International-Disaster Medicine

Orientation and Travel to Christchurch

2009-08-29T15:03:00.000-07:00

Orientation was what you might expect: lots of folks giving often-repetitive information. The travel briefing was excellent! To the point with the exact stuff we need to travel. The other talks were on safety, safety, safety, and ecological protection and human resource behavior for supervisors.

A very useful aspect of the orientation was that I got to meet many of the folks I’ll be working with on the Ice. Nice folks.

Finally, the orientation ended and we boarded busses to the Denver Airport. Standing in a very very long line, American Airlines did a nice job with our group check-in. That was important, since our bags were being checked together (and bonded) so that they could go straight through to Christchurch. That saved us a lot of hassle schlepping our bags from place to place at various airports.

Flights were all on time, although the waits at Denver and LAX seemed interminable. After 14+ hours on the Quantas flight to Sydney, we had less than 1 hours on the ground before boarding another flight for Christchurch. However, since we didn’t have to go through customs or immigration there, it seems like we all made it.

Now we’re in Christchurch. Weather sucks. Winter, overcast and drizzly. I did pick up the shirts I had made with the McMurdo medical logo.

This evening, I went to dinner at Dr. Rob Sweeney’s home, our New Zealand doc for when we have to MedEvac folks off the Ice.

Tomorrow, I go to CDC (Clothing Distribution Center) to get my flu shot and my ECW (extreme cold weather) gear.

Arrival in Christchurch was simple enough, until after passing through the immigration, customs and biosecurity (for unwanted plants and animals) screenings, I was suddenly pulled out of line “at random.” Fortunately, the fellow erred in thinking I was with another group. When he discovered I wasn’t, he let me proceed to the waiting shuttle.

Then to the Crowne Plaza.

Nice big place right in the middle of town. And, what a quaint town it is. It’s been described as the most English town outside England. I’d agree.

Even the Avon River winds through town and, like some English university towns, they often punt (use a pole-powered open boat) on the river. However, it’s really cold here; I didn’t expect that.

The first evening, I was kindly invited to Dr. Rob Sweeney’s home for dinner. He’s the liaison physician and works closely with Leeann Stringer. Great homemade pasta dinner and, for “dessert,” a tour of the Christchurch Hospital ED. Looks like any modern Western ED, so should do nicely.

The next morning, I walked around the central city, stopping in a couple of places for bites to eat. That’s not a doughnut, but rather a bagel with lox (smoked salmon) and a coffee mocha. Nice presentation in a very small coffee shop.

At noon, we went to the Antarctic Center’s CDC (Clothing Distribution Center) to get our ECW (extreme cold weather) gear. It was complicated enough to need a video to further confuse us. However, Todd, a heavy equipment supervisor and long-time Polie was kind enough to personally guide me through the process. Lots of switching gear until I got the right stuff—blue boots, larger pants, a pair of heavy mittens and, at Georg Bakker’s suggestion, also a lightweight jacket.

I then had to retake the computer security on-line training. Apparently, doing it once about 5 months ago wasn’t sufficient. Then, I met with the incoming station manager, Don Brogan. Great guy! We’ll be working closely together. We then met with the overall New Zealand manager who will be coming down to the Ice in a few weeks. He invited me to dinner along with Gary, our USAP air boss. We first ate at Valentinos and then went for a decadent dessert around the corner at Strawberry Fair.Both were excellent, as I knew they would be; Gary has been “doing” Christchurch and New Zealand for 18 years.

Then, back to bed for an early morning call (2 am wakeup) for our flight. I packed up, went to the lobby with all my gear, checked out and, just as Don drove up in his car, we received notice that the flight was postponed for 24 hours due to weather on the Ice.

Back to the room and, at 8am, breakfast with Don and Gary. After going to the Antarctic Center to pick up our per diem and do some work, we set out for some sightseeing southeast of Christchurch. Fantastic scenary surrounded us as we traveled first to Governor’s Bay. There, we stopped at “SheChocolat” where I had a mocha coffee—with a chocolate spoon made from their homemade chocolate. We then proceeded to Arakoa, an old French whaling village where we had lunch, walked around the quaint and quiet tourist town.

The next day was similar. Our flight was cancelled again, so after work at the Antarctic Center, including a conference call, we set out for New Zealand’s west coast. Quite a ride over some very windy roads. Beautiful! And, after stopping for a snack at Arthur’s Pass where we spotted Kea, a mountain parrot, we continued on to Greymouth. Great pizza was followed by a coastal trip near sunset. For anyone who has visited Bryce Canyon in Utah with its amazing rock formations, this is even better. It has both the rocks and the sea. We didn’t get back until

about 10:30 pm. But, I was sure that we would be delayed again. Wrong!

Arising reluctantly at 2am, I struggled to get my bags ready, get dressed and get downstairs. Yes, we were going. So we went to Denny’s for breakfast and proceeded to the CDC to change into our gear, repack our bags and get processed to take the flight. My bags were somewhat over the limit, but the tolerant Kiwis running the show were lenient when I explained that I was carrying some medical gear. (I was.)

We all checked through to the waiting area, viewed an instructional video, and finally boarded busses for the short trip to the C-17. Don Brogan was interviewed (above)by New Zealand TV. “Catering” on the flight consisted of being handed a bag lunch as we boarded the plane’s stairs.

With about 142 “souls” on board, we occupied both seats along the side of the plane and some airliner seats in the center. Of course, we were packed into the giant plane along with a considerable load of cargo—including our bags.

Surprisingly, the plane was really not very cold, so we removed most of our ECW for the 5-hour flight. Sleep was the main activity. We needed it, especially since the general feeling was that we would probably get “boomeranged,” turned around to return to Christchurch due to bad weather. Wrong again!

Five hours later our C-17 landed smoothly at McMurdo’s snow-covered (actually packed snow) Pegasus runway. We donned all our cold weather gear, collected our carry-on bag, and walked out onto the Antarctic continent.
The famous “Ivan the Terrabus” was there to carry many of us (me included) to McMurdo Station. The trip only took about 25 minutes. I later found that the journey had been abbreviated because we were able to take a shortcut road across the sea ice—a road cleared on frozen ice over the ocean. The Terrabus got us to within 50 yards of our destination, Building 155, before it died. It is now in for repairs and we went in for orientation to McMurdo and room assignments.

Getting Ready to Go (Way) South

2009-08-17T22:30:00.000-07:00

Tuesday, August 4, 2009. Having arrived in Denver for my pre-deployment orientation and meetings, I boarded the shuttle from the Staybridge Inn to Raytheon Polar. We arrived at 7:15 am and, surprise! We couldn’t get in, since the security person that had to “badge” us doesn’t arrive until 7:30. However, this gave me time to talk with Daisy Hoffert, our PA for the summer season. She’s now working at a prison and previously worked in EDs and ICUs.

Today was a chance to not only to get a series of very interesting flight medicine/MedEvac talks by Maj. Greg Richert, our chief flight physician, but also to obtain more information about the Pole than I had been able to previously get. He has been there for 3 years in a row. So has Tara Stoddard, who is our civilian flight nurse. (Daisy, right above, our PA is with Tara demonstrating the earplugs we were given.) Great folks!

We also had some small meetings with Greg, Doug Freer (below, left, a just-about-retired Navy Captain) who is the Raytheon’s polar Medical Director, and Leeanne Stringer (below), our New Zealand nurse contact for evacuations to and treatments in Christchurch. We had lots of discussions about preventing and dealing with flu, especially H1N1, for which we don’t have a vaccine as of yet. These would continue the entire time I was in Denver, with continual flu plan revisions as more information became available through the CDC.

Wednesday, August 5, 2009 This morning our group toured the insides of a C-17 and had the crew clarify some patient-transport procedures. They proved to be much easier to understand once we saw the plane and equipment. I’ll rarely have to be involved in loading these patients; it will be a very unusual situation for me to fly with them. I am the last bastion of medical care at McMurdo, so this won’t really be part of my duties. However, preparing the patients for transport will be.

I had dinner with Gerry Katz, a very smart internist/hospitalist who has served as medical director for and consultant to the program for about 20 years. He provided lots of insights on the program and my duties on the Ice.

Thursday, August 6 through Friday, August 14, 2009: Lots of reviewing protocols and employee-applicant medical charts. I’m now part of the “PQ” process. That means physically qualified for deployment to Antarctica. The requirements are rather strict, but lots of people apply for medical waivers. Some of them have significant medical problems. The question then is, do we give them a medical waiver? Three of us review the charts, generally independently. The medical director then makes a recommendation and passes it on to the NSF medical director.

We had weekly conference calls with Palmer Station (opposite Punta Arenas, Chile and Ushuaia, Argentina), the South Pole station, and McMurdo. Kind of unbelievable that we’re talking with folks in Antarctica!
Over the weekend, Mary Lou and I had a great mini-vacation to Golden, Colorado. I’m not a train nut, but their railroad museum provides a restful stroll among lots of vintage rolling stock—and a short trip aboard a steam-locomotive-driven train. While there, I got scalped (a #2 clipper at my instruction) in an old-fashioned barber shop on the main street. My barber was 80-years old and still a sharp guy who sold tickets to football games on the side. (No, he wasn’t a bookie.)

We then had dinner with two physicians who were my residents in the first and second classes at the University of Arizona: Rick Dart and Katie Hurlbut. They’re married with 3 girls, a great home, and top-notch academic jobs. Rick has long been the director of the Rocky Mountain Poison Control Center. Katie continues on faculty at Denver General Emergency Medicine residency program.

On Sunday we visited the Denver Zoo and their Natural History Museum. (Do you know why there won't be any more bear photos until after I leave Antarctica? Of course, there are no bears of any kind there!) Compared with what we have seen in DC, Chicago and elsewhere, they leave a lot to be desired.

The second week was much like the first, except that I had meetings with a number of folks who will direct areas I have to deal with on the Ice. A highlight was that Mary Lou and I had dinner with Gerry Katz and his fiancé, Deidre. Excellent food and hospitality!

This weekend, orientation--and travel to Christchurch on the way to the Ice!

Antarctica--Preparing to Go

2009-08-02T11:27:00.000-07:00

After completing tons of paperwork—often supplying the same information multiple times—and finishing the grueling PQ (physical qualifications testing) including a cardiac treadmill test, I finally began getting information about orientation and travel.

I’ll leave for Denver on August 3 to get training on aeromedical evacuation using the Air Force planes that we use to transport folks and material to and from “the Ice.”

I’ll then remain to be oriented on the multitude of administrative details that accompany the job of McMurdo’s Lead Physician. We’ll also, presumably, go over the plans for preventing (a dubious effort) and dealing with flu epidemics at the various Polar stations.

So, what has been the most onerous part of this ordeal? The packing. Although the details keep changing, it appears that we have a limit of 75 pounds of stuff we can take with us for the 6+ months. And, that is reduced by about 22 pounds for the ECW (extreme cold weather) gear we are issued in New Zealand. I’ll be taking stuff for Denver (Mary Lou will be up there part of the time and take most of that back to Tucson), stuff to have as cargo on the plane with me to the Ice (if it doesn’t get bumped), stuff to carry on (computer, ECW gear, camera, “bounce-back bag” in case our plane has to abort due to weather or mechanical issues), and stuff to mail to myself from Christchurch (CHCH, or “Cheech”). Some of my gear, such as my roll-aboard, I’ll leave in New Zealand for when I return.

Well, the adventure begins—tomorrow!

Project HOPE: USNS Confort Continuing Promise-09

2009-08-02T10:23:00.000-07:00

The following very loooooong description is a nearly day-by day chronicle of my time as the Project HOPE Chief Medical Officer aboard the USNS Comfort's Coninuing Promise-09 mission.

The following is a brief summary of the times and places in which I participated. Before I joined them, they had already visited Haiti and the Dominican Republic. I joined the ship just as they were departing "DomRep" on their way to Antigua. This was their preliminary schedule. We did more in Nicaragua and less in Colombia--for both political and security reasons.

St. Johns, ANTIGUA: May 5-16
1. Multicultural Center: 5/6-15 (100 to 70 providers; 500-700 patients/day)
2. All Saints Primary School 5/8-11 (30 providers; 3-400 pts/day)

Cartagena, COLUMBIA May 20-23
R&R Only

Colon, PANAMÁ May 24-June 2
1. Gimnasio Puerto Pilón (13 Gen/Ped; 5-600 patients/day)
2. Roberto Mariano Bula Stadium (8 Gen/Peds; 700 pts/day)
3. Escuela Efraín Tejada (4-500 pts/day)

Tumaco, COLUMBIA June 6-17 (Incomplete info)
1. Hospital San Andres de Tumaco
2. Hospital Divino Nino
3. Reverine Battalion 70 Base Hospital
4. Caprecom Gen Medicine

La Unión, EL SALVADOR June 21-July 2
1. José Pantoja Hijo Escuela (June 22-26)
2. Centro Escolar “República de Argentina” (June 22-24)
3. Hospital Nacional de La Unión (Teaching; June 22-July 1)
4. Centro Escolar Cantón Loma Larga (June 25-28)
5. Escuela Ramón Mendoza (June 27-July 1)
6. Centro Escolar “El Carmen” (June 29-July 9)

Corinto, NICARAGUA July 3-14
1. Hospital Espana (Chinandega) (July 4-14; 600 pts/day)
2. Clinic Raymundo Garcia (Somotillo) (July 4-14)

Project HOPE: Antigua/Barbuda

2009-07-23T14:23:00.000-07:00

Project HOPE
USNS Comfort hospital ship
May 1 to July 14, 2009

What an experience! The following documents my timeworking as the Project HOPE Chief Medical Officer aboard the USNS Comfort, one of the US Navy’s two hospital ships.

For 2 ½ months, I sailed to various sites to help provide medical care during their Continuing Promise-09 mission.

I left Tucson on Friday, May 1, for Santo Domingo, Dominican Republic, to join up with the USNS Comfort, that had already provided medical care in Haiti and was just finishing in the Dominican Republic. Things went smoothly until I got to Santo Domingo. While I successfully met up with another teammate, Jane Bower, RN, who was also from Tucson but was coming from visiting family on the East coast, but the Navy did not show up at the airport.

Flights were good. However, no one picked us up in Santo Domingo and we had no clue where to go next. So, we tried to call the US Embassy emergency number, figuring they could contact the ship; no answer! We then went to the embassy. Not helpful. Finally, we asked the driver to take us to "the Marriott," where we knew the LDS volunteer team had gone. Right brand; wrong hotel. They had actually made reservations for us at the upscale Renaissance Marriott without telling us. So, the Navy went to the wrong place the next day to pick us up. Unfortunately, the snafu cost them an on-time sailing; they are making it up en route to Antigua (pronounced "Antiga").

When they finally found us, we were successfully transferred via “hospitality boat,” the ship’s primary people mover that we would all get to experience multiple times in the future. While I was locating my berthing, we got underway. (By the way, “USNS” stands for United States Naval Ship—meaning a ship sailed by government-employed civilian sailors from the Military Sealift Command.)

Being "at sea" from Saturday May 2 until Tuesday May 4 gave me plenty of time to explore the ship, which I describe below:

Saturday, May 2 and Sunday, May 3:
The ship is HUGE! I'm slowly figuring out how to get around. They let us have free run of nearly the entire ship. The Medical commander, Captain James J. Ware, gave me a personal tour. I was added to the small ship's executive committee (EComm) and we just had our first meeting on Sunday, trying to meet Antigua's last-minute credentialing requirements.

Everyone on the ship is really nice. The Project HOPE people are amazingly helpful. Some will be with me the entire trip. The other three groups are military (US Navy, Army, Air Force and Dutch, Canadian, Dominican Republic, etc.), the civilian mariners who actually run the ship (Military Sealift Command or MSC), and some other NGOs (Operation Smile in Nicaragua, LDS, some folks from UCSD, etc.).

There are so many senior officers that I bunk with 7 others. However, the bunks are wide and comfortable and there is a large anteroom with a lot of locker space. I could unload all my stuff and have room left over!! Women officers’ quarters are one deck down.

Food is plentiful, but it takes some knowledge to know where to get the stuff you want. Sometimes it's in the officer's mess; other times it is 'around the corner' in the general mess.

There are 3 gyms on the ship with lots of equipment. While only 1 exercise ball, there are lots of treadmills and exercise bikes. The "heads" (bathrooms) and showers are fine--when they work.

Sunday we had an at-sea replenishment. That means there were both air (helicopter) transfers of huge pallets of materials and food (called “VertRep” or Vertical Replenishment), and ship-to-ship transfers (using hoses) of jet (helicopter) fuel and ship fuel (called “UnRep” or Underway Replenishment). More than 500,000 gallons passed between the two ships. The next time we did this, off Colombia, I helped with the lines for the UnRep. Also, I attended 2 hours of CME-credit programs. These are ongoing, so I should be able to attend quite a few.

Monday, May 4, morning:
Today is one of the few 'down days' while we're on the ship. I (as of now) only have 2 meetings (med exec committee and the briefing for Antigua) and 1 ("man overboard") drill. Only 2 meals: "brunch" at 10:30 and a "steel beach picnic" from 2-7pm. No 6am reveille and no patient care. By the way, reveille, the wake-up call for the ship, is simply an announcement over the loudspeaker: “Reveille, reveille! All hands heave out and trice up! Reveille!. . . Breakfast for the crew!”

Yesterday, I think I must have traveled the length of the ship (900 feet) several times, often going from the bridge to the "basement" level. Quite a workout.

Monday afternoon:
Today (the "down" day), I had a med-exec meeting at 11 am, a "muster" and abandon ship drill at 1 pm, another med-exec meeting right after the drill, and another one at 6pm. We are trying to get everyone's credentials in order for Antigua. The photo on the left is some Hopies at the drill on the flight deck. "Covers" (hats) and long-sleeve shirts required.

Apparently, tomorrow we anchor in the harbor at St. John at 7am. Some folks--especially the surgeons-- will go ashore to talk with the local medical folks about follow-up for any surgical patients.

Tomorrow is also the first wash day for us. We get to use the washers for two 24-hour periods a week. I bought some high-energy 2Xultra Tide, which is the only one you can use. We'll see if I try it out tomorrow.

The folks on the boat are great. The physical therapist gave me my first lesson in how to do cervical spine manipulation. He promised to teach me more stuff. Should come in extremely useful at McMurdo Station.

I'm going out to the "steel beach picnic" in a few minutes. However, for the first time, we have hit a squall--so it's wet and cold. Too bad!"

Note that communications have been spotty while we were at sea. Only a satellite phone and intermittent internet connections. Hopefully, it will improve when we are in port (it didn’t). The internet connection is verrrry slow in the ship's internet café reserved for NGO personnel. Due to security concerns, it also has no SKYPE connection. When the phone connections are working, I use a very expensive ATT calling card to make calls from the ship.

