In March I participated in the MOCA WNY medical mission to the Dominican Republic. I will JUST write about the medical mission now and do the beach/resort/tourism posts later. This ended up longer than I planned but it covers the whole week rather than the daily posts I did about previous missions. It is 6000 words and a 30-minute read and much more enjoyable to read on a tablet or computer than a phone. Maybe once I retire I will figure out how to do these as an audio “blog” or podcast (but with photos).
For about 20 years MOCA has been going on medical missions; providing both gynecological surgery and primary care. They went to Africa for many years, but after Ebola they started going to the Dominican Republic yearly and also went to Cambodia once.
I was hoping to go on last year’s mission but it was the same weeks that Alex and I visited Japan. I did participate in the Meat Raffle last year so I was an expert this year at the big fundraiser. See the short post below (from January) if you haven’t read it yet.
Over $10,000 was raised at the meat raffle and other donations help support the charity as well. Wegmans donated a lot of vitamins and OTC medications. Catholic Health System donated surgical and anesthesia supplies and medications. I paid for my own airfare and hotel but neither were very expensive.
Below are links to the MOCA of WNY information pages.
https://mocaofwny.wixsite.com/mocaofwny/about
and here is a link to their FB page if you want to follow them for the future…
https://www.facebook.com/MOCAofWNY
To Donate you can mail a tax deductible contribution to:
MOCA of WNY 121 Sunburst Circle East Amherst, NY 14051
or electronically…
https://mocaofwny.wixsite.com/mocaofwny/donate
In the months leading up to the mission I tried to prepare well as I was going to be the only anesthesiologist on the trip. Usually there are at least two; both to split the work hours and in case someone has a medical issue. On one mission a nurse fell in the dark and broke her wrist, luckily she was just one of several RNs. I panicked in the DR when I ate a salad at a “non-resort” restaurant (forgetting the rules while trying to find a healthy appetizer on the menu). Luckily I did not get ill. I swam quickly away from some scary black sea urchins I saw on one of my open water swims (rather than getting close for a better look). Next year I am definitely talking someone else into coming, it will also allow me to work one day with the primary care team instead of at the hospital.
I spoke to the anesthesiologists from the last two MOCA missions, but they had been at two different sites, neither of which we were visiting this year. They had no ability to give general anesthesia the last two years. They used spinal or combined spinal-epidural anesthesia for all the cases. I was preparing for the same and assembled enough needles and spinal/epidural medications to do 20 cases. In case there was the ability to do general anesthesia I also brought a lot of airway supplies and the pharmacy provided propofol and dexmetetomidine for IV general or deep sedation.
When I learned that in previous years there was no ability to monitor End Tidal Carbon Dioxide (ETCO2), which has been a standard of care in the US for 40 years, I wondered about buying a portable device. Pulse Oximetry devices are now on watches as well as cheap finger clips being available (I used one on my Mt. Kilimanjaro hike) but a portable ETCO2 monitor for EMT use was a few thousand dollars. I did find a small, basic one meant for veterinary medicine on Ebay for only $200. I had bought a handheld ultrasound probe (it uses my iphone as the screen via Bluetooth) before my first medical mission a few years ago so I was well equipped.
In Fiji we had used the ultrasound to confirm that a pregnant woman’s uterus still had a fetal heart beat. And if there was a patient with awful scoliosis or morbid obesity I had recently been doing some practice with ultrasound imaging for spinals in my total joint patients. The ultrasound can also be used to find a vein in a very difficult case or to do a basic cardiac exam if someone had a loud murmur on a preoperative exam.
I was also planning to do ultrasound guided TAP (transversus abdominal plane) blocks for post operative pain control as I would not have any spinal morphine available. I had not done one in ten years but I reviewed them on YouTube. I printed out an information sheet (in Spanish and English) for our nurses and the local staff.
The “TAP Block” injection is the ideal and most recent solution to manage pain after abdominal surgery. It entails the injection of a local anesthetic near the nerves supplying the lower abdominal wall, guided by ultrasound. (1)
At the end of the operation, before the patient leaves the operating room, the injection is given. It is safer and lasts longer than other pain relief methods, usually providing pain relief for the first 12-18 hours after surgery, which is the most critical post-surgery period.
