Interlude: Dominican Junk Food

If there's one secret about me that's been revealed here in the DR, it is this: I am a closet junk food eater. It is difficult for me to admit this in public, especially given the fact that I'm studying to be a doctor and all. But no matter where I go, I can't help but be absolutely fascinated by the wide variety of  yummy snacks that people eat to clog their arteries.

So here's a whirlwind tour of the junk food of the DR. Unfortunately, I don't have pics of the "good" traditional junk food (a.k.a dulce de leche) that people *should* be eating when they visit another country. Nope--my junk food stash is the starving student's version, otherwise known as an emphasis on stuff that can be bought at the store or on the street for super cheap...:-)

1) Cookies



Dominicans love their cookies. That said, don't expect to find a lot of oversized chewy chocolate chip cookies a la Mrs. Fields. The hot, humid climate, in addition to the necessity of snacking on the run, has inspired a wide variety of sandwich cookies. My favorites are the "Mabel Mais" cookies in the yellow/red/white package, in the flavors Dulce de Leche and White Chocolate.

But what's most fun about cookies in the DR are the wild, zany flavors. The one on the bottom right is a pack of cream coookies with an orange filling. It was simply delightful--a bit like a cookie version of an orange creamsicle. My favorite "exotic" cookie, however, comes from the "Dino" line. These cookies definitely take the cake in terms of strange flavors, ranging from bubble gum to tropical punch. Pictured here are the green apple cookies, which taste surprisingly good. They also have the added benefit of imparting a green tinge to the tongue, hence the phrase "pintas lenguas verde" (paint tongues green) on the label...

2) Chocolate


So, I only have one thing to say: chocolate is not very impressive here in the DR. Most of the good stuff is imported from either the U.S. or Europe. I did try the Italian-manufactured Kinder "Bueno," which had chocolate-covered wafers with a smooth hazelnut filling. Being a hazelnut fanatic, I of course found these delectable, though I found myself unsatisfied by the relatively small serving size...

The other candy bar, "Mas-Mas" (more, more), which is made by a Dominican company, was much less impressive. Though it claimed to be milk chocolate, its texture was grainy and bitter. Indeed, the only novel selling point was its curious mix of ingredients: milk, raisins, and peanuts. The good news is that I paid about 14 pesos (a little over 33 cents), so at least I wasn't losing out on any money...

3) Chips (and salty snacks)



My somewhat hum-drum chocolate experience was redeemed by chips. Now this, the Dominicans do with style! I was delighted by the various salty snacks made of different starches such as yuca, plantains, and batata. There were also Pringles with a delightful "Limon" flavor, which was perfectly tart and zesty.

But by far the most exotic chip compilation was the "Mofongo Snax." It is patterned after the traditional Dominican "Mofongo" dish, which is pictured below:



For those who don't know, a Mofongo generally consists of mashed up plaintains, yuca, and fried meat. The chip version sought to recreate it through a mix of pork rinds, yuca and plaintain chips. Interesting concept, no doubt...

Well, that's all for the cultural junk food tour. Will return to serious posts shortly, but stay tuned for the next interlude of "food porn..." :-)

Day Twenty Three: Doctor for a Day

Most of you know that I am in my fourth year of medical school.This means two things:

1) I am purportedly at the peak of my clinical skills as a med student; and
2) I am absolutely terrified of the leap I will have to make next year when I actually graduate and have a "M.D." after my name.

As I approach the end of med school, I find myself torn between those two thoughts. On the one hand, I am excited to finally be able to take charge and provide direct care for my patients. On the other hand, it is terrifying to think that I must soon accept full responsibility for all of my medical decisions.

Nothing like volunteering in a relief mission to put things in perspective...

Earlier this morning, Adam, Ana, and I decided the best thing to do was to keep working in our respective areas so we could keep some continiuity of care for the patients. When I arrived back at the White Tent, I was greeted by the nurse I had worked with the day before, who immediately told me that our attending physician had just been assigned to go help with relief efforts in Port-Au-Prince. "It's just you and me today, I'm afraid," she told me. "Oh, and we have a new nurse today, who still has to learn the ropes. God help us..."

The significance of this didn't hit me until after I had helped the nurse take morning vital signs.

