A Lasting Link

For those of you that know me this post should not surprise you at all. I'm coming up with a plan. For those of you that don't know me, let me explain. When things bother me I tend to have the same pattern of thought/action. Initially I'm quiet and introspective, then I am reflective, then I make a plan, and finally I put my plan into action to try and assuage the yucky feelings I have from whatever bothered me.

Given the patient that I saw the other day it should come as no surprise to anyone that I have started to put a plan together. There is the one health educator who works for the hospital and I met another young guy who works for the Peace Corps (totally bilingual) trying to do a health project in the same provinces. My idea: Become a puppet master or maybe a salsa instructor....yea that sounds better let's go with Salsa Instructor. I am going to provide both of these two individuals with the support they need to work together and actually have some sort of impact on this community.

The young guy has already received permission from the parochial schools to carry out a healthy behaviors teaching piece, which can include contraceptives including condoms (YAY!) and the health educator already has some of the support of the public hospital. All I am going to need to do is help plump up the education that both of them has around HIV, provide them each with some female condoms (as the research shows these are more culturally appropriate), and then send down some pamphlets/literature in Spanish that they can help deliver to the communities to increase awareness and knowledge to help decrease the stigma.

Will it work? I'm not completely sure. Will these two people be receptive to the crazy nurse in Boston who sends them HIV education care packages? Maybe. Will it make me feel better? Yes....absolutely. Trying to set up a sustainable connection between myself and the DR and trying to empower the community of the DR to face their epidemic in their way is something that I feel very strongly about. I really think that given resources and education communities tend to be able to solve their own problems. Will I be enough of a resource and will these two individuals have enough of an impact to solve the problem? Probably not, but its worth a shot. Maybe it will help that one 26 year old...in which case I will consider it a total success. I guess we will have to wait and see.

And It Happens Again

How is it that even in the DR patients are able to crawl into the deepest crevices of my soul and get stuck there?

Today during the clinic I was pulled aside from the elderly Dominican woman I was taking care of to take a look at another patient. One of the NPs on the trip thought the patient may have had syphilis and now the patient was being very quiet and not talking. They decided to grab me because of my background working with STIs and the fact that I was a male.

Let me back track for a second. When I am working full time in Boston I work for a company that focuses on testing and prevention for HIV. I am an ACRN. For those of you that don't know, that stands for AIDS Certified Registered Nurse. I had to take a test and everything to prove that I know sort of what I'm talking about when it comes to HIV. Naturally, before heading to the DR I did a lot of research on the epidemic in the country and found some interesting articles. Originally I was going to try and sneak down a boat load of condoms (male and female) but I was unsure how some of our religious hosts would react so I wanted to meet them and discuss maybe a shipment in the future (more to come on this). I digress, in reading the articles I had this inkling feeling that I may find patients throughout the clinics that had an undiagnosed case of HIV or AIDS given the amount of stigma related to the epidemic in the country. 

I walked over to the young 26 year old Dominican male and introduced myself. I explained that they asked me to come and speak with him because I had a lot of experience in this area. I immediately noticed the spots on the patients hands that the NP thought may be the progression of syphilis, but it didn't really look like syphilis to me. I asked to see the soles of the patients feet which he allowed me to and noticed the same spots. After asking a few questions though, with all of the other female nurses still around, the patient stated that he was not sexually active. 

I then had the other female nurses leave and the patient disclosed a yellow discharge from his penis for about 2 years around the same time the spots started on his hands and feet. I explained that this type of discharge is not usually associated with syphilis and the patient probably had chlamydia or gonorrhea. It was at this point I realized some of the info the patient gave with the female nurses present may not be accurate. I decided to ask the patient questions about sex again. The patient was silent.

It was during this bout of silence that I noticed just how skinny this 26 year old was. I can't imagine that he weighed more than 130 lbs soaking wet and was about 5'10" To break the silence I asked if he was always skinny. He said he had been skinny but had been losing weight recently and he wasn't quite sure why. 

At this point I asked the patient if he ever remembered being sick for a long time, 2 weeks or more with the flu, a fever, or the sweats. The patient remembered an event about two years ago when the discharge began. He complained that he had not slept well for almost a month, he woke up soaked in sweat, and had a really sore throat.

Red flags were finally going off for me and I asked the patient to open his mouth. He had oral thrush. He wasn't a diabetic and he did not use an inhaler which was enough info for me to confirm my suspicions. I asked the patient a third time about his sexual history. The patient told me he did not sleep with women and when I asked him about sleeping with men was completely silent.

Sitting in silence my heart sank into my lower intestines. I was now armed with a lot of very indicative information and no means to provide the patient with the appropriate test, care, or resources. In the US, I could have easily tested the patient and made a quick referral into care and had him on HAART within 2-3 months depending on his mental health status. In the DR, I had nothing but my own prescription of PEP in case I got a needle stick.

