I'm super excited- David is visiting me here in the DR and arrives today!!! We are spending the weekend up in the northern part of the the DR in Cabarate for an adventure. The first adventure starts tonight- we are driving (!!) at night (!!!!!) up to the North tonight. Keep your fingers crossed for an uneventful trip up north!
Driving is pretty insane here, especially in the city. There really are no road rules here. People drive down one way streets the wrong way, there are huge potholes that will total your car, scooters weave in and out of traffic and on the sidewalk, cars honk to let you know they are passing you/going through an intersection/saying hello/mad at you/think you are pretty. Also, even "highways" here have the occasional obstacle of someone selling something between lanes, animals crossing the road, etc. Today will be my first time driving in the DR. I hope it goes well!
As for our trip.... check out the itinerary so far!
Saturday- repelling off the 27 charcos
http://www.youtube.com/watch?v=gGGt92vPGUI
Sunday- Master of Ocean competition and then surf lessons for us
http://www.youtube.com/watch?v=YlWRnGjo0Wk&feature=fvsr
Monday- scuba, surfing, and some R&R!
I can't wait to post pics to share next week! :)
Also, I GO HOME NEXT WEEK!!! As much fun as I am having here in the DR, I am excited to return home to family and friends... even if there is plenty of snow waiting for me. I'm also excited to start the next exciting part of 2010- match day (!!), figuring out where we will be living after match day, two weddings for friends, OUR wedding, gosh I just can't wait for it all! But first, picking David up from the airport with a HUGE smile! :)
Friday, February 26, 2010
Tuesday, February 23, 2010
I love USA scrub nurses!
Working in the DR has made me grateful for a lot of things that I never considered before. For example, when I would walk into a labor & deliver (private!!) room in the US to deliver a baby, everything would usually be set up for me: the patient would be draped, my sterile gown and gloves would be ready, all my supplies would be arranged, and I would easily have access to anything I needed, but if something wasn’t available I could ask for it and easily obtain it (medications, different surgical instruments, etc). When one of these things didn’t happen, I have to admit I would feel annoyed, even sometimes rolling my eyes that this wasn’t ready for me. Don’t get me wrong- it’s not that I felt entitled as a medical student, it’s just how most residents and attendings would react to this situation so I guess it’s a learned response, albeit a kind of lame immature one. Clearly, none of this exists here in the DR.
When I am walking briskly (no one seems to ever be rushing here, even if the patient you are transporting to the delivery room has a head hanging out of her vagina) to the delivery room I know that I can’t expect anything. Sometimes I walk in to the delivery rooms and they are still blood all over the table and floors. Sometimes, I walk in and there are no open tables for a delivery. Sometimes, when it’s a great day I have a clean and ready table. As for the rest, even on good days, it’s up to me. Before I tell a patient she can go ahead and push her baby out, I have to walk down to the pharmacy and ask for what I will need during the delivery-sutures, tools, gloves, local anesthesia, cord clamp, you name it I better ask for it otherwise I am going to be out of luck! Sometimes, this happens quickly. Other times, the people in the stock room don’t seem to care that there is a baby threatening to pop out of my patient and they take an unbearably long time getting my order ready- yes I’m sure that I need that needle driver! Once I return to the delivery room, I have to arrange my own sterile zone with the supplies that I got from the stock room. If everything goes well, I get the baby out without having to give an episiotomy (something I still cringe when doing). Now what do I do with the baby? In the US, there are tons of people in the room- family, father of the baby, nurses, other physicians, etc. Sometimes there is a nurse or resident or medical student in the room, but most of the times there isn’t. So the way that I learned you ask for something is by yelling as loud as you can: “Where is the pediatrician? Give me oxytocin!” Sometimes it comes quickly (Gracias a Dios!) but other times it takes a few yells and my building anxiety that whatever I said in Spanish isn’t clear or is just plain being ignored. The operating room is run mainly in the same way. Sometimes there is a scrub nurse who will help out. But for the most part, the lowest ranking resident is expected to set up everything for the surgery, including the trip to the stock room and arranging the surgical tools for the procedure (something that is usually done by the scrub nurses).
It was a tough transition at first and some days I still struggle when I realize that I have to be the one who has to draw the blood if I want to know if my patient lost too much blood during a delivery, but I can say it’s a good learning lesson. I have learned how to be more decisive, gained some clinical self-confidence, and learned how to yell a bit- all things that I’m proud to have learned.
I would like to take this moment to tell all scrub nurses back home and to those at the future hospitals that I will work at THANK YOU. Thank you so darn much for taking care of these things. Thank you for making it possible for me to walk into a room and focus all my attention on the patient and her care. Thank you for doing a job that I’m sure can be annoying at times and definitely tends to be thankless. I appreciate you so darn much. I will never again roll my eyes when things aren’t ready for me- I will know that I have the capability to do it all myself but I will be grateful for any help you can provide.
Hierarchy
A hospital is often set up like the military: there is an inherent rank system. When I first started working in the hospital, I remember thinking it was stupid that as a medical student I could ask some questions to residents but was not to bother the higher ups (senior residents, attendings) with these questions. I thought it was silly that people to treat people on the same team differently. Now that I have a bit more hospital experience under my belt, both in the US and abroad, I really respect the system of hierarchy in teaching hospitals. Now it makes total sense why I would ask an intern how to chart a patient’s findings but only trouble the attending with what he thought those findings suggested about the patient’s condition given the most recent publications in the field. I also think that the system is in place not just to feel great once you reach the top, but also for patient’s safety. As a medical student, I was responsible for my patients. I had an intern co-sign my orders and oversee everything that I did. Together we would present my patient to the team of residents. The senior resident would ensure that no mistakes were made with the team of patients. The senior resident would double check any concerns with the attending faculty staff. Built into this hierarchy are many levels of double-checking. So to people who hesitate to go to a teaching hospital because residents work there, I would like to argue that you are more likely to get excellent care at a teaching hospital because there are so many different types of people (i.e. rank) taking care of you that often have different perspectives on the same clinical problem.
