Pasaquina

Isn’t it awesome when a plan comes together as a result of good leadership and teamwork?  Today we had both and were able to accomplish an incredible amount- finishing up with a morning seeing hundreds of patients in La Union, loading all of the equipment onto the flatbed trucks, transiting to the next site and offloading and setting up there.  We did all of this in about 8 hours and in 120-degree heat.  I have to give hats off to our Site Leader CDR Lefebvre, the Advance Team and all the others that worked in concert with each other to pull off a seamless and highly productive day.    

Our next workstation was at a school in a quaint little town East of La Union named Pasaquina.  If there ever was a town that in my minds eye was the quintessential Central American town as you might see in the movies or in storybooks, Pasaquina was it.   

We pulled into town around 2pm after we made it past the run in with the cows on the road a ways back, and were immediately welcomed by children running alongside the bus in their school uniforms waving and smiling.  I leaned over LT Jacobson to peer out the window at the incredible houses lining the streets, painted with bright pastel colors like pink, orange, green, and with traditional Aztec and Mayan symbols everywhere.  The roofs of the houses were all of the overlapping red curved shingles that are so typical of the Moorish/Spanish architectural influence.   We passed the town center square and main Iglesia (church) with a façade adorned with Roman columns and three gorgeous spires topped with crosses.  I snapped photos out the window of the bus, hoping some would turn out ok.  This was just too beautiful.  I turned to LTJG Sam Harris, a Navy male nurse (MURSE), sitting next to me and said, “I dig this place, it has a good energy about it.”  

Harris, who has been (attempting to) grow a mustache (Deployment Stache- Navy Tradition) said back to me “Baldwin, you taking more photos again?”  I snapped one of him and told him he’d be good on Reno 911.   Let me know what you think.   The other guy growing a deployment stache is my Canadian Murse roommate LT MacLean.  His stache is a bit more filled out.  The only time I grew a Navy mustache was during Dive School.  Our whole unit did in Panama City, Florida.  In fact my Diver ID card has a photo with a mustache. But I digress…. 

We reached the school and had to wait for a while as the security detail set up.  Out the window LT Jacobson snapped a shot of some of the kids.  They were loving the attention and started smiling and posing.  It was adorable.  When we finally got off the bus, and through the school gate, we encountered an open-air school, with classrooms connected, and a large canopy of trees above.  It was a perfect spot for a shaded medical clinic.  There were kids everywhere- running, jumping playing, whispering curiously about us Americans, and some had a large jump rope.  Before I could say “Hola” one of the little girls had placed one of the jump rope handles in my hand and the other in her friend's hand and she said “Listo!”  (ready).  We began to twirl the jump rope and the girl was jumping away.  A crowd formed and clapped to the beat.  After some minutes she took the handle away from me, the rope continued to turn, and she said “Vaya!” (go!).  I pointed at myself and she nodded yes.  Ah what the heck, here goes nothing.  

The girls swinging the rope were half as tall as me, but I got in there and jumped away with big combat boots on and half ducking so I could make it under the rope.   Did fairly well for a few minutes and then got bold and tried to throw in some dance moves and that was my downfall.  That, folks, is the story of how I came to jump rope in fatigues in the El Salvadorian town of Pasaquina.  I think that my friend and Army communication officer 1^st Lt Michaela Encarnacion probably has some incriminating photos, but it was worth it.  

We offloaded our gear and setup the school area to begin seeing patients the following day.  The shade was welcomed, as this was the hottest day we had encountered yet with the heat bulb hitting the 120-degree mark.  Navy MURSE and future Reno 911 star Sam Harris chatted up the owner of a nearby food/beverage stand.  His name was Oscar and his family was there making Pupusas and serving bottled beverages called FANTA Champagne and Fresca.  Both Sam and I were dubious of these drinks, especially the “Champagne” in a soda bottle, so we decided to try.  The El Salvadorian version of FRESCA is in my humble opinion the exact same thing as Mountain Dew, and as Sam related the Champagne tasted like Ginger Ale (and did not give him a buzz whatsoever). 

The school kids got out their brooms and mops and swept the area clean.  The children were so well behaved, and everyone we had met thus far in this town of Pasaquina was extremely nice.  

By 4pm that afternoon, under the leadership of CDR Lefebvre we were set up and ready to go for the following day.   Everyone boarded the bus and most of us passed out on the drive back to the COMFORT INN.  The food at this El Salvadorian COMFORT INN was so good it didn’t make sense.  In the United States I have not been to a Choice Hotel that has had a buffet like this.   The great part was that it was open from 5:30 pm until 11pm, so many of us ate when we got back from work at 6pm and then again before bed.  Comfort food never tasted so good.  

The next day we started early at 730am and were determined to see as many as possible in the town of Pasaquina.  Our general medical team of providers was made up of myself, LT Jacobson, CDR Schwartzman, Project Hope Ann, CDR Bruno Himler from the Public Health Service, and a few doctors from El Salvador Ministry of Health that were screening for H1N1.  

We got a group shot at the beginning of the day.  Dr. Schwartzman again set a blistering pace and we all strove to keep up.   The El Salvadorian woman Krisia was once again my translator, and she did a good job of keeping the health education, diagnoses, and stories between the patients and I flowing. Dr. Himler and Ann worked nearby and we would every once and awhile consult each other with questions or interesting cases.  As with every day, there were some incredibly sad cases that we simply could not do anything about, some cases where we were able to make a profound impact, and the majority of patients that we helped leave with some education, medication, and a smile.   For lunch, Dr. Himler gave Krisia some money to go out to the central market in town and she returned with big bags of fruit for us.  

We recognized the bananas, apples, lychee, and mangos, but one piece of fruit was there that none of us recognized- a soft Zapote.  I dug into it with my spoon and unearthed some mushy red stuff and sucked out a large smooth seed.  Krisia screamed to me “Don’t eat that!”   I’m not sure why.  I ended up spitting out the red stuff as well.   Couldn’t stomach it.  (Please don’t tell Krisia or Dr. Himler).  

Comparing and contrasting patients from the various sites we have been, I must say that the patients in Pasaquina are the most healthy yet, and have the best chance of being seen by a local medical clinic.  I attribute this to the small town atmosphere; the way people take care of each other and town leadership.  The Mayor himself passed through the site today, and when finished drove to remote areas outside town to spread the word of our presence.  He returned with dozens of these folks (many of them with Cowboy hats) and stayed until every single one of them had been seen and then drove them back to their homes.  Now that is caring for your people.  The name for cowboy in Spanish is “vaquero” derived from the word for cow “vaca.”  The sombreros (hats) of some of these cowboys here in El Salvador were amazing.   Studded with jewels, rocks, family emblems, etc.  

