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 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!

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 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 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...