeling). I’m embarking on this journey with Emily…she still counts as new because I’ve only seen/talked to her through VTC/Facebook a couple of times...we’ll actually meet for the first time at the airport. Another source of anxiety is that I don’t know ANY spanish. However, the anxiousness fades fairly quickly as I prepare for what is ahead and watch this motivational speech:
                              https://www.youtube.com/watch?v=nuHfVn_cfHU
           Here’s the short list of things I’m excited about: 
                 1. Uh hello I’M ON A BOAT!
                 2. I don’t have to “dress up”! (This might very well be #1…after all I was “most likely to wear sweatpants”) 
A uniform is very much welcomed in my book since I don’t have to worry about doing my hair (YAY for hats) or putting together a stylish professional outfit. 
                 3. Project HOPE has been around longer than the Peace Corp so clearly they know what they are doing and I'm someone who craves efficiency and a plan. 
Some of you may be wondering: What does Project HOPE do?
        When you go on their website (http://projecthope.org/) there is an extensive list but the summary is: “Project HOPE delivers essential medicines and supplies, volunteers and medical training to prevent disease, promote wellness, respond to disaster and save lives around the globe.” Now what did I take away from that statement? 
                             ESSENTIAL: (adjective) absolutely necessary; extremely important. 
We are so lucky to live in America…land of the free, home of the brave…where many think a morning Starbucks coffee is essential to daily life. Louis C.K. puts it in perspective...
            

While first-world-problems.com and the assortment of Internet memes provide plenty of entertainment...I get the opportunity to experience a totally different side of the world and hopefully witness what it is really like to be able to provide the very definition of essential healthcare to more than deserving patients. In our country we have Urgent Cares and MedClinics on nearly every corner making access to healthcare easier than setting up a successful LinkedIn profile…who knows how often these patients get healthcare attention? I will not take these experiences lightly!

What do I know about the places I will be visiting? 
           We will be in port at Buenaventura, Colombia…all it takes is quick Google search to know it is not the place you want to be
                                                 Here’s a link for you to read at your leisure:

           Next stop: Roseau, Dominica

Now to tie it all back to pharmacy...after all this is part of my APPE 4th year rotations

Preparing for Malaria Prophylaxis
·                        From Lexicomp:
·      MALARONE: Atovaquone and Proguanil (a TOE va kwone and pro GWA nil)
o   Prevention of malaria (prophylaxis): Atovaquone/proguanil 250mg/100mg once daily starting 1-2 days prior to entering a malaria-endemic area, continue throughout the stay and for 7 days after returning
o   Administer with food or milk-based drink at the same time each day
o   Adverse reactions: abdominal pain, N/V (nausea/vomiting), elevated LFTs (liver function tests)
§  Less common: HA (headache), dizziness, pruritus, diarrhea, anorexia, neuromuscular and skeletal weakness
o   MOA (Mechanism of Action):
§  Atovaquone: selectively inhibits parasite mitochondrial electron transport
§  Proguanil: the metabolite cycloguanil inhibits dihydrofolate reductase, disrupting deoxythymidylate synthesis.
§  Together: atovaquone/cycloguanil affect the erthrocyctic and exoerythrocyctic stages of development
o   Atovaquone: >99% protein binding, Proguanil: 75% protein binding
o   Metabolism: Proguanilàhepatic to active metabolites: cycloguanil (via CYP2C19) and 4-chlorophenylbiguanide
o   Bioavailability: 23% when administered with food

·      Why no doxycycline? Because I didn’t want to deal with the photosensitivity and esophageal erosion...my twin sister took doxycycline for awhile and was so nauseous she couldn’t even…So why? Why? Why would I put myself through that when I’m expecting to already be motion sick half the time?
  
    "It's not your life, it's life. Life is bigger than you. Life isn't something that you possess, it's something that you take part in and you witness" - Louis C.K.