By some sort of divine intervention one of the women being seen by one of the other groups informed our NP that she was an HIV counselor/tester/educator at the local hospital. She was actually sitting outside at the time and had a few minutes to chat with me. She provided me with her name and phone number and told me if there were any patients I was concerned about I could have them contact her directly. It was sort of surreal. She is the only HIV educator/counselor in the whole provincial area and she admitted that her knowledge of the virus itself was very limited. I offered, in exchange for her serendipitous help, my email address and the promise of education materials and condoms (more to come).

I returned to my 26 year old and provided him with the woman's name and address. I felt it would be inappropriate to introduce the two given the stigma in the community around the epidemic, but I stressed the importance that he visit the hospital to receive more testing as soon as possible. I was careful not to be specific as I didn't want to cause any mental health issues, but I did want to emphasize the importance of the follow up. After explaining 6 times that the patient needed to go to the hospital he looked at me and froze.

After about 3 minutes of silence he said ¿La prueba es por VIH? ¿Tengo SIDA? or "The test is for HIV?" "Do I have AIDS?". I didn't think it was possible for my heart to sink any lower, but it did. I was honest and explained that I thought he had a lot of symptoms that in the US would indicate the need for an HIV test. I explained that there were medicines available to treat it and that it was important he didn't ignore the things wrong with him because they wouldn't go away they would only get worse and then they may not be as easily able to treat them. He looked at me with understanding and just sat staring blankly for some time. Then he promised he would go to the hospital tomorrow and slowly walked out of the church.

I had wanted to treat his STI and his oral thrush but was advised by the woman who worked at the hospital it was better he go tomorrow symptomatic so that they would understand the need for him to be tested and treated quickly. It bothered me a great deal because I have no way to know whether or not he actually will go in. I have no way to know whether or not his test will be positive (maybe I'm wrong). I have no way to know if he could really get the treatment he needs in his small village without getting completely ostracized.

This is the patient that I will take back with me to the US. This is the patient I will remember when I think about this trip a year from now. This is the patient that will always keep me wondering, "I wonder what happened?"

First Impressions

The first day I arrived in the Dominican Republic I was hit with the culture shock that I really hadn't experienced since I was in Bali. While I was in Argentina, even walking through the shanty towns I was never struck with a feeling that my life was vastly different than the life of the people around me. However, walking around the DR I am struck by the poverty that pervades almost every neighborhood we come across. Every time we walk anywhere I feel like I am Santa in the Macy's Day Parade. Even those who don't really want to see us look because we are such a spectacle.

It's odd to take a walk around a neighborhood and have everyone, children, adolescents, adults, and geriatrics, come to the door to watch you walk by them during the day. What is odder still is the fact that these people never look truly happy to see you, but if you were to wave to them they behave like I would if a Kennedy called my house.

The feeling of being completely visually different is always striking when working abroad. Then, on top of being physically different, to know that my lived experience is so far from the norm here. I have never had to wake up and worry about getting malaria, my aunt dying in childbirth, or being able to carry home enough water to drink and wash with in my entire life and that is really the difference that you can feel walking around these villages.

There are a lot of college courses that talk about "white privilege" or "first world problems", but until you are standing in a third world country its hard to viscerally understand these concepts. If you were to google a definition you could read it and understand the meaning of the phrases, but the true comprehension would be lost. Until you have been walking around and can feel someone's eyes not looking at you, but staring at what you represent the whole understanding of these issues feel very different.

It's not that I feel guilty for my life, although I do think that may be a piece of it. More to the point its that I am completely befuddled at how my life is so much different. In taking care of these patients day after day it is obvious that we are not different biologically. Yet there is something that happened that prompted me to be born to a place where I can come back to a bed with a mosquito net and type on my Ipad while the children born here collect plastic bags to make into a ball for a game of catch. Confusion is really the only way that I can think to describe the feelings I associate with the ideals that are illustrated by me walking around the streets of El Cercado. Total and utter confusion, but I guess that is normal in some way.

I think the important thing in continuing the work here in the DR is not that I need to understand the differences between my life and the people I am helping, but rather to understand that there are huge differences between our lives. The fine details are not important because knowing there is a difference I can elucidate a way to help by working with the patient to identify the difference and a culturally appropriate intervention. Basically, its cultural competence by admitting that I am totally culturally incompetent.

This will probably be my only heady blog for the whole trip, but I just wanted to get some of this stuff out in the open for others who may feel this way too!

