Continuing Promise 2009

Final Day of the Mission

2009-07-14T17:58:00.000-07:00

Today was Sunday. The day of rest. But not for the Navy Medical Strike Team. Today was our ultima dia (final day) of providing medical, optometry, and dentistry to the kind people of this rural town in Northwest Nicaragua. Sure, hundreds of the population had come through the line more than once and gotten a second and third and even fourth medical opinion at the same medical clinic, but we were helping and that is all that mattered. I loved the people at this site. They lived off the land and although poor, they had solid values. Once again, still in a slumber, I paid an early morning visit to the Food Stand of Erika and Cristina and baby Angel for several cups of instant coffee and even had to go for a Coke Light this morning and one of those Gelatin things out of the Yellow Bear container. They badgered me again for not getting them a whole assortment of medications for the baby, and I once again told them I was doing my best. I know Latinos are melodramatic with their body language, but the Nicaraguans take the cake. They are feisty! If I don’t hear the word “dolor” (pain) again for quite some time I will not be disappointed.

After the patients are let into the gate, they assemble into different lines marked off by ropes based on what specialist they need to see. This morning I peered out the window and saw a big someone seeking services that had come to the incorrect clinic- a cow. Yes, that is right, a cow had gotten into one of the lines and was waiting patiently to be seen. Unfortunately we had to turn the cow away, but called one of our vets who administered some vaccinations, and the cow ultimately got what he came for. I snapped a photo through the blinds as they took the cow away and chuckled.

My translator today was a middle-aged woman from Managua named Denise. She spoke English so well, I didn’t realize she was a native Nicaraguan. We moved fast today wanting to help as many people as possible on our final day, and having an outstanding communicator helped out tremendously. I was especially grateful when Maria came along- a 17 year old girl that was late on her menstrual period. I asked how late, and she said just over a month, looking terrified. We did the test, and sure enough she was pregnant. When I delivered the news, she was devastated and scared. Tears streamed down her face. She was trembling. In Spanish I tried my best to console her and ask if her parents knew and if they would be supportive. Maria shook her head no. Between sobs, she told us how her parents had told her that if she got pregnant as both her older sisters did that they would disown her. At this point I took her hand, and looked desperately on Denise, and together we were able to get Maria to have some hope. She wanted to go to Veterinary School in Managua, was unmarried, and we tried to encourage her. It was going to be tough, but she could do it. Unplanned pregnancy- an issue that affects the entire world, but especially challenging in this region.

At lunch I spoke more extensively with Denise about life in Nicaragua. She told me that her parents took her throughout Nicaragua countryside when she was growing up, so she was able to see the differences between urban and rural living of the people. Over the past few decades there have been so many upheavals from socialist influences, corruption, civil war, coups, farm redistribution, and now a cycling back to the Sandinista leader everyone knows as just “Daniel” (Daniel Ortega), who was elected by the highest candidate percentage of the vote (although just 38%) in the past election. Denise shook her head side to side when talking about this….politics. There is so much more to be done and for a just democracy, there needs to be fair elections. I listened some more and then changed the subject...I emphasized our desire to partner and learn and assist Nicaragua in education and public health issues, and she said “Thank you. For this we are most grateful.” And we got back to doing just that….

There is an ER doc in our group, CAPT Andy Johnson, that is super talented and the head of Emergency Medicine at a great Navy training program in Portsmouth Navy Hospital. We call him “The Machine”, because he consistently outdoes the rest of us in the number of patients he sees each day. He has a focus like none other, and works straight through lunch. Throughout the mission the 200 mark had so often evaded Dr. Johnson’s grasp. Today was the final day, and as the afternoon was winding down, we got hourly updates from Dr. Cole on Dr. Johnson’s status. Sure enough, around 3:30 pm Dr. Johnson triumphantly marched into our room- “Two Hundred and Seven!” That got a standing ovation and many looks of astonishment. I dropped my stethescope.

We saw so many patients this final day that we overloaded the pharmacy. We took turns helping out in the back handing out packets of vitamins, and medicine for pain and gastritis until all were taken care of. Chief Weber walked in with a several day old baby that was crying. It was a great sight. Big Chief Weber and the tiny infant. And then the baby spit up and it was an even better sight.

The five days in Somotillo was wrapping up. We had done our job- 6000 patient encounters during our time here. In a demonstration of our commitment to the partnership with the Nicaraguan Ministry of Health and the Town of Somotillo we presented them with a token of our thanks, and they in return presented our team leader Dr. Cole with a very large bottle of aged Nicaraguan rum. We all clapped and thought it an awfully nice gesture. That evening we enjoyed that rum, telling story after story from the travels of our past months together. Dr. Ed Taylor entertained us with the playing of a Nicaraguan flute and many of us dressed in the host country attire as we celebrated the culmination of mission that we will remember forever.

Now starts the journey home. From Corinto to Managua, and Managua to Miami, and then eventually back to Washington D.C. where this journey started back in May. This seven weeks has been filled with so much emotion, reflection and memorable times. A mission where we made new friends, helped thousands, educated, were humbled, and made many throughout the Americas smile. I am glad that I wrote down these reflections. On this journey I have met some of the most incredible, talented, and compassionate health care providers in the world today. We crossed the Panama Canal and the Equator for the first time together. We saw upwards of 60,000 patients over the past two months, worked long days in the heat, helo rides, boat rides, good times and bad times together. I hope that it provided a view into the great work and important component that Humanitarian Assistance/Disaster Relief makes in our Global Security Strategy today. It truly influences the relationships amongst the governments and on an individual level of how the United States is viewed. This “soft power” is crucial in bringing our nations together in peace and partnership enabling a more prosperous and safer future for all. This is Continuing Promise 2009. Until next time…from the USNS COMFORT. Go NAVY MEDICINE!

Nicaraguan Coffee and Six Fingers

2009-07-12T21:53:00.000-07:00

The weekend is here in Nicaragua and for the Navy Medical Strike Team that means two more days of humanitarian assistance in Somotillo, Nicaragua. We are starting to get into a routine, and today we were up in plenty of time for breakfast and without the disaster from Friday morning. Snoozing in and out along the way on the bus sitting next to Dr. Lynn Sterni, I apologized each time I fell asleep on her shoulder. I think I am becoming narcoleptic. Either that or caffeine has no effect on me any more. Probably the latter. When we arrived at the site I visited my friends Erika and Cristina and baby Angel at the food stand, and Erika made me two strong cups of coffee as I held little Angelito. The premature baby had had diarrhea for the past few days so I questioned whether he was able to get any sleep the past night, and they answered yes, that the medicine had worked and the baby had slept. “When are you going to give him a bath?”, I asked. Sure enough that’s what they were preparing to do as the father cut a plastic bag of water and poured it into a metallic bowl, and in went little Angel for a good scubbing. The chickens scrambling nearby took a moment to observe. They would be lunch in a little bit. If they only knew… Cristina shooed them away and she showed me the green T-shirt she had on today which said “Jamiaican Me Crazy”. She had no idea what it said or where Jamaica was, so I told her what it meant. She smiled.

My translator today was a gorgeous 19 year old woman named Ariadna from Managua. I couldn’t for the life of me figure out why she was here volunteering her time to translate. She was not part of the Mormon church crew and just didn’t seem the type to do community service on the weekend like this. She was shy and her English needed some work. I was patient and by the time we had seen a dozen or so patients she had the hang of it. It was only upon further questioning that I was able to ascertain that she was starting a job next week in Managua at a call center where she would have to be speaking English. So this weekend was her forced practice. Not a bad idea. Smart girl I surmised. And she told me she had a fascination with Looney Tunes Band Aids (Tweetie Bird to be exact). I obliged and she put one on her arm and then in a show of team spirit put one on my arm as well.

An elderly woman came in mid-morning (I think her name was Matilda) who had six fingers on each hand and six toes on each of her feet. Most cases of polydactyly (extra digits) people have a non-functional appendage, but this woman had an extra “pinky” on the lateral portion of the hand that had full functionality and worked very much like an opposable thumb. It made for a handshake like none I had felt before. She was a very sweet woman and proceeded to give unsolicited hugs to both Ariadna and I in a show of thanks. Genetic mutations such as this are fascinating to me, so I asked Matilda whether any of her family shared this morphology. Her sister had extra digits as well, and sadly she was not able to have children (she had lost three due to miscarriage). You could just sense and feel the long life and wisdom this woman had had.

For lunch I showed Ariadna how to eat an MRE (she was mesmerized), and I decided to risk eating the quesadillas that Cristina and Erika were preparing. Over by the stand I saw the two main Chiefs for the site – Chief Francis and Chief Weber. They are the ones who make the site function logistically (busting their tails in the searing heat all day) and I tip my hat to them. Chief Weber is permanently based with the USNS COMFORT in Baltimore and is going to ride in the Baldwin PA Health Ride we are doing in October – www.healthride.org Please check it out and make an impact in combating childhood overweight and obesity.

Every patient I see I make sure to ask what type of work they do. People in the Somotillo region are mostly farmers that grow corn and beans. This morning I met a guy named Jose who grew and processed coffee. I told him about my love for coffee and he told me all about Nicaraguan coffee and how it is the best in the world. I mentioned (in passing) that I would love to try some, not thinking anything of it. Well, guess who showed up this afternoon on his bicycle with a big green pot of coffee and a matching green coffee cup- Jose! He had gone home and brewed some up fresh for me and the docs. With a bit of trepidation I accepted Jose’s cup of Nicaraguan Joe. It was awesome! Hit the spot. In return I scrambled to find a “regalo” (gift) to give in return and luckily in the MRE container there was a leftover Lemon Pound Cake safety sealed in the brown plastic. I gave it to Jose with pride and told him that this is what we eat with coffee in the U.S. He opened the package and smiled after taking a bite of the pastry. Whew…..