   #firstblogEVER #HOPEyoulearnedsomething #moretocome #2LouisCKquotes?

Tuesday, May 26, 2015

Shenandoah University School of Pharmacy and Project HOPE – we’re ba-ack (and better than ever)!


Welcome back! After a year off, we’re excited to be partnering with Project HOPE again for our 6th year of the unique, life-changing advanced pharmacy practice experiences (APPE) to help the international community!  This year we will be sending six (6) fourth year pharmacy students (P4s) on the Continuing Promise 2015 with the USNS Comfort. 

The adventure starts very soon…  from May 28th to June 27th, P4 students Alyson Dunlavey and Aquisi Harris, along with preceptor Lance Sateren, will be sailing to Panama and El Salvador.  Following Alyson and Aquisi, Heather Heskett and Emily Hesse with preceptor Earl Rogers, will be joining the USNS Comfort to assist in Columbia and the Dominica from July 5th to August 8th. Our final group will be from August 14th to September 10th.  Amanda Shifflet and Ryan Garner, along with preceptor Bill Strein, will be visiting the Dominican Republic and Honduras.

We wish our P4 students and preceptors an adventure of a lifetime on the Continuing Promise 2015 with their Project HOPE APPE!  A special thank you for our partners at Project HOPE for making this possible, and to Ms. Nichole Clinedinst, Winchester Experiential Coordinator, for all her time and effort to make the rotations a reality for our students!

Please visit the rxprojecthope blog frequently to follow their adventures and learn of their experiences on the USNS Comfort!


Monday, August 19, 2013

knowledge is power

Wednesday, August 7, 2013- Falcemia

Liz and Cindy left today, they were invited to a forum for the Lactancia Materna week in Santo Domingo in which Project Hope and Teresa will be recognized and receive a few awards. The house was not the same without them (super sad face).  

For the first half of the day we shadowed Dr. Rodriguez again. It’s crazy how prevalent sickle cell anemia (“falcemia” or “anemia falciforme”) is in the DR. One of the patients today was a carrier but when the doctor asked what “falcemia” was the mother responded by saying “I think it’s some type of virus.” When lunchtime rolled around, I went to look at the community health room and there were no handouts or information regarding sickle cell anemia. So now we have a project concept- basic patient health information handouts. When I helped Liz do some of the surveys some of the patients told me that they would be interested in knowing more about high cholesterol so Sara will be making one for that and I will be focusing on sickle cell anemia.

       We had two patients who had giardiasis- a parasitic disease, which inhabits the digestive tract. Symptoms include loss of appetite, diarrhea, hematuria, stomach cramps, upset stomach, etc. The parasite blocks nutrients from being absorbed. Like other parasites this is passed via fecal-oral route so proper hygiene is very important. This is very hard to detect so most of the time it’s misdiagnosed and several tests must be conducted but since people can’t afford that Dr. Rodriguez just prescribes them metronidzaole or albendazole for 10 days. If symptoms get worse they are to return to the clinic immediately or just return in 10 days for a follow up.



Thursday, August 8, 2013- Eid

       Today is EID (it began last night after sundown)- it marks the end of Ramadan, a Muslim holiday in which fasting occurs from sunup to sundown for ~29-30 days. Eid is celebrated with families and friends (similar to Christmas to Christians/Catholics). Since this was going to be Sara’s first time away from her family we asked Teresa for permission to go to the capital to go to a mosque so that Sara could pray and celebrate. We left in the morning and made it to the afternoon prayer.
 


1st Pic: Mesquita Al Noor in Santo Domingo (pretty much the only mosque in the DR)
2nd Pic: Sara and I at the mosque (I wore a hijab to respect their tradition)

Later on that day we met up with Liz and Cindy. We walked up and down El Malecon, which is like a seaside boardwalk, it goes along the coast for almost half of the city, there are several restaurants, hotels and even an outdoor gym along its’ way. After asking around we ended up at “La GuaGua,” an amazing restaurant that actually had a “guagua.” There was a variety of different foods, majority were American style- like nachos, French fries, sausages, empanadas… it was delicious!