Clinic...Finally a patient

After being here for what seems like an entire week we had our first clinic today. What is so interesting to me about the clinics here is the fact that the entire process is very reminiscent of the types of clinics that I have in Boston. Basically a big group of nurses travel to a set location in some country side village with a bunch of medical supplies and simply start to see patients. The only difference between here and Roxbury is that all of my patients here speak Spanish and there are no resources for me to connect them to at all.

Prior to the actual first clinic day I questioned the validity of a project like this that truly does not feel sustainable. Is it actually helping the people we are seeing or are we creating more problems? 

After my first day here I have no doubts that I am doing the right thing. We follow the World Health Organization guidelines for caring for individuals in third world countries and some things from my Boston job still ring true even in the DR. Sometimes all people need is a nurse to sit down and listen to all of he problems in their life....even fit he nurse can't fix them. At the end of the day people really just want to know that someone...anyone, even a foreigner who is butchering their language actually gives a shit. It's so simple and so sad that no matter where I go in the world this is a recurring theme. 

We went to two different places today. At the first site indefinitely was getting my bearings, but eventually I got into the swing of things with very little problems. By the time we made it to the second site I was my old Boston van self and patients were opening up to me. An old man actually admitted to me that he was an alcoholic which sounds really stupid but I saw it for what it was, a first....a very important first. 

I also got the chance to go with one of the other nurses to visit a young man, 25 years old, who had polio and needed to be evaluated. The man was contracted but generally in good health. Entering into this small shack to visit this man I was hit with the realization that the basic things for a nurse are still true. I spent a significant amount of time doing education around position changes and chest PT two basic things that whether I was in a hospital in Boston or a shack in the DR were exactly the same. 

The final part of our day had nothing to do with my ability to take care of patients but was still a fairly important nursing job. We unloaded a giant garage of random boxes of donated medications, sorted them, reorganized them in the garage to make them easily accessible, and provided education regarding the supplies to the local church aid organization. So simple, so labor intensive, and so necessary in many ways. 

Part of me was nervous I was going to come to the DR and halfway through the trip be upset at the lack of sustainability for many of the projects we help with, but I'm not at all. I'm pleasantly surprised at the impact we are able to have through education and simple labor that otherwise the people of the DR may not have access to throughout their life. 

That's all for now...this is going to be another post for another time so sorry if it gets loaded with a bunch of others.

An Early Reflection

Sitting on a bus driving through the Dominican countryside I finally have time to think through my experience thus far.

Let me start by talking about for the first time leaving the country it really didn't hit me that I was going until 10 minutes before I was getting in the car to go to the airport. It was a strange experience I had done all of the things to prepare: packed my bags, reorganized my supply bags, got my prophylaxis meds, called the credit card company, but it just didn't really hit me the way it probably should have until I was putting things in the car. I think it's probably because I'm still a little unsure of how things are going to work here. I'm just trying to go day by day with no expectations and go-along-to-get-along until I finally have my bearings.

As far as the actual travel to the DR goes it was pretty simple and easy. The flight was technically not delayed but in reality it left almost 1.5 hours late keeping in perfect form with my international travel experiences (check out anamericaninba.blogspot.com for more info). One crazy thing happened though which may be a bit of bad karma for our trip. The group of 6 people from our trip on our flight each had two bags which were all at the maximum weight limit(most well over 50lbs). The airport staff were very accommodating when we told them what we were doing, however as we were sitting on the runway one of the airport staff informed the whole flight that our plane was not weighted and balanced correctly and was offering $500 for someone to take a different flight to San Juan and then get redirected to santo Domingo for 8 in the morning. I almost took it....If I didn't have my groups money for the taxi I most definitely would have taken it, but I sat on my hands and waited patiently. Eventually no one took the deal and the airline actually picked a name at random to take the deal. I felt awful because the man clearly did not want to change his flight especially when I normally would have taken the deal and I am sure hat our overweight bags were the problem. Such is life I guess, but I am still worried we may have incurred some level of karma that will take a while to repay. Honestly, I'm just hoping the bitch will take payments and won't demand one lump sum.

When we got to the airport it was pretty simple to get through customs. We waited at the airport and helped everyone get phones and then after a breakfast and a batido we negotiated a cab ride to our place and headed out. My first Spanish speaking snafu came in when I thought I had told the driver that we were staying at the Bella Vista and he thought that I meant the street was Bella vista. Eventually we figured it all out and made it to the place. 

After settling in we took a quick walk to the beach. As we were walking to the beach cars and trucks were beepingand shouting...mostly at the girls....one particularly friendly man from the van marked Jesus Cristo El Rey called me a Maricon...I'll let you look that one up but it was a fun welcome to the country.

 We kept walking, no worse for the wear, and I got my first up close view of the ocean. The ocean here is gorgeously bright blue with huge rolling waves. The sun is warm and fantastic after being in the dreary winter or Boston for the last few months. We were accosted by a few locals but I think I'll probably do one whole post on the locals that like to bother the group of us for different things. 