One of the cowboys let me try his sombrero on and I felt like an El Salvadorian for a brief moment.  Krisia asked me what cowboys are like in the United States.  I explained that the term described the men from the Wild West and was also used today as a descriptor in reference to a person who lives their life not always in accordance with the rules.  I think she understood.   That evening the movie “Space Cowboys” with Clint Eastwood was on TV at the hotel, which I found ironic and timely.   

Towards the end of the day we got word that we indeed HAD seen ALL of the adult patients in the town of Pasaquina and were close to the mark of 500 patients seen.  In an attempt to make that mark some began soliciting patients to be seen and some of the military guards with their M-16s were evaluated for “dolor de espalda” (back pain) and treated with some Vitamin M (Motrin).  By all means, they deserve it!  After standing outside in the blistering heat all day, I got them some water too. 

I just wonder if they passed through the lines to get a bracelet as the others had (given that these were the people they were guarding).  One of the guards I think had a crush on LT Jacobson.  He kept going back to see her again and again.   

Have you ever drunk wine out of a box before?  I know many of us are familiar with Franzia.  But, what about water out of a bag?  That is the way they do it down here in El Salvador.  The water comes in a clear plastic bag, they tear off the corner, and suck.   The tap water is not potable, so it is imperative for the people to consume clean water, and they have realized that bagged water is a much easier, and cost effective means than bottled water.  

The production costs, and trash volume are considerably less.  This makes the cost of such bagged water much less.  At the end of the day I was craving some ice cold bagged water, and for 15 cents I got myself one.  Snapped a photo first.  Check it out.  Doubles as an ice cold compress for head and neck as well.  Novel idea.  I actually recommended to my patients with knee and other joint pain to first use frozen bagged water to ice their injuries and then drink it.    

The following day was our final day ashore and we gave it one last final push to the finish led by Dr. Schwartzman.  Before we headed out and back to the ship I stopped into one of the corner stores run by a family from Pasaquina.  I wanted to get one last glimpse of this friendly town.  Inside I met five generations of a family names Reyes, including the youngest who was sporting a T-shirt saying “I love Mom”.  

The second eldest had fought in the El Salvadorian Civil War and spent his entire life otherwise in Pasaquina.  I shot the bolado with him for awhile in Spanish, about their new President Funes, about the stability of their the town, the Coup in Honduras, and about their family.  I even went so far as to inquire whether they could use a doctor like myself down here in this town.  Si, claro!  (Yes, for sure!).  “Quien sabe”, (who knows!), I told him. I might be back before I know it.  And the Reyes family will be the first to visit when I do.   Hasta luego Pasaquina.   
 

Remain Overnight in El Salvador

After some EXTREMELY long boat trips back and forth from the ship to shore in El Salvador, the decision was made to allow us to remain overnight in La Union so that we could maximize our time for patient care at the medical site.  I think it was an excellent call made by our fearless leaders CAPT Cole and CAPT Anderson.  I would now be going ashore for four days and staying overnight at a hotel called (you’re not going to believe this)- THE COMFORT INN.   

How to pack?  Trying to fit enough clothes, a computer, and workout clothes into a small backpack for four days was just not happening.  Something had to give, and that thing was the excessively large book I have been reading by Tom Wolfe called A MAN IN FULL.   I crammed in some extra socks and T-shirts and we were off.   That morning we traveled by helicopter which made it super convenient, and we were seeing patients by 8am!   

El Salvadorians have some interesting cultural ways about them.   One thing in particular is their preference for gold teeth.  I have seen more golden smiles over the past few days than I have in my entire life.  After asking many patients about their golden “crowns” I came to find their common response was an even bigger smile, and a gracias (thank you).   When asked why they didn’t prefer a traditional tooth colored crown they answered that in their culture it is a sign of wealth and vitality to have golden teeth.  Some I saw had their two front teeth etched with their initials.  I snapped a few good photos with some and for a second thought about changing my veneers to gold.  Nah…. 

Something else I observed was a functional fashion piece that woman wore called a “De Lantal”. It was an El Salvadorian version of the fanny pack or purse. They look like a frontal dress/apron with pockets and lace adorning them and they come in many colors.   They carry anything and everything around in this thing- money, medical records, food, and even little dogs.  I kept getting the pronunciation of DeLantal wrong, calling it a “frontal” a “vestida de fronte” and other things, so one woman finally set me straight and had me stand up and took hers off and made me try hers on.   It was yellow and I suppose my own El Salvadorian version of a “man purse”.   Hey, I’m embracing the culture, what can I say?  

I saw patients today with a Pre-Dental student from UCSD named Rowan.  He is a real life version of Casper.  That’s what everyone calls him so I did the same.  Casper is a sharp guy.  He speaks Spanish and has quite a command of medical knowledge for his level of training.  He also has a high degree of care and compassion.  We made a solid team for the day. At one point in the day, a Cowboy looking guy asked if Casper was my son!  I had to take a step back and say, “Wow, am I really that old!” From that point forward I made sure to introduce Rowan as my brother.  I got some even stranger looks from that pronouncement, but all the well.   

One lady we saw came all the way to San Salvador for a medical visit.  She launched into a flurry of questions and demands from the get go, and we had to tell her to go a little slower and to tranquilo (relax).  We ended up talking with her for a half hour about her lifestyle, and ways to improve her health, and must have said something right because this lady proceeded to change her tune remarkably.  She told us that her trip was well worth the wait and she was happy with the medical care she received and then gave both Casper and I a small poster with a poem on it and she proceeded to sign the back and say Muchas Gracias.  After she left we read the words more carefully and what it basically said was that she would be with us forever, and if we ever destroyed or threw away the poster we would owe her dearly and God would come after us.   Rowan and I looked at each other, nodded, and simultaneously put the posters away in our bags.   

As the afternoon came to a close, we were sweaty, exhausted, and definitely ready to experience a real 

hotel in La Union, El Salvador.  We piled onto the big bus and it took us to the top of the hill overlooking the town, and there it was, the COMFORT INN.  I found out my roommate for the next three nights would be Major David Hsieh, the same guy I had roomed with in our Colombia stint.  This hotel was quite a bit nicer than that one though (no bed bugs), and the TV got several channels other than CNN International.  We were halfway through watching an episode of The Simpsons (even funnier in Spanish!)  when the news flash came on about the death of Michael Jackson.  I couldn’t believe it.  The first cassette tape I ever had was Thriller and I have memories of my brother Matt and I performing Beat It and Billie Jean with our pretend microphones downstairs in the basement at our old house in Amish Country.  Full on with our parachute pants from the ‘80s.  We listened to that cassette tape so much it wore out and snapped one day. RIP MJ.   We’ll miss you.  Buenas noches from La Union.   

In El Salvador and onto the ship the news spread quickly and on the front page of the paper the next day the headline read “El Rey de Pop Murio”  (The King of Pop Died).   Some patients even had T-shirts with MJ’s picture on it that they wore to the patient exam site.  I wish that I had had my camera with me.  I’m sure one of the newbies got a shot of it.  