Our EID feast!!!

Friday, August 9, 2013- Dermatologist

       Sara has been getting a rash on her hands. Dr. De la Cruz saw it the other day and recommended her to go to a dermatologist. So we woke up early and headed to a Dermatologist Institute where the majority of physicians in this country rotate. It was a very big building with hundreds of people in the waiting area. After waiting for about 3 hours we received a prescription for “Mometasone” and were just told it was contact dermatitis (luckily the visit was like $3). The doctor told us to come back in 15 days, although she didn’t say why, but luckily the cream has been working and there is no need to spend half a day waiting to be seen for 5 minutes.



Saturday, August 10, 2013- Farewell Cindy (sad face)

        We woke up super early today because we were so excited to go to Sambil. Apparently it’s a new huge (& expensive) mall in Santo Domingo, which has an aquarium- AQUAMUNDO!!! We had lots of fun at aquamundo, we learned about so many different species of fishes and sea life… and were even able to hold starfishes!!!! After we ate lunch we went to see Despicable me 2 in SPANISH… movie tickets here are about $3 – CRAZY!




Sunday, August 11, 2013

       Today was a rather sad day since Cindy left us (good luck Cindy in your last year of undergrad!!!) We went to a vegetarian restaurant (my first time) surprisingly it was really good! Then we walked to a nice bakery were we ate yummy blueberry cheesecake and a phenomenal tres leche cake.



On our way back we stopped by what looked like a chain pharmacy… Farmacia Carol. This is the first pharmacy we have seen in the DR that actually has a staff pharmacist at all times. It was what Sara and I consider a “legit” pharmacy! It was a great feeling finally meeting a pharmacist in the DR. We spoke with her for a while, apparently pharmacists only go to school here for like 5 years max.



1st pic: Farmacia Carol- Speaking with the pharmacist

2nd pic: Farmacia Carol’s mission and vision statement

August 12-14

       I’ve been doing further research on sickle cell anemia in the DR and many physicians consider it an epidemic. About 10% of the population has sickle cell anemia! I have been working with Dr. De la Cruz to come up with a message to target patients to get tested and to know whether or not they are carriers. Knowing if you are a carrier is important because if 2 carriers have a baby they have a 25% chance of having a baby who has sickle cell anemia.

Sickle cell anemia is a genetic problem more commonly seen in people of African descendant, in which the body produces abnormal shaped red blood cells (RBC). These cells are more like a half moon (crescent) or sickle shaped and because of this they don’t survive as long as normal RBC, which leads to anemia. In addition, the sickle cells get stuck in the blood vessels causing a blockage of blood flow that causes the patient lots of pain and eventually organ damage.

       We also came up with counseling points, which help reinforce the “teach back method”, that Jillian and Derek taught the staff. The majority of our time these last few days have been in the community health center, counseling patients on their prescriptions. If a patient needs their first dose, we administer it!  

Wednesday, August 14, 2013

Parading all the way.

Saturday, September 3, 2013

Today was the day we were waiting for, one of the main purposes we were staying in this nice hotel in Santo Domingo. We were attending the breast-feeding walk that was organized by the National Commission of Lactating Mothers. The event was scheduled at 4 pm so we had some time to spare. We took our sweet time waking up in the morning to get ready. I was fortunate to have taken a shower first. However, poor Evy was in the bathroom when the electricity went out. It only lasted for a few seconds but unfortunately when she tried to turn the water on, there was no water. Therefore, she decided to take a shower after breakfast. Breakfast was another story to tell. They had everything one could ever imagine, from various cheeses to different lunch meats, fresh fruit juices and fresh fruit. It was difficult making decisions on what to eat. After a long hearty breakfast, we decided to venture back to the room to get ready for our day out. But of course we had to experience one more bout of electricity going out when we were in the elevator on the way down. Thankfully, it again lasted a few seconds and the elevator took us down. 






