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.

Santiago Homecoming

So...we're back from Jimani! The trip was many things at once: fun, grueling, heart-breaking, eye-opening, and most of all, unforgettable. After around 14 hours of travel, we finally arrived back in our apartment in Santiago. Our fellow apartment-mates welcomed us back with the following feast for dinner:



The dish in the rectangular glass pyrex dish is called a "pastelon," which is a traditional Dominican dish made with eggplant and ripe platanos. Heather's Mom, who is Dominican, was good enough to make it for us. It was delicious, and a far cry from the copious amounts of peanut butter sandwiches we had been subsisting on for the past few days.

Stay tuned for more posts about Jimani in the coming days. I need time to decompress and upload more photos...

Day Eighteen: Off to Jimani

So, we're off. As you can tell, we spent most of last night procuring lots of supplies for our trip (which mostly consists of junk food).

I will not be blogging during this time, but will be chronicling my experiences by hand so I can blog retrospectively.

If all goes well, Ana and I will be spending a week there. Will write more when we get back to Santiago!

Day Sixteen: Return to El Llano

Today, Adam, Ana, and I decided to take a short field trip to El Llano to visit Maribel Dulce and Dina. It was a relatively short visit, but reasonably productive given the fact that we didn't have an attending physician with us to do house calls.

We stopped at Maribel Dulce's fairly early in the morning. Ana and I had planned to give her a calculator and a notebook so she could take better stock of the empanadas she was selling. She was, as we thought, tickled to death with the thought of owning a calculator.

Our visit to Dina and Ramon was equally successful. Ana and I stopped at the grocery store last weekend for a frame to fit a nice familiy picture we had taken. When we gave them the picture, Gilbert, the three-year old, connected with it promptly. He liked sitting down with the picture and repeating "mommy, daddy, and Jaely" (his sister). Later on, we were able to get another good picture of them by the fogon (traditional stove):



We got back from the mountains late that afternoon, and Adam made a lovely dinner of breaded chicken breast and rice pilaf. So it was all in all a very laid-back day: good friends, good work, and above all, good food!

Day Fifteen: Flying Solo

So, it's Monday, and Ana and I are the only med students in the house. Adam is still stuck somewhere in Samana with his friend, and Linda is working at the Pequeno Pasitos clinic this week. Plus, we learned that the attending physician who was supposed to be with us this week is not coming down at all. Apparently he learned that his passport was expired ...just as he was about to take off from JFK International Airport. So we are truly the orphan med students...

Today we went back to the hospital and tried to make the day seem as normal as possible. We attended morning conference, saw a couple of interesting patients with the team, and spent some time in the consult clinic. It was so hot inside the consult room that I nearly passed out!

But the patients were definitely interesting. I saw my first case of dengue hemorrhagic fever today, as well as another patient with newly-diagnosed AIDS and possible PCP Pneumonia. It was interesting to observe how the Dominican doctor handles confidentiality, however. Even though the patient purportedly did not know his diagnosis, the doctor seemed to have no problems talking about his virus load right in front of the patient and other family members. Part of me wonders if this is something cultural, or if it was just this particular doctor...

Then, in the consult room, we saw a thin, tired-appearing 19-year old girl who had multi-drug resistant TB. She had had recurrent activations of her infection ever since she was a teenager. This time, she came to clinic because she was having severe flank pain when standing up. The attending physician seemed concerned about the disease spreading to her kidneys and immediately sent her for some tests. Ana and I were both shocked to see this disease progress so rapidly in someone so young.

When we got back to the apartment following the afternoon conference, we found Adam waiting for us. Apparently he had gotten stranded during his travels, but thankfully he arrived back safe and sound. We talked for a long time about his time in Jimani, and it sounded like he was able to initiate a lot of projects. Talking to him made me even more eager to go there...

Adam also mentioned that he probably hadn't had a home-cooked meal since he left for Jimani last week. So here's what I made:



Our menu included fried rice with a stir-fry made with eggplant, tomatoes, onions, and eggs. It tasted pretty good, if I may say so myself. And Ana made a lovely salad with avocados and red peppers. Here's some more "food porn":



As they say here...buen provecho!

Weekend #2: Relaxation and Carnival

Finally, a chance to unwind! And as much as I miss the sights and smells of the mountain, I will admit it is nice to be back in a fully-enclosed building with less mosquitoes. :-)

Saturday was basically spent doing laundry. After 5 days of trekking through mud, dust, horse manure, and whatever else was on the mountain ground, our clothes and towels were all a grimy mess. Thankfully there were only 4 people in the apartment this weekend. Adam was vacationing with a friend in Samana, and Michael and Cynthia had left early that morning to go to Jimani (a Haitian bordertown) to work at a hospital.

Linda, who had just come back from Jimani last night, said that there was still a tremendous amount of work that needed to be done. Apparently there is more organization now than there was when Michael was there three weeks ago. Most patients there were pretty stable, having all had external fixations in place for bad femur fractures from the earthquake. Dr. Chaplin, our attending, stayed there an extra day, since he was basically running an ad hoc medical ICU. According to Michael, we will all have individual 4-5 day shifts there. Ana and I will go this coming Thursday, so it looks like we have a few days to get ready.

