Archive for Dominican Republic

D.R. Wrap-Up

Our final two days in San Francisco de Marcoris included Q.I. presentations about both programs we observed. The five of us who worked at the Hospital San Vicente de Paul, invited hospital administration, staff, and students to our presentation on the Kangaroo Care/Programa Caguro. Everyone did a wonderful job and the hospital team was very receptive to, and happy with, our observations over the two weeks. Later the same day, the second group presented to the Manhattan community and were also well received. No doubt we all learned a lot about a vastly different healthcare system than our own, and are so very grateful for our time in the D.R. Many of the people we met during our journey there will be faces remembered for the rest of our lives.

On the day before we flew back to the U.S., Dr. D gave a wonderful presentation on her research on Health and Spirituality, at the hospital. It was a big turn out! After grabbing our bags, we packed in to a minibus with fewer seats than people, and began a loooooooong, hot, squished journey to the capital, Santo Domingo. Many acres of rice fields, mountains, small towns, and farms later we arrived at the University, where we had a meeting with the new administrators about the purpose of our trip/projects.

Then piled back into the bus and drove around until we found our hostel for the night. Hostel Nomadas is a little slice of heaven in a beautiful city. We got out to do a bit of sightseeing, which included setting foot in the oldest cathedral in the New World. Amazing. Then the night ended with a lovely dinner on the rooftop of the hostel.

We all learned so much on this trip. And though it’s nice to be home, the experiences and people in the D.R. will be missed.

 

Vámonos al la playa

This weekend we had a wonderful getaway adventure. Our trusty driver, and our hostess, drove took us through the city of Nagua. Where we visited the Nagua campus of University de Santo Domingo. It was very impressive! The center is open air and feels as big as a futbol pitch.

We kept going on to Playa Grande. It was everything we’d hope it would and more: white beaches, clear water, sun, and great company. A few sunburns later, we were all ready to head to the hotel Bahia Blanca. It was a hidden gem in Río San Juan. Owned by a lovely Canadian woman, it is tucked away amongst a few small beaches. We ate dinner at an Italian restaurant in town called La Casita. With stuffed bellies, we returned to the hotel and continued the adventure on Sunday. We explored beaches and enjoyed wandering

Early morning swim

Early morning swim

around town. Then we returned to San Francisco de Macoris by bus (with air conditioning!).

This morning we all squeezed into our little red mini bus and headed out to the community of Manhattan for a health fair for the pregnant women who lived in the area. We talked about preeclampsia, baby development, and prenatal nutrition.

This afternoon a few of us went out to the countryside to enjoy an afternoon at El Rancho de Don Lulu. The bravest of us all headed up the mountain for a hike. The hiking group had some hiccups along the way, but returned safely after a few hours thanks to their trusty guide…who happens to be the pet dog of the man who usually guides people to the mountain top. He was off today but his sweet pooch made sure everyone was accounted for. Back at the ranch, the hikers cooled off in the natural spring pool there.

Tonight, we are finalizing presentations for tomorrow morning!

It’s Friday in the D.R.!

This morning we sent a few people to the hospital, while the rest of the group headed out to Manhattan’s La Casita de Salud, where a CPR training session took place. Community leaders were trained in CPR (RCP, in Spanish), and taking blood pressure readings. The road there was a bit bumpy (literally) thanks to road construction. Despite getting started a bit late due to the costruction and a non-functioning projector, it was a great program. A large, stuffed batman doll and an inflatable CPR doll, MiniAnn, served as the willing patients during the demonstration. Back at the hospital we intended to interview the hospital administrator about both programs in which we are involved. Unfortunately, he was not there. But as Dr. D says, “Flexibility is our motto.”

After lunch together, we all piled into a couple carritos (small taxis) and headed to La Sirena, which is basically a slightly smaller version of our super Walmart in the States. They have air conditioning and ice cream with marshmellow fluff topping. Needless-to-say, it’s a small piece of paradise here in beautiful, hot, sticky San Francisco de Marcoris. There we worked on our presentations while munching on snacks in the food court.

Tonight a few people are going out dancing in town, while the rest of us are staying home to write blogs and get ready for our one-and-only trip to the beach tomorrow. Happy Weekend to all!!

Community Immersion

Over the past several days, we have been working on our evaluation project and have been interviewing leaders in the community and hospital about the vision they have for improving maternal care.

We have finished our interviews and are now compiling our data.

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Over the weekend we had the chance to go to beach! Quite a few of us got some pretty bad sunburns 🙁 but the beach was absolutely beautiful!