We called for a cab to take us to “plaza España.” The cab driver we found spoke almost perfect English with a NY accent. We asked him where he was from and he said he was from the DR but he had visited NYC every year because he has extended family there. He was very entertaining and gave us a good tour of the city on the way there. We arrived at the “plaza España” and visited the “Museo Alcázar de Colón”, which was built under Diego Columbus, son of Christopher Columbus. There were a good number of tourists there and we each received a set of headphones and an English audio guide that guided us through each room in the house. After a walk back into history visiting various artifacts and paintings from Diego Colombus’ time, we decided to get something to drink because it was extremely hot, which is typical during midday hours in the DR. We stopped at a little restaurant and ordered fresh passion fruit and mango juice, which was extremely refreshing at that time. 


It was then around 3 pm and decided to go to the meeting spot (Puerta del conde) where the walk was going to take place. On the way up the street we shopped a little (pretty expectant, 3 girls and lots of stores, it was irresistible). We arrived a little before 4 pm and there were a few people there. But of course we should have known better, as Jillian explained, everyone was on Dominican time. Around 4:30 pm, we saw two ‘gua guas’ full of people from the clinic in Herrera. They gave us the big Project Hope sign to hold as we were walking down. The parade finally began, mind you, this was the first time I was part of a parade, but Evy and I were really enjoying our time. The marching band was in front of us and we were behind them holding the sign. Towards the end, we were getting tired and some people from the clinic held the sign for us. We ended up again near the Museo Alcázar de Colón, and there was a big stage set up for the organizers to give a few words. We saw our preceptor Teresa and met her beautiful children and she also gave a few words about the importance of breast-feeding. After speeches, there was a dance performance and we sat in the grass and witnessed some traditional dancing. Just before we headed out, Teresa was giving away donuts and soda. As fattening as that sounds (pharmacy student personality), it was something we needed after a day of walking in the DR sun. Teresa drove us back to the hotel and we just relaxed before deciding to go out again. 



For dinner, we decided to go to the local grocery store and have ourselves a feast in the hotel. So we picked up various fruits (guava and mango), cheese, olives, and crackers and brought it back. The whole night we sat around just chitchatting the night away and enjoying our little dinner.




Sunday, September 4, 2013

On Sunday morning we enjoyed the same breakfast that we did the day before. Fortunately, we did not have to deal with the electricity going out while taking a shower. Our plan for the day was to visit the infamous botanical gardens. Jillian and Derek also had the pleasure to visit the gardens, but they did not have much time to spend there. When we arrived by taxi, we went to the booth to buy tickets. There are two types of tickets: one for locals and one for foreigners. Apparently, they charge foreigners 5x the price for tickets. Thankfully, Evy spoke Spanish and was able to get the regular priced tickets. She only spoke a few words in Spanish hence why they thought she was a local, had she talked more they would have probably figured out she was not local. We walked to the snack bar area where there were trains that would take us around the gardens. There was a tour guide as well who spoke in both English and Spanish so we could know what everything was around the gardens. When we took the tour, it looked like an Amazon jungle with all the different type of trees and forested areas. There were at least 5 different types of palm trees. As we were touring, the train stopped at the Japanese garden and we were able to take pictures there. It was a beautiful sight! After about ten minutes, we had to go back to the train to finish up the tour. When we finished we were famished, it was extremely hot so we decided to get fruit popsicles to cool us down. Now these fruit popsicles were made of REAL fruit, which is pretty expensive in the US but it only cost us $0.05, which is amazing. Afterwards, we also met a very nice security guard who took us to the medicinal herbs garden and he knew almost every herb there which was amazing. We thought he would be a good tour guide! 