On Sunday, the four of us headed out to see the local Carnival festival. Apparently Dominicans like to party--the whole month of February is basically "Carnival Season," with massive parades being held in many of the towns and cities each Sunday. It was quite a sight. Here's a picture of the huge Carnival display outside the national monument:



I always find myself particularly drawn to the masks. They are somewhat a mystery to me--but apparently they are worn to symbolize various deities or representations of the supernatural. The display I'm showing below also contains a variety of whips, which are toted around by people dressed as demons. Not sure exactly what they symbolize, but I've heard the demons marching in the parade will indeed whip you if you get in their way...



And finally, here's an illustration of just how turned around things get in Carnival. This is a picture of a common tradition: men dressing in women's clothing.



After Carnival, we went home and had the rest of my birthday cake. Yes, my birthday was a week ago, but I managed to keep it a secret from everyone until Ana found out. She was good enough to make a yummy cake for me, the remnant of which is pictured below:



So all in all, a great weekend. Next week will bring more excitement, I'm sure...

Day Twelve: Si Dios Quiere...

The Dominicans living here in the mountains have a standard response whenever I tell them, "I'll see you later." There is always a momentary pause--after which there is a smile, a half-hearted shrug, and then the famous words: "Si Dios Quiere" (if God wants). At first, I found myself puzzled by their response. But upon further thought, I came to understand it. After all, they had probably been visited by many volunteers in the past, many of whom had made empty promises to return. It was perhaps only logical that they had left it in God's hands whether or not they would ever see us again.

Ana and I wrapped up our last clinic session and spent the afternoon finalizing our needs assessment report of Dina's family. In the midst of it all, we were able to fit in one final basketball session. I am amazed by the progress we made in the past 5 days. The respect that the girls have for Ana is almost palpable, and in some ways, I think her basketball clinic had more of a positive impact on their health than anything "medical" we could have done. There's nothing like taking up a sport to encourage healthy habits and build self-esteem. Here's a final picture of the team:



Our parting from Dina and Ramon was a sad one. It was late in the afternoon when we were finally able to get up the hill, and Ana and I were scrambling to catch the last gua gua off the mountain. We said that we would visit them again before leaving for the U.S., and of course, they responded to our promise by saying, "Si Dios quiere." In any case, we did manage to take a family photo of them, which we plan to send to them in a picture frame by next week:



And of course, before leaving the mountain we called "home" for the past week, Ana and I couldn't resist visiting Maribel Dulce again and buying one of her famous empanadas for the road:



Ana and I would stand at the side of the road for a long time before catching the last gua gua that would bring us back to our Santiago apartment. We licked away the last of the grease from our empanadas as we waited, watching the locals mill around the small village store. It was hard to believe that soon, we would be amidst the crazy hustle and bustle of city streets, where the sounds of car horns and sirens would replace the sounds of insects buzzing and roosters crowing. And hence, our time in the mountains had come to an end

Day Eleven: The Little Things

Each day, Ana and I would come back to Maribel Dulce's home from the clinic or our home visits and be greeted by the incredible smell of fried empanadas. In the DR, empanadas (a savory pastry pocket filled with meat and cheese) are typically consumed in the late afternoon and evening. Just two weeks ago, Maribel Dulce decided to step up to the task and open up what is the only empanada stand I've seen in El Llano. Every few days, she takes a huge bag of yuca flour, roasts it together with a special sauce, and sets out to knead the dough with the help of a couple of other men from the village. She then spends a day rolling out the dough into pastry sheets and making little pockets with the filling. The empanadas are then brought outside to be fried and eaten. They are quite good. Ana and I have had empanadas every day after basketball practice.

Up here in the mountains, life is slow. So slow, in fact, that one almost becomes hypersensitive to the little things that happen throughout the day. You start to become aware of the fact that the air feels and smells different right before it rains. You start to notice all the different personalities of the million-and-one roosters and hens that strut and scamper across the mountain roads, walking around as if they owned the place. And of course, you start to pick up on little idiosyncracies of people who actually live there.

It is interesting to me just to hear Maribel Dulce talk. I learned that she herself was a health "promatora" many years back, and I can definitely see the influence. She speaks slowly and deliberately, using her face and hands to gesture an inexplicable amount. To be fair, she is probably the perfect person to be hosting a couple of "gringas" for the week. But it almost makes me laugh to see her face crinkle at our sometimes glazed expressions when we don't understand her, or to see her eyes light up when we somehow are able to understand her thick Dominican Spanish at a first pass.

And then, there is Ramon. Just 25 years old, and it appears that he has lived enough for a person at least twice his age. Every time Ana and I ask a question, or try to give a piece of health advice or counseling, he responds with a lengthy anecdote or account of his personal experiences. When we tried to talk about the need for water purification, he told us he used to work at a water purification company and proceeded to quote us methods for purifying water via chorine and UV rays that he learned at his job. When we brought up the need for him to stop chewing tobacco, he told us that he used to work in a tobacco factory and that it was there when he discovered that "chewing tobacco made his toothache go away."

I asked Dina how she was able to put up with someone who knew so much and talked so much about everything. She simply smiled at me and said, "I like it. Sometimes it gets too quiet around here..."

