My mentors in austere medicine warned me that with an interpreter I would be lucky to see 30 patients per day. That concerned me because the local missionaries indicated at our first organizational meeting in the Dominican Republic that we were expecting to see 100 patients per day. On top of that, 100 cards were being handed out at each of the four locations we would be visiting.
It wasn’t long before I became aware of a pattern. Every patient had “just run out” of his blood pressure medication. Unfortunately, the medications they were taking were often combination drugs with some components not known to the US market. We simply tried at first to match as many medications as possible using our stock, but eventually I found myself recommending that they go back to their own local source for medications. I no longer trusted that we were being given an honest history, and my worst fear was that our patients would start mixing medications and sustain a complication.
It was obvious at several locations that sexually transmitted diseases were a frequent complaint. I could do a private examination behind curtains looking for vaginal discharge at the perineum, but I was warned to have the local female physician present to prevent false allegations about Americans performing an inappropriate private examination. It seemed best to treat for everything because we had no laboratory to view discharge under a microscope or KOH to test for various organisms. Doxycycline, metronidazole, a shot of ceftriaxone, and Diflucan to be taken at the end of treatment were given to most of our female patients with vaginal discharge.
I trained in the pre-ultrasound days of emergency medicine, and I have limited ultrasounds skills (in my opinion). Nevertheless, years of sitting in lectures and hanging out with excellent ultrasound physicians help ultrasound skills develop with time. I took a small portable ultrasound machine with me, and was delighted with the role it served. The ultrasound proved to be a valuable tool for pregnancy confirmation, finding lung rockets for congestive heart failure, assessing level of hydration by viewing the inferior vena cava, and assessing right upper quadrant pain. It was awkward at times and we had limited options for finding a darkened work area, but were delighted with the benefits of ultrasound in the austere environment.
Our medication options for treating parasites were limited because mebendazole is now off the market and albendazole is very expensive (75$ for two doses). Fortunately, we were able to purchase a plentiful supply of this medication in the Dominican Republic. We were again forced to treat many patients empirically because we had no resources to test for parasites. The risk-benefit ratio for this practice seemed to be excellent, and we treated many patients based on history and examination findings.
Our preparation for providing emergency care to team members also proved valuable. I had an emergency bag filled with medications and equipment specifically dedicated to caring for the team. Three team members became incapacitated with traveler’s diarrhea and required treatment. All three team members had recovered within 24 hours of treatment. Ciprofloxacin was used to address the E. coli, loperamide to slow the diarrhea, promethazine for nausea, and sometimes dicyclomine to manage crampy pain that developed. Intravenous fluids were often suggested, but I followed the World Health Organization’s perspective that oral rehydration is commonly all that is needed. That truism proved correct, and no intravenous fluids were ever needed.