That morning I realized that in a technical oversight, and maybe due to lack of room in my backpack, I had failed to pack my toothbrush and toothpaste.  Luckily we had a dental contingent next door, and I signed myself up to be seen, and got a quick exam and a toothbrush J  Problem solved. Back to work. Rowan and I were cranking on seeing patients, with a pace set by Navy Cardiologist CDR Eric Schwartzman who was new to this site this day and uber fast..  We had to see as many as possible by lunchtime, because that is when we were told we would break down in order to get to another site about a half an hour away where we would travel to and set up to begin afresh tomorrow.   Helping us triage the patients today we had two fantastic nurses from the NGO Project Hope named Marley and Karri.  Marley is a nurse at SF General, where I spent many a day and night during medical training.  It has been fun relating stories from the “Mish.”  Marley has been there for many years and is probably the most positive and happy-go-lucky person I have met on this trip.  Her daughter is also with us serving a different type of population- animals- as a vet.  Karri recently graduated from Johns Hopkins School of Public Health and is also a Neonatal Intensive Care Nurse.  

The other woman from Project Hope we have with us is a Certified Midwife named Ann from Seattle. Ann brings a wealth of experience and knowledge to the team and has a positive attitude and smile that is contagious.  I made sure to get a photo of them during the morning.   Project HOPE has been in existence for 50 years and has impacted hundreds of thousands of lives for the better.  We are overjoyed that they are part of Continuing Promise 2009.  

Lunchtime came and it was as hot as its been yet- close to 100 degrees.  Some genius had misplaced the MREs so we were stuck with boxed lunches prepared by the ship consisting of canned ham, cheetos and softbake cookies (exactly what we had just been telling our patients not to eat).  I put the ham down the hatch, but said no thanks to the other processed bolado.  We loaded up the trucks with all of the dental, medical, and optometry supplies and drugs in under an hour with an extremely efficient assembly line.  

By the end of the lifting workout we were drenched with sweat and even the lukewarm bottled water hit the spot.   I handed one to CDR Schwartzman, the cardiologist, and as I did I saw a divine omen on his chest!  In perfect symmetry on the front of his brown T-shirt in emblazoned sweat was the form of a heart.  He truly was meant to be a heart doctor! 

The past two days our small medical team had seen over 1000 patients at the La Union site, and we set our goals for the next town called Pasaquina about 30 miles away to the East toward the Honduras and Nicaragua border.  The drive there was gorgeous as we hugged the coastline, with the ocean on our right side and the volcanoes to the other.  We began to head more inland, and suddenly screeched to a halt.   Many of us had been dozing off and we jerked awake.  The reason for the sudden stop was a herd of cattle crossing the street (some walking and standing in the middle of the street).  The driver honked and we waited patiently for the cow to make up its mind whether to step aside and let the bus go by, or stand it’s ground..  Cow vs. Bus full of American Military/NGO Humanitarians.  

It was a peaceful exchange, the cow relented, and we were on our way.   Meanwhile, not too many miles away in the country of Honduras, we were hearing reports from the security element that the Honduran President was not ruling within lawful constraints and that a possible Coup may be in the works.  Given our nearby location to the border, there was much talk of contingency plans.  I raised my head, peeked above the bus seat in front of me and made sure our heavily armed El Salvadorian military escorts had our front and our tail.  We were a caravan of humanity, hope, and continuing promise moving through the Land of Volcanoes to the next town we would help and heal with compassion. 

Halfway through the Mission - I was once a Newbie too

The motley crew that I flew into Panama with three weeks ago left two days ago.  On their way out in revolving door style, they tagged an incoming crew of about one hundred new people to replace them.  They came from all over the United States- Navy Reservists, Project Hope, UCSD pre-dental society, Latter Day Saints, and more.  Wide eyed, excited, not knowing what to expect, full of enthusiasm, and making new friends left and right.  Those of us who have been on board for awhile (I hardly can include myself in this group) were ordered by the boss to get these newbies up to speed on protocol as soon as possible. In this entry, I would like to touch on some “Newbie” behavior that was observed and cannot go without being mentioned (and this was me just a few weeks ago, so I am making fun of myself too).

1)  Writing everything down- Inevitably on the first day at morning meeting, everyone has pen and paper out, fastidiously taking notes of anything said by anyone.  “The Mets won last night”, someone says.  Write it down.   “I had to get up twice last night to use the john”. Write it down.   Chief reads the Plan of the Day detailing the movies playing today, food selection, trivia question of the day.  Write it down.  All of this information is on your email people!  Write it down.  Oh it is?  Doh!!

2)  Relentless enthusism- During the evening meeting last night after a broiling and exhausting day, the boss asks if there are any questions.  There is a newbie that asks a question about nothing to do with the topic at hand.  “Do you know what is for breakfast tomorrow?”   Or on the boat today from a Dentist.  “Can I drive the boat?”  “No!  You are a dentist, not a coxswain.  Please sit down.”

3) Taking photos of unextraordinary items.  The rate of photos taken is at its peak upon first arrival and then inevitably falls off during ones time here.  The first few days newbies will take photos of everything- the trash cans, a lobster tail, a life jacket, a soda machine, a spin bike.  It is unbelievable.  This morning while waiting to board the hospitality boat ashore we were instructed by U.S. Marine Corps Gunnery Sergeant Roberts to not take any photos in order to enable a safe boat entry.  A newbie did it.  They pulled out their camera to take a photo of one of the lifeboats.  “Put that camera away!!”, yelled Gunny.  We were boarding….  Another newbie couldn’t resist.  They tried to stop their desire, but their hand overruled their brain and they whipped out their camera and snapped a photo of the steel post by the steel door.  It was an awesome shot.

The boat ride out to the dock was packed with newbies this morning, and a few of the docs and I tried to use the lengthy transit time of one hour and 30 minutes (helo took 5 minutes) to give some advice to the new docs on seeing patients, how to fill out the forms, what to expect, etc.  We were about halfway there when the stank hit us.   Pee Yoo!  It was a mix between the smell of  a flipped over Port-O-Potty and a Sewer Leak.  

We looked out into the water and there was trash floating everywhere.  “Must have rained a lot last night”, said the Captain of the boat.   Large rains wash the trash in the ditches out to sea.  A very rudimentary sewer system.   People leaned over the side to snap photos of the garbage.  I was one of them.  It was brilliant.