And of course, it has been a delight to observe the subtle changes in Dina and Ramon's children over the past few days. On our first day we were there, they seemed scared of us, but raucous and unruly at the same time. As we kept up our visits, they became calmer and much more friendly. But the best part came after we bought them toys. I had learned, from watching my brother's kids, how toys could be a valuable part of a child's development (as well as life-saver for parents). And lo and behold, it worked. Both of the toddlers were very occupied with the toys we brought, leaving Dina more time to tend to the baby and to finish up her chores. Dina even told us she had a little time to read in the morning, which made her very happy. Here's a picture of Gilbert, her three-year old son, playing with blocks:



It is hard to belive that tomorrow will be our last day staying up here on the mountain. On the one hand, I am happy to be returning to Internet access (so I can finally load all of these posts), reliable electrical power, and less mosquitoes. But on the other hand, I know it's the little things up here that I will miss: the fact that people smile and say "hola" to you on the street, the roosters crowing at all hours of the day, and of course, the enticing scent of freshly-made empanadas after a long day of hiking.

Day Ten: House Call

Wow--today was certainly action-packed! After another breakfast of toasted bread and chocolate milk, Ana and I literally set out to conquer the world. Our morning started out on the wrong foot, however. Yesterday, we bought Maribel Dulce five oranges and a pineapple as a thank you gift. This morning, we awoke to find that she had cut up four of the oranges in halves for us to eat with breakfast. Turns out that she had one orange last night (which, according to her, was extremely good), but then discovered that it hurt her teeth tremendously to chew the pulp.

So much for our thank you gift...

In any case, this morning, we were told to help out with home visits in the morning since the whole medical team from Brown was going to be there. Ana and I got there early and spent time chatting with Diego about Dorka and her family. Soon enough, Michael, Heather, and Cindy arrived in short order. We filled a bag with all sorts of medicines and set off to visit the people living in a remote village called Los Pajones. We hiked for about 15 minutes before coming to our first destination.

Our first home visit was quite sad--a 72-year old woman who looked at least 20 years older than her stated age. She had a history of high blood pressure, stroke, and diabetes, and, according to the niece, she had been feeling extremely lousy for a long time. When we saw her, she was in prominent atrial fibrillation, and there were crackles in both lungs. We were told by Diego that the woman was dying, and that everyone was fairly certain that she was on her way out. And with 4+ pitting edema in her legs, and overly-distended bladder, and signs of congestive heart failure, she couldn't have been that comfortable at all.

So what did we do? Other than tinker with her blood pressure meds, start her on a beta-blocker to control her heart rate, and discuss the feasibility of starting her on a diuretic--we did absolutely nothing. I'm really starting to get the sense that symptomatic control is the best one can hope for out here...

The next house visit was not much better. We took care of a couple who had some minor ailments: controlled hypertension and back pain. Their father, however, was also not in good shape. When we saw him, he was lying on a thin matress on a pile of old blankets. His body was fixed in a contracted position, and it was physically impossible to break him away from this fetal position, even to examine him. And it was heart breaking to do so. He had evidence of a pronounced facial droop and asymmetrical muscle strenth. But by far the most disturbing sight were his pressure wounds. Bound to his bed for many months, he was starting to get nasty bed sores on his bony prominences. And there were many of those sores on his body. Michael and I tried getting a blood pressure, but could only manage to get a systolic number due to the fact that he wouldn't relax his arm enough for us to check it properly. We noted, as we were busy moving him around, that the man smelled absolutely horrible. Indeed, we realized that this was because he had been sitting in his own feces and urine for quite some time. The couple taking care of him knew how important it is to change positions frequently, but both of them were too busy with handling their own issues for them to give him very much attention.

We were able to see a few more cases that morning, including a man with aortic stenosis, a woman with possible tuberculosis, and a man with asthma. But overall, I felt these home visits went far more smoothly than the ones we had done previously. Heather is essentially our attending now, and she has adapted incredibly well to her new role as a leader and chief caregiver.

I should mention that these home visits are primarily for patients who live in areas so remote that it is extremely difficult for them to access the clinic. As such, it would usually take us the whole morning to see 5-6 patients, since the houses were so far apart from one another. Walking through the woods and mountainous terrain made me very appreciative of just how strong one has to be to live here.

After our home visits, Ana and I scampered off to Santiago to try and get some toys for Dina and Ramon's children. This turned out to be a far more labor-intensive experience than anticipated. Diego was able to give us a lift into the city in the early afternoon. Ana and I had about two hours to take a cab back to our apartment, eat, go toy shopping at the market, and find our way back to the Gua Gua stop for the last ride up to the mountains. We made it, just in time...only to endure a very long ride up the mountain with a fairly reckless driver (though it seems that reckless is the norm over here). Finally we arrived in the mountains...ten minutes before basketball practice was supposed to begin. Feeling disoriented and quite car sick from the ride, I managed to stumble behind Ana as we trekked up the hill to deliver goods to Dina and Ramon, and then back down again to play some basketball with the girls.

Thankfully, the day had a happy ending. We may not have saved the world, but we did manage to get back to Maribel Dulce's house in one piece...

Day Nine: Poor but Rich

So the good news: I survived the nighttime insect swarm that apparently invaded our beds. And the extremely cold shower that followed my awakening only served to sharpen my awareness of how absolutely different my life is from the people who live here.

Breakfast today was again, simple but delicious. We had 2 pieces of toasted bread each, as well as a generous mug of hot chocolate milk. It felt good to drink something warm this morning, since the temperate had literally dropped 30 degrees overnight.