Ever since the heart-warming exchanges from yesterday's time in the tent, I found myself looking forward to any sort of patient contact I could have. Taking vital signs was a good excuse, since it allowed me to lay hands on every patient and at least impart a little laughter to their ordeal by speaking to them in my horrible Creole. Today, however, things were different from the moment I found a patient who had a slight fever. What resulted was the following exchange I had with the nurse:

Me: "I think this patient is feverish. His temp is 100.8."
Nurse: "Oh...okay. I'll make a note of it and tell the doctor when she..."
Me: "Wait, I thought the doc was in Port au Prince today."
Nurse: "Oops, you're right. So...what do you think we should do?"

I looked back at the nurse to see if she were joking. When she stared back at me in all due seriousness, I snapped back to attention. We ended up giving him Tylenol as I asked the patient questions and looked back in the chart for clues. Silently, I found myself cursing at the haphazardly-organized charts, which contained patient notes scrawled on everything from napkins and index cards to legal-sized paper. When all was said and done, I couldn't figure out if he had a new infection from his leg wound, or if he was developing a clot in his leg. Both scenarios were quite possible, but unable to do anything else at the moment, I decided to check back on the patient later and move on.

Over the course of the morning, I would move back-and-forth between the feverish patient, another patient with severe eye pain, as well as a post-op patient who was severely nauseated. I found myself particularly concerned with the eye pain patient, since I was able to see a huge area of pus that seemed to ooze out of her pupil. It was clear to me her eye was badly infected...perhaps to the point that she might need IV antibiotics as well as an opthalmologist to save her eyesight. Not knowing what else to do, I ran to the pharmacy and grabbed a couple of bottles of antibiotic eyedrops from a bin I had seen a couple of days before. Inside, I prayed that she wouldn't lose her vision...or more importantly, that my small intervention was the right thing to do.

As if in response to my silent plea for help, a doctor did manage to stop by our tent late in the morning. The doctor, who in reality was a second-year family medicine resident on her first day of duty, had just been appointed "medical director" of the tent patients that morning and was making rounds to get to know everyone. When I told her about the eye pain patient, she seemed very concerned. After examining the eye itself, the doctor sighed. "Don't worry," she told me. "What you did certainly did not harm her, but I think she needs an eye specialist. Who knows if we're going to be able to get one out here..."

After that, the doctor left, leaving me to fend for myself for most of the afternoon. During this time, the nurses and I managed a patient with a near-syncopal episode during physical therapy, a woman who was having a spontaneous abortion, and the post-op man from the morning (who began vomiting that afternoon due to lack of a proper bowel regimen). Things were amazingly chaotic. As I ran to the pharmacy, drew up my own IV meds, administered medication doses to patients, and tried to work together with the nurses to make sure everyone was stable--I gained a whole new level of appreciation for the potential experience I would have next year as an intern.

But just as I was getting too complacent with my new role as an ad-hoc attending physician, I made the crucial mistake of forgetting a key lesson: "always expect the unexpected." Indeed, the winds around the tents had been picking up that entire afternoon, beating aggressively against the walls of the tents as they coursed through the area. My tent, the White tent, shook dangerously with each passing gust. It was the flimsiest of all tents, and I could see the patients and their families cringe with every movement and swaying of the tent.

As I was drawing up a final set of IV meds, a particularly strong gust of wind came through and knocked down a huge wooden bench of supplies that had been anchoring the tent down. Boxes fell directly on my ankle, causing a sharp pain in my foot. I watched helplessly as the wind buffeted the wall back and fourth. At one point, I glanced down at a male patient who was trying his hardest to have a bowel movement on the bedpan. "Is the tent going to fall down on me?" he asked me slowly in Creole, holding tightly to his bedpan. "I don't know," I responded gravely, not quite knowing what else to say.

Luckily, several other volunteers had heard about our plight and offered to help put new stakes in the ground so that the tent could stay put. And my foot was fine...only amounting to a number of superficial abrasions. By the time the nursing shift ended at 8pm, I saw the real attending physician enter the tent out of the corner of my eye. Apparently, the group from Port Au Prince was able to come back earlier than they thought.

Feeling thankful, I heaved a sigh of relief, gave the attending physician an account of what had happened that day, and left the tent, grateful to come back to my role as a fourth-year medical student.

Day Twenty-Two: "Help Me and I'll Help You"

We woke up today to an eerily beautiful Sunday morning. It was, in fact, the prettiest morning I had seen in quite a while. The sun hadn't yet come up completely as I walked out on the hospital balcony, feeling at peace amongst the subtle gradient of blues, purples, and reds that caressed the sky. A faint breeze rustled the tents below--a refreshing change from the strong winds that frequently blew sand into our eyes in the heat of the afternoon.

