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!  

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.

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 1^st 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! 

More work and visits before our final goodbyes - Last week in DR!

We spoke to our preceptor, Teresa, to inquire about the possibility to returning to Santo Domingo to see a hospital in the capital.  Luckily, she said we could spend our last couple of days in D.R. in the capital city!  This meant that our last day in Monte Plata would be Monday (7/22). As a partying project, we made a video about the transformation of the storage room and various items that are available therein.  The final video will consist of Abdias, Liz, Jillian and I introducing ourselves as different members of a healthcare team and how we utilized our skills to make the storage room more efficient. After that short segment, the video will be edited and there will be a voice over describing the different sections of the storage room. Before leaving Monte Plata, we thanked the staff for being so welcoming and receptive to our ideas.

The staff at the Monte Plata Project Hope clinic are truly fantastic. They are passionate about their work and are very receptive to new ideas for the benefit of the people of Monte Plata. I'm surprised we actually ended up taking this group photo. Everyone seemed busy at the time but it turned out very well.

We checked in the same Hostel as before, Dominico Mundial, in Santo Domingo that is located in Zona Colonial. It is an ideal location because the it is a major tourist attraction.  It is home to the first cathedral built in the Americas and the first pharmaceutical company in the Americas.  There are also many parks, museums and a walking mall that encompasses many restaurants and shops.      

The next day (7/23), we went to the big Project Hope almacén in Santo Domingo.  In this instance, this almacén translates to actually being a big warehouse. Inside there’s a section of the warehouse reserved specifically for Project Hope items.  Even though the section of the warehouse is for Project Hope, the Order of Malta actually owns the space.  Much of the items are donations from AmeriCares, Gifts in Kind (GIK) and Food for the poor.  This almacén functions as a distribution center for many Project Hope affiliated institutions in the country.  We spent some time making sections for syringes by volume, syringes with needles by gauge and also insulin syringes.  Organization in this almacén isn’t as important because its main purpose is to serve as a distribution center as opposed to a storage unit. 

The middle picture shows some of the signs we created for syringes, syringes with needles and insulin syringes so they could be easily identified

Wednesday was exciting since we would be getting the chance to see the Ministry of Public Health. The Ministry of Public Health is the national health authority in the Dominican Republic.  In short, their mission is to ensure access to quality healthcare, promote health programs and to enhance user satisfaction and generate public awareness in matters of health. We also given a tour of the many areas including their almacén, pharmacy and various people in charge of making sure the proper paperwork is and used and used correctly as well as making sure the medications are handled correctly until they reach their final destination.

Jillian, Liz and I in front of the Ministry of Public Health sign in Santo Domingo

On Thursday, we had the opportunity to visit a medical sub-center. This was as close as we could get to a hospital. The director of the sub-center was kind enough to give us a tour of the building. We saw the operating rooms, inpatient rooms, nursery, emergency room, pharmacy, and more. The most shocking room was the nursery. It was empty, literally empty. There were several beds for mothers and several metal cribs for the babies. The cribs for the babies did not have mattresses in them because previous babies had soiled them and the sub-center could not afford to get new ones. We were all very shocked by this room. Maybe Project HOPE can help them find more waterproof mattresses or more preferably waterproof mattresses.  It would ideal if the sub-center itself could afford to purchase some on its own as well as occasionally receive donations from Project Hope.

The main part of our tour was the pharmacy. It was a rather small room filled from floor to ceiling with medicines. This was the main pharmacy for the sub-center. If a medication is needed in another department they have to come to this pharmacy to obtain the medication. This pharmacy also had a small “pick-up” window where patients could bring prescriptions. While we were touring a patient came with a prescription for simvastatin. The pharmacy technician grabbed the bottle of simvastatin and just poured some into small cup, this is what we would call “eye-balling” it. Jillian and I took the time to look at a few of the medications on the pharmacy shelves. This was the first pharmacy where we saw contraception outside of the emergency contraception with we saw at the Padre Martin pharmacy in Monte Plata. They had two different brands including a copper Intra Uterine Device (IUD). They told us that they dispense it often. This was also the first place where we saw narcotic medications. These were kept in a locked cabinet.

 

Some pictures from our visit at the sub-center hospital in Santo Domingo. The top left picture shows the empty cribs that we saw in the nursery. Hopefully that room can become usable with waterproof mattresses. The rectangular picture on the left shows one of narcotic medications available in pharmacy's locked cabinet. This was morphine sulfate. The two middle pictures are of the contraception available at the pharmacy.

For our last two work days in the D.R. (7/23 and 7/24), we were able to teach the ‘teach back method’ to the staff of the Herrera clinic in Santo Domingo.  Thanks to Liz and a medical student at the clinic, Jillian and I were able express the importance of the method. This time, we actually went through a mock patient interaction scenario where the method would be utilized.  I believe the ‘teach back method’ can have a greater impact in Herrera clinic relative to Monte Plata because patients are not given the first dose of the their medication in the community health room. Furthermore, it was important for doctors to be cognizant of the methods since they play a vital in making sure patients know critical information about their medications.  They may be the only one to give patients health information throughout their stay at the clinic. Despite the Herrera clinic being in the bustling city of Santo Domingo with many patients, the method has the chance for increased patient compliance and health literacy.