We eventually left the house to get to clinic around 8:30 a.m. And already there was a long line of people waiting to get in the clinic when we arrived. I was assigned to the role of taking vitals this morning, and it gave me a chance to do a lot of counseling about diet and exercise (a lot of female patients were frustrated with their weight on the scale). Ana saw them in clinic with the doctor, and apparently were more than a fair share of interesting patients. There was one child who was given treatment for worms since his mother saw some in his stool. And it was also "Papanicolau Day," so many women were there to review their results. Out of the approximately seven women who came for their results, two had cervicitis. Fortunately, the Dominican government has a similar sort of reporting system to the United States for sexually-transmitted diseases. Good to know that they are keeping an eye on things, I suppose...

After clinic, Ana and I paid another visit to Dina, the 18-year old mother of three that we met for the first time yesterday afternoon. She was in good spirits when we saw her, and she was very excited to see us. Her husband, Ramon, was there as well. Whereas yesterday, both of them had been reserved and polite when interacting with us, we found them to be extremely talkative and open with us today. Thanks to the good weather, we had a great chance to have a look at the household. As I said before, the whole family lives on a farm up on a very steep hill that looks something like this:

De Medical Adventures in GuaGua Land

The view from the top of the hill is absolutely amazing. The farm itself however, is extremely poor. Dina and Ramon have no share in the land--they were placed there by a landlord who gives them a living space in exchange for taking care of the farm. There is no running water, and the family uses a latrine. Animals seem to have utmost control of the place, running to and fro in the fields as well as in their house. It is a far cry from what they must have been used to in the city. I could only imagine what Dina must be going through, being only 18 years old and with three very young children.

Ramon, however, seems to be very supportive of his wife and family. Unlike other spouses, who seem not to care one bit about what goes on inside the house, he seems to love Dina very much and would do anything to make sure his wife and kids are happy. "I am a lucky man," he told me, when I asked him how he felt about his circumstances. "I am very poor, but I have a wonderful wife, three beautiful children, and good work. And look...the view up here is pretty, and it is quiet and peaceful. So in a way, I am rich."

I was so touched by his words that I couldn't help but smile the whole rest of the time I was there. Dina, who sat next to me, couldn't stop smiling either. I was struck by just how much they seem to love each other, despite the fact that they were so young and virtually stuck on an isolated farm in the middle of nowhere. To me, their situation was tragic. But given their attitude, I left the farm with a glimmer of hope that their story might actually have a happy ending.

In other news, Ana led her first basketball workshop for the girls in the village. She had originally thought of the idea when remembering the youth basketball clinics she taught at for her local youth group. Anyway, it was received with a good deal of excitement here in El Llano. It is amusing to me to think of the little improvisations we've had to make while being in this town, however. We ended up holding today's session in a small, enclosed concrete area with no basketball net. Ana is determined to find a real basketball net tomorrow. We shall see...

Dinner was a huge heap of fried cheese and batatas. It was really good, but had the side effect of making both Ana and I bloated and sleepy. Will write more tomorrow...

Day Eight: Life in the Mountains

So the immersion adventure begins. During last week's excursion up to Pequnos Pasitos, it was decided that we would go up to the mountains two at a time to stay in one of the rural villages for a week and to perhaps implement some small public health intervention. Ana and I volunteered to be the first two guinea pigs for the experience, and so we woke up at 5:30 a.m. to prepare for what will probably be the absolute highlight of this trip.

We packed hurriedly and with a frenetic sense of urgency--despite the fact that we had spent so much time packing the night before. Because of our communal laundry habits (and the fact that we don't have a dryer), we had laid out a huge collection of clothes to dry the night before our trip without realizing that we had to factor in "drying time." What resulted was a collection of half-dried clothes that we were forced to pack in our backpacks, which only got wet again when we sauntered out into the rain.

When we arrived at Pequeno Pasitos via Gua Gua, we were immediately put to work. Ana and I were asked to take vital signs and to switch off with one another so we could each have individual time to work with the doctor. The doctor was great to work with, since she always took time to explain things and didn't seem to patronize the patients. Plus, she spoke to us only in Spanish, which was an added bonus since it forced us to stretch our language skills.

Clinic was interesting, not so much because of the patients, but because one of the medical staff suddenly got sick. Marta, one of the cleaning ladies, was struck by a sudden episode of dizziness, nausea, and vomiting. With prodding, she eventually went home to rest. No one thought anything else of it until she sent someone to the clinic to pay Marta a house visit and take her blood pressure. I turned out to be the lucky person, since no one else was available to do so.

Marta's house, like many others in the village, was a tightly-constructed hut made of wood and covered by a metal roof. Her room was small but tidy, comprising nothing more than her bed and a few possessions displayed on a number of make-shift shelves. When I saw Marta, she was sitting up in bed and seemed relatively chatty despite her ill appearance. But as I examined her, it was clear that her body said otherwise. Her blood pressure was moderately elevated, but what concerned me most was the fact that her heart rate was barely in the 50s. I hurried back to the clinic, eager to tell the doctor that she should at the very least have an EKG done and some labs drawn. But before I could say anything, I was told that none of that was possible at the clinic. They did not own an EKG, and it seemed that Marta would have to make the 40 minute trip to Santiago in order to have any sort of lab test done.

