Blog for pediatric residents of Cohen Children’s Medical Center of NY as we travel to the Dominican Republic and work in international health

Towards the end of 2012, Henry Schein Cares foundation donated a large supply of oral hygiene kits for both children and adults to the Cohen Children’s Medical Center, Pediatric Residency, Global Health initiative in the Dominican Republic. Our residents have been visiting a marginalised community near La Romana in the DR for the past year and establishing a continuity, primary health care presence as part of a Global Health Care program. Partners within the community had identified addressing oral hygiene as a priority. Together with the supplies provided by Henry Schein Cares foundation, Dr Mihir Vyas and Dr Navin Bophal, both in their second year of pediatric residency training at Cohen Children’s medical Center of NY have layed the foundation of an oral hygiene education project within Bateye 16 in the Dominican Republic which future residents will be able to reinforce, expand on and hopefully obtain measurable outcomes of improvement.

Below is the written account of their experience during their 2 week visit.

 

Thursday, December 6, 2012

Final thoughts

 
Prior to leaving NY for the DR, I felt indifferent about coming here. I signed up because global health was always something I’ve wanted to try, but that enthusiasm waned as I became more involved and more fatigued from my daily schedule as a resident. Being down here has been a roller coaster ride. It’s been fun, frustrating, sometimes infuriating but in the end, extremely rewarding. There’s so much need here and within the batey. Our discussions with various collaborators always ended up being highly visionary – huge dreams that could bring so much change and benefit many. But our goal here has always been small, to merely continue to lay the foundations that others have started and that future residents will continue to build.

Despite seeing the dire need that exists within batey 16, I have seen so many parallels with health care in the U.S. The disparity in care that exists in the Dominican Republic also exists in the US, where the poor and minorities have poor access to quality preventative medicine and often end up seeking care when it is too late. I’ve also seen these kids, who live in dirt and grime, with rags on their back, who are just as fun, just as cute and just as snotty as any American child. Making a connection with them was the most valuable part of my experience here.

I’ve also been privy to a different culture and a different way of life. People are warm, accommodating and flexible, qualities that are often lacking in the hustle and bustle of NYC. Where as in NYC it is impolite to smile at a stranger, here it is impolite not to smile.

I feel like I’ve gained so much from these children and their parents. I only hope we have given to them a fraction of what I have received. I come back to the States with renewed enthusiasm that I hope to pass along to the residents who are to follow.

Adios,
Navin

 

Terminado!

 
Yesterday we returned to the Batey with Denny. We began the day at Good Samaritan Hospital where we gathered medical supplies for the day. They had a stock room dedicated to supplies and medications that have been donated in the past, some new others old or expired.

Arriving to the Batey with medical supplies seemed to change the atmosphere. Suddenly every child and adult had a illness that required our immediate attention and/or some type of intervention. We stayed focused and visited specific houses that required our attention. We had found colostomy bags and colostomy ports at the hospital, and although they were a tad big, any bag was better than a rag for our child with a colostomy. We also found out that her surgery was postponed because she was sick with a cold at the time of appointment and the next appointment she was given was in 8 months. We also followed up on a rash we had seen, which although appeared non toxic and the child was not symptomatic, the team had trouble diagnosing what it was (any help is appreciated). The rest of the houses we visited required wound care supplies (really bad bug bites, or small lacerations) and treatment for tinea.

Later, we met with Danielle, who is in charge of providing biological water filters to the Batey. He took some time to explain how these plastic containers with sand and gravel actually provide gallons of clean water each day to these families. Currently, about 20 houses do not have water filters in Batey 16. His team has also been tracking the incidence of diarrheal illness, and in general, they have seen it dramatically decrease (exact numbers to follow). Their goal goes further than just providing a filter, but to also educate health promoters in the community about diarrheal illness and signs/management of dehydration. Seeing that this is in line with our goal of improved hygiene, there may be a role in residents in the future to provide the teaching on these.

