NURSING AT McLEAN
Learning from Patients in the rural Dominican Republic
By Amy M. Clark, RN
As I boarded the plane to the Dominican Republic, I recalled my introduction to that country with Los Medicos Valadores, when I was a third-year undergraduate nursing student. I wondered how this new journey with Intercultural Nursing Inc. (INI) would differ from my first trip, now that I am a registered nurse and nurse practitioner graduate student. The assessment skills I have gained over the years; the emotional lens through which I view the world, which changed significantly during my 20s; and the group with which I would be traveling are obvious differences. On my previous visit, I worked on an interdisciplinary team of doctors, nurses, and dentists. This time, I would be part of a team comprised entirely of nurses.
As I anxiously passed through customs, I felt beads of sweat form on my brow. My heart and thoughts began racing: Would they pull me aside to question me? Would they check my baggage and find a single bottle of expired acetaminophen and confiscate all of my supplies? I had heard horror stories from the nursing group leaders about airport staff in Santo Domingo, but to my surprise the customs officers were pleasant. Soon, I passed through to the other side of the airport entrance, where I met several other traveling nurses.
We stayed that night in the capitol, waiting as more nurses trickled in from the states. Early the next morning, we set out to Cotui, the place we would call home for the next two weeks. After a five-hour bus ride along windy mountain roads, we arrived and were immediately enveloped in hugs and warm welcomes from the nuns and housekeeping staff, who offered us dinner, sheets, and a room to set up our mosquito nets.
Before nightfall, we grouped ourselves into teams to unpack, take inventory, and sort the supplies for our visits to the campo over the next two weeks. Each nurse was responsible for bringing at least 100 pounds of supplies to DR, which ranged from personal care items like shampoo, deodorant, vitamins, and feminine hygiene products to antibiotics, fungal creams, and silvadene to jump ropes, coloring books, crayons, stuffed animals, and stickers. It took 24 of us over four hours to break down the supplies. In the midst of the organized chaos, we looked in awe at all we had collected. However, we wondered if 24 nurses could really have an impact or if our help would be welcomed.
The next morning, we joined two nuns, one priest, and two translators as we piled into pickup trucks crammed with enough supplies to serve 300 people, and ventured off to our first campo, El Cruce de Maguaca. As we drove down the narrow dirt roads of Cotui, the importance of our mission quickly became clear. We were greeted with bright smiling faces and waving hands. People ran out of their huts and leaped with excitement to acknowledge the trucks as they passed.
At El Cruce de Maguaca, a line of people had already formed along the barbed wire fence. As the drivers turned off the engines and opened the beds of the trucks, butterflies danced in my stomach. I felt incredibly eager to set-up and begin. Patients appeared with a variety of issues: acid reflux, headaches, orthostasis, urinary tract infections due to dehydration and malnutrition or, even worse, entire families with gastrointestinal problems caused by parasites that contaminated the village's water supply. Others suffered from scabies, tinea capitus, infected wounds, pneumonia, hypertension, kyphosis, seizure disorders, bipolar disorder, post-traumatic stress disorder, and Parkinson's.
After treating the first forty patients, I decided to find the nearest latrine. On my way through the village, I noticed an extremely emaciated man, with sunken eyes, sitting on a plastic green lawn chair. I could not help but say hello and ask how he was feeling. Apparently surprised that I acknowledged his presence, he said that he was well, and invited me to sit with him. He then ran into his house, which was made of branches and pieces of scrap tin, to get a second green plastic lawn chair for me. As we sat together, I asked why he was not going to the clinic.
"I don't have money," he responded.
The clinic costs approximately five cents, which is charged to families to maintain order. Past clinics in Cotui had been disorderly because of insufficient supplies and the urgent need for medical care. The man gave permission for me to do an assessment of his health. It quickly became apparent that his entire body was wasting. In broken Spanish, I asked if he thought he was healthy, and he told me that he was diabetic, did not eat daily, could not afford insulin, and felt dizzy, nauseous, and tremulous most days.
I persuaded the man to come with me to the campo to receive care. There, I explained to the nuns that the man needed medical attention. They understood and said that anyone who needed medical treatment but did not have money could be seen. I felt relieved, knowing that I would meet other people in this man's situation.
Despite the hundreds of people we saw daily, my energy for the mission never subsided. Although I felt physically fatigued toward the end of the day, I felt mentally eager to continue. Each night I found myself lying awake, smiling underneath my mosquito net, thinking about the faces of the people I had encountered throughout the day. At times I wondered how I could smile about people who are surrounded by such destitution, but the thought quickly passed as I remembered the kind acts and conversations I had shared. It really was not until I met one of my last patients that I could conceptualize my conflicting emotional experience.
As the eighty-seven-year-old man limped towards the metal chair, he removed his sombrero and greeted me. I could see the gentleness in his light brown eyes and the genuineness in his smile. When I asked how he was feeling, he seemed reluctant to disclose how much pain he experienced, and said that he was very well. Eventually, I learned that two years ago he suffered a fall that caused significant damage to his left knee. While examining him, I realized that this man, who still worked in a pineapple field at the age of eighty-seven, needed a knee replacement. He had significant atrophy below his left knee, due to disuse from pain, and suffered severe swelling, crepitus, and stiffness in his joint.
In the United States, a man of this age would more than likely be retired, perhaps filling his days by reading newspapers or playing cards with friends. He would receive a knee replacement, without question, and Medicare would cover the majority of the cost. However, here in DR, I could help this man only minimally. He did not have government assistance, he would never see a doctor about his condition, and he would not have surgery. My eyes filled with tears at the thought of telling him I could provide only Ibuprofen for the pain, muscular rub, and education. Although I felt extremely disappointed at what I could offer him, he looked back at me with joy and admiration.
"I think it's working," he said, referring to the muscular rub I had applied on his knee.
As I apologized for not being able to do more, he interrupted to explain how thankful he felt to have met me, and to receive my support, knowledge, and, most of all, care. At that moment, I realized that talking to a nurse, and receiving education, medications, and comfort was just as important to him as a surgical repair. These were the things that mattered; this interaction was what he valued.
As our bus left Cotui for the airport, I felt saddened. Yes, it would be nice to sit on a toilet again, rather than hover over a latrine or bucket. Of course, I would enjoy a warm shower and clean drinking water. However, I did not miss those comforts as much as I would miss the kindness, compassion, and strength of the Dominican people and the simplicity of their lifestyle.