Anyway, now that the background stuff is taken care of, I want to write about the hierarchy here in the DR. The inherent rank system in here is very strict and ordered. Residents are not only color-coded with particular uniforms depending on rank, but they also get to do completely different tasks during their day. For example, the intern takes care of absolutely all paperwork for everyone. The second year resident gets to assist in surgeries and do vaginal deliveries. The third year resident gets to be primary surgeon but not if the fourth year wants the case. So far this doesn’t sound tooooo different from what happens in academic centers in the US. Some hospitals tend to make a bigger deal out of hierarchy than others in the US. For example, in obstetrics, southern hospitals tend to be quite stringent about hierarchy and each person’s defined role within the system.
Well here in the DR things intensify. If an R2 disagrees with an R3 (R2- second year resident, R3- third year resident) they are falling out of rank. Today, I saw someone disobey their rank by disagreeing with a treatment plan. Not only were they humiliated by a team of superiors in front of the completely naked and exposed patient as this resident was suturing her up, but later the educational director came down to talk to this resident about his misconduct. The director punished this resident to 30 hours of call effective immediately and assigned the rest of the team additional call too for not being able to settle this within the team. What I saw today was a down-right denigration and humiliation of a resident for speaking his mind. Pretty crazy huh?
For those of you not in medicine, most teams of residents in the US would agree that patient safety is key. If someone does not agree with the treatment plan they are generally encouraged to speak up. Granted, there are proper times and places to bring this up (not appropriate to ever make another team member look bad because it makes the team look bad) but in general it is encouraged. If there is a conflict between team members (it happens to the best of us, especially in a field like OBGYN!), in no ways is this EVER discussed in front of a patient.
I’m learning a lot here in the DR. I am not as scared of hierarchy- I can appreciate its value now. And I kind of like that superiors are given proper respect (i.e. standing up when an attending enters the room, etc). That said, I also am happy that I will be going back to the US for about a million reasons, one of them being that as a team member I will probably always have a voice in the decision-making process involving my patients.
Spanish homework!
Sorry for the lack of recent posts! I went on an adventure Friday afternoon through Sunday night and then didn’t have access to the internet. Also, I got assigned homework in Spanish! I foolishly mentioned the ACOG practice guidelines which are reviews that OBGYNs use to get updated on the most recent relevant findings on a particular condition to my team. They showed me one that was from a few years ago about polycystic ovarian syndrome. Foolishly, I offered to translate it for them. I say foolishly because I didn’t realize that it was 10 pages long- which is pretty awful for a scientific article! Anyway, I spent the next two days working on it with the help of google translate. I learned tons of new vocabulary in Spanish but at the end of it, I’m just so proud that I could take pretty darn dense text in English and translate it to Spanish. Clearly, I won’t post the article here because that would ruin any chances of having any continued readers to my blog. :)
To make up for it, here are a whole bunch of posts to make up for my absence!
Thursday, February 18, 2010
Gracias a Dios!!
Great news- my computer is working again!!!! I was super upset yesterday: having computer problems is hard enough, but having to explain what is wrong with your computer in Spanish was just too stressful for me! Anyway, somehow I managed to communicate with the computer repair store nearby. Today, I went to see them and they told me (Gracias a Dios!!) that my computer was completely back to normal an hour after I left it!!! I guess my computer wanted a siesta, too. And they didn't even have to do anything so it was free!
Sorry for being so dramatic- my computer is back! And so will my blog entries! Horray!
Sorry for being so dramatic- my computer is back! And so will my blog entries! Horray!
A so so day
Im typing from a public computer at an internet cafe... i´m still keeping my fingers crossed that the computer repair store will be able to help me squeeze another week or so out of my laptop! in the meantime, i apologize for grammatical errors and mispellings... this keyboard is full of spanish symbols so typing is difficult!!
So I learned something about myself today... I prefer the controlled environment of the operating room to than delivering babies in the delivery room at least here in the DR. There is something really comforting to me about having a patient draped, semi sterile (we still have flies in the operating room here), and just focus on incision in front of me. I´m not sure whether this tells me anything about my future in obgyn (will i be specializing in gyn surgeries in my future??) or whether it just tells me something about what my future would be like if I practiced here in the DR.
I don´t mean to sound negative- I´m learning tons and everyone that i am working with is awesome and super helpful. Everyone I work with are incredibly skilled surgeons and clinicians. Today all the language and cultural barriers just got to me a bit. There were a few empty beds today so the cleaning staff decided to wash down the floors. I guess it´s great that they washed the floors down after being coated in blood and stool and other fluids since I got there... but the way that they wash the floors down is by covering it with several inches of soapy water that they sweep across the floor and let air dry. So I spent the day wading through this soapy dirty water with patients walking barefoot through it as I helped walk them to the delivery room. Something about the standing water just was too much for me... I couldn´t take it. I know I sound like a bit of a wimp but my reaction to the "cleaning" was a visceral feeling that I couldn´t overcome- I couldn´t wait to leave work. i´m sure that part of my reaction is due to the fact that I´m working in another country and another language so i´m still adapting... some days will be tougher than others and it´s hard to predict what will set me off one way or the other.
Oh well... tomorrow is another day. And in one week David will be here,,,, yayyy!!
So I learned something about myself today... I prefer the controlled environment of the operating room to than delivering babies in the delivery room at least here in the DR. There is something really comforting to me about having a patient draped, semi sterile (we still have flies in the operating room here), and just focus on incision in front of me. I´m not sure whether this tells me anything about my future in obgyn (will i be specializing in gyn surgeries in my future??) or whether it just tells me something about what my future would be like if I practiced here in the DR.
I don´t mean to sound negative- I´m learning tons and everyone that i am working with is awesome and super helpful. Everyone I work with are incredibly skilled surgeons and clinicians. Today all the language and cultural barriers just got to me a bit. There were a few empty beds today so the cleaning staff decided to wash down the floors. I guess it´s great that they washed the floors down after being coated in blood and stool and other fluids since I got there... but the way that they wash the floors down is by covering it with several inches of soapy water that they sweep across the floor and let air dry. So I spent the day wading through this soapy dirty water with patients walking barefoot through it as I helped walk them to the delivery room. Something about the standing water just was too much for me... I couldn´t take it. I know I sound like a bit of a wimp but my reaction to the "cleaning" was a visceral feeling that I couldn´t overcome- I couldn´t wait to leave work. i´m sure that part of my reaction is due to the fact that I´m working in another country and another language so i´m still adapting... some days will be tougher than others and it´s hard to predict what will set me off one way or the other.
