Highlights and Lowlights from Monte Plata 2019

Highlights and Lowlights from Monte Plata 2019

Changes

This was a good year.  It was also a different year.  This year our team went to Monte Plata as we had done before in January of 2019 but this year we planned and did our project as a one week project.  Now on the surface, it would seem as if that is not a really big deal. We still had to recruit, supply and to execute in the same manner.  It seemed that recruiting went easier in asking people to commit for only one week.  In the past the commitment has been one with options.  They could come for two weeks, one week or part of both.  It made it difficult for me because of having to make sure we had the people in the critical positions covered for the whole time.  For example, if all of the anesthesia personnel wanted the first week then the surgeons on the seconds week couldn’t have as many tables to work.  If all surgeons wanted the second week then the anesthesia from the first week had no cases to do.  In most years, I don’t have the team completed until December with sometimes filling in the last slot in early January.  This year with only one week to choose from, we filled the team to capacity in late September.  There is a capacity for the camp where we stay and we filled that number and with the right mix of participants in the critical slots.

For the most part the supply side is a little easier except for the medications.  We collect disposable supplies year round and sterilize them in October prior to the trip.  I estimate how many cases we may do based on prior years experience and on the personnel that we have signed up.  So 1 or 2 weeks just requires different estimations and then collecting the supplies.  God provides all the time, but we sometimes have to work harder.  We must order medications for the clinic and medications for anesthesia in advance, so the estimates differ in amount depending on numbers that we estimate. 

This year we had 42 participants with us and each was able to take a 27 gallon plastic tub with supplies.  Since the airlines limits the weight to 50 pounds for each tub (or suitcase), that gave us a capacity of 2,100 pounds of supplies.  Realistically we probably had around 1600 pounds when we were all packed.

There was a concern with changing to one week we would be sacrificing the reach of the project.  As it turned out we did as many surgeries as last year in two weeks.  This was by having 3 OR tables running for the 5 days of the week instead of 2 tables for 8 days.  The clinic was clearly busier each day of the week with more patients seen daily but only going to 5 locations instead of the 8 last year. 

There was a more concerted effort on the ground in the DR prior to our arrival to advertise and spread the word of our coming this year with radio ads as well as the truck with a loud speaker going thru the towns to announce our arrival. (I’m fairly sure that technique would not go over well here in the States announcing the arrival of a new doctor in town.)  We chose the towns to visit based on last year’s turn out so as to maximize our impact and, it seemed to work.

The Team

We returned to the same “camp” for housing.  We have stayed in a compound that is surrounded by an 8 foot cinder wall.  It contains the Eva Russell School that was built by the local church who sponsors us in the town. 

It was almost new when we first started coming to Monte Plata in 2003.  It has changed over the years with a few new buildings and expansions and growth of the plants and trees.  One of the upgrades this year was converting two of the shower bathrooms downstairs near the classrooms to bathrooms with multiple stools.  That is great for the kids but for our team of 42 it was a little problem especially when one of the remaining 4 showers broke (think gushing water and broken pipes).  That left 2 baths and showers upstairs for the 26 girls and 1 shower and 2 baths downstairs for the 16 guys.  Not quite the standards for a 4 star resort.

We had 13 first timers with us this year and our returning participants had logged 1 -19 previous trips besides myself.  They came from South Dakota, Des Moines Iowa, Chattanooga Tennessee, Kansas City, Jackson and Jefferson City Missouri.  The remainder of the group came from Wichita, Winfield and Arlington Kansas.  It is always interesting to hear the stories of the group when we begin to get to know each other.  Everyone comes for different reason and at different seasons of their life.   We had participants born in the 40’s, 50’s, 60’s 70’s 80’s and 90’s. 

We also had 2 young people born in the 2000’s.  But even with the age range differences, we all enjoyed each other and learned from each other.

Medical and Dental Clinic

We have been blessed with a stable crew of providers to staff our clinic over the years and it paid dividends this year with the shortened schedule.  Our first clinic day was for the people of Monte Plata.  We stayed in the camp since it was a holiday for the school.  It helps to allow the clinic team to do their first day in the camp to develop processes and procedures that allow them to then take the show on the road so to speak.  They then traveled to El Cacique, Don Juan Chirino and Kilometer 12 to provide clinic services to the rural areas surrounding the Monte Plata area.  Our total patients seen between clinic, eye, dental and surgery were actually 10 more that seen in the previous year on a 2 week project.  Our three pharmacists (a rare bonus to have three) were able to dispense 2439 prescriptions to those we saw.