After clinic, we had a wonderful lunch of rice, black beans, and broccoli. Diego, the clinic director, took us to fulfill our promise to Fatima (a patient whom we saw during our previous visit), which included dropping off a lab slip so she could have her TSH rechecked. We then journeyed to El Llano, a small village within the clinic's catchment area, up an incredibly big hill to do a home visit with an 18-year old mother of 3 very young kids. She and her husband were once inhabitants in Santiago, but they decided to move out to El Llano when her husband was promised a more lucrative job on an isolated farm. It instantly became apparent to me that they had made some pretty steep sacrifices. They young mother really wanted to have a career as a singer, while the father's main wish was to return back to Santiago to take care of his sick mother. Instead, they chose to leave the city and live in a remote shack in the middle of nowhere, with no running water and no help to bring up three young kids. It was indeed a way of life they hadn't known previously.

We finally met our house "mom" that afternoon. Her name sounds almost too good to be true: Maribel Dulce. And indeed, it is a name that suits her well, given her incredibly sweet nature. Her home, small as it is, is wonderful. It is certainly more "cush" than Ana and I were expecting, especially since there seems to be running water and a semi-workable toilet.

Dinner here was pretty simple, but very tasty: eggs and mashed potatoes. When I asked Maria what she had put in the eggs, she smiled real big and said in a proud voice, "milk, butter, and Parmesan cheese." Ana and I simply looked at each other and smiled. Given our lactose intolerance, this was certainly going to be an interesting week...

And tonight, we're sleeping in beds in a house that is partly open to the elements. It's been raining here the entire day, and the dampness in the room is palpable. What a drastic change from the living conditions in Santiago. Just sitting in bed, writing this blog entry with a flashlight, I now see that we are surrounded by all sorts of flies, mosquitoes, and other random tiny insects. Here's hoping that we don't get eaten alive tonight...

Weekend #1: Surf and Turf

Finally, a weekend has come and gone! It was nice to have a couple of days just to bask in the sun and enjoy the beauty of the Dominican Republic. Especially after the rather unexpected turn of events at Pequeno Pasitos yesterday, we were all feeling like it would be good to get away for a bit.

And what better place to do so than at the beach?

So Saturday, we spent at the beaches of Sosua. It was about a two-hour bus ride from Santiago, most of which was spent chatting with Ana about odd experiences we had had on the hospital wards. When we arrived, we took a taxi to a little village called Cabarete. Heather (the resident), who is Dominican, knew of a beach there right against the barrier reef that has wonderful surfing, and we ended up deciding to spend the entire day there.

We had lunch by the seaside, watching the powerful waves crashing intermittently on the shoreline. Heather, Linda, Michael, and his wife, Robin, all had grilled fish. Adam and I went with the Chicken Criollo (chicken marinated in a tomato-based, zesty sauce), and Ana went totally "American" and had herself a nice juicy burger. We then rented two surf boards and agreed to take turns surfing. I mainly stayed on shore, hoping to catch up on some work. But soon, the lure of the ocean was too much for me, and I ended up going for a run with Ana to a more tranquil portion of the beach that was some distance away. We stayed there for a long time, talking, doing yoga stretches to the rhythm of the waves, and collecting seashells. On the way back, we both decided to venture onto a shallow portion of the reef when I lost my footing and slipped. Ana did as well, and ended up being partway pulled to sea by the strong current. Luckily, she managed to survive, as did I--save for some nasty cuts to the foot and the knees!

We got home late that night and stopped at an empanada stand. It was really my first taste of Dominican food in the week that I have been here, and it was delicious. I had something called a "quipe," which is a savory pastry pouch made with bulgar wheat and filled with beef and cheese. My first bite yielded a mouthful of meaty, cheesy, greasy wonderfulness. I can't imagine how much cholesterol I'm clogging my arteries up with, but it was very much worth it!

I also decided to make Pao de Queijo for dinner that night, which was gobbled up almost instantaneously. It was pointed out how I have an almost obsessive tendency to track down recipes from countries I've visited in the past, whether it be pad thai sauce or, in this case, Brazilian cheeseballs. And yes, I will admit that I am very much preoccupied about food...:-)

And it was food that was on my mind the next day, when I thought of what I could do for my Sunday project. It was my birthday, and, having had my fill of the "surf," I decided to stay on land to relax and catch up on projects. Adam had bought a bunch of green bananas more than a week ago, hoping that they would ripen. In short, they never did. We were left with a bunch of bananas that no one knew what to do with, so I turned them into a green banana coconut curry.



Okay...so it doesn't look very appetizing in the pan, but I wasn't smart enough to take a picture when we had plated it with rice and a tomato/cucumber salad. Still--it was delicious. and a perfect end to a peaceful, relaxing birthday.

Day Five: Orientation to Pequenos Pasitos

It is hard to know where to begin with this post. We went today to visit Pequenos Pasitos, a small clinic and community center located in the hills near Santiago. For 6 years, Brown has had a close connection to this clinic, supplying both a supply of medical personnel and students interested in sustainable development to the area.