Antigua/Barbuda

Tuesday, May 5, 2009:
The officer's mess is around the corner (literally) from the general mess. If I need relative quiet, I eat there. Or when I need some soda when the other mess is closed. Otherwise, I eat with everyone else--so does the commodore.

No, my cruise is not luxurious, but interesting--at least to me. Today was pretty much all meetings, so I only have walked ~10,000 steps, so far.[I had a pedometer with me.] The meetings included the department head meeting, the Commodore's brief, the teleconference with the Panamanian preplanning team, and a couple of others. I'll run one of our few formal Project HOPE meetings this evening.

Tomorrow, I am assigned aboard ship. One of the Navy docs told me that, since they considered this a "marathon," they gave us these "down days" so as not to wear us out. We are, however, on tap if something goes wrong or someone is needed elsewhere.

Wednesday, May 6:
Good morning! Not much new this am. I'm aboard ship today and did "rounds" with our nurses on the various wards. All okay. We’re already planning for our “liberty port,” Cartagena.
We have to follow DOD and Navy rules about shore leave, which means only staying in specific hotels, staying within a certain area, and “buddying up” in groups. We won’t make Cartagena hotel reservations yet, since plans may change. They're worried about our acquiring a case of swine flu (like the USS Dubuque in California that was also supposed to have a HOPE mission on board). If that happens, everything stops and, I think, we're quarantined for a while. We'll see.

In the meantime, the first group went ashore in Antigua to do screening for potential surgeries and to start seeing medical folks at the clinics. I think my first day for that is on Friday.

Wednesday, evening:
Of course, I read the schedule wrong. Someone pointed out that I'm actually going to be working clinically on shore tomorrow. I'm off on Friday.

My schedule, as far as I know it is: tomorrow "on the beach" i.e., doing clinical work at the "multicultural center" clinic site. Friday, I'll be helping a USPHS Captain and former cruise ship inspector for the CDC do a public health inspection of our ship. Saturday, back on the beach/clinic. Sunday, I'll be helping teach ACLS at St. John University. So, I'm keeping busy.

While we refer to "going ashore" as "going to the beach and the beach does look very nice, we can't really go to the beach for recreation when we are ashore working. The DOD requires that we stay at our assigned location, and even have to stay there for lunch. We take lunch (MREs) and water with us every day when we go ashore. There is a lot of waiting (below) to get on the boat going ashore. This continued the entire voyage--except in Colon, Panama, where we were tied to a pier; there we waited for ground transportation.

Thursday, May 7, evening:
I'm just back on the ship and had dinner. Saw about 25 patients in a shortened day today. We tried to use a ferry as a launch to shore, but it came late and we didn't arrive at the site until after 9:30.

The clinic is a large “multicultural” building in which we are able to place all of our medical, surgical, optometry, dentistry, pharmacy, radiology, and support (communications/administration) functions. It is also air conditioned and relatively bug free. We use curtains to cordon off each clinician’s “office.” What I didn’t realize at the time was that this was, by far, the most upscale facility we would be in. Thanks to the Chinese government for building it.

When we were finished and ready to return, we got back onto the “party boat” and proceeded slowly into the channel, at which time the ferry lost power and started drifting. So, the trip back to the ship took nearly 2 hours! Again, we didn’t appreciate how comfortable and dry these transfers from ship to shore were until we got to our final three ports.

We had an evening briefing at 7pm and a medical “hotwash” at 8pm. Long lines at the phones prevented me from calling home.

Friday, May 8:
I'm “on the beach” the next 5 days. Tomorrow clinical. Sunday teaching. Monday through Wednesday (at least) clinical. I finally found the gym with both weights and the big ball. I did most of the exercises that Laurie Rain (wife’s trainer) gave me--but probably not all.
Today, I did laundry. Even putting stuff in the dryer, it took about 3 hours! I had done shirts previously in the sink--which worked well. That was my method from then on.

An interesting thing happened today. A couple of the younger physicians stopped me yesterday as we were going onto the beach. One asked, "Are you famous?" I answered, "Yes." Then they figured out that they had read "Getting into a Residency" when they were applying to residency.
Weather nice and about 85 degrees. Humid and occasional rain, of course. Despite the problems with the commercial "ferry" yesterday, it seems to be working now, so we will have a slow, but dry ride to the shore.

Food is very good--as long as you don't eat the fried stuff. Air conditioning, especially down in the officers' berth where I live is excellent. Kind of smells like a dorm, which you'd expect and is no problem. Everyone makes an enormous effort to keep everything clean and respect the light and sound needs of everyone else. And, since I have both ear plugs and the great eyeshade, and my special pillow, I sleep very well.

I have a 4:15 am wake-up call tomorrow. We're seeing about 1,000 patients/day at two sites. Very few pediatric providers, so I'll be a pediatrician again tomorrow, I imagine. As it turned out, I was a “pediatrician” for the rest of the trip. Kind of nice, since I will next be going to the only continent without children—Antarctica.

Saturday, May 9, at 9:30pm:
Finally got back and got dinner. I saw about 45 children today.

They speak English here, so communication is generally not an issue—unless they are immigrants from Latin American countries. I am on shore also tomorrow (teaching ACLS at the St. Johns University), and working at the same crowded site Monday, Tuesday and Wednesday.
I'm not sure what time our boat leaves tomorrow morning [To go ashore]; I suspect about 5:30 am.

Sunday, May 10, evening:
I got through to Mary Lou on the phone, but it went dead after 30 seconds. Bummer about the phones. They all went dead at once. The funny thing was that I looked down the bank of telephones and everyone was just staring at their handset—as if they could make it reconnect. Also, the other computer system went dead; the router or something.

Today we arrived at about 7:00 am at the University of St John, but the class didn't begin until 8:30. Since there was a beautiful beach there, we walked along it in the surf. My convertible pants really were useful. [They zip off to become shorts.] Apparently, the educators did this routinely, but didn’t tell anyone else about their beach time.

The ACLS class was mostly Antiguan doctors. They were very appreciative of us being there and really liked the class. I gave the two lectures and we all then did the break-out sessions with the manikins. After the class, we dropped the manikins off at the new, Chinese-built hospital. Quite nice. (The Chinese government has spent a lot of money in the Caribbean!) We then went to the pier to await the local commercial ferry hired to take us back and forth. We waited two hours. At least the ice cream place was open. The trip back then took 1 hour! I slept part of the way back.

There was a mothers' day dinner but, unfortunately, many of the mothers on the HOPE team were still on the ferry. They were not pleased. Same for the military women who missed the dinner. Very sad.
I'm working all day on Monday, Tuesday and Wednesday. Probably won't be back on the ship Wednesday until at least 6pm--probably much later. I'll try to call home tomorrow, but the line for a phone is usually 1/2-hour long in the evening after we return. If I can't call, I'll at least try to get onto a computer and write.

Tuesday, May 12, evening:
No way I could wait for the phone tonight. Saw about 45 kids; then they decided that since peds was almost done, I should switch to seeing adults. I got back to the ship just before 7pm. At least dinner was still available.

Saw several cases I referred to surgery today. Circumcision, deep foot foreign body, and a hernia. I also diagnosed (new) a case of autism, some interesting dermatology cases, scoliosis, temporal lobe (partial) seizure disorder, etc.
Thursday May 14, evening:
Today I finally got to move to a bottom (much more desirable) bunk. Big change in crew over the next week. I'll be keeping this bunk for the duration.

I saw about 50 pediatric patients yesterday. Saw some very interesting cases among the not-very-sick "well-baby" or "cold" or "general physical exam" checks. However, this won't continue. I suspect the patients will become very sick as we move along in this mission. Tumaco, Columbia is supposed t

o be about as bad as Haiti. I have one more clinical day here tomorrow. While I haven't seen a lot of the island, I sure have seen and gotten to talk to lots of the people. In reality, I think this is better than visiting the island--although a little time in a resort (Sandals is here) would be nice.

Friday, May 15:
Last day today in Antigua. Some interesting stuff and, I helped some people who would not have been otherwise helped. For example, I got a wheelchair for a 9-year-old boy with severe cerebral palsy, but who was awake, alert and a very happy guy. A girl who came in for a "check-up" had had two prior open-heart surgeries and had a loud murmur. I got her an echocardiogram and consultation with our cardiologist. I diagnosed another partial seizure disorder in a child and prescribed medications.

As soon as we were done with pediatric patients, they switched me to adults; my first patient was a 35-year old guy who had become a quadriplegic in 1991 from a car accident. I was able to aggressively treat his infections with our injectable antibiotics and give his very good caretaker parents medications to use at home. We got out of there about 3 pm--the earliest yet, so they could pack up and be ready to get stuff back to the ship.

The bottom bunk thing didn't work out too well. I awoke at about midnight and couldn't breath. I was nauseous and only could smell mold. I went into the passageway to get some better air. When I returned, I moved into my old top bunk--and slept well. I asked our ship's environmental expert to check out that bunk. There may be a problem.

We weigh anchor tomorrow at about 11am. Then a relatively peaceful trip over to Cartagena. There are many fewer military personnel aboard and only about 7 Hopies [Project HOPE people]. Life will be fairly calm. The military folks, Hopies, and other NGO folks are getting along great! Really a nice environment.

Now, off for some "liberty" in Cartagena, Colombia; then to Colon, Panama, the Canal, and the rest of the voyage.

Project HOPE: Cartagena to the Panama Canal

2009-07-23T14:22:00.000-07:00

At sea to Cartagena, Colombia

Saturday, May 16, early morning & noon:
I'm again in the midst of doing my laundry. It's almost 6am and my clothes are in two dryers. We're about to go to sea toward Cartagena.

[Then, later: ] It's 11:10am and we just got underway for Cartagena, exactly on time. According to the weather briefing this morning, we expect pretty rough passage and low ceilings with intermittent rain. No problem--big boat!

It's exciting that the Cartagena liberty will be just as I expected. Hope there will be good weather there. But, who cares?
I got a somewhat unexpected package from a departing Hopie this morning. It was a jar of gefilte fish, a box of egg matzos, and a can of chocolate macaroons. They're left over from Passover. (The macaroons were excellent, the rest was just okay. But, they came from a Navy source originally.)

I also did my laundry at 5am, since it was less crowded than otherwise. Still, lots of folks down there. The process is to put the stuff in the washer (it shows you the amount of time for your settings) and go exercise. I did Laurie's exercises plus a few minutes on the spin bike. Last night I "ran the ramps," a favorite exercise on the ship. These are loading ramps that go from the waterline up 7 stories. They're used to load cargo, but especially patient litters in a mass disaster. Quite challenging. I could do two ups and downs. Hopefully, this will improve over time.
Anyway, I went to my meetings from 7:30 to 9:30. The rest of today is pretty free and tomorrow is a "holiday" schedule, so no meetings.
One other thing: We'll be changing our clocks in the next couple of days--probably Monday--so that we are only 2 hours different from Tucson for the rest of the cruise.

Saturday afternoon, May 16, 2009
We just passed St. Kitts and Nevis. Seas aren't bad right now. We'll see what happens.

Sunday, May 17, 2009 6am:
I slept in until about 6:15. Then I went to run the ramps. I'm now up to 2 1/2 laps. Each lap is 12 ramps. They go from the waterline to the flight deck. I think it's 6 stories high.

They gave me access to the Navy computer/internet system, since the leadership was frustrated that they couldn’t send me things through the ship’s intranet. Much faster than the NGO lounge computers. Now, I'm using a computer in CASREC (Casualty Receiving) that the nurses use when we have patients. Better keyboard and very convenient, since the ramps take off from CASREC. This is also where we go to get onto the boats (hospitality boats or rented party boat) we use to take us to shore. We also pick up our water and MRE for the day here.

Today is holiday schedule, so we don't have brunch until 10am. We have to "muster" to take account of everyone on board. That won't be until 1 pm. Then, man overboard drill (photo right). Very laid back. No meetings. Tomorrow is also not too bad. They decided to change the clocks back tonight, so we get another extra hour sleep.

Tomorrow is also a "Safety Stand Down" day where we will review safety procedures, have the mandatory fire and man overboard drills. Generally, no stress.

Our berthing is almost empty. Major Dave Polston (non-medical, but planning to go to PA school next year) remains aboard. Great guy!

Also, we only have five Hopies on board. Three leave in Cartagena and we will get others. I assume that the pediatrician will bunk with us. He will be the only other guy among the Hopies. (Surprisingly, he didn’t. He was given a bunk in a different berthing.)
We'll have 27 Hopies in the next rotation (assuming everyone shows up). Quite a mob. I'm working to memorize their names. We'll have a woman general/trauma surgeon, Sharon Weintraub.

Sunday, 10am, still somewhere at sea:
Just had brunch. Strange. [this is what was on the buffet] Eggs, meatballs, French toast, cookies, hot dog rolls, and salad. We did have hot sauce on the table at every meal; that made their eggs tolerable.

Monday Morning, May 18:
Semi-busy day. We had "muster" at 0730, a short briefing at 0815, a "safety brief" coming up in a few minutes that will last an hour, the fire/man overboard/abandon ship drills, a departmental safety brief at 1430, a general brief at 1900 (photo left). In between I'll continue trying to write the Zambia paper.

Monday afternoon, May 18:
Earlier this afternoon, several of us went on a tour of the engine rooms (plural), including the drive shaft for the ship's single screw (propeller) and the aft steering area. It was over 100 degrees, 100% humidity, and noise that would make a rock band suffer. We were given ear plugs, however.

Monday evening, May 18, 2009:
I just tried to call you, but our phone system is dead; everyone is very frustrated about that.

I'm giving a rabies talk tomorrow along with the videos. I checked them out on my computer, and they work. (The movies wouldn't project on the LCD screen, so the audience crowded around the laptop to see them.)

Did I tell you that we had crab legs for dinner? Kind of mirrors the Katrina experience--except that I have a much better place to sleep here. . . . continuing exercises. The ramps are hard.

Tomorrow will be less intense, since there isn't much to do except prepare for Cartagena. We're also gearing up for Colon, Panama. The infectious disease guy here has worked out nice plans to protect us [from H1N1] and contingency ("branch") plans in case a staff member gets ill. I think they'll probably work out well.
Now, to bed. I'll try to call tomorrow. Hopefully, ATT will have the system working.

Tuesday, May 19, morning, still at sea about 9 am:
Good morning! I've been up since 5am (alarm clock) to run the ramps, shower and eat breakfast. We've already had two meetings and I am off now to give my rabies talk. It's in "2 aft" at 0930. Lots of Navy lingo I have to learn.

We won't be ready to disembark tomorrow until at least noon. We'll anchor about 0930, but we need to bring a barge alongside to use for the small boats. Then, another safety brief. Finally, what they call the "Liberty Line," where everyone lines up to get checked off and sign additional forms before they can leave.

I have 21 new Hopies coming aboard in Cartagena. At least I won't have to orient the new ops officer, since she was a Comfort ship's officer up until a year ago when she retired.

Tuesday night, at sea:
Lots of meetings today. Briefs about Cartagena, of course. Also about Panama and Tumaco, Colombia. It seems that the water may be so rough outside Tumaco that we will only go in every three days and RON (remain overnight) at, from the photo, is a very nice motel--very new. (Wow! Can photos be deceiving!) We'll then rotate back to the ship and a new group will go out. May be similar in El Salvador.

I plan to rest tomorrow evening. The next day, photos of the old city. The next morning, I'll return to the ship, stow most of my stuff, and go on the dive trip. We leave from the ship. That's all for tonight.

Wednesday, May 20, late morning:
The computers went down again last night, so I couldn't use them this am.
I changed some money on the ship and will be off around 2pm to the shore. I have to be back for an 8am "call away" on the ship on the last day [Friday, May 23] to go on the dive trip. Everyone is at the Hilton and will be coming back for it also. More from Cartagena if I can get an easy connection.

Wednesday evening, Cartagena, Columbia:
Unbelievably, there have been no phones that I could use with either my calling card or credit card in Cartagena--so far. I'll look more tomorrow. In any case, even if I have to pay the exorbitant Hilton rates, I'll call you tomorrow. The phones on the ship were down when I wanted to call you before I took the boat to town. [ Mary Lou ended up calling me at the hotel. Her rates were cheaper than Hilton's.]

The whole going to town bit off the boat was, as expected, confusing. However, we finally got on the speedboat they rented, since one of their boats broke down. It was a fast, 10-minute trip. Then we waited another 10 minutes in the steaming heat for a van to pick us up. We thought it would only take us to the gate of the Colombian Naval Base where we landed. However, the instructions were to take us directly to the hotel. Neat!

We checked in on the lounge floor, in the lounge. Nearly the entirety of both of these floors is taken up with Comfort officers. However, I started talking to a couple next to me in Spanish. The woman, actually, was from New York. But, in Spanish, it turns out that she is a VP at Jackson Memorial Hospital in Florida. I mentioned that I might contact her to send the hospital a "gratis" child who might need heart surgery in Tumaco, Colombia. (That, unfortunately, never materialized.) Since we saw two in Antigua, this is almost a certainty. Who knows what will happen; but, it's a great option. The man, who spoke limited English, is Colombian and in a medical type company. I asked him if he could supply free translators for us in Tumaco. He said he probably could and would contact me; we'll see. (Again, no luck.)

I then took a cab into the old walled city. It's about 10 minutes away. But, the one neat thing we were briefed about was that all cab rides in Cartagena cost $5,000 pesos ($2.50). I tried to go to the Inquisition Prison, but it was closed for repairs today. It will be open tomorrow. I'll go tomorrow afternoon. Tomorrow morning, I'll go to El Castillo, that is the #1 tourist site in the city. Of course, it is outside our permitted travel area, so the Navy has had to arrange a special tour for us.

I was invited to a military-military (US-Colombia) social event, but my clothes wouldn't work at this formal function: boots, work clothes and Proect HOPE shirt.

Thursday afternoon, 4:30 pm
As I'm going on the dive trip, I'll be leaving the hotel quite early tomorrow. If the phones work on the ship (they haven't been working the last two days--nor has the internet), I'll call you from the ship after the dive trip. We leave early the next day for Panama.
We visited the castle and El Palacio de la Inquisition today. Fair. Ate lunch at a very nice (and well air conditioned) restaurant.

Saturday, May 23, 9:30 am:
All the phones on the ship have been down for about 18 hours and the internet was also down. The internet went up again, at least temporarily, while I was waiting. Surprise! I can send you a message.

New crew aboard. Very nice group. The new HOPIE Admin Officer, Tracey Kunkel, is really pleasant and, of course, knows nearly everyone on board.
We also got a real chef (white hat and all) who teaches at a big school. Unfortunately, for his first meal, we ate hot dogs off paper plates in stifling heat and no air. (Unfortunately, he lasted only a couple of weeks. He broke his arm and had to leave the ship.) The main generator went down on the ship. The ship is really old. It's back up; and the air is moving again.

I have a meeting in a few minutes as part of the medical executive committee that approves credentials. This time, we have all the Hopies' credentials--I think.

