Fatima’s Blog

Final Week

My final week in the DR was a good one. I had to move again after Myisha left, but that was anticipated. I was able to take advantage of some unexpected free time the first half of the week because my attending and the fellow were in Haiti for a conference.  After settling into my new temporary home, I found some hidden treasures in my new neighborhood such as a movie rental place and two sushi restaurants (btw…Dominican sushi adds platanos maduro (sweet plaintains) – a nice twist). I enjoyed some time relaxing and doing some final shopping with Sue, my attending’s wife. She turned out to be a God-send throughout this month and she really was a nice bit of home during my time in the Dominican Republic.  What her and her husband have committed to doing in this country as a young, newly married couple is amazing and something I truly commend them for. They are a great example of being obedient to God’s plan for our lives – even when it takes us in unexpected directions. 

The second half of the week I was back in clinic and again was touched by the resilient children that I encountered.  One in particular was a 6 year old girl who had a condition called Erbs Palsy (palsy = paralysis; Erb and Duchenne were who the condition was named after).  This is a condition in which there is injury to the upper set of nerves that go to the arm.  The group of nerves that serve the arm is called the brachial plexus.  The brachial plexus originates from the spinal cord and branches out to form several individual nerves that are innervate the muscles from the deltoid all the way down to the individual muscles of each finger.  Erbs Palsy is a paralysis of the arm caused by injury to the upper group of the arm’s main nerves.  These injuries are most commonly due to a difficult delivery during birth.  The condition, called “shoulder dystocia,” is one where after the head is delivered during a vaginal birth, the shoulder is in a position where it does not follow as it naturally should.  It is “stuck” and requires specific manuevers – or an emergency cesarean section – to deliver the child.  The condition is considered an emergency as the fetus can die if it is not delivered in a timely manner.  Erbs palsy occurs in situations of shoulder dystocia if the infants head and neck are pulled toward the side at the same time as the shoulders are passing through the birth canal. Again, Erbs palsy can occur through other methods of injury to the brachial plexus, but in my patient’s case, shoulder dystocia was the cause.  Depending on the cause of the damage, the paralysis can either resolve naturally over time or the patient may need rehabilitative therapy, or require surgery. My patient had rather severe paralysis and already undergone surgery in 2009 to transfer muscles from her back to her arms so that she could have basic function of her arm such as lifting from her left shoulder and baseline muscle strength.  However, she was back because although she could move her arm from her shoulder joint, she wasn’t able to voluntarily flex her arm at the elbow (the same movement necessary to do bicep curls).  Her parents were hoping something could be done surgically to help her be able to do things like feed herself with that arm or brush her hair.  Fortunately, there was a surgical option, and the parents seemed willing to pursue it.  What touched me the most about this patient was her energy.  Again, despite the fact that she was dealing with a form of paralysis at such a young age, her condition hadn’t taken away her child-like innocence and energy.  Throughout the office visit she was smiling, playful and generally just happy to be there. She did not give my attending any trouble in examining her and she was more than happy to smile for a picture when I asked.  Although it was evident that she made efforts to hide her deformity – as I have realized is the pattern with all the children I have taken pictures of – you could not tell by the smile on her face that she had anything on her mind aside from being a happy 6 year old girl.

Picture of the hospital - and a glimpse of Dominican traffic

My patient (Yemelyn) with Erbs palsy (left arm)- the palsy is not evident as she has posed in a way that it wouldn’t be

A little girl with a hip fracture that wasn’t healing appropriately.  So we had to place her in this thing called a “Spica cast” so that her hip and leg would be stabilized enough for it to heal. She had to be put to sleep for it only because one can imagine that putting a contraption like this on a child while expecting them to stay still is almost impossible.

An adorable 17 month old boy (Salomon) with a condition called hemi-vertebrae where one of his vertebrae don’t fully form (only half of it develops) leading to a curve in his spine.  This is something that has to be followed at this time. It may either be a mild curve - if the other side where there is no vertebrae isn’t fused; or it may be a surgical case if the other side is fused.  If it is fused, it has to be released so that his vertebral column doesn’t bend severely enough to compress his spinal cord  

Not the best x-ray, but a little bit below where the number 29 is (orange writing), on the left side of the vertebral column, you see the hemi-vertebrae. It looks like a wedge between the two fully formed vertebrae - one above and one below it.