The helicopter that had left an hour after our boat from the ship, passed us overhead.  We waved.  Despite the garbage, the lengthy boat ride had been nice.  Beautiful volcanoes were visible in the backdrops, as the sun rose above their peaks.  Some El Salvadorean fishing trawlers headed out to make a day’s catch.  El Salvador has a brand new Port (just finished this year) in La Union.  We passed by it in the small boat and I became curious why the USNS COMFORT had not been able to pull up here (the Port was plenty big enough).   I asked the skipper and he told me that the previous El Salvador government had spent all of their money on this Port, and run short on being able to secure permitting and they had no Tug Boats.  The new El Salvadorian President was sworn in just three weeks ago, and considers this Port part of the prior administration and does not as of yet have it as a top priority item.  Reminds me of some of the Bush to Obama priority changes.  Occurs in every country.

One of the new guys on board, sitting next to me during the boat ride is CAPT Maurice Sheehan, a Nurse Practitioner in the Public Health Service, Psychiatry trained, former Navy special operations, who just returned from a year in Afghanistan.  He lives in San Diego now, and we swapped some good stories of times in San Dog.  The man has 35 years of service to the country, and is still deploying left and right.  Impressive.  When we reached the school site, he and I went to the Tienda to get some café and a pupusa.  Esmeralda was not here today, and I hoped that she was able to receive some help for her eye.  A traditional El Salvadorian food is called the Pupusa. 

 

The name adorns the title of stores, and food stands throughout the country.  This mashed corn wrap is a staple of the diet and folded into it can be all sorts of things from cheese, pork, and even some sort of colorful flower (that after I requested was told was out of season).

Today, I was able to obtain a relatively quiet room to work, and also was lucky enough to snag a native El Salvadorian named Krissia to help translate.  It allowed things to run much smoother, and my dolor de cabeza would be less intense today.    Full up on some coffee we set to work and encountered several interesting patients.

A 24 year old man came in with an injury to his left arm that had not healed correctly. He had fallen off of a horse seven years ago, and broke the lower part of his humerus (upper arm) clear in half.  Unfortunately he did not obtain any treatment at that time, and the injury healed such that he now could not flex his arm past 90 degrees, but also could hyperextend his arm to almost 40 degrees the other direction.  When he did so it appeared that his arm was on backwards.  

We took some X-rays and requested a surgery back to the ship to rebreak the arm and set it, but unfortunately our site leader, CDR Ed Taylor told me the Orthopedic doc did not have the equipment necessary to do such a surgery.   I wrote a referral out to town and hopefully the guy will be able to have his arm reset.

As I mentioned in my Preventive Medicine blog entry from Colombia, the people here in the agrarian regions of El Salvador demonstrated socioeconomic driven behavior towards activity and healthy eating habits as well.  This lifestyle of living off the land through hard work lends itself to lengthy life span and staving off chronic disease.  Today alone I had a 92 year old patient, and 87 year old patient, and LT Jacobson had a 102 year old!   None of them smoke or drank alcohol, none of them had owned a car, and none had access to processed food or sugary drinks.  I applauded them and prayed for a paradigm shift like this in the future of our own country.

My translator taught me the El Salvadorean word “Bolado” over lunch.  Bolado is the equivalent to the phrase “Dakine” in Hawaii or simply “stuff.”  It is what a person from El Salvador says when he is referring to something but doesn’t say the actual word because it is inferred by tone, or he/she simply forgets it.  I tried to use the word Bolado as frequently as possible throughout the afternoon and got some instant smiles.  Take care of your Bolado.  Make sure to take Bolado three times per day with lots of water.  I need to use the Bolado.  I’m still not sure I’m using it correctly, but thanks Krisia nevertheless for teaching me that.

Before heading on this mission I was able to participate in the Memorial Day Parade in Washington, D.C. with the Special Olympics Lions Club.  As a Lion, I was proud to ride atop the float with several Lions who are WWII and Vietnam veterans.  Lions Club International is the largest service organization in the world, and has contributed greatly to our humanitarian mission this year by providing eyeglasses for those in need.  

Today we passed by El Clubo do Las Leones (Lions Club) building in La Union.  I saw the familiar emblem and smiled to know that the Lions were here in El Salvador.  Having met two outstanding International Presidents of the Lions Club- Al Brandel (current President) and Kay Fukushima (past President) I made a note to stop by this esteemed organization’s chapter in La Union.

One of the patient’s I saw today was a special needs patient female named Jennifer who because of mental handicap was blind, and struggled with speech and seizure disorder.   The girl’s mother is terribly worried about her daughter and the lack of support she has, and the lack of knowledge on her daughter’s condition and future prognosis.  After looking at the girl’s CAT scan of her brain, and providing the mother with the knowledge that there is nothing that could be done for her daughter medically, I had an idea to refer her to the Lions club for help in finding a group of other special needs patients in the area or even in San Salvador.  I hope that these connections with the Special Olympics and Lions can span the Americas and provide this girl with some guidance and hope.

Chief Caldwell, a very nice female Chief Petty Officer Corspman on the COMFORT team busted into my “office” at 3pm and said, “Doc Baldwin, you have to get going.  

It’s time for you to get back to the ship!”  I’m glad she had been keeping track.  LT Jacobson, LCDR Bacon, and many of the others had already taken off on the boat retrograding back through the sewer smell.   It paid off to work late though, as we were dropped at the helicopter zone and soon found ourselves in a chopper passing over the hospitality boat full of newbies below.  Sure enough as I looked down, I saw a few of them pointing upwards, cameras in hand, snapping away.  Newbies.

El Salvador- Make a Smile Every Day

The country of El Salvador may be small (7 million people), but it packs a big punch.  It is the size of New Jersey, and is tucked next to Guatemala, with Honduras above, and Nicaragua to the south.  They call it the "Land of the Volcanoes" for a reason, and this morning we found out why.  We flew to shore by helicopter and were able to see with our own eyes the breathtaking views of volcanoes making up this country on the "Ring of Fire."  I was all smiles as I snapped photos out the window, the rotor blades whishing overheard.   Islands of volcanic rock (now overgrown with vegetation) were scattered below, while the main coast lay ahead 

with billowing volcanic mountain peaks shrouded in the early morning mist.   My fellow doctor and mentor, LT Jacobson, nudged me and pointed earnestly at the approaching town below- La Union.   La Union is one of El Salvador's oldest seaside villages, has one of their newest ports, and is host to their Navy.  After setting down in the parking lot of the Port, we boarded a relatively large and nice commercial bus to make the transit to town.  The only problem was that the village streets of La Union were not built to handle a bus of this size.   As the driver navigated one corner turn we almost took out a woman selling food at her sidewalk stand.  I looked back and she was yelling bloody murder with her hands raised up to the sky.  Poor lady.  On the side of the road little piglets trotted along (what a peculiar sight!).  Also, I spotted several women carrying baskets of food on their head without holding on!   So cool.  Functional balance.  Hope it doesn't lead to dolor de espalda (low back pain).