Oh well... tomorrow is another day. And in one week David will be here,,,, yayyy!!
Wednesday, February 17, 2010
Computer died
Sorry folks- looks like my blogging will have to slow down from now on. My computer won't start anymore- awesome timing!! I will post as often as I have access to a computer that someone lends me (thanks peace corps people staying at the hostel!!).
A quick story to share. I was really frustrated/upset that my computer choose today to die. I decided to go out on a run. It was a great run fueled by a bit of anger. A little boy (maybe 12 years old) tried to stop my while I was running and grab me. Maybe it was the adrenaline, maybe it was my computer, or maybe he just plain deserved it but I pushed him so hard after he touched me that he fell down on the ground. As I ran away I told him something very unpleasant about his mother. Perhaps I over-reacted but maybe he should just not try to touch me again.
Hasta la proxima!
A quick story to share. I was really frustrated/upset that my computer choose today to die. I decided to go out on a run. It was a great run fueled by a bit of anger. A little boy (maybe 12 years old) tried to stop my while I was running and grab me. Maybe it was the adrenaline, maybe it was my computer, or maybe he just plain deserved it but I pushed him so hard after he touched me that he fell down on the ground. As I ran away I told him something very unpleasant about his mother. Perhaps I over-reacted but maybe he should just not try to touch me again.
Hasta la proxima!
Tuesday, February 16, 2010
An incredibly cool physical exam finding!
I really wish I had access to uptodate or other internet resources that I use at home! I had a patient come in with one of the most obviously abnormal findings I've ever ever seen! Not to sound totally creepy but she had the absolutely largest most inappropriate sized breasts EVER. As in she was a super small girl who had breasts that were EACH probably the size of two watermelons, as in a minimum weight of 20lbs. And to answer Meredith's question- waaaay larger than any implants possible. It was insane. I'm sure she has some hormonal problem but I have never ever heard about something like this! Friends from home, please email me if you find any links on uptodate about really huge breasts! I don't want to dare risking googling "really large breasts". ;)
Ahora tu eres dominicana!
Labor and delivery can be crazy in any country. At least from my perspective, the craziness here in the DR is a bit different than what I am used to. At home, when there are sick patients or stressful situations you can tell because everyone is revved up. Here, no matter how crazy things seem to be from my perspective, residents are still laughing, making jokes, planning the weekend, etc. Sometimes it's hard for me to realize that there is a critically ill patient because no one seems to be acting any differently- I guess they must all be so used to seeing this acuity of illness. I'm impressed with how darn calm they all are and how much fun they make work to be!
Today I worked again on L&D. Today, I ended up repairing at least 6 episiotomies (I lost count!). For non OBs, this can be tricky because there are often many different layers of suturing that have to be done depending on how far the episiotomy extended. I feel like I'm getting pretty good at it! I even have fun chatting with the patients (of course in Spanish) during it. I'm excited that I think my surgical skills are getting more confident but I'm also really proud that I'm able to start being more like the clinician I feel I am at home- consoling patients, chatting away, etc. After some awesome encouragement from Nina, I realized that I could still be the clinician I wanted to be even though it's in another language/culture and even though no one else I was working with was being supportive to these patients. It felt great to hold a laboring woman's hand, acknowledge her suffering, and tell her to relax nicely. I felt like the OBGYN I like to think I will become one day. So thanks Nina!!
Sometimes the labor room is especially busy and there isn't any room for more women to deliver. I saw a resident deliver two separate babies on a regular hospital bed today in the laboring room. I felt so bad for these women- they were laying in a pool of their own blood, stool, and amniotic fluid and were covered in it! The other women in the laboring room (about 20 or so) were strangely respectful- they all kind of stopped screaming during these deliveries and looked away to give these women some amount of respect for what she just went through. These are some super tough women that I'm working with!!
A crazy thing happened today- the power went out in the hospital twice! One time, while I was delivering a baby! Since the delivery rooms have no windows it was completely dark. No one around me seemed to care that it was dark so I waited a few seconds and then just tried to continue working. Luckily, the lights came back on before I completed the delivery of the baby's shoulders! Power outages still happen here in the DR often- not as much as in the past- but it probably still happens a few times a week. Looking back at the power outage today, it's really cool how I didn't even think to get stressed about it being completely dark- I just kind of kept working. I doubt that I will ever have to deliver a baby in the dark back home in residency, but it definitely is something that has boosted the confidence I have in my clinical skills!
One of my favorite things that happened today is related to the title of this entry which translates to "now you are a Dominican!" I forgot to mention earlier that since deliveries happen so fast and supplies are minimal, the only protection I have from the patient and her body fluids are my glasses (thanks Mom!), scrubs, and a single layer of gloves. For anyone who has seen a delivery before, you can recognize how difficult it is to deliver an infant and only get your gloves dirty. Anyway, after getting splashed today by various body fluids, I picked up a habit that I had seen the other residents doing- I now tie large black garbage bags around my waste so that when I do get splashed my scrubs are less likely to get drenched. I spent the rest of the day walking around in scrubs and garbage bags. One of the attendings saw me and told me that I finally was becoming a Dominican. She then encouraged me to show off my new attire so I did a nice catwalk down the laboring room and everyone stopped to applaud and cheer me on. It was super fun but I guess a little strange if you weren't there! Who would have known that something as gross as getting soaked by body fluids would turn into something that helps me become more accepted by colleagues?! :) That said, I really look forward to practicing back home where I don't really have to worry about getting covered in someone's body fluids.
Today I worked again on L&D. Today, I ended up repairing at least 6 episiotomies (I lost count!). For non OBs, this can be tricky because there are often many different layers of suturing that have to be done depending on how far the episiotomy extended. I feel like I'm getting pretty good at it! I even have fun chatting with the patients (of course in Spanish) during it. I'm excited that I think my surgical skills are getting more confident but I'm also really proud that I'm able to start being more like the clinician I feel I am at home- consoling patients, chatting away, etc. After some awesome encouragement from Nina, I realized that I could still be the clinician I wanted to be even though it's in another language/culture and even though no one else I was working with was being supportive to these patients. It felt great to hold a laboring woman's hand, acknowledge her suffering, and tell her to relax nicely. I felt like the OBGYN I like to think I will become one day. So thanks Nina!!