After visiting the beautiful botanical gardens, we went back to the hotel to meet another volunteer, Cindy. She is a microbiology major, applying to medical school. We met her at the hotel and decided to order Dominos for dinner. Surprisingly, it was similar to the Dominos in the US, which I didn’t mind at all because I was missing good old regular pizza. After chatting for a bit and getting to know Cindy, we decided to call it a night as we had to head to Monte Plata early the next morning.



Monday, September 5, 2013

We were up early Monday morning not knowing what time Orlando was going to come pick us up, but he was there by 8 am. We met with Teresa and had a little meeting about our future plans for the week and the whole trip. She came to meet the new volunteer as well and talk about her project as well. We took the two hour car ride to Monte Plata and got there just in time for lunch. After a delicious lunch made by Aude, we went into the clinic and worked in the community health portion, where the pharmacy sends the patients after they get their prescriptions filled to get more counseling on the medications. Evy and I would discuss the important aspects of a certain medications that we thought were important for a patient to know, and she would translate it to the patient. Meanwhile, Liz and Cindy were surveying patients for Liz’s project. After work, we decided to head into town to get some ice cream. We ended up picking up a 2 pint bowl of tres leche and it was delicious!



Tuesday September 6, 2013

Today was a pretty busy day for us. We started out by exploring different pharmacies in town. We first visited a community pharmacy where they stored almost every medication that we see in the US. The brand names were different but generics were mostly similar. We even saw different combination medications such as amlodipine/candesartan. The one thing we didn’t see was insulin and the technician informed us that insulin is only sold in certain places. The medications were stored in a cool room with air conditioning, which was surprising, as most other pharmacies did not seem like they had AC. 

After visiting that pharmacy, we went to the subcenter in town. Its called a subcenter because it’s secondary care and was not built as a hospital it was built for a former dictator. After the fall of the dictator, they wanted to demolish the building but a nurse said that they could build a subcenter there to serve the local population. We visited the pharmacy there and they only had injectable medications, oral medications had to be ordered from the outpatient pharmacy. They also had insulin! We moved to the upper floor and visited a TB clinic and talked about how patients are diagnosed with TB in the DR because most people are vaccinated for the TB so the typical PPD test would not be viable here. They talked about how they use chest X-rays, sputum samples, and just plain symptoms to diagnose TB. We went on to further visit the area where women give birth and we saw a woman lying down who had just given birth (mind you she didn’t even seem like she had a baby). We also saw the subcenter’s out patient pharmacy where they get their oral medications if needed. 



For the afternoon, we went back to the clinic and spent time with the pharmacy technician at the pharmacy, Yahira. We wanted to understand how medications are given out and how she takes care of inventory in the system.



Sunday, August 4, 2013

New faces in the Dominican Republic

Disclosure: Certain things will not be explained in complete detail because Jillian and Derek did an amazing job explaining it already (look below).


 Monday, July 29, 2013- We have arrived!!!
We flew in this morning/afternoon. Orlando, Liz and Abdias picked us up and it took close to 2 hours to get from the airport in Santo Domingo to Monte Plata. After arriving we dropped off all our stuff and met the staff at the clinic [which is literally 10 steps away]. We also met Aude who made us amazing food!!! 
Super excited to be here!!!




Tuesday, July 30, 2013- Official 1st day at the clinic

As part of the 5 stars program, mothers have to exclusively breastfeed their child for 6 months… this literally means EXCLUSIVELY that includes NO water, juices, baby formula etc. So of course I had to know how they could tell if it's exclusive or not because I know from experience that when something is looked down upon it’s easier to fib a little than to admit the truth. That being said, Reyna (the supervising nurse at the clinic) taught us that they are able to tell whether or not a mother has been breastfeeding their child exclusively because the texture of the baby’s skin feels different. A baby who has been breastfeed exclusively has skin that feels soft like a “sponge cake” and if the mother is giving the baby formula it feels thicker due to the increased fat content of the milk.