The medical treatment plan for El Salvador involves a number of different sites, so today numerous teams went out to different school sites throughout La Union.  Our site was the Jose Pantojo Hijo Escuela near the town center.  As we approached the gates to enter the school, we were cheered.  Many vendors were there taking advantage of the crowds selling beverages, trinkets, and food - including a Burger King cart (who knew the King was in La Union, El Salvador?).   After we entered the site, things were a bit more under control, and LT Jacobson and I set about getting our bearings.  We saw our fearless site leaders, pediatricians CDR Bill Scouten and his deputy, MAJ Dave Hsieh, who filled us in on the lay of the land (how things were set up).  It was the first day on this site, so nothing ever goes according to planned. Mass chaos begins to take on some order after a few days.  Still, I couldn't help but be frustrated by the situation.  Our rooms were much smaller than in Tumaco, and once the Gynecologist arrived and needed my table, I found myself situated outside of the building next to a sewer drain.  There were a slew of new people working with us in El Salvador- Latter Day Saints translators as well as medical students from Virginia College of Osteopathic Medicine.  During the morning I tried my best to do it all- function without a translator, teach the medical students practical information, and in the process see as many patients as I could.  I could barely hear anything as it was, so when they started up the generator next to my workspace, I was yelling to communicate and a jackhammer started going off in my head.  I had dolor de cabeza (headache).  I stood up and walked over to a tienda de comida (food vendor) and ordered a coffee.  The 80-year-old woman behind the counter introduced herself as Esmeralda (cool name) and proceeded to tell me that she couldn't see out of her left eye.  I took a thorough history of her condition from the other side of the counter, and figured out that she had had a minor stroke. I told her that there was not much to do at this point.  "Lo Siento", I said (I'm sorry).  She nodded, and nodded again and then stared off into space.  She forgot what I was there for so I reminded her "un Café por favor.” At that point I began to worry what she was going to even put in my cup!  Have no fear, she managed, and soon I was caffeinated again.  To be honest, El Salvador coffee is not quite Juan Valdez, but it did the trick!

The most memorable person from this morning was a young boy named Antonio who came up to me as I was doing a heart exam on an elderly gentleman with congestive heart failure.  Antonio's mother was on the other side of the room receiving acupuncture and standing still as her curious child was watching me intently.  After I finished with the exam he approached me and asked what the stethoscope was for?  

I smiled and carefully put the earpieces in his ear and talked softly into the other end of the stethoscope.  Antonio jumped back in glee.  He ran across the room and put the stethoscope over the heart of his mother, and soon with his hand he made a fist and released and then made a fist again, in a heartbeat type motion.  Smart kid!  I proclaimed to him that he is officially a future doctor in El Salvador.   His mother (still with acupuncture needles all over her body) smiled proudly.

Noon came, and we got a call for lunch.  Thank goodness.  I was spent.   MRE for today is drum roll, drum roll..........Meatloaf!  I was so hungry and sweaty and tired by this point I could eat anything, even the cheese omelet MRE.   LT Jacobson, Major Hsieh, and I huddled up under the shade and shared some stories from the morning.  LT J. had a very interesting case of a 64-year-old woman with clubfeet.  Usually this condition (feet face downwards and inwards) is corrected at youth if medical support is available.  She showed me the photos of this grown woman who had persevered with this condition throughout her life.  What courage and strength!

The average worker here in La Union earns five dollars per day, and they are expected to support a family with that salary.  Can you imagine???  Based on the patients I had seen thus far today, no one, and I say no one, had health insurance.  It became obvious that for many it was a choice between healthcare or feeding their family.  One of my first patients of the afternoon was a nice 52-year-old woman named Ana Maria.  I took her into the physical therapy room away from the generator noise, and sat down to chat with her.  She told me how she has back pain, and gastritis, and also showed me a large scar on her left shoulder she received from a machete attack during the El Salvador civil war.  It had rendered her left upper extremity largely useless.  

I asked a bit more about the injury and that obviously struck a cord, because I could see her eyes instantly tear up and she described how her husband had been killed in the war, and how her two hijos (sons) had fled to the United States, and how she has not seen them since.   She was all alone.  I held her hand as she cried and allowed her to mourn and said a prayer for her.  We conversed back and forth in Spanish for quite some time, and I think more therapeutic than anything I could have done for this woman medically, was just spending time with her.  As she left she said "Hasta Manana", which means "Until Tomorrow."  I didn't have the strength to tell her I was not coming out tomorrow, but I sure hope that whomever Ana Maria does see tomorrow, they take the time to hear her story.

My biggest smile from the day came mid-afternoon when an elderly woman named Rosa came over to my area and was all in a tizzy.  She was wearing a pink embroidered pullover of sorts, completely soaked through with sweat, and was toting a large envelope full of MRI results and X-rays.  I asked her to tranquilo (relax) and to please sit down.   I took a look at her patient form and at the top right hand corner it said "Surgery."  They were screening for surgeries today, so at first I thought that this woman was in the wrong area.  As I interrogated her she revealed that she has a brain tumor and that she had been told she needed surgery as soon as possible.  My heart sank as I reached for the scans she had brought with her.   She talked a million words a minute as I looked at her films, not catching any of the details that she was telling me, except for the last part about how she didn't want to die.  On the plain X-ray I could see the mass, but on the MRIs I had a difficult time finding anything out of the ordinary.  It was time for a curbside consult of the great Dr. Biondi (radiologist).  "Siguame" (Follow me), I told the woman.   We walked through the crowds over to the rudimentary X-ray machine setup, and found Dr. Biondi munching on some MRE (I believe it was the much loathed cheese omelet).  "Only one left", he said.   I explained Rosa's case to him, and he agreed to take a look.   Rosa waited nearby with worried eyes, her granddaughter by her side.  

I told Biondi that I couldn't find the tumor.  He confirmed that neither could he, and that the X-ray looked like an osteoma (bone growth) that was nothing to be concerned about.  "Buenas Noticias!"I yelled to Rosa holding up the scans.  She looked bewildered.  You don't need surgery!  You don't have a malignant tumor in your head!  Rosa looked up to the sky and raised her arms and said "Gracias a Dios!" and proceeded to come over and give me a big hug and plant a big one on my cheek.   She was beaming from ear to ear and announced to everyone in the crowded waiting area that she did not need surgery after all.   It was great.   Pure and simple- a great moment.

The prescription I give every patient before they walk away is "Hace una sonrisa cada dia" (Make a smile every day).  As I returned to my office area, I passed by the tienda with Esmeralda, and craved another coffee.  Checked my pocket and sure enough had a quarter for one.   "Un café por favor", I said to Esmeralda.  She must not have remembered me because she asked if I was a doctor and told me the story again about how she could not see out of her left eye.  Hmmmm..........  I explained to her once again that I am Dr. Andres and that I was here earlier, and that I would try and help her after she got me a coffee.   Coffee in one hand, and Esmeralda in the other, I paid a visit to Optometry and with a bit of string pulling got her a patient form to be seen, at least evaluated.  She asked for a photo and I said only if she gives me the biggest smile possible.  She followed doctor's orders as we donned two grand "sonrisas" for a great photo to culminate a great first day in El Salvador.