Sometimes the labor room is especially busy and there isn't any room for more women to deliver. I saw a resident deliver two separate babies on a regular hospital bed today in the laboring room. I felt so bad for these women- they were laying in a pool of their own blood, stool, and amniotic fluid and were covered in it! The other women in the laboring room (about 20 or so) were strangely respectful- they all kind of stopped screaming during these deliveries and looked away to give these women some amount of respect for what she just went through. These are some super tough women that I'm working with!!
A crazy thing happened today- the power went out in the hospital twice! One time, while I was delivering a baby! Since the delivery rooms have no windows it was completely dark. No one around me seemed to care that it was dark so I waited a few seconds and then just tried to continue working. Luckily, the lights came back on before I completed the delivery of the baby's shoulders! Power outages still happen here in the DR often- not as much as in the past- but it probably still happens a few times a week. Looking back at the power outage today, it's really cool how I didn't even think to get stressed about it being completely dark- I just kind of kept working. I doubt that I will ever have to deliver a baby in the dark back home in residency, but it definitely is something that has boosted the confidence I have in my clinical skills!
One of my favorite things that happened today is related to the title of this entry which translates to "now you are a Dominican!" I forgot to mention earlier that since deliveries happen so fast and supplies are minimal, the only protection I have from the patient and her body fluids are my glasses (thanks Mom!), scrubs, and a single layer of gloves. For anyone who has seen a delivery before, you can recognize how difficult it is to deliver an infant and only get your gloves dirty. Anyway, after getting splashed today by various body fluids, I picked up a habit that I had seen the other residents doing- I now tie large black garbage bags around my waste so that when I do get splashed my scrubs are less likely to get drenched. I spent the rest of the day walking around in scrubs and garbage bags. One of the attendings saw me and told me that I finally was becoming a Dominican. She then encouraged me to show off my new attire so I did a nice catwalk down the laboring room and everyone stopped to applaud and cheer me on. It was super fun but I guess a little strange if you weren't there! Who would have known that something as gross as getting soaked by body fluids would turn into something that helps me become more accepted by colleagues?! :) That said, I really look forward to practicing back home where I don't really have to worry about getting covered in someone's body fluids.
Monday, February 15, 2010
An adventrous weekend!
I had an AWESOME time this weekend! I woke up early on Saturday and took a bus to the northern coast of the DR called Samana. Of course, the bus had to break down along the way. And of course, there was no cell phone reception as we were driving through the hilly jungle on a dirt road! I finally got in- 4 hrs late- to Samana and decided not to have too many more adventures that day. Instead, I headed to my hotel in the sleepy fishing village of Las Galeras using the public transportation (called a gua-gua, it's a really small minivan that they cram about 10-15 people in, and sometimes live chickens!). Although the trip was exhausting and at times stressful everything was totally worth it once I got into Las Galeras. My hotel was heavenly- huge, safe, clean, warm water in the showers, overlooking the ocean, with a balcony... it would be a great hotel room in the US but it was absolutely INCREDIBLE in DR terms and in my mind after living here!
The town of Las Galeras was incredible! It's a one-road fishing town where everyone is friendly and no one is ever in a rush to do anything. I strolled on down to the most amazing beach I've ever seen and took a glorious swim in the warm crystal blue ocean. When I got out, a man walked towards me and asked me if I would like him to cut down a pineapple or coconut from one of the tress on the beach for a snack- don't mind if he does! I spent the rest of the afternoon just relaxing, taking tons of pictures, feeling so darn lucky to be working in a country this beautiful when you get away from the city! I can't wait to show you all the pictures- not a bad day of work!!
Since it's a fishing town, the food was all incredible and heavenly and inexpensive. I spent the evening talking to people who walked by my table under the palm trees, listening to music locals were playing, and sipping fresh juice. It was pretty darn awesome. I can't say it enough- this place was paradise. I could easily see myself never ever leaving here. The biggest problem I had here was overcoming my inertia and strong desire to just never do anything ever again.
The next morning, I went whale watching!!! It was awesome!! I got to see humpback whales several times- incredible!!!!! Definitely a once in a lifetime experience. Every year humpback whales travel to this area. My tour guide was the woman who first realized that humpback whales migrated to Samana between January and February. She came to work as a scuba instructor, found a humpback whale on a dive, and never left; now it's 25 years later and she doesn't miss the snow in the US at all! How amazing is it that I got to watch the whales with such a legend?! I took tons of pictures and can't wait to share them with you! In the meantime, check out her website for more info about the amazing trip!
http://www.whalesamana.com/home.html
http://dr1.com/travel/special/whales.shtml
I also did some touristy things in the villages I spent time in this weekend. I bought an awesome painting from a local artist. I also bought David some hand-rolled Dominican cigars to share with the guys on our wedding day! :)
As I've learned so many times here in the DR, Dominican time is a bit different and it's best not to plan your day out too well. My 4-5 hr whale watching trip was 7.5 hrs and despite frequent reassurance not to worry about time from the locals, I was less than 30 seconds from missing the last bus back to the capital! I came back to the hostel super excited. My first weekend exploring the country on my own was a huge success! I had an amazing time and better yet, I had an adventure that gave me tons of confidence with exploring the country and speaking conversational Dominican (which is very different than conversational Spanish!).
Perhaps the best part of my weekend was a phone call I got from David. As our Valentine's day present, he bought tickets to visit me in the DR!!!!!!!!!!!!!!!!!!!!!!!!!!!!! I have had trouble sleeping since I found out the great news- I just can't wait to show him off and show him the DR! I'm excited for all the fun trips we will have! My biggest challenge is going to be getting David to be patient with Dominican time here- he's even more of an itinerary type A personality than me! I get to see David next week! Yay yay yay!!!
The town of Las Galeras was incredible! It's a one-road fishing town where everyone is friendly and no one is ever in a rush to do anything. I strolled on down to the most amazing beach I've ever seen and took a glorious swim in the warm crystal blue ocean. When I got out, a man walked towards me and asked me if I would like him to cut down a pineapple or coconut from one of the tress on the beach for a snack- don't mind if he does! I spent the rest of the afternoon just relaxing, taking tons of pictures, feeling so darn lucky to be working in a country this beautiful when you get away from the city! I can't wait to show you all the pictures- not a bad day of work!!