Saturday evening May 23:
I tried to use my AZ email connection and it shut down. I then tried to call you and the phones went dead, apparently moments before I arrived to use them--the people were still staring at the handsets. I think there will be some repercussions, since a Navy Captain was on a call with his home when they died.
I'm really tired today. Probably a combination of the diving and shepherding the new folks through the system. I still have a 6:45 (1845), 7pm (1900) and 7:30 (1930) meeting; then I'll try to go to sleep. We arrive in Colon, Panama tomorrow morning at about 7am and then begin working very early the next day.

Sunday May 24, 2009, morning:
I haven't looked outside yet, but I think we are in Colon, Panama. Got a lot of sleep last night. Today is more meetings and, I hope, time to work on the book (“Improvised Medicine”) chapters.

I'm not sure when this message will get out. We were told that the Internet and phones are down--again. It seems like they are down way more often then they are "up."
Off to breakfast now. More later, assuming that this goes through.

Monday: May 25, morning:
We are at a cruise ship pier and we have "mini-liberty" in the evening. Almost all of it was closed yesterday evening, but it contains lots of shops, 3 bars, restaurants, etc. they will be open beginning this evening for us until 11pm.

I was off today, and visited the pier, where the surgical staff were having the screenings for patients who needed surgical procedures done on the ship. Communication was up and down most of the day.

Monday afternoon, 1 pm:
It seems that I will be giving a tour and a talk (“Medicina Improvisada”) to a group of Panamanian emergency physicians on board on Wednesday afternoon. The lack of internet and phone access is becoming almost a joke around here. It’s been down far more than it’s been up.
Not much else happening. I'm out at the site working tomorrow. Probably will mostly see kids. They'll probably be sicker than they were in Antigua, but I'm awaiting feedback from the folks who were out today.

One of our new Hopies is Daniel Fieth (at right), who will be filling in as public affairs officer for a short bit of the trip. Actually, he is a budding lawyer, who will enter Yale in the Fall.

I wrote the following as part of my daily report to Project HOPE: May 25 SitRep: Jumping into the fray, the surgical section of our Hopie team, including general/trauma surgeon Sharon Weintraub (photo, right), began carefully screening patients for potential surgeries aboard the USNS Comfort in the coming week.

Conducted in a makeshift on-pier clinic in a covered area alongside the ship, the team screened hundreds of patients for a variety of surgical procedures. Adding to these surgical patients was the cadre of Hopie nurses and physicians working at the on-shore clinical sites distant from the ship. Departing the ship at 5:45am, they worked steadily through the day, delivering healthcare to needy pediatric and adult Panamanians.

Tuesday, May 26, 5:30 PM:
Wow! I didn't think communication off a Navy ship would be this difficult. The phones and civilian email have been down for more than 12 hours now. I'm on the military email system and just finished dinner after being out at the "MedCap" clinic site all day. The often-crowded NGO computer room "lounge" is shown at right.

Our clinic here is rather makeshift. It is a large cinderblock room that we divide up with our portable curtains (below left).

I only needed a translator 3 times in our makeshift pediatric clinic (at left). The first time was for a word that even our Nicaraguan doc had trouble with, since they don't use it there. It is "anemia falcipara." Sounds kind of like malaria, but the mother said that it wasn't. Turns out that it is sickle cell anemia! (In other countries they use thee word “panacytosis” for the same disease. Obviously, some adjustments need to be made to one’s Spanish vocabulary as you pass from country to country.)

The second was a lady who, in a strange accent, went way too fast. I asked the translator to come by. When she repeated the same thing for her, it was much slower and clearer; I didn't need a translation--it was understandable.

The third time, I guess I understood the lady, but the story was so strange that I was sure that I was wrong. Even with the translator, it was very strange; so was the lady. Interestingly, the indigenous patients we see, such as the woman at the left from a relatively remote island, spoke good Spanish.
Anyway, my Spanish is doing extremely well. I don't have to ask the patients to slow down, only to speak louder, since the din there is unbelievable. Also, very little light, so my portable headlamp has come in extremely useful. The only good part is that there is some air conditioning. But, it is so hot and humid that it can barely keep up.

That resulted in a number of waiting patients developing heat exhaustion, that they rushed in to have me treat--along with an acute asthma attack, an MI, some patients with sycope and falls. Anyway, they recognize that I'm the emergency medicine guy and the "go to" person for these medical issues.

I'm on the ship tomorrow and will give a tour and a lecture in Spanish to a group of about 20 Panamanian docs. It was quite something setting it up, but it seems to be falling into place. Dr. Elis Gonzales, and emergency medicine colleague from Panama, worked with us in the MedCap at my request. He's not bilingual, so all our conversations were in Spanish--and no problem at all. He's gathering the group for the tour.

The woman in the photo to the left is Kendra Dilcher, who assisted us in the clinic, in Project HOPE administration, and on the wards. She is a premed student who is both talented and charming. She should make a great physician.

It's hard to believe that I'm already on the second country (of 5) on this adventure. I really expect much sicker folks in Tumaco, Colombia than we have seen so far. We'll see. The first case today was a tragic 12-year-old boy with ichthyosis (hereditary skin condition). The photo shows him with his mother and our awesome Navy pediatric nurse-practitioner, CDR Kelley Hamon.

Wednesday, May 27, 6:30 am:
The connections with the outside world only became available again today (Wednesday) about 2 hours ago (4:30am Panama time). I'll write later.

Thursday, May 28, 4 am:
Good news yesterday. The Navy agreed to do our underwear, towels, etc., in their laundry. I put my first load out this morning. We'll see what happens. (They wouldn’t take the laundry, since I hadn’t sorted it into a bag for whites and another for coloreds. We’ll try again with two bags next time.) That will save me an enormous amount of time. I'm still doing my shirts in the sink, and that's working out well.

I had the Panamanian doctor tour group yesterday on the ship. Went well. Today, I go to the clinics. Very busy. Tomorrow, they've asked me to go to the Ministry of Health with a Preventive Medicine group to talk with Panamanian physicians again. They want me to give the short REEME talk! (REEME is the http://www.reeme.arizona.edu/ web site with >700 free Spanish language health professional educational programs for download. Most in Power Point.) Good news about that is that we don't leave until about 9:30 am. VERY late day.

Well, off to breakfast now. I had a lot of photos taken by my berthmate, a real professional photographer, Paul Kline. the photo at right is one of the few anyone was able to take of him. He's going to give me jpegs of them on a disk to use. Kind of neat. He has a 4-page spread coming out in the September “Modern Photography” magazine.

Saturday evening, May 30:
Good afternoon/evening on Saturday. Just returned from the Bola Stadium site. Lots of patients. I did organize it somewhat today, so the flow was a bit better--and we were actually able to read the names of the patients.

We saw a kid with no pectoralis (chest) muscle on one side, but there is nothing to do about that in this setting. I saw another boy with a growing (but benign) lesion in his proximal humerus. We got him into an orthopedic surgeon here, since our surgical schedule is booked solid. Also got an infant with tracheomalacia in to see a local ENT for scoping. This was done through the on-site physician from the Health Ministry.

Lots of other patients. Frequent treatment for parasites. Also we often alter kids’ asthma treatment so it is correct.

Just before we left the site today, the skies opened up. Most patients, who sit outside waiting, left. So, we got to go home a little bit early. However, they needed some additional help, so I will probably work both Monday (previously scheduled) and Tuesday morning until we close up shop.

Sunday, May 31, 2009, 5:40am:
Today I have the “day off.” That means I’ll finally get to the questions for the chapters (“Improvised Medicine”) and, maybe, the Zambia paper (didn’t happen).
This evening I am invited to a “DV” –Distinguished Visitor- dinner with an admiral/physician and the Asst. Secretary of Defense for Health Affairs and, I think, the US Ambassador to Panama. Should be good food. Actually, it was mostly the same food served in the general mess hall. Only, it was served in a little fancier style.

Sunday, afternoon :
Not too busy today. Went to the morning brief and follow-up, the 2 pm brief, a meeting with the public affairs officer (Navy), and then will go to the DV dinner, 7pm brief, 7:30 remarks by the DVs, and go to bed. I'm supposed to be able to put my laundry out tonight. We'll see what happens. I washed socks yesterday and 3 underwear today in the sink--just in case.

Monday, June 1, 4 am:
Okay. It's 5:30am here. I'm off to breakfast and then to work. We have to meet on the pier at 6:15 am.
I'll at least write you later. Dinner was great! Lobster and steak and double-baked potatoes (or something like that). Note that the crew had the same food. It was a very special dinner for everyone. The guests were the Acting Under Secretary of Defense for Health Affairs and a 2-star admiral--who called one our Hopies "Marsh" in his talk. The guy's name is Marshal Cusic, and he's a pediatrician who is also a former admiral. the other person in the photo (at left) is Cynthia Capello, our Hopie nurse-anethetist.

Some other aspects of being tied up at the cruise ship dock in Panama are not as good. While we had easy access to the pier and did not have to use boat transfers, like an RV, we had water supply and sewage lines connected from shore. Turns out that the water pressure could not support the volume of water they required, so we have a water shortage on board. Showers are "navy style", laundry was not washed, and we eat meals using plastic utensils and paper plates, etc., so we don’t have to waste water washing dishes.

Monday evening:
Two neat things today when I returned to the ship from the Clinic:
1. My wash was done and waiting for me. The darks--including the socks (I only put in two pair as a test) and the whites (including my socks) came out great! I'm not going to try using it for my shirts, although I might try it for the pants. They're way too big anyway. [We were worried that the cotton shirts and pants might shrink in hot water or the amazingly hot dryer.] The towels are CLEAN!
2. I got your care package. Great candies! I have a slight cough again. It is probably due to seeing all the kids. So, the candies are very helpful. The ponchos should be great when we hit Tumaco, El Salvador and Nicaragua.

Saw 45 patients (adults and peds) today. I'm bushed. I go out again tomorrow. We'll see whether it is a 1/2 or whole day at the clinic. Probably will be something in between. My Spanish is getting much faster, if not "better." However, my voice is a bit hoarse and the place is noisy, so it makes it difficult at times. However, I'm getting much better at understanding them, even when they talk fast. I've been helping some other "Spanish-speaking" physicians do some translations when they couldn't understand what was going on. Neat, huh?
I'm off to the evening brief. I'll go to bed immediately after that and write you tomorrow morning, if there's time. I'll call tomorrow evening if the phones are up. They're supposed to tell us the schedule for the Canal crossing tonight.

Tuesday, June 2, 5:40 pm:
Well, I finally caught a cold here. Hopefully, it will soon pass. I didn't go to the clinic today, since we screen patients away who have a cough--and I have a cough. I think it's already improving.

They shut down communications from the ship early this am. There was a death of a Chief Petty Officer and they curtailed outgoing information until they could notify the family. They call it "River City," but no one seems to know why. It seems like the 42-year-old woman died in her sleep. I think she told someone she wasn't feeling well. Her bunkmates found her in rigor mortis in her bunk early this morning. Everyone was really shook up. However, it really separated the Navy from everyone else, since the response was strictly Navy.

Tomorrow, the Canal! We are still supposed to leave at 6am and, according to treaty, have priority. It should take about an hour to take on the line handlers and pilot. So, if all goes as planned, we should start through the locks at about 7am our time--5am your time. How long will it take? Generally between 8 and 10 hours. But, it depends on a lot of factors.

Project HOPE: Panama Canal through Tumaco, Colombia

2009-07-23T14:21:00.002-07:00

Wednesday, June 3: PANAMA CANAL
Well, we did go through the Canal. On her computer in Tucson, Mary Lou saw the ship go through the first lock, at Gatun, about 4:30 am. She couldn't make out individuals though. I was on deck waving but couldn’t get a screen shot. Eventually, she saw someone she thought was me, but I was in a meeting (2 pm Main Planning Board) by then.

Wednesday, received at 9pm MST, sent at 2:30pm MST:
It's about 4:30pm. We're through the Canal and proceeding to Tumaco, Colombia.
The internet and phones have been down since early this morning (about 9am our time). They decided to do the "1-hour" process of switching to another satellite. Of course, they still can't acquire a signal. Don't know when that will occur. But when you get this, it will have happened--at least temporarily.

I went to the Tumaco planning session. The "final" word is that we will be anchored about 3 miles off shore. That means that we will both be able to make water and to discharge treated sewage; a huge help. As of now, we have no potable water remaining that is not for emergencies. Of course, we still have some sodas, bottled water, etc. Now that we're through the Canal, we can begin making water again. Yea!!

While we were in the Gatun Lake, Chaplain Dave Oravec (right), led a memorial service for the Chief Petty Officer who died in her sleep. This was a very fitting place to do that.

It appears now that all transportation from the ship to the shore will be via helicopter. As of now, the plan is for us to RON (Remain Overnight) for up to 3 days at a time before the next crew arrives. We'll see where I fall in this rotation. El Salvador is almost assuredly the same. Not sure yet about Nicaragua.

Tomorrow (Thursday) is a holiday schedule. "No meetings," although we have a credentialing meeting at 10am. Our "muster" is at 1:30 with the mandatory fire, man overboard, and abandon ship drill. I'm an old hand at this now, having gone through it twice before.

Also, laundry is tomorrow, assuming they have the water to do the wash. I need my handkerchiefs done, since I still have my cold.

Thursday, June 4, 6:30 am, at sea in the Pacific:
I'm swaying side-to-side as I type this. Seas are up and there is virtually no visibility.

Glad that we have excellent navigation radar. I hope everyone else in this sea lane also has it. Torrential rains. I suspect that the poncho package arrived none too soon.

We have water back, external communications and, hopefully, "adult cutlery" later today. It gets old very fast using paper plates and cups and plastic cutlery to conserve water. It will be good to return to the real stuff.

I'm hoping to be able to attend some CME courses this afternoon. Today, there will be two talks on Malaria.

Friday, June 5, 2009, 12:30 pm, at sea:
I thought I'd write a little about this morning's interesting activities.
As for overnighting on shore, I am not in the first group to do this. Many of us may actually go out each day via helicopter to the site. They only have about a dozen medical providers staying overnight right now. The helicopter ride each way is only about 3 miles.

So, what happened today? We are, of course, in transit to Tumaco, Colombia. That is near the Ecuador border, so it means that we were a couple of hundred miles or so north of the equator. We weren't supposed to go across the equator, since it would have taken us out of our way.
However, there was a real medical emergency aboard a US Navy vessel that required that we quickly steam to a site where a helicopter transfer of their patient to us could be made. This put us way to the west and way ahead of schedule. So, the powers-that-be requested that we be permitted to cross the equator--which we did about 4:45am today.

What's the big deal? In the Navy, this is a significant rite of passage for any sailor--and anyone else aboard. Those who have crossed the equator are permitted to participate in a ritual that changes them from "Pollywogs," generally known as "Wogs," to "Shellbacks." You only go through the ceremony once; once is enough.

Most of the folks on board, including some of the most senior officers, were Wogs. All of us were required to be in our berthing at 8pm last night. We were told to wear clothes "that could be disposed of afterward." That didn't bode well.
At 5am, a raucous din filled the berthing space as the Shellbacks rousted us all out of bed. We were quickly hustled into CasRec (the large Casualty Receiving area with an ominously red-colored floor). What followed was a procession of lots of physical exercises, hosing us down--initially with fresh water (inside the ship) and salt water (when we finally got on deck near the end of what turned out to be a 4-hour ordeal). We intermittently had flour, eggs, and other unusual items dumped on us; they concentrated these on the military folks, thankfully. After the first hour, we were trooped into the mess hall and green eggs, pink pancakes, and blue hash were dumped directly on the tray. Those who ate them said they tasted fine. I just wasn't up for them.

Then, off for more shenanigans. Basically, it was like a giant fraternity initiation. It was sort of what I expected, although it lasted a lot longer than I thought that it would. Due to really bad outcomes in the past on some Navy ships--especially the "gray hull" ships where this lasts all day, they make it clear up front that no one can touch you, no sexual harassment, and they can't make you eat anything. Oh, yes. They don't want you too near the rails outside where you might fall over. In fact, since blindfolding is a ritual part of this, the only place they did it was in the very controlled setting of the inside ramps.

The ceremony ended with being sprayed with yellow sea water, doused with flour, a few other odds and ends on the flight deck, and finally, kneeling before King Neptune and being anointed with coconut as a Shellback. Whew! I could barely stand up when it was over and, actually, just awakened from a 2-hour nap. That's the first time since I've been aboard that I was in my rack during the day. Of course, that was after lunch--hot dogs and hamburgers.

I'll be receiving both a card that states that I am a shellback—which is used to avoid this if I ever am on a ship that may cross the equator. I was told that I'll also get a card saying that I traversed the Canal in a Navy ship. Less dramatic, but nice.

While all the shenanigans were occurring on the ship, the Project HOPE blog (www.projecthopeinthefield.blogspot.com) published some information about the work being done on this mission: Posted June 5, 2009: The number of lives Continuing Promise 2009 touches is simply staggering. At the mission's halfway point, Project HOPE volunteers and their military and civilian partners have seen 40,000 patients, performed 112 surgeries and had 170,745 medical encounters. Amazingly, the treatment pace is only accelerating.

Saturday, June 6, 2009, 5:29am:
Not sure when you will get this. I heard that the system went down again about 6pm last evening--our time. Apparently, we continue to lose acquisition of the satellite.
The schedule for this site [Tumaco, Columbia] came out. I go out for only the day (as long as the helicopters keep flying and the boats keep running to bring us back) on Sunday and Tuesday. Wednesday through Friday I'm RON (Remain overnight) at the motel. I am a day tripper again on Sunday and Monday. Then, I'm not scheduled to work until we reach El Salvador.
I'll try to call later--if the system is working.

Saturday morning, 7:25 am:
The word, for now, is that communications will be down every day between about 5pm and 11pm (our time). It seems that something is interfering with the signals during that period, but they don't know what. Also, there is an issue with the computer server room overheating. Those are the problems they know right now. Strange!

The "evolution" (process) at Tumaco is having a rough start. Weather is terrible, meaning that we may not be able to get folks ashore, either by air or boat. That will really hamper activities. We'll see what transpires.

One really nice thing: Our Hopie surgeon is an avid reader. She said that she was starting on the last book she brought with her and I offered her “Demon Doctors” (a book I wrote) to read. She said she loved it and that she thought that it was very well written. Very nice review.

Sunday, June 7, [received Monday morning]
I'm not sure if the internet is up. If not, you'll get this tomorrow. It's now about 8pm our time.
Today was the first day on the "Super Site." I mainly did adults today, since they thought they didn't have enough peds patients. Wrong, of course. At the end, I had to switch to peds and saw some of the most interesting cases. I'll try to continue doing peds in this population. Our pediatric medical team is great!