As a Mosaic Jetblue member I get two free checked bags so I could bring my supplies and and also a bag of vitamins and OTC medications, my extra suitcase weighed 48 pounds (with toys for children and sponge candy for the DR hospital nurses). I had Spanish and English copies of a letter from the DR minister of health in case my suitcase was searched.
For myself I just had a smaller suitcase and a backpack (and my tropical hat). Fifa would be left in the care of Alex, with some extra walks by my friend Mark on days they had both work and school.
About a week before the trip, MOCA’s physician contact in the DR sent me these photos of the just renovated hospital’s operating room.
WOW! Brand new equipment including a modern ELECTRIC bed and a new anesthesia machine. Based on that information I felt it was worth trying to bring a bottle of Sevoflurane (anesthesia gas) with me. A careful reading of TSA rules said that you are allowed to bring “medications” that are more than 3oz as long as you declare them. I took it out of my backpack before security and the TSA agents just opened it and did a “vapor” test. I didn’t even tell them I was a doctor or going on a mission trip.
I had assumed that most of the 30 people in the MOCA group would be on my flight from Buffalo to JFK and then onto the DR, but there were only a few of us. Through the group’s WhatsApp chat I located the other 5 people and introduced myself before our flight. A few people had actually gone down the day before (I would have done so if I had known) and others went on other airlines from Buffalo through Atlanta or Houston. There were also people on the trip from NYC, Miami, and L.A.
The only people I really knew in advance were Emme Nylander, MD (the gynecologist in charge of the mission, who I work with at Sisters of Charity Hospital in Buffalo and Daniela Señor who is the MOCA administrator (and would be my translator and assistant in the OR). I would later recognize a few people from the Meat Raffle and some nurses who I had worked with years ago but I am VERY bad at names and faces.
The early morning flight (Saturday 2/28) from Buffalo was on time and the one to the DR was delayed only an hour. I got some nice sunrise shots on the Buffalo to JFK flight.
Our connection was very tight so actually the delay was not bad, it allowed me a 30-minute terminal walk including a visit to the “secret” outdoor area at Terminal 5. I noticed that JetBlue finally has a premier lounge but my Mosaic 1 status is not enough use for free, one needs to be Mosaic 3 or 4 or pay $75.
On the JFK to DR flight (3.5 hours) I watched “One battle after another”; I had wanted to see it in an actual theater but it went to streaming before I could. I had no idea the plot would be so political and psychological (and a critique of our current political mess in the USA), the previews I had seen made it seem like a routine action film. I liked it a lot.
The DR is between Cuba and Puerto Rico. It is actually well east of Miami and is one time zone off. The capital (Santa Domingo) is on the south shore, Punta Cana at the far eastern end is the expensive, popular resort area. Puerto Plata on the north shore is a more modest area and has two cruise ship ports.
I got some nice photos of the coast and mountains as we were about to land, including a great photo of the city harbor. The grassy peninsula at the bottom has the original fort built to protect the harbor in 1577.
And here is the photo of me and my friend in front of it a week later when I visited the city.
I’m sorry for digressing into travel blogging. it is hard to stick to only the medical mission.
I sat in the front of the plane so I was one of the first people off and there was almost no wait to get through immigration (I spoke Spanish to the official) and later customs. There was an easy online form in advance that gave you a QR code that was scanned as you left with your luggage.
As our flight had arrived an hour late, by the time we had all collected our luggage two other flights had landed and a dozen of us were collected by the same hotel shuttle bus for the 30 minute drive to our resort. It was jungle hot (80s and humid) and the bus’s A/C was very welcome!
At the meat raffle, Emme had asked if I preferred for the group to stay at a nicer or more affordable hotel. I told her that I could afford nice but she should see what the students and residents wanted. When I got my booking info and saw that the 7 days (including taxes, fees, all meals AND alcohol) was less than $800 I worried about how cheap it sounded. But when I googled the resort and saw the photos I was very surprised!
I was checked in and settled in my nice, big, air-conditioned room before 5pm. There was a huge patio! It had a TV with many channels in both Spanish and English, I only turned it on to watch the World Baseball Classic (rooting for the DR of course). I think MOST of the people at the resort were Canadian (although there was a mix of locals, Europeans, and Americans as well. Since they can’t go to Cuba anymore and don’t want to deal with ICE in the U.S. to get to Florida, the DR is a great option for them. There were many cheap direct flights to various cities in Canada and at $99 a night, many were staying for 2 or even 3 weeks. A lot of Maple Leaf flags were hanging from windows and balconies.