Since it's a fishing town, the food was all incredible and heavenly and inexpensive. I spent the evening talking to people who walked by my table under the palm trees, listening to music locals were playing, and sipping fresh juice. It was pretty darn awesome. I can't say it enough- this place was paradise. I could easily see myself never ever leaving here. The biggest problem I had here was overcoming my inertia and strong desire to just never do anything ever again.
The next morning, I went whale watching!!! It was awesome!! I got to see humpback whales several times- incredible!!!!! Definitely a once in a lifetime experience. Every year humpback whales travel to this area. My tour guide was the woman who first realized that humpback whales migrated to Samana between January and February. She came to work as a scuba instructor, found a humpback whale on a dive, and never left; now it's 25 years later and she doesn't miss the snow in the US at all! How amazing is it that I got to watch the whales with such a legend?! I took tons of pictures and can't wait to share them with you! In the meantime, check out her website for more info about the amazing trip!
http://www.whalesamana.com/home.html
http://dr1.com/travel/special/whales.shtml
I also did some touristy things in the villages I spent time in this weekend. I bought an awesome painting from a local artist. I also bought David some hand-rolled Dominican cigars to share with the guys on our wedding day! :)
As I've learned so many times here in the DR, Dominican time is a bit different and it's best not to plan your day out too well. My 4-5 hr whale watching trip was 7.5 hrs and despite frequent reassurance not to worry about time from the locals, I was less than 30 seconds from missing the last bus back to the capital! I came back to the hostel super excited. My first weekend exploring the country on my own was a huge success! I had an amazing time and better yet, I had an adventure that gave me tons of confidence with exploring the country and speaking conversational Dominican (which is very different than conversational Spanish!).
Perhaps the best part of my weekend was a phone call I got from David. As our Valentine's day present, he bought tickets to visit me in the DR!!!!!!!!!!!!!!!!!!!!!!!!!!!!! I have had trouble sleeping since I found out the great news- I just can't wait to show him off and show him the DR! I'm excited for all the fun trips we will have! My biggest challenge is going to be getting David to be patient with Dominican time here- he's even more of an itinerary type A personality than me! I get to see David next week! Yay yay yay!!!
A different world
Today was my first day working on labor & delivery. It was pretty darn insane. The laboring room is a large shared room where about 15-25 women wait to be completely ready to start pushing and give birth. While they wait, most lay completely naked, legs spread open, screaming in pain as others walk by ignoring them. Everyone at the hospital seems very used to the fact that women are screaming all the time and ignore it, some even laugh at a particularly vocal patient. At one point today, a woman was screaming so much so I went over to her to check to see if she was complete (ready to deliver). One of the residents stopped me and said, "Don't worry. Ignore her. She will learn we don't give preferential treatment for being loud and she will quiet down." I felt so awful that I had to ignore this woman who was shrieking in pain. It felt so wrong to let her deal with the pain by herself. In case I forgot to mention earlier, patients are not allowed to have visitors so they go through all of labor, delivery, and postpartum alone; they can't see anyone outside the hospital and no one can see their baby until they leave.
Another fantastic quote from today... a patient was just admitted from the emergency department in labor. It was her first time giving birth. She didn't want to lay down on her hospital plastic mattress because there were no sheets on it and it was dirty from someone else's blood. When she told the resident who tried to get her to lay down on the mattress so he could examine her, he laughed and said, "This is a public hospital stupid. We don't give everyone bed sheets. Lay down."
The lower level residents deliver the babies. The upper level residents wear white and therefore usually only stop by if needed. For the most part, we are on our own in the delivery. The goal of the residents in the delivery is to get the baby out as quickly as possible. If the woman is scared or isn't pushing "enough" , everyone in the room laughs at the patient and tells her to "stop dreaming and grow up." Some of the residents smack the patient on the forehead if they think she needs a "wakeup call" and needs to push more. If you are taking too long in the delivery, the senior resident comes by and says "This is taking too long. Cut her right now" (cut means cutting an episiotomy to make more room for the baby to come out). During one of my deliveries today, the baby was making good progress and was coming out just fine. This patient was young and this was her first delivery so she was scared and needed some coaching; she had only tried pushing 2 or 3 times. When the senior resident said the patient was taking too long, he told me to cut her. I hesitated, not just because I didn't have experience with episiotomies or not just because I thought that she didn't need to get cut (even though I don't think she did), but also because this woman did not receive any pain killers or analgesia of any kind before he wanted me to cut her. He pushed me aside, took the scissors and cut about 2 inches into this woman's perineum. Despite seeing many natural child births back home and all the births I see here are without analgesia so I had heard my share of screaming and pain, I had to look away from this patient when she started screaming. I have never ever in my life heard that kind of a scream. The resident gave her a large episiotomy and pulled the baby out without any consideration of pain relief, not even local analgesia. He walked away and the woman was left there alone, bleeding, still shocked by what had just occurred. She laid there alone, naked, with her legs still in the stirrups, bleeding because the resident had to go to another delivery and didn't have the time to stitch up her wound for another ten minutes. When I finished with the patient, I walked away and realized that my surgical mask was wet and that at some point during this episode I must have cried.
As I mentioned before, physicians here do not use ultrasound monitoring to hear the fetal heart beat; instead, they listen using their stethoscope. This is a technique that I am still working on. One of the residents teased me that I didn't know how to do anything here and asked how we could possibly monitor patients differently in the US. As I looked around the crowded room full of women in labor, windows open, with flies accumulating on the patients that were too exhausted to scurry them away... I didn't know where to begin describing the difference. I started telling this resident that where I trained, every patient was constantly monitored for contractions and fetal heart tones. I didn't even bother to describe that every patient had a private room or the other luxuries patients have in the US. I could tell that talking about constant ultarasound monitors, let alone central stations with computer access to these monitors was an entirely different world. I'm learning tons from my experience, some are positive experiences and some are negative experiences but all are great opportunities for learning. That said, I know that I will come away from my month here with an extreme gratitude for the medicine I have a privilege to practice back at home.
Another fantastic quote from today... a patient was just admitted from the emergency department in labor. It was her first time giving birth. She didn't want to lay down on her hospital plastic mattress because there were no sheets on it and it was dirty from someone else's blood. When she told the resident who tried to get her to lay down on the mattress so he could examine her, he laughed and said, "This is a public hospital stupid. We don't give everyone bed sheets. Lay down."