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On Monday after we got back from the beach, we had the opportunity to accompany community leaders on home visits. During these home visits, we were able to observe the living situations of those living in the city and see some of the health problems within the communities. We talked with the patients about their health and answered some of their questions. One visit in particular that stuck out to me was a visit with a 23 year old lady that was 4 months pregnant with her first child. Her baby hadn’t moved for over a day and when we started to talk to her, she told us that she fasts 4 days a week including fasting from water. We talked to her for about 40 minutes to emphasize the necessity of food and water for her baby. These visits enabled us to think on our feet, especially how to address these health problems in low resource areas.

 

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A Birth in Dominican Republic!

Christina Cummings and I had the opportunity to be in clinical at the hospital on Thursday under the guidance of two midwives from the University of Massachusetts. As mentioned in a previous post, there are multiple women in each room. We started out the clinical day in the post-partum room where we performed newborn assessments. Often, newborn assessments are not completed unless the newborn is in obvious distress. This can cause serious problems to be overlooked and not identified immediately. There were a few pre-nursing students that came with the midwives from the University of Massachusetts. Because Christina and I did newborn assessments in our maternity rotation, we were able to help teach the other students how to assess the babies.

After we did newborn assessments, we went into the room for women waiting for Caesareans. This provided Christina and me the opportunity to learn about antenatal care in an area of low resources. Unlike most places in the United States, electronic fetal monitoring does not occur. We were taught how to perform Leopold Maneuvers to figure out the position of the baby in the mother’s uterus. By doing Leopolds, we were able to estimate where the baby’s heart was and use a fetoscope to listen to the baby’s heart and take heart rate. It was so incredible to be able to hear the baby’s heart beat while still in utero, but it was even more amazing to watch the mother’s face when we let her listen. We were able to do this for a mother with twins also so it was informative to compare what the Leopold’s felt like for a multigestation pregnancy compared to just one baby.

From there, we moved into the early labor room. These women all were having vaginal births and were less than 7cm dilated. A few women were on Pitocin to augment the contractions to speed up the labor process but no pain medication was given. Christina and I provided labor support by fanning them to keep them cool, holding their hands, encouraging them to change positions, and rubbing their bellies during contractions. One lady had been there for several days and had not progressed in cervical dilation. Fear was etched across her face and she kept asking why the pitocin wasn’t working as she had been at 4-5cm for 8 hours. The doctors said that if she didn’t progress to 8cm by 3pm that day, they were going to section her. Therefore, food and water were withheld from the patient. However, this was not communicated to the patient and she was obviously frustrated and scared of what was going to happen to her. One of the midwives really advocated for this patient to have her pitocin turned up because there was really no need for a section. We found out the next day that the doctors listened to the midwife and once her pitocin was turned up, she delivered vaginally 3 hours later. This experience speaks volumes about the role of the nurse in patient advocacy. Because this midwife acted as the patient’s advocate, the patient was able to deliver in a way that was healthiest for both her as well as her baby and in the way that she wanted to.

While we were there, one of the other ladies broke her water and after a vaginal exam was performed to check how dilated she was (no privacy), she was taken into the closed off area of the maternity floor to deliver. Christina and I went with her and in less than half an hour later and after Christina excitedly yelled “Empuje, Empuje!” many times, she delivered a beautiful baby boy. Christina stayed with the mom as she delivered the placenta and I went with the pediatrician and the baby. The babies are not washed but are just dried with a towel. One of the practices that the DR doctors do is stick an NG tube down the baby’s trachea because they believe that it helps to suction the fluid out of the lungs. However, there is no evidence to this practice and actually can hurt the baby. No footprints were taken but weight and measurements were. After all of this was done, the pediatrician handed me a diaper, a baby cap, socks, onesie, and a blanket, and mittens for their hands. I dressed the baby, swaddled him in the blanket, and then gave him to his mother
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No words can describe the beauty of pregnancy. How incredible it is that two people can create another being that grows and develops inside of its mother. It fascinates me that the baby knows how and when to be born and the process by which it transitions from intrauterine life to life outside the uterus. Watching all of this unfold at clinical was breathtaking and it was beyond an honor to share in this moment with the mother and the baby, whom was named Jahle (spelling unknown). I felt undeserving of the privilege to dress the baby for the first time and to hand the baby to his mom and was unable to do so without beaming with tears in my eyes. Yes, birth is messy and laborous, but it is nothing short of absolutely miraculous.

Dominican Republic Orientation

Before I begin writing about our experiences in Dominican Republic, I want to say that although I will try to capture the experiences of all of us in the group, what I write will inevitably be reflections of my own experience and my perceptions.
After a 3 hour plane ride and a 2 hour bus ride from Santo Domingo to San Francisco de Macoris, we arrived at the homes of our hosts Tuesday evening. Two students are staying at one home and the other 6 and the faculty leader is staying at another.