We weren’t meeting for dinner until 7pm so I got in a short swim in the 80 degree ocean and briefly explored the resort on the way to eat. We ate in a nice corner of the very large dining room, with a view of the beach. There was a huge and varied buffet for every meal, and always a variety of seafood options for me. After dinner we had an orientation meeting.
We were given a brief orientation and told that the medical team would spend a full day Sunday at one of the rural clinics (they went to different ones every day) but the surgery team would not leave for the hospital in Guananico until 1pm Sunday. We would set up all our work areas and the operating room and evaluate the patients scheduled for Monday surgeries.
We had all brought the medications we had in our luggage (drug mules!) to dinner for Frank (a regional director of pharmacy for Wegmans), here he is with the ones for the first day’s medical team clinic work. He has been coming on the MOCA missions for many years.
The medical team spent the day seeing patients at a rural clinic.
The last day of the mission at the hospital we made a special video to thank Wegmans and their pharmacy director Gina. “THANK YOU WEGMANS”!
As I had Sunday morning off, I went for a long run and after breakfast sat in the shade by the pool and read my Kindle for a few hours. I noticed (and liked) that the resort was very multicultural with hispanic, white, and black guests interacting. In Buffalo a lot of cultural activities are very segregated still.
I went back to my room and changed into my tropical doctor costume.
I joined some people for lunch (it was always easy to find our group as often we were in scrubs) and then we squeezed into the van for the drive to the hospital. There were usually a few more people than seats in the van, they set up cushions in the aisle. I always made sure to get there early to get a real seat (and wore my seatbelt, which I was glad of when the van once screeched to a stop, avoiding a lamb darting across the road to catch up with it’s mom and sibling).
It was only 22 miles but the drive usually took 45 minutes. While the first part was on a nice highway, the next part was hilly and winding with broken pavement. And the overloaded van had a low ground clearance so it drove very slowly on the bad sections. Cars and motorcycles were always zooming to pass us. Here is a video of the bumps!
As soon as we left the coastal resort area the nation’s poverty was very visible. But of course poverty is much worse in Haiti (and Honduras where my last medical mission was). For comparison, USA is $90K and Canada $60K.
The landscape was very beautiful though and there were lots of cattle and other livestock. Most of the homes had a few banana trees and probably other fruit trees I didn’t recognize.
Guananico seemed to be a little more prosperous, there were nice houses along the main road (all with lots of gates and bars on windows) and some clean retail areas. Most of the side streets seemed to be unpaved, which must be awful in the rainy season (May to November).
There was the smallest possible ambulance in the parking lot. I wasn’t sure anyone over 6 feet would even fit in it. Luckily most people in central america (and Spain) are not that tall, I am almost average height there. But the ambulance and hospital were all very new and clean. They had only really re-opened a few months before we arrived, having been damaged in the last big hurricane to hit the DR.
MOCA had a dozen large containers of supplies that were stored in the DR in addition to everything we had brought with us. The surgical techs and nurses prepared all the supplies for the pre-operative area, the operating room and the recovery room.
One of the pre-medical students helped me unpack and organize all my supplies and medications. She was observing Ramadan, hard with the 12 hour days.
I had a list of medications that were left at the end of the previous year’s mission but had been told that many were expired. A pleasant surprise was that there were two full drawers of medication in the operating room.
Most of the Spanish names were easily translated. I did use Google to figure out what Adrenol and Adrenalina were exactly (norepinephrine and epinephrine). There was some fentanyl that I would add to the spinal blocks and some Valium that I gave one patient for sedation when I was almost out of propofol. IV valium hasn’t been used for surgery in the USA in thirty years as midazolam/versed wears off much more quickly and doesn’t hurt on injection.
I filled the empty spots with my medications that they did not have stocked.
Even though this hospital was recently renovated and had modern equipment it did not have pipelines of oxygen or suction (as in more developed countries). They had large oxygen tanks and electric powered suction machines. There were no iv infusion pumps for us so I used my math to figure out how to count drops of fluid as they had to do in the REAL old times. Propofol at 8 drops per minute (1 drop every 7 seconds) = 100 mcg/kg/min for an 80 kilogram patient.