Their cases always seem to have something new and different every year.  This year a man walked into the clinic with a leg wound that had been present for months.  When he pulled his pants leg up we saw a lower leg with no skin left in place and a non healing wound.  It the US the only option for him would be an amputation since the wound could not heal without months of intensive therapy and possibly skin grafting.  We were left but to clean up the wound and dress it properly.  We frequently take for granted the facilities and technology we have in the states.  Most were seen and given prescriptions for their most acute need along with vitamins and parasite treatments.  Some were referred to the hospital clinic for us to see and some had surgery that week others that were referred were then sent to the capital if we were unable to care for them in our surgery clinic.

Our dentist worked under very primitive conditions and was able to provide a full range of dental services to 109 patients.  Everything from cleaning, to filling to sealants and extractions were done in a portable chair in our open are clinic with a gasoline generator to power the dental equipment.  Eye exams were done on 315 patients and 157 of them received glasses.

Surgical Services

We continue to work with our colleagues in the Hospital Provincial de Monte Plata.  Some of the staff there has been in Monte Plata since before we came and it is always great to see them and be greeted by the enthusiasm of the patients.  Each morning as we arrived to the large lobby area we were greeted by applause from the patients.  We then would sing “Alabare” and start our day with a corporate prayer.  The hospital works hard to improve the health of the people in Monte Plata and has initiated a campaign to encourage all their staff to reach out to the patients and ask “How may I help you”.  They had buttons made for each of our team and presented them to us with our name on the button to make us feel at home and part of them. 

With our team consolidated to one week, we were able to have three operating tables work at the same time.  It did present some problems from a space standpoint.  Last year with two tables in one OR and one preop room and one post op room we were all close by each other.  This year with more volume we needed two post op and two preop rooms.  That meant that we were spread over a larger area on the second floor of the hospital.  The hospital normally doesn’t use the second floor for patients, just surgery and labor and delivery with the nursery.  We had to use walkie talkies to be able to communicate between rooms and to staff to keep the flow of patients.

Most of our patient has their surgery done as an outpatient going home the same day.   The larger surgeries like gall bladder surgery or hysterectomies stay overnight and go home the next morning. 

That means that we have to transfer the patients to the service of the hospital for overnight care.  The hospital medical director has worked with us at least 3-4 years and she assumes the care during the night.  We return the next morning and see the patients and dismiss them.  The hospital does have an elevator but it broke twice while we were there.  Once while trying to bring the heavy anesthesia machines up to the OR.  The second time was late in the day on Wednesday.  We were all tired and the last patient was ready to go downstairs to her bed.  All of the staff was done except for post op crew.  They were the last finished most days due to the nature of their area.  As they were waiting for the elevator it broke (think trapped between floors).  The prior time with the machines and two of our transport crew a short wait was endured before the hospital opened the door with the key to the elevator.  This time after waiting and trying to figure out what to do with our patient (do we carry her down the winding stairs?) the hospital maintenance staff arrived.  They went on the roof and did something and returned to the second floor and opened the outer door with the key and yelled up the shaft in Spanish “lower, lower, lower” until the elevator was visible and the inner door was opened.  They then motioned for us to push the cart and patient onto the elevator.  After a short delay of people looking at each other, we pushed the cart and patient into the elevator.  (Did I mention that there was not one of those stickers in the elevator telling when it was last certified?)  The maintenance person then closed the outer door and ran down the stairs to the bottom and opened the outer door with the magic key and yelled again in Spanish “lower, lower, lower” until the elevator appeared slowly from above.  Then, he yelled “stop, stop”.  We pictured someone on the room lowering the rope attached to the elevator hand over hand until it was in just the right position with beads of sweat on his forehead.  He then opened the inner door to the huge smiles of the staff that pushed the cart out and down the hall as if nothing happened.