The lower level residents deliver the babies. The upper level residents wear white and therefore usually only stop by if needed. For the most part, we are on our own in the delivery. The goal of the residents in the delivery is to get the baby out as quickly as possible. If the woman is scared or isn't pushing "enough" , everyone in the room laughs at the patient and tells her to "stop dreaming and grow up." Some of the residents smack the patient on the forehead if they think she needs a "wakeup call" and needs to push more. If you are taking too long in the delivery, the senior resident comes by and says "This is taking too long. Cut her right now" (cut means cutting an episiotomy to make more room for the baby to come out). During one of my deliveries today, the baby was making good progress and was coming out just fine. This patient was young and this was her first delivery so she was scared and needed some coaching; she had only tried pushing 2 or 3 times. When the senior resident said the patient was taking too long, he told me to cut her. I hesitated, not just because I didn't have experience with episiotomies or not just because I thought that she didn't need to get cut (even though I don't think she did), but also because this woman did not receive any pain killers or analgesia of any kind before he wanted me to cut her. He pushed me aside, took the scissors and cut about 2 inches into this woman's perineum. Despite seeing many natural child births back home and all the births I see here are without analgesia so I had heard my share of screaming and pain, I had to look away from this patient when she started screaming. I have never ever in my life heard that kind of a scream. The resident gave her a large episiotomy and pulled the baby out without any consideration of pain relief, not even local analgesia. He walked away and the woman was left there alone, bleeding, still shocked by what had just occurred. She laid there alone, naked, with her legs still in the stirrups, bleeding because the resident had to go to another delivery and didn't have the time to stitch up her wound for another ten minutes. When I finished with the patient, I walked away and realized that my surgical mask was wet and that at some point during this episode I must have cried.
As I mentioned before, physicians here do not use ultrasound monitoring to hear the fetal heart beat; instead, they listen using their stethoscope. This is a technique that I am still working on. One of the residents teased me that I didn't know how to do anything here and asked how we could possibly monitor patients differently in the US. As I looked around the crowded room full of women in labor, windows open, with flies accumulating on the patients that were too exhausted to scurry them away... I didn't know where to begin describing the difference. I started telling this resident that where I trained, every patient was constantly monitored for contractions and fetal heart tones. I didn't even bother to describe that every patient had a private room or the other luxuries patients have in the US. I could tell that talking about constant ultarasound monitors, let alone central stations with computer access to these monitors was an entirely different world. I'm learning tons from my experience, some are positive experiences and some are negative experiences but all are great opportunities for learning. That said, I know that I will come away from my month here with an extreme gratitude for the medicine I have a privilege to practice back at home.
Friday, February 12, 2010
A great week
I finished off my first week at work. Today was a really awesome day. I felt like I knew what I was doing, felt pretty confident with my Spanish in the hospital and outside of it. Today everyone was celebrating the upcoming Valentine's Day. For about two hours, everyone kindof stopped working to enjoy food and spending time together at work. It seems corny but it was really cool! One of the attendings brought his guitar and everyone just sang, danced, and had fun! Everyone was having so much fun in our party in the emergency room that they decided to move the party to the labor floor (the big room with tons of hospital beds and naked pregnant women waiting for the doctor to be ready to deliver their baby). Although everyone in the party was having a good time, but I have to admit it was really a bit weird to be dancing, singing, laughing in a room where women were screaming in pain as they had natural child births! That said, it was really nice to feel included and see how different the dynamics between co-workers can be in a hospital at a different country.
I have a really good friend at the hospital who is a first year resident. She is a native Haitian, who moved here to the DR for medical school. Her husband is in the US trying to take the US medical exams and get into medicine in the US. And she is super patient and kind with my Spanish. We had tons of fun chatting today; it was only once I got home that I realized that talking to her was pretty effortless even though it was in Spanish! This must mean progress!!
Tomorrow morning I am leaving for an adventure! I am going to Samana, a peninsula north of the capital. The region is known for some of the world's best beaches, amazing nature scenes, and whale watching! I'm excited to be venturing out of the city! I can't wait to tell you all about it!
I have a really good friend at the hospital who is a first year resident. She is a native Haitian, who moved here to the DR for medical school. Her husband is in the US trying to take the US medical exams and get into medicine in the US. And she is super patient and kind with my Spanish. We had tons of fun chatting today; it was only once I got home that I realized that talking to her was pretty effortless even though it was in Spanish! This must mean progress!!
Tomorrow morning I am leaving for an adventure! I am going to Samana, a peninsula north of the capital. The region is known for some of the world's best beaches, amazing nature scenes, and whale watching! I'm excited to be venturing out of the city! I can't wait to tell you all about it!
Thursday, February 11, 2010
Rounds
"Rounds" are a way for a team of physicians to review patients and the day at hand. There are many different ways of "rounding" , some more formal than others. Most of the time in the US we have walking rounds where whoever is taking care of the patient updates the team with how the patient has been doing over the past 24 hrs. In general rounds are a way to exchange information as well as to learn from the patients. Rounds usually have a bit of hierarchy involved- the attendings are everyone's boss, senior ranking residents are responsible for the team, residents are responsible for their patients, medical students are responsible for staying alive. :)
Here in the DR, rounds are very structured and formal. Every morning, the residents that are post-call present to the entire hospital in a conference room. It took me awhile to realize this but everyone sits according to rank. The pre-interns sit in the back and wear beige scrubs, the interns are the next up in green scrubs, the upper level residents wear all white, and the attendings sit in the front row. The first few days, I sat in the back because I didn't want to get in anyone's way and because I feel pretty lowly in the scale of my medical training in general, let alone in Spanish. As a guest visitor, however, I get to skip up a few ranks and now sit in the second row from the front. It's pretty neat although the attendings see me more and try to engage me in debates for "my professional opinion" about the debate at hand from my experiences in the US and of course "what Williams says." Williams is considered a Bible for Obstetrics and it is really worshiped here. FYI Williams is written at UT Southwestern, one of our top programs we ranked!