The day ended with us seeing a bit less than the day before – about 1500. Since the town had only a few thousand people, we began to realize that those people we thought looked the same as yesterday, probably were the same people from yesterday…….
Oh well, it’s all good. We’re providing a stockpile of medication for them. The longer it lasts the better. Just so long as they know the proper usage. And it’s not like we are doling out Diprivan or Propofol or something like that (MJ).

I am trained as a medical doctor of the Allopathic discipline. Many other docs are trained additionally in the Osteopathic discipline, learning to do “adjustments” and chiropractic treatments. I have never been much of a fan of these but tonight I changed my tune. After several days of seeing hundreds of patients I felt like dog doo, and my back was stiff as a board and my neck jacked up. Barretti is a D.O. (Osteopath) and so I gave in and asked him to crack my back and my neck. I am now a believer. Thanks Mike. See, I knew under that insolent hard shell with your jaded view of the world, there really is a nice guy who can crack peoples joints and allow them to feel better.

Nicaragua- Woman with 20 Children

2009-07-12T16:31:00.000-07:00

“Baldwin, Holy S%#* it’s 6:15!” screamed Mike Barretti. “Bus leaves in 15 minutes!” We had both slept through our alarms and we scrambled to get ready on Friday morning for the trek back out to the medical site in Somotillo. Mike elected to forgo the cold shower and shave in order to get some breakfast, as I chose to face the frigid water in hopes that the bus would be late and I could still snare some biscuits and coffee on the run. Dang that was cold! I exited the shower and tried to slide the door back the entire apparatus came unhinged and crashing downward. Shaving my my beard and at the sink navigating around the broken plastic/glass was a chore. The morning was indeed off to an interesting start! And as anticipated the bus was bit late, so I inhaled some eggs and beans and threw some coffee down the hatch and then boarded the bus to Somotillo. I took a moment to reflect that although we were in the second poorest country in this hemisphere (behind Haiti) the beauty of this land was worth a million. The view out to the San Cristobel volcano looked gorgeous in the morning light and many of us leaned over each other to try to get a moving photo through the bus windows (note to reader- this never results in a quality photo). During the drive I embarked upon a new book by Michael Creighton called NEXT and then sadly was told that he had passed away last year. The Harvard medical school grad wrote many novels and also was the force behind the TV show ER.

We reached the health clinic in Somotillo at 8 am and the line of patients was enormous. I tried to take a picture that captured its enormity- the crowds of a few thousand stretching down the street and around the curve. It reminded me of the start of a large marathon race. The majority of the patients were mothers with their children. Most of the fathers away in the fields working. I went over to the food stand that I had spotted yesterday run by a few ladies named Erika and Cristina and they yelled out, “Hey Andres!” Wow, they remembered. “Me falta un café (I need a coffee)”, I said. This was no STARBUCKS. The water heated up in pot over fire, a chicken ran by, and Erika’s premature little girl was crying at top volume. The instant NESCAFE coffee was not nearly as good either, but it woke me up and got me through the morning. Cristina begged me to get her baby some more vitamins, and also some cream for the rash. I saw a stash of medication that they had collected already (no doubt in barter) and began to see the way that things work around here.

My translator today was an extremely knowledgeable woman named Karen who currently lives in Managua but grew up in the United States in Los Angeles. Her English was better than many Americans I know. She had done quite a bit of medical translator work before, and with these skills we set a rapid pace of seeing patients. It was a good thing considering the line outside. In the examination room with us were Dr. Barretti, Dr. Ed Taylor (Family Practice doc), CAPT Sheehan (Nurse Practitioner in Public Health Service). We were flying. By mid-morning we had already seen about 800 patients, and the line outside still kept going and going… Most patients here in Somotillo were the same- country farmworkers and housewives – the overwhelming majority of whom had headache, gastritis, and dizziness. So much so that we were already filling out the forms by the time they presented to us. Some unique patients that I saw were a woman who had no teeth, but wanted to show me her smile anyhow ☺, a man sporting a Nautica (one of my sponsors) cap and having no idea what Nautica meant, and an 80 year old woman who had twenty children over her lifetime. At eighty years of age she told us that her youngest was 30 years old, and that only eleven of her children remained alive today. Many of them were killed in the Contra-Sandinista conflict during the 1980s she said. I had to take a moment and regard the uteral courage of this woman. Upon further questioning I found out that she has over 100 grandchildren all throughout Nicaragua. What a life force!

The crowds were so large that we ate a working lunch, having some MRE crackers and cold beef stew while answering questions about headaches, gripe (flu) and cough (toz). Early in the afternoon Karen and I went through the typical patient visit and wrote out the prescriptions for a nice mumbling young lady and thought we were through, but at the end she opens her mouth and showed us something. She had a frenulum (that piece of tissue that connects your toungue to the bottom of your mouth) that held her entire tongue down. She had extremely limited movement ability for her tongue and she was able to tell us it prevented her from rolling her R’s and speaking effectively. I thought how nice it would be to get it cut back, and ventured with the woman over to Dentistry to see if we could do some minor surgery. No more surgery room aboard the USNS COMFORT, but with some urging and serious courage on this girl’s part we decided to do it right then and there. We numbed up the underside of the tongue, and got out some sharp scissors, and Dr. Sanchez dissected away avoiding the large bleeding vessels and carefully giving this girl the ability to move her tongue around (something that we take for granted every day). Afterwards she could roll her R’s (I still can’t for some reason and am considering a frenulumectomy, but others tell me that is not the problem).

The afternoon wore on and we began to see our first patients from Honduras. CDR Ed Taylor, who is from Honduras originally, jumped up and told the room when he encountered a nice woman from his home country. She had heard of the USNS COMFORT team being close by and had crossed the border to be seen. Several more followed and many more would come over the next few days I am sure. Outside the crowds became unruly outside the pharmacy, and the pediatrics waiting areas were overflowing us adult providers agreed to see some kids as well. The pediatric bail out was fun and gave a change of pace to see some different issues- lots of scabies, diarrhea, parasites, and parents stating that their children were not eating (no appetite). Most of these children were normal weight and their mothers were the opposite. But have to put it gently. Health education and reassurance I think is ofen times the most valuable in this type of setting and population.

By the time 5pm came it had been 9 hours of seeing patients, and in all the site had seen close to 2000 patients. I must have seen close to 150 and Barretti, Taylor, and Sheehan was up there as well. As we so often joke on this mission that it is “Not about the numbers” CAPT Sheehan pushed the joke even farther as he grabbed the stacks of hundreds of patient encounter forms and flipped through them all. It was a record setting day out there today, and the most prescriptions given out by far for the entire mission thus far. Great job to the Medical Military Strike Team led by Dr. Cole!

Thoroughly spent we retreated to our hotel in Chinandega, and found one hundred of our fellow humanitarians there as well. The boats and helicopters were grounded due to bad weather and they all would be staying over crashing on our floors, or on cots if available. I joined the table with CDR Santa (UNC grad and Navy NP), Jefferson Medical Student Majit Gupta, and several others including Dr. Richard Soetens, a Dutch physician. Soetens claimed a cot in our room. I’m not sure if either of us got any sleep that night with Barretti’s drunken snore. Well, until tomorrow from Nicaragua. Buenas noches.

Mission to Somotillo

2009-07-10T20:05:00.000-07:00

The mobile medical strike team (MMST) led by CAPT Jeff Cole assembled at 7am on July 9th in the casualty receiving area onboard USNS COMFORT Our mission- get to the remote rural town of Somotillo in northwestern Nicaragua ASAP to relieve fellow humanitarians and wreak as much positive goodness on this town over a five day period as humanly possible. This was it. What we had trained so hard for.

Donning our high speed sunglasses, stethoscopes, and lifejackets we ran up the stairs to the main deck to get on the uber fast RHIB (rigid hull inflatable boat) and get quickly to shore. “Go ahead and take a seat!”, shouted Gunnery Sergeant Roberts. “It’s going to be awhile!” Sure enough, the strike team was foiled once more on achieving an expeditious delivery to target. We took a seat, and some of us even laid down for a snooze on bed of lifejackets.

After finishing three books over the past few days, I was glad I snagged a few more before leaving on the mission this morning. I whipped out my IPod and a murder mystery by Dean Koontz and tried to stay focused on the five-day mission that awaited us. My teammate, Dr. Mike Barretti, cursed the situation and then cursed that I was reading books. Barretti means well, trust me. He finally has made a valiant effort to quit smoking and for that I am proud of him.

A few hours later we descend onto the RHIB held by a single tether line to the ship crane above. Sure hope it doesn’t snap, I thought, while preparing to do a inverted dive and duck if it for some reason it did. We touched down safely and were on our way. Instantly the feeling of Navy pride returns as we are skimming the water toward shore. Barretti is making the best “Washington Crossing the Delaware” stance he could and I snap a photo.

This is what it must have felt like back in the day (well sort of). Just at that moment, CAPT Sheehan leans over and informs me that the Carinto harbor that we are about to enter was mined by the United States just under three decades ago during our “clandestine” operations working against the Sandinistas. Sure hope they are cleared now. Wow, what a difference a few decades

and the fall of the Soviet empire makes. I see that Sheehan has quite a bit of knowledge on Latin American history and a penchant for political science, so I make a mental note to pick his brain over the next few days about the “true” state of affairs here in Nicaragua.

