A MEDICAL ADVENTURE IN THE DOMINICAN REPUBLIC

Paula Radulski Fall 2013 for Winter trip 2014

My Experience in the Dominican Republic

Medical Mission in the Dominican Republic:

A Dream Fulfilled

Providing medical assistance in another country has long been a dream of mine. While a previous aspiration was to assist in childbirth in South Africa (an opportunity I still may pursue), I immediately knew I had to apply when the chance to offer medical relief in the Dominican Republic arose. Despite initial uncertainty about funding, I chose to trust and embrace this opportunity to help others. I was fortunate to receive a partial scholarship late in the semester from the Dorothy B. Padula Memorial Fund, which was incredibly helpful in defraying the cost, and for which I am deeply grateful!

The Journey and Accommodations

Every step of this journey was an adventure, from fundraising for medications to our arrival in the Dominican Republic and each clinical experience.

We stayed at Fusimana, a retreat managed by Catholic Charities. Despite the lack of hot water, the accommodations were quite comfortable and civilized, reminding me of the church camps of my childhood. The top bunk of room 14 became my daily haven, and I'm proud to say I perfected the ascent and descent, no doubt thanks to muscle memory from years past.

Preparation and Organization

Our educational experience began the day after our red-eye flight, following a brief rest. The entire camp was divided into groups to inventory and sort all the medications we had transported from the United States, along with those stored locally at Mother’s Wish and on the Fusimana campus. I was assigned to the GI table, handling medications for gastrointestinal issues (GERD, minor esophageal reflux) and diabetes mellitus. Our task was to inventory these medications and prepare two bins daily to supply the pharmacies at the two different clinic locations. We had to estimate the daily medication usage for each clinic, inventory the bins at the end of the day, and then restock them. We developed an efficient system for working from our “main stock” to provision the clinics.

Teams for other major medication categories, such as dermatology, cardiac, pain, and village medications, operated with the same system. I was truly impressed by the collective effort and cooperation in filling these bins and assisting each other in breaking down medications into smaller, patient-ready doses. Everyone pitched in—bottling vitamins, cardiac drugs, metformin, or whatever was needed. Many hands indeed made light work; it was a wonderful experience!

Village Outreach.

Students also had the valuable opportunity to meet with village health leaders to assess community needs. I met with R… from Sondora, a village near Lajas. She identified hypertension and diabetes as the two main medical concerns and highlighted a couple of patients for our home visit team to consult with. We also discussed which individuals with new issues should be seen at the scheduled Sondora clinic. R… reported minimal domestic violence, two new pregnancies, and one recent death, with no new health issues requiring immediate attention during this visit. I was impressed by the commitment of these village volunteers to providing healthcare for their communities. Unfortunately, I missed the Sondora clinic as I was assigned to the home visit team that day.

Clinical Experiences 

Home Visits

My clinical experience began with the home visit team. Our initial schedule in Lajas was quickly altered to attend the funeral of a respected former village leader. We attended out of respect for this individual, also named R…., and her family, even though the village was not on our clinical schedule. The service was held in her home, which was a very nice dwelling, comparable to what one might see in the States, and was crowded with people inside and out. As the priest had not arrived, an informal service led by a village elder was underway in the main room. We were ushered in and given preferential seating. It was much like a stateside funeral, except for the private home setting. R…’s family accepted our condolences with great dignity—grief requires no translation.

I visited two patients in their homes: Mr. B, a 95-year-old man with uncontrolled hypertension but otherwise in good health, and Ms. A, a 78-year-old woman with uncontrolled hypertension, uncontrolled diabetes, congestive heart failure, and a history of recent CVAs (strokes). She was non-ambulatory due to post-CVA loss of strength and balance. Mr. B was well cared for by his wife, who lived with him. Ms. A, who lived with her elderly husband, relied on family members who did not reside with them. Her daughter lived nearby, on the same path. There were no telephones for emergency communication.

Ms. A and her husband were not capable of caring for themselves or each other. They depended on the daughter, who visited twice daily to help them out of bed, prepare meals, and return in the evening to put them to bed. The home was built on a concrete slab, which I thought was fortunate for them, making me wonder how they afforded it. The structure itself was wood with a tin roof, and the windows had shutters and some old lace curtains. A functional, old-fashioned kitchen had been added at some point, and chickens wandered freely through the house. I did not see a bathroom and am unsure of the facilities. These individuals were living in poverty.

