Tuesday, April 27, 2010

From Carrie: First impressions

Rhea, Jess and I also had the opportunity to travel to Santiago. We were in the Dominican Republic for 2 weeks in the beginning of April. We were hosted by Dr. Martin Medrano, head of Geriatrics at the public hospital in Santiago, who also hosted Janina. The public hospital, Hospital Universitario de Jose Maria de Cabral y Baez, provides free care for those without insurance and for the underinsured (often with the government insurance).

Our first day on rounds with the Geriatrics team was interesting, we saw a wide array of patients, many of them hospitalized for similar reasons as our patients at Columbia, although the plan of care often differed due to resources. The layout of the Geriatrics floor consisted of 2 large rooms, each with 4 patients. There was a nursing station outside in the hallway, so if the patient or families needed anything there was usually a nurse nearby. The nurses usually knew where to find the doctors if they needed help, they didn't use pagers!

Vital signs were taken by nurses on a regular schedule (2-3 times every 24 hours), and by the interns when pre-rounding. Records were all kept in a paper chart which was often at the bedside. The paper record included much of what we have in the computer: progress notes, consultant notes, a list of medications (updated daily), allergies, vital signs and blood glucose levels, blood and urine test results, as well as notes from ancillary services such as PT, OT, and nutrition. One thing I noticed about having a paper chart, and few computers, was that it brought care back to the bedside. Compared to our normal days at Columbia, the doctors were more likely to go into a patient's room to find information, and follow up rounds were at the bedside. This also made communication more frequent between the patient families and the medical team.

There were often multiple family members with patients at all hours of the day. Instead of being a burden to the nurses or doctors, these family members were expected to be there. On the rare occasion when family was not present, it was usually a sign of severe poverty and even neglect. While family members were throughout the hospital with patients on all services, there seemed to be the greatest number of family members present on the geriatrics floor. The family members were responsible for providing information on rounds (such as overnight events, current state compared to baseline, and ability to pay for future tests) and were in charge of the patient’s lab results and radiology films (which were often stored under the mattress). Families also helped with much of what we view as nursing activities, including chest PT, exercises, and helped to prevent falls in high risk patients (there were no nursing 1:1s).

I wondered, was the family presence in the hospital a Dominican thing, or was it only at the public hospital? According to my host mother, Bienvenida, there were more family members with patients at the private hospitals because there was more space and private rooms! So it was definitely a Dominican thing...

This made me think of the large families which often visit my Dominican patients at Columbia. My experience at Columbia is that when large numbers of family members arrive, the staff often gets overwhelmed and the family is asked to leave, particularly if it is late at night. Often there is at least one family member who stays as long as possible with the patient, but at times this person is thought to be checking up to make sure that everything is done correctly, or wanting it done in a different way. My experience is that this type of family behavior is the exception at Columbia instead of the norm. Looking back on it, the Dominican families must feel a bit helpless, as they are not counted on for lab results, x-rays, or PT, they are not always included in the minutiae of the daily plan. This has made me recognize that the family’s presence in the hospital is a cultural expectation, nothing more and nothing less than a demonstration of their love and respect for the patient.