By the time we reach shore it is 10am and we board the bus for the bumpy ride through Chinandega northward to Somotillo (about 3 miles from the Honduras border). Wow, this is the Short Bus! I sandwich my legs into the small seat space by the window (why did I have to pick the seat with the wheel well???) and knees jab into the back of my teammate in the seat in front of me. Next to me sits a lady volunteer and I thank her for being a member of the team and helping on the mission. I tell her that she should join the Navy (always recruiting J) and she tells me she doesn’t want to shoot guns and be sent to the front lines in a war zone. Really??? I begin to form an answer, but then decide it is not even worth it. Back to the book. We pass by Chinandega, and see the sign- 60km to Somotillo. My legs have lost feeling by this point, but I ignore it and press on.

Off to the right hand side we catch a glimpse of an enormous volcano (it must be 10,000 feet) with steam spewing from the top. I come to find out the name of the giant is San Cristobel and it is one of seven volcanoes that are semi-active in the country.

By the time we reach Somotillo the Dean Koontz book is almost history, and it is just past noon. We carefully approach the target site making sure to hit every pothole along the way, and once secure, we charge the building (Centro de Salud – Raymundo Garcia) and announce the cavalry is here! Our fellow humanitarians, weathered and spent from their numerous days here, are overjoyed to see us. Ready to go, the first thing we do- lunch! Luckily the Centro de Salud (in addition to a large amount of flies) has a set of rocking chairs that instantly remind me of Cracker Barrel. Dr. Schwartzman (heart sweat man), Dr. Arthur (fellow Duke grad), and I man the rocking chairs and ingest our MREs. The relieved troops leave for the trek back to the ship and the new MMST sets up shop. The area where we are seeing adult patients is full of flies, BUT it is air conditioned (when the electricity is working). I look at the bright side. Barretti doesn’t.

It always takes a few patients to get back in the swing of things after being back onboard the ship for a while. The Spanish isn’t quite flowing right. You are caught off guard by a different regional style of the medical Macarena “dolor” dance. But eventually things get going, and you’re back in a routine again. This town is interesting. For one, it is definitely “el campo” (the country) and all these people are farmers, or do something related to agriculture. Somotillo is an impoverished town with little to no infrastructure and this tells me that 1) there will be less chronic health problems due to obesity 2) there will be more rashes, allergies, GI issues, skin infections, parasites due to lack of hygiene and 3) there will be A LOT of children because there is not much else to do around here besides create them.

As the afternoon progresses I am working without a translator, which I am able to do, but boy does it get tiring. A female patient asks me if I am from Cuba, I say no, she asks me if I am from Mexico, I say no, and finally she says United States? Yes. Peculiar. Later I come to find out from CAPT Sheehan that Cuba (and to some degree Mexico) have had a large impact on the medical care and medical training of the people in Nicaragua. This woman had never seen a doctor from the United States helping (especially one that could try to speak Spanish).

By the end of the day I was desperately in need of a coffee, and so I ventured out into the dirt road looking for some instant café. There were lots of roosters running about, and guys on their “Tricicletas” – that’s what they called them here for the bikes to transport people around. I found a food stand and it was super filthy. I surveyed the scene where the coffee was prepared and that was not as bad, so after some discussion my gut and I agreed to give it a go.

What’s the worst that could happen? The senora preparing the coffee invited me into her “shack” and I saw on a hammock her small baby that had recently been born eight weeks premature. The woman begged me for some vitamin drops for the babe and to give her some extra money. I gave her some help and returned with the drops in time to pick up my coffee. It wasn’t that bad (and as I’m writing this no issues to speak of).

We packed up shop around 4pm and boarded the buses for the long haul back to Chinandega where we would be spending the night at the Volcanoes Hotel. Thank goodness for Dean Koontz and his easy to read murder mysteries. Just as the killer was about to strike, BOOM! , a tire blew out on the right back wheel of the bus, and we ground to a halt. I have never seen a tire changed so fast by the driver of a bus. He found a rock on the side of the road, and backed up onto it (using it as a jack), and changed that tire like a NASCAR pit crewman. Most of us used the extra time to visit the bushes on the side of the road to take care of some business.

We were slowed by a banana carrying truck the rest of the way, so by the time we reached the hotel the Koontz book was complete (they got married). I gave the book to Barretti and he scoffed at first, but ended up taking it. We’ll see if he reads it. The Volcanoes hotel turned out to be extremely nice. A quiet place, with view of the volcano in the backyard, and a nice bar and restaurant. The MMST settled in for our first night ashore and did what a joint medical team does after a hard days work. Until tomorrow…..

Nicaragua 98.9 FM

2009-07-07T11:58:00.000-07:00

The sea state here off of Nicaragua is the worst it has been yet. When you run on the treadmill it becomes an intense alternating hill workout as you run downhill when the ship rolls one way for ten seconds and then run desperately uphill as it dips the other way for 10 seconds. Last night I lay in bed rocking from side to side, and even when I braced myself against the railing I could feel my internal organs moving back and forth. I could not fall asleep. And when I finally did, I would constantly get startled awake during a severe roll of the ship as I slammed into the rail of my bunk.

But alas, morning came and I was awoken this time at 0430 by Gunnery Seargeant Robert’s voice shouting “Serial Callaway, Serial Callaway, Muster Team such and such in the Casualty Receiving Area with Combat Cargo (that’s his call sign). Every night before bed Gunny posts the manifest for the different groups going out the following day. It is commonplace to check and see what boat or helicopter you are assigned to and what time your “Serial Call Away” is. I looked last night and next to my name it said, helicopter, 0730, PAO! What the heck? PAO is public affairs officer. I found out that my first day ashore in Nicaragua I would spend doing interviews with a radio station and a TV station talking about the mission. “You know how to talk to the media Doc!” That’s what they told me. True, but I haven’t done any interviews in Spanish before. This should be interesting….

In an earlier blog entry I mentioned the phenomenon in the military called “Hurry Up and Wait.” Well this morning it was ringing true. We were supposed to go by helicopter, they fell behind schedule, then we were ordered to go down to take a boat, then after waiting another 45 minutes, were ordered to take the helicopter again, then the swells got really bad, the deck was pitching back and forth, the helicopter couldn’t land, so in the end we ended up in the RHIB boat going ashore (3 hours after we were supposed to leave). I’m glad that Julie Moreno (Surgeon General’s assistant) brought me the latest Economist for something to read during this dwell time. Thanks again, Julie!

The RHIB ride turned out to be the best mode of transportation anyhow.

By this point in the day, the sun was shining brightly, and it felt great to get sprayed a bit as we were skimming quickly across the water towards shore. LCDR Morris (Navy Surface Warfare Officer) was with me for the day and she was grinning from ear to ear. She said,“THIS is why I joined the Navy!” I nodded and replied, “You’ve got that right, ma’am! So many people don’t know what they’re missing!”

We rounded a beautiful jetty of rocks with a white lighthouse and a statue of an important Nicaraguan leader (couldn’t quite see the features or inscription from this distance to tell you who exactly). But what I did see were the waves behind the jetty and the incredible right to left surf break that was occurring. Note to self and others- great waves in Central America.

Once we reached shore, we spotted our escorts- Air Force CPT Rebecca Garcia (Public Affairs Officer Extraordinaire), U.S. Navy Petty Officer Second Class Lenin Sanchez (originally from Nicaragua) and the driver Luis from Managua. No bus. Today it was a ride by SUV. We made our way to the town of Chinandega- population approx. 100,000, Nicaragua’s fourth biggest city. The country of Nicaragua lies between Honduras and Costa Rica in Central America, has a population of about 6 million people, 80% of whom earn less than 2 dollars per day. Over the past three decades they have experienced a lot of turnover in government, insurrection and war, including the Contra-Sandinista conflict in the early 1980s (Contras backed by the U.S.) But all is stable now in Nicaragua (for the most part), and the purpose of Continuing Promise is to demonstrate the U.S. commitment to working together towards peace, mutual education and health. With this in mind, I would make sure to emphasize this in the interviews. But over the next few hour I simply wanted to get a feel for this country and its people. I stared out the window of the SUV and just took it in- lots of children on bicycles, even more “cataneros” (bicycle taxis with covered rear cab), a very bumpy road with potholes, people here carrying things on their heads as well, cows on the streets, and sign after sign for Coca-Cola. Now we know who advertises the most in Central America and is perpetuating this “diabetes” thing. Hey, at least they were being active. More than the U.S. can say. The houses bore the same beautiful pastel colors and Mayan influenced décor as many of the houses did in El Salvador, but with a unique Nicaraguan style that I can only describe as “edgy”.

Because of our morning delay, by the time we reached Chinandega (30 minute drive from the Boat Landing Zone) we had missed our TV time slot, and would have to be content with the radio interview. Fine by me. Go with the flow. Semper Gumby. I had brought an extra change of clothes this time just in case we happened to get stuck out here overnight. The weather guy announced last night that a Tropical Storm was moving in today, but weather guy is always wrong, so it would most definitely be sunny. And it was!

We arrived at the radio station about noon- Radio Mas Stereo 98.9FM- “Noventa Ocho PUNTO Nueve!!” That’s how I was instructed to say it. They have a website. www.radiomasstereo.com A very friendly gentleman and nice lady (both in early thirties I’d say) greeted us and brought us into the control room.