Rounds at this hospital in the DR starts off with a prayer. One of the senior residents leads the prayer thanking God for the honor to serve this population, and prays for the safety of the residents and the patients; then, everyone joins in and recites the Our Father. One of the senior residents then lists off all the deliveries, complications, births, deaths, surgeries, procedures, number of blood units available today, etc. Next, the resident presents patients in the past 24 hrs that had complications or were particularly unique.
The volume here is like nothing I've ever heard about- at least 60 deliveries/day. One resident told me that this morning she delivered 36 babies this morning. WHAT?!! I have no idea what to expect next week when I work labor & delivery but have a feeling it will be challenging!
The severity of cases discussed here are equally insane. Everyday we talk about things that I've been told I would probably never see in my career- here it happens every day. It's really exciting to come home and read about things that I've never even thought could happen. I'm learning so much!
Here in the DR, rounds are very structured and formal. Every morning, the residents that are post-call present to the entire hospital in a conference room. It took me awhile to realize this but everyone sits according to rank. The pre-interns sit in the back and wear beige scrubs, the interns are the next up in green scrubs, the upper level residents wear all white, and the attendings sit in the front row. The first few days, I sat in the back because I didn't want to get in anyone's way and because I feel pretty lowly in the scale of my medical training in general, let alone in Spanish. As a guest visitor, however, I get to skip up a few ranks and now sit in the second row from the front. It's pretty neat although the attendings see me more and try to engage me in debates for "my professional opinion" about the debate at hand from my experiences in the US and of course "what Williams says." Williams is considered a Bible for Obstetrics and it is really worshiped here. FYI Williams is written at UT Southwestern, one of our top programs we ranked!
Rounds at this hospital in the DR starts off with a prayer. One of the senior residents leads the prayer thanking God for the honor to serve this population, and prays for the safety of the residents and the patients; then, everyone joins in and recites the Our Father. One of the senior residents then lists off all the deliveries, complications, births, deaths, surgeries, procedures, number of blood units available today, etc. Next, the resident presents patients in the past 24 hrs that had complications or were particularly unique.
The volume here is like nothing I've ever heard about- at least 60 deliveries/day. One resident told me that this morning she delivered 36 babies this morning. WHAT?!! I have no idea what to expect next week when I work labor & delivery but have a feeling it will be challenging!
The severity of cases discussed here are equally insane. Everyday we talk about things that I've been told I would probably never see in my career- here it happens every day. It's really exciting to come home and read about things that I've never even thought could happen. I'm learning so much!
Wednesday, February 10, 2010
An awesome 24 hrs
Last night I met really neat people staying at my hostel. They are ecology graduate students that do field work throughout the DR. They spend months at a time exploring the huge uninhabited areas of the DR- they even travel with a donkey! I had such a blast learning about what they do- it's totally different job than anyone I've ever met. I've been here less than a week and have already met so many incredible people!
Since there were some guys in the group, I ventured out of my hostel after dark. We went to an authentic Dominican restaurant. The food was awesome and the company was wonderful. As lame as it sounds, making new friends every few days is really awesome. The restaurant had live music and dancing. I loved watching Dominicans dance- they are incredible! I even got to dance a bit. It was a blast!! Being here in the DR makes me feel so alive sometimes- the music, the people, gosh it is just awesome!
I went to work with a level of excitement- today would be better because I would be better prepared. I understood much more of the morning conference. The acuity of illness seen in this hospital is insane. As a quick example for any medical readers, a woman came to the ED pregnant with pre-eclampsia which turned out to be thyrotoxicosis which rapidly lead to congestive heart failure, C-section, ICU admission, and sadly death... all this happened within a matter of a few quick hours.
I felt brave today in the ED. I walked into the crowded waiting room and did my own triaging. I saw some really awesome patients. I understood them (for the most part) and they understood me (for the most part). I presented my patients in Spanish using all the right words I had written out the night before and admitted several to the hospital. All of this would be pretty easy standard stuff at home but I was just so darn proud that I could stay afloat today. As a result of the mini personal victories, the number of patients and the acuity of illness seemed less overwhelming.
I have a HUGE amount of respect and love for my co-workers in the hospital. They are incredibly patient and kind with me. More, absolutely everyone I have worked with has unheard of phenomenal clinical skills. I can't say this enough- they are AWESOME whether they are medical students, interns, or residents. For every pregnant patient, they use their stethoscopes to measure the fetal heart tones. How insanely awesome is that?! Clearly, it's a technique I'm still learning since back home I was pretty spoiled with using Doppler ultrasound on everyone (and used to be super proud of being able to hear the heartbeat easily).
So the past 24 hrs has been awesome. I'm still sweating tons, learning tons, and adjusting but today is the first time I'm excited to say I feel like I'm making progress. :)
Since there were some guys in the group, I ventured out of my hostel after dark. We went to an authentic Dominican restaurant. The food was awesome and the company was wonderful. As lame as it sounds, making new friends every few days is really awesome. The restaurant had live music and dancing. I loved watching Dominicans dance- they are incredible! I even got to dance a bit. It was a blast!! Being here in the DR makes me feel so alive sometimes- the music, the people, gosh it is just awesome!
I went to work with a level of excitement- today would be better because I would be better prepared. I understood much more of the morning conference. The acuity of illness seen in this hospital is insane. As a quick example for any medical readers, a woman came to the ED pregnant with pre-eclampsia which turned out to be thyrotoxicosis which rapidly lead to congestive heart failure, C-section, ICU admission, and sadly death... all this happened within a matter of a few quick hours.
I felt brave today in the ED. I walked into the crowded waiting room and did my own triaging. I saw some really awesome patients. I understood them (for the most part) and they understood me (for the most part). I presented my patients in Spanish using all the right words I had written out the night before and admitted several to the hospital. All of this would be pretty easy standard stuff at home but I was just so darn proud that I could stay afloat today. As a result of the mini personal victories, the number of patients and the acuity of illness seemed less overwhelming.
I have a HUGE amount of respect and love for my co-workers in the hospital. They are incredibly patient and kind with me. More, absolutely everyone I have worked with has unheard of phenomenal clinical skills. I can't say this enough- they are AWESOME whether they are medical students, interns, or residents. For every pregnant patient, they use their stethoscopes to measure the fetal heart tones. How insanely awesome is that?! Clearly, it's a technique I'm still learning since back home I was pretty spoiled with using Doppler ultrasound on everyone (and used to be super proud of being able to hear the heartbeat easily).