Today, we returned to finish our follow up houses. We finally finished! Actually, it was very anti-climatic considering how tired we actually are and how much work is still left to be done. I hope that our efforts in providing continuity for these children is not in vain. They have defintently demonstrated to us that they have retained some of what we taught them.

Reflecting on our experience here, I can definitely say that it was valuable and educational. Not only did we learn about tropical diseases (dengue, malaria, leptospirosis) and practiced our clinical skills, but it has made us realize the importance of continuity and education. Regardless of the resources, the most common complaints seen in the Batey are really no different than those seen in 410/urgi/ED. Kids will continue to be snot monsters and pass it along to each other, and we find our selves saying the same thing to Batey parents as we would at home. Although these families need certain resources, it is apparent that with some basic education we can change the culture of illness in their community and improve their overall health. Not to mention, they would save tons of money by not having to travel to the hospital every time their child has a runny nose. Further, there is so much that requires change, it can be daunting and frustrating. As a group, we have to realize that it is so important to have a strong foundation for our goal and need to remain focused on our objectives.

 

Wednesday, December 5, 2012

House to House

 
As Navin mentioned in the previous post, we have continued our goal of visiting all 106 houses in Batey 16, performing a health assessment, providing education on hand or oral hygiene, and giving toothbrushes and tooth paste to reinforce our teaching. We are almost there! Only 10 houses to go, and follow up on a few that were not home.

We are starting to feel really comfortable in the Batey, and the children are also warming up to our presence. We now walk around with a nice little entourage of kids, holding our hands or poking at us as we go. The best part, as Navin mentioned, is that they are remembering what we talked to them about.

On Monday we went to the Batey for the first time with Denny and his wife Crystal. Crystal runs a school program for 5-8yo which teaches basic manners and encourages the importance of continued education for a better future. Before going to the Batey, we visited Good Samaritan Hospital. It was night and day compared to the hospital we saw in Guymate. It had about 25-30 total beds. There was up to date ED room, similar to a one in the states, with a separate peds area. The hospital had a CT, 2 Ultrasound rooms, and even portable X-ray machines. Their pediatric section of the hospital was small, but had rows of mothers and kids waiting to be seen by the pediatrician of the day. There was a small inpatient Peds service, and a small section for a newborn nursery with 3 working isolets.

Going into the Batey with Denny was a good experience. Since he spoke Creole as well as Spanish, he was well received and respected in the community. The kids all knew him, and swarmed him as we walked around. We split in two groups for the day to cover more houses. Denny and I revisited some houses that we were concerned about from last week, and Navin and John continued where we had left off last time.

Towards the end of the day, after Denny had already left, we ran into a boy who had just cut his foot with a machete while he was cutting sugar cane that he was gonna eat. He had about a 3-4in laceration of the skin overlying his medial aspect of his ankle, and bleeding pretty significantly. We quickly realized that we had no medical supplies to clean or dress the wound, and neither did the community. We irrigated the wound with copious amount of water, applied pressure initially with a tshirt and then with a towel, called for a motorcycle taxi, and sent him to Guymate hospital. The experience made us realize that in the future residents should probably carry a bag with simple medical supplies; betadine, gauze, bacitracin. It really would come in handy seeing that almost every kid has some kind of cut or overly scratched bug bite on them.

Overall, the last few days in the Batey have been pretty rewarding. We feel that going house to house has allowed for us to build a relationship with the community, providing that continuity of care for these kids, and we feel quite comfortable there. Seeing that the kids remember what we taught them has been encouraging and we hope that at least some of them incorporate it into their daily lives. The best part of the day is when one of the kids flashes a smile or wants to be held (sometimes even without underwear on). It makes us realize that no matter what situation they are in, kids will be kids.

Ps. For future resident: please watch the series Renegade before coming down. It’s apparently very popular here, and as John put it “he likes to open doors with his foot.” We hope to continue going house to house with the same enthusiasm.