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The bus ride allowed us to see the country as we traveled from one of the two biggest cities in the country through mountainous rural areas into a different city. San Francisco de Macoris is the third largest city in the country. Motorcycles, taxis, “carditas”, and mopeds speed rapidly along the street and appear not to abide by any sort of traffic regulations. Traffic accidents, including those involving pedestrians, are common and a major reason for emergency admissions into the hospital. The city is noisy with dogs barking and the traffic and trash litters the street. We are able to walk to the hospital in about 25 minutes and receive far too many cat calls from the Dominican men.
Yesterday (Wednesday), all of us went to Hospital de San Vincente de Paul for an orientation. The hospital is at the end of a street off the main street. We met and spoke briefly with the hospital director as well as with the director of nursing. Much of what was said went over my head due to my inadequate Spanish and the Dominican accent. Those who are fluent in Spanish are having difficulty understanding at times due to the accent and different idioms. IMG_1163

 

We then went to see the Kangaroo Program that the hospital has. The Kangaroo Program was created to help premature babies with temperature regulation. Because babies, especially those born prematurely, are unable to regulate their temperature effectively, they can lose heat quickly. Thus, it is critical that babies are kept warm. In a lower resource area like Dominican Republic, isolettes are limited. Kangaroo care uses the heat of the mother’s body to warm the baby by keeping the baby skin to skin with the mother. In order for babies to be in the kangaroo program, they must be stable. In the United States, viability of a premature infant is about 23 weeks gestation. In the United States, viability is at 28 weeks. This reflects a great disparity in the technology and care between the United States and the Dominican Republic as the vast majority of the 28-weekers in the United States survive.

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After spending time seeing the Kangaroo Program, we went to the maternity floor. There are six different rooms that the women are in, with about 8 beds per room. There is no air conditioning in the rooms and the ceilings have water dripping from them.

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Once the women reach 4 cm in dilation, they are moved to Sala de Cinco, which is the room for active labor. Once they progress to 7cm, they are taken back to a delivery bed where they deliver.

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There is also a surgical room for caesarean sections. Something that struck me about maternal care was the fact that 50% of births in Hospital de San Vincente de Paul are elective C-sections and 90% of births in private hospitals are C-sections. Because C-sections carry more risks than a vaginal delivery, I am curious if maternal mortality would decrease if C-sections were performed more sparingly. The women receive no medication for labor pain and are often there for days or even weeks because they are admitted to the hospital under false diagnosis of “active labor.” I met a lady today who had been there for 2 weeks and still is yet to deliver. Approximately 1/3 of all births are to teenagers so there is a Sala de Adolescente (Adolescent Room). Once the babies are born, the mothers return to one of the 6 rooms on the floor and the babies stay in the room with the mom. They do not have beds for the babies so the babies are in the beds with the mom. There is a unit in which they put babies that need some extra care. In this unit, there are baby cribs and a few isolettes. It was incredibly simple compared to a NICU in the United States and personally reminded me more of the set up of the newborn equipment in a normal delivery room.
In addition to seeing the maternity floor, we were able to see a dialysis center that was completed donated by a famous Dominican baseball player whose name I do not know, and we walked through the pediatric floor and the ambulatory clinic (outpatient). The outpatient clinic has multiple specialties, but is not open all day every day like the OB/GYN and pediatrics floors are.

This tour allowed us to have a taste of what the healthcare system looks like in Dominican Republic as well as see the facilities and resources available before we begin our project.

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Reflection before we go: ABSN Dominican Republic

Tomorrow morning we will begin our journey to San Francisco de Macoris, Dominican Republic as part of a Quality and Safety Improvement Project. In preparation for this journey, our group of 8 students obtained $390 worth of funds through hosting a “Kid’s Day” fundraiser and through donations of our families in order to purchase medical supplies for Hospital de San Vincente de Paul. This morning we met at the nursing school and divided up the supplies into all of our suitcases. These supplies included, but were not limited to, infant stethoscopes, a newborn blood pressure kit, pediatric resuscitation equipment, surgical drapes and gowns, surgical instruments, vaginal speculums, prenatal vitamins, tylenol, baby blankets, pacifiers, preemie diapers, and sterile gloves.

For our Quality Improvement project, we will be talking with members of Proyecto ADAMES, an organization that formed to address maternal and infant mortality in their community. We will be speaking (in Spanish!) to nurses at the hospital, community leaders in the surrounding barrios, and people at the university.