So the past 24 hrs has been awesome. I'm still sweating tons, learning tons, and adjusting but today is the first time I'm excited to say I feel like I'm making progress. :)
Tuesday, February 09, 2010
No other words- insane.
Today was my first day working in the emergency department at the largest (and public!) hospital in the Caribbean. Every morning starts out with a morbidity and mortality reviewing what happened the day before. This morning, over 60 babies were delivered. The cases discussed were probably the most insane things I've ever heard about- a baby weighing 7500 g at birth, insane infections of the uterus. We just don't ever see these kinds of things in the US.
Everyone in the hospital is very friendly and welcoming. My Spanish is getting better- at least for today! I spent a lot of time with the residents today, learning how to describe patients in Spanish when presenting them to attendings. Although I have plenty of practice speaking to patients in Spanish, learning the medical lingo for describing them to other physicians was tons of new vocab. It was really tough!
The ED in the hospital is a large room with lots of "stalls" with patient beds. Women are told to enter their stall and take off their clothes; there they lay completely naked, alone, exposed on tables covered in garbage bags to keep them clean. The women that are allowed into the ED out of the small crowded waiting room of about 50 women are triaged, which means only the ones who are suffering most are seen. I've seen plenty of women who I thought were suffering in the US but I NEVER ever witness the agony of each patient who came to the hospital. These women literally come in because they are dying. I knew to expect a much different type of experience this month, but nothing can prepare you for the types of things I saw today.
Although I only worked 7am-12pm, it was the hardest day of my life. I walked out feeling sick, everything was a blur. As I pushed past the 50 or so people waiting for space to open up in the lobby to enter, a woman saw me and tried to give me her newborn baby to take with me. I walked home feeling completely exhausted and numb. At home, I couldn't do anything but lay down and try to sleep. I forced myself to wake up and eat lunch. Luckily, my hostel mother saw the exhaustion in my first day and gave me a cup of amazing Dominican coffee. I felt better soon and was motivated to read up on all the ill patients I saw today. Tomorrow will be another challenging day for sure, but I look forward to the challenges ahead of me.
Everyone in the hospital is very friendly and welcoming. My Spanish is getting better- at least for today! I spent a lot of time with the residents today, learning how to describe patients in Spanish when presenting them to attendings. Although I have plenty of practice speaking to patients in Spanish, learning the medical lingo for describing them to other physicians was tons of new vocab. It was really tough!
The ED in the hospital is a large room with lots of "stalls" with patient beds. Women are told to enter their stall and take off their clothes; there they lay completely naked, alone, exposed on tables covered in garbage bags to keep them clean. The women that are allowed into the ED out of the small crowded waiting room of about 50 women are triaged, which means only the ones who are suffering most are seen. I've seen plenty of women who I thought were suffering in the US but I NEVER ever witness the agony of each patient who came to the hospital. These women literally come in because they are dying. I knew to expect a much different type of experience this month, but nothing can prepare you for the types of things I saw today.
Although I only worked 7am-12pm, it was the hardest day of my life. I walked out feeling sick, everything was a blur. As I pushed past the 50 or so people waiting for space to open up in the lobby to enter, a woman saw me and tried to give me her newborn baby to take with me. I walked home feeling completely exhausted and numb. At home, I couldn't do anything but lay down and try to sleep. I forced myself to wake up and eat lunch. Luckily, my hostel mother saw the exhaustion in my first day and gave me a cup of amazing Dominican coffee. I felt better soon and was motivated to read up on all the ill patients I saw today. Tomorrow will be another challenging day for sure, but I look forward to the challenges ahead of me.
Monday, February 08, 2010
Staying afloat
Today was my first day of work but it was more of an orientation day than work. I spent most of the morning waiting to figure out who I will be working with. As I tried to chat with peers, I was scared to learn just how different certain dialects of Spanish can be and how difficult it can be for me to understand them. Many of the people I met used slang and spoke rapidly… all which made me feel really uneasy about signing up to work here a month! I guess my biggest worry was that everyone here would think I was stupid or would ignore me. I’m used to feeling like a good student and was suddenly totally overwhelmed with the thought that I may be the dumbest person that they work with all year because my Spanish isn’t up to par and because I’m not used to their way of doing things.
Luckily, I met a really nice residency coordinator who answered all of my questions nicely even if I had to ask her to repeat things a few times so I could understand her. I was relieved to find out that nothing was lost in translation and that the residency coordinator here understands that I am just a medical student and that I don’t start my residency until the summer. Phew! She was very friendly and encouraged me to make the experience my own. I’m only required to be at the hospital from 7am until noon! Of course, they said I could stay longer and work as much as I want, but that would be up to me. It felt like a relief that they don’t seem to expect much out of me. I’m worried that I will disappoint everyone! This week I will be working in the emergency department of the women’s hospital. Next week I will be working the labor and delivery floor. After that the post-partum and then “we will see”.
I got a tour of the hospital today. Since it is so warm outside always, most of the hospital has tons of windows for “natural air conditioning”. The hospital is divided into large open wards where patients have no privacy and at times are sharing beds. Women sit bed next to bed naked, moaning, exposed. My first reaction was to look away in the hopes of providing decency. In the laboring room, women lay in their beds, waiting for their turn to deliver. Perhaps most shocking was the delivery rooms where women were on small tables completely naked but covered in blood, being operated on in a large common room. It was definitely something that I’ve never seen before.
I'm sure that I will have more stories to tell later in the week once I start working more. In the meantime, I'm trying not to be too hard on myself. There are times when I feel great being here and there are times when I'm not going to lie- it's a struggle. I started feeling really overwhelmed and tired at the end of the day today; I was frustrated with my Spanish and still struggling to run in the weather. I wanted to use the internet and feel like myself again but the internet went out. I felt so alone and wasn't sure how things were going to turn out. Luckily, as I went to the kitchen to get a snack, I met wonderful people my age and spent the rest of the night with new friends. Even more, I was super excited to find out the internet returned. Thank goodness!! So the day started out exciting, then I got frustrated with my running and my language skills, but ended well thanks to David's phone call, new friends, and internet access. I'm glad to report that I think that qualifies as staying afloat. :)
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