The staff at the hospital smiled and said hola but there was almost no coordination between them and our group. JB (the DR physician who worked with MOCA) practiced on the other side of the island and didn’t seem to have a great working relationship with the local staff. Weeks before the trip I had asked JB to get me contact info for the anesthesia providers at the hospital (the website said they had done some orthopedic surgeries in January) but he never did so.
I tested the anesthesia machine and it seemed fully functional but the oxygen sensor was not working and I couldn’t find a replacement. The spanish interface was easy for me to understand. I only used general anesthesia for one patient who had a patchy spinal block, the rest got spinals or epidurals and sedation with propofol or valium.
While setting up, someone on the team found the cutest little lizard in one of the rooms. She was a good organic, non-toxic insect control system!
No patients showed up to be evaluated on Sunday, theoretically three women were supposed to be there for us to pre-op. We squeezed back into the van for the trip back to our resort.
Almost no one wore helmets on motorcycles, scooters or electric bikes even while sharing the bad roads with trucks, cars, and even livestock. I got a few family hazard photos, but this really scary one someone else in the group shared with us…
The trauma ERs deal with some horrific accidents and then limited orthopedic surgery options leave many people with lifetime disabilities we no longer see in the U.S. On my last mission in Honduras we took care of many people with old, untreated orthopedic traumas.
Instead of eating dinner at the resort we all went to a seafood restaurant on a lagoon a few blocks outside the resort. I had run around the lagoon on Sunday morning and seen the egrets that had all returned to the trees to spend the night.
The tiny kitchen was a little overwhelmed by our large group!
I was lucky to have been at the first table to order and be served so I didn’t have to stay out too late. On the walk back to the resort I got this wonderful photo. The moon was almost full, the next night would be the lunar eclipse.
I only had time for a short ocean swim on Monday morning as I needed to shower and eat, and be in the van by 8am (and sunrise wasn’t until 6:30am). A cruise ship had spent the night at sea and would dock at the port next to the resort.
I always had a traditional DR breakfast and a fresh fruit smoothie; although they had the usual American options of omelettes, pancakes, etc. The hard boiled eggs and muffins were my lunch.
On the way to the hospital we stopped at a corner grocery store and a few people ran in to get snacks and drinks to leave in the break room at the hospital. The hospital had a cooler with filtered water as well to refill our water bottles.
Our first case on Monday was an abdominal hysterectomy, in the U.S. this would have been done laparoscopically or robotically. I used my Spanish “script” to interview the patient and talk to her during the epidural but Danielle was there to “translate” my Spanish 🙂
I gave all the patients Celebrex, Tylenol and Pepcid orally before surgery, to help with intra and post-operative pain and reduce gastric volume/GERD.
Without a pathology lab on site they looked inside the specimen to rule out any obvious abnormality.
We had no more gynecological patients but there was a woman in the hospital who was 40 weeks pregnant and had a “large” baby on ultrasound and she accepted a ceasarean section instead of trying an induction and trial of labor. All my patients gave me permission to take and share photos.
Neither her husband nor mom was “brave” enough to join her in the operating room but Danielle and I were there for company.
Even though it was late there was time on the drive back for a quick stop to get some beer, apparently a MOCA tradition (just Kola Real for me).
Before dinner I snapped this photo of a cruise ship heading back out to sea. Back in Buffalo a few weeks later I talked to an OR tech who had been on a cruise that stopped there the following week (out of Fort Lauderdale
After dinner I walked to the beach and got this photo of the full moon.
The MOCA group arranged to stop at the gazebo overlook at 7am before breakfast to see the eclipse but this would turn out to be too late, by then it had set behind the mountains to the west of us across the bay. I shared my photos from my early run with everyone.
The Worm Blood Moon would be the last total lunar eclipse until 2028 (a year I am desperately looking forward to!!!)
Alex got this next shot while walking the dog at home in Buffalo. It doesn’t show in the photo but the dark part was RED, “blood moon”.
I was reading a book about a Navy Seal recently and he would tell his daughter when he went on missions to look at the brightest star in the sky and he would also at the same time. Alex and I were looking at the moon at almost the same moment from 2000 miles apart. ❤️
The 5-mile run took a long time with all the photo stops so I only had time for a 5 minute shower and then hurried through the resort to wolf down a hearty breakfast.