Dominican Republic is a country in the Carribbean that shares the island of Hispanola with Haiti. Approximately 9 million people live in Dominican Republic, with over half living under the national poverty line (Foster, et al, 2010). As with many lower-income countries, Dominican Republic is marked with financial inequalities as the poorest half of the country owns less than one-fifth the GDP and the richest 10% own two-fifths the total GDP (Foster, et al., 2010). Although 97% of all births occur within a hospital, there is a high rate of maternal (150-160 deaths/100,000) and infant (22 deaths/100,000) mortality (Foster, et al., 2010). While this rate is much lower than that of other “developing countries,” hospitalized births with skilled birth attendants are not the norm in other countries, as it is in Dominican Republic. Therefore, a need exists to improve quality care.

Foster, J., Burgos, R., Tejada, C., Caceres, R., Altamonte, A., Perez, L., Noboa, F. (2010). A community-based participatory research approach to explore community perceptions of the quality of maternal-newborn health services in Dominican Republic. Midwifery, 26, 504-511.

 

Alternative Winter Breaks – Recap of Bahamas, Dominican Republic, Jamaica

The weeks following my Alternative Winter Break – Bahamas trip have been both challenging and rewarding. With the start of my final semester in Nursing School, I’ve begun a variety of different tasks and processes to complete my transition from “Student Nurse” to “BSN-prepared Registered Nurse”! There have been so many wonderful moments throughout the past years of Nursing School, but I can’t say I’m not incredibly excited to graduate and begin working. However, that process can still seem quite far away, especially when getting caught up in readings, assignments, papers, quizzes, and tests. I know I’m not alone, though, as many of my fellow Senior Year classmates are always able to provide the exact countdown to graduation – 96 days as of today! Overall, though, it’s the little things throughout the process that make the entire journey worthwhile – one of the most recent ones being the presentations of all the Alternative Winter Break students.

Over 30 Emory School of Nursing students (from juniors to nurses in Master’s programs) traveled to either Jamaica, the Bahamas, or the Dominican Republic in the early part of January. We reconvened just a short while ago to present our trip highlights and information taught (and most importantly – learned) to a variety of fellow students and faculty at the School of Nursing.

The Bahamas group focused on the variety of care that the nurses provide on the rural island of Eleuthera, and the way that these nurses act in a variety of roles that far surpasses the work I’ve ever done as a student nurse. We spent a great deal of time either in the clinics, working directly with these nurses, or at schools providing health talks and education on a variety of topics. The Bahamas group was also especially amazed by the level of community involvement, knowledge, and caring throughout this culture. We couldn’t overemphasize how welcomed, respected, and appreciated we felt throughout the entire trip.

The Dominican Republic group similarly felt this same sense of welcoming and appreciation while they were working with a variety of different patients in the DR. Many of these students were able to work in a maternity/labor & delivery clinic, where they were able to perform perinatal and neonatal assessments, as well as actually deliver some infants! They described how the nurses in this community were able to do so much with the limited resources that they had; a finding also similar in the Bahamas. Many of these students participated in a new infant care system in this clinic known as “Kangaroo Care” – a process in which there is almost constant skin-to-skin contact between mother and baby during the initial days after birth. This Kangaroo Care is able to keep a great deal of premature babies alive at this clinic, despite the fact that they do not have many technologically advanced tools and resources.

The Jamaica group had a variety of different experiences, some of them arguably the most challenging of all three groups. These students explained how the majority of the patients they interacted with were incredibly poor, needy, or abandoned. Much of the time was spent at the “Missionaries of the Poor” Catholic monastery near Kingston, where different missionary Brothers provided care to anyone who was in need. They described the importance of religion in this care, and how it was incorporated into their daily lives. These students also had the initially heartbreaking experience of working with many abandoned and disabled children through this program. The students expressed their initial feelings of overwhelming sadness, but soon learned to see the joy and resilience of these young children. One of the students emphasized how much happiness she found in these patients, despite their obvious hardships. Finally, two of the Missionary Brothers actually came from Jamaica to sing a song for us and promote a concert they are having in March to raise money for the Missionary, which is funded completely through donations.

Overall, it seemed quite clear that all of the students not only had an amazing experience and provided a great deal of teaching while abroad, but they also learned so incredibly much. Some of the common words throughout all three presentations included: “helping,” humbling,” and “enlightening.” We all expressed that all of the hard work before and during the trip was more than paid off whenever we received a smile, hug, or “thank you” from any of the patients we interacted with. We’ve all gained so much respect for these countries, and especially the work that the nurses and medical personnel do there. We’ve learned how dedication, perseverance, and motivation in any situation can enable such incredible things to be accomplished, especially in healthcare settings with such low resources. I’m sure that for many of us, including myself, these trips were some of the best highlights of our entire Student Nursing career.