We shot the stuff for awhile in Spanish, the nice lady asked me about the shoulder pain she was having (no doubt from her heavy shoulder bag) and then after about 20 minutes the station owner showed up carrying ice cold bottles of guess……Coca-Cola! He expressed his gratitude for the help that COMFORT was providing the people of Chinandega and Nicaragua as a whole. We began the broadcast and I did my best rendition of “Noventa Ocho PUNTO Nueve” I could. They seemed to like it. Then I launched into an introduction, gave some facts about our Mission - where people could be seen, how long we were going to be here, and then I got tongue tied. This was hard to speak at a fast pace in Spanish on the radio. So I just said it again- “Noventa Ocho PUNTO Nueve!” and they smiled and nodded in approval. Luckily the phone rang at that point and a caller had a question. I beckoned Petty Officer Sanchez to help with the translation, and through him I was able to explain some treatment modalities for the caller’s Kidney Stones and Urinary Tract Infections. Bottom line- drink more water and not Coca-Cola! We also talked at length about the enormous problem of Gastritis (Irritated Stomach) in Latin America and how it can be due to parasitic worms, spicy food, not enough water, too much alcohol, and stress. Towards the end of the interview the manager came in and offered some spicy rice and beans along with some more Coca-Cola and all I could do was chuckle- Noventa Ocho PUNTO Nueve! J

The interview must have had an impact because as we were leaving a few people came DIRECTLY to the station for a medical evaluation. Our driver Luis had been listening to the interview from the SUV and he said that most people here in Nicaragua typically listen to the radio for news vice the television. So hopefully the radio spot will help get the word out about the opportunity for medical care and the civic and humanitarian projects that the USNS COMFORT team is providing in partnership with the host nation of Nicaragua. I’ll let you know the turnout we get in a few days…..

We had not had lunch yet, so after the radio interview we found a relatively modern restaurant called “Tip Top” which I can best relate to a Kentucky Fried Chicken/Chic-Fil-A in the United States.

Looking for a non-fried option the gentleman behind the counter offered grilled chicken and I agreed. When he plopped an entire small chicken down in front of me I was stunned. Good thing I was hungry. It hit the spot after shipboard food and MREs. After lunch we ventured across the street to the Town Center where there was a playground area for kids. LCDR Morris chatted with some of the kids nearby and they ran over to CPT Garcia and I and started yelling “Gringo!, Gringo! Gringo!” and motioning to the swing set.

I replied “No soy Gringo”, but I don’t think it had much of an effect. They believed Garcia. Next thing I know I was swinging on a swing trying to get as much altitude as possible, with the little boy next to me trying to get even higher. It was some good community relations for the day. They were adorable.

The ride back to the ship was by RHIB again and by this point in the afternoon the skies were threatening rain. The seas were picking up big time, and we all prepared ourselves for a wet and wild ride back.

For someone who loves adventure and adrenaline, riding a RHIB is a lot of fun.

Safely back onboard the ship, I shouted one more time “Noventa Ocho PUNTO Nueve!” Viva Nicaragua! Viva Los Estados Unidos! Estamos unidos! (We are united!).

Nightlife on USNS COMFORT / July 4 with the Surgeon General

2009-07-05T19:59:00.000-07:00

What does the crew do at night aboard the USNS COMFORT you may wonder? Well last night may illustrate a few of the options. There are only so many places to go and things to do onboard a ship. After dinner, I ventured towards the operating room. Inside I saw a group of folks watching the movie “Don’t Mess with the Zohan” (relatively funny Adam Sandler movie). Two of my friends, LCDR Vic Diaz (my Nurse Anesthetist roommate) and Lieutenant Junior Grade Marcela Zelaya were part of the group. Those two could be brother and sister.

Zelaya, whose family is from El Salvador, is extremely smart, speaking six languages, getting her PhD in astrophysics, and a former Olympic Trials qualifier in swimming. If they made a female version of the Zohan who was from Central America it would be Marcela. She’s Wonder Woman. After a while I grew tired of the movie and moved along to see what else I could find going on aboard the ship.

I ventured back to the galley to get some more water because I was already dehydrated (hot ship). People are stil getting soft serve ice cream, but I decide against having another. In line is LT Matt Gill, public affairs officer extraordinaire for the mission. I’ve been corresponding with Matt for months now, working on several strategic communication initiatives to get the word out about Continuing Promise 2009. He is a levelheaded Naval Officer with Explosive Ordnance Disposal and Navy Diving background.

Gill is steady, does not overreact, stays on point and gets the message across- just what you need in a Public Affairs Officer. You wouldn’t know he has such a dry sense of humor until you got to know him better. He has a great family back home in Norfolk and soon they will be headed to their new port station in Naples, Italy. I snap a photo of him and move along.

I hear my name (or something close to it) called from across the room. It is Warrant Officer Tuparan- a gregarious Navy Officer of Filipino decent who works in Patient Administration. “How you doing Alec?Need anything?” He’s the guy who knows how to get something if you need it. Kind of like “Red” in the Shawshank Redemption.

So when the paperwork needed to be straightened out, Warrant was the guy who knew someone who knew someone. “Nah, I’m good Warrant. Thanks, though!” I filled up another glass of Gatorade and picked up some more saltine crackers (that’s all they have to eat on the mess decks after dinner is over). I like the crackers. Warrant Tuperon always has jokes, and smile on his face. I hope his kids will go into Navy Medicine as well.

There is someone singing/rapping “In Da Club” by 50 Cent from across the room (fairly well I must say). The ship is having their COMFORT IDOL finals tonight – Karaoke style. I just watch for a bit, and see that the guys and gals are having fun. The “Fun Boss,” Jeremy (recent Penn State grad, not in the military) has things under control and is doing his job. The Fun Boss’s sole job that he is highered for on the deployment is to come up with events each night and at liberty ports for entertainment.

He hosts Bingo nights, Video game competitions, Athletic bouts, Karaoke, Movie Screenings, etc., etc. I went up to him and asked if he had a business card. I just want to see if his card reads “Fun Boss”. One of my good friends worked for the Sheraton in Hawaii and his job was the “Director of Fun” for the hotel and that’s what his business card said. No kidding

I ventured downstairs to the Officers Lounge and found CDR Bill Graf. Dr. Graf is an interventional radiologist and a fellow Navy Deep Sea Diver. He is a steadfast athlete, and we always seem to find ourselves PTing (physical training) next to each other.

I just found out a few days ago that Graf and I both grew up in Lancaster. A cool thing about the Navy is that you can be halfway around the world, and meet someone that grew up down the street from you. Two days ago while running with Graf on the treadmills I noticed the yellow LIVESTRONG bracelet on his wrist. “You lose someone to cancer, Sir?” I asked him. He told me the story of how his wife had lost someone and was very active with fundraising for cancer research and supporting the LIVESTRONG movement created by cancer survivor Lance Armstrong. I told Graf the story of my uncle who had rapidly and painfully lost his life to pancreatic cancer and the work I do with PANCAN.org. Tonight Graf handed me a cap and a yellow LIVESTONG band. I put is on and we got a photo. “PA Pride” (Pennyslvania Pride) we both said and pounded fists to our chests.

Time to head back to the other end of the ship and see if anything is happening back there. I stop quickly to check the computer and see if the outside communication is working. As usual the answer is no. Only email we are receiving is from intranet (within the ship). The one message I did receive internally from the supply office informs me that I have a letter and package waiting at the post office. Wow! Things were looking up. I go up there and ask the postal clerk (it’s after hours but they are still up watching movies) what he’s got. He hands me a bag and a letter.

In the bag is a white T-shirt with El Salvador proudly painted on the front with adjectives and things that make the country special. It was a gift from one of the El Salvadorian patients I had seen and the note expressed her thanks to all on this mission. Even though the T-shirt was three sizes too small, and had colorful writing that would not last long in these washers, it was the best token of graciousness that I could have received and it made my night. Thumbs up to you!

In a jovial mood, and feeling even more joyful because it was the eve before Independence Day, I decided to return to my favorite chair in my room and put in the HBO TV series John Adams. Very fitting to watch the signing of the Declaration of Independence that occurred 233 years ago on a DVD video player on my Mac on my lap in the underbelly of a floating converted Oil Tanker off the coast of Nicaragua. If you have not seen this Series based off of David McCullough’s book chronicling the life of our 2^nd President John Adams, I highly recommend it. Paul Giametti does a fantastic job playing Adams and clearly shows the courage and fortitude our founding fathers displayed time and time again so that we could live with life, liberty and the pursuit of happiness. I have not felt very homesick up until this point, but everyone wants to be on American soil for July 4^th. So any of you reading this, please give a salute, a howdy! and a thank you to any military personnel you know serving around the world today. With these thoughts in mind, I dozed off to sleep in the chair, woke up at 1am, and my first thought was Happy 4^th of July! Next thought was “Hey Baldwin, get in your rack for Pete’s sake! You fell asleep in this chair for the past three hours!”

Happy Independence Day! I am still shipboard since I’ll be working the back half of our Nicaragua stay ashore (my friend Karen Jacobson and others have been out there the past few days). Today is another good opportunity to work out a lot and read medical textbooks. This morning was the ritual Dave Bacon spin class, followed by a reading session on Bioterrorism agents. When I was falling asleep from the material, I decided it was time to work out once again. Sick of running and falling off the treadmill, I asked a recent Newbie, LCDR Lynn Sterni if she wanted to run the ramps of the ship with me. She nodded yes in a manner that said “yes, get me out of here!”

The ramps are switchbacks used for loading and unloading large cargo, and also the entry point for mass casualty receiving. The walls of the ramps are lined with stretchers and the floor painted red to conceal the blood. Pray we do not have to use them. From bottom to top at a gentle incline is .16 miles. So going up and down three times completes a mile. Sterni is a pediatric anesthesiologist in the Navy. She has red hair, practices in St. Louis, is super nice, and I always see her working out. I come to find out while running the ramps that she is an outstanding runner and triathlete. I was winded trying to keep up with her. Turns out that she was at the TAPS Good Grief Camp in D.C. that my foundation Got Your Back Network (www.gotyourbacknetwork.org) helped out with in May for families of the fallen. Very nice thing for her to do. She is quality people. After 9 times up and down on those ramps (3 miles) in the stifling heat with calisthenics in between, we were drenched with sweat and spent. Two solid workouts on the 4^th and we were ready for the Ice Cream Social that evening.

