Last week, a Physicians for Peace team of volunteers from Minnesota escaped the cold for a while to travel to Santiago and Santo Domingo in the Dominican Republic. They worked with medical professionals in the local hospital, teaching new methods in fabrication of burn compression garments and masks. Here are their reports from the field:
12 January 2009
The team arrived safely in sunny Santiago with all of our luggage and equipment.
The morning started with a meeting of all therapists, doctors, a seamstress and tailor, and others from both Santiago and Santo Domingo. We shared our individual goals and expectations of this mission and reached a concensus on our plan for the week. It was learned that the prosthetist/orthotist from Santo Domingo worked previously as an artist with the man who discovered a ‘larimar’ mine in the southern part of the D.R. This beautiful blue stone is only found in the Dominican Republic and has been a favorite purchase among the Minnesota team. The stone is named after the founder’s daughter Larissa and the the Spanish word for the beautiful sea, ‘mar’, thus larimar.
We broke into 2 groups to maximize our learning. One group went to evaluate and treat the burn inpatients. Both the physiatrist and the therapists demonstrated excellent comprehension of the patient’s needs and presented an appropriate therapy plan. The other group took a facial moulage (model) of Liz Rivers, the inventor of the plastic face mask for burn survivors, as a demonstration. After the morning coffee, snack and then lunch (they feed us well here), we began to prepare the model and fabricate the plastic face mask. We had both experienced and novice learners in the face mask techniques. It was clear after our face mask was formed that we really didn’t have the same plaster or oven to heat the plastic with which we were familiar. Everyone worked together to get us a variety of D.R. dental plaster to try to find the one that would perfom most optimally. After experimentation with various mixtures of plaster, water, and salt, we decided on an acceptable formula.
All 4 learners had an opportunity to ‘pull’ a face mask and cut it out to get the feel of the material. The enthusiasm of each of the participants was amazing; the group worked long after their day was finished and everyone is eager to begin again tomorrow.
Signing off for now,
Team Minnesota
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13 January 2009
Jana and Dr. Fisher made it to the hospital for rounds and beat the local staff there for the 8:00 start. Rounds begin and end with a prayer and a blessing. The burn unit physiatrist stressed the importance of
‘team’ rounds and checking in with the plan for the day as the Minnesota team strongly supported.
After rounds, the inpatient rehab team discussed specific patients and their care plans with the physiatrist and the rehabilitation therapists. Jana, the physical therapist from the Minnesota team, observed patient treatment and made recommendations for progressing the treatment plan for specific patients. Both therapists from the D.R. were eager to learn any new techniques.
Meanwhile, back in the outpatient lab, there were many projects happening simultaneously. Augustin from Santo Domingo taught Ana Ariceli from Santiago how to make a tight elastic shirt for a 4-year-old child with severe scars on his chest, back and arm. The boy was burned from hot coffee which spilled on him.
Another outpatient who arrived at the clinic, an 18-month-old boy who climbed on the table and spilled hot water on his face on 12/26/08, was fit with a compression headband to prevent scars from forming on his forehead.
Other therapists and orthotists were practicing making face masks and taking facial models. After some late-night experimentation in our hotel room, we figured out what we felt would be the best mix and formula for the plaster. The hospital engineer was able to get the plaster we needed today. A D.R. therapist aide volunteered to be the ‘model’ for us. The process involves holding still while your face is covered with a ‘frosting-like’ material and then covered with plaster strips. The nostrils are the only part left uncovered. He talked about not having any feelings or thoughts while waiting for the plaster to dry. He said his ‘mind went blank.’ Hopefully, he’ll be able to share this meditative technique with the kids he will be working with later.
Beth’s observation as a first-time volunteer: Just want to let anyone who wants to go on a mission such as this know that there were several nights of planning by our Minnesota team prior to leaving. This included setting the goals of the mission, agreeing on a loose agenda, listing and gathering supplies needed, and a packing night when we packed the 200 pounds of supplies we were going to bring. Some of these were needed for the teaching, and some we will be bringing home for use on other missions. I am finding that one needs to be both goal oriented and very flexible at the same time. While we hope to complete our goals by the end of the week, each day is filled with many challenges. Sometimes the supplies you brought before are not able to be located, or supplies you asked the host to supply are not present or even available. The people you are teaching are not always available when you need them, or the lights go out for awhile. Lots of extra people are passing through the room and watching what you are doing to name a few. These are just a few of the unexpected things that can happen. This is all offset by the enthusiasm, energy, and warmth of the people we are working with. When you are teaching a new skill, suddenly you look up and there are several other people helping out, each wanting to get their hands on the project. I love the camaraderie and how freely people offer ‘touch’, caring, and compassion during their daily interactions.
We all work so well together and are having a great time both during the day and in the evenings.