 

Friday, November 30, 2012

Refocusing our strategy in the batey

 
Since we arrived in La Romana, there has been a lot of confusion amongst all parties involved with regards to the role of Cohen’s residents. Previously, residents were working with Dr. Benitez, a local doctor, treating acute issues in Batey 16. But since the summer, we partnered with the NGO 180 degrees to assist their mission in teaching and promoting health within the batey. We were confused in the sense of how to combine these 2 experiences, do something worthwhile while here and to gain some independence so we are not relying solely on 180 degree or Dr. Benitez. Mihir and I did a lot of brainstorming, had a lot of conversations with all the people involved in our global health elective, and we believe we found a solution.

The plan is to go house to house in the batey with 2 objectives in mind. Firstly, we are to address the medical needs of the children in each household and provide care when feasible. Secondly, it is to provide education on select health topics. We decided we are going to tackle the issues of hygiene, and provide teaching on hand hygiene and oral health care. We are instructing parents why it is important to wash your hands, when to wash your hands and how to do so effectively. We are also teaching how to brush your teeth and giving out toothbrushes and toothpaste to each household. We hope future residents will will assess how much each household remembers about each health topics, reinforce this teaching and teach something new. Moreover, we are surveying each house to see how often their children have transmittable illnesses, and we hope to see a decline in the incidence of these post-teaching.

The past 2 days have been the most fun of the trip. The community has been very receptive to our presence and genuinely interested in what we have to teach. Most importantly, the kids are retaining what we are teaching. While the parents often have a glazed look in their eyes, the kids are recounting each step of hand washing or toothbrushing word for word. Not to mention the excitement with free toothbrushes and toothpaste.

We also continued to follow up on medical needs. We reassessed the child who was vomiting on our first trip into the batey only to find that he had been admitted and discharged from the hospital for IV hydration. He has been improving since.

As we move from house to house, an entourage of children follow us, curious to see what we are doing, and eager to receive a toothbrush. We’re excited about this project as it gives us focus and provides a project that future residents can continue. To us, what we are doing seems small, but I feel like in a community like this, something so small can go a long way.

 

Wednesday, November 28, 2012

Outpatient Pediatrics in Guaymate Hospital

 
This morning Mihir and I got to observe a local pediatrician run a pediatric clinic in Guaymate Hospital. The outpatient pediatric service runs on Mondays, Wednesdays and Fridays from 8-9:30am. We arrived a few min before 8 and the hallway was brimming with eager parents, children in their arms and laps.

The clinic took place in a large room with a desk, chair, exam table and little else. The room provided no relief from the thick humid tropical air as there was no air conditioning, no ceiling fan, but just a light breeze from a window.

The pediatrician saw patients in 2 minute consultations. Paperwork consisted of filling out demographic data on a paper spreadsheet. No individual charts or progress notes. No vital signs taken, only short histories and physical exams. We began to see patterns in how she managed various illnesses – children with fever were sent for platelet counts to rule out dengue, and given prescriptions for acetaminophen; children with diarrhea were told to drink juice and given a prescription for metronidazole; vomiting children were sometimes given metoclopramide. The antibiotic fosfomycin seems to be a popular choice for skin infections, as it was used to treat a cellulitis and a skin abscess. One ill appearing child was admitted to the hospital for dehydration and pneumonia. For admission, a legal size piece of blank paper was taken. She scribbled a line down half the page. Half the page was dedicated to admission orders and the other half to an H&P.

At first, it seemed these medical decisions were abrupt, lacked thought and were aggressive. But upon reflection, we realized perhaps being trigger happy in these situations is how you need to be in a resource poor area. A pediatrician is only available for 1.5 hours three times a week, and these children are likely to be lost to follow-up. Perhaps it is best practice to treat diarrhea with antiparisitics rather than risk an evolving parasitic infection. In any case, the care we provide at 410 clinic is leaps and bounds ahead of anything I witnessed here today.