July 4 was extra special this year on USNS COMFORT. The Acting U.S. Surgeon General, Admiral Galson, came aboard with his staff (my friends Julie and Tomas) to visit the ship and to celebrate the anniversary of the U.S. Public Health Service.

We have just shy of 100 Public Health Service Officers onboard from all throughout the country. They serve in numerous roles from Environmental Health Officers, to Epidemiologists, Physicians, and Veterinarians. Over the past few months while in Washington, D.C. it is been an honor to help Admiral Galson with his “Healthy Youth for a Healthy Future” initiative combating childhood overweight and obesity throughout the United States. For more info see: www.surgeongeneral.gov and pledge your support today.

For the Surgeon General’s visit we had a very nice dinner in the Wardroom with distinguished staff. They brought out the best china and silverware for the occasion and everyone in attendance had a personalized nametag at their table setting, as well as a colorful Independence Day menu.

Given the choice of ribs or chicken, I went for the poultry. I sat next to a very nice Veterinarian LCDR who I found out attended Cornell University for Veterinary School (the same undergrad school that my parents and sister attended), and it was fun to talk about the beauty of Ithaca, NY and Cayuga Lake. I have been there many times. Across the table from me was CAPT Beadle who has led the Medical Operations and planning for this mission from the start. She is the brains and the powerhouse behind the medical planning and execution. I told her good job- “Bravo Zulu ma’am!” Bravo Zulu (BZ for short) means good job in Navy lingo. “We’re not quite there yet! Almost,” she said. With all the moving parts that this mission has, the amount of time she has put in is remarkable. I hope CAPT Beadle feels proud and people give her a pat on the back for the great job she has done. Dinner was excellent (best food I’ve had on board yet) and I thanked the Petty Officers who served us and asked them where they were from and what their goals were. Solid kids. The Surgeon General made some remarks in addition to the Commodore (Captain Negus), Captain Ware (Medical Commanding Officer), and Captain Finger (Ship’s Master). They call this trio of Captains the “Three Amigos.”

After dinner we had the usual 7pm Confirmation Brief, and the packed mess decks as always felt like a sauna. The Three Amigos name a “Person of the Day” every evening and tonight it was a truly special person- the lead vocalist for the Air Force Band. As if on cue she took the microphone and started singing right in front of the American Flag- “God Bless America.” The entire crew came together singing in unison to finish out the hymn and you could feel the pride. The only thing missing was fireworks. But we did have Ice cream! Tonight it was the real stuff- fresh with several flavors from the scoop- no soft serve. As they turned on the movie Flags of our Fathers, enjoying the dessert, smiles abounded and we (at least for a little while) forgot we were off the coast of Nicaragua. In our minds and in our hearts we were home, proud to be Americans, celebrating the day that 233 years ago fifty six patriots pledged their lives so that we could live in freedom. God Bless America.

En Route to Nicaragua- A Crowded Ship

2009-07-02T18:31:00.000-07:00

“MAIL CALL!” Now that is something you don’t hear everyday, unlike the numerous routine announcements over the 1MC aforementioned (by the way I am several steps closer to finding out the person whose voice belongs to TAPS, TAPS, LIGHTS OUT- he works in ADMIN and his name starts with a D). “ MAIL CALL!” Again I heard it. This is the first day we have received mail since I have been onboard.

And to anyone in the Navy it is a beautiful thing to hear, because it means that there is a chance that someone out there may actually care about you while you are gone on this hunky piece of metal floating in the ocean. When I was a Midshipman at 20 years old in the middle of the Persian Gulf on the USS CHOSIN (CG65), I was the one made to fish the mail buoy out of the ocean after they dropped it from the sky since I was the youngest Mid. I thought I was going to go overboard into that warm sea snake infested water. But, I am still here. This time the mail came by helicopter and I went upstairs to the post office to see if there happened to be anything good. People pulled out goodies left and right- some were stale crackers, playing cards, smokes, beef jerky, some magazines from a few weeks ago (PEOPLE, US Weekly) when they were initially sent (pre-MJ death). My mustached RENO 911 friend got a huge box of Chiclets and said, “Hey Baldwin, here you go!” and threw some my way. Yes, my favorite flavor! Getting anything is good. Many have been on this ship for three months now, and it was great to see their smiles while opening their mail. It makes such a difference. During a deployment when you are upended from your family and regular world, working your tail off day in and day out, any notion of support is magnified, as is the opposite.

Last night at the 7pm confirmation brief there was a very special promotion ceremony of the lead Dental Officer, CDR Hartzell, to CAPTAIN in the U.S. Navy. CAPT Hartzell and I have done numerous recruiting engagements together for Navy Medicine, and I was happy to see him put on the rank “full bird.”

The insignia for Captain in the Navy and for a Colonel in the other services is an eagle with wings outstretched. He gave an inspirational speech to the packed house. It made me look forward to getting promoted to Lieutenant Commander a month from now in Seattle.

One of the best parts about getting promoted is the “wetting down” ceremony. This is a longstanding military tradition where the person promoted throws a celebration with his/her closest mates utilizing the extra money he will earn in the first month in higher pay grade. CAPT Hartzell is going to have his wetting down when the crew gets to the liberty port in Panama City the middle of this month. It’s ballyhoo that I have to miss it. I am sure they will have a fun time. My D.C. officemate LT Marcy Morlock has gladly volunteered to “spend” my money for wetting down in D.C. So to all my D.C. friends, standby for early August.

It is July 2, and today we pulled anchor and began the short transit to the final country of the mission- Nicaragua. We have experienced yet another influx onboard USNS COMFORT. This time the majority come from the UCSD pre-health professional society and also from the Army.

Couple that with the hundred plus folks returning from staying overnight ashore (Navy SEABEES and medical providers) and the Canadians returning from their Canada Day celebration in San Salvador (I wonder if MURSE shaved the stache?) and you have a crowded ship. Don’t get me wrong, this is no submarine where you grow used to being an inch apart at all times from another human being (it can be weird, trust me), but this is definitely a packed house. Peoples’ nerves are on edge. The urinals are overflowing (this morning I stepped into a bathroom full of who knows what), there is no more OJ, and my laundry has been mixed up with some guy (I presume) who wears size XXXL. You can also tell it is a crowded ship when they whip out the plastic spork like utensils and paper plates because (bless their hearts) they can’t keep up with the dirty dishes.

I’ve been back there in the scullery and it is hot. The other thing that becomes a problem is remembering whether you have met someone yet or not. My rule of thumb- if there is any question- I introduce myself (or reindroduce if it may be). That prevents the awkward silence and is just nice. Trouble is that THREE times today, I have gotten the response, “Yes sir, we met YESTERDAY.” Dangit! Just curious…

CAPT Hartzell and I decided to use this time with so many new folks aboard to give another “Opportunities in Navy Medicine” talk to anyone interested. Today we put on our Summer Whites, with CAPT Hartzell proudly sporting an additional bar (for CAPTAIN) on his shoulder boards. He spoke about the 18 or so years that he and his wife (also a Navy Dentist) have been in the Navy and the places they have been. He showed slides of his time as department head aboard the USS Ronald Reagan aircraft carrier.

They have had an extremely interesting career path. His wife actually was involved with tracking down Saddam Hussein (utilizing her language skills not dentistry) and she was awarded the Bronze Star (the first female Navy Dentist ever to receive it). They are a tough duo and proud of their service to humanity and their country. My time comes to speak. I feel back in my element up there speaking to the crowd of about 30. I name the talk “Adventures in Navy Medicine” because that is truly what it is- an Adventure of perennial opportunity. Best decision I have ever made. Up there in front of the group talking with them about the breadth of things you can do as a Navy doctor, telling stories about travel, service, and humanitarian aid missions.

And the best part, as both CAPT Hartzell and I mentioned, are the people. Lifelong friends. People like LCDR Todd Gleeson, Infectious Disease Specialist, who many years ago as a 2/C Midshipman at Duke University was my platoon commander. And now 14 years later, he is still a colleague and a friend. Here in Central America, Todd, LT Jacobson and I say BAF, Best Amigos Forever.

Pasaquina

2009-06-30T11:04:00.000-07:00

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

2009-06-29T09:11:00.000-07:00

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

2009-06-25T10:24:00.000-07:00

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

2009-06-23T12:58:00.000-07:00

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

2009-06-20T14:58:00.000-07:00

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

2009-06-18T18:19:00.000-07:00

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

2009-06-18T18:08:00.001-07:00

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.

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

Catholic Mass aboard a Ship

2009-06-16T11:00:00.001-07:00

The days run together out here and after a while you forget which day of the week it is. Weekends and weekdays are all treated the same way. There is a certain time of the week though that does stay sacred and that is Sunday and we are all given a chance to give thanks and worship.

Tonight we had a very special guest aboard to lead Catholic Mass- the Bishop of South America’s Northwest Region. About 50 of us gathered in the Wardroom in our Coveralls and Working Uniforms facing a makeshift altar of a card table draped with white tablecloth, Jesus on the Cross, two candles, and a statue of the Virgin Mary. We joined in song as we waited for the Bishop to arrive. As he walked in and we stood, he related to us that he had taken the RHIB boat (fast boat) over to the Ship at night from shore, and was a bit soaked J. We helped him get dried off and luckily the ceremonial garb had been kept dry in a dry bag. I was raised and confirmed Catholic, and even served as an altar boy back in Lancaster, PA, but this was the first Catholic I had been to onboard a ship, and from a distinguished high ranking member of the Church. It felt good to take a break, convene together, and have some time to think about things. Sunday was always a day that my family got together when I was growing up, and here too aboard the USNS COMFORT we were family.

Two weeks into this mission and it feels like I have been out here for a few months. So many experiences happen each day, peaking the senses at all times, making the perceived time seem longer than the actual time. That is my theory anyway. It is the same type of feeling that I had when I was going through the intense experience on TV.

