Return to the DR

    September 11-18, 2021

    It has been 19 months since I last came to the Dominican Republic due to the world wide pandemic of Covid. 

Our September 2020 project to Rio San Juan was canceled and them the January 2021 project to Monte Plata was postponed to March then May then June then cancelled.  Now finally we are able to return for the first surgical project to the DR.  I have come to the DR once or twice a year since 1997, the absence has been noticeable for me.  I have missed the land and its people, my friends here. 

This project to Sabana Grande de Palenque or just Palenque as we call it, represents a new beginning of projects to help the underserved in the DR and around the world for Medical Ministry International.  We have hammered out protocols to keep both participants and patients alike safe from Covid but they are untested.  So while our goal is to help those who need help and show the love of Jesus to the people, we are also going to prove that it can be done safely.  The 24 page protocol document has been developed by a team at MMI and was created to cover every aspect of a project but has not been tested.  Such is our mission.

Monday September 13, 2021

    The travel Saturday was uneventful with new apps on our phones to do the customs declarations and Covid vaccine documentation.  Even with that change it didn't really streamline the process (I'm not sure that there is a word for streamline in Spanish).  But we cleared customs and the Health Ministry wanted to open each of our 17 tubs of medical supplies.  Almost everything was cleared because of the copious explanation of one of our CRNA's who is fluent in Spanish.  It just takes time. 

Then the school bus ride and we were aware that it was hot and muggy even with the windows down.  We took an route that I had not been on before thru San Cristóbal province and saw the mountains and the plains before them.  Once reaching the coastline, we were at the camp by 5:30 pm in time for dinner and then off to our rooms to try to get organized.   

    We were able to sleep in Sunday morning (7 am breakfast bell).  And after breakfast we had a short worship service under the canopy outdoors of the thatched roofed pergola.  The sea breeze was helpful to cool things down.  The camp was an event center outside of town near the cliffs overlooking the ocean.  It is owned by the Seventh Day Adventist Church and can house 900 people (Dominican style).  Our small group of 17 North Americans and 10 Dominicans could spread out consistent with our Covid precautions and relax while at camp.  The bonus was that our sleeping rooms had air conditioners!!  Since we were all vaccinated and we were mostly in the open air, we were able to go with out our mask while in camp.

    After breakfast we unpacked all our supplies from the tubs and our suitcases and organized the supplies and then left for the hospital.  It was a 15 minute drive to the Hospital Municipal Tomasina Valdez.  We surveyed the facilities and then had a quick lunch that was sent with us from the camp and the team began to set up the two ORs and preop, postop, central supply and supply room while I went to the clinic with the Gynecologist and our interpreters.  We were able to see 52 patients by 5 pm and the OR's were almost completely set up with our equipment and supplies.  The hospital was hot and crowded.  Most everyone was wearing masks but social distancing was all but impossible.  I tried to use a face shield but could not because of the noise level and I can't hear the people in front of me speaking softly, thru mask and in a different language.  Putting on non sterile gloves was almost completely impossible because I was unable to slip them on with my hands because they were wet all the time because of the heat and humidity.  So, hand gel was used copiously.

    The hospital administrator was a young anesthesiologist by the name of Edwin.  He was very helpful and excited about us being at his hospital.  Our participants were mostly MMI return participants but we had a OB nurse from Wichita and a scrub nurse from Kansas City area that had previously been on projects with another organization.  So our team was very experienced.

    We were back to camp and sat down to dinner around 6:30 pm.  Afterwards, we had a clinic on how to do the rapid Covid test.  We had been given 100 test to be used on our project.  So we practiced on the standards that were included in each box of supplies.  Alex our project director was comfortable with the procedure for the following day.  I had scheduled patients deep into the day on Friday and now I was having second thoughts about some of the patients after seeing the small size of the team and facilities.  We were trying to keep it simple but I may have made things more complex with my scheduling.  Bill and I would have to talk in the morning.  I was able to speak to family back home before bedtime.

Monday evening

    I awakened around 5:30 and got cleaned up in the dark as my two roommates were still sleeping.  That gives me a chance to go get a cup of Dominican coffee and enjoy the still cool morning and have my devotion and time to write.  Yesterday was a good day.  It was full of unknowns but was very productive.  Since the team had set up on Sunday they were able to start the first cases by 9:30.  That was fortunate since we had 11 cases scheduled for the first day.  We set up the Covid testing site outside near the generator under a tree behind the hospital. 