Hospital–Maternity Floor

Many of our team members were very interested in spending some time on the maternity floor, so we had people rotate in and out during our day in the hospital.  It ended up that we were supposed to meet back at 7:00pm to change out of our scrubs and head home, but when we all made our way back up to maternity, a patient with whom the student had been working was fully dilated and of course we wanted to stay to see her give birth.  The patient was Haitian, as were a number of other patients on the floor.  She did not speak Spanish, and the nurses only spoke a few words of Creole.  We saw the importance of communication and how patient care is in some ways very dependent on this ability to communicate.

We understood that the patient was “happy” to have us all with her in the room for the delivery.  We all crowded around the delivery table in the small, dimly lit, hot, humid room.  One student noted how different the sounds were in the delivery room compared with those in hospitals in the US.  The window was open, so we could hear cars passing, music playing, people talking outside.  There were no sounds of the fetal heart monitor beeping telling us the baby’s heart rate was accelerating as it should.  The woman, though it was her first birth, made barely a sound.  The auxilary nurse who has much experience, yet little formal nursing education, delivered the baby, and this was not because the OB doctor or even resident didn’t make it there in time,  it was because in the DR normal births are performed by the nurses.   After the birth, the nurse stitched up the small tear by the light of one small lamp, and our students performed the newborn assessments with the guidance of Dr. Foster.  There was much excitement in the room; for some of us this was the first birth we had seen, while others on our team are planning to continue to study midwifery.

It had been a busy day on the Maternity floor; they had so many women deliver, that they actually had some women sharing beds in the post-partem ward.  Before we barely had time to wipe down the table, another woman, also Haitian, was wheeled into the room ready to deliver.  We were excited to see another birth and once again everyone crowded around to watch the nurse deliver the baby.  However, as she delivered the excitement in the room quickly dampened as the baby was stillborn.  Later it was decided that the baby had probably been dead for about 10 days, and the causes were congenital.  It was hard for us to watch the events that ensued; it is difficult to imagine what these nurses experience when the deliver sometimes multiple births such as this every day.  After a woman delivers in the DR it is not customary to show the woman the child, and this is especially the case after a stillborn birth.  Dr. Foster and other students wanted the woman to be able to see her baby, as we were not sure that she even understood that she knew that her baby was dead.  The nurse had put the baby on the floor and was waiting for another nurse to bring her a cardboard box which is where they put stillborn babies.  Dr. Foster though was able to convince the nurse to let the mother hold her baby as studies have shown that this helps the mother to cope and decreases post-partem depression.  We are not sure whether the woman actually understood what had happend until that moment since she also only spoke Creole.  She just laid there for a couple minutes with her baby on her chest looking sad and confused.  We later found out that a resident had performed an ultrasound on her and had done an assessment earlier that day and had charted that everything was fine.

As there were more women ready to deliver, we helped the woman off the table into a wheelchair and accompanied her into the post-partem ward with at least 10 other happy mothers and their babies who had delivered that day.  At first our team members felt very upset that this woman who had just lost her baby had to be in such a room, without even any family with her.  However, as we sat with her in the room trying to comfort her, another woman in the ward, a sister of another patient walked over took her hand and shared a glass of juice with her.  Then slowly others approached her, held her hand, and told us they would take care of her.  We asked one woman if she was a friend or family member, and she replied “Today we are all family”

Hospital San Vicente

On Tuesday we had our first day in the hospital. We divided up into little groups to work on different floors. Many members of our team are very interested in Maternity, so they worked with Jenny our faculty leader to the maternity department. Jenny has worked on various research projects in the hospital, so when we arrived on the floor everyone greeted her with hugs and kisses! Others from our group worked on the pediatric floor, ICU, and the clinic where people received vaccines. Karen and I observed in the emergency room. We actually even saw two codes performed. As I just finished my first semester of clinicals and don’t have any experience int he emergency department, so Karen who has years of experience in the ER was explaining the similarities and the many differences between running a code in the US and running one in the Dominican Republicchong qi zhang peng! It was interesting to observe the hierarchy in the personnel in the emergency department among the nurses, pre-interns, interns, residents, and attendings. Karen said that although things are so different, some of their interactions were so similar to those in the US. It was really interesting also to see the contrast in the care provided by the community health nurse and that provided in the hospital. In my opinion it makes a big difference if people are working in their own community, because there is a sense of patient care when working with family, friends, neighbors, that I think sometimes gets lost when you move farther from the community.