It’s go, go, go, and rarely have a chance to step back and reflect. Tonight was good for that.

The reflection must have been calming because I awoke the following day feeling as bright eyed and bushy tailed as ever. Even without coffee I was raring to go at 5am ready to hit the shore and see patients all day long. We were assigned to the RHIB boat again today, but today the water was glassy and we were able to pick up speed and not get wet.

Amongst our crew was CAPT De La Pena, a 70-year-old Family Practice doctor, who is a bulldog and funny as all get out. For him to be hard charging as a Navy doc at this age is commendable (I think he joined with he was 52 J). Also in the mix was Petty Officer Waters, a fairly new Navy recruit (age 20 I think) who I had noticed working all sorts of thankless jobs such as dishwashing, cleaning the johns, scrubbing the decks, and now she was headed out to the site to help out. I was happy for her. She’s the type of young service minded youth that is good to see. And she wasn’t afraid to speak her mind either, which made for a good laugh most of the time.

Things were a bit disjointed at the site today. We arrived early, and I saw the largest group yet waiting to be seen outside the fence of the school.

In particular I noticed a lot of children (ninos). Supposedly there were several busloads of families from the “campo” (country) that had been bused in overnight to be seen. This was going to be fun I thought. The most interesting patients (and often the most appreciative) are from the rural areas. We waited for about an hour and they still had not let the patients through the gates. There had been some confusion and fighting outside about who would get to see the doctors first, as the government had pushed the “campesinos” (country people) to the front of the line. This was not taken well by some. Eventually they barged through the gates and my translator and “nurse” Maria and I set to work. Much was the same patient in and patient out, and to keep myself sane I would try to have each patient leave with a smile, even if it meant just talking with them about their lifestyle, what they liked to do for exercise, what they liked to eat, and give them some advice on living healthy. I asked them about their families, their love life, their goals, and dreams, and to tell a story about the country or the city or their youth in Colombia. As opposed to many of the patients that I have seen in urgent care settings in the United States who just want to get in, get their medication and get out as soon as possible, their was a different type of appreciation and respect for doctors here in Colombia. These people literally hung on every word a “U.S. Doctor” (me) said to them. The most productive part of these visits was health education, teaching the patients about the importance of exercise, what foods to eat, to not smoke, not drink alcohol, limit sweets, and lose weight. They may have been fooling me, but these patients clearly took what I said to heart and started making lifestyle changes even right there in front of me as they turned over their flasks, cigarettes, chocolates and hard candies. It was this lifestyle education (clearly missing for some) that I found most rewarding, as it is this knowledge that will sustain and make a difference into their futures.

This afternoon my favorite patient of the day came in. A 75 year old gentleman, looking a bit hunched over, with his shirt draped over his shoulders, came in with his daughter. She explained that he had traveled over four days from the country (much of it by boat) to get here to Tumaco. Four days ago he was working on the farm and to avoid colliding with a branch had put his arm out and proceeded to dislocate his shoulder. As I removed his shirt I saw his left shoulder clearly out of socket anteriorly. Wow! Four days ago?? When one dislocates a joint the muscles contract around and unless you pop it back in immediately, it becomes increasingly difficult to get that joint back in articulation the more time that goes by. This 70 year old farmer was extremely strong and this was going to be challenging without any anesthesia to relax the joint. I asked his permission to yank on his arm to try and see if I could force it back in, and he replied, “Yes, whatever it takes. I have traveled long and far in a lot of pain. What is a little bit more?” I used all my strength to try and force the head of the humerus bone back into the normal shoulder socket. It would not budge. Damn! I took off my uniform top, as I was sweating up a storm. “Let’s go over to the physical therapy room where I can put you on a table to get some leverage.” There was a stretcher set up on a stand that had been functioning as a PT table and I put the man up on that in a prone position. I then instructed an assistant to take a sheet and wrap it around his body to provide leverage the opposite direction to which I would be pulling traction on the man’s left arm. I had my friend and Dermatologist Dr. Carrie Hall who was nearby push on the Humeral head as I pulled the man’s arm downward with all of my might. It still was out. The man winced in pain, but said Sigua! Sigua! (Continue! Continue!). We realigned and took our positions and then on the count of three, I pulled again as hard as I could.

As I released the humeral head slid back into normal position! The old man rolled over with the biggest smile on his face that I have ever seen. He shook out his arms and shoulders, looking like a Colombian Michael Phelps shaking out his muscles on the blocks before a race. As we rigged up a shoulder sling for the man, his daughter and he could not stop saying thank you, and I smiled and said you’re welcome. This was a team effort. Yes indeed it was.

Day 6 ashore. 70 patients seen today. 457 patients and smiles this week. Total Colombia patients seen by USNS COMFORT Team- 9,968

Force Protection

2009-06-15T16:11:00.000-07:00

There is nothing better than waking up to the chirping of birds, and the nice cool breeze blowing off the water. That’s how things started off today around 0530 and for a moment I thought I was back in Hawaii again. The hotel where we were staying had an immaculate collection of flowers and by the looks of it we could have been back in Hawaii. All of us well rested, we put on our uniforms and headed down for breakfast. Things just kept on getting better and better because the coffee they served us was the best coffee I think I have ever had. I asked the guy to pour me three cups. Heck I could have stayed there all day drinking coffee.

In fact I was so into coffee this morning that right when we got to the site I visited the little food stand and ordered some more from the nice ladies inside. They were full of questions and before I knew it I was behind the counter with them snapping photos.

With two coffees in hand (one for me, and one for my nurse and translator Maria) I made my way to our “office.” It wasn’t the tidiest of offices I have ever worked in. In fact it wasn’t even close. But it worked and that is all that mattered.

Maria and I embarked on our second day of this three-day stint ashore and we decided to put our discouraging day behind us, and made it a goal to make every patient leave with a smile and feeling better than when they stepped into our office. We were upbeat, jovial, and there were Buenos Dios, and Buenas Tardes all day long. People would come in and complain and complain and Maria and I would somehow in the end make them smile.

It is not often that a physician will ask where you live, what you eat, what exercise you do, what you like to do for fun, how many kids you have, what your goals are in life, where have you traveled? I wish I could have captured the quixotic looks that I got from some people when I asked them “Que comes” (what do you eat). Most of them said, “Well I eat normal Doctor”. But what types I insisted, and they rattled off pescado, pollo, carne, verdures, arroz con coco, and platanos. I like bananas. I don’t love them, but I love the word for them in Spanish- platanos.

One of the biggest laughs we had this morning came when we were talking with an older gentleman and his daughter about a rash the guy had over most of his body. It was partly due to lack of good hygiene and lots of sweating. I encouraged the gentleman to duchar (to bathe) every day and use plenty of sopa. Mucho sopa. Sopa is muy importante. Very important for cleanliness I said. The daughter and her father looked dumbfounded. Unbeknownst to me, the word for soap in Spanish is jabon. Sopa is the word for soup.

We couldn’t get the image of bathing with chicken noodle soup out of our heads for a while. That is the power of things getting lost in translation and provided for some good humor for both the patients and us.

Ask yourself this question…..If a medical team from Johns Hopkins or Harvard set up a tent outside your town and offered up free prescriptions for many of the drugs you usually have to pay for, and also offered free glasses, eye exams, even surgeries that you were planning to have by the local surgeon, and pay a lot for, but now could be done for free by perhaps even better doctors, what would you do?

To what extent would you go to get the free and more skilled surgery vice having to pay thousands for it on your own? How demanding would you be?

And would you say thank you even if you didn’t get your way? Would you understand that others in your town need to be seen as well? And if you got to go twice you may exclude someone from being seen at all?

These are all questions that I posed to myself to try and understand the social behavior I was seeing every day out here in Tumaco, Colombia. I found it fascinating what a wide range of socioeconomic status there was in the patients we were seeing- I drew these conclusions based on how people dressed, whether or not they had shoes, were wielding a cell phone, had a photo ID, etc. Some showed up at our site with high heels and their best Bebe outfits on or Armani and carried a tremendous air of entitlement. Some had expectations beyond comprehension, and we routinely had to talk people down to Earth and let them know we are not miracle performers and cannot to Neurosurgery here at a makeshift hospital clinic at a holed out Elementary School. On the other hand, there were some that were truly poor, truly sick, some that had hiked for days to get here to get medical attention and were extremely appreciative, some that gave out hugs, and even more that said muchas gracias doctor. I could feel my whole mood and energy shift each time I encountered a different side of this range in the patients. I could see it in my assistant Maria as well.

So much of how we feel and what we do is driven by attitude. If I had an attitude meter I would have ranked each patient by that on a positive and negative scale, and then correlated it with their socioeconomic status, where they live, age, gender, and type of medical issues. Perhaps I will do this in El Salvador. It would make for an interesting study. My hypothesis- those from the country, those that are older (both men and women), that truly are the poorest, and ironically that have the gravest of medical ailments (hernia, cancer, broken bones) will have the more positive attitude.

Today we would need that positive attitude because at 2pm the pharmacist barged into our medical space and pronounced that we were completely out of pain medication. We were all out of Ibuprofen, Tylenol, and Aspirin. Zero, Zip, Zilch left. I looked at the full room of patients to be seen, and stared back at the pharmacist and said “Huh? Are you serious!?” How we did not have an unlimited supply of these drugs that we give to virtually every patient was beyond me, but the immediate task at hand was how to handle the patients in front of us. We thought outside the box, giving prednisone to quell some pain and inflammatory processes, and pepto bismol for the antacids (which we also had run out of). The site leader CDR Bill Scouten (pediatrician extraordinaire) called it a day and ordered shutdown of site and back to the hotel we went. Early day. Big question was what on Earth were we going to do tomorrow without any pain medication.