We had to use rocks from the ground to hold the papers in place on our makeshift table.  What would we do without white molded plastic chairs?  All the patients spread out and waited their turn to have the test done.  They were entertained by the nasal swab portion of the procedure as long as it wasn't their turn.  Fortunately, all of the 11 patients tested negative.  By lunch time, I was able to go back to the front of the hospital and use one of the consultation rooms to set up our clinic and Dr Teo served as my translator.  We saw 17 more patient and were able to almost completely fill the surgery schedule of the 60 cases that we budgeted and brought supplies to accomplish.  All totaled I walked 3.2 miles during the day but also had a lot of sitting time.  It is ironic that the role I served as runner in this incident is the same as Mandie had done on her first project in 1997 knowing only one phrase "venga aqui", come here.

    The mornings and evening have been cool (fortunately I brought a light fleece blanket to put on the bed).  But the days are still and hot.  One of the ORs had a good air conditioner and is on the west side of the building.  Most of the OR in this country have frosted windows in the OR to allow light in the room if the power goes out (which it does with some frequency).  The other OR had a air conditioner but it didn't work as well being on the east side (morning sun).  We did try black trash bags and blue drapes over the windows to try to help some.  That was the GYN room for us, but also the delivery room for the local Dominicans. 

We had 7 deliveries while we were here and they would come in and use the delivery table beside our OR team.  We did enjoy seeing the newborns.

    I wasn't needed in the OR since we had 2 surgeons at each table, so I didn't do any surgeries this trip.  All has gone well so far.  By the time we finished and drove home in our big yellow school bus it was 7:20.  We had our spaghetti dinner with flan and we were all ready for a shower and to bed.  At least, the more mature of the group were.

Tuesday evening

    Today went both fast and slow at the same time.  We had a full schedule for surgery.  And all but one showed up.  Alex and I ran the Covid testing site again near the generator beside a star fruit tree (carambola).  I had never seen one before but the fruit was beautiful.  All of the testing for the cases of the day were negative.  Everyone we have seen has been vaccinated with at least one shot.  At the end of the schedule, as a favor to the hospital administrator, we tested a girl who was positive.  I was somewhat relieved to know that the test actually worked and we were easily able to recognize a positive test.  My busiest time was walking the patients from outside near the generator back around the hospital and to the waiting area for the preoperative room.  The one patient that didn't show up first thing in the morning had the form we had filled out wrong.  It showed Sabana Grande de Palenque as her name but actually on her identification card, the one filling out the form read her address instead of her name.  They also didn't record her phone number so we had no way to call her to see why she wasn't there.

    Our day was set to start on time with a 7 year old boy with a hernia.  After his Covid test, IV start and the walk down the long hall to the OR, at the last minute a local GYN stated that they had an emergency C Section that had to be done first. 

So, the young boy was turned around and walked back to the Pre operative room to wait an additional 2 hours for the room to be free and ready for his case.  With this addition and the fact that we already had 12 cases on the schedule, we thought this was going to be another late day.

    The other OR room was starting with a patient with a large fibroid uterus but also a large incisional hernia.  That case took a couple of hours as did their next hysterectomy.  The room that started late after the C Section had 7 cases that went pretty fast because of the nature of the surgeries.  Since the patient that didn't show up was scheduled in the GYN room meant that both tables finished about 5:15 pm together.  The people in the Post Operative/Recovery Room are always the last to leave so some of the team was able to leave and stop by one of the beaches on the way home.  The last 7 of us finished up and left for camp.  When we arrived we found the rest of the team already there.  The beach was rocky and had sea urchins all around the shallow water.  The other thing we noticed was that the generator was off because it had a short and they were trying to fix it.  It wasn't fixed until after our dinner in the dark outside.

    It wasn't until returning to camp that Alex told me that the patient that didn't show up for her surgery this morning had been killed in domestic violence last evening.  We had no other information and the team prayed for her family.  The mood was dampened by this news and the fatigue of a long day.  I went to bed shortly after dinner.  As a part of the projects, a trained Dominican MMI health educator joins us on all projects.  They share health education and the gospel message with the patients and family as they wait to be seen or for their surgery.  The fact that the patient had been presented the gospel and told how much God loved her the afternoon before her death is the only reassurance I could have after such a sad day.

Wednesday evening

    I was up around 5:45 this morning and our team devotions was presented on the Love of the Father. How appropriate. 

