La silla!

This word was a huge part of my everyday life at work in the DR. “La silla!” refers to the wheelchairs in the hospital that have seen their better days. These wheelchairs, probably thrown out every day at some hospitals back home, are the lifeline of the hospital that I’m working at. If you are riding “la silla” that means you are too sick to walk. For these tough physicians at this busy hospital you have to be REALLY sick to merit a push on the wheelchair. For example, a woman who is septic and semi-conscious will probably get a ride on “la silla”. I say “probably” because despite the selective use of wheelchairs in this hospital, they are still hard to find.

In my time in labor and delivery, “la silla!” was in high demand. Don’t get the wrong idea, women who are 10 cm dilated and ready to start pushing their baby out are still not considered in dire need for a wheelchair and so they usually walk down the hallway across the hall to the delivery room. Can you imagine convincing a woman in the US to walk anywhere when they are completely dilated without any pain killers whatsoever?! Before my experience here, I thought it just wasn’t possible but women do amazing things here.

We do use the wheelchair often here in labor and delivery. Women who are crowning (medical word for head is almost ready to deliver) get to ride “la silla!” Of course, la silla is not exactly an awesome thing to ride. Actually it’s pretty horrifying at times. The wheelchair turnaround is fast and many times women are told to sit in the wheelchair even though the wheelchair is covered in the last patient’s (or the one before that, too) stool or blood. Sometimes, we put a plastic garbage bag or paper bag down out of courtesy for the patient before they sit down but sometimes there just wasn’t enough time.

For me, it never got easier when I had to shout at the patients to get on the wheelchair. It just felt so wrong to yell at a woman in so much pain, a woman who is about to deliver, and forcibly make stand up, put her legs together, and sit down in the nasty “silla.” I know that it’s done here this way because of the volume of patients and the different culture of medicine care here. I remind myself that they have the patient’s best interest in mind- it’s better to deliver in the delivery room than on the nasty dirty plastic mattress or “la silla” and sometimes you have to be forceful to get the patient to understand they have to hurry. But man, I sure won’t look at a wheelchair the same way ever again.

"Bonnie"

I met an incredible person today in my hostel. She was a 72 year old woman who is here as a Peace Corps volunteer. She shared with me her story and I hope to share it with you too. I learned so much from her. So many of the lessons I have learned here in my time abroad have been from simple conversations with new friends. I am so grateful for these discussions.

This woman worked as a nurse and administrator for most of her life. After retiring, she continued her public health interest in graduate school. Unfortunately, her husband passed away. She told me that she has had a very fulfilling life and she felt that she had to give back somehow to show her gratitude so she signed up for the Peace Corps, a 27 month obligation. She is working in a small village close to the border of Haiti where she has at most 2-4 hrs of electricity, no running water, but occasionally has access to a latrine. Her description of her everyday life (using a can of water carried from a well a long walk away to take a shower, burning trash when it piled up, spending time with locals empowering them with information about their health) was humbling. I had to ask her- how could she do it? How did she have the courage to do this at any age, let alone at an age when most people would rather not have any more challenges in their life? She told me that things were tough sometimes (she is in the capital because she has come down with dengue fever for the second time in the past month), but she has learned how to be less complacent and how to enjoy simple joy more (a local saving an orange for her because he remembered she loved them). Wow- what a cool gutsy woman.

My experience here in the DR has been challenging but for reasons very different than hers. I have not been woken up at night with a rat biting my fingers like she has, but I did share with her some of the stories I have shared with you about my medical experience here. I was proud that I could contribute a story or two who I got to know today and really admire.

David arrives today!

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! :)

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!

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!

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!!

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!

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.

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!!!