Ana and I were joined by Adam and our new attending, Dr. Fowler, last night. We had decided before going to bed that we would float around the next day and go wherever help was needed. As it turns out, there was finally enough help at the pharmacy for all of us to be assigned to the tents or to the ICU for the entire day. And so, Adam was sent to the Brown tent to help Rhianna (the resident), Ana went to help out Dr. Fowler in the ICU, and I sauntered off alone to the White tent.

My mind flashed back to some of the experiences I had had during my afternoon in the Brown tent the afternoon before. As much as I wanted to go in and help the patients, a part of me hesitated at the thought of subjecting the patients to their daily routine of painful wound dressing changes and physical therapy. It was heartbreaking to see them cry and wince as I ripped off bandages and rinsed their large, open wounds with saline. And it was equally hard to watch as the physical therapists came in, fully ready to give their "tough love" as they pushed, pulled, and tugged at the patients' arms and legs--desperate to infuse function back into those injured limbs amidst their screams.

So it was with somewhat mixed emotions that I entered the White tent to meet the patients for the first time. But to my surprise, many of the patients were gone. When I asked the nurse where everyone was, she answered, "Why, they're at church, silly! It's Sunday..."



Directly to the right of the White Tent sat an old Chapel, which had since been transformed into a "makeshift pediatric ward" for the interim. There were crowds of people spilling out of the entrance. To my amazement, I saw row upon row of patients in wheelchairs and crutches, singing and clapping happily in rhythm as their pastor led them in song. Many of them were people I had just seen the day before, laying weakly in bed and moaning in pain as they did their daily physical therapy. But there they were, transformed right before my eyes, smiling and rocking gently from side to side to the music.

I couldn't help but marvel at the healing power of religion.

The church service lasted for the entire morning, creating a major hiccup for nurses wanting to administer meds and for surgeons who needed to take their patients to the operating room. Thankfully, the patients' high spirits were contageous enough that no one overreacted. For me, it truly was the perfect day to become acquainted with the White tent. I took my time helping the nurse with vitals, dressing changes, and medicine administration, pausing numerous times to talk to patients in my limited Creole.

There was one patient, in particular, who took great sympathy to my attempts to learn her language. Her name was Katherine. She was a thin, spunky 19-year old who had sustained a fairly extensive crush injury to her left leg, as well as a nasty gash to her thigh that had since become badly infected. As I carefully cleaned her wound--a task that caused her great pain--she would divert her attention to improving my pitiful Creole. It got to the point that she refused to acknowledge me when I spoke in English, preferring to speak to me slowly in her language until I got the gist of what she was saying.

"Ede m ede ou," Katherine pronounced gravely to me, as I finished wrapping her bandage. (Help me and I'll help you).  I simply smiled to show my gratefulness, to which in response, she smiled back.

I would eventually work for twelve hours that day before heading back to the pharmacy to help inventory the medications. Leaving the tent, I felt a strong feeling of awe at the sense of community that was so present among the patients. Indeed, this communal respect had always been there to some extent. But somehow, it had been amplified in an unforgettable manner by the intimate sharing of faith that had taken place during that morning's church service.

I, for one, was glad to have been included...no matter how briefly. For the first time during my time in Jimani, I went to bed feeling strangely refreshed by the day's work.

Home Sweet Home

So it's been a couple of days since I've returned from the DR. I've got many posts to catch up on, but I have to say--it's wonderful to be home and away from the constant symphony of honking horns in Santiago.

I'm still catching up with a slew of projects that have accumulated while I was away, but I will still continue updating the blog with posts from the last part of my trip.

Stay tuned...

Day Twenty-One: Life in the Tents

One of the first things people notice when when they arrive at Good Samaritan Hospital is how desolate and isolated the hospital seems from the rest of the town. Indeed, it is located up on a hill, about a kilometer away from the city center of Jimani. The terrain around the hostpial is dry and dusty. Mountains flank the area on either side, leading one to an even greater sense of being landlocked and lonely.

Currently, there are a total of three patient tents at Jimani. Each tent is located outdoors and has approximately 15-18 patients. Conditions inside can get pretty crowded, especially since each patient usually has 1-2 family members staying with them to tend to their every need. Whereas in the U.S., nurses are responsible for cleaning and feeding their patients, as well as helping them use the bathroom, the Haitian families insist on doing everything themselves. Just sitting back and watching the interaction between each patient and their families and friends is touching in and of itself.