The Villa del Sol Hotel where we were staying had a piscina (pool) and I when we got back to the Hotel I had a sudden urge to swim some laps. Only problem was that I hadn’t brought a bathing suit. No matter. Boxer briefs would have to do and splash was in the pool. Felt so good to stretch out in the pool and get some exercise. A few of us then ventured out to the beach and stuck our feet in the water of the Pacific Ocean. We very quickly removed those feet from the Pacific Ocean when one of our legs came in contact with a dirty diaper floating nearby. We then saw the large degree of other trash floating in the water. Ok, this was definitely not Hawaii.

As we were walking back to the Hotel, machine gun fire “pop, pop, pop” was heard not too far away. We ducked and looked around. There we stood on the beach in our skivvies bracing for gunfire. More came and it went on for some time, and then a helicopter buzzed overhead. We were nearby the Marine Infantry base so no doubt a training exercise but damn that scared us.

Dinner this evening was some excellent fish, along with Chicken Foot soup. I realized that this was called Chicken Foot soup when my big spoon picked up a scoop of soup and I almost put a chicken’s talon in my mouth. Wow! It sure was good. So that’s what they were doing with all the machine guns. Kiling the chickens.....

After dinner we learned we would have the chance to go to the Grocery Store in town tonight, but first needed to have a force security briefing by the military group coordinating our force protection. What I learned next was truly fascinating. A Commander from the U.S. Embassy entered and gave us a list of phone numbers to call in case of kidnapping or other dangerous encounters. We were told that on the way to one of the sites today the Veterinary Doctors came across a pile of dirt squarely placed in the middle of the road and were turned back because of supposition of an IED (Improvised Explosive Device) placed inside or a potential ambush site. The Colombian Marines did a safety sweep in the woods around the location. This is the type of professionalism that these Marines displayed. They were always locked on and had their M4 Carbine Machine Guns on the ready at all times. We learned from the Commander that 1/3 of the cocaine that reaches the United States comes from this area of Colombia and the FARC is very active here. The bounty for a Colombian Marine’s head is priced at $2000. He said this area is the most dangerous in Colombia, but at present with the thousands of forces here for our protection it is the safest. That got me thinking…..for both Governments to provide this level of protection and care for some lowly vitamin and Tylenol givers from the United States, meant that the danger was truly there, and the larger diplomatic ties at stake for Colombia-U.S. relations were huge. I recalled reading a bit about the Colombian American Free Trade Agreement last year that didn’t make it through congress. The potential economic impact for the future of this relationship as well as the pursuant restriction of the drug trade are immense for both our countries. If they were to allow even one American on a humanitarian mission to their country get kidnapped or killed, the impact would be devastating. Yes, this is real. And yes, this makes sense now.

It was after nightfall as we boarded the bus bound for the SuperMarket. The reggae/rap/Latin music blared and at each door and in the aisle we had Marines wielding their machine guns protecting us. As we sped along we also saw Marines on either side on motorcycles escorting us with a gun wielding motorcycle backseater aboard. It was the strangest situation, because the music was great, we all were a bit rowdy after having a beer or two, and we were in a caravan with intense force protection to the grocery store.

The bus dropped us off and sped away not wanting to spend too much time in one spot for fear of someone placing a bomb. The Marines had set up a perimeter around the Supermarket and had done a thorough search and secured the inside. The place was ours. We each picked up a shopping cart and went about our shopping. Colombian coffee, toiletries, some snacks. I even ran into a guy in the butcher’s shop who I had treated yesterday in my office for his knee pain! He held up a pig’s foot and asked “Lo Quieres” (you want one) and then thanked me for my help yesterday. “De nada mi amigo”, (You’re welcome my friend). “Buenas noches” (Goodnight).

The bus returned and the Marines beckoned us to board quickly and soon we were driving again with our entourage through the streets of the Red Zone protected by the Colombian Infantry and eventually arrived safely back home at Villa de Sol.

I went straight to bed looking forward to the morning and hopefully waking again to the sounds of birds and feeling at least for a second that I was in Hawaii again.

Desperately in Need of an Ice Cold Beer

2009-06-14T08:59:00.000-07:00

It was way too early. At 5 am I sleepwalked my way through breakfast and put on my headphones to listen to some Pearl Jam and broke out the book “Three Cups of Tea” about Tom Mortenson and his success in building schools for children in Pakistan. I needed some motivation to get through this upcoming 72 hours ashore in Colombia. We repeated the drill of getting from boat landing zone through town, and to the medical site. We were again greeted by droves of waving young children and adults waiting to be seen by U.S. medical providers. I asked one woman how long she had been out here and she responded “a las dos de la manana” since 2 am in the morning. Heck she should have just camped out overnight.

With thousands of patients to be seen, a hard rule was laid down by the government that they had to make a choice of what problem was bothering them most - and that is all they could be seen for. So for instance if a patient came in and was treated for back pain, and they also needed reading glasses, they were not permitted to go to optometry to get those glasses. The surgeons were also completely booked up on the ship, and we were told no more surgical candidates would be considered. This set the tone for the days to come. I closed my eyes and mentally checked myself, preparing my mind for the upcoming discouragement. I needed to put on my 3^rd world glasses and make myself believe that simply seeing these patients and providing them with some basic medications would make a difference in their lives.

The translator I was assigned today was a young 19 year old girl named Maria from Bogota, Colombia. I noticed right off the bat that she was quite shy and I tried to help her feel at ease by offering her some coffee and some items from the MRE for the day. I explained to her that the best method of interrogation for these patients is if I say hello and introduce her and then she fires off the questions as I fill out the encounter sheet and offer my advice and she translates it back. This technique I noticed worked best because it makes the translator a type of “buffer” and compassionate bearer of the bad news. Even though I understood most of what was being said by the patient and could have spoken more, to have someone from their own country say “the U.S. doctor apologizes that he cannot help you more, but he can offer you pain medicine and vitamins” seemed to be more effective and less devastating for the majority of patients. I introduced Maria as “mi amiga” (my friend), and “mi emfermera” (my nurse) which I noticed she took a lot of pride in after seeing a number of patients. As we got more comfortable working together she became more and more engaged with the patients. I have a lot of respect for these translators who are volunteering their time to do this service. Every so often Maria’s friend and fellow translator Carolina every once and awhile would pop her head into the exam space and say hello. Carolina had a very warm presence about her and a beautiful smile. She is the vision of what I always have had in my minds eye of a Colombian woman- slender, with olive skin, long dark hair, and gorgeous brown eyes. She had a Roman Numeral II written after her name and I asked why? Turns out that one of the other translators name was also Carolina Pinzon. Lots of commonality of names down here in Colombia. I think the name I have seen the most repeated is Maria.

Maria and I had a good system down and we were seeing patients at lighting speed. Most had good attitudes and just wanted their pain taken care of, or some medicine for a rash. I made a point to ask every patient what they ate, and what sort of activity they did. If they smoke or drank, I came up with a plan for them to stop. Everyone was told to drink lots of water, no sugar or postres (cake), and went through a stretching routine with me before they were allowed to go pick up their medication and vitamins. They also were not allowed to leave until they responded to “dame una sonrisa” (give me a smile).

I must have been getting low on blood sugar, or just couldn’t deal with the heat, or the incessant claims of no money and no health insurance, but late in the morning I snapped while seeing a patient with an infection in his middle finger after a botched orthopedic surgery repair of a complex fracture. The man carried his X-rays with him and was basically dripping pus from his infected hand all over the folder containing them. This would never happen in the United States. “Why didn’t you go back to have it fixed”, I asked? The man replied that he didn’t want the surgeons to mess his hand up more, and that he was scared to go back. I squeezed more pus out of the wound and stared at the gentleman’s middle finger which took about a 45 degree turn midway at the proximal joint. This was simply UNSAT (what we say emphastically in the military for unsatisfactory). Normally I would incise this wound and drain the pus and put him on strong antibiotics, and then get him into surgery ASAP to fix his hand. In this situation, my hands were tied with no more surgeries allowed and limited ability to do minor surgery here in the field. I tried to get as much of the pus out as possible and instructed the man to keep it extremely clean, and take the full course of antibiotics that I gave him. And then I struggled with whether to tell him to go back to the surgeons that had botched his repair in the first place. The man said he was willing to wait two years for when and if the COMFORT ever came back to have it done then. And he said “voy a llegar al primer dia” (And this time I will get here the first day to sign up for surgery).

After seeing the middle finger guy, I was ready for a break and some lunch. The lack of follow-up and good care made me so mad that I again had to close my eyes and talk myself down. “Don’t get sucked in to each case, dissociate yourself from it Andy, look at the big picture” With that I shook it off, and decided to go talk with some of the locals who were selling different types of fruits by the roadside. A man with a machete cut open some oranges and papayas and I paid him a few pesos for some. He also sold me some “zapotes” which after tasting them are a bit like sweet pumpkins. I then splurged and at the corner stand had the nice Colombian ladies give me an ice cold bottle of Coca-Cola to be drank with a straw. Ahhhh that hit the spot.

The afternoon was again filled with much of the same, and I tried to focus on the positive cases and doing as much as I could. I was getting tired. The lack of sleep the night before was truly taking its toll as evidenced by the Colombians complete and utter inability to understand my tired Gringo Spanish. A woman came in who was deathly skinny and who had eyes that bulged, and I immediately narrowed down the diagnosis to either anorexia, hyperthyroid (Graves disease), or a big parasite in her gut. The most likely cause was a hyperactive thyroid and so I looked on the pharmacy sheet for the medication to give her and it was nowhere to be found. Can’t even give her what she needs and it would only last her a bit of time anyways…. I walked over to the pharmacy to make sure and yes indeed, no PTU.