Daily driving photos…
I was photo bombed while taking my morning selfie!
After arriving at the hospital on Tuesday we learned there were no patients for us and after waiting until 11am we would end up heading back to the resort. I voted for us to all go to the village clinic and help the medical team but …
Both the mom and baby and the hysterectomy patient were doing well. The TAP block seemed to have worked well as the patient didn’t need any narcotics until after midnight.
I wandered outside the hospital for a while and said hi to the people at a tiny food stall at the bus stop on the street. I also said hola to the adorable cattle. Meat IS murder…
Driving back to town, there were some police officers checking vehicles. It was apparently fairly routine for any cars heading away from the direction of the border with Haiti (which was about 80 miles west of Guananico). We Yanquis were just waved past.
Even though our surgical volume was low, the medical side of the MOCA mission was very busy every day at rural health clinics. Here are some photos from the week. Many of the adults and children they saw had not been to a physician in years. They put flouride gel on childrens teeth, checked hemoglobins and gave out vitamins and iron. Patient’s were discovered to have hypertension and diabetes (both silent killers) and hopefully would be able to get continuing treatment. They also talked about health care to several school groups. The DR does have a public health system and it is getting better every year.
They diagnosed several kids with major medical issues and arranged follow up evaluations at the pediatric hospital in the capital. There was also a Haitian woman who was 4 months pregnant and had some lateral abdominal pain. The gynecology residents were concerned about a possible ectopic pregnancy. Her husband who was Dominican didn’t want to bring her to a hospital because the goverment hospitals report illegal Haitian immigrants and they are deported. The next day MOCA arranged for them to come to the hospital and be seen by us, not the local staff, and using my handheld ultrasound they happily found that she had an intrauterine pregnancy and likely just a painful but normal expanding uterus.
This is a long public health article about the DR system. Only read it if you are REALLY interested. In summary…. Since 2001 they have been expanding a universal public health system but people in rural areas still have limited access. Middle class people in urban areas often have private insurance and use private offices and hospitals with better quality and less wait times.
Back at the resort I had a light lunch and then another ocean swim. I found some small coral heads this time and saw a dozen small tropical fish and a few hand sized ones and more of the scary black sea urchins. Before dinner I read my Kindle and enjoyed a mock-a-colada on a lounge chair listening to the waves.
Wednesday, March 4th, we knew we had a vaginal hysterectomy scheduled, as she had been seen the day before, and we also would do a tubal ligation.
I had noticed on our arrival that the large oxygen cylinders were not strapped to the wall. This is a huge risk in a country that has earthquakes and hurricaines. If that tank falls over and the regulator breaks off, the cylinder can become a missile and go through a door or wall or a person! It was something I had read about in a book about “Anesthesia in the Developing World”, before going on my first mission.I had Daniela write a note explaining the issue and hope that someone dealt with it by now. The plastic bottle below was a “sharps” container. The third photo is of my “emergency” drugs, all the same as I would have set up in the U.S.
Both patients had spinal anesthesia. They recovered very quickly, here is the tubal ligation patient barely an hour after surgery enjoying rice and beans and chicken with her sister and mother at her side.
I am glad that everywhere I work in Buffalo has electronic medical records as my handwriting seems worse every year.
The medical team at the clinic had another busy day and saw a nice rainbow.
On the drive “home” we saw a yard full of goats, sheep and pigs.
Thursday morning was our last drive to Guananico and I guess I finally had stopped taking photos from the van. But here is one from before leaving and outside the hospital when we arrived.
We did just one surgery on Thursday and then spent a few hours packing all of our supplies back into the storage containers.
I had some people help me go through all the old medicines. Anything very expired we threw out, the ones less than a year expired we donated to the hospital pharmacy and the unexpired ones we packed away for next year. I tried to carefully record what we packed away.
And then the sad farewell photo….
I left all my scrubs at the hospital, including from the last day, so… casual wear for last van ride.
The wind was strong in the afternoons and as the tide was low it wasn’t a good time for an ocean swim so I instead had some gelato and iced coffee and read my Kindle on the beach.
I had been reading a great historical fiction novel about the DR in the end of the dictator Trujillo’s thirty year reign. It was recommended to me by another physician on the mission. It is about the Mirabal sisters (code-named las mariposas, the butterflies) who were active in the underground resistance against the dictatorship.
