The Importance of Sustainable Resources

Reflection: February 12, 2013

Today’s discussion on sustainable resources for the physicians and patients of Dominica was a very welcome one. It really helps to reflect back upon our experience in Dominica and identify the limiting factors to their access to better healthcare and ways for us to help. My fellow students and I brainstormed and came up with some ways we can make resources more readily available to practitioners in Dominica. Some ideas we came up with include the donation of more reference books and continuing education materials (ex. Pharmacist’s Letter) on a regular basis so they can keep up to date with current practice guidelines. We also agreed that the donation of a laptop to each rural clinic would greatly improve their access to information and also allow them to communicate more readily with other practitioners to discuss specific patient cases. A laptop computer would also allow them to communicate with practitioners in the U.S. (ex. consult on Skype with pharmacists/preceptors of this rotation) in order to get a second opinion on specific patient cases.

Another important discussion is that of coming up with sustainable resources to give to the patients in order for them to continually learn about their disease states. My fellow students and I came up with the idea of printing off our brochures that we created for our ‘Becoming the Expert’ topics and sending these down to Dominica regularly so they get a consistent supply of information. We can also get the nurses and practitioners at the clinic to regularly report to us what type of information the patients are requesting and create custom brochures that teach them more about their topic or concern.

            Of course, all these ideas hinge on the commitment of students and pharmacists to continually participate. Ideally, this rotation will eventually be an ongoing one where a new group of students will continually replace the last so that there is always a presence in Dominica. As of right now that is not plausible. Instead, we need to get past students and preceptors to maintain a connection with this initiative and provide help where they can. The best way to do this is to come up with a list of what needs to be achieved and have a clear understanding of who will take on each task. Technology such as Google Docs has allowed us to share this information very readily. Perhaps the creation of a liaison that is in charge of communications with a representative in Dominica and reports back to the group in the U.S. will be a good way to ensure we have regular communication with the people of Dominica. This role can see a different student taking it on each month so the responsibility is shared.

            I speak for my fellow students and myself when I say that we were truly touch inspired by the people we met and the experiences we shared in Dominica. It is vital that the experience not be limited to a 6 –week rotation but rather an ongoing and mutually beneficial relationship with them. I believe that we can achieve this together if we put our hearts and our minds to it.

- Joanne

            

Princess Margaret Hospital (2/1/13)

Today we split into two groups to visit Princess Margaret Hospital and Jolly's pharmacy in Roseau. At the hospital we
learned about the inpatient and outpatient pharmacy. The outpatient pharmacy was accessible by the public while the inpatient pharmacy was connected to the outpatient but hidden from view. This allowed the pharmacies to remain connected but handle separate duties. The medications available varied between the two just like they would in the US. The inpatient pharmacy had IV and injectable medications available to treat patients with more serious conditions. The outpatient pharmacy did not handle injectable medications. If prescribed, the patient would need to obtain these medications from a private pharmacy. The doctor could also prescribe oral medications that the outpatient pharmacy didn't stock. The patient would buy these from a private pharmacy as well. The hospital had significantly less medications than an independent pharmacy such as Jolly's. All of the outpatient medications could easily fit in two (possible one) double door cabinet roughly 5 feet by 8 feet which would be unheard of in the US. The medication availability was extremely limited, which makes sense when you think about how the government basically gives them away free and the government has limited resources.

Unlike community or outpatient hospital pharmacies at home, the pharmacists at Princess Margaret Hospital helped the person in front of them from the point of handing over their prescription (or medical book) straight through giving them the medications. This wasn't a 'ready in 15 minutes or less' situation.  The pharmacist only worked with one patient at a time which seemed to help get the patients in and out of the hospital much faster. Since the population is smaller than the States, this system works out well because the hospital seems to fill roughly the amount of one community pharmacy in the States or less. The lines would be miles long if the community pharmacies in the US followed this system.

The technology usage was very different from the United States. Almost everything was done manually at Princess Margaret Hospital using paper and pens. There was no robot to fill the prescriptions. Like the rural clinics, the hospital did not have vials. Pills were placed in plastic zip-lock bags that were labeled with patient name, directions and the name of the medication. There was no sterile compounding area with a hood. Nurses mixed the IVs at the patients bedside. There was a simple computer system that used Miscrosoft Access to keep track of inventory but this was not comparable to the US where the computer system stores every detail about the patient and their medications. The computers system store a patient's electronic medical record in the States and the patients in Dominica still use their medical notebooks/journals for their medical records. While the journals are a great record keeping system since they follow the patient everywhere, they lack details that electronic medical records could have.