Week 3

This was a short week in clinic because I had a visitor.  One of my closest friends from college came and spent 6 days in the D.R. with me, and we got to spend some time doing the toursity things, and visiting a local resort.  I really was able to take in a lot of the rich culture and history of the Dominican people.  The town of Santo Domingo, and specifically the Zona Colonial (Colonial Zone), is the area where Christopher Columbus (Cristobal Colon as the Spanish say) first landed and where many of the key historic figures and leaders lived.  It is such an interesting mix of statues, modern-day houses, historic buildings, and even ruins that come together to make the city.  From the first “gate” to the city to the home of Christopher Columbus and his family which is still standing, Dominican pride is constantly evident.  There are amazing churches, monasteries, old forts/battlegrounds, and graveyards all around.  There are many little parks and areas where people just sit and take in the sights.  It really is quite impressive and makes me so grateful for the ability to see and appreciate life beyond my little bubble.

Some pics from our sightseeing:

 Myisha and I at the beach

Example of a typical mini-square that is dedicated to someone who played a key role in Dominican history.  The benches are a welcome relief after a lot of walking and the trees are good shade from the sun.

 El Palacio Presidencial (Presidential Palace)

The former home of Cristobal Colon and his family for over 50 years

Formerly the main (and only) entrance to the city

Due to various factors, I moved to my final “home” of 3 since getting here.  It is in a much quieter part of town, and for that I am grateful.  Life in the DR is definitely different.  Some of the differences are things I can get used to and have come to appreciate.  As I mentioned before, the weather is awesome, and no matter how bad a day or week I may think I have had, taking one look at the Caribbean instantly calms my nerves.  I love the fact that you can get great-tasting, home-cooked food for approximately $3.50 at any time of day.  Their café con leche – which is like 5 times stronger than the average cup of coffee in the
U.S. – is so good. I’m a bit nervous I’ll be going through some serious withdrawal when I get back. 

People don’t flush toilet paper down the toilet here. It has something to do with the high tide and the fact that the sewage system is somewhat fragile.  As a result, people throw their “post-void” tissue in a small trash can that is near most toilets.  It definitely takes some getting used to, and I have forgotten sometimes out of habit – I hope the system doesn’t collapse because of me.  

The mosquito bites here are some of the most painful things I’ve ever felt – despite using bug spray with 40% DEET (OFF only has 15%, for the sake of reference) – some of these mosquitos are vicious. 

Waiting 10 minutes for the shower water to get hot has also required some adjustment - but at least it’s over 70 degrees outside at 8am.

Despite my short week, we still had some rather interesting cases.  The most touching one this week was that of a very young girl, I believe she was 6, who presented with congenital absence of the femur (pics below). This is a condition in which, for whatever reason, the femur fails to develop.  There are several stages of this condition as the patient could be born with the femur totally absent, or only partially absent.  It may be present, but may be so small that it cannot function normally.  It can happen to one femur or both.  In her case, the right femur and tibia failed to develop so she basically had a hip joint with her ankle and foot attached; on the left, she had her hip joint, a very small femur bone and her knee then tibia/fibula then foot.  It was obvious from the moment that her mother carried her into the room that she was self-conscious and very aware of her deformity.  She kept her right hand covering her right foot and throughout the doctor’s exam, she made sure to cover up any exposed parts when he was done.  Her mother and aunt were there that day because they were looking for documentation stating that she was being cared for at our hospital.  After a very long conversation and a bit of a round-about way of getting to the point, we realized that they were hoping to take her to the United States.  They were already aware that she was not a good surgical candidate, but were hoping to get her to the States to get her better prosthetics.  The ones she had in the past, which were made in the D.R., usually broke down after about 3 months; and after having invested hundreds of thousands of Dominican pesos her mother was very frustrated.  The mother heard that prosthetics produced in the U.S. were more durable and would hopefully last years.  Although this mother did not express her frustration in tears, it was very obvious how much pain she was in and how the stress of her daughter’s condition was weighing on her; and the patient herself was painfully uncomfortable with her condition.  She refused to have her picture taken – the first time that has happened – and throughout the interview, she made every effort to keep her deformities hidden. The attending was ultimately able to take time to address the mom’s concerns.  Despite being unable to “cure” her, his goal in this case was to ensure that she can live the most functional life possible and be happy.