After arriving to the hospital our Covid clinic was set up outside and today we had one of our patients test positive and thus her surgery was canceled.  That was for both her protection (postoperative morbidity and mortality are higher in patients with Covid) and for our as a team.  The remaining 13 patients were negative.

    Our most challenging case was a patient who had a hemoglobin level of 4.9 mg%.  That is a dangerously low level.  (Normal hemoglobin levels should be 12-16 mg%).  She needed a hysterectomy because of continued uterine bleeding but the hemoglobin was too low to safely do surgery.  We ask her to obtain 3 units of A+ blood for transfusion.  The patient had to find a place that would sell her the blood.  She had to go to multiple places and towns to find the blood and paid around $60 a unit and brought it to the hospital with her.  Only then was it cross-matched, meaning that she had to buy it not knowing if in fact it was comparable for her to use.  It was comparable and we went to the small lab in the hospital and they took the first two units out of the refrigerator in the Styrofoam dinner container and two units were given over the next 3 hours.  The surgery went very well to remove the enlarged uterus with little bleeding and the third unit was not needed.  That meant that it would be wasted if not used today.  As God would have it, another patient called Alex to ask him if he knew of anywhere that they could obtain a unity of A+ blood, so it wasn't wasted.

    Even with the cancelation of the morning, our surgery schedule was going to be too heavy.  With a smaller group of participants and knowing that we were doing a pilot project with the Covid protocols, we cut back on the budget of cases we brought supplies for and had anticipated.  That however doesn't take into count how long or how hard the cases are.  We preach flexibility to the participants of the team especially the new participants because the changes in delivery of health care are so different than back home.  But sometimes returning participants, who have adapted to the changes last time, are still thrown off by the fact that it is even more different this time, me included.  As I said, this project I did not do any surgery.  Fortunately it wasn't needed but also my midrange vision is deteriorating and so is my hearing over the loud suction machines and masked voices.  Lastly, my back will not allow me to stand for prolonged times or lift as I could before.  So my functions were mostly administrative and clinical consultations and problem solving.  Who knows what the next project will hold.

    The rest of the day was very busy with 3 hysterectomies and 4 tubal ligation, 4 inguinal hernias, 2 umbilical hernias and 2 local minor procedures.  We were back to camp to find that we did have power and lights but it was stiller and more humid (if that is possible) without a breeze.  We haven't have any organized activities this trip but all have enjoyed each others company.

Thursday morning

    I woke up around 4:30 or so this morning not necessarily worried but concerned.  The team's Covid testing was scheduled to be done at the hospital this morning.  We were able to convince the doctor that would be doing the test to come to the camp and do the test for us before breakfast.  We all had breakfast and then as we were loading onto the bus, we were told that all of us had passed our Covid test.  Yeah!!  That was a big relief because of all the logistical details that would have to be in place if someone had tested positive with quarantine/isolation and flight schedule changes and delays.

    Then we went to the hospital to start our day.  Sprinkles moved into the area for the first time during the project.  This is normally the rainy season.  As the rain started, we had to move our Covid testing site inside the hospital.  We started testing and the rain passed and the hospital said we needed to move outdoors to do our test so they could use the room (they never did use the room).  All of our tests returned as negative for Covid today.  We were able to do the following surgeries: 3 Hysterectomies, 2 tubal surgeries, 4 inguinal hernias and 2 umbilical hernias.  

    Power in the hospital is not constant.  The hospital is connected to city power and frequently goes off.  For that reason they have a generator as a back up.  It is run by diesel fuel and we help pay for the fuel since they don't normally have to have the generator for what they do.  The power went out during surgery today.  That means equipment (mostly with battery back ups), lights and most importantly air conditioners stopped working.  The rest of the hospital has open louvered windows so you can see and there is a breeze.  Not so for the OR's.  So one of the Dominicans yelled out the window for someone to start the generator.  He tried but couldn't start it so he pulled his Honda Civic up and used his jumper cables to jump start the generator.  I don't think that they use that technique back in Wichita.

    The difficult part was the constant changes in the schedule for tomorrow, Friday.  Since it is to be the last day of project we were trying to keep it on a lighter side with no patients requiring overnight stays, since we are leaving the country on Saturday.  That would leave the follow up of the patients in question.  The last case of the day was to be an umbilical hernia repair but in the preop area she said she wanted to have a hysterectomy instead of the hernia repair (yes, she did still have a hernia).  She stated that she had heavy bleeding and had an ultrasound and blood test with her that we hadn't seen when she was originally scheduled.  We reviewed the sonogram and new lab work that we hadn't seen before and found that she had a dangerously low platelet count and any surgery would be contraindicated.  Her surgery (umbilical hernia repair) was canceled and our gynecologist prescribed a med for her to stop her bleeding and she was referred to a local gynecologist for follow up.