In regards to payment for prescriptions, ages 16 and under receive prescriptions free of charge along with those 60 and older. Everyone else between those age groups must pay a flat fee of $5 (EC). The $5 fee is the same for patients picking up one script or multiplication scripts. For inpatient, the patient was suppose to pay for 3 days worth of the prescription but if they couldn't afford it that didn't seem to be a problem. 


The differences between Dominica and the United States hospital pharmacies are substantial. While the US is more advanced, especially technology wise, the Dominican way with the medical notebooks is beneficial. The notebook basically tells the medical timeline of each person and they can bring it anywhere they travel in Dominica. This would be valuable in the States since patients see numerous doctors and don't always know their past medical history or want to share it. Patient care in the United States could be optimized with medical histories that travel with the patient. Overall, both countries can learn from each other. It was a great experience to be tour the hospital, observe their practices, and learn more about Dominica healthcare.

A Visit to Jolly's Pharmacy

Friday morning we made the trip to Roseau to visit Jolly's Pharmacy, a private pharmacy similar to a mom and pop drugstore in the U.S. The manager, Orrin, gave us the grand tour and described many of the differences between pharmacy practice in the U.S. and Dominica. Having studied in Seattle, he is familiar with U.S. standards and understands the distinctions.

Orrin explained that there are no laws regulating the practice of pharmacy in Dominica - quite different from the strict rules we follow at home. Pharmacists do not even need to be licensed to work here! Instead, their clinical judgment and ethics guide their practice. The inventory  at Jolly's was impressive, as they stocked several medications in the pharmacy and kept extra in storage. Orrin explained that they use more than five suppliers in multiple countries to maintain stock. The orders take at least seven days to arrive, with many taking up to two weeks. That process was much different from our single wholesaler agreements that deliver medications the next morning. It really made me appreciate the accessibility to medications that we are all so accustomed to. It is hard to imagine waiting more than a week to receive the medication that you need.

While we were at Jolly's, I couldn't help but think of the rural clinics that we visited in southeastern Dominica. The public health care system struggles to maintain their stock at these clinics, often limiting therapeutic options for patients. Luckily, patients can purchase prescriptions from private businesses like Jolly's if they are not available for free through their clinics. Other major differences exist with their computer system (or lack there of) and the size of their staffs. Record keeping is done by hand at the rural clinics, with a single pharmacist managing a district of five villages.

The visit to Jolly's was very insightful. I'm glad I got the opportunity to meet such an inspiring pharmacist. He has great ideas on improving pharmacy in Dominica. Learning from him was definitely a great addition to this rotation and strengthened my understanding of pharmacy practice in Dominica.

Bridget Sterling

January 29, 2013 - Cinnamon Iced Tea Demonstration and Group Yoga

After our morning at clinic and House of Hope, we were able to have a relaxing afternoon at Jungle Bay. After enjoying a wonderful lunch, we got to watch a demonstration of how to make our beloved cinnamon iced tea. Joanne, the head chef, heard about our infatuation with this wonderful drink and showed us how she boils the cinnamon bark in water to extract the flavors. After 10 minutes or so the "tea" is poured into a pitcher and mixed with lime juice and sugar. Just 3 ingredients, so simple, yet so delicious. Our group fell in love with this tea on our very first night at Jungle Bay and now we will be able to make back home!

 We had some downtime to work on our herbal scavenger hunt interviews before we had our group yoga session with Nancy. As the sun began to set, we were treated to an open air yoga class with the sound of the ocean as our soundtrack. We were expecting a typical morning yoga session that Nancy usually puts on, however we were in for quite a unique surprise. Instead of working on our balance and strength with the typical warrior poses and sun salutations, we spent the class in variations of the shavasana corpse pose. We used a bolster for most of our poses. For example, one of the poses was to simply place one leg over the bolster as we lied on one side of our body. Nancy challenged us to clear our minds of any outside thoughts and learn to relax and enjoy ourselves in the moment. It certainly was a very novel idea for us as we have been so busy with our final year of pharmacy school and all the stress that comes with rotations and job-seeking. This yoga session with Nancy was truly a great way to cap off our trip to Dominica. The people of this country have humbled us and taught us to be more patient, slow down, and appreciate the simple things in life. I tried to channel this attitude into my yoga session and I hope my fellow group members got as much out of it as I did.