I have attempted to copy and paste some basic online pictures that serve as good examples of what my patient had.  Unfortunately, the internet in my new home is not cooperating with me so I am unable to do so.  But if you go to the following links, these will hopefully be helpful.

www.tmc.edu/tmcnews/03_15_98/page_06.html - the pic at the bottom of this page is a good basic review of our bone anatomy

http://www.netterimages.com/images/vtn/000/000/001/1988-150×150.jpg - the baby at the top is a good example of what my patient’s deformity looked like

Pictures

Below are just a few pics showing you the variety of patient cases that we typically deal with.

1.         

Antonio - a little boy who was born with bilateral amputations.  We had to operate on his right leg because the bone was growing and breaking through his skin.  He will be fitted with prosthetic legs after he heals from this surgery.

2. 

A Surgeon in the Making - I’m practicing my suturing skills closing Antonio’s wound during surgery :)            

3.       

Carlo - A 7 year old boy with polydactyly

4.

Polydactyly be gone - Carlo’s new hand

5.        

Pedro - A 13 year  old with very severe scoliosis.  His case is sad in that whether or not he gets surgery, there are lots of risks.  If he is left to grow without an operation, he faces risks of severe deformity and likely paralysis.

6.

Dayan - A 15 year old with cerebral palsy which left him with deformity of his left hand and foot.  He was upset and crying that day in clinic, expressing his frustration that he was born with this cross of deformity.  He will be operated on and will have to wear braces the rest of his life so deformity does not recur.          

 7.

7. Laury - A 16 year old with achondroplasia who was in clinic due to an infection and fluid build up in his knee.  The device you see is an external fixator which is meant to keep his bones stabilized while they heal.  His deformities had actually been repaired in the past but unfortunately recurred.  Today was a stressful day for him and his mother as it is just the two of them and they live over 5 hours away.  Despite that, they have been at the clinic at least once a week due to his need to be followed.

Week 2

I would say this has been the week of tears…not mine, but those of the patients that we saw in clinic. Some were tears of disappointment, others of fear, and others of the overwhelming stress of dealing with their child’s condition. As I mentioned in last week’s blog, we have clinic Mon, Wed and Fri.  This week seemed a lot busier than last, and we saw the typical population of patients with scoliosis, congenital limb disorders/deformities, and traumatic fractures that were being managed post-operatively.  For whatever reason, this week we saw several children who had rather severe cases and/or those that the doctor was unable to do anything about surgically.  Many parents came in with the hope that their children would be “normal” - whether that meant they would be able to walk without a limp, speak normally, or dance at their Quinceanera (the Spanish version of “Sweet 16″).  But we unfortunately had to tell several of them that we either could do nothing for them, or that the services we could offer would only serve to restore function rather than normalcy to their lives.

 There are two particular cases that touched me this week.  First was the young children who came in with scoliosis at varying degrees of severity. As we discussed the need for surgery with each child, it was obvious by looking at them, that they were often quite afraid.  Some had heard rumors of being left paralyzed and were terrified by that thought.  Others were upset because they would be unable to dance at their upcoming birthdays or other special events.  I quickly became grateful not only for my health, but also for the little things that I take for granted every day - like a straight spine and the ability to dance whenever I want. Fortunately, we will be able to share stories of past successful scoliosis cases with these children and hopefully give them the courage they need to go through with the surgery if they choose to do so.