I am occasionally asked what kind of cases you not want do while you are there.  This year I tracked the cases and found them to fall in 5 categories.  The first has to do with coexisting illnesses that make surgery too risky.  While it might not be too risky here in the States, in the DR on project we just don’t have the back up in either technology or personnel.  This would be like patients with uncontrolled high blood pressure or blood sugars.  The second category is for conditions that are too complex.  Cases of obvious cancers that are extensive can’t be adequately staged or treated there in a Provincial Hospital.  I saw a 19 year old with a large mass under his chin that pushed his tongue up.  We don’t have CT scans or many diagnostic studies to define the problem.  The third group involves patients that have conditions that require specialist in areas that are not present on our team.  We had many patients that desired surgery for urologic conditions and we didn’t have a urologist with us, nor the equipment that they use.  One of the broadest groups is for patients that we can’t operate on are those that have pain that is not related to a surgical problem.  When patients know we are coming they show up with symptoms but don’t know if surgery will help their condition but rely on us to tell them if we can help.  Frequently those patients are relieved and reassured that they don’t need surgery.  We had advertised that we would take care of hernias.  One patient came in to have his hernia fixed but it was a herniated disc in his back that he had and it’s not something that we could or should do surgery.

One patient that we saw was an American who was in the DR with another ministry drilling water wells for the villages.  He fell off a ladder and landed on his arm.  It caused quite an abrasion.  After 4 days the pain and swelling had not gone down.  He saw one member of our group at a local ice cream shop one evening and was excited to see American doctors. 

He came to the surgery clinic the next day and we were able to get an x-ray of his arm to find no fracture.  Our clinic provided the antibiotic and wound care he needed to get him thru his project and returned to Michigan for follow up. 

The last category of people who don’t get surgery are those who have conditions where surgery is contraindicated such as for keloid scars.  These can be unsightly but the repair is almost always associated with re-occurrences of the scars that are worse than the first.  We strive to above all do no harm with our surgeries.

An unusual case this year was a young man who was in a motorcycle accident that resulted in him being thrown from the cycle and fracturing his femur and tibia. 

The femur was repaired with a plate place in surgery and a device called an external fixator for the tibia fracture.  That in and of itself was not unusual but it happened 3 years ago and the fixator is usually removed after 6-8 weeks of healing.  For some unknown reason (think financial) he was sent home with the tools to remove the fixator but the patient never followed up with anyone.  He saw one of our translators a month ago and when he heard we were coming he asked if we could help.  Pictures of the leg and device were sent to me over WhatsApp and I showed it to our surgeons who showed it to orthopedics surgeons. 

They said we could and should remove the hardware as the risk of osteomyelitis (bone infection) was very high as long as it stayed in place.  We took some special instruments from the States with us and saw the young man and said we could help.  He was ecstatic having been limited in his activities for over 3 years from the device.  With sedation, a 7 minute procedure was done to remove the device and he went home all smiles, well mostly smiles.

  We sometimes examine patients and end up referring the patient to specialists in the Capital city.  Some follow up and go; others don’t for a number of reasons.

Progress

Sometimes it seems as if nothing changes.  It almost was like stepping into a time chamber for us and we return and seem to pick up where we were last year.  This year a couple of things changed.  The ministry works largely because of the permanent staff in the Dominican Republic.  They do all the leg work to make sure we can do what we do with the government blessings.  They also maintain all the hard assets necessary for doing the short term projects.  That includes trucks, buses, cars as well as all the OR tables, lights anesthesia machines and supplies that we bring in excess of need.  Several projects are unable to bring anything with them and the extras are what they run their project with.  This year I was pleased to be able to tour the newly constructed warehouse.  It was made of 3 shipping containers in a “U” shape with a metal 2 story building over the top. 

It is in a secure area with some land around it.  It is quite an improvement for the ministry and the staff to have.

The second area was in personal growth and development of the staff.  One of the interpreters that I have worked with for 10 years will begin the final year of medical school in the DR in March along with a second person a year later.  Another supply manager last year has left the ministry to start his own foundation in Sabana Grande de Boya to help the youth of his home town.  It is so easy to get excited and want to come back to a place where there is such a giving and caring environment.

Conclusion

I think that the point is that there is not a conclusion to helping others.  The need continues and by addressing that need we all can find meaning in our lives.  So while we may know we are home by being reminded with the blistering cold winds and snow, we know we will step back in time to the DR in a few months to the warmth of not only the weather but the friendships we have made and cherish.