I did see a primary chancre (syphilis) for the first time in years. Also an 8-year-old with probable sarcoma of the tibia, some operable hernias, an infant with a single descended testicle, massive keloids on the back of a very cute teenager's ears (that I finally got derm to remove), and an undiagnosed moderate-to-severe asthma kid.

There was on child with a very rare dysplastic syndrome (below). Nothing can be done about it; she seems very well socialized in her community. That's the good news. (As with all the other patient photos on this site, they all gave their permission to be photographed.)

It was about 95 degrees and 95% humidity in the room, and there were Colombian military with M-16s everywhere. Security is tight!

We got to the site by boat. They lower us to the boat using the lifeboats as "elevators" down to the water. (That's also how we got on the ship initially in “DomRep”=Dominican Republic.) we then took the "hospitality" boat to the boat landing zone (BLZ), which is on the Colombian Coast Guard base. What is neat is that is where they keep some of the boats they capture in the drug war. It includes a semi-submersible, the newest thing in drug running. It looks like a poorly designed submarine. I've got photos.
Coming back, we took a Colombian patrol boat. Rather than the 40 minutes it took going, it only took 17 minutes returning. The little boat had two 150 horsepower engines! That's the way to go!

Tonight, we have a concert by Juanez on the flight deck. Apparently, he is a big deal in Latin America. I'm going to bed instead.

Monday, June 8, 8 am:
Why are the Navy's boats so slow? I know why the other ones are so fast. The Navy boats to carry passengers carry about 30 people. The Colombian boats only carry about 12 each. The Navy also has small fast boats on board for patrol, but they're too small to effectively transport us to shore. (Hah! Hah! Wrong! We used these RHIBs—rigid-hull inflatable boats in Nicaragua for transfers to shore.)
The ship's Preventive Med guys gave a briefing on snakes and other poisonous stuff in Colombia. Bad idea! They scared nearly everyone on the ship. Unfortunately, they didn't even have a clue how to answer the question: What do we do if we are bitten? The easy answer: Call one of the 3 emergency physicians on board. They'll figure it out.

Monday noon:
The MSC Entrepreneur is one of the civilian mariners (MSC) who sells frapacinos to those going ashore in the boats. 25 cents for a cup and the first one is free.
The sleeping child is just a cute photo I took. The mom was the patient and she laid the child down to take a nap on the floor on the blanket she brought. The Comfort photos were as we were leaving and arriving yesterday.
Here are some Hopies working in the kitchen as volunteers. The Hopies were just working one meal. Lots of the folks do that. I was a little sick, so they didn't want me near the food.

I'll be on shore tomorrow and then RON the next three days. I won't be at the computer until, probably, Saturday--assuming that they're up then. By the way, the system goes down in 2 hours, again.
No more today, since the system will go down. I'll try to call in the next 1/2 hour. We'll see if it works. [It didn't.]

June 11 SitRep: HMD COMMENTS.
(Thursday) Neither heat, nor rain, nor thunderstorms, nor . . . You get the idea. Nothing slowed our clinical efforts ashore. More than 1,000 patients treated each day meant that a large proportion of the area’s poor were receiving care; some for the first time in years. Surgery, of course, proceeded, with the Hopie surgical team contributing mightily to the effort.

Monday evening, June 8. Received Tuesday, June 9, at 10 pm:
Today was very busy; I did almost all kids. Some very unusual cases. Cerebral palsy, cyst in a leg (removed), partial absence of the cervical spine (congenital), femur cyst with fracture I diagnosed, etc.

The trip back was different. We went aboard one of the hospitality boats. Two things were of concern: the 1st mate of the ship (the most experienced person who could do it) was driving the boat, and the other hospitality boat passed us, not having been allowed to board the Comfort because the seas were too rough. Anyway, the trip back was very rough, wet, and uncomfortable. We all survived. (The folks in the other boat were taken back by helicopter.) They say tomorrow they will make some quick decisions about whether to boat us or fly us in.

Wednesday, June 10, 6am:
We have a late "call-away" today. It's already 0655 and we've just been called. Our boat actually is supposed to leave the ship at 0730, but that involves first lowering us to the boat. A few people have to go from the lifeboat to the hospitality boat to cross over to a small inflatable. We have enough folks in our group that I'm certain that we're taking the hospitality boat. A safer ride.

I'll be ashore until late Friday evening. [Mary Lou wrote: The next time I heard from Ken was Friday evening, June 12, when he got back to the ship. But he later sent copies of the daily 'Situation Reports' he sends to Project Hope. He writes them in advance so they’ll be available, even when he’s on shore.]

RON site: Tumaco, Colombia
I bought two T-shirts from the place we RON’d in Tumaco, the Casa del Sol Motel. It was to remember the absolute worst motel I ever stayed in. Remember Boy Scout camp? It was about three steps below that level of cleanliness and comfort. I could see the ground through the floorboards. Since mosquitoes were a huge concern, this was particularly bothersome. That there was blood on the “clean” sheets also provided a clue to the sanitation level. We would have been far better off sleeping in a tent. (Note: the folks who were billeted in the main building found the accommodations much better; I was in a “cabin”.)

This was us sitting outside waiting for them to figure out in which rooms we could sleep. This wasn't rocket science! It still took hours to straighten out.

Sure, the food was edible. But, do you really want chicken feet swimming in your soup? The veterinarians insisted on identifying every chicken part that showed up in the soup. Almost no one ate it.

June 13 SitRep HMD COMMENTS

As some Hopies prepared to leave for home, others continued with a full surgical schedule and crowded on-shore clinic supersite

With the supply of medications for the clinics running low, an emergency shipment is expected late today; it should be available for tomorrow’s patients. One child and his mother had extraneous 6th digits; the mother was removed. The child's will be.

We are now seeing lots of adults and children from very rural areas, many of whom have scant access to medical care. We are providing what we can, and referring those in need of additional services to the on-site Colombian Ministry of Health personnel.

Lots of asthma, but we must improvise by making spacers for the inhalers with plastic bottles or styrafoam cups.

Of course, the stickers I bring are always a popular item. I'm not sure how happy the mother was (right) when her children demanded that she wear one on her forehead.

June 14 SitRep HMD COMMENTS
(Sunday) Finishing a round of “RONs” (Remain Overnight) stays in Tumaco, our clinical teams returned wet and weary, just in time to participate in the US Army’s birthday party. Kendra Dilcher (our premed student and the youngest civilian on the ship—a tradition) read the letter to the Army from President Obama. Dr. Marshal Cusic,
our most senior Hopie, (a retired Rear Admiral in the medical corps), helped cut the celebratory cake. Our Army contingent was serenaded by the US Air Force band, demonstrating how the civilian and multiple military branches work together well on the Navy vessel.

Sunday, June 14, 3:30pm:
Extremely busy day! A former premature kid, now about 18 months old, who had a below-the-knee amputation and toes amputated on the other foot for problems at birth and also has fingers fused. However, he was otherwise normal. Very strange!

Yesterday, I had a child come in that was born at home. It was about 8 hours old. How did they cut the umbilical cord?
I asked. Well, we had an old pair of scissors in the house. I revised the umbilical stump and sent the child to the hospital for 24 hours observation. I had to beg for the suture to tie the cord and used a suture removal set scissors (not very sharp) to cut the stump. However, it went well.

Today, I saw a 5-year old whose father brought her in for some generic complaint. However, I quickly realized that she couldn't hear--or talk. I asked the father about this, but he denied that there was a problem. She had two older siblings at home with the same problem. I was able to get the Colombia social service involved. Of course, none of them had ever attended school. Amazing denial in the father.

One interesting thing was that I worked with a couple of Colombian medical students. They were supposed to be there as translators but, since we didn’t need them in that capacity, I offered to have them simply work with me clinically. Quite a nice experience. Hope they learned a lot.

What else? Lots of umbilical and inguinal hernias, some undescended testicles (can lead to cancer), a case of pulmonary stenosis in a kid, scabies--of course, chickenpox, new migraine diagnosis in a child (last patient of the day, of course), severe strabismus, complex seizures, some very (very very) unusual congenital abnormalities, a 14-year old girl with congenital absence of a pectoral (chest) muscle (second one on this trip) with resulting poor breast development on one side, severe scoliosis, lots of cerebral palsy, microcephaly, a ton of massively perforated ear drums—one bilateral and one through which I could see the ossicles (ear bones) moving, a few pneumonias and urinary tract infections, and a partridge in a pear tree (not really).

Okay. So what's the big news? I was supposed to be on the last boat to the ship. I was aboard as more and more folks showed up. Finally, they said that everyone who had been ashore the prior night should go back to the dock--presumably to fly out, since the boat was 50% over capacity. Then, suddenly one of the enlisted guys pointed at me and said, "You too, doc." I'm one of the few that treat the enlisted people very nice. I guess it paid off. I flew back to the ship. From the time 11 of us (capacity load) lined up, it took less than 5 minutes to put on our life vests, helmets, goggles, get in, belt up, and take off. The trip was 5 minutes long. Wow! I'll send you the photos in the next couple of days.
Anyway, I've got to go off to the briefing now. Tomorrow I'm on shore for the last time in Colombia.

Monday, June 15, 2009 3:14am, Tumaco. Columbia:
Today is my last clinical day in Tumaco. I worked all but two of the days here. I'm really tired and need the rest. We actually leave on Wednesday. It should take about 4 days to get to El Salvador. There we are supposed to only do "air ops," so I should get more rides. (Of course, that wasn’t how it transpired.)
I tried calling last night but, as usual, the phones and internet were down from 8pm (when I had time to call) and 11pm (when I was already asleep). They don't know what the problem is, since they are sending the signal to a new satellite that was supposed to work fine.
Off to work now. More later when I'm back on the ship.

June 15, 2009: SitRep HMD COMMENTS (by Ken Iserson)
The penultimate clinical day. Crowded with patients, as usual, our clinic teams, including lots of Hopies, saw more than a thousand pediatric, adult medicine, and women’s health patients (fairly typical). The dental and optometry clinics, staffed by other USNS Comfort healthcare professionals continued to treat the long lines of patients that arrived each day we were here. Today also saw the last of our departing Hopies head for the airport. We’ll miss them all.

Tuesday, June 16 [Our 36th Anniversary, for those keeping count]
Big day for us in Tumaco. The last surgeries were completed this morning, the last clinic day was held ashore at La Escuela Max Seidel supersite, and the last of our departing HOPIES left the ship for the airport. It was sad to see them go. Their replacements (as if they really could be replaced) arrive when we reach El Salvador. Also leaving today will be our Chinese hospital ship delegation and Commodore Lineberry, who is being replaced in a normal rotation schedule, by Commodore Tom Negus. (Commodore is the title for the Navy Captain ultimately in charge of the mission.)
This morning, before they left, I gave the Chinese delegation a well-received brief on Project HOPE's mission on the USNS Comfort and its activities in China. Lots of questions. Here is a photo of me giving a briefing on Project HOPE to the Chinese Navy delegation. The guy working next to me is “Magic” Johnson, the chief planner for the mission. The soldier in the back of the room is the military liaison to the Chinese Navy. He speaks both Spanish and Chinese and is based in Hong Kong. That is the Senior Captain Lao with the 4 stars/bars. Hope you like the photos.
Tuesday evening:
Today, we had one of the best lunches here that we've had. It was reasonably good Mexican food. You got to build your own burrito. No one else quite did it right. Mine was excellent!
Next, La Unión, El Salvador!

Project HOPE: El Salvador

2009-07-23T14:21:00.001-07:00

Wednesday, 11:30 am: At Sea going to El Salvador

Well, we left only 15 minutes behind schedule. Now at sea toward El Salvador. We now have a bit more rockin' and rollin' on the ship.
Today I learned that I may be giving some talks to physicians in El Salvador. We'll play it by ear. (Didn’t happen.)

We have our abandoned ship/man overboard drill in a short while. They just announced the fire drill that precedes it.

Wednesday evening: at sea between Columbia and El Salvador
After I sent you the photos, I went down and changed the linens on my bunk. I discovered the wrap-around bottom sheets that work great. Not too many of them, but I know how to find them rather easily now.

Off to dinner now. I finished a very good, short, and very scary book by Elie Weisel, "Night," in its new translation. I borrowed it from a berthmate, an Army major. We've had some interesting discussions about it. I've actually found it quite fun to live in a "cabin" with various other folks.

We get our new Hopies in at El Salvador. For now, relatively quiet. We had the birthday celebration for the Navy Medical Corpsman service (111 years) this afternoon.

Quite moving. Everything, including the small table with all the accoutrements, exactly follow important Navy traditions. I couldn't get near the large cake; they devoured it.

The new book I just got from our library is: David Sacks' "Language Visible" about the alphabet. Looks interesting. (It was sooo dense that it put me to sleep after only about 10 pages each time I tried to read it—admittedly only after a very long day.

Thursday, June 18, 4 am: At sea
We have been really rocking and rolling for about 18 hours. I don't suspect that it will stop until we anchor in El Salvador. I’m not seasick, but it just gets annoying after a while. Not much else going on right now.

Friday, June 19, 4am at sea:
Not sure what day this is (or date). The ship is on "holiday routine," meaning few or no hot meals and only one "muster" at 1330. However, I just completed my volunteer duties helping handle the line for an "UnRep." "UnRep" means Underway Replenishment. That takes some explaining.

US Navy ships can replenish fuel while at sea from another ship. This is the second time we've done it. It means shooting a guide line from our ship to the supply ship and then pulling back progressively heavier lines until we are pulling the actual oil lines over. They then plug the oil hoses into the tank and start pumping.

They asked for volunteers to help manage the line. Folks from every department went, although I was the only Hopie. Nice group. The work wasn't too hard, since we had enough folks to do it. We pulled the lines over and then played them back to the other ship when we secured the fuel hoses. They don't let us use gloves for safety reasons. Strange, but it worked fine.

One interesting thing was that, because of the ship design, we were working through and in the enlisted male berthing area. They are stacked 3 high and have only one large locker apiece.
At 2pm, I'll be giving a premed/res talk to a group of students aboard. I've already worked with some of them clinically.
Anyway, that's all for now. We change our clocks back 1 hour tonight, so I'll only be 1 hour ahead of you (in Tucson) for the rest of my time on the ship.

Friday, 10 am:
Foolish thing. I was in such a rush this am that I locked my key in my locker. I thought I had an extra key stashed, but couldn't find it. So, I had to have the security staff come down and cut the lock off one locker. I'm now using a combination lock on it. No problem. We always have the "safety light" on in the common room where the lockers reside. (Of course, I found the key—in a bottom drawer—when I was packing to leave the ship.)

Friday afternoon
I just finished the talk to the students. They are premed and medical students with the UCSD "pre-dental" program. It ended up that I had about 10 students there. Nice kids.
Paul Kline, the professional photographer who was with them in Panama sent me this note: I put a photo book together, you can find it at http://www.blurb.com/bookstore/detail/728333 100% of profits got to Project HOPE.

Saturday, June 20, 7 am: at sea off Central America
We had scooped ice cream last night. Very nice. Normally, it’s soft serve.
In El Salvador, I'll be on shore from Tuesday through Thursday the first week, and then from Saturday through Thursday the second week. I probably won't have any communication during those times.
Decent sleep last night--we also had an extra hour. Excellent!

We get 18 new HOPIES. A male surgeon, a pediatric nurse practitioner, a nurse-midwife, an "advanced pharmacy tech"--who is actually a 4th or 5th year pharmacy student; a new PAO who used to be a Navy PAO; a "veterinary tech" who is the daughter of one of our Hopie nurses and is applying to vet school; the daughter of the Chief of Naval Operations; and a lot of nurses. We still have 8 Hopies on board, so again, it will be quite a crowd.

In El Salvador and Nicaragua, I'm ashore 7 days in each country--1 less than in Colombia. The clinics in both countries should be filled with very poor folks.

Saturday, June 20 later:
Hope you’re enjoying your Saturday. We’re still at sea, of course. Supposed to get to our anchorage tomorrow. Not sure what time. We are now only 1 hour ahead of you. Off to a meeting shortly (daily briefing). Here is my SITREP to HOPE:

June 20: Back to normal schedule (an hour earlier due to changing time zones), we began preparing for our El Salvador mission and welcoming the newest Hopies aboard.
Patients triaged in Colombia: 16,097
--Average number of patients triaged in first four countries: 10,808
--Healthcare encounters in Colombia: 65,425
--Total number of healthcare encounters for CP09: 255,634
--Total number of patients treated during CP09: 59,330
--Prescriptions filled during mission: 107,063
--Pills prescribed (and individually counted and bagged) during
mission: 1,881,748
--Number of surgeries in Colombia: 247
--Total value of surgeries in Colombia: over $1.2 million
--41 percent of surgeries were pediatric

Sunday, 5:30 am, anchored off the coast of El Salvador:
Last day of summer. Wow! The shore scenery in El Salvador is quite impressive. Lots of "extinct" volcanoes. Tomorrow starts the big clinical push. I'll try to catch up on my paperwork today.
Monday, June 22, 4am, La Union, El Salvador:
I just got the emails, since our systems went down soon after I called you yesterday. I'm packed and on my way to breakfast to meet with half the new Hopies (the ones who came in last night). Then, off to shore. Guess what? Helicopter rides both ways today--or at least that's the plan. It saves a 90+ minute boat ride.

When I get back this evening, I'm supposed to go to a "DV" (Distinguished Visitor") dinner with a medical admiral who's here. He's supposed to work at the clinic site today.

Monday, 3:30pm:
Today turned out to be very short. I was on a helicopter about 8am and another returning about 2:30pm. They are in trouble with their transportation, so have to push people through earlier than they want to.Tonight is the dinner with two admirals. Actually, I met and worked with one, a pediatrician, today. Nice guy. To me (non-Navy), he's "Mike."
Tomorrow, I plan to catch up on some stuff and get ready for four days working in a row--three of them on shore. The reports are that the Comfort Inn is really nice. (It was.)

Monday, 4:40pm:
All ship communications are down, again. I tried to call but, as usual, they're dead. Hopefully, this will get to you eventually. It seems that my on-shore schedule may have changed. I'll probably be able to write you definitely tomorrow. But, as of now, I'm RON for Tuesday, Wednesday and Thursday--returning to the ship Thursday night.

Wednesday, June 24, 4:20am ashore in La Union:
Believe it or not! I am on the very fast computer at the hotel. Very nice place. No one wants to go back to the ship. Excellent bed, air conditioning, clean, good shower (warm, not hot water only), good food.

I am off to breakfast now. No idea when I will be back from work. But another night here I think. Then back to the ship. Since I had to change schedules, I do not know what my new schedule actually is.

The DV dinner was, essentially, boring. However, I actually worked clinically with the admiral and his El Salvador friend, both of whom are pediatric nephrologists, twice. Very nice. The Navy guys were somewhat envious.
Kwashiorkor

While with him, I diagnosed a case of kwashiorkor (very severe protein malnutrition). Initially, it appeared to be nephrotic (kidney) syndrome, but I used the “Improvised Medicine” tool of measuring mid-arm circumference with my hand and showed that he was severely malnourished. In follow-up, that proved to be correct.I’ll try to contact you later, but the one computer is usually fully occupied.