Strategic Pause

The past two days have been what is referred to as a “Strategic Pause.”  I like to call it a much needed break.  It’s a time to recharge the batteries, get rested up, physically fit, and mentally ready before we hit the ground running again in El Salvador.   Seeing hundreds of patients each week, many you can help, and many you cannot, takes its toll.  I have only experienced one country thus far and it kicked my butt. I look around and know a lot of these heroes have been on board since day one and this will be their 6^th country in the last 3 months!  There is a phenomenon known as “Compassion Fatigue” and it has been found to occur in humanitarian providers when they try to relate and give some love to patient after patient after patient.  There is only so much we can give, and eventually, (especially in the 3^rd world) the burden and guilt of not being able to help patients more can get overwhelming and providers can break down.  We have been advised to look out for each other as medical providers.  El Salvador is going to be logistically challenging with long 1-2 hour boat rides ashore, followed by lengthy bus rides to the medical sites.  Doing this day after day after day in the heat is going to require the best spirits we’ve got and the utmost resolve. 

To help with this, the first part of our “Pause” occurred yesterday with a Steel Beach Picnic.  In the Navy these are terms for a big BBQ on the flight deck with fun and games and the ability to wear anything you’d like (within reason).  After Dr. Bacon’s spin class, I donned some shorts and a polo shirt and went topside to partake in the action.  Up top the sun was blazing, a basketball court was set up, the band was playing, and the grills were cooking up some burgers and dogs.  

Someone brought over a Hawaiian Lei and gave me the honors (I suppose this was the theme) and suddenly we were dancing on the Steel Beach.  The shower I had just taken after spin class immediately became a waste as I started pouring sweat once more. Ah, it’s all good.  This is fun!  

I applied some sunscreen (mother would be proud), and went about getting a burger.  You can’t set your expectations too high aboard the COMFORT with the food.  That is why we have come up with a completely different rating scale for the ship.   My good buddy and fellow doctor Karen Jacobson taught me this scale.  A burger that may rate a 3 in the regular world takes on a rating of at least a 7 onboard COMFORT.   Put some ketchup on this burger, throw on some cheese, and it’s a COMFORT 9!   

One of the coolest operations I have seen in the Navy is what’s called Underway Replenishment or “UNREP” for short.  Today USNS COMFORT was refueled by USNS Peary.  Unless it is nuclear powered, a ship at sea obviously has a limited supply of fuel.  Instead of having to depend on pulling into a foreign port to fill 'er up, we do it by bringing an Oiler alongside the ship and running the fuel hoses between the two while steaming at 13 knots side by side.  It is remarkable to see.  I first experienced an UNREP when I was 20 years old and a Midshipman on “summer cruise” in the Persian Gulf.  At that time, I was on board the USS Chosin (CG65), a Ticonderoga Class U.S. Navy Cruiser (read- incredible ship that can launch a lot of cruise missiles and also coordinate and track everything in the air with its Aegis Radar system).  How do you get the hose from one ship to the other you may ask?  Well, that’s what I wondered when I was a scrawny 20 year old, and when the Chief brought the gun out, I was like “What the heck??”  What happens is a gun shoots a small line across the brim between the two ships. This is secured, then a firmer line is fed across, and then the fuel hoses are taken across and fueling begins.  

The coordination between both bridges (the ship drivers) needs to be perfect to maintain a constant and unwavering gap between the two ships of 150 ft.  To do this they are in constant communication, maintaining steady course and speed and always making minor adjustments to stay aligned.  Refueling takes hours so the hyper vigilance of the navigator and ship captain are intense during this time.  It is tradition to pass gifts (such as cookies) back and forth over the line.  Another tradition is what’s called the “breakaway” where one ship, after completion of UNREP, will haul in the lines, increase speed, and break away, all while playing music very loudly, and with many of the crew topside dancing and waving goodbye to the other ship.   

Another maneuver that takes place during this time is called a Vertical Replenishment, or “Vert-Rep” for short.   When both ships have a helicopter landing zone, helos can be used to transport (lift) cargo from ship to ship.  After we were all fueled up today, the USNS Peary’s helo made several trips back and forth and I caught some photos of it as I was reading my book outside.   Watching the helo fly sideways and backwards made me scratch my head.  Incredible that these birds are flown by 20 somethings, and maintenance is done by some kids who are just 18 years old.   

The pilots and maintenance crew of our Helicopter Squadron on this ship (named the Witch Doctors) are incredibly talented and professional young men and women who play a pivotal role in transporting personnel and patients back and forth from the ship each day.  Without them and their hard work, our mission would not be possible.    

Last evening we had the Colombia Close-Out Brief.  The Close-Out briefs are awesome (I got to see the Panama one as well). They highlight the hard work that all of us did in that country, giving the department leaders (Medical, Surgery, Dentistry, Veterinary, Engineers) the chance to showcase their team’s work.  Our trusty leader CAPT Anderson from the Department of Medical Services eloquently spoke about the 16000 patients we saw and over 60000 prescriptions filled as a whole during our time in Colombia.  This was close to 5000 more patients than we had seen in the previous country of Panama.  He told us about the words the Mayor of Tumaco gave at the Closing Ceremonies, where he stated, “Tumaco was founded 365 years ago and has suffered much strife, poverty, and corruption.  After the gracious visit of the USNS COMFORT to our region, we are healthier, smarter, safer, more energized, and most importantly, filled with hope for a brighter future.   Day ONE of the New Tumaco is today, thanks to the Barco Blanco (White Ship).”   Looking around the room during the brief I could see the character of the people in the room. What everyone here has in common is that we are not just medical and service providers, but we are also good people- people with empathy, compassion, and the will to sacrifice to improve the lives of others.  I am so grateful to be a part of this mission.  

Life Aboard a Ship

After the intense pace of the past two weeks in Colombia- seeing thousands of patients, transporting hundreds of us back and forth from the ship each day, and performing life changing surgeries aboard- things seems to have slowed down now that we are back sailing on the high seas.  We are underway (in transit) to El Salvador and the medical folks now have a lot of time on our hands.   So what do we do you ask?  How is life aboard a ship?  I thought I’d provide a glimpse into some of the quirky things that happen aboard a floating hospital ship of the United States Navy.