We spent 2 hours walking around Monte Plata looking for a router (the router that was here before we arrived broke… super sad face). We seriously thought it wouldn’t be that complicated but apparently no one in Monte Plata sells any, not even the “computer stores” in the town. I never realized how dependent we are on the Internet. There’s a landline phone here but the phone number is unknown and I guess it will remain unknown because we have yet to ask anyone for the number



Wednesday, July 31, 2013

Today we shadowed Dr. Rodriguez, a pediatrician. We saw 3 children with typical presentations of dengue. Dengue is a tropical virus transmitted by mosquitoes, which usually breed in standing water. Subjectively, the majority of patients present with headaches, fevers, joint and muscle pains and objectively they have decreased WBC & platelets and an increase in lymphocytes. After the fifth day the WBC and platelets slowly start increasing, with the WBC going up first. When someone has dengue you can only provide symptomatic treatment- acetaminophen for headaches or fevers, keeping them hydrated, etc. Since dengue is viral, antibiotics are not effective and the only thing you can do is monitor the patients' WBCs and platelets and make sure the dengue doesn’t become complicated (will elaborate in a second). Dr. Rodriguez believes [translated] “it's not the illness that kills a patient but the poison that is given to cure it.” For many patients, Dr. Rodriguez didn't prescribe any medications.



Thursday, August 1, 2013- Dengue

       We followed Dr. Monzueta, another pediatrician, today. Six of 16 peds patients had dengue. So we learned a lot more about dengue. According to Dr. Monzueta, there are 3 types of dengue- Classic with no alarm symptoms, with alarm symptoms, and severe (hemorrhagic). Alarm symptoms consist of mild bleeding such as in the nose, gums or bruising, and vomiting. With the hemorrhagic the patient gets internal bleeding which can cause shock and lead to death. Since there is no specific therapy, at this point all that can be done is pray for the patient. Thus “what doesn’t kill us makes us stronger” is a belief that many have, including Dr. Monzueta. Interestingly, although dengue is viral it doesn’t transmit immunity so if someone has had dengue they can get it again, again and again.

       Two of the peds patients also had amebiasis, which is an infection caused by an amoeba (a parasite). This is really really rare in the US and more commonly is seen in underdeveloped parts of the world where there is a lack of adequate sanitation. It is highly contagious and someone who has it can transmit the infection through his or her stool. The doctor prescribed the children metronidazole and told both the child and parent to make sure they wash their hands after using the restroom.

After lunch we shadowed in the “laboratorio.” They do ALMOST everything in this lab. We were able to watch 3 rapid HIV “one step ” tests, which is an immunochromatographic assay that detects the antibodies of HIV in human whole blood serum or plasma. It looks similar to a pregnancy test- 1 line is the control line and a second line if a patient is HIV positive. The test even differentiates whether the patient has HIV type 1 or type 2. If the results are positive, the sample is sent to the capital, where they confirm it using another method. All the HIV results are kept in a HANDWRITTEN book with the patients’ name, cedula (similar to our social security #), DOB, test results (if positive, method used for confirmation and its’ results), technician’s signature and doctor who ordered the test. No one has access to this book except those who are imperative to the patient’s care. 














Friday, August 2, 2013- Santo Domingo

We took the guagua today to Santo Domingo where we will stay for until Monday because we will be participating in a “lactancia materna” walk, which is dedicated to the importance of breastfeeding. 

We were able to see the other clinic (looks almost identical to the one in Monte Plata) and we also met our preceptor (Teresa), Mr. Richard Farland who is the president of Farland Capital Inc and his daughter today. Mr. Farland is very passionate about giving back to the people of the DR. As a child he was raised here for a few years because his father was the last ambassador that served during the dictatorship of Trujillo. Interestingly, he was also once a Project Hope board member. 


At the end of the day, we went to our hotel and took a walk that ended at the best frozen yogurt shop EVER- yogen fruz- a Canadian frozen yogurt company that blends fresh fruits with plain froyo… apparently there’s 2 in VA and we never knew!