Adios amigos, hasta manana,
Steve, Liz, Jana, Patty and Beth
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14 January 2009
What a great day! We had 3 outpatients who were perfect for teaching both scar and contracture management. The Dominican Republic team was able to continue practicing their skills making splints for legs, arms and a face mask on a 13-month-old child. In the U.S., we would take the facial impression under anesthesia, but here we had to take it awake. Luckily, we had the help of the prosthetist from Santo Domingo who has had experience taking models on young children awake. We were able to get a fairly good fitting face mask and the mom was willing to bring the child back on Friday for more work and to check in with her to see how things are going. This patient and her mom traveled 3 1/2 hours by bus from her home on the border of Haiti. We are breaking accessibility boundaries by providing these rehabilitative services here in Santiago instead of having her take the bus to Santo Domingo which is 2 hours further. This child also needed a custom glove. Luckily, we had 3 bags of custom compression garments donated by Bioconcepts and a pink glove in one of those bags fit the child perfectly – like a glove! There are also many opportunities to improve on the follow-through for outpatient visits, both with the doctors and with the therapists.
Dr. Fisher and Jana are working with the D.R. physiatrist and physical therapist on many things. We made some medical and rehabilitative suggestions.
We were so impressed with Augustin, the tailor from Santo Domingo. He has designed a compression glove and elbow sleeve which are extremely unique in design. We hope to publish a paper showing this effective ‘thumb’ design.
We have more ideas than time for the next 2 days, but as always, things will work out!
Adios amigos,
Jana, Patty, Beth, Ramon, Steve and Liz
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15 January 2009
The team had a very successful and busy day. The highlights of the day for us were several:
1) A five year old who was thermally burned in a house fire 30+ days ago, and whose mother died in the fire, had not walked and was refusing to try. The psychiatrist and staff felt there was a significant psychological component. Once the wounds were visualized, we realized that increased compression and vascular support was required to improve comfort. In the morning she walked 15 feet with a single ace wrap. With a double ace wrap, the child stood and walked 75 feet with support of two people. She had little or no pain complaint. About an hour later she walked out of the burn unit pushing a toy, a distance of 500 feet. We were even impressed at the success of “double ace wrapping.” The burn staff of the DR was definitely struck with the importance of a very simple rehabilitation method.
2) We were successful in contacting and cooperating with the Orthopedic department of the children’s hospital with stretching and and beginning a program of serial casting on a complicated 8 mo old child with knee contractures secondary to contractures. We also fabricated an elastic hand garment and a transparent face mask to minimize hypertrophic scarring. We believe this type of intensive follow-up interdepartmental effort was a good initial demonstration.
3) We continued to teach and demonstrate the art of fabrication of face orthoses and garments. The Santiago team independently took the facial moulage and poured the mold with minimal verbal directions. They continue to demonstrate great enthusiasm and rapid learning. For only the second time since we’ve been training the D.R. staff, the tailor from both Santo Domingo and Santiago came onto the unit to measure a patient for compression garments to his lower legs. They have been working on the patterns and will fit the patient tomorrow.
4) There is an incredible opportunity for the physical therapist to be involved in the outpatient burn clinic. Today alone, we saw 5 patients from the clinic who needed rehabilitative interventions and will require many follow-up visits from the therapist to complete their rehabilitation goals.
Liz and Beth’s view from our balcony:
Liz’s and my room has a very small balcony overlooking a bustling street. I spend a few minutes overlooking ‘our’ street in the morning, after work, and then again before bed. Two dogs live with their owner outside of a business. The dogs are frequently sleeping in the corner of the building on the sidewalk and the owner is usually outside on a lawn chair or inside the business – he may be a guard or perhaps the owner? Then, there’s the woman who sits on her piece of cardboard on the sidewalk asking for money – she’s very feisty. In the evenings, there are vendors cooking their wares in a pot of hot oil. Lots of people are passing on the street and the traffic is constant as well as the horns. Motorcycles dart in and out of the 2 lanes of cars. It’s become a friendly, familiar scene, and I’ve grown fond of our little neighborhood.
Last day tomorrow! We’ve got lots to do and several patients coming for more therapy.
Adios,
Patty, Steve, Jana, Beth and Liz
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16 January 2009
Again, the day was jam packed with planned and unplanned activities!!! The Santiago 4 face mask team and Minnesota team started right away at 8 AM re-pouring to get the impression to make a new model for the young boy’s new face mask. The Minnesotans did enough of the process this time to assure a high quality plaster positive model. Ana A and August started right away finishing my experimental right hand glove. It confirmed again that their machines cannot sew children’s gloves. These machines cut the fabric, so if it gives proper vascular support, the seams tend to tear apart. But I wore my glove all morning, and it is a better example of acceptable support to improve healing and decrease scarring. They measured an outpatient for a new garment that helped the person stretch out his contracted shoulder and elbow, since he claimed he could not move. Nina and Steve worked with him and made considerable improvement in just the half hour it took to get his new design of garment.
The team made a very nice, well fitting face mask for the young boy and made arrangements for him to return to Santiago for revisions in 3 weeks. He will return to Santo Domingo in 6 months because he is growing so fast that he will need a new impression and model at that time.
Liz worked on getting the momentos for each of the persons we worked with and a letter in English and Spanish to thank them for their dedication, passion, and investment in this training. We passed them out while both teams drew up closure of work with the patients. Then we all had lunch and did a little ceremony to pass out their certificates of attendance. They cheered each person, everyone had photos, and then everyone cried, hugging and kissing. We changed to street wear and set off to pack up all the equipment we need to use at the next country or burn center. Then we re-focused to plan the next couple of days’ adventure. It is 2AM, so I will pray this blog is coherent!
Adios,
Patty, Steve, Jana, Beth and Liz