Prior to arriving, we were told that this clinic would be a key way to see how Internal Medicine was practiced in developing country. Among the learning objectives in particular was observing how chronic diseases such as diabetes and high blood pressure were treated in remote areas with no access to medical care. I had wondered how this would work. Prior to this, the only experience with chronic disease I had had was in the U.S., where patients were told to come in for check-ups every 3-6 months to see how things were going. Admittedly, I had a hard time seeing how treating chronic diseases would work without this framework.

Turns out things weren't as put together as I had initially thought.

So we set out around 7:30a.m. in the morning on a GuaGua bus, ready for 40 minute drive up a foot of a mountain. Our team, which at that point was comprised of 8 people, quickly filled up a vehicle. But just as I thought the bus was considered full, the driver would stop and 4 more people would enter. Partway through the ride, I ended up sitting next to an ice cream vendor from Haiti. Not having enough room to place his enormous cooler, he ended up placing it on top of his lap and part of mine as well. We had an interesting conversation, though I dared not bring up the topic of the recent earthquake given our brief time together and my difficulty in understanding his Spanish. Adam, who was my travel buddy from our first day together in Logan Airport, sat on my other side, dozing fifully. To my amusement, the ice cream vendor ended up asking if he and I were brother and sister! This is particularly funny when considering that I am full-blooded Taiwanese and Adam is Italian by descent...:-)


When we reached the main Pequeno Pasitos clinic and community center, it was mid-morning. The facilities there are absolutely incredible, especially considering that the people who started it literally had to build from scratch using materials that they had brought over from the U.S. They also built a school in the past year, on evidence that that higher rates of preschool education contributes to better maternal and childhood health outcomes.


Diego, the visionary founder of Pequeno Pasitos, then took us up the mountain for several homecare visits. The first was to a mother who had preeclampsia and who had given birth 12 days ago to a preemature infant by cesarian section. We trekked up the mountain, each carrying several bags of food, for quite some time, stopping briefly to catch our breath and to grab something to drink. When we finally arrived, we were greeted by an angry dog and a naked two-and-a-half year old boy playing outside a fairly disheveled-looking hut. His mother was inside, keeping house and watching over her new child. We greeted her, gave her the foods, and proceeded to check up on how she was doing. Michael, one of the other students, took out his stethoscope and took her blood pressure. It was still elevated, but the mother seemed otherwise well. Dr. Gould, our attending, wrote a script for atenolol to control the blood pressure and reassured the mother that everything would likely return to normal in a few weeks.

The baby, too, was doing fine and sleeping soundly. After checking up on the incision, Linda, one of the two med students interested in OBGYN, took the sutures out. We all took turns counseling the mother on nutrition and baby care before leaving her home and hiking to the next home.



At the next home, which was much further up the mountain, we stopped at the house of an elderly woman who had been newly diagnosed with high blood pressure and diabetes a year ago during the last round of homecare visits. Her blood pressure was still fairly elevated when we checked it. When we asked if she was taking her medication, she responded yes, but that she had just run out of pills a week ago. Dr. Gould then asked the group if we should increased the dose of her current medication, or if we were at the point of actually needing to prescribe another medication.

Throughout this whole discussion, Diego had been fairly silent. It seemed he could not contain himself any longer though. Right in front of the patients, we were told that because of severe financial constraints, the Paqueno Pasitos clinic was not able to provide any more medicine for adults. For the past several years, Diego had fought to support various groups of Internal Medicine doctors and medical students as they organized electives and missions to provide primary care for the remote villages. His efforts had helped many, but ended up being a drain on his initial mission: to improve the health and wellbeing of mother and their children.

The tension in our group was quite evident as we stood there in front of this woman's hut. On the one hand, we all knew that she was "unhealthy" by U.S. standards. After all, she had uncontrolled high blood pressure, diabetes, and was feeling occasionally short of breath doing everyday tasks. In the U.S., it would be considered sacriligeous to diagnose a patient with those diseases and not treat them. But on the other hand, it seemed wrong to start someone on a course of treatment--only to discontinue it suddenly when resources went dry. If that was the case, it surely seemed we were doing more harm than good.

Heading down the mountain, it seemed that everyone's momentum had been deflated. We came in thinking in our hearts that we would be "knights in shining armor." But it soon became clear that we walked into a situation far beyond our control.

We spent the rest of that afternoon back in our apartment, talking to one another over "El Presidentes" (the national beer of the Dominican Republic) about how best to help Pequeno Pasitos. It was apparent that going from house to house with prescriptions for high blood pressure pills was not an effective approach to help that community. While there, we saw so many other issues that seemed more relevant than knowing one's A1C or blood pressure numbers: for instance, access to nutritious foods, poor health literacy, hygiene.

Ana and I volunteered to be the first 2 students to participate in the Pequeno Pasitos home stay program with a family in the community. We start tomorrow morning. Although we do part time work in the clinic, it seems that our afternoons are free to do whatever projects we wish. I'm planning to bring camera and journal with me, with the goal being to listen and to collect stories from the people living there. Too often, their needs get caught up between organizational agendas, and I'm hoping to be able to get some good informal interviews (perhaps a casual community needs assessment) so we can break through that barrier.

Hopefully this will be the case. This story will undoubtedly continue next week...

Day Four: When Zebras Become Horses

In medicine, there is a funny tradition that refers to common diseases as "horses" and rare diseases as "zebras." It's typically the "zebras" that will earn a lucky doctor the chance to publish a case study and be famous. For American physicians (or those in wealthy countries), it's the patient that rolls in with malaria or typhoid fever that gets people excited.