Wednesday, 5:30pm, La Union:
Today was extremely busy. I saw about 50 patients and consulted on lots more. Some very ill kids. One child had a syndrome of bowing of his legs—Blounts syndrome (right). A few days later, I saw a child that presented similarly, but he had rickets. We could difference with radiographs.
The child (left) has Sturge-Weber syndrome. We helped adjust his seizure medications. The tiny hand has fused fingers (syndactyly).

A child (dental patient) who loved the finger puppets I was distributing. The girl (below right) has a traumatic cataract.

The girl below came in bacause, after a coma of unkown eitiology, she couldn't wak. Her parents got this radiograph and came to us. We referred her to the Health Ministry to replace her destroyed (seems like trauma) right hip.

We arrived about 7am and left about 5pm. I have now showered, am obviously at the computer, and will soon eat. Good food. Should be back on the ship tomorrow night, unless things change.

Thursday, June 25, 4:30 am:
I return to the ship this evening. Hopefully, the phones will be working and I can call you. Actually, I am not in my room much. When we return, we sit in the restaurant and socialize. Quite nice. Or, outside by the pool.

I just learned that the new schedule has our peds team going back to the ship this evening, staying until Sunday am, when we go RON (same hotel but different clinical site) for 3 nights. We get back to the ship for one day before we leave. We were sitting together when we found out. Everyone was pleased. This is a nice place and we avoid the approximately 1 1/2 hour boat rides.
The El Salvadorians are really pleasant people. Some of the cases we have seen are repaired spina bifida with major ulcers on the feet due to lack of sensation, Sturge-Weber syndrome (facial vascular malformation and brain calcifications), child with a traumatic stroke but neurologically normal, cerebral palseys, lots of syndactally (fused toes and fingers), traumatic cataract, etc. etc.

Friday, June 26, 2009 at 6am, aboard the USNS Comfort:
Feel good. Limited communication, but someone did tell me about Michael Jackson's death and Farrah's. They also thought that I should keep up with the news. Once I get to the hotel again, we have international CNN as well as HLN--in each room!

Phones, of course, were down last night. Hopefully, I can call sometime today. Apparently, we have something less than 1/4 of our home's bandwidth for the entire ship right now. Unbelievable!

Guess what? Today marks my being more than 3/4 done with the Comfort mission.

I'll be on shore from Sunday and return on Wednesday, July 1. I think I may be on shore in Nicaragua July 3 through 4 or 5. They're revising the schedule because they have to limit boat transits to daylight hours for safety. So, they can generally run each of two boats only once in the morning and once in the afternoon. Each transit takes about 1 1/2 hours (each way). So, staying on shore is great!

Among the great medical staff with whom I have been working on this mission, one stands out: Dr. Jose de la Peña. A retired private practitioner, he joined the Navy and has refused to retire until he can no longer do the job. Captain de la Peña is such an able clinician, he leaves everyone else in the dust. (Photo on right)

Friday, 9:30 am, Ken's 'day off' aboard ship:
Yes, almost home. Well, sort of. I asked today whether they had the hotel rooms we need in Managua "on their radar." That's Navy speak. Anyway, I found out who needs to get on it. So, when I see him next, I'll ask.

Anyway, kind of bored today. On shore, I'm busy from 6am (or earlier) until I go to bed. Here, I only have a few meetings and some admin stuff. The clinics fill up quickly. An important element of working here is to know where the location of the cleanest outhouses.

They're having the Shellback certificates professionally printed, so they are supposedly mailing them to everyone who leaves the ship before they arrive. We’ll see if that really happens.

I looked at the latest version of our schedule. It seems like I will only be on the ship 5 or 6 more days. The rest of the time, I'll be ashore. Wow!

Friday afternoon, 2:30pm:
Hello from El Salvador! specifically, La Union near the Honduras and Nicaraguan borders.
I've been ashore working the last 4 days, and just returned yesterday evening. Very busy clinics with lots of sick kids. I'm seeing kids only on this mission. I'll see adults only at McMurdo Station (Antarctica—from August 2009 until February 2010).

While our accommodations ashore were rather dismal in Colombia, here they are at a Comfort Inn, which is far nicer than any Comfort Inn I ever stayed at in the U.S. The clinic is at a large school. It is a series of one-story open-air buildings (the heat index is at or above 100 degrees). The El Salvadorians are nicer than any group of people we've encountered so far.

The town is sort of like rural Mexico.
We're anchored about 6+ miles off shore. The ship cannot get in closer for a number of reasons, such as lack of English-speaking harbor pilots and not enough draft in the channel. So, we sit out here rocking and rolling next to one a number of islands.
Most of our trips to and from shore are by boat and take 1 1/4 to 1 1/2 hours! Not exactly smooth. Luckily, I don't get seasick. I have had 3 helicopter transfers, but I expect that most of my travels will be via boat. Each (ship) boat accommodates 30 passengers.

In the pediatric clinic, each of us sees 40 to 50 patients per day.

I'm the only one in our peds group working without a translator. I guess I have learned some Spanish after all. Quite nice. I worked with two women El Salvadorian medical students today. I think that they had a good experience. They asked to have a photo taken when we were through.
My patient, shown in the photos, had a terrible burn contracture of her ankle and knee. After surgery aboard the Comfort, she had full mobility again.

Our pediatric group, again, is magnificent. That may not be clear when you see Bill Scouten doing the “chicken dance” to show a child how to do part of his neurological testing. Kelly Hamon, of course, was unbelievable. And, on this part of the mission, Faye Pyles, a Hopie and retired Navy pediatric nurse practitioner was there to assist us.

We're seeing a wide variety of rather significant illness. However, unlike Zambia, we haven't seen any malaria yet. We did see one child with dengue fever, however.

As for safety, we are as safe as we would be doing a clinic with a significant police presence in downtown Baltimore or DC. We have both the El Salvador military and our own force protection. Absolutely no incidents in any country I've visited. (There was a Colombian military guy who accidentally fired his weapon inside our veterinarians' bus. He is now on extended duty somewhere in the jungle.)

Friday, 3:00pm:
Well, I was at the phones, dialed the number, put in my card number, and the phones went dead. Everyone on the phones was left just staring at their handset.

So, I don't know when this will get through to you. We just finished dinner. I first sat with our ship psychiatrist and we discussed SSRIs (since they said I'll be the Polar shrink) and then with the El Salvadorian Navy representative--who speaks very good English. He gave me a great local geopolitical lesson. Very interesting.

Anyway, my dinner was a great set of classes. Sort of like what I expect at the Pole. Of course, I sat with two people that no one sat with--how stupid those others are. I think, however, that lots of folks are (1) scared of talking with the psychiatrist, even though she is very nice and (2) afraid that the El Salvadorian wouldn't speak English. I actually wanted to speak in Spanish, but he said that my Spanish was too good and he had to practice his English more than I needed to practice Spanish. Quite a nice complement!

Anyway, all for now. I hope the system comes up and I can get any other messages--and you can get any I sent. More tomorrow, I hope.

Sunday, June 28, 4am:

Anchored off La Union, El Salvador, I'm off at 0605 on the boat to my clinic site and then RON. The new site is at least 45 minutes from the "BLZ" (Boat Landing Zone). So, after a trip of about 1 1/2 hours on the boat, then walking 1/4 mile to the bus, we'll take a long bus ride to the site. I expect that we won't be there until about 9am. It can be a little longer, depending upon how many cattle are in the road.

I have some audio books to listen to on these trips. Of course, it will be another 45 minutes or so back to the hotel in the evening. At least these busses are usually air conditioned. The heat index here today (in the sun) was 113 degrees!

Of course, when we get there, we first get to offload MREs (Meals Ready to Eat) and other equipment needed for that day.

Mary Lou called at the hotel using SKYPE; it worked fine, except the hotel operator did not know who was in each room. And I was hardly in the room anyway. So, for the first week, she didn't talk to him when he was ashore. But, Mary Lou doesn’t give up easily. So the second week I was there, I emailed her to arrange a time that I would be in the room (and the room number) so she could call. Worked great! The call was clear and cheap. It’s so much better than the satellite connection from the ship. We could actually have a conversation!

They also had TV in the hotel, with CNN and actual news—some in Spanish. They get little news on the ship, and so I receive news updates in summary from ML via email. Very useful.

Monday, June 29 : Ken's situation report for Project Hope:
Sunday: After a couple of days rest on board the Comfort, some of our Hopie practitioners are going ashore for four days of work in the clinics, relieving some who are already ashore. The tenuous nature of and limited ability to transfer personnel from the Comfort's anchorage more than 6 miles off shore has resulted in increasing clinicians' time "RON" (Remaining Overnight).
June 30: Situation report, written by Tracey Kunkel (left), Project Hope's operations officer and a nurse who recently retired as chief of the USNS Comfort's OR:

26 HOPE Volunteers
· Communications down
· Ken Iserson ashore for clinical work until we leave El Salvador
· Several Hope Volunteers RON
· Local El Salvador nurses aboard for Subject Matter Expert for lectures, Project Hope educators involved
· Last day of surgeries
Dr Iserson still remaining ashore. Communications are still down. CAPT Ware stopped me to tell me how impressed he is with this group from Project HOPE. Elizabeth Roughhead and Diane Speranza on a ComRel [“Community Relations”: non-medical volunteer projects] at a special needs school.
Mission totals to date:
Patients Triaged in El Salvador: 15,222
Patient Encounters in El Salvador: 58,874
Total patient encounters on Continuing Promise mission to date: 314,508

Wednesday, July 1, 2009, 5:30 am. Ashore in La Union, El Salvador,
It is not quite 530 am here. Last work day in El Salvador. We are back to the ship this afternoon and we leave for Nicaragua tomorrow. I diagnosed a case of rickets today! I have actually never diagnosed a case before.

Quite a surprise happened as we finished work at the clinic today. The city mayor threw a “thank you” party for us. It included a magnificent Tres Leches cake! Since I’m a connoisseur of this type of pastry, I can say that it compares favorably to the best I ever had—in Hermosillo, Mexico.We can see Nicaragua from the ship. We are actually anchored at a site where El Salvador, Honduras and Nicaragua meet. So, the ship master (Capt. Finger) said that he only needed to let out the anchor chain a bit and we would be in Nicaragua. Actually, we will be somewhat further down the coast, as you have probably seen on the map. Puerto Corinto.

Anyway, today is July 1! I am more than 80% done with the mission!

Wednesday evening, aboard the USNS Comfort:
No way that I can get near the phones tonight. A huge group of Army reservists just arrived and they’re lined up to call home.

As for our on-shore schedule, they still don't have a clue. They're going to spend tonight--and probably tomorrow--changing it again. I'll let you know where and when as soon as I know. The only thing that I have made clear is that I will leave the ship on July 13.
Now (8:10pm), I'm going to bed. Really pooped. Oh, yeah. At the last minute, they pulled me off the boat dock to take the helicopter back. Fifth ride.

Wednesday, July 1, 8 PM:
CAPT Tom Negus, the Continuing Promise mission commander (Commodore) wrote in the ship’s blog:

Miracles happen everyday...

I want to tell you a story that Doctor Iserson from Project HOPE shared with me the other day...A woman brought her 7-month old son into a medical site a couple of days ago for evaluation and consideration for cleft palate surgery. Understanding the impact that a cleft lip and palate would have on the trajectory of this young boy's life, the mother was very anxious that her baby might obtain corrective surgery.

Unfortunately, since we had already been in El Salvador for a number of days, all of the surgical time available was booked up. The mother did not know this...while she patiently waited in line carrying her hopes and dreams for her son's future, she had no way of knowing that the odds were already greatly stacked against her. Yet she persisted, waiting for several hours in the long lines that generally form hours before the medical sites are opened.

The mother finally made it into the site, where her baby was carefully checked in, weighed, measured by our on-site corpsmen and volunteers, and directed to the appropriate station for evaluation by a doctor. The mother held the baby in her arms as she sat at the desk that served as the doctor's office, describing her hopes for her son, while the doctor gently examined the young baby. He was very professional and compassionate when he explained that surgery would correct the abnormalities in his lip and palate, but that he wasn't sure that there was any more surgical time available.

Knowing this, he carefully counseled the mother that there was little chance that there would be any surgical time remaining. But, given the enormity of the potential outcome for the child, he left the mother waiting as he contacted the surgical team to check the remote possibility that there might somehow be an opening. The doctor returned and, when he saw mother and child sitting at the desk with all the hopes of the world wrapped up in that tiny bundle, he said he had to wait several moments to compose himself before he could utter the words "Yes, we have room for your son".

By a strange and wonderful combination of events, there happened to be one last opening--for the precious baby from La Union, whose life will be forever changed thanks to the loving persistence of his mother, and the miraculous surgical slot held open just for him.

Thursday, July 2, aboard the USNS Comfort, anchored off El Salvador:
We'll leave sometime around noon today. It is only about 12 hours to Puerto Corinto, [Nicaragua].

One way that we’re using this time is to help repackage the large shipment of medications we just received; it’s about time. Under the supervision of the pharmacy staff, including our Hopie senior PharmD student, we’re putting tablets and capsules from large bottles into bags to give to patients. Of course, we’re using a slicker method than simply counting the pills.

I forgot. They just issued a new on-shore schedule. It has me going out for the day on July 4, RON from July 6 to 9, and again on July 11.

I'll be on the ship to pack and do any last-minute paperwork on July 12. I leave for Managua on July 13. Wow! That's soon.

On to Nicaragua!

Project HOPE: Nicaragua to Tucson

2009-07-23T14:19:00.000-07:00

Friday, July 3, morning, aboard ship, anchored off Nicaragua:
The internet has been down almost all the time here.
Off to a talk on Forensic Entomology and then a day of credentialing “Operation Smile” folks.

[This is a joke from AZ Medical Association's newsletter. Mary Lou sent it to me. Hope you all like it. for the lay people in the group, 'HIPAA' is the medical privacy act restricting the release of patient information.]
Quote of the Week : "Knock-knock."
"Who's there?"
"HIPAA."
"HIPAA who?"
"...I can't tell you..."
~Author Unknown (provided by Sue Sisley, MD)

Friday evening, aboard the Comfort:
I told the knock-knock joke to quite a few folks already.
I have the July 4 card [from Mary Lou] out to open tomorrow. I'll take it with me to shore in case the helicopters don't work as expected and we have to stay ashore--on cots at the hotel. More later, going to bed now.
My departure certificate from Commodore Nagus, the bags in our berthing to separate burnable from non-burnable trash, a ship map (from the wall), and our low-tech berthing name chart

Puerto Corinto/Chinandega, Nicaragua and our clinic.

Saturday, July 4, morning, aboard the Comfort:
Well, I'm still on the ship. We were scheduled to leave by small boat for shore at 6:10 am. We were the second boat that was supposed to go. They got both boat loads up top and then decided that it was not safe. They took us downstairs again and we are waiting for helos (which were already overbooked for the day). But, when the third (late) boat load was supposed to go, they reevaluated and decided that they could go by boat; mistake. There was an accident and an Army Sgt got some fingers injured. So, everything will be by helo now. And, since we are only allowed to fly by daylight and there is a 20 minute+ ride to the site once we land, I'm really not sure if we will go, or if we will get back this evening if we do. Well, the idea is to be flexible.

About the powdered milk products [that were recalled]. I guess the Navy knew about that a week ago. They had us take all our powdered milk drinks out of our MREs and discard them before leaving the ship. They didn't say why; only that they were contaminated.

HAPPY FOURTH OF JULY!

This is a notice in the building we are using for our clinic notifying everyone of the wonderful scope of services we would provide. Although there was some question about whether the services were being hyped too much by the local authorities, this is a very accurate translation of what we said we would deliver.

Saturday, 6pm, aboard ship:
Finally back from shore. We were helo'd in and out. Long wait both ways, but the trip is about 8 minutes and then the bus takes about 5 minutes more. However, due to the delays, we had a very short clinical day. Too bad. We saw a number of sick patients. I saw another malnourished kid, a kid with primary pulmonary hypertension, one with strabismus (sent to surgery), and another with a thyroglossal duct cyst (also sent to surgery). The patients and other Nicaraguans on site were very nice and glad to have us there--despite their official government stance.

This is me in our makeshift pediatric clinic and, below a cute patient. Of course, the girl on the right has classic herpes zoster. She was only 14-years old and without any other medical problems.

This boy has neurofibromatosis. Note the cafe au lait spots. He has a neurofibroma under his eyelid. We were able to refer him to ophthalmology to have it debulked so that he could use his eye.

The twins shown on the left had, unbelievably, symmetrical pneumonias! One had right lower lobe; the other had left lower lobe. They were clinically well and could be treated as outpatients.

This girl has cerebral palsey. And, while we couldn't do much for her, we were able to greatly help her mother by providing a wheelchair. She had been carrying her around nearly constantly.

This was now becoming nearly impossible, since the child was much heavier than what the mother could handle. Sometimes, it's the small things that make a big difference.

The girl below has, according to a cardiac ultrasound done in Managua, transposition of the great vessels (of her heart). That requires some complex surgery. Why they didn't at least already do the first part, no one knows. She has "clubbing" of both her fingers and toes. With some difficulty, we got the local health authorities to officially refer her to the one pediatric center in the country.

The child on the left (below) is a 9-year-old with cerebral palsey. The girl, below, had severe painful lesions (with pus) on all her fingers. Turned out to be scabies. We saw quite a variety of scabies on this trip. Probably more here than anywhere else.

However, Nicaragua is proving to be a difficult mission site, particularly because of the trips to shore, bad sea conditions, and long way for some of the staff to get to the distant clinic site. We have been sitting directly in this year's storm path. The weather pattern that is keeping storms out of the Gulf of Mexico is pushing them along the southern coast of Central America. And the Comfort is anchored in the middle of it. There has been a lot of rocking and rolling!

Saturday, 9:30pm:
I tried to call you twice. The phones were down both times. I guess I should have called when I was ashore, but wanted to know whether I'd get back to the boat first. They say that transfers on Monday (my first day RON) may be challenging, since heavy thunderstorms are expected. So, it may limit both boat and air ops. We'll see what happens.

General Trip Information
As things wind down, and Continuing Promise 2009 has about 10 more days at the final stop in Nicaragua, I want to mention all the organizations involved in this huge undertaking.

The mission is providing not only the medical care I'm involved with, but also veterinary, educational, construction services (SeaBees), dental, and a whole raft of other services.

We have an extremely talented Air Force band aboard. To call them a "band" does them a disservice. They can play anything in any circumstance extremely well.

