Introduction

Short-term medical missions provide an opportunity to treat patients with limited access to care. Some missions are more loosely organized while others have an ongoing presence in different countries [1]. The number of short-term medical missions continues to increase, and the broad definition encompasses a variety of different services. These services can vary from surgical procedures to health education and clinic operations [2]. With the Guardians of Healing, I was able to go to Higuey in the Dominican Republic and participate in a short-term medical mission.

The Dominican Republic has a per capita expenditure on health of $495; this is significantly lower then the regional average [3]. In the Dominican Republic, there is disparity with respect to wealth and limited access to healthcare. Access to medical care is extremely limited and chronic diseases are major contributors to mortality in Latin America. Mortality is associated with low education and food insecurity [5], and there is an increased under 5 mortality in the poorest 20% [3].

The Guardians of Healing is a 501(c)(3)non-profit that organizes medical missions to developing countries, most recently Haiti and the Dominican Republic. The mission of Guardians of Healing is “To provide and facilitate compassionate healthcare and medical education at no cost to underserved communities.” Healthcare professionals, medical students, and non-medical individuals are invited to participate. To date, Guardians of Healing has helped over 7,000 patients.

For students with a desire to travel, medical missions are an incredible chance to see how medicine works in other countries. It is also a chance to interact with patients and to participate directly in patient care. I was trained to take blood pressure and obtain chief complaints as part of triage, as well as assist in pharmacy duties. I was able to observe surgeries, and to experience a brief taste of the culture of the Dominican Republic. I was also able to listen to a regional discussion of the changes to the national constitution. This experience was unlike anything else I had done before, and provided an exposure to medicine unlike anything I had experienced in the United States.

Local Involvement and Preparation

Significant challenges such as the differences in education of local health care professionals, the level of interest in international collaboration, and the regional medical needs are important to take into consideration when organizing medical missions [1]. An understanding of the needs of the population is crucial; it is important to be able to fulfill the wants of the population being served. A huge asset to our trip was coordination with the local and national government prior to our arrival and throughout the course of the trip. We were provided with a school complex for clinic operations as well as access to a hospital with two operating rooms. A group of regional physicians was recruited to support the clinic; this provided a sense of cultural sensitivity and acceptance. Consideration of the local environment and the capabilities of the cooperating hospital were critical to the success of the mission [4]. Furthermore, issues with local vernacular were circumvented with support from regional physicians.

We convened at the resort before heading off to the school to set up the clinic. At the school we were met by a group of teenage boys kicking around a ball and shooting another into a dilapidated hoop. Shooting hoops with the kids while we waited for medical supplies, we were able to chat and learn more about the area we would be working in.

Once the clinic had been set up, the surgical team jumped into a pickup truck and went to the hospital. Armed with surgical tools and medical supplies, we flooded the supply closet and began to unload. For me, this was a crash course in surgical equipment. As we sorted and organized, the different types of sutures, syringes, and catheters were all explained and discussed (Figure 1). The local nurses scuttled back and forth while we worked, stepping over trays and asking questions about supplies they didn’t recognize. After a few hours in the cramped closet, drenched in sweat, we were finally done.

Fig. 1: (A) Surgical supplies organized by need and procedure; (B) The collection of sutures on top of the supply closet.

Patient Recruitment and Identification

Community members were invited to the clinic by word of mouth and flyer distribution throughout the town. Hundreds of people came to the school, lining up outside the gate and waiting to be seen (Figure 2).

Fig. 2: (A) Patients waiting to be seen in the courtyard of the school; (B) The line of patients outside of the clinic at the beginning of the day.

Regional physicians identified patients with surgical needs prior to our arrival; additional patients were identified in our clinic. Patient screening was performed to minimize complications as a result of our interventions. The majority of surgical cases were hernia repairs, appendectomies, and open gallbladder removals; these operations would greatly improve the quality of life for our patients. Schedules varied throughout the course of the week, our cases were juggled with the normal flow of the hospital.

Surgical Operations

The hospital had two operating rooms; surgical schedules were coordinated to maintain the normal flow of the hospital and to accommodate the patient load from our mission. Emergent surgical cases took precedence over non-emergent cases, our schedule was modified as needed. Over the course of the week, it was a struggle to maintain a semblance of organization. The combined supplies of our group and the hospital inundated the supply room.

Patients often walked into the operating room while holding their IV bags, and climbed onto the operating table. No blood pressure cuffs or heart monitors were attached to patients. For the majority of the week running water was not available, isopropyl alcohol was used instead to scrub. Anesthesia was administered regionally through the spine. The local anesthesiologist generally did not stay for the extent of the procedure, but would return to check on the patient at various time points. Prevalent concerns included efficient use of surgical supplies and a lack of sterile gowns. Only critical instruments were pulled from the surgical trays to prevent waste of surgical supplies. The covering for the operating table, either a plastic or cloth sheet, was changed between cases.

Cesarean Section

An expectant mother who was eager to deliver walked into the operating room. The local surgeons were scheduled to perform the cesarean section, I was invited to stay and watch. They eagerly began the procedure, without cauterization or suction, with quick incisions and dissection of the abdomen. When the uterine wall was punctured, the fluid drained into a bucket stored at the foot of the operating table. After the infant was delivered, he was handed to a medical resident and carried to the bassinet stored in the hallway between operating rooms. The placenta was delivered, and the surgeons began to close. At the end of the procedure, the mother breathed a sigh of relief and thanked the physicians. Her son was born, though he was without a nationality. As his parents were Haitian, they would need to return to Haiti to fill out paperwork for him to become a Haitian citizen.