- Joanne

Monday January 28- Coconut oil

Today was our second day visiting Moses. We began the day by helping peel pidgeon peas to help Moses prepare his lunch. Our second task was to prepare coconut oil which proved to be a very labor intensive and time consuming task. We used 8 coconuts and the first step was to beak the coconut and grate it. Each of the students had the opportunity to grate the coconuts. We then added room temperature water to the shredded coconut and extracted coconut milk. We did this by squeezing the wet coconut shreddings into a bowl. The third step was to extract the coconut oil which we did by boiling off the coconut milk. After an hour of boiling we began to see coconut oil starting to form over the layer of coconut milk.  Each student got to take home a small bottle of coconut oil which Moses added a drop of bay oil too. Moses said the coconut and bay oil mixture could be used for sore muscles and massages. After collecting the oil there was a cheesy mixture left at the bottom of the pot which Moses let us taste. He called it coconut cheese and it had a very sweet coconut taste. Working with Moses really reminded me of the people of Dominica. Making a small amount of coconut oil took a lot of work, time and dedication; over this rotation I have realized how hardworking the people of Dominica are, yet how happy they are and how little they complain.

House of hope on Thursday January 31

Our group went to the house of hope on Thursday. We painted the two side walkways to finish what the other group had started last week. Most of the children don't talk and so we hope that they will enjoy the visual effects we paint at the home. After painting, we fed the disabled children, many of whom we learned had been abandoned by overwhelmed family members . 

One of my group members and I fed a little girl named Melissa. She was 8 years old but had the body of a 4 year old and sat in a stroller. Her right ring and middle fingers were webbed together and she had myopia for which she constantly tried widening her eyes with her fingers to help her see. Because of her eyesight, she relies of her sense of touch and hence, we played with a piece of wool woven fabric. My group member a I couldn't help but note the difference in health care with disabled children in North America vs. Dominica. In the US, Melissa would have probably had surgery to separate her webbed fingers, dental surgery to fix her missing and misaligned teeth, some kind of eye surgery or glasses and physiotherapy to help with her walking and communication. With those kind of resources, she could have had a semi-normal life. 

It's amazing that she was very aware of herself and her surroundings. While feeding her she would reach for the spoon when she wanted another bite, grabbed for the napkin when she  wanted to wipe her mouth or nose and reached for her cup when she was thirsty. 

We also noticed the lack of basic supplies at the home such as sippy cups, bibs, linens and towels. I'm sure they would greatly appreciate any such donation but definitely were not complaining about how little they had. The whole experience was a great lesson in humility that will never be forgotten. 

~ Sincerely  Maria

RiverCyrique (Jan 31st/2013)

It is Thursday and our second week in Dominica which means today would be our last clinic day :(.  Time has actually flown by so quickly on this island that it's actually really saddening thinking about leaving.  Our group was split into two for today, 5 of which went to the House of Hope and the rest of us to the clinic in Rivercyrique.  Today was an especially exciting day for us because although we really enjoyed our time at the LaPlain clinic the past 3 times, we were eager to experience a new clinic and learn even more about the workings of the healthcare system in Dominica.  It was about a half an hour drive to the clinic and upon arrival, all of us got down from the vehicle eagerly waiting to talk to our patients and have them teach us as much or even more that we can offer them.
 
The clinic was smaller than the one at LaPlain with fewer patients, 5 specifically due to the lack of a doctor or a pharmacist but considering there was 5 of us and 5 patients to talk to, we were more than happy to spend time with the patients.  The most amazing thing for me when talking to the patients is the difference in their mindset compared to patients in North America.  It's very difficult to explain, until you observe it yourself because some things are better understood with experience alone.  With their many disease states and hardships in life they still manage to have a smile on their face, do not complain and are always grateful and enjoy our company. 

After we all had a chance to talk to our patients, understand their disease states better and make our recommendations the nurse on duty offered to let us accompany her on a couple of house visits to patients who were either bed bound or too incapacitated to make it to the clinic.  Again, we were all very excited as this would allow us to see a different side of Dominican culture, specifically the caring, tight knit community side.  We walked for a bit and arrived at our first patient's home, he was a young male suffering from epilepsy.  Due to his severe epilepsy he was unable to communicate as much except for the basic yes and no.  The thing that touched me the most from this visit was how close knit the community was and how this patient's extended family was looking after him, specifically his cousins. 

The next patient that we visited was an elderly 91 year old female who was blind and bed bound.  The warmth that we felt from this patient's family when we entered was actually unimaginable.  Despite all their hardships, they were very excited to meet with us, strike conversations with us and welcome us into their home.  Experiences like this definitely stay with you for a lifetime, and I highly recommend everyone experience trips like this at least once.  It completely changes your perspective on life and hopefully makes you think.

Pearl