Please be sure to check out these organizations sites for information on their activities. Here's the list, it is impressive!
Host Nations: Antigua and Barbuda; Colombia; Dominican Republic; El Salvador; Haiti; Nicaragua; Panama
US Government Partners: Air Force; Army; Coast Guard; Marines; Navy; U.S. Public Health Service, Department of State; USAID.
International Partners with military members on the Comfort assisting with the mission: Antigua and Barbuda; Brazil; Canada (lots of folks, including dentists); Dominican Republic; El Salvador; France (Haiti only); the Netherlands (multiple entire surgical teams); Nicaragua; Panama.

Non-governmental Organizations (NGOs) aboard ship or who donated pallets to provide to the countries: Agua Viva; Angel Mission; Food for the Poor; Hugs Across America; Institute of the Americas, International AID; Latter-Day Saint Charities; Lions Club; Islamic Relief; Nour International Relief Aid; Operation Smile; the Paul Chester Children’s Hope Foundation; Project Handclasp; Project HOPE; Rotary International; UCSD Pre-Dental Society; University of Maryland; University of Miami; the Wheelchair Foundation.

Sunday, July 5, 8 am, aboard ship:
There are supposed to be big seas tomorrow, so we'll see if I can even get off the ship for RON. We're really rockin' and rollin' today. Tomorrow is supposed to be much worse. And no, I don't get seasick. A physical therapy friend (Navy) told me in these seas, you should sleep on your stomach and it doesn't even seem like your rolling. Another option is to sleep on your side with your back braced against the wall. He was right.
I'll try to call you in a bit. I think the phones are actually up right now.

Sunday, July 5, 6pm:
Hello from the USNS Comfort! Still rockin' and rollin'. Someone said that this is how babies must feel when they're rocked in a cradle.
Lunch was interesting. Operation Smile is aboard for about 5 days. They are a complete team for 3 or 4 ORs that only fix facial deformities--primarily cleft lips and palates. Very cool organization that has long term commitments to any country they visit, arrange good follow-up care, and do in-country teaching through a very specific didactic/clinical program associated with these surgeries. Very impressive.

I had lunch with their chief plastic surgeon, Dr. Rafael Gottenger, who it turns out, practices in Miami, is originally from Venezuela, and is a Jewish child of Holocaust survivors. I then went into the main mess hall and ended up sitting with another plastic surgeon, Dr. Rodrigo Neira, one of their senior staff people, and a guy who I asked if he was one of their electronic medical records folks. No, he was actually the son of the family that funds all of OP Smile's Nicaraguan operation; I think they're billionaires. Anyway, nice guy. I told him about REEME (http://www.reeme.arizona.edu/) educational site. The surgeons also.
In a half hour, I go to the "Main Planning Board" meeting. That's where they hash out everything for the next few days. Sometimes it is very interesting. I suspect that today may be one of those days, since they have to discuss operations in the face of tomorrow's inclement weather.
Monday, July 6, 5 am on the ship:
Off to the shore soon. They are supposedly using large inflatable's [RHIBs or Rigid-Hull Inflatable Boats] to transport us. Hope we don't get too wet.

Monday, 6:30pm, Chinandega, Nicaragua:
Hello! Yes, everyone was a bit concerned about using the ¨RHIB¨boats. But, as it turned out, it was a faster, smoother, and dryer ride than any of the other methods (and about as fast as the helicopter).
We got to the hotel. Not as nice as El Salvador, but much nicer than Colombia. Food good. The problem is that they could not, apparently, count the number of folks they put ashore and match them with the number of beds. We have 17 too many folks in the hotel. I have a room, but we also have a cot. I expect that we will be sharing the room with a third person--I will have a bed.
I will probably not have to worry about them again at least until Thursday, and probably Saturday when I go out for the last time.

Tuesday, 4:30 am, Chinandega, Nicaragua:
Good morning! Room not bad, as I said. However, my Canadian roommate cannot sleep with the air conditioner on. Kind of a pain. But we do have a good ceiling fan. At least he doesn’t snore.
Off to breakfast now and then to work. Should be a very busy day. Also, at least I am not at the ¨far¨ site that is more than an hour away. That group didn’t get in until after 8pm last night! They´re staying at our hotel, since there is no place to put folks up near that site.

Wednesday, July 8, 5 am, Chinandega, Nicaragua:
I went to bed at 8pm. Yes, I was very tired. About 8:15 pm, we suddenly got a new roommate in the cot. It was a member of the Air Force band that travels with us. They were stranded here. He left before I even got up (4:30 am).
Off to breakfast and work. Only a few more days!

Wednesday evening:
I just got back. The last of us (I was one) worked 11 hours! I ended up seeing patients in peds, then adult med, then Optometry!

No dramatic stories about these kids--they're just some of the cute kids I saw in the clinic. Of course, the girl on the left brought her own footstool! Wow!

The story was that while a bunch of distinguished visitors were touring, the locals let in 100+ more patients to impress their leaders with the numbers. Of course, this was just as all the RON personnel were leaving. We had only a skeleton crew.
As we struggled to see these patients, I moved over to seeing adults. Then, just after I finished, the electricity went off. So, we rushed over to the Optometry section with our flashlights to help them out. Surprisingly, when I asked if I could assist, I was told that if I could do funduscopic exams (with an ophthalmoscope), I would be a real asset. Being old, I still use that instrument regularly; we finally saw all their patients.

Thursday July 9, 4:30 am:
Hello. This morning we’re up and going. The power was already off when you called last night, so I’m surprised that you got through. It went on and off several more times throughout the night.
I’m going to pack up now, since I hope to be back on the ship later today.

Thursday evening, on the ship:
After an interesting ride on the inflatable (stayed dry!), I just had a shower and changed clothes. The boat is rocking so badly that I just had to run over to check out a guy who had a forklift tilt against him; he was okay.
The phones were down when I passed them.
I'm tilting too much to sit here at the computer much longer.

Friday, July 7, late afternoon , aboard ship:
News! It seems that weather conditions have gotten so bad that they had to keep everyone ashore who was there. They will work tomorrow--probably instead of those of us who were supposed to go out. If that's true, I'm done with clinical on this mission. We'll see. I like the clinical; just not the transportation to and from the shore.
Of course, they then may change when I leave the ship to be sure that I can get ashore. I'll keep you posted as things develop. Interesting how their plans never seem to come together.

Friday evening:
I just got out of the 7pm briefing. Long one. I won't be going to shore [tomorrow], unless things change.

Saturday, July 11, 5am:
Staying on the ship today.
When the electricity went out at the end of the work day in the clinic on Wednesday, everyone was surprised when I was able to pull a mag light off my pack--the one I tie on there. It was very helpful until the lights went back on about 10 minutes later.
Lots of folks leaving the ship over the next few days. The big move is on July 13, so I'm glad that I will already be in Managua in case that doesn't work too well.
No, I haven't packed yet. I need the stuff to live here the next couple of days. However, I can start some packing later today. I hope that the new bag works okay. I'm sure it will. I actually have not acquired much--mostly caps and T-shirts.

Saturday afternoon aboard the USNS Comfort, anchored off Puerto Corinto, Nicaragua:
Hot and muggy here. Well, I started "pre-packing." I don't think I'll be going to shore tomorrow, so I'll only need to pack and do some other mundane stuff. The psychiatrist asked me to teach her hypnosis tomorrow. So, a little teaching, also.

Home soon! I only need to get to shore, then to Managua, to the hotel and a dinner with the Nicaraguan HOPE staff, and then to the airport. Not too complicated. (Wow! Was I naïve! As it turned out, this became very complicated.)

As I'm sure you've figured out by now (5:43pm), the internet and phone have been down for hours. I'm writing this in the hope that it gets through at some point. We'll see.
Not much else. I talked with the USAID folks and the Nicaraguan Ministry of Health about REEME and the video and the Grave Words booklet. She said that their consular officers have to do death notifications all the time.

Saturday, 8pm:
Wow! Tomorrow is my last full day on the ship. I think we'll leave the ship around 5am or so. Then go by bus to Managua. All the HOPIEs are going together and staying at the same hotel.
I just tried to get on the phones, but since they were down all afternoon, there is an hour lineup to get to one that works--three of the ten aren't working.

So, I'll call you tomorrow (I'm not going ashore) and write—assuming that the systems are up.

Sunday, July 12, from the Comfort:
I just finished teaching hypnosis to our ship psychiatrist. She then taught me more about Cognitive-Behavioral psychotherapy. Very useful.

Today, I pack for real. I sent you the Managua plan. Hope you get it.Monday.

July 13, from Managua, Nicaragua
The simple process of getting us and our bags to shore, and putting us in a bus to Managua was a bit more complex than expected.

The first step, the night before, was to put our large bags into huge “tri-fold” heavy cardboard box to be VertRepped (lifted by helicopter) onto shore. There's some Hopies waiting in line to put their bags in the boxes. The VertRep was to happen first thing in the morning.
The plan was for us to go to shore via RHIP (inflatable). I double-packed everything inside heavy plastic bags inside my large bags, in case we got wet. Some of it went into a large

Same for the bags I carried onto the RHIB (electronics, etc.). When we got on the RHIB, I asked Mr. Lieberman, the First Mate (second in command of the ship) if we would have a dry ride. He said, “I have some good news and some bad news. . . Yes, you’ll have a dry ride on the RHIB. But, we’ll only be taking you to rendezvous with a hospitality boat that will take you the rest of the way.” So, we met up with this larger boat, that went round and round until several more RHIBs had rendezvoused. Then, finally, we went to shore. For the first time, the sea was almost flat; it was a dry ride after all.

But, then the real problems began. “Sorry, we don’t have a bus for you,” said the ACE Team leader (the folks who manage us on shore). “In fact, your baggage won’t arrive on shore until 1 pm; it was 7 am, about 95° and 90+% humidity with little shade. Not a good situation. After considerable coaxing and him probably not wanting to hear our complaints (HOPIES, Dutch military, UCSD dental folks) for hours, he arranged for us to sit on an air conditioned bus and then get our luggage several hours earlier than planned.
We then took the bus to Managua with our well-packed luggage on a flatbed truck following behind. The trip was uneventful and the small hotel was excellent.

Amazingly, our HOPE Nicaraguan Country Director, Balkiria Montoya, took our entire group on an extended tour of some surrounding national parks with volcanoes (note the sign for cars, below--they're serious--the volcano is active!), the town of Granada (looked like a place to go back and visit), and lunch at a wonderful open-air restaurant with traditional food. That's Sra. Montoya with Jacob Steele, our PAO (below, right).

Tuesday, July 14, Managua, Nicaragua to Tucson, AZ
The trip home was a little stressful, given that American Airlines got us to the tarmac on time, but then returned to the gate for a “minor” mechanical problem. I had less than an hour in Miami to clear immigration, customs, repeat security screening, and get to the gate. I made it; one of my bags (that they destroyed in a conveyor belt) did not.

Mary Lou met me at the airport and we drove home. Back in Tucson, back home, and resting (not rocking) around 7 pm. I’ll now be home for about two weeks, with a short trip to speak at the Wilderness Medical Society meeting in Snowmass, CO, before leaving for my Antarctic orientation and then to “the ice.” I’m supposed to arrive at McMurdo Station, Antarctica, on August 20, if the weather permits.

More posts from Antarctica!

Project HOPE

2009-04-25T13:18:00.000-07:00

The big white ship with “HOPE” emblazoned on its side. That’s my childhood image; I associated it, as did many others, with Americans providing needy people around the world with medical care.

Surprise! Project HOPE is alive a well, although their old Navy hospital ship was retired in 1974.

Today, the organization continues its mission: To achieve sustainable advances in healthcare around the world by implementing health education programs and providing humanitarian assistance in areas of need.

Project HOPE now operates both land-based and ship-based missions. My involvement? Beginning May 1, I’ll be their Chief Medical Officer on “Project Continuing Promise” to the Caribbean, Central and South America. Based aboard the US Navy’s hospital ship USNS Comfort, our HOPE team will help provide medical care and education for healthcare professionals in rural areas of Antigua, Columbia, Panama, El Salvador, and Nicaragua. (On this mission, they’ve already done that in Haiti and the Dominican Republic.)
What will I be doing, exactly? Not sure yet. But, I expect to be working alongside some super healthcare professionals who, as do I, want to pay back the world for the privilege of working as a medical professional.

Who else will be participating in this effort? The US military and Public Health Service, as well as the Canadian Forces and some other NGOs (non-governmental organizations) will provide an immense amount of medical and dental care, while military veterinarians and engineers will have their own humanitarian assignments. Of course, equipped with 12 operating rooms, surgeons (some assisted by HOPE nursing staff) will operate on prescreened patients who would otherwise not be able to get the treatments they need.
To find out more about Project HOPE, go to http://www.projecthope.org/. To volunteer or register for possible work in a disaster, go to www.projecthope.org/joinhope/volunteer.asp.

Southern Africa—Photos

2009-04-19T05:44:00.000-07:00

“All work and no play . . .” Not for me. So, in that spirit, my wife met me in Johannesburg (JoBurg), South Africa, for a tour of some game parks and Cape Town. Some of the photos were also taken at (1) Heathrow Airport on the way to Zambia and (2) Botswana—Chobe National Park on a short respite from work in Zambia.
The pictures will tell the tale. Enjoy! (I took all the photos of land animals with a Nikon D60 and a 55 to 200 mm telephoto lens. For the others, I used an 18-55 mm lens. They all look much better when larger and not formatted for the web.)

Some INTERESTING SIGNS from Heathrow Airport on the way to Africa. (Am I the only one who thinks that advertising “Great British Food” is an oxymoron? There’s also SCENARY of the Cape of Good Hope, including the old lighthouse, and a disturbing, but frequent “township” (e.g., shantytown) outside Cape Town. The “grass shacks” are rondavals. Very practical and with concrete-like floors made from dried dung, people still live in them in parts of Africa, including in Zambia.

VICTORIA FALLS (Zambian side), sunsets in Africa, and some PICTURESQUE SHOTS. Note the photo of Table Mountain from Robben Island, where Nelson Mandela was imprisoned.

The BIRDS, including a rather rare photo of the Knisna loorie. The African Penguins are from a colony on the Cape in South Africa.

FISH and SEA LIFE from the Two Oceans Aquarium in Cape Town.

THE “BIG 5,” so-called by hunters, who considered these the most dangerous animals to hunt. They are the Lion, Black Rhino, Elephant, Leopard, and Cape/African Buffalo. You really don’t want to confront any of these animals when on foot. The trick is that these animals, other than an enraged bull elephant, will not attack the jeep in which we rode. If a bull elephant runs toward the jeep, however, you “floor it” and hope for the best.

The OTHER INTERESTING LARGER AFRICAN WILDLIFE: cheetah, giraffe, spotted hyena, crocodile, baboon, monkey, various antelope, warthog, hippopotamus, lizards, zebra, puff adder (venomous snake), African Rock Python (non-venomous), and wildebeest.

I hope you enjoyed these pictures! I certainly did when I was taking them!

Kapiri-Mposhi, Zambia

2009-04-18T08:16:00.000-07:00

“Two countries north of South Africa” is how I have had to describe Zambia’s location to most people. About the size of Texas, this is “real Africa,” chock full of most tropical diseases—with pandemic malaria, malnutrition, HIV, and TB. Compliments of the wonderful folks at the Massachusetts General Emergency Department who run the Maternal-Infant-Health Initiative (Thomas Burke, M.D. and Roy Ahn, M.D.), I got an opportunity to work and teach at a rural district hospital in Kapiri-Mposhi for a month. What an experience!

Our mission was to help supply sustainable medical advances, especially to improve pediatric and maternal health, which is a critical problem in all of sub-Saharan Africa. Some of our team’s accomplishments in the short time we were there included teaching formal classes to the clinicians, and then doing bedside teaching on:

the placement of intraosseous needles (a nurse-midwife is doing her first one in the photo-right),

neonatal resuscitation, (Below are the resuscitation and post-resuscitation--normal child--photos.)

and the use of the portable ultrasound machines that the program had supplied to them for obstetrics and other (chest, abdomen, fractures, hydrocephalus) uses.

We also showed them how to make an inexpensive (~$10) neonatal warming lamp that rapidly became a routine part of their medical care. Normally, the infant is placed on the bed, below. But with the severe preemie shown below, brought in many hours after a home delivery with an unmeasurably low temperature, holding it up to the light before instituting "kangaroo care" was the best option. The child died several hours later.

Supplementing Dr. Katamba, the sole local (actually from the Congo) physician, our team, at various times, consisted of (left to right) Suzy, Maria, Joe, me and Lynda (not shown).

Maria Mennicke, M.D. (above and right), a Swiss-German surgeon in a fellowship at Mass Gen Hospital, who primarily taught OB ultrasound to the midwives, but was also a great cook,

Joe Novik, M.D., about to become an emergency medicine faculty member at Bellevue Hospital in New York City, who helped in pediatrics and taught non-OB ultrasound,

Sujatha (Suzy) Prabhakaran, M.D., our obstetrician, who was instrumental in teaching manual vacuum extraction, OB ultrasound, and obstetric techniques,

Lynda Tyer-Viola, RN, Ph.D., a Mass Gen Hospital nurse midwife-educator, who helped keep us on track and who is trying valiantly to find funding to keep this invaluable program going past September 2009.

Calum McGregor (left) and Humphrey Chibilika (right) were our country and local program managers. Without them, none of this would have worked. Dr. Alfonso Vaccaro (center) departed as I arrived, but left me with the invaluable resource, “Oxford Handbook of Tropical Medicine.”

We also practiced medicine under the most austere circumstances, successfully treating—without monitors (this is the standard OB stethoscope they use), bedside labs, or nearly any other “routine” facilities—

the frequent cases of cerebral malaria (this child, arriving in coma, went home a week later),

severe malnutrition (kwashiorkor, and occasionally pellagra and marasmus) due to their protein-poor diet, whose staple was the maize dish, nshima,

and a multitude of tropical diseases, such as cutaneous larva migrans

hypersplenic malaria syndrome (The patient’s spleen tip is ~1 inch above her pubic symphysis),

and puff adder (venomous snake) bites--with a photo of the culprit's cousin, below.

Our team effort made a real difference that will be sustained long after anyone remembers that we were there. This type of program, rather than the multimillion dollar boondoggles so common throughout the world, is what really makes a difference “on the ground.” Hopefully, funders will see this and continue these efforts.

Who’s calling?? Really??

2009-04-17T09:20:00.000-07:00

My home phone rings and a very nice voice says, “This is Dr. Harry Owens.” Although I’m expecting his call, just the fact that it comes through clearly and seemingly, with little or no delay is startling. After all, he’s calling me from the “South Pole.” Actually, as he explains, he is the lead physician at the McMurdo Station on the edge of the Ross Sea in Antarctica.

That is quite a way to either the geographic South Pole (where there is a much smaller station that McMurdo supports) or the magnetic pole, which over (or under) water.

