Fanny packs are pretty ridiculous things in the US. The last time I had a fanny pack was as a prop for a pretty awesome (if I do say so myself) costume party… and yes I had neon green sunglasses on too. Fanny packs are not a laughing matter here in the DR; they are part of the uniform for residents. Each resident wears a fanny pack- the bigger the better. Each person buys their own and jams it with as many medical supplies as they can. Attendings will often demand an inspection of a resident’s fanny pack to ensure that they are fully prepared for their day of work.
As ridiculous as it is to picture everyone wearing fanny packs all day long, they are a necessity here. The hospital does not have much medical supplies that are shared so everything else has to be the personal property of the physician who wants to use it. For example, if you want to know your patient’s blood pressure you better have your own sphingomanomoter. If you want to staple a lab value to the patient’s chart, you better have a stapler or a glue stick. If you want to use lubricant during a vaginal exam, you better have it in your fanny pack. These residents had everything in their fanny pack! At times, I had a hard time fitting in here because of my lack of a fanny pack. What do you mean you don’t have a stapler with you?! How can you not have a glue stick on you?!
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.
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.
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! :)
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.
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.
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!
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!
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!!
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.
