By: Nathan Mall, MD
I traveled to the second largest city in the Dominican Republic, Santiago de los Caballeros. I arrived at midnight and started to work bright and early the next day at the Hospital Universidades Jose Maria Cabral y Baez. This hospital is the only teaching hospital in Santiago and functions much in the same way as teaching hospitals in the United States. I learned a great deal from their residents about their health care system, their struggles to bring appropriate orthopaedic care to their patients, their culture, and their friendship.
Some believe Santiago was founded by Christopher Columbus, while others believe that it was part of the first wave of European colonization but may not have been founded specifically by Columbus. I was able to go to the Centro Leon, which is a museum devoted to Dominican culture and ancestry. Originally, this area was used for sugar production, but now relies on telecommunications and tourism to contribute to the countries GDP.
They have a very famous baseball stadium called Estadio Cibao, home of the Aguilas Cibaeñas baseball team. The Dominican Republic hosts many major league baseball players during their winter league play.
Culture
In my time in the Dominican I got a feel for their culture. They truly enjoy life and enjoy eating, drinking, and their music.
The culture is much more expressive than ours, except when it comes to pain. I only twice heard a patient express pain while I was there, one was an elderly woman who yelled in pain, the other was a young man that had surgery the day before and was asked to come to conference and move his arm and he simply said that it hurts, but did not grimace, scream, or cry. The people are very flamboyant and passionate. They speak loudly and are not afraid to speak their opinions. They are very giving despite having very little. The people work hard but also enjoy life. Whole neighborhoods would be out on the street playing dominoes, laughing, drinking, and enjoying each other companionship. There is a large disparity between the rich and the poor, with very little in the way of a middle class. The poor are very poor, some with broken bones cannot afford to have a cast put on. I asked how much it would cost in US dollars for a cast, and it was two dollars. The rich drive very nice cars and live in nice homes and usually have second homes at the beach or in the mountains.
Many patients that would like to seek treatment have to arrive at the hospital by five o’clock in the morning. They wait in long lines to be registered and are then allowed into the hospital. For more urgent patients there are two Emergency rooms, one for internal medicine and one for trauma and surgery. The Emergency room is dominated by orthopaedic patients, most with long bone fractures from motorcycle accidents or gun shot wounds. They are seen in the emergency room by the residents who will put them in traction using a Steinman pin and two milk jugs filled with water for weights. They then await a bed, which can take hours to days.
There are around 50 patients or more lying in rooms in the hospital for months as they try to come up with the money to pay for the treatment that they need. Some cannot, and they lay in traction for 6 weeks or more. Because of this problem, many of the patients who get surgery have fractures that are malunited, angulated, or infected. This only makes the already difficult problem of operating with limited resources that much harder. The average time from the fracture to the time the surgery is performed was at least 3 weeks.
Radiographs are often one or two views of a particular injury, they are often malrotated, and the patients have to hold onto their own xrays. They are kept under their beds, however the patients also eat in their beds and so many of the xrays get wrinkled from lying on them or food spilled on them. Patients must pay for their own radiographs, CT scans, and MRIs and thus they must be very careful about what they order.
However, there is a large disparity between the public teaching hospital and the private hospitals. The private hospitals have much better radiographic capabilities, better operating rooms, better equipment, and better implant choices. However, these hospitals serve the minority of people in the country.
Surgical Treatments
The operating room conditions are bleak. At the beginning of the case the air conditioning is turned on, and if it doesn’t work they cannot use that room. Trays are incomplete, some even without knife handles. The surgeons must either use the scalpel by hand or use a clamp to hold the knife blade. The nails are of limited sizes and they use the one that fits the best, but this may be 4-5 cm shorter than it should be because the next size available is too long.
The screws are often too long or short as they may have only four or five different lengths available. External fixator parts are removed when fractures are healed and are washed and sterilized and then used in the next patient that needs one. However, despite all of this, the reductions they achieve and the care of the patient is amazing for the resources they have.
Patients with lower extremity fractures typically undergo spinal anesthesia and must sit up on the bed despite their fractured extremity. The patients are usually wide awake during surgery with minimal sedation, however, they never complain or scream in pain. Infection is always a concern because there are four patients in a room, some with infections and there is no isolation like in the United States. They prep and drape the patient in the best way they can. Drapes are cloth as are the gowns and are reused after being cleaned and sterilized.
Residents
The residents care deeply for their patients and are doctors for all of the right reasons. They want to help the poor people of their country and want the best for their patients. Residency is 4 years, and they take call sometimes every third night. Their call room has air-conditioning, but also has a leaking ceiling and bunk beds that don’t appear to be the most comfortable. However, they rarely use them as they are typically very busy when on call. The classmates are very good friends and almost all of their pictures are with each other. The work very hard and play hard too.
The fourth year residents are typically the ones that do the majority of the surgeries, usually with no attending physicians around. The 3rd year residents operate occasionally, and the second year residents are only in the OR to help prepare the room and the patients, to transport the patient, and perhaps may scrub in to pull traction. The rest of the time they are seeing the massive number of people that come through the clinic and the emergency room. The residents have to do everything themselves, they set up the rooms and cases, they act as their own scrub nurses, they assemble their implants, and transport the patients. They have nurses, but they often do not bother to come in the room during the cases. 
They are paid by the government and make about 6,000 dollars a year or $500 a month. Most of the residents still live with their families. There is no 80-hour work week. If they make a severe mistake they are punished with 48 hours straight in the hospital and for more minor mistakes they have to write a particular sentence like “I will not lose the patient’s x-rays” one thousand times. Other punishments include giving extra conferences, and they have a new one of translating the materials I left for them into Spanish.
All of the residents care deeply about learning and are very educated in orthopaedics, especially orthopaedic trauma. Despite the language barrier, I could tell that they really understood many of the more advanced principles in orthopaedics. They did lack some knowledge in sports medicine, oncology, and pediatrics. However, this is not because of lack of effort but lack of resources. They do not see these problems commonly and the most recent journal article they have is a 2006 Journal of the American Academy of Orthopaedic Surgeons.
They also have other humanitarian interests, and one resident even started a foundation to help even more people. When he gets done working way more than 80 hours a week, he then works with his foundation to distribute food as well as to try to get more people access to health care. They are in desperate need of equipment, especially spine, arthroplasty, and arthroscopy equipment and implants, as this is difficult for patients to afford and to bring in to the country.
The residents treated me much better than I could have every expected, making sure I have plenty to eat and drink. They took me out almost every night and really took care of me. For this I will always be very appreciative. I am amazed at their love for life, their country, and their work. It is a hard system, and it would be easy to become complacent or frustrated, but they keep working to being the best health care they can to the people of their country.
From this experience I was able to see first hand how good things are in the United States, and that our physicians and patients take this for granted. The thirst for knowledge that the residents I met had was inspiring, and will help me to study harder, learn more, and take advantage of the resources we have available in the United States. I was able to help with two medical missions while in college, and this trip has reaffirmed my dedication to continuing to serve developing countries when I complete my training. I learned a great deal about the Dominican culture and their respect for physicians, and I only hope I can continue to aid in education and training of these new friends of mine.