    As usual the post op room is the last to leave the building since it takes around an hour from the end of surgery until they are awake enough to be discharged.  When all were discharged and the staff had cleaned up, we headed back to camp and got there by 5:45.  That was enough time to relax a bit before dinner and some time to play dominos after dinner, a Dominican staple for sure.

Friday

    I finally slept thru the night and woke early to have a cup of Dominican coffee while sunrise was happening and do my morning devotions before anyone else was up and stiring.  I love this time of day here.  After breakfast the team picture was taken and morning devotions were shared.

Todays schedule was difficult with a C Section by the local gynecologist being added on to our overly busy schedule.  They also asked if they could use our supplies (drapes and disposables) and had one of our participants assist them.  We of coarse said yes.  So, that occupied one of our OR's and the GYN room already had 2 hysterectomies that were added on to the schedule.  One case was a lady who came to be seen on Monday after we had already filled our schedule for the week.  She said that she would come each day in hopes that someone cancelled and a spot would open.  So sure enough, every morning at 8 o'clock she was there without eating or drinking after midnight and waiting until 10 to see if anyone cancelled.  None of the other hysterectomies did cancel so we felt compelled to add her on Friday.  The second hysterectomy was a 40 year old who was the daughter of a Dominican team member who needed the surgery so we added her on to the schedule also.  So our "light schedule" took us until 4 pm to complete.

    Another patient was a 43 year old lady who wanted a voluntary sterilization procedure.  We questioned her as to why at that age she wanted the procedure.  She responded that she has a 20 year old, and 18 year old and a 6 month old.  Enough said.  We finished the schedule doing 10 total cases and still had to tear down and pack the entire hospital.  Fortunately, there were enough Dominicans to do the heavy work and we were back to the camp by 5:45.  We knew we were doing what we were supposed to do when we saw the rainbow shine over the hospital as we left.

    We had dinner and a time of sharing afterwards.  It was a little different since most of us were returners and knew everyone from previous projects.  The hospital administrator and director came by the camp to say thanks and to invite us all to return next year September 10-17, 2022.

Saturday morning

    We got to sleep in until breakfast at 7:30.  I still was up by 5:45.  It was a very slow and casual morning since we didn't have to leave until 10 am for the airport so a leisurely breakfast and time of visiting and relaxation.  Several people planned to go to the hospital this morning to check the patients and discharge them.  Yesterday during the day I worked on revisions to the Covid protocols hopefully to make them more useful for future projects for MMI.  We had successfully proved that we could safely do a surgical project under these precautions but they did require some modifications based on our experiences.  Bill asked if I could go with Alex and the gynecologist to discharge the patients since he wasn't finished packing.  I thought I was closer to being finished than him so I said yes.  Then we waited at the bus for a bit until Alex came to go with us.  By the time he came and we left, I saw Bill bringing his bags to the front of the camp.  

    We arrived to find the hospital padlocked in the front, so we went around the building and found the ER entrance and went in thru that entrance.  Rounds took longer than we thought since one of the patients was the daughter of a staff member.  So not only did it take time to inspect the wounds, and give the instructions but also remove the Foley catheters and wait for them to be able to void.  The staff members daughter had to ride with us back to camp to ride back to SDQ on our bus as well.  So, when we got back to camp the entire team was on the bus waiting for us and I hadn't started packing.  Ugh! For an organized person having to hurry and not methodically place everything in the bag was stressful.  I had to sit on my roller bag to get it closed and my duffel bag weighed in at 49.7 pounds.

    We left camp at 10:40 (instead of the 10 am as planned) and traveled the hour and a half to the airport to find it under construction and somewhat disorganized and crowded (so much for social distancing, but everyone was masked). 
Finally, I cleared all the hurdles thru ticketing, baggage, customs and immigration.  It is much harder to hear and understand someone thru a mask when English is their second language in a cavernous room full of people.  I made it to the gate an hour and a half before departure (they suggest you arrive at the airport 3 hours before departure and it sometimes takes that much time).  I embarked on the plane thinking about how I am looking forward to the next time, God willing.

JPS