New projects with pharmacy and hospital visits mixed in

For the majority of the week beginning on 7/12, we continued our work in the storage room of the Monte Plata clinic. It was more or less putting the final touches on our project.  All the signs for the various areas are clearly displaced. We continued making more “ofertas” or special offers in mini-bags for the pharmacy. According to Jahiri, the staff member in the pharmacy, they sold very quickly. She even says patients still inquire about them after they have run out.  Since there are many ofertas in the storage room, the key will be coordinating how more ofertas can be brought into the pharmacy.  Ofertas have been a great success and I hope it continues. We were told by Don Teo, the person in charge of the almacen, that the storage room will look the same once we return and visit the D.R. I will hold him to that!

Collage of completed Project Hope Monte Plata Clinic storage room. Top left: Medications. The shelves run across most of the room and acts as a divider to the back area. Top right: Syringes, Dentistry, Sonography, Gynecology and nursing. Bottom left: cleaning supplies. Bottom middle: Many Bandaids! Bottom right: miscacllaneous items with made ofertas for August to be given as gifts for women and children who complete all requirements of the 5 Star Program.

 Another potential problem that I looked into was the VCR player.  I thought I had seen the last of them!  There were several old educational videos available at the community health room.  However, many of them were unplayable due the condition of the VCR.  I was able to clean the spinning rim or the more technically term is the rotating head drum.  This was something my uncle taught me how to do when I was a little boy in Cameroon.  It’s done simply by opening the VCR and cleaning the drum thoroughly around with alcohol. Unfortunately, only one VHS tape on dengue education was playable. Considering that VCRs are less prevalent and DVDs are the norm, the clinic will be better served with DVD player.  While patients are waiting to be seen in the waiting area, educational videos can be shown to the patients. I believe Liz and Jillian were looking online to see if any international organizations, such as PAHO or UNICEF, had some Spanish educational videos that could be utilized for the clinic.  Yet another project!

Here I am removing the VCR from the VCR stand below the TV. This is what faces the patients in the waiting area everyday.  During the day, patients mostly watch spanish soap operas.

 On the Wednesday (7/17), Jillian and I had the chance to visit the Padre Martin pharmacy which was established by the Order of Malta.  According to their website, the Order of Malta are a “lay religious Order, traditionally of military, chilvarous, noble nature”.  Their headquarters are in Rome, Italy.  They provide many essential medications to the public at a relatively low price and they are constantly busy. Due to the pharmacy’s religious affiliation, there’s hardly any family planning products available to the public.  Jillian and I had the opportunity to inquire about the medications that can be sold without a doctor’s authorization. We were just simply told that there is such a differentiation.  My understanding from the response we received was that they must have a list visible to all the workers in the pharmacy that helps them distinguish between prescriptions and non-prescription medications. Some examples of medications that require a prescription are: pregabalin, montelukast, and acido mefenamico.  These medications are marketed in the United States as Lyrica, Singulair and Ponstel respectively.  We were told there was a pharmacist that works there but she wasn't present when we visited.

When a particular medication isn't available at the Monte Plata clinic, patients typically come here. 

Ponstel (Mefenamic Acid): Non steroidal anti-inflammatory indicated for menstrual cramps. Singulair (Montelukast): mostly for Asthma. Lyrica (pregabalin): for nerve and muscle pain

Further into town, we visited the sub-center hospital.  It serves as the main hospital for Monte Plata municipality of about 57 thousand plus people.  Monte Plata is also the name of one of the 31 provinces present in the Dominican. Essentially, the sub-center is in Monte Plata, Monte Plata.  This is true of the other regions of the Dominican in case you aren't confused already.  It was makeshift hospital considering it wasn't originally designed to be a hospital.  In fact, it was scheduled to be demolished. 

When we visited, the main lobby was filled with patients sitting and waiting to the seen. On the right side was the pediatric wing of the hospital that had an enclosed hallway that led to small room with 2 sick patients on hospital beds in the corner of the room.  Further down was an even smaller room for procedures.  The main floor also included: laboratory room, nursing, vaccinations, pediatrics, surgery lab, and an administrative room. The inpatient rooms were upstairs along with: psychiatry, HIV counseling and delivery rooms for expecting mothers. The concern with the setup of the hospital was that both inpatient and delivery rooms were upstairs because such patients would have the most trouble getting upstairs.  Moreover, there are no elevators.  As mentioned before, this could be due to the fact that the hospital had to be setup as is since it was not originally designed to function as a hospital. The benefit of the upstairs area does provide the benefit of added privacy and confidentiality.  As a side note, we later found out that a new hospital Monte Plata province is being built. It will be able to accommodate over 200 thousand people. The 120 inpatient bed hospital will also be able to perform surgeries that usually had to be done in Santo Domingo.  Some of its other features include: laboratory and diagnostic testing, 3 operating rooms, and 15 offices for various medical specialties.   

The director of the sub-center was very gracious in giving us a tour of hospital. He asked if we could spend some time in the hospital. Unfortunately, we were unable to due to our other projects at the Monte Plata clinic.

We then went across the street to visit the “Farmacia Santo Cristo.”  It’s a much smaller pharmacy than Padre Martin but we were able to find the first birth control pill in Monte Plata.  It was actually plan B one step or “PostDay 1” to be used only as an emergency contraceptive and taken within 72 hours of unprotected sex.  It costs 200 pesos (or $5) but it is not covered by Senasa.  “Seguro Nacional de Salud” (SENASA) or National Health Insurance is one of the Dominican Republic’s major health insurance providers. Again, the person running the pharmacy was someone with no pharmacy education background. It’s unfortunate that many popular pharmacies can not afford to have a pharmacist who can counsel patients on proper medication administration, storage, or provide other pertinent information. The business model dictates that patients may purchase what they desire without the benefit of having a pharmacist on hand. Moreover, a vendor cannot be forced to give instructions to patients or else he or she might lose a sale.

The lady we spoke with at the Santo Cristo pharmacy was very informative and knowledgable about some medications despite not having any pharmacy training

 On Friday (7/19), we had the chance to teach ‘the teach back method’ to the staff members of the clinic. I had been creating and preparing a PowerPoint presentation on the teach back method. Jillian and I created an educational document for patients that explains what the teach back method is and how they can best benefit from it. This will be hung on the walls and on the doors of community health room, nurses area and doctor's offices. We also created a document for doctors that includes important questions that should be asked to patients upon completion of the consultation. This document can help doctors as well because it can serve as a way of reminders doctors to teach relay information they may have forgotten to give.  The photo below on the left is for patients and one on the right is for the doctors.

We set up an ideal time in the afternoon….an hour before the clinic closes on Friday at 4pm when there are hardly any patients waiting to be seen.  With Liz’s help translating, Jillian and I were able to talk and discuss the teach back method with the staff.  The teach back method is essentially having the patient repeat back what said in order to confirm patient understanding.  This is something that is stressed to us in pharmacy school in order to improve patient compliance and health literacy.  The staff was very responsive and had much to add to the discussion. Abdias was also able to add much to the discussion given his medical background and enthusiastic way explaining concepts. It's always entertaining! Even though there is the potential for unreceptive patients or time constraints with doctors, they all recognize that it’s an important method and that there are some communication challenges that the teach back method can help alleviate.

'Teach back' presentation and discussion