Ana and I were able to go to visit the tents briefly in the afternoon, immediately following our pharmacy duty. We helped take vitals and did a couple of wound dressing changes. It seemed that almost every patient there had very extensive orthopedic surgeries as well as amputations. Many of them also had numerous skin grafts put in place as plastic surgeons attempted to debride and treat wounds. It is heartbreaking to watch them scream and squirm as we pull away their dressings and clean their wounds. What is more humbling is the way the Haitians always seem so grateful amidst such pain, even muttering "merci, merci" to us as we pull away pieces of dead skin from their wounds.

At one point, I was asked to help a woman out who said she needed something for her child. She turned to Ana and said one thing, but in the next moment, she turned to me and said something completely different. With an animated gesture at her chest, the woman started saying "pompas" over and over again in a mix of Creole and Spanish. Somehow, I took this to mean "breast pump" and scampered off in search of them. When I came back with containers from a breast pump kit, she burst out laughing and got the Creole interpreter. I soon learned that she really wanted "diapers," and that this is what she meant when she asked for "Pampers." I think I was the laughingstock of the whole tent that afternoon...

I almost hate to say it, but I'm starting to wonder what Ana and I will really be able to do once we fully transition the pharmacy over to others. In the tents, it really seemed like there was an overflow of overly-qualified people who could changed IVs, wound dressings, and provide effective triage. But, we shall see what tomorrow brings. It seems that there is no shortage of work here at least...

Day Twenty: Pharmacists-in-Training

So today, we found out that our newfound "go with the flow" mentality would land us in odd places. Ana and I became inducted into our roles as the new pharmacists of the Jimani mission. Exactly how this came to be was a coincidence, not to mention somewhat unexpected. As we sat on the 2nd floor hospital balcony, sipping a disgusting brew of instant coffee and commiserating about not having anything useful to do, the hospital pharmacist finds us. We soon learn that he was going to be leaving tomorrow and basically needed someone to run the pharmacy until the real pharmacist came back sometime next week. We then proceeded to have a comical exchange that proceeded something like this:

Him: "So, do you think can help me out in the pharmacy?"
Us: "Yeah, sure."
Him: "Ever had any experience doing anything in the pharmacy?"
Us: "No"
Him: (pause) "Well...then I think we'll just keep things real practical today."

We spent the next few hours doing practical things indeed. Ana and I were quickly put in charge of reconstituting IV medications, doling out narcotics, and drawing up medications for the operating room. At the same time, Tom, the pharmacist would be tucked away in the back, trying frenetically to organize the pharmacy in some sort of logical pattern so that we wouldn't be overwhelmed. The mornings was quite busy, with nurses from the tents dropping off list after list of medications that would need to be filled as soon as possible. It was there in the pharmacy that we spent the majority of our day, trying to milk Tom for as much experience as possible. "Remember...you guys may be the only ones running the entire pharmacy tomorrow." he reminded us, "So learn as much as you can."

Around midday, we started hearing screams coming from the operating room. Minutes later, one of the surgical nurses came stumbling through the door of the pharmacy, mask half-hanging from his face, saying "Give me 2 of Fentanyl and 2 of Versed, now!" Nervously, I drew up the meds, looking quizzically at the pharmacist to check if I was using the right syringe or if I had the correct amount. The nurse took the syringes and left, only to return ten minutes later for more medication when the screams hadn't stopped. We heard bits and pieces of the story as the nurse popped in and out of the room. Apparently the patient was a young teenage girl who had been taken to the operating room to fix a leg fracture. The anesthesiologist who had been at the hospital for the past two weeks had returned to the U.S., leaving the surgeon no choice but to sedate the patient herself. As a result, the patient had been under-medicated and was now in severely intractable pain. In addition, one of the drugs she had been given (Ketamine) was notorious for producing hallucinations, and it was said that she was stuck in a dream where she thought that the surgeon was cutting off her leg rather than attempting to fix it.

An hour passed. Several doses of Versed and Fentanyl later, the girl had finally quieted down, but it was clear that her bloodcurdling screams had touched all who heard them. As for me, I couldn't stop picturing in my mind the pain she must have felt as the surgeons operated on her leg. The image would stay with me all day as I drew up more syringes filled with painkillers. I knew the root of the problem was the fact that the whole Haiti relief effort operates on a constant rotation of medical teams with staff who have different skill sets. How I wished for a new anesthesiologist to arrive who would make things better!