Teach back presentation and discussion at the Herrera clinic in a meeting room in Santo Domingo

Friday was rather short since we had an afternoon flight. Jillian and I went into town to purchase some last minute souvenirs. Teresa was very thoughtful in taking time out of her busy schedule to pay us a visit before we left. I consider her my mother in the Dominican. We said our finals goodbyes. It was truly amazing to come in contact so many great people who do great things for the betterment of others and society as a whole. It has truly been an unforgettable experience.

And that wraps up our journey in the D.R! Hope you enjoyed reading. Look out for 2 more final recap blogs of our experiences in the D.R from Jillian and I.

Last Weekend in D.R: Bayaguana and Trekking

Since we would be leaving the Dominican Republic on Friday, our last weekend in the country was upon us.  On Saturday (7/20), Jillian, Liz and I decided to venture out to the town of Bayaguana to see the cascada or waterfalls. Bayaguana is town just east of Monte Plata municipality.  This trip was far less complicated than our travels to Las Terrenas because the gua-guas or local buses go directly into Bayaguana.  No waiting for another bus for us this time. As Jillian mentioned, schedules for the gua-guas are non-existent.  It’s really just a matter of arriving at one of the several gua-gua pick up “stations” and checking to see if the gua-gua is headed to Bayaguana. A pickup station basically consists of standing on the side walk and waving as the gua-gua approaches. It’s a taxi! We only waited for about 10 minutes until we found a gua-gua headed to Bayaguana.

We packed ourselves in the gua-gua  per usual.  The van meant for comfortably sitting 8 people quickly filled up to the standard 15.  We meet the youngest passenger on this gua gua.  She was a beautiful 4-day old baby girl.  The mother just left the hospital.  This put into perspective what mothers have go through to get healthcare for themselves and their babies. I couldn’t help but be concerned for the child considering the heat, lack of air conditioning, and the bumpy, unpredictible ride on the gua-gua.

Beautiful baby girl we saw on gua-gua

 We passed through many palm tree plantations on the way. One can see many miles of dead palm trees.  The palm trees are native to Africa but are grown in the D.R. for their seeds.  The seeds produce an oil used as cooking oil or to manufacture soap, washing powders or other industrialized products. After about 30minutes, we were in Bayaguana. Unfortunately for us, we found out that it would take an additional 30 minutes for us to get to the waterfall.  There weren’t any gua-guas around to take us there so riding on the back of a motorcycle was our only option.  We were a little hesitant because of the uncertainty of it all. I don’t think any of us had ever ridden on a motorcycle and we would also be without helmets. Nonetheless, it was a go!

Not the safest but it was a fantastic ride. You can see some of the terrain we went through in the bottom left picture and the one adjacent to it. The picture on the bottom right is of one the drivers stopping by for a tank fill at someone's house. I'm not absolutely certain what exactly was poured in.

Jillian and I hopped on one motorbike and Liz on another.  After only a few minutes into the ride, we quickly found out that it would be impossible to walk. Our path was mostly going through country roads. We passed through many potholes, small towns, and traversed past many rocky and muddy roads.  Riding on one was quite exhilarating. It was like a video game. The drivers were very skilled at driving around bad patches on the road, passing through dirty puddles of water or passing by cars struggling to get through the rough terrain. Since riding motor bikes is a main mode of transportation in the DR, I can’t help but be amazed at how mothers are able to carry their babies while riding on one.  There’s also the added difficulty of travelling in the rain.

We finally arrived to the incredible scenic waterfalls. It was breathtaking. Moreover, we couldn’t have asked for a better day weather wise. You can see the many pictures we took below!

Breathless!

On Sunday, we decided to trek through the fields behind the guesthouse.  There a long path that gives the illusion that you would be headed for the mountains. This wasn’t the case.  Parallel to our path was a Haitian neighborhood that stretched for about half a mile.  The few Haitians that come to the Monte Plata clinic come from this area.  We decided to travel along there to see the Haitian neighborhood.  We passed through a dirt path that was rocky and muddy in some areas with beautiful trees around us. Many of the houses were unfinished and built with wood or scrap metal. The people were very, very friendly and said hello to us as we passed by. We witnessed a group of guys approximately in their 20s learning how to play the guitar.  It was poorly out of tune but they were enjoying their time together. Further down, we met a group of people sitting in a circle with books open, trying to learn Spanish. It’s fantastic that they are trying to assimilate into the Dominican culture because my impression is that there is a negative perception of Haitians in the Dominican.

The top two pictures are people we met in the Haitian neighborhood. The bottom picture shows a gathering of people trying to learn Spanish. I thought it was fantastic that they are trying to assimilate into the Dominican culture. One of the potential projects for the Monte Plata Project Hope clinic is to make the Haitians feel welcome by developing signs in Creole and to educate the staff on basic Creole language skills. Abdias, the Haitian medical student who has helped us throughout our time her is taking on this challenge.

The rest of our walk towards the unreachable mountains was mostly open fields. We saw numerous mango trees and its seeds on the ground throughout our trek.  Animals we met along the way were horses, cows and dogs. We retreated back to the house when we reached fork in the road that led to dead ends.  On our way back through the Haitian neighborhood, we met an older gentleman who was very eager to see us.  He was very excited to have his picture taken in front of his house.  His smile widened from ear to ear when Jillian showed him the picture she took of him on her camera.  Coincidentally, we met a family in same Haitian neighborhood that also wanted to be photographed . It was a great way to encapsulate the day.

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