In the States, both elderly people may have had access to medical care or be admitted to a medical institution. (Since this trip, I have learned that many American people in the United States do not have access to medical care at home or in an institution). Mr. B was safe and well-cared for, but Ms. A was barely surviving. She urgently needed hospital care, which would be the standard in the US. There was very little food in the home. To complete Ms. A’s medical treatment plan, we determined she needed to be seen by a physician and left to relay this to the medical team at Fusimana. Walking back, we met our physician, Dr. Cindy, and decided to return to see Ms. A immediately.

When we returned with Dr. Cindy about an hour later, Ms. A and her husband were already in bed for the night. It was only around 3:00 p.m., and the family caregivers were gone. A few crackers were at the foot of the bed for a meal. Dr. Cindy assessed Ms. A's needs, and we concluded that we required more information from her caretakers before prescribing medications to ensure accurate adherence to the treatment plan. We planned to return the next day to meet with Ms. A’s daughter, the primary caregiver. Although we didn't leave medications that day, we did offer hope. Ms. A shared her strong faith, saying God took good care of her, and though her home wasn't grand, she looked forward to living in a mansion with her King one day. She expressed gratitude for being alive one more day and was thankful for our visit, which clearly brought her joy. She also mentioned the difficulty of eating when food was unavailable. Our return plan included meeting the caregiver, bringing food and medications, and bringing a physical therapist to set Ms. A up with a walker for increased independence. We all wished we could do more. While in a perfect American scenario, we might have rallied community support for cooking, cleaning, and assistance, here in Lajas, we respected the cultural reliance on family members.

We returned the following day unannounced (due to the lack of phones). Two daughters, along with children and grandchildren, were present. The elderly couple was dressed and out of bed. We spoke in depth with all the providers and finalized a plan of care. Our physical therapy student returned with us and set Ms. A up with a walker. Although the space was tight, we were hopeful this would allow her to get up and ambulate more, which would improve her condition. Her husband also needed a walker, as he was a "wall walker," holding onto the walls to ambulate. We didn't have the opportunity to work with him.

It’s remarkable that this family allowed us into their home. It was crowded upon our return, and I am certain our presence and teaching fatigued the elderly couple. However, we left them with hope, which is often the best medicine.

Earlier that same day, in search of directions to Ms. A's daughter's home (again, unannounced, with no phones), we had visited the home of JL. JL and her family welcomed us warmly. It was evident that the entire family—grandparents and children—was happy that we were in Lajas to care for their community. Pappy, JL’s father, a resilient elder, personally escorted us to the homes of Ms. A’s daughter and Ms. A.

The Clinics

The clinics were held in schools and churches. Village leaders managed attendance by selling tickets, with the money going back into the villages, ensuring that people would show up for their appointments—a sound plan. The providers (doctors and nurse practitioners) relied on the nurses and nursing students to review the client's medical history, perform assessments, and determine a plan of action based on the visit's findings. This gave the student nurses a practical opportunity to utilize and refine the skills we had been accumulating in school. I embraced this opportunity and look forward to repeating the experience.

My first clinical experience was in a church in Yaroa. As an athletic trainer accustomed to working in the field with limited equipment, this environment did not faze me. I thoroughly enjoyed applying all my skills to assess my client. With the assistance of my nursing preceptor/interpreter, the process went smoothly, though the assessment and plan took time due to the client's many needs and the complexity of determining an action plan. She was a diabetic with uncontrolled hypertension. She hadn't eaten that morning as she wanted a fasting blood glucose test. We gave her peanut butter crackers before she left, as too many hours had passed since her last meal. I cherished this experience and was motivated to develop an efficient head-to-toe assessment plan moving forward.

Each clinical experience presented varied ailments. Diabetes, hypertension, and asthma were the most common issues among my clients. I also assessed for COPD, sleep disturbances, GERD, orthopedic problems, dermatological issues (calluses from milking cows, rashes, acne), urinary tract infections, and chronic infections. It was encouraging to be able to help these individuals, to offer them tangible solutions for their ailments, treat them effectively, and provide a sense of hope that treatment would improve their health and encourage compliance. This truly is my passion.