Ana and I spent the rest of the day in the pharmacy, familiarizing ourselves with its contents and reorganizing where we kept key medications. We also got acquainted with the huge donation pile sitting outside the hospital doors:



It is amazing to see the things that people donate. There are, of course, boxes upon boxes of medical supplies. Indeed, we have everything from multiple cases of Vicodin to boxes of IV antibiotics. There are surprising amounts of "big gun" drugs present...everything from Meropenem (a really strong antibiotic) to bottles upon bottles of Gabapentin (a drug used for seizures and/or nerve-related pain).

The day passed by quickly for Ana and I as we continued our work as "junior pharmacists." I was struck by the sheer absurdity of the situation that all these licensed medical professionals were trusting us and our amateurish skills in light of such important work. Never in a million years did I imagine I would be reconstituting drugs or determining appropriate doses for patients...and certainly, this sort of situation would never happen back in the U.S.

We were late for dinner service that night (which was probably the same spaghetti and spam served the night before), so Ana and I had a somewhat improvised supper of tuna fish, ketchup and mayo on stale loaves of bread. But the after-dinner company sure made up for it. We spent the remainder of the night hanging out in the ICU, trying our best to learn Haitian Creole from the patients and their families. It turns out that they are all wonderful teachers, hungry for company and for human interaction to comfort them in times of great tragedy.

Tomorrow, it looks like Ana and I will be staffing the pharmacy part time as we train another nurse to help with our duties. So I hope this means that we will be transitioning to patient care responsibilities. We shall see...

Day Nineteen: The View from the Back of the Gua Gua

There are two main rules to gua gua riding. Rule number one: the best seats are usually in the middle of the vehicle, since gua gua drivers will always load the back or the front first. Rule number two: it is important not to sit rigidly. As people are squeezed in next to you in increasingly alarming numbers, do not, whatever you do, square your shoulders and stiffen up in an attempt to save room. It is always more comfortable if you relax and let yourself sink in to the next person.

Unfortunately, we failed to follow any of these rules on our way down to Jimani.

Ana and I left our apartment around 6:15 a.m. to catch the 7:00 a.m. bus to Santo Domingo. We left together with Rhianna, a Medicine-Pediatrics resident who had just arrived in Santiago the day before. It only took us about two and a half hours to get to Santo Domingo, after which we then embarked on the most "treacherous" part of the trip: a 6+ hour gua gua ride to the border of Haiti on a crammed vehicle. With our bags filled to the brim with supplies, we were eventually crammed in the back seats of the gua gua and forced to sit rather stiffly against the countours of our bags as more and more bodies were packed into the vehicle. What resulted was a terribly uncomfortable ride, where time knew no end. We tried hard to doze off as the afternoon sun burned hot against the windows and as the stereos blared batchata music in the background, but to no avail.

Finally, we arrived at our destination nearly ten hours after we left Santiago. Tired and travel-weary, it was perhaps merciful that our first view of our worksite was a beautiful one:



Jimani is a small town on the border between the Dominican Republic and Haiti. It is home to the Buen Samaritano Hospital, which was initially opened up to house several hundred Haitians requiring extensive orthopedic repairs immediately after the disasterous earthquake on January 12. Since then, the patient census has dropped considerably, as the number of orthopedic surgeries have since dwindled. The patient needs, however, still appear to be intense. Most still require surgical care for extensive wounds and complex fractures, as well as medical care for infections and other postoperative complications that may arise.

Rhianna, Ana, and I dropped our stuff off in the hallway and went on a quick tour of the hospital. There appears to be a building that houses the administrative offices, the operating rooms, and a tiny ICU that appears to be two small rooms separated by a small corridor. Outside, there appears to be two large patient tents for adult patients, as well as a small chapel that is dedicated to pediatric patients.

During dinner, which was a weird mixture of spaghetti and spam, it became clear that we had absolutely no clue what role either of us were going to play. After all, we had no clue what the administrators had in store for us. It was as if we were in the back seat of a gua gua and had no sense of direction. "Well, let's just go with it," Rhianna suggested, resigning herself to whatever assignment that would be posted on the bulletin board in the morning. "Either way, we will be helping people..."

That night, we were shown to our new quarters. They were much more luxurious than I expected, especially since we had running water and a shower. The three of us were placed with about 7 other volunteers in the same room, but as cramped as we were, sheer exhaustion made it easy to fall rapidly into a thick, dreamless sleep.