Why is he calling? As part of my interest in international and disaster medicine, I thought that a stint as physician in one of the most remote places on earth would be fascinating and educational. I understand that it will be a bit different, taking care of a relatively closed community in a very inhospitable environment. Shackelton and his crew survived after his ship, the Endurance, was crushed by the sea ice. So, it can’t be that difficult, right? Who’s calling?? Really?

What makes this opportunity interesting and exciting are the difference in the patient community, the chance to hobnob with really smart scientists and support personnel, and the difficulties in communication, consultation and evacuation. Of course, there’s also the scenery.

I’m hoping to meet Dr. Owen, who has had an adventurous medical career, not waiting until retirement to do so. Born in rural northern Arizona (see, we already have Arizona in common), he spent a long time as the “boat doctor” on the Amazon River. That’s where he learned Portuguese. Subsequently, he has worked with poor populations in Guinea-Bissau and other African countries.

Why were we talking? It was actually the “technical interview” for the position that begins next September (or earlier). We’ll see what transpires. If you’re interested in this type of position, it goes through Raytheon Polar Services, based in Centennial, CO (www.rayjobs.com/index.cfm?NavID=21&CFID=2086470&CFTOKEN=79932663).

Update (April 8, 2009—My birthday!): I was notified that they would like me to serve as Lead Physician for the Austral summer season. Of course, I accepted. More about this later.

Local boy makes good

2009-02-26T04:18:00.000-08:00

When I’ve seen the president speak to congress over the years, I never dreamed that there was a virtual army of people helping to support the effort. When President Obama spoke to congress this past Tuesday (originally called “State of the Union,” but altered to conform to historical precedent), I returned to my native Washington, DC to be part of the effort. When virtually all of the U.S. government hierarchy is gathered in one place, a bit of security and medical preparedness is in order.

Deployed with a very experienced 5-person “strike team” from our AZ-1 Disaster Medical Assistance Team (an emergency nurse and 3 field/flight paramedics), we were only one of 5 such teams from around the nation to be on standby for any untoward events. The “army” consisted of large hazardous materials teams, some of whom were set up on the Capital’s front lawn, military medical teams, personnel from Congress’s Office of the Attending Physician (OAP), the DC Fire Department’s EMS system, and others. That, of course, didn’t include the hordes of security folks.

After a several-hour-long briefing, our team was on the “front line,” being stationed across the street from Capital in the Rayburn Office Building. Generously hosted by the OAP nurses, we were joined by an experienced U.S. Navy medical team from Bethesda Naval Hospital (also equipped with a full complement of emergency medical gear) and a Capital policeman to guide us to where we might need to respond. The clock above our heads in the photo has lights and buzzers signaling what Congress is up to (voting, in session, adjourning, etc.).

The Navy team was led by LCDR J. Michael Ray, a maxillofacial surgeon. A fascinating and dedicated health professional (planning on an academic career once he leaves the Navy), his trauma experience has included being the triage officer during a massive 12-hour fire aboard a nuclear-powered carrier a couple of years back. True to the spirit of excellent emergency medical care, the key element of his story was remaining calm in the midst of disaster. Well done!
Thankfully, there were no incidents. About 11:30 pm, we all packed up and went home. An instructive, but happily uneventful mission. Now, off to Zambia!

Ship of State: Hospital Rebagliati, Lima Perú

2008-11-30T10:26:00.000-08:00

With about 1,400 inpatient beds, Lima’s Hospital Edgardo Rebagliati Martins is more a small city than simply a healthcare facility. From a distance, it appears to be a large cruise liner parked near Lima’s core (photo). So, of course it needs its own “hospital.” That is its emergency department with not only a “Shock-Trauma” room (up to 6 patients, but only 2 monitors and often only 1 or 2 stretchers), but also separate areas for admitted critical patients (ICUs), overcrowded wards for dozens of admitted stable patients (female and male wards--photo, below), a chest pain/cardiac area (photo, below) that often held overflow admitted ICU patients, and a series of areas (tópico) in which to evaluate all other ED patients.
The first thing to mention is that the emergency physicians working there are world class. They often must bounce among the various areas during each 12-hour shift and still know all their patients. One area that has a constant presence during weekday day shifts is triage. Dr. Walter Guzman (photo) practices elegant emergency medicine in the most trying circumstances. With only a desk and a chair to work with, he must rapidly assess the myriad of patients presenting through the ED portal, determine the severity of illness, and direct them to the proper 24/7 tópico—shock-trauma, medicine (photo, below), surgery, trauma (i.e., orthopedics), urgent care, or in some cases, for an appointment or to another hospital or clinic—especially if they are part of another Essalud hospital’s system and they aren’t unstable. (Any unstable patient that presents gets seen, whether they “qualify” for Rebagliati or not.)

Occasionally, pediatric or OB/Gyn patients show up at triage. While Rebagliati has emergency department specifically for those areas, they are on the far side of the complex—a long distance.

Most of my time was spent bouncing between triage and shock-trauma, the two areas most akin to modern emergency medicine. Why the emergency medicine residents don’t spend time in triage is something I can’t understand. Rapid assessments and decisions (akin to Sherlock Holmes’ method) is at the core of our specialty.

Demonstrating both the best and worst aspects of Rebagliati, when a middle-aged man arrived in Shock-Trauma hypotensive and tachycardic at 200/minute (supraventricular), there was no stretcher on which to put him. One of the two monitors was disconnected from another patient so he could be monitored. (The lack of monitors led to often asking “Which patient is on which monitor?”—often, one monitor was being used simultaneously for different measurements by more than one patient.) That demonstrates an obvious problem with a quick fix.

The second part of the story shows how good Rebagliati's emergency physicians are. Dr. Carmen Vela, without a moment’s hesitation, grabbed a thick blanket, put it on the floor, and carefully lowered the patient to his “bed.” (photos)

Readying the defibrillator, she then administered verapamil—with almost immediate success. The patient beamed a smile at the staff; the physicians were rightfully concerned about how they had to improvise beds and monitoring in such a large institution. In reality, putting patients on the floor is rare, even at Rebagliati, although they often must remain in wheelchairs for quite some time. In my nearly four decades, I have only seen a critical patient urgently put on the floor for treatment only once before—at Montreal’s Royal Victoria Hospital. So, I guess Hospital Rebagliati is in good company.

Belying the Emergency Department’s crush and confusion, the ICUs and wards are calm and spacious. (photo)

With no more than 2 beds to a room on standard medical/surgical floors, every room has a panoramic view of the city—much better than in most 5-star hotels. ICU beds consume about 10% of all the hospital’s beds.

All the emergency physicians were very gracious and helpful. Wanting to be a real part of the team, Dr.Rolando Vásquez Alva (center, below--his wife took me on a tour of the Hospital de la Solidaridad system) literally gave me the shirt off his back. It was the white scrub top with “Médico—Hospital Rebagliati” on the pocket.

I wore that the rest of my time there. Giving a talk every day, two were to Emergency Medicine residents and the others were to the asistentes (attendings).

They didn’t laugh at my Spanish and even asked great questions. Muy amable!

Since this experience was through Healthcare Volunteers Overseas (http://www.hvousa.org/), and was the first time they had an emergency physician work with them, a few additional comments are in order.

First, if you cannot do at least passable Spanish, don’t bother. Emergency Medicine, unlike medical specialties, does not lend itself to translation; things move far too quickly. Second, without Spanish, I probably would never have even gotten to Rebaliati’s ED.

Taking a cab to the hospital’s main entrance on the first day, I wore the Essalud white coat/mandil I had purchased my first day at Hospital Almenara. This allowed me to easily pass the myriad of guards and guardians at the various portals. I then went straight to the “gerencia” (office of the network director).

Once there, the secretary started by asking me for my “papers.” I had no papers but, luckily, I did have the name of the administrator coordinating the program for Essalud. A lot of running around followed, but eventually I got back to the same office and was ushered into the gerente (director’s) office. “How can we improve our emergency department?” he asked in Spanish with the hospital director looking on. Luckily, having already worked in two other Essalud hospital EDs, I could quickly tell him that the hospital (1) needed more ED beds, (2) more Emergency Physicians, and (3) more Emergency Medicine residents. Monitors weren’t on the list, but I know my colleagues at Rebagliati are pushing for them.

Hospital Rebagliati’s Emergency Physicians are overwhelmed, understaffed, and lacking vital equipment (beds and monitors, at least). However, their persistence and excellence will, I’m sure, prevail to improve the system. Really. Really!

Healthcare Containers—Hospital de la Solidaridad System

2008-11-29T17:43:00.000-08:00

What can you do with a lot of abandoned container trucks and some abandoned land? How about building “private” hospitals to serve the poor? The idea of Dr. Luis Castañeda Lossio, formerly the director of Peru’s Institute of Public Health and now Lima’s mayor (second term), his idea was to provide high-class medical care at extremely low cost. Five years ago, the first Hospital de la Solidaridad opened to serve Lima’s northern area. Housed in a seemingly endless line of cargo containers, virtually every medical specialty and normal hospital service (except overnight admissions) is provided. What a concept!

The cargo containers (except for their walls that are unvaryingly corrugated metal) have been transformed into warm, seemingly spacious, well-lit clinics. Many of the doors are sliding glass, further obscuring the containers’ original use.

Whereas a visit to private Peruvian clinics often costs the equivalent of $50 US or more, a consultation at Hospital de la Solidaridad costs 1 ½ NS (about 50¢ US). Similarly reduced prices are offered at their fully stocked pharmacies and for high-tech procedures, such as CT scans (offering the latest in three-dimensional reconstructions) and surgery. In some facilities, the ORs, equipped with the modern surgical and anesthesia equipment, are used for surgery under general anesthesia.

It’s no wonder that the system now boasts 14 such facilities, with many seeing 4,000 to 5,000 patients a day. Their medical staff are all specialists,

including physiatrists (and a full complement of physical therapy services), psychiatrists, dentists and oral surgeons (most of the dental chairs have televisions sets attached for the patients to watch; the patient in the photo is waving "hola" to the camera), optometry (with eyeglass services), and ophthalmology, pediatric surgery, cardiology, endocrinology, etc. Rather than waiting months for an appointment at a government hospital, patients usually get seen the same day they come to the clinic—and often can have any necessary procedures done that day or the following day.

On-site laboratories provide most test results within 1 hour. Most notably, people coming to the hospital are treated like private patients by a staff that is unwavering in its pride for their system.

Two items struck me as being so unique that they deserved a special mention. One was the massage area for patients. According to the staff, it helps relieve patients’ stress. You bet! Also, although these facilities were designed for Limeños living in the heart of Perú, all the clinic signs are in both Spanish and English. Why? Because, as was explained to me, foreigners also use the facilities when they get ill, and they want them to feel welcome. Now, if we could just get U.S. hospitals to provide bilingual signs.

The Solidaridad hospital system's business model is described as “public-private.” Clinicians (usually on days they are not working at other facilities) get to work in nice surroundings and in fully equipped offices. They get a percentage of what they earn. The rest goes back into the facility.

The remarkable quality of the service was recently demonstrated by a university study comparing patients' perceptions of the service provided by Hospital de la Solidaridad compared with the other generally available services (Ministerio de Salud and Hospitales de Essalud).

You may wonder how I got to see this intriguing system that should be a model for similar systems throughout the world. It was complements of Lic. Carolina Vasquez (right, in the photo, below), a dynamic public health nurse and ardent advocate for the Hospital de la Solidaridad system who, I have no doubt, will eventually play a large part in the functioning of Perú’s entire healthcare system. (I worked with her husband, Rolando Vasquez, M.D., an excellent emergency physician and great guy, in Hospital Edgardo Rebagliati Martins.)

The question is: If Lima, Perú can develop this fantastic healthcare system, why hasn’t it been copied in the rest of Perú, Latin America, and elsewhere in the world? It took one mayor’s vision, some empty cargo containers, and strips of empty land. It’s about time that inexpensive, comprehensive, and respectful healthcare was available to all. Really. Really!

How high can you go? Cusco and Machu Picchu, Perú

2008-11-29T14:53:00.000-08:00

Located in the Andes 11,203 ft. (3,395 m) above sea level, Cusco—pronounced “Cosco” in Quechua (photo)—is a UNESCO cultural heritage city and the gateway to Machu Picchu. Originally, Cusco was the Inca Empire’s capital, known as the “navel of the world.” Built in the shape of a sacred Puma, it still has the amazing megalithic Sacsayhuaman as the head. In the photo, notice how the Incas perfectly shaped multi-ton stones so that they fit perfectly without mortar—and have not collapsed despite numerous earthquakes (photo).

Since I had the opportunity of spending a week there while working in the emergency department of the city’s Es Salud Hospital, I took the opportunity to explore the city as well as Machu Picchu, world-renowned Incan religious site. First off, the food was excellent! Everything from their traditional dishes, such as causa—potato layers with chicken and avocado (photo), to their unique type of pizza from wood-fired stoves. They also have several traditional mercados (markets), all with Quechua selling traditional foods, such as the woman (photo) sorting through mushrooms for some customers.

The first question, of course, was how could I quickly accommodate to the altitude? Adjusting to the altitude is vital, since some of the archeological sites around the city are at even higher elevations. Some preplanning helped, since it required a prescription medication. Acetazolamide (cabonic anhydrase inhibitor) 250 mg twice a day until any symptoms resolve limited my dyspnea when climbing some of the steep areas in the city and at the scenic sites. (Ginko bilboa is also supposed to help, but I didn’t try it.) A quaint Cusco custom is that visitors are asked to sit down on arrival at their hotel and drink a cup of cocoa tea. Does it help? Who knows?

My first surprise was that I was staying at a small bed and breakfast, the Casa Residencial Lecaros (Calle Centenario 649). It turned out to be great. The accommodations were spacious and clean. Breakfast was great and differed from the typical tourist fare. It was also “down the street” or “around the corner” from nearly anything worth seeing or doing in the city. But, without a doubt, the fantastic element that cannot be duplicated elsewhere is Nataly Lecaros, the tiny bundle of energy that manages the residence (Photo of her running to open the front gate. Did I mention that the place has excellent security?).

Nataly, (photo) a Cusco native who loves her city, adores talking with her guests—in English, Spanish or, if you are really daring, in spotty Quechua. Personally, our discussions were a wonderful addition to my “Spanish immersion” experience as well as providing amazing insights into the local culture and politics. She also knows everyone in the city and can quickly arrange nearly anything or solve any problem with some quick phone calls.

She also pointed out how to best use the tourist admission card I bought—including a wonderful but little-known cultural dance presentation (video). She also invited me to a guitar concert by a Lima-based, internationally known classical guitarist. Her brother was the lead violinist for the string quartet that backed up the maestro.

Not on any tourist card, but a fascinating find, was finding escritores, people who typed out letters for those who couldn't write. I found both a mural depicting them (photo) and the real thing on a little-used side street (photo).

Of course, I took a day to visit Machu Picchu, which is actually at a lower altitude than Cusco. Leaving before the sun rose (la madrugada), I took the train (photo)

to Aguas Calientes,the world's ultimate tourist trap built at the base of the mountain. Since I booked a “package,” a guide met me and was able to take my pack while I was on the mountain; I thought it best to keep the pack, since it contained my rain gear and the all-important water.

The bus trip up the mountain is, using the old Disneyland designation, an “A ticket” ride. It’s not the altitude or the amazing scenery, but rather the near collisions with descending busses that makes you think that the end is near; it isn’t. (photo) According to a local guide who sat next to me, there has never been a significant bus accident on the mountain. And, in fact there seem to be no dents on the busses (or any bus carcasses visible over the side of the mountain road).

Machu Picchu, built on the top of an Andean mountain, with agricultural terraces below, evokes a mystical aura, even in hardened and cynical travelers. While much of it has been reconstructed, enough remains of the original (per initial photographs) that it is an authentic Incan site. Never conquered by the Spanish, it remained virtually undisturbed for hundreds of years until its “scientific discovery” by Yale’s Hiram Bingham in the early 20th century. What amazes me is that Bingham scaled the mountain covered with jungle overgrowth on a hunch that something there might be of interest. Once he got there, he didn’t think it was. Wrong! Of course, he returned shortly thereafter and began the site’s scientific exploration. (Most of the artifacts are at Yale University, but negotiations are underway to return them to Perú.)

Pictures do more than words to show Machu Picchu’s splendor (photos).

After a lunch of alpaca (it was really good; I didn’t try cuy—the traditional guinea pig), I wandered around Aguas Caliente until in the late afternoon I departed on the train at my assigned time—and in my assigned seat. The trip is way too long—but it’s worth it. Since I was to begin work in Cusco’s Es Salud Hospital the next day, I could not spend the night. That would have lessened the hassles and permitted me to go up the mountain again the next morning. Maybe next time.

Cusco and Machu Picchu are both world class destinations. Peru and Peruvians are wonderful. Go and enjoy. De veras. De veras!

(My) Tale of Two Hospitals—Perú

2008-11-23T17:26:00.000-08:00

My work with Peruvian emergency physicians began at two large health centers. Although both are tertiary care referral hospitals in Perú’s Es Salud (Social Security—photo) system with its own set of referral clinics and hospitals, working in each highlighted their uniqueness.

A little background is in order. The Es Salud system cares for the country’s workers, retirees, and dependents. Other parts of their medical system include hospitals of the Ministerio de Salud (General Hospitals) for the poorest part of the population, military/police hospitals (the main Air Force Hospital has an emergency medicine residency program), and a wide range of private hospitals/clinics.

The first place I worked was at Hospital Almenara (photo), which resides in one of Lima’s (probably ~8 million people) poorest and most dangerous areas.

A structure worn down by time and overuse, it nevertheless boasts impressive programs, such as a successful transplant center. Its emergency department has a small (and sadly, shrinking due to budget constraints) emergency medicine residency program. They now have just 1 high-quality resident per year (photo).

The quality of their emergency physicians matches that in any of the world’s best emergency departments, but are divided between emergencioligos (residency-trained emergency physicians) and emergencistas (other specialists working in the ED).

Most patients are sent to the medicine, surgical, obstetric or pediatric consultorios (examining rooms) for their initial examination and testing. These specialists care for the patients and put them in their observation areas if they need admission or watching. If they are too sick, they are sent to the critical care observation area (photo), run by the emergency physicians. Patients who are initially too sick to go to the specialty areas enter the shock-trauma room (they get very little trauma), also run by the emergency physicians. Like elsewhere in the world, getting patients into a hospital bed takes many hours, sometimes days—even when they are on ventilators in the critical care area. On average, half the patients in the critical care area are intubated at any time.

In contrast, Hospital Nacional Sur Este—Cusco looks like it was built last week, although it is 20-years old. Clean and spacious, its clinics and ICU (but not its wards) are also overcrowded. Unlike Hospital Almenara, though, stretchers don’t line both sides of the ED hallway that makes the trot to Almenara’s shock-trauma room (when the quiet, but irritating buzzer sounds) a matter of trying not to step on people or get crushed by waiting family members as you quickly slither down the hall. Similarly, Cusco has specialty consultorios, but the emergency physicians run two of their own—for emergencies and “urgencies.”