 The other case was that of a 9 year old boy with rather severe Cerebral Palsy.  It is a very broad term describing condition in which an unknown insult occurs during pregnancy and/or delivery that causes varying degrees of brain damage.  All types of cerebral palsy are characterized by abnormal muscle tone (i.e. slouching over while sitting), reflexes, or motor development and coordination.  It is not a condition that can be blamed on any particular action or person.  It can present as a “simple” case with the child losing use of one limb or as severe as what we saw today where the child is unable to function independently due to quadriplegia, mental retardation, the inability to speak, and the need for 24-hour care.  The child today was “adopted” by a local neighbor who is not a blood relation when he was two years old. For reasons that I am still unsure of, she decided to care for this child and raise him as her own.  For the past 7 years, she has cared for him with the hope that one day he would be able to walk, talk and live as a normal child.  She hadn’t previously seen a surgeon but had seen another local physician who gave her the rather false hope that it was possible for him to be “normal” one day.  After examining the patient, the attending physician today had to share with the mother that he felt it would be best to simply monitor him in the future.  He explained that there is no surgical procedure that will change his condition.  The tears that followed were heart-breaking, but served as an opportunity for the pastor and others in the room to minister to her, explaining that God has used her to care for this child and that God has used the child to bless those he has come in touch with.  He reportedly brings so much joy to her other 3 children at home and is a source of love for those that he encounters.  So although this was a hard encounter in that we couldn’t fix his problem, we were able to be inspired and hopefully encourage a woman who took it upon herself to so selflessly take care of someone who she saw was in need.  I was really blessed by this encounter.

My First Week

It’s officially been a week since I arrived in La Republica Dominicana…and I must say I’m kind of falling in love.  Some things have been an adjustment, while others have made me feel very at home.  Since being here, I have learned that Dominicans are really great people to be around - and they know how to have fun, they speak Spanish REEAAALLLYY fast,  their cafe con leche is excellent, if you can drive here - you can drive anywhere, they love merengue and they all seem to have more than 1 job. 

I was welcomed at the airport by one of the men that works for the hospital and brought to my hotel which is more similar to an efficiency. After quickly getting settled in, I went to sleep since it was 1am and I had an early wake-up.  The introductions at the hospital on Monday went very well and I was happy to enjoy my first taste of home-made empanadas brought in by one of the hospital employees.  Mon, Wed and Fri of each week are clinic days while Tues and Thurs we are in the operating room.  Every day, an excellent lunch is provided by the kitchen staff and I love being able to eat it outside while enjoying the breeze and seeing the Caribbean sea off in the distance.  Each day we got to see kids (and some adults) who came from near and far with various orthopedic issues.  The surgeons at this hospital deal mostly with fractured/broken bones in the leg, congenital deformities (like clubbed feet) and scoliosis.  Some times people will come in with a need for a revision of a surgery done at another hospital, or they wil be there for monitoring of a problem that is being treated by non-surgical methods. 

The most touching case I saw this week was that of a 23 y.o. painter/art teacher who, in Oct of 2010, had been held up at gunpoint for his car.  In an effort to turn off the car and get out of the way, the robbers impatiently shot him.  As he stumbled out of the car and tried to get away, he was shot a second time and as a result suffered two injuries (one shot to his thigh bone and the other right above his ankle).  Fortunately for him, his injuries were in his lower extremities so he was not killed and isn’t suffering any permanent loss of his walking abilities.  His initial surgery was done at an outside hospital and he unfortunately developed a bad infection of the hardware that was placed in his leg to stabilize it and allow it to heal.  He presented to my attending to discuss plans for further surgery and what could be done. Fortunately, the shooters have been caught and are in prison.  Despite all that he had been through, he showed such maturity in being grateful for the fact that his injuries weren’t worse and he remained positive about his recovery even though he’s had some serious complications.

Outside of the hospital, I’ve learned a few key things: there is a switch for the hot water (in order to take a shower) - and if you don’t turn that on, you will be unpleasantly surprised after 5 minutes when your hot water shuts off; next time I travel, I will be bringing ear plugs as the high energy level of the island is great during the day, but when it’s time for bed, if you’re a light sleeper like me, it’s not the most helpful; and finally, there’s no way I can be unhappy in a country where at any given time I can see the sea and palm trees.  Life is good.  I haven’t been able to take many pictures as I haven’t done too much sight-seeing and I’ve been discouraged from appearing to “tourist-y”; but once I do, I will post some.