First thing’s first- the 1MC.  That’s what the ship’s loud intercom is called.  Several announcements occur each day at specific times, and they establish a structure of sorts.  One might even find themselves anticipating the announcement, or after hearing them so often find that they get in your head, like a mantra.  At 0600 (6am) overhead we hear “Reveille, reveille.  All persons out of their racks.   Breakfast for the crew”.  There is a particular southern accent and enthusiasm in the person’s voice that makes this announcement, and at breakfast you will hear people mimicking it.  The question is who actually does make this announcement?  No one seems to know.  We always look around at breakfast wondering what body that voice belongs to.   At 0900 (9am) and 1500(3pm), like clockwork, the “sweeper” voice comes on calling all enlisted assigned to a broom, “Sweepers, sweepers, man your brooms.  Give the ship a good sweep down fore and aft.  Now Sweepers!”   This proclamation is clearly stated by a different person and voice than the 0600 wake up call, but with an equal level of enthusiasm.  A few minutes before 2200 (10pm) heard over the 1MC is “Tattoo, Tattoo, standby for Evening Prayer”.  At this point the Chaplain gets on the horn and says some encouraging words about the day and the days to come.  At precisely 2200 the Tattoo voice says “TAPS, TAPS, lights out, all hands turn into their rack, no movement about the decks, TAaaaaaPS.”  I wish I could sound off what this sounds like but this is yet again another voice with a real southern drawl on the end.  No one seems to know who onboard does this announcement either.  I’m just waiting for the day I run into someone in the passageway and I say hi, and he says hi  back with that TAaaaps voice, and I say Ah ha!   Reveille, Tattoo, and TAPS are traditional calls that have occurred on Naval vessels for hundreds of years and have significant tradition.

My favorite thing about being out in the middle of the open ocean is the sky at night. There are not many places where you will see stars so bright.  When I was a kid I took a class in astronomy and used to recline my chair and stare up at the planetarium ceiling at the myriad of stars.   Last night I couldn’t sleep and ventured up to the top of the ship with a chair.  I took a seat and reclined.  It was like I was back in that planetarium again. With no ambient light from cities, and the ship’s lights for the most part off, it is total darkness, and there are thousands upon thousands of stars visible.  So peaceful.  This was the way to get away.   Cool ocean breeze, the sound of the ship’s generators mixed with the splashes of water being cut, this is one of the little things, along with the many others, that makes being out to sea with the U.S. Navy so special.

I had a hard time sleeping last night as we were rolling in the high seas- the worst we have had yet.  Side to side, side to side- it affects everything.  Try sleeping when you are being rolled from one side of the bed to the other- hey, at least it keeps me from snoring (or at least my roommates say).  During high seas some sailor always seems to get rolled out of his or her rack while he or she is sleeping, as happened this morning to a poor girl who now has quite the bump on her head.  Top bunk bump.  Things fall all over the ship.  The galley is the worst.  Pans and bowls toppling over, doors slamming, chairs sliding, coffee mugs containing hot joe swishing back and forth during breakfast and morning meetings.  Spill, ouch, that’s hot.   Running on the treadmill takes on an extra degree of difficulty.  Focus and spatial orientation to maintain position on the tread while running with the ship swaying is not easy, and a number of people have done faceplants while underway (myself included).  The other things that sway back and forth during rough seas are one's stomach and insides, and for some, this leads to the awful expulsion of food, acid, and bile out the wrong end.   Luckily that does not include me, but I must admit, even my tummy is feeling a bit out of sorts this morning.

The other thing that occurs like clockwork while we’re underway is LCDR Dave Bacon’s 10am spin class.   It is not publicly advertised, but is always packed thanks to a faithful following.  It is the toughest onboard, and although Dr. Dave had no formal spin instructor experience before this mission, he is a good motivator and dedicated to the hard music. It is undoubtedly that dedication that led him to getting his PhD in microbiology and the acclaimed work he did in Peru. Today’s spin class was tough, and I was glad.  The rocking of the ship didn’t matter that much on the bikes.  It just made it more fun.  By the end of class, I had a puddle under me from sweat.  I looked around and no one else had a puddle.  I was drenched.  Why the heck did I sweat so much?  Had I contracted Malaria?  I sure hope not.  I’ve always sweated a bunch.  Must just be the way God made me.

Food.   You can always count on four square meals a day when on ship.   Breakfast at 6, Lunch at 1130, Dinner at 0430 and “Midrats” (Midwatch Rations) at 11pm.   Now if you consume all of these meals in their entirety (which many do), you will get fat.  Where else in the world do you have such a controlled environment where you can count on all these meals each day?  Heck, back home I have a coffee&bagel for breakfast, turkey sandwich for lunch, and a big salad for dinner with some healthy stuff in between.   This is a smorgasbord comparatively. The good thing is that there are healthy and “semi-fresh” options every meal with protein, grains, vegetables, and fruit.  You need to appreciate the good things while out at sea, so the soft serve ice cream at night is always a big hit.  Now, if you have done Dave Bacon’s spin class it’s a green light for the soft serve.

Let’s talk about close quarters.  In our everyday lives we may run into someone at work once or twice throughout the day and say hello.  When on a ship, you run into people constantly.  

I’m not sure how others feel about this, but sometimes it can be awkward when you have a serious 10 minute conversation with someone in the morning, tell them you hope they have a great day, and then 30 seconds later run into them passing in the stairwell, or in the passageway, and you’re like “Well, hi again!”, and then 10 minutes later when you’re going to work out or do laundry you run into them again, and you just nod. A ship is like a big box with numerous compartments and levels, with mice scurrying around and only so many places to go.  A big social experiment of sorts.  It is this confined nature of a ship that leads to so many good friends being made on deployment.  In regular life folks have the option of getting away from people if they are introverted or just don’t feel like engaging people.  When you are on a floating box for four months you have no other choice.   You have to eat.  You have to interact.  You have roommates.  Most of us hardly knew anyone else aboard when we got on the ship (I only knew one person).  After months of confined and forced (sometimes) interaction together- working, sharing stories, laughing, and sometimes even arguing- you get to know people in a way that you don’t in the traditional work world.  You are working on a mission together.  You emerge with friends for life from all over the U.S. and the world- friends you will drop anything to help in the future, and vice-versa.

Some Colombians do the Craziest Things

 

Today was my final day ashore seeing patients, and it turned out to be quite an adventure.  We rode the RHIB ashore 

again, and our Coxswain Petty Officer Hall handled that boat on full throttle the best I have seen yet.  We practically pulled up alongside the pier at full throttle and none of us suffered a drop.   

The influx of people traveling from the countryside was evident as we were greeted as we stepped off the bus by the largest crowd of patients yet.   At our 0730 physician huddle meeting with today’s Site Leader Dr. Cole, we were told that today would be full throttle for Adult Medicine with a goal for close to 1000 to be seen by days end.  Pediatrics would attempt to see 500 kids for total of 1500.  “Get to work!”, Cole said, “and remember, the more patients we treat, the more of an impact we have on the people here, so work expeditiously.”   