One client, a 39-year-old female with three young children who suffered from uncontrolled hypertension and diabetes, particularly stands out. She refused to take her medication, stating she was uncomfortable with it. Her blood glucose levels had increased since her visit six months prior. She was overweight and incredibly stubborn. There was a significant degree of frustration because her noncompliance was twofold: she wasn't taking her medication, and her acceptance of the medication during the previous visit, only to take it home and not use it, was a waste, ultimately denying treatment to others.

My challenge was to educate her about the consequences of uncontrolled diabetes: blindness, HTN, infections, weight gain, fatigue, and so on. Another key argument was that her children needed a healthy mother, conveying my concern for her as an individual. She remained very stoic. I struggled to get through to her the necessity of taking these medications and that her condition would not simply disappear. I believe the turning point was suggesting that Metformin could ultimately help her lose weight. She finally agreed to take the medications. I hope the medical group visiting in July will observe an improvement in this woman's compliance, health, and attitude. She is from Arroyo Ancho. Given our limited medication supply (it was the last day of clinics), sending medication home with a client whose compliance level was unknown was challenging. I had to trust that my message resonated with her. This experience underscored the vital importance of follow-up visits.

Another client was suffering from asthma, possibly triggered by allergies. We lacked the facilities at the clinics to perform allergy testing for a definitive diagnosis. However, we treated the asthma with an emergency inhaler, a controller inhaler, eye drops for irritation, and nasal spray for allergies. The education for this client was extensive and challenging. My interpreter and I demonstrated the use of the inhaler with a chamber, wrote out step-by-step instructions that the client repeated, and conducted a teach-back session, yet we struggled to get the client to "Respire lento" (breathe in slowly/gently). This is a common issue; based on my observations as a health aide in an elementary school, it takes time and practice to master the concept of inhaling medications correctly. In retrospect, I wish I could have had time to reassess this gentleman's progress after a short break—anywhere from an hour to a day—to repeat the teaching and verify his understanding. Unfortunately, we did not have that luxury. Nonetheless, being able to recognize and treat illnesses and help people feel better is immensely gratifying. What happens after they leave the clinic is beyond our control, and while we encourage them to return, that, too, is out of our hands.

Yet another client presented with chronic back pain and a vaginal discharge that had persisted for about seven years. After reviewing this with my nurse preceptor, we made a plan to treat both the woman and her partner. It was highly likely that the infection would clear up with a six-month treatment but would then return, and while probably not an STD, the partners were likely transmitting the infection back and forth. I was so pleased when our providers agreed to treat both partners, even though the male was not present. As this woman left the clinic, her face radiated relief and hope for the treatment to be effective. It was deeply gratifying.

Time and again, visiting these people in the Dominican Republic, we witnessed tremendous resilience in self-care, deep faith in God, and strong family support for the elderly. This truly warmed my heart. Every client I saw was well-groomed, and most were alert and oriented, showing pride in their appearance. The clients displayed humor and forgiveness when I struggled with their language. I loved making them smile and laugh; that in itself was good medicine for both of us. One adult female client had some delayed mental issues, and her adult brother ensured she made it to the clinic for evaluation. He introduced himself, expressed concern for his sister, and was present for the medication education. This level of concern impressed me, as it is not always something I observe in the States.

Community Visits

The Hospital in Puerto Plata

We visited the hospital on January 2, 2014. Our visit was a positive and emotional event. Our group gave a presentation on the benefits of breastfeeding and how to manage various common conditions or issues. The Puerta Plata nurses were very receptive, asked many excellent questions, which our group answered well. At the end of the presentation, PRHDR donated new stethoscopes to the nurses in attendance. We were short about four, and Dr. Cindy Robertson and the student nurses from Husson College donated their personal stethoscopes to the group of Dominican nurses. It was a very moving moment, and I don’t think there was a dry eye in the room. The Dominican nurses appeared to be hardworking women who took their jobs very seriously.