How interesting to be placed in a situation where all of your "zebras" turn into "horses."

And this is, in essence, what has happened in the past few days that I've been here in the DR. I'll admit it...there's something tantalizing and very refreshing about seeing things exotic and out of the ordinary. And already, since I've been here, I've seen dengue, tetanus, and at least two cases of adult meningitis that were precipitated in some way by pre-existing head trauma. None of the other residents or doctors blinked an eye when we asked specifically to see these patients. It still amazes me that these cases are considered "bread-and-butter" down here.

But all that aside, I think there is a fundamental difference in how people approach rare diseases. Where as in the U.S., we'd be content to use all resources available to work up an interesting case, decisions for expensive tests are made with more care--as if the medical providers involved are always cognizant of the fact that they don't have very many resources. Rule is--if they can't do anything to fix a problem, all investigation stops there. The charts here are filled with so many abnormal lab and imaging results that haven't been pursued farther. For example, once a tumor is identified, there is very little motivation for doctors here to pursue further studies. Chemotherapy and other treatments are limited, and patients usually can't pay for it...so to Dominican providers, there's really no indication to do more.

But it's the patients with these diseases that turn out to be sad cases. There was a 37 year old with Cushing's Syndrome due to an adrenal mass with a compression fracture who had been bed-ridden for 3 months. In the United States, her outcome would probably be much better given our access to physical therapy and bone-building agents. But here, she was doomed to wait in a room she shares with 3 other patients, awaiting possible surgery that may or may not occur. There was also a 16-year old who had a perforated appendix just a few days after having a cesarian section. She eventually returned to the operating room to have surgery as well as a drain to get the infection out of her abdomen. Afterwards, she seemed to develop every complication in the book: sepsis, DIC, pleural effusions, anemia...the list goes on. And all this at the tender age of 16. It is difficult not to wonder how different her medical course would have been if she were treated in the U.S.

We had an easy afternoon today. Our attending presented a gazillion x-rays for the Dominican residents, who seemed overall to be extremely pleased to have such a great lecture. I was stunned at how much they were able to distinguish. When we, the medical students, looked at the films last night, we were overwhelemed by the unusual diagnoses we were presented. But the Dominican residents seemed pretty unfazed. There was one film showing Varicella Pneumonia (a complication of chicken pox) that essentially stumped all of us Ameircans. But the Dominicans got it almost right off the bat.

Dinner was a feast, as usual. I shared cooking responsibilities tonight with Heather, the resident. She made Dominican-styled beans, and I cooked up fried rice, chicken, and a Pad Thai stir-fry.

Tomorrow will definitely be an action packed day. We head for A Mother's Wish...the organization that sponsors a clinic way up in the Mountains near Santiago. This should definitely be a change of pace, which, at this point, is much needed. I can't wait to spend a day outside of the hospital!

Day Three: Intensive Lessons

As I continue to write, it strikes me that there is one thing very different about my being here in the DR than in any other country. In years past, I would spend weeks and weeks reading everything I could get my hands on about a country. I would immerse myself in books designed to give me a 360-degree perspective on the land, its people, and its history. But there was essentially no time for me to do so before this trip. I was, like so many foolish medical students, so caught up in the frenzy of the residency interview trail that I had little energy for anything else.

How unfortunate that it's now that I'm realizing how much that fund of knowledge helped with my ability to feel connected with a country.

In retrospect, I also know that my experience is much different because I'm with a big group of people. And our mission is to learn about medicine and medical practice in another country...not just to learn about foreign culture and customs. So I guess I shouldn't feel so sad about spending most of the day in a university hospital, isolated by thick, insitutional walls from getting to really know the country.

That's not to say that my experience in the hospital is bad, however. I guess I wish I could connect with the residents and patients better. I'm aware now of how much easier it is to do this alone rather than in a group.

But that's not to say that I didn't enjoy the hospital time today. We had one more student arrive over night last night, which brings our group to a grand total of 7 people. So they ended up splitting us up into 2 groups: one group went to the ER, and the other to the ICU. I was placed in the ICU group, which was great since our attending just happens to be a pulmonogist with critical care experience.

So what does the ICU look like in a tertiary care center of a relatively impoverished country? Well, to be honest, it didn't look like an ICU at all. The majority of the patients appeared like those who could be managed on the floors of a general medicine ward in the United States. We saw a total of 3 patients there today--2 with mengingitis, and another who had a motor vehicle accident. All three of them looked relatively stable and well-cared for. Hours later, we learned from the group in the ER that the hospital literally turns away patients whom they believe can't be saved. So realistically, we probably were not seeing "sickest of the sick" in the country.

Afternoon conference was boring as usual--focusing on the basic science of gastric ulcers and their treatment. I'm only on day 3 of my time here, and already the difficulty of following Dominican Spanish is starting to get to me. It defintiely doesn't help that the residents and interns presenting cases always tend to mumble...

Dinner tonight was fabulous as usual. We had pasta with Bolognaise sauce, an Italian style pasta / avocado salad, and egg-plant parmesan. Dessert was a simple and utterly delicious shake made from zapotes.