I snagged my trusty partner and translator Maria, and we hunkered down in a partitioned corner across from my roommate (and chainsmoker) Dr. Mike Barretti.  Mike is an incredibly smart guy, certified in Internal Medicine, means well, but has a bitterly sarcastic attitude sometimes.  He’s from Boston, and that says a lot.  He’s tough as nails.   For anything it provided a much needed respite for some laughs throughout the day when we needed it most.  He even had his travel size IPod player there playing some AC/DC as we worked.

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Each day I start out full of energy with the best intentions, full of coffee, and resolved to connect with each and every patient I see.  That lasts for awhile and then you hit a really tough patient that drains you, and in order to pick up the pace again you need a really special patient to bring you back.   That special patient this morning was a 84 year old woman full of life named Ines Cortez.  Inez didn’t look a day over 65 and had a smile and energy about her that brightened up that room really quickly.   Maria and I are so used to patients coming in and asking for (often demanding) pain medicine, vitamins, etc.  When we asked Ines “Cual es tu problema” (what is your problem) she responded that she didn’t have a problem.   She said she just wanted to talk to us, and didn’t want any medication like the others.   Maria and I exchanged smiles, and moved our chairs closer to find out more about this interesting woman.  Ines lives in the country, about 3 hrs away from Tumaco, and she told us about the Americans that had come to her farm to stay recently, and how they had gone on adventures, had fresh fruit, seafood, and lived off the land for months.  She told us all about her children and grandchildren and how some remain tending to the farm and some are working in Bogota and other cities throughout Bogota.   Halfway through our meeting with Ines, she stood up and came over to each of us and gave us a big hug and kiss on the cheek and said “Muchas Gracias por su ayuda y amor a Colombia.”  (Much Thanks for your help and love to Colombia).  That was so unexpected that it made my day.  I think it made Maria’s as well.  I told Maria in English that Ines is what in America we call an “Old Soul”, someone filled with wisdom and hope that comes into your life and affects you positively.  We bid Ines goodbye and emerged refreshed, with smiles a bit bigger, and ready to see a dozen more.

We hit lunchtime 1130 having seen 40 patients.  If we kept up the pace it could be 80 or 90 seen by the end of the day.  Lunchtime is always tough with sun beating down and eating the day’s selection of MRE preserved (dog)food.  It takes a lot of will at this point in the day to reengage, but this was the final push for Colombia and therefore after handing out some Reeses Pieces to the kids, Maria and I did a cheer and got back to work.    

Around 1:30pm I heard Mike exclaim from across the room “Hey Baldwin, have you ever heard of anyone having 17 children!  I have a patient here who has had 17 children!”  That’s the most I have ever heard of and I went over to talk with the woman.  She was middle-aged and relatively healthy looking.  “Wow!”, I thought as I tried to do the computations in my mind to figure out how this 46 year old had managed to do that.  Not but ten minutes later, a woman named Luz walked into my “office” and Maria began to question her.  “Dr. Baldwin!”, Maria said.  “This woman has had 20 kids!”  What was going on?   This woman was only 42 years old!   She was from the country as well.  What she said next was the sad part though.   Ten of the twenty had not survived, and two of the remaining were sick with leukemia and malaria.  I couldn’t help but shake my head, and say what??  This woman had my attention.  What she said next however, is what really threw me for a loop.  Luz’s chief complaint was gastritis, basically a mix between heartburn, stomach upset, and all the like.  She told Maria and I that she used Maalox to help treat the discomfort, but that the medicine was expensive and she could not afford it. Instead of Maalox, Luz  told us she resorted to drinking her own urine to help quell the gastritis pain she felt on a regular basis.   I turned to Maria with a puzzled and questioning look to make sure I had heard her correctly.  Maria nodded yes.   OMG.  We circled back and asked her the question again, and again this “home remedy” was the drug of choice.  We surrendered our questioning at that point, and I wrote Luz a script for double supply of Nexium for her gastritis so that she would at least not have to resort to the alternative for a while.  WOW.   Double Wow.   Haven’t ever seen or heard of that before, but as I write this I suppose that it would (although having uric acid itself) provide a buffer to the even more acidic stomach environment.   

Paula came in about an hour later, just as we were really losing steam again.   She was 18 years old, had an average build, was appropriately dressed, and appeared in relatively good health, other than being for the most part deaf in the left ear.   We treated her for the typical problems of headache, gastritis, and gave her multivitamins.  At the end of the visit she began to tell Maria the story about how she lost her hearing in the left ear.  When she was six or seven years old Paula said, she was near a city and saw on television of a cartoon character taking a rod and putting it through one ear and seeing it come out the other.  No she didn’t do that!  Yes, she did.  Paula proceeded and ran into and perforated her left eardrum and broke off the tip of the rod in her left auricular process.  I peered into her ear and saw the degree of scar tissue in there and felt horrible for this young girl.  I tried to be optimistic with her saying that is why God gave us two ears so that we can survive without one.  You are a survivor I told her, and she smiled.  

The patients kept coming in up until 4pm when the word came to shut down.  Maria, and I saw about 80 patients today.  Our final patient was a 12 year old boy named Andy (Andres).  He came over to me and pulled up his bright yellow shirt revealing a sternal scar where he had had his chest cracked as a child for a congenital heart defect.  They had fixed it and he wanted to show me and have me listen to his heart.  His heart beat strong and normal “Lub, dub, lub dub” and I 

asked him if he played sports.  Futbol (soccer) he told me.  Well you have an athlete’s heart full of courage I told him.  And for your body to grow strong and healthy you should take these vitamins every day, and eat well.  “Que sobre helado?”, the little Andres said (What about ice cream?).  “Tan poco”, I replied with a smile.  “Tan poco.” 

The ride back to the ship to the hospitality boat was long and slow as usual, but I didn’t mind.  I kept thinking about the nice 84 year old woman Ines and the way she lived her life amongst nature appreciating every second.   I wiggled my way up to the bow of the hospitality boat and stood at the apex for the hour long transit and enjoyed the sound of the cutting through the waves and the water splashing to the sides.  I didn’t mind my legs getting soaked by the spray.   It provided my muddy boots with a much needed cleaning.  

As we were hoisted up to the “Barco Blanco” (White Ship) as the Colombians called it the sun was setting and I snapped some photos to remember the moment.   After some good chicken for dinner, after the sun had set, my roommate LCDR Dave Bacon found me and told me they were doing a yoga class topside.  It was a temperate night, the stars were out, and I said, ah what the heck.  Yoga is great for core strength, flexibility, and simply when you want to zone out and enjoy some solitude and silence.  It’s even better when you are doing it outside on the flight deck of the USNS COMFORT 6 miles off the coast of Colombia.    

Day 7 ashore.  Total patients saw today- 85  Total by the team – 1500  Cultural lessons learned- many