Removal of a Trichilemmal Cyst of the Scalp

A lithe older man walked into the operating room at the end of our first day. He showed us his scalp, and laid face down on the table. He had a large cyst on the posterior surface of the scalp. After application of betadine and local administration of lidocaine with epinephrine, a central incision was made through the epidermis. Blunt scissors were used to create space to remove the intact cyst and excess pus was drained. Care was taken to ensure that the cyst would be removed whole and would not recur. Stitches were sewn, the incision was disinfected, and the patient was informed that the procedure was done. He jumped up from the table, thanked us, and walked out of the operating room.

Abdominal Procedures

Umbilical and inguinal hernias were the majority of hernia repair cases seen during the course of the week. Before the procedure began, I was allowed to palpate the hernias on the patients. Patients of a variety of ages and sizes were selected for surgery, there did not seem to be a unifying characteristic between them. Cholecystectomies were also done on a number of patients. While our surgeons primarily did laparoscopic gallbladder removals in their daily practice, the hospital’s laparoscopic equipment was in disrepair, so open procedures were performed. After administration of spinal anesthesia and insertion of a Foley catheter, an incision was made on the abdomen, and layers of fascia and fat were dissected away. The surgeons explained each step and the function of the gallbladder in digestion as the surgery progressed. After clamping and removal of the gallbladder, sutures were used to close the site of incision and the other layers. Each layer of sutures was a means of protection against infection.

Adult Circumcision

On the fourth day at the hospital, a 23-year-old male came into the operating room. He had difficulty urinating due to constriction of the foreskin, phimosis, and was looking for help. Previous efforts had left him dejected; nothing else had worked. Our surgical team prepared for circumcision; the area was shaved, draped, and sterilized. While neonatal circumcision is performed on a significant percentage of infants worldwide, adult circumcision is very rare [6]. As the patient was anesthetized, it was disclosed that he was from Haiti. After everything that he had gone through, this procedure would increase his quality of life and his confidence. He struggled at the beginning to let the surgical team operate, anxious of the delicate nature of the procedure. Local anesthetic was applied, and the dorsal slit technique was used, which is useful in cases of phimosis [6].

Post-Operative Care

After procedures were completed, a surgical technician would come in and slide the patient from the operating table to a different gurney; the gurney served as a shuttle between the operating rooms and the main hospital.

Clinic Operations

After two days with the surgical team, I was ready to see the clinic. I was trained in blood pressure measurement and assigned to triage. Stumbling early to comprehend what individuals were saying as they spoke at the speed of light, I was able to catch up and get into a groove that matched the more experienced nurses and staff. My clinical experience in the United States has primarily been in Pediatrics, both in Emergency Medicine and with a mobile clinic. If I had not been able to work with Spanish speaking patients in both circumstances, effective communication would have proven almost impossible. The rhythm of triage, with its constant flurry of noise and chatter, was incredible. We moved quickly and efficiently, taking blood pressure and listing two or three key symptoms. Unsure as to whether or not I was taking inaccurate measurements, I asked a nurse to double check when the readings I got were highly elevated. A significant number of patients came in with hypertension. Individuals of increased risk and lower socio-economic status in Santo Domingo have a prevalence of hypertension of 73% [7]. Runners waited at the door to take the patients to their next location, determined by how sick they appeared and the severity of their symptoms. Physicians handled patient consults and prescriptions with help from medical students, nurses and physician assistants. A dentist and a dental assistant also provided a tremendous amount of dental care throughout the week, from cleanings to administration of fillings.

At around 4 pm, we stopped triage for the day. I ventured to the makeshift pharmacy to see if they needed help. After running medications to other volunteers for a while, I was deemed ready to grab prescriptions and explain them to patients. Vitamin supplements were typically prescribed to the pediatric population in addition to other needed medications. Aspirin and antibiotics were common prescriptions in the adult population. Explaining how to apply antifungal medication or take nutritional supplements over the noise was a challenge, eased by hand motions and excessive repetition of instructions.

Patients, eager to prepare for future illness, would regularly ask for medications that were not prescribed. The logic was that they might need these medications at some point, even if they were of no use at the present time. We had to explain that this wasn’t responsible or feasible; we could only fill prescriptions as designated by the physicians.

Education

While the cadence of patient visits was faster in clinic then my experiences in the United States, the common complaints of children translated regardless of region or socio-economic status. Concerns included nutrition, weight management, and treatment of different maladies. In the surgical setting, getting to stand at the operating table and ask questions was amazing. This was a crash course in surgical procedures, from different tools and procedures, to how to prevent contamination and maintain sterility in the operating room. Furthermore, the efficient use of tools and understanding of the local environment was interesting to observe. As opposed to in the United States, where there is typically a plethora of different tools and specialized equipment, procedures were done with the least number of tools necessary to reduce the need for additional kits.

With respect to surgical procedures, the anatomy of the patient and the finesse of the operations were novel and exciting. I was excited to be able to contribute and discuss, even though my knowledge is basic in comparison. An example of this was during an open gallbladder removal. During the operation, we discussed the function of the gallbladder and its role in digestion. It was exciting to realize that my undergraduate coursework had relevance; that while I had a long way to go in terms of education and training, I was moving in the right direction.

Conclusion

The differences between medical care in the United States and in the Dominican Republic from a systemic approach are stark. Short-term medical missions provide an opportunity for education and understanding of the differences in medical care. I was fortunate enough to work with a group of individuals that were incredibly receptive and eager to share his or her expertise. I was able to absorb an extraordinary amount of information and experience in a short period of time, while being able to interact with a diverse group of truly amazing individuals. Short-term medical missions provide a moment to see how cooperation and coordination can produce incredible results. Everyone has something to learn and gain from these medical missions; it provides a chance to compare medical care, customs, and cultural trends.