We toured the pediatric unit, where we saw 4 children admitted for IV hydration. Saline and lactated ringers hung from bottles attached to the wall, trickling into IVs secured to the children’s hands with cardboard and tape, with no pump to control rate. We went to the ER, where we saw an elderly man with elevated blood pressure. No doctor had arrived in the ER yet to care for any of its half a dozen patients.

We later regrouped with Lilo and the team at 180 degrees (the NGO we have partnered with) where we discussed our goals and objectives in this collaboration with one another. We are working on setting up a health fair next week where we can educate the community in the batey on health issues such as oral hygiene and hand washing, as well as hand out toothbrushes and toothpaste.

It’s another hot and humid day in La Romana, where electricity can be extinguished as quickly as a candle in a breeze. Here’s hoping that our fans will run through the night so we can get some rest.

 

Tuesday, November 27, 2012

Into the Batey (11/27/12)

 
Today was an equally exciting but more focused day as we had more hands-on medical care. Our day started in Guaymate where we saw a general practitioner in a small clinic in town. The clinic had 2 examination rooms with some medical equipment, scant medical supplies and medications. We saw a physician interview and examine an middle aged man with back pain. There was no supply of pain medication in the clinic, so she gave him 2 pills of acetaminophen from her purse and wrote a prescription for ibuprofen. I was surprised as she wrote the script on a letter size piece of paper that had been cut into squares and then subsequently stamped.

We later proceeded to batey 16 where we spent the remainder of the day. We were fortunate to have 3 translators with us. Rosa, a Peace Corps volunteer from the U.S., John and creole interpreter. Getting to the batey was an, erm, interesting experience. We hopped onto motorbikes and sped away into the sugarcane fields that surround these impoverished communities.

Once we arrived, we referred to the previous group’s work on children in the batey and their health issues to triage what houses to visit first. We saw a 4 year old female with h/o SBO s/p colostomy since age 4 months. She was due for a reversal in May of this year, but mom had never followed up. We were told that she had a recent colostomy site infection the week prior and was hospitalized for IV antibiotics. When we saw her, she was well appearing, her colostomy site pink and viable. However there was no bag or dressing in place; it was simply exposed to the inner surface of her stain-laden dress. Mom said she ran out of colostomy bags and occasionally covers it with a cloth, and cleans the site several times a day.

We proceeded in a similar manner to visit other children on the list. While I was expecting impoverished conditions, it was nonetheless striking how these children live. They are covered in dirt and grime, copious nasal secretions dripping down their noses, their scalp and bodies littered with fungal lesions. It became frustrating seeing kids with medical issues that will never receive the proper attention or treatment. For example, we saw a 7 year old girl who had a recent seizure episode. She was referred by a doctor for EEG and a neurology appointment, but her mother explained to us in tears that she cannot afford neither the monetary or the temporal expenses of this medical care. We also witnessed 2 young boys who are cousins who both have cataracts and poor vision who can’t, and probably never will have surgery.

Despite these tragic stories, we witnessed a commonality that can be experienced in pediatrics anywhere in the world. Children crying at the sight of a stethoscope, refusing to open their mouths when approaching them with a light, or the simple laughter of a baby who has yet to experience stranger anxiety.

We hope to continue going house to house, finding out the needs of these parents and children, and give them whatever care we are equipped to provide. I hope to return to that girl with the colostomy with proper supplies to care for her wound and to give relief to the many with excoriated tinea corporis. Only 2 days here and I feel I’ve seen more than a lifetime of problems. We’re only scratching the surface.

