We have now completed three days of community clinics and are starting to get the hang of the workflow. Our first day was at El Rosario and we all woke up bright and early to prepare. Annie gave us a quick de-brief about the different stations and flow of patients: first, registration and history, vitals and labs, consults with physicians and lastly, pharmacy. We received our assignments and reported to our stations for work.

At the vitals and labs station, there were two teams to collect patient’s weight, height, blood pressure, and temperature. We had a few basic labs available such as the urine pregnancy test, urine dipstick, blood glucose, and hemoglobin. At the Sonando Porel Cambrio community, Cindy was assigned to the vitals and lab station and was surprised to find that many children were a couple standard deviations below the normal growth curve of healthy children of the same age. At another community, El Rosario, Cindy also noted the large number of adults who were hypertensive. She realized how essential the triage process was in screening at risk patients and identifying those who need further attention or future referrals.

Purnima worked as a scribe at consults with a Venezuelan doctor named Jenni. They quickly bonded over their love of food and passion for community medicine before quickly establishing a workflow. Jenni explained that she will translate the pertinent history of present illness and any findings on physical exam as Purnima took notes. As patients trickled in, they started to see a pattern of nutritional deficiency arise as many patients had complaints of fatigue, dizziness and poor access to food due to finances. In particular, a 24-year old woman came complaining of paresthesias in her fingers and fatigue and was found to have low hemoglobin. She explained that the last time she ate meat was months ago and that her daily meals consisted of only rice because her family did not have money to afford meat or other foods. She had to travel to another city to find work, which did not provide enough finances to support her family’s nutritional needs. Jenni explained that in remote parts of Santo Domingo, the people are very poor with many only make $400 per year. Hence, the patient was anemic and likely had a vitamin B12 deficiency, which was causing her symptoms. The next step was to counsel on the importance of incorporating different food groups into the diet and providing vitamins and iron to help.

Aaron worked in the pharmacy, which consisted of a team of 5 people: 2 “runners” who organized and pulled the medications to be filled, 2 interpreters who labeled medications in Spanish, and 1 pharmacy lead who took care of the final step of checking and approving everything that was dispensed from the pharmacy. Although Aaron had already worked in vitals/labs and in consults by the 3rd day in clinic, he felt that despite having little patient contact, pharmacy was one of the more fulfilling stations since it required streamlined teamwork and problem-solving skills. These were the reasons that had motivated him to pursue medicine and continue work in global health. For instance, each clinic day was at a different community, so the set-up of pharmacy had to adapt to each environment and the team had to quickly strategize on the best way to set-up the station for the day. We adapted and molded the pharmacy station to the constraints of the space and resources, placing our medication bags in optimal ways for efficient access and often utilizing objects at the sites to better stabilize our tabletop on the modular table legs.

Throughout the day, pharmacy was busy fulfilling orders for each patient from the providers and scribes in the consult station. To function well, pharmacy required clear communication and teamwork since fulfilling a single order requires the runners, the counters, the lablers, and pharmacy lead to work in symbiosis. The runners pulled the proper medications from their perspective bins/luggage. Then, the counter fulfilled the correct medication dosage and amount into medication bags or bottles. Following the counting of all the medications associated with a single order, the interpreter would then print labels in Spanish with the name of the patients, medication, and instructions and information for proper use of each medicine. Finally, the pharmacy lead, who was the nursing professor, would verify the order and ensure that each bag contained a dental hygiene kit and age/gender-appropriate vitamins.