Our tour of the hospital revealed open wards, reminiscent of hospital space in the 1940s or 1950s in the USA. Apparently, it is not unusual to wait days to be seen in the Emergency Department. Patients sometimes leave and return the next morning rather than waiting all night. Patients were required to provide their own bedding. People looked well cared for and content. I noted a significant need for disposable supplies at the hospital, such as gloves, bandages, and sterile gauze. At several stations, I observed nurses rolling bandages. There also appeared to be a shortage of nurses.

Lajas School

Our group had the chance to visit the local school in Lajas. The children were quite excited for our visit. One of the NP students was an excellent leader for this activity, opening with "La Bamba" and "Twist and Shout" on his guitar. He split the children into four groups so that everyone had a part to sing. It was a great icebreaker for the students, the teachers, and us. We asked them to draw a picture of their life goals. Their drawings depicted dreams of becoming nurses, doctors, lawyers, architects, engineers, pilots, taxi drivers, and grocers—all kinds of dreams. Everyone was very animated when sharing their ideas with the group. It was an opportunity for all of us to explore what is or could be in our future. Every school should have a performer to facilitate career exploration; we need to offer this in the States.

Recreation and Reflection

We had time daily to socialize after the clinics. There were impromptu games of volleyball at the community court. Many of us enjoyed the fresh fruits offered by local vendors. Internet access was available for a small fee at the foot of the hill (I did check in with my family a couple of times). But the main entertainment began after the medication bins were packed for the night. The Gazebo was the central meeting spot for most of the camp. Nightly entertainment was provided by the camp’s musicians, and everyone was encouraged to join in. Some enjoyed board games—cards, Yahtzee, Catch Phrase, Scrabble—while others learned cultural dances from the local interpreters.

The trip to Cabarete Beach was one of my favorite outings and was perfectly timed at the end of the clinics when we were all ready for a break. Having taught swimming and trained lifeguards for years, and feeling like "part mermaid," I found the water lovely, the waves tall and exciting, and the company delightful. Having grown up in the south, it was so much fun to be back in warm waters and riding the waves—something impossible in the frigid waters of Maine unless you're "part walrus." The weather was perfect! The only downside was leaving so many of our group behind at Cabarete when we headed back to Fusimana, as they had made arrangements to stay a few more days and fly out later. A bit of the spark was missing from our group when we returned to Fusimana, Lajas, to pack.

Summary

The decision to travel and serve in the Dominican Republic was, without a doubt, one of the best I have ever made! I learned from every aspect of this journey, from people of all ages and temperaments. Professionally, as an athletic trainer, I felt I had many unique skills to offer. Academically, as a nursing student, I had the opportunity to apply newly learned clinical skills in a real-world setting. It was deeply gratifying to serve and help so many people with medical needs. Sometimes the most we could offer was hope, which was more than they had before we attended to them. Socially, it was fulfilling to work and connect with people from varied backgrounds. We shared so much humor in our daily experiences at Fusimana, relating over cold water showers, early morning rooster calls, midnight cat fights, and losing power. It was fun! It was great camaraderie. It was family.

My 16-year-old son, a high school junior, questioned me one day before the trip, "Mom, have you ever made goals? Did you meet them?" His question caught me by surprise!

I responded with great enthusiasm, "Yes, Kellen! Look! I am going to the Dominican Republic for medical missions! I am in nursing school! These are things I wanted to do with my life! Who would have thought? Dreams can come true!" I am so happy that he could witness these goals attained and that I could provide an example for him. I feel incredibly blessed to have achieved them.

My spirits have been uplifted significantly since my return from the Dominican Republic. Yes, I have a lot of work to catch up on for this semester. Yes, I still need to complete taxes and the FAFSA for myself and my two girls in college. But this positive experience lifts my spirits and allows me to move forward with great hope and confidence. It gives me energy. I see a great future!

This entire journey—nursing school combined with the medical relief trip to the Dominican Republic—is a dream come true. I am so inspired to continue learning and growing, and I am already planning my return trip to this mission, hoping to bring my son with me next time. I feel so blessed to have made this trip and to have met and worked with all these professionals.

My cup runneth over. Thank you so much for this opportunity!