We learned tonight that we may be able to go to Haiti this weekend or next. Will update on this tomorrow, perhaps...

Wow...I am worn out. I will end here and go to sleep. Meantime, stay tuned for tomorrow...:-)

Margret

Day Two: Excursion

Another day come and gone. And what an eventful one it was! We woke up at 6:30 a.m. to the sound of roosters crowing, and it literally felt like we hit the ground running.

After a quick breakfast, we arrived at the hospital at 7:30a.m. for morning report. So much of this seemed incomprehensible, especially to me and my pronounced inability to understand Dominican Spanish. The room we were in seemed extremely crowded with residents and interns. And of course, there was the constant hubbub of cars, sirens, honking horns, and other sounds that comprise the cacophonous symphony of Santiago's streets.

We then went on rounds with the attending physician. As usual, the pathology and high acuity of the cases never failed to astound me. Our first patient was a man who had organophosphate poisoning from ingesting rat poison in a suicide attempt. As we stood there discussing his case, the medical intern was stationed in a corner, patiently pushing atropine every 15 minutes in order to counteract the poison. As we left his room, I remember thinking with amusement about how different things would be in the U.S. if interns were really made to do things like that...

The other patient who really caught people's attention was a 30 year old woman who had untreated HIV for the past 8 years. She presented with a 3-day period of pronounced neck swelling in the context of a month-long history of constitutional symptoms. There were so many things that were apparently going on with her, ranging from significant anemia (the lab reported a hemoglobin of 2.9...this has to be a mistake) to an extremely huge mass on her neck that has yet to be biopsied. She also had evidence of tuberculosis in her lungs symptomatically and on x-ray. In the United States, any one of these would qualify a patient as a train wreck. Here in the DR, every patient seems to be an overwhelming mess. I really admire the attendings here. I don't think I would have the stomach to do the extent of the "watch and wait" type medicine they do...

Our attending, who is probably the most energetic yet laid-back person I know, decided to give us the majority of the afternoon off so we could get to know the city better. This was a blessing to our group, as the majority of us are foodies who were anxious to see what the local markets were like. What a treat, to be in a city where we have a seemingly endless variety of produce, beans and grains.


It was my turn to make dinner. We had Chinese-style fried rice, porkchops with orange marinade, and a salad made from avocado, cucumber, and red peppers. The avocados here are amazing...so much so that we had another dish made with avocados flavored with fresh-squeezed orange juice and salt. Yum...it was heavenly!

These nights, we eat family style. There are 6 of us sitting around the table, eating happily and sharing stories. It's times like these when I feel particularly grateful I'm here with a big group. I will definitely miss experiences like this in a couple of months when I'm in Cambodia as the only medical student particpating in that rotation.

Well, I should get to bed. I need to get up early so I can start brewing the coffee in time to drink it. We only have a french press coffee brewer...which makes for wonderful strong coffee, but takes a long time to make.

Til next time...

Day One: Arrival

Well, I'm finally here. After one cancelled flight, a frantic rebooking on another plane, an unexpected 24-hour stay back in Providence, and a red-eye flight to an alternate city...I am finally here in Santiago, DR. I traveled here with Adam*, a friend and fellow 4th year med student, and already, it's apparent that we're being tested by our abilities to "go with the flow." But to be honest, it hasn't at all been bad so far. As surreal as the past 48 hours seem, I was definitely impressed by how smoothly everything has gone. Even as we passed through airport customs--an experience frequently dreaded by many international travelers--everyone just seemed so amazingly relaxed.

Maybe this is the famous "island mentality" that everyone speaks of. If that's the case, I'm glad I'm here to partake of it in heaps.

So Adam and I arrived at our apartment a little before noon. We were early in fact, and had to await the arrival of the rest of our roommates to let us in. They arrived within a few minutes, and thankfully, we all became fast friends.

And after a fast lunch, we were off to do rounds in the hospital. We were all taken aback at the level of pathology: newly-diagnosed AIDS with Toxoplasmosis, Mesothelioma, a couple of pleural effusions with mysterious relapsing fevers...and the list goes on. What was most challenging about this experience was going back through all the charts to glean as much as possible about the patient's story in Spanish. This, as most people know, is a task that can be daunting in one's native language. But add to this the unfamiliarity of medical terminology, the odd quirks and idiosyncracies of a hospital's charting system, and of course, bad handwriting...and you've got what seems like an overwhelming task.

Hopefully things will get a little less overwhelming as the month goes on...

But all in all, I'm happy. I'm here with a group of awesome people (thus far) who are here to learn and appreciate the culture. Our attending, who was, incidentally, my first-year Doctoring teacher, is awesome. We also have a resident (Heather) staying with us who is Dominican and speaks fluent Spanish. And I'm gradually trying to transition back in to "Adult Medicine Mode" after 3 months of doing Pediatric-related rotations.

It's also our attending's birthday today, and we celebrated in full force with a Dominican-styled dinner: Mojo-marinated chicken, rice and beans, and plantains. And there were lots of "El Presidentes" (apparently the national beer) to go around.

But now...it's off to bed. Will try to post pictures of our apartment tomorrow. There are 6 of us now who live here, and it already feels a bit snug. When the full group arrives, we will be sharing only 1 bathroom between 8 of us. Fun times to come for sure...

* Note: All names have been changed to protect privacy