If you don’t want or plan to read it, here is a link to their story. Their family plantation was very close to Puerto Plata and I saw murals of them on many schools I drove past. There was a woman at the pool with a tattoo of three butterflies on her leg. If I was in the DR longer I would have visited the memorial and museum.
https://www.britannica.com/biography/The-Mirabal-Sisters
I knew a lot about Trujillo’s awful reign (he was as bad as Batista or Baby Doc and, like them, supported for decades by the CIA and State Department) from another book about the DR I read four years ago.
Llosa is a Peruvian author who won the Noble Prize for Literature and I just randomly read his great historical novel about the awful regime. After it fell there were very bad times afterwards as (like in 18th century France) there was so much violence against all the professionals of the ruling class that it took decades for the universities and goverment to recover. I listened to a generic “history of” book, it really seemed like it was written by AI. I never knew that the U.S. army occupied the DR from 1916 to 1924 to prevent populists from taxing or taking the U.S. owned fruit and tobacco and sugarcane plantations. In 1965-1966 the U.S. again intervened to prevent the installation of a socialist goverment after Trujillo’s death.
This summary was written by Adriano Espaillat, the first Dominican American U.S. Congressman, in 2022.
After the murder of Rafael Trujillo, Dominican Revolutionary Party founder Juan Bosch was elected president. Bosch was toppled by a military coup just seven months into his term, and the Dominican Republic plunged into political turmoil. On April 28, 1965, President Lyndon B. Johnson ordered troops into the Dominican Republic through “Operation Power Pack” to protect American lives and property in the Dominican Republic.32 President Johnson, however, also declared that he had taken this military action to prevent the establishment of a “communist dictatorship.”33 Similarly, the U.S. Ambassador to the Dominican Republic William Tapley Bennett, Jr., described how intervention was necessary to “prevent another Cuba.”34On April 28, 1965, more than 22,000 U.S. troops, supported by forces provided by several member states of the Organization of American States initiated a military intervention in the Dominican Republic.35 Ultimately, 42,000 American armed forces were deployed to the Dominican Republic and remained there until September 1966.36 More than 3,000 Dominicans and 31 American servicemembers lost their lives.37
This audiobook was about the Caribbean cultures that were thriving and advancing before 1492.
It was a little too academic but it was informative. I was VERY distressed to learn that they ATE manatees!!! But I guess several thousand pounds of meat floating just below the surface would be very tempting to someone in a canoe with a spear who was sick of eating fish and root vegetables every day.
A month before the trip I read a very good book about the last 30 years of American immigration policies for refugees from Central America and how they have created our current disastrous situation.
Friday was a “free” day for us. There were a lot of day trip tourist activities available as there was a huge industry set up to entertain the thousands of cruise ship passengers who arrived at the ports several days per week. Most of the people on the mission had been to the DR so many times that they had done all of them already; so the “official” MOCA activity for the day was a day at a fancy beach club. As we were already at a beach resort and I would be spending another four days at a different all inclusive beachfront hotel, I found a fun day trip for myself. (travel tip: always book these excursions yourself on the Viator app or the operator’s own websites… the hotel lobby prices are almost double).
We hiked up a jungle trail for about 45 minutes and then slid down rock slides and jumped off waterfalls. Very fun and exciting.
Hiking in my water shoes was a little challenging.
I had my GoPro attached to my life jacket so got some good action videos. Here is one of a slide and one of a cliff jump.
The “traditional” Dominican lunch at a restaurant afterwards I could have skipped (clearly oriented to cruise day visitors) but it was an interesting group. Some of the young American women were in nursing school and actually heading to Santa Domingo to do a several week clinical rotation/mission at a women’s prison there.
I had a great massage at a nearby Spa in the afternoon.
The last night we ate at the Italian Restaurant/Steak House.
It was actually RAINING on Saturday morning for the first time other than a few stray sprinkles and one overnight rain a few days earlier. Everyone else headed to the airport while I was picked up by a driver I had hired to take me to see La Isabela archeological site and museum. Columbus built the first European settlement in the Americas in 1493 on his second voyage with 13 ships, 1500 people and European livestock.
I hope you enjoyed this lengthy report. Please share, comment, subscribe (FREE) to my blog.
Very interesting – You really do a great service