Until tomorrow,
Mivin

 

Monday, November 26, 2012

11/26 Day 1

 
Navin and I arrived at Casa Pastoral this morning. We contacted Moises (hospital CEO) who in turn contacted Emilio(casa pastoral corganizer) to let us into the house. He helped us to ultimately get in touch with Lilo (NGO from 180 degrees). Lilo met us at the home, along with a translator named john. We exchanged dollars to local currency at the bank and then they showed us how/where to find the public transportation that we would use daily to get to and from Guymate, a main town near the bateye 16. It was about 30min ride on a small packed bus to Guymate. This bus travelled only too and from La Romana to Guymate every 15-20 min and the station it left from is about a 5min walk from casa pastoral. We arrived in Guymate and visited the small 22 bed hospital. We also had a chance to meet with its director Oscar. He is enthusiastic about visiting residents and openly talked to us about what type of roles he thinks we could play. He also talked about the many political hurdles that stand in his way to provide for the community. He thought we may be of biggest help if it was possible for us to give talks to a group from the community or health care staff about febrile illnesses(dengue, leptospirosis, malaria being the most prevalent), respiratory illnesses, diarrhea and dehydration since these are the things they see the most. We also suggested giving specific talks to their nurses or healthcare workers. He talked to the head of his nursing staff and said that she would come up with relevant topics for them. We spoke specifically about the pediatric service. They had an epidemiologist who brought him specific number of patients seen. The hospital saw abt 31000 pediatric patients a year. He had stats on exactly what percentage of these had diarrheal illness and febrile illnesses. There is one pediatrician on Monday, Wednesday, and Friday from 8am to 930am to see all pediatric patients. Their inpatient peds are taken care of by general physicians. We took a tour of the hospital. It consisted of about 20 beds. They had a separate room for pediatrics with about 5 beds. The cribs were old, mattresses dirty. The two beds that were occupied by 3 or 4 year olds had no side rail. They both had IVs, arm boards made of what looked to be an sponge and cardboard. Saline hung form a hook on the wall. They had a separate delivery room with one bed that had stir ups, an assortment of tocolytics and basic antibiotics and surgical supplies in one corner. They also had two neonatal warmers which were never used bc nobody knew how to use them and also bc they were afraid of “baking” the baby. We also saw their emergency room. The director encouraged us to spend some time shadowing the pediatrician and an emergency room doctor this coming wed when the pediatrician would be back for clinic. After leaving the hospital we saw the 180 degree office, which essentially was a house with two front rooms and back sleeping room. They had a few computers and bookshelf of supplies. Also they had a binder of immunization records from the different bateyes they work with. Lilo told us that these had not been updated in over a year and were in no way comprehensive since the government put an end to their immunization program. They took us back to a bus stop where we rode the bus back to la romana ourselves. Later that night we met with Dr. Benitez (Denny). We went out to dinner and discussed current and past projects that residents had done. He expressed that he felt that the work residents were doing in chronicling patients and their problems, following it with interventions and then reevaluating the interventions had a positive outcome. He also said that going house to house instead of making a clinic day worked better to gain the trust of the community, which was a big issue already. He also mentioned that he had seen a positive improvement in the community after talks given by residents were later followed up on door to door to see if they still remember what was talked about. All in all the day was quite productive day with a bunch of different ideas and thoughts being thrown out by a number of people. I think myself and Navin both are still trying to find our bearings in the town and this new environment. However, at the same time from the number of stimulating conversations we have had today, we are inundated with thoughts for how we can make this experience more organized and also find a way to longitudinally connect each 2 week experience going forward. Until next time, Nahir

5 Responses

  1. Hello, yeah this post is actually nice and I have learned lot of things from it
    concerning blogging. thanks.

  2. I read this article fully about the resemblance of most recent and earlier technologies, it’s awesome article.

  3. Thanks for such a superb blog. Where else could
    anyone get that kind of info written in such an ideal way?
    I have a presentation that I am presently writing on, and I have been on the look out for such fantastic information. Happy to discover your site.

  4. Hey there i just visited your website for the very first time and i extremely loved
    it, i bookmarked it and will return.

  5. Excellent write-up, I’m a frequent visitor of your blog. I really like reading your content.

Leave a Reply