After walking along the water for a while we found a restaurant with an outside patio. We got the local beer, el Presidente, served in a bamboo coozie. I got picadas and papas frites a go-to from my Buenos Aires days and settled in for a typical long Dominican restaurant experience. 

We walked back to the hostel and waited for the other groups to arrive who did without any issues and then went out for another dinner. Another typical Dominican dinner that turned into a welcome beer and chatting session. We even got a piece of cake with dulce de leche and a little song because the waiter liked us and said it was one of our birthdays. Well that is all I have for now. I'm not sure if I'm going to be able to post this tonight but either way I've written the post and it's what I'm thinking now so even if I have to post it retroactively it will not be retroactive thoughts.

                                 

The Bostonian Heads to the DR

And here we are again....Sigma Theta Tau Gamma Epsilon chapter is sponsoring me to go on another trip. This time I'm headed to the Dominican Republic with Intercultural Nursing!! Well I'm actually already here. We have had quite the adventure so far but I'm happy to report everyone is here and we made it with all of our luggage.

Let's go over the basics of the trip. A group of nurses, nursing students, nurse practitioners, and nurse practitioner students all go to the Dominican Republic and bring a bunch of medical supplies, set up shop at a different site every day for two weeks and just see patients. It's a very similar mobile health model to the company I work at in the US. 

Our first day we spent at a hostel in the capital and we are about to head out to our first area of the island. Here we will reorganizing our supplies and get ready to see the patients. 

I've already done and seen so much here and I've only been here for a few hours. What I'm most amazed by is how quickly my Spanish is coming back. I'm considered one of the Spanish speakers and the staff at restaurants usually identify me to speak with them. Now we are eating breakfast and getting a little pep talk from our leader .

Moving forward I'm not sure what my internet access is going to be like but I'm going to try and at least blog retroactively. I may try to write another blogger-type reflective post on the first day of the trip and my culture shock getting here but for now I should finish breakfast and get ready to get in the bus.

Chau!!! 

A President's Call to Action

President Hester Klopper is the first non-North American to take the position of President within STTI. This is probably fitting since the 1st international site opened in her home country of South Africa. Listening to the new President speak you become quickly enticed by her accent to want to hear her. Then once you actually hear what it is she is saying you want even more to soak up every word.

In the President's Call to Action she asked three things of STTI as a community, Serve Locally, Transform Regionally, and Lead Globally. Some of these goals may feel lofty, but in hearing the President explain them it becomes apparent exactly what she means and just how easily this could be accomplished. I'm going to break it down much like the President did in her address to the delegation just to tease out a few other points.

Let's begin with the idea of Serve Locally. This seems like such an easy concept. Its something that nurses do everyday that they practice whether they realize it or not. To serve the community you come from almost seems unnecessary to say to such a accomplished room of individuals, but I think there was a reason this statement is so important. It is not just talking about serving your local community.

Its about serving the communities you do in a way that behooves you to understand their culture. As the organization becomes more global and more nurses begin working outside of the country it is important to never lose sight of meeting our patients where they are at. Its so simple and yet so impactful. Trying to provide people with services they don't need is one of the ways to quickly not only become an irrelevant volunteer, but its also a way to hinder global relationships. We must as nurses approach communities at home and abroad with our knowledge and determine how best we can help them based on what they say not based on what we think.

The next part of the Call to Action was Transform Regionally. I think this part of the call to action is specifically focused on the nurse members. As the nursing world changes, technology expands, treatments become more complicated, and the world diversifies we need to be able to transform ourselves. We need to as a chapter and a region identify the problems the nursing community is facing and determine the best way to change ourselves to suit those needs while maintaining the true spirit of nursing. It is by no means an easy task to examine what is not working with our practice, our chapter, or our region but it is a necessary step to elevating the nursing practice throughout the world.

The final part of the Call to Action was to Lead Globally. This seems pretty self-explanatory but once again I think there may be more than meets the eye. While it is important to be leaders throughout the globe and be a reputable source of care and information for people in need of help and knowledge, I think it is equally important to lead with a global focus. By this I mean that I think when we lead we need to be thinking about how whatever decisions we make are going to affect the world at large. Certain leadership decision that seem simple may have implications that we have not truly recognized. Leading globally we need to begin to be thoughtful and mindful about our decision making process and just how much one simple decision could change things for a group of people we had not considered.

Ultimately the Call to Action is a call to be and do better. The Call to Action is about embodying the values of being a nurse and being a Sigma Theta Tau (Love, Courage, and Honor) nurse specifically. We must Lead Courageously Throughout the Globe, Transform our Regions with Honor and pride, and we must Love the Service we provide to our Local Communities.