What was the tool most often lacking? Carbon paper for the mountain of paperwork they had to complete. The photo is of the ED director, Dr. Paul Olivera in the emergency consultorio.

I worked in both and occasionally saw some of the adult patients' children who warranted one of my finger puppets (photo). This is one of the cutest--and she loved the camera.

The emergency physicians also run the adult holding/observation area and shock-trauma room (photos).

Pediatrics has their own holding area (photo). These twins have bronchiolitis.

Cusco, the gateway city to the famed Machu Picchu and Sacred Valley, means that many patients are Quechua, descendants of the Incas. Some, as with the woman was gracious enough to allow me take her picture (photo), speak no Spanish.

Yes, I did learn two Quechua words: wawa means baby and wasi means house. The first is bread that looks like a Jewish cholla. The other is part of the name of many hostels and restaurants.

Another striking thing is the number of patients with polycythemia. Cusco is at about 10,000 feet, so when people come in with headaches, short of breath, and very red palmar creases, they are probably destined for therapeutic phlebotomy (photo). The patient shown had a hematocrit (blood count) of 68%, about 50% higher than normal.

The similarity between the two experiences was that my colleagues at both institutions were top quality practitioners who want to improve Perú’s emergency and disaster care. They’re very serious about this and have plans to do this. With the frequency with which Perú suffers from disasters in some part of the country, it is amazing that they haven’t done more to advance the specialty that, rightly enough, Perú calls “Emergency and Disaster Medicine.”

A word about my own experience is order for those who may want to follow. (I’m working here through Healthcare Volunteers Overseas—www.hvousa.org. The photo is of Gastón Barenchea, an orthopedic surgeon who is the local HVO coordinator and Constance Lopez, a physical therapist and HVO volunteer.)

Workable Spanish is essential to get the most from this experience. So is clinical expertise. For example, when they asked this extranjero to intubate a patient (photo), it was good that I made it look so easy and fast that the word quickly passed among the staff that I actually knew what I was doing. (It was a really easy intubation—but without all the usual equipment.)

Unlike other HVO physicians, I gave only one formal talk at Almenara and one—with the topics given to me about 15 minutes before I started—at a private clinic; I gave four talks at Es Salud in Cusco. All talks were in Spanish. Most of my time was interacting one-on-one with the emergency physicians, examining patients with them and discussing treatment options and differential diagnoses.

My EM colleagues, most of whom are under age 40, are smart, well-trained, and practice emergency medicine with the same direct, rapid, no-nonsense approach to diagnosis and therapy taken by the best EM physicians everywhere. Besides that, they were extremely gracious, treating me to traditional Peruvian fare—I skipped the cerviche (raw fish) and cuy (guinea pig), thank you very much—and invited me to their home for dinners and even a spouse’s birthday party (photo).

My impression, after working at two of the four hospitals I will be at in Perú is that Peruvian emergency medicine is alive and well and, if the Peruvian population’s best interests are considered, will become a large and vital part of the country’s medical and disaster system. Really. Really!

Peruvian Emergency Medicine: Alive and Well

2008-11-13T14:23:00.000-08:00

Yawn . . . Another medical meeting: predictable, boring, and with many suboptimal presentations. That is NOT a description of the recent meeting of the Peruvian Society of Emergency Medicine and Disasters (Sociedad Peruana Medicina Emergencia y Desastres) held in Lima.
The tranquil darkness and comfortable seats at Perú’s emergency medicine meeting belies the frenetic, often crushing milieu in which most of the participants work. For 3 full days, we gathered with our Peruvian colleagues to exchange information and to hear Peruvian and international emergency medicine specialists discuss vital topics in hospital-based emergency medicine, prehospital care, and disaster medicine. Disasters were, of course, the meeting’s main focus, since it was held in Perú.
Peruvian physician can talk about disasters authoritatively since the country frequently has a wide variety of different natural disasters (earthquakes, tsunamis, mudslides, fires, and epidemics). In fact, every public gathering begins with an announcement of where the exits are in case there is an earthquake. They’re really serious about this—as they should be.
Unlike similar meetings in the United States, this was a real international meeting, with presentations from emergency physicians from Argentina, Columbia, Panama, Mexico, the United States, and from the Pan American Health Organization (PAHO).

Two of the talks were by Dr. Alberto Machado (above), past president of the Argentinean Society of Emergency Medicine and co-author of the excellent new Spanish textbook, Emergencias (EdiMed, 2008). All the talks were great! And, of course, all were in Spanish.

My presentation, Improvised Medicine, was in rudimentary Spanish. But, since Peruvians are so polite, they were a great audience. Subsequently, I had lots of very enthusiastic comments about that talk—with the great question: “When will the book come out?” (Autumn, 2009, Cambridge University Press—but initially, only in English, is the answer.)
This was a long meeting. Twelve hours a day for 3 days. And then, of course, there were the festive dinners (Loma saltado, below)—and lots of the traditional, very potent drink, Pisco Sours. One, such dinner, with dancers and dancing (a whole other story—some of which was posted on YouTube), went on until 2:30 am.

We started again at 8:15 am. Whew! I was tired. I don’t know how they do it on a regular basis.
So, you missed the conference? Good news! Within a few months, the http://www.reeme.arizona.edu/ site will host the slides for nearly all the talks. Of course, you have to be able to read Spanish.
To my Peruvian Emergency Medicine colleagues, especially our host, the Society’s president and one of Perú’s most respected physicians, Dr. Nelson Raúl Morales-Soto, thanks for the wonderful conference! It demonstrates how far the specialty has advanced in Perú—and how close you are to becoming one of Perú’s major medical specialties. Really. Really!

Election night—Perú

2008-11-09T05:20:00.000-08:00

International travel means meeting new people, experiencing different cultures, and trying new cuisines. There are, however, a few times when being immersed in the American milieu seems to be essential. One of those is election night.
So, with that in mind, and just having arrived in Perú at 5 am that morning (no sleep, of course), I sought out an American contingent with whom to watch election results. Where would Americans gather? A bar, of course. So, after some inquiries by the fine staff at my hotel (the small Hotel Casa Andina Classica on Ave 28 Julio), I discovered that “The Corner Bar” was where lots of Americans would gather. It was only about 6 blocks away.
Not really knowing what to expect, I wandered into the sports bar at about 6:45. The East coast polls were about to close and I wanted to hear the first results. I don’t frequent bars, so I really didn’t know what to expect. But, and adventure is an adventure.
Only a few folks were sitting around. One of the TVs was tuned to the election, but the few patrons didn’t seem interested. “?Hay un grupo para observar los resultados de la elección?” I inquired. The bartender pointed upstairs, so I headed for the stairs.
Indeed, the second floor had 15 televisions, all turned to election night coverage. The few Americans and their Peruvian friends (often spouses) began drinking while energetically discussing American politics. “You know,” said one, “they had to turn away more than 100 people for the last debate. I couldn’t get in it was so crowded.” It was 7:30 and only about 1/3 of the chairs were filled, but within an ½ hour, the place was a mob scene as the first results trickled in.
During the debates, the bar reserved one section for Republicans—with TVs showing Fox, of course. The other section (larger) was for Democrats and had CNN. Internationally, except for the business folks and politicians, I’ve found that most of the Americans I meet are Democrats—often very liberal. But that makes sense. These are people who appreciate other cultures and understand that there is a world beyond our borders. But, I digress.
Tonight, only one TV was tuned to Fox. Loud cheers erupted as Obama took and held the lead. Alcohol was served to some tables in giant beer bongs, tall tubes with spigots. I stuck to Pisco Sours, the Peruvian national—and pretty potent—alcoholic beverage. Okay, somehow I had forgotten my wallet. The other Americans were generous enough to buy my drinks. Thanks!

By 8:30, everyone was in a joyous mood—due both to alcohol and Obama’s success. I never met a Peruvian (or any of the many people from across Latin America) who was not rooting for Obama.

Around 9:30, I peered over at the Fox screen. What?? They had just declared Ohio for Obama. CNN was still stewing over the results. I yelled, “We won!!” but only a few folks could hear me over the din. At my table, they asked me what I meant. Well, being marginally able to add at that point (2 Pisco Sours and about 35 hours without sleep), I pointed out that with Ohio plus the 77 electoral votes on the West coast and Hawaii, Obama had gone over the 270 he needed. “Really?” they asked. “Really??”
Yes, I assured them. We won.
Great night for America—and the world. We all won. Really. Really!

DO YOU REALLY WANT TO DO THIS?

2008-10-29T07:41:00.000-07:00

Do you really want to do international or disaster work? Really? Really?

When doing this work, the rewards are personal; your effect may be minimal; and the physical and emotional stresses may be significant. Yet, there is no doubt that participation in international medicine and disaster relief can be worthwhile endeavors, if you know what you are getting into.
Having counseled thousands of medical students about which specialty to enter, my key question is: “What is the downside in going into the specialty of [fill in any specialty name]?” That, of course, includes my own specialty, emergency medicine. If they don’t know the negatives about a specialty they are entering, they have an increased likelihood of being unhappy with their career choice. They won’t know whether the positives (they always can list most of the specialty’s positive aspects) sufficiently outweigh the negatives to make the choice what they want. (I emphasize that advice when I speak at medical schools, medical student conferences, and in my book, Iserson’s Getting Into A Residency http://www.galenpress.com/.)
So, with that in mind, here are two excellent, well-written articles providing a glimpse—and lots of practical information—about international medicine.

International medical work. For a general overview of everything you should think of before enlisting in an international foray and many sources to go through to get various kinds of experiences, read:
Preparing for international medical service. By Suzanne Sarfaty and L. Kristian Arnold. Emerg Med Clin North Am. 2005 Feb ;23:149-75. (www.med.umich.edu/medschool/global/er4.pdf)
These two physicians, with lots of international experience, have described the personal qualities necessary for an international health experience, the practical and mental preparations to undertake in advance, and the willingness to work in a different culture and under what may be austere conditions. This article is unique, in that rather than providing the generic platitudes that populate other articles on this topic, it has very practical information that potential international healthcare providers can use to find an organization with the right “fit” and to get themselves ready to go—or to make a reasoned decision to abandon the idea completely.

Disaster work. So, you want to do disaster relief work? You want to hop on a plane and go help those poor people on the other side of the world (or in another state) that just suffered a major disaster? Not so fast! Most people are surprised to learn that a massive influx of well-meaning, unorganized volunteers from outside the affected area is generally not needed or desired.

Unless you are part of an organized and experienced team, you will probably only get in the way. If you don’t believe me, read Sherwin Nuland’s article. Dr. Nuland is a surgeon at Yale an and amazing medical writer who did just that after the 2004 Tsunami hit Southeast Asia, killing nearly 300,000 people and displacing millions from their homes. He describes how naïve it was to immediately hop on a commercial plane with 6 compatriots and go to Sri Lanka to help.
A report from a relief mission: after the deluge. By Sherwin Nuland The New Republic. 2005 April 11;232(4708):30-33. (http://74.125.45.104/search?q=cache:66SZcRV0DyYJ:209.212.93.14/doc.mhtml%3Fi%3D20050411%26s%3Dnuland041105+Nuland+%22a+report+from+a+relief+mission%22&hl=en&ct=clnk&cd=1&gl=us)

He wrote: “I am not sure just what it was that made me drop everything on December 31 and join six colleagues on a medical relief mission to Sri Lanka. At the moment I made the decision, it simply seemed like the right thing to do, and in retrospect it still does. But it turned out that the need for our small group was very different than we had anticipated: there was far less acute disease and injury than expected, but the human misery was of a sort that will require attention for years to come. In a strictly clinical sense, we accomplished far less than we had hoped. . . . Disaster relief is only the most immediate kind of relief that this punished place requires. . . . In retrospect, we were like an amateur and astonishingly naive flying squad or rapid-response team. . . . I had brought with me a set of surgical instruments to be used as though in a field hospital, assuming that my principal work would be to treat the late consequences of major trauma. I was wrong. The tsunami had an effect similar to that of September 11, when emergency rooms all over Manhattan prepared themselves for an influx of the seriously injured, and very few came. The reason was the same: almost everyone caught up in the disaster was killed.”
We saw this after Hurricane Katrina, when hundreds or thousands of medical and rescue personnel showed up from as far away as France, Japan, and Israel. But by the time they arrived, enough resources were in place. These extra folks simply used resources that were needed for the local population. The only exception was the Canadian Rescue Team that responded as soon as the Hurricane hit, did hundreds of rescues, and left before nearly any other outside resources could mobilize. Way to go Canada!
If you are really interested in doing disaster work, join your Disaster Medical Assistance Team (www.hhs.gov/aspr/opeo/ndms/teams/dmat.html), Medical Reserve Corps (www.medicalreservecorps.gov/HomePage), Red Cross disaster team through your local branch, or a similar group. That way, you will have the necessary training and logistical backup when the time comes to respond—and you will be welcomed.

So, do you still want to do this? Really? Really? (with apologies to Rachel Maddow.)

2008-10-26T15:28:00.000-07:00

Flexibility is the name of the game in international and disaster medicine. I have seen that repeatedly while working with the Disaster Medical Assistance Team and in various international venues. Two examples:
I will be leaving to teach improvised medicine in Peru in a few days. That trip is through both the organizers of the Peruvian Congreso Internacional de Medicina de Emergencias y Desastres and an international healthcare educational organization, Healthcare Volunteers Overseas (HVO).
At the Congresso, I will be speaking to a very large audience of emergency medicine clinicians on Medicina Improvisada. Since the Peruvians are great hosts, I suspect that a lot of wining, dining and conviviality will also occur (this is a photo from the 2006 Peruvian EM Congress).
Following this, I’ll be giving talks to healthcare professionals at various public hospitals in their Es Salud system. The topics will again be based on my new book, Improvised Medicine: Delivering Care with Limited Resources (Cambridge University Press, 2009). All the talks will be in (gringo) Spanish, although they have also offered a translator. I’ll concentrate on OB/Gyn, Pediatrics, Orthopedics, and general improvised medicine topics.
So, what is HVO (https://www.hvousa.org/index2.htm) and how can you participate? HVO (photo of logo) is a non-profit organization that sends healthcare professionals from the academic and private sectors from the US and Canada to various countries around the world to train local health care providers in: anesthesia, burn management, dentistry, dermatology, hand surgery, hematology, internal medicine, oral and maxillofacial surgery, orthopedics, pediatrics, nursing education, physical therapy and wound management.
You don’t see emergency medicine listed? So, why am I going? That’s where flexibility—on everyone’s part—comes in. HVO was willing to suggest to the Peruvians that they might want emergency medicine clinicians—and they agreed. I’m kind of like the parakeet in the mine. If I don’t keel over (and if both the Es Salud audiences and I think that the experience is worthwhile), they may send more folks in my specialty. Personally, I think it is a great idea.
Much more information is available on the HVO web site. But the key information is that they currently have HVO projects in Africa, Asia, Latin America, Eastern Europe, and the Caribbean. Currently HVO supports over 70 projects in more than 25 countries. Volunteers generally serve for one month, but there are some sites where one may serve for two weeks. There are opportunities for longer placements if a volunteer has the time available. Unlike some other NGOs (non-governmental organizations), spouses and families frequently accompany volunteers on their assignments. Often, family members are able to volunteer, even if they are not healthcare professionals. Volunteers pay for transportation to and from a program site. Many sites provide room, board, and daily transportation for volunteers once they arrive. HVO is a non-profit organization, so you can ask your accountant what you can deduct.
Oh yes, flexibility. Communication between HVO and Peru was often delayed, so information about exactly what I was to do was delayed until this past week. I’m sure that it may change once I’m there. No big deal, but simply a caution that rigidity does not serve you well in international medicine.
And, after many problems with communications between Doctors Without Borders (MSF) (www.doctorswithoutborders.org/index.cfm) and myself—seemingly due to an over-ambitious spam screener in our University’s e-mail system—I just interviewed with them in LA. I also got to visit their demonstration refugee camp in Griffith Park (photo at right). Amazing, but our guide through the exhibit was Bev Bauman, M.D., an emergency physician and MSF veteran whom I have known for a long time (photo below). Hopefully, I’ll be working with them in early 2009. But, you don’t know if, where and when almost up to the moment you go. Again, flexibility. Glad I’m “retired.”

Getting Ready--What retirement?

2008-10-20T09:43:00.000-07:00

"What kind of retirement is that?" is most people's response to my list of activites. "No, not retirement, just a more flexible career path," I reply.

I did officially retire on July 1, 2008, from the University of Arizona as Professor Emeritus after nearly 28 years on faculty in the Department of Emergency Medicine. My goal is to devote the rest of my career to international and disaster medicine. Let's see what has transpired so far.

July, August and early September involved 14- to 16-hour days finishing my newest book, Improvised Medicine: Delivering Care with Limited Resources. (My many other, non-clinical books have been published by Galen Press in Tucson; http://www.galenpress.com/)

Improvised Medicine describes how healthcare professionals can practice medicine after disasters, in Third World countries, in remote settings, or simply when the normal equipment they use is not available. Some folks have taken to calling it MacGyver Medicine. Unfortunately, a TV show took the name. The book covers all of medicine, but has extensive and detailed chapters on dentistry, orthopedics, and anesthesia, since many practitioners are not familiar with the commonly needed (and improvised) techniques that are often needed in remote or resource-poor settings. The anesthesia chapter, for example, describes how to administer open-drop ether--a technique that can be easily used by any healthcare practitioner, is available in many resource-poor settings, and very few modern anesthetists know how to do.

While the book manuscript was supposed to be sent to Cambridge University Press on September 30, Hurricane Ike intervened. I was deployed to Texas with the Disaster Medical Assistance Team. First, I went to San Antonio to help NY-2 (Bronx) and TX-2 (El Paso) staff the emergency medical part of a special needs shelter for evacuees.

I then was sent to the University of Texas-Medical Branch/Galveston emergency department to help FL-2 and FL-5 DMAT teams staff that facility. The medical campus is huge, but the only functional part was the emergency department--run only by the DMAT teams. Lots of very sick patients.

If you're not familiar with DMAT, it is a group of medical and support personnel who have real lives, but are willing to be called up (much like the military) when a national disaster strikes. Great folks! (The picture above is of the NY-2 team with a patient and me with the very cumbersome electronic medical record we had to use.)

Once sent home, I finished the book, more than 1,000 pages of manuscript, and sent it off. Now Cambridge U Press has it. Hopefully, it will be out in 2009.

All of November, I'll be lecturing and doing clinical teaching in Peru, complements of the Peruvian Emergency Medicine organizationa and Healthcare Overseas Volunteers (teaching at the public hospitals.) The photo above is when I visited Machu Pichu the last time I taught in Peru.

Tomorrow, I visit with the Doctors Without Borders folks in LA. We'll see how that goes.

Until next time, Think global, act local--but act!