I pleaded with her to go and see a doctor here in Colombia. She said she couldn’t afford it and didn’t have health insurance. Doesn’t your husband? She wasn’t married. Doesn’t your work provide? I don’t have a job. I looked into this woman’s eyes and realized the reality of the situation- she was going to die soon because she simply did not have access to care.

I needed an ice cold beer.

Luckily we were headed to the hotel Villa del Sol that evening, and after about two hours of waiting for the bus and the room, we were able to change out of our sweaty uniform and dirty boots, grab a cold shower (no hot water), and crack open a semi-cold bottle of beer. Whew it had been a long day.

Dinner that evening at Villa del Sol was delicious compared to the Ship and the MREs and so we savored it. We also welcomed the chance to watch CNN International on the TV in our room and heard about the killing that had occurred at the Holocaust Museum in Washington, D.C. My roommates for the next two nights were Pediatric Neurologist and Air Force Major David Hsieh and Navy Commander and Family Nurse Practictioner Jim Keilak. All three of us supposedly snore, and upon realizing this we wished we had a tape recorder to capture the orchestra of sawing to come that evening.

As we lay down to sleep on rock hard mattresses we inspected for bed bugs. By visual inspection I decided my bunk was good to go. Jim took a bit more caution and sprayed Permethrin all over his bed. Can never be too safe I suppose…. Jim had turned the Air Conditioner on a few hours ago, and there apparently was an issue because the thing started leaking water all over the floor. We placed a bucket underneath and hit the wall panel in which it was installed a few times, and it stopped leaking for a bit. But as my eyes closed for the night I heard drip…..drip……drip……

Full Moon over Tumaco

2009-06-13T10:30:00.000-07:00

The second day’s journey out to the Medical Site was a lot faster, but we paid the price. When the seas are rough and you’re riding a RHIB boat (high speed Special Operations rigid inflatable boat) be prepared to get wet. We got soaked. I loved it, but I don’t think the Dermatologist next to me did. It reminded me of the days in Hawaii with Mobile Diving Salvage Unit ONE (Special Ops Dive Unit) tearing it up out to a dive site. Yee haw! Go Navy!

The skies were overcast today and the air hung with humidity where you could just sense the coming rainstorms in the air. As we boarded the bus from the Boat Landing Zone to the medical treatment site I readied my camera to movie mode to capture some of the scenery upcoming. Perhaps when I have a better Internet connection I can put some of the video footage up on this blog. It was 8 am and children were already outside playing soccer, dogs scampering through the streets, and slews of people walking making their way by foot, bike, and car (even canoe) to the site where the “almighty Americans” were providing excellent medical care, and most importantly it was FREE. The houses that we passed were constructed loosely and hoisted on stilts of wooden posts with planks connecting them to each other. There was water all around. It was like a poor man’s Venice. I shook my head in wonder- curious at how these living spaces are able to withstand strong thunderstorms or high winds, and if they even had a physical address that people could send mail to. Heck, did these people in Tumaco even have a postal system? I asked the young Colombian infantry soldier standing next to me on the bus wielding his loaded M4 Carbine machine gun if they had a “correo” (post office) here in Tumaco, and he said “por sopuesto” (of course). They must post office boxes…..

Upon reaching the school we saw a crowd of hundreds of adults and children waiting to be seen. It was more chaotic than yesterday outside the fence of the school, but with intense security from the Colombian Infantry, the treatment zone inside was more orderly and organized. I was directed to a new “office” space in the last building and assigned a translator named Gloria. Gloria is in her 20s and as luck would have it, a 4^th year medical student from Bogotá, Colombia. Score! I found out very quickly what an incredible asset she was. Yesterday’s translator was helpful, but this woman knew the language, AND she knew medicine. Throughout the morning we became quite the team seeing patient after patient with increasing efficiency. The Spanish word we heard the most was “dolor” meaning pain followed by our question where does it hurt - “donde le duele”? To this we would get a cacophony of a reply sometimes with intense emotion of the man or woman telling us how basically every part of the his/her body “me duele.” The ensemble of saying such while touching the head, the back, the stomach, the knees and the toes brought about our reference to this as the Macarena Dance of Dolor. Haha. It shouldn’t be funny, but with the passion that some of these patients described their pain symptoms (whether embellished or not) is worth noting. I couldn’t help but thinking that every person out there was passing the advice “Do the Macarena Dance and the American Doctor will give you Tylenol, Motrin and Multivitamins. If you don’t do a dramatic presentation….then you may be out of luck!” Sad thought but most likely true. At the rate we were giving out Tylenol, Ibuprofen, and Multivitamins I began to wonder how long our supply would hold up.

Several patients this morning related their pain symptoms to the lunar cycle. At first when I heard a woman use the word “Luna” (moon) I asked her to repeat what she had said and looked to my translator. She looked as perplexed as me, and interrogated the patient in detail about this correlation. The woman insisted that her “dolor de cabeza” (headache) was worse when there was a full moon, and less intense when there was a new moon. I took her word for it, and gave her some Tylenol for the pain. It must be a “Luna Llena” (Full Moon) over Temaco I said to Gloria. Both she and the patient nodded. When a young healthy and relatively well dressed guy told us the same thing later about his hand hurting because it was a full moon, we pressed him as to the reason why this would be the case. He said he didn’t know, but that it was just the case. Hmmm…..interesting cultural attribution for pain. I saw a clinical study begin to formalize in my head. Wouldn’t that be an interesting study?

Outside our cement schoolhouse turned medical clinic we began to hear the pitter patter of rain and the sky opened up. After such brutal heat the cool breeze and precipitation felt great. Time for lunch and another MRE (meal ready to eat). These MREs are prepared for soldiers in the field that are burning many calories in training or in battle. Therefore they are jam packed with calories. My lock sealed package containing Spaghetti w/ Meat Sauce told me to prepare for a 650 calorie bolus to my gut. I didn’t feel like going through the heat up process so I downed the pasta cold, and moved on to what was next- peanut butter and lemon pound cake. Sorry, can’t stomach it. I opted for a piece of bread and some Juan Valdez coffee, and headed back to see some more patients.

The rain had driven some patients away, but the die hards remained. One of these patients was a jovial 80-year-old man who in no way shape or form appeared to be 80. His energy and spirit and healthy lifestyle in the farmland (campo) no doubt was the reason he looked twenty years younger, as he stood before me with his button down shirt and white cap on. What he was missing though was his left hand. It appeared to have been sawn off at the wrist and I asked him what happened. While laughing he told me about how one of his farmhands over 40 years ago had gotten angry and kidnapped him, and threatened to cut his head off. After some negotiating the slighted worker apparently consented to just cutting his hand off. “Jesus Christo!”, I shouted. “Si, Gracias Dios” (Yes Thank You God), the man replied. He didn’t need anything special. Just wanted some Vitamins and to say thank you for coming to his town to help the people of Temaco. Wow, what a refreshing patient to have at this point of the day. I snapped a photo with him and bid him a wonderful day and much luck.

The patients kept flowing in, and the complaints and questions and our responses and prescriptions much the same. I tried as hard as I could to learn something unique about each patient, make them smile, and to get them to improve something in their lifestyle to get them healthier. Exercise, eat more fish, dance, make a smile each day, and try to ride a bicycle. To a lot of these prescriptions I would get a laugh and a smile, and that felt good. I don’t think that they are used to their doctors here in Colombia (if they even have one) being caring and funny and talking to them much. One older gentleman came in who definitely was not the role model for prevention. I was able to decipher that he drank a lot of alcohol, and smoked a pack of cigarettes a day. I sternly told him that he needed to change his lifestyle, and the guy actually listened. He said that whatever an American doctor told him to do he would do, and so I proceeded to reach into his shirt pocket, take out his pack of cigarettes and threw them in the trash. I asked him to hand over his lighter, and in turn gave him a bottle of water, and made him promise me that when I return next year (we’ll see…) that he would be running, swimming, and rowing a canoe each day. With a smile and enthusiasm he agreed. I couldn’t believe the way he looked at me. It was as if I spoke the Gospel. If I tried to take my roommate Mike’s (or any American for that matter) cigarettes away and throw them in the trash they would have a fit.

The next patient was a 24-year-old woman who entered with her entourage of 4 young children. This was evidently a fertile woman. When I heard her chief complaint that she had not had her period for 6 weeks, I broke a smile, and said “Wow”. Let’s go and see if there will be another member of the clan. I helped her out by carrying her little boy (14 months of age) and holding the hand of her little girl (3 years old) as we made our way over to the lab for her to put some urine in the cup for a pregnancy test. I babysat the kids when she went to the port-o-john and as little Jose played with my stethoscope realized how great it must be to have kids. The lab technician put the indicator strip into the urine and as we waited the two minutes, the drums rolled……YES, two stripes meant pregnant and we all clapped and I told little Jose that he would have another hermano or hermana (brother or sister). Happy Day for all! I hope they have the funds to support all these kids. Dad was away working so that was good.

I was headed back to my medical corner when I heard someone yell my name from across the schoolyard. It came from the Eye clinic. A volunteer beckoned for me to come over and take a look at a guy’s leg. I rushed over and saw an older gentleman farmer who was missing most of his teeth, and appeared to be going blind from cataracts. He had a large gash on his left lower leg that was oozing blood. “He cut it on the barbed wire outside”, the volunteer said. No problemo. To clean it up we used some mouthwash (Cepacol), which was just as disinfecting as any other. The man winced a bit as it burned the bad critters away. I scrubbed the wound and then threw some stitches in, antibiotic ointment, gauze pads, and ACE wrap and the guy was good to go. “Time to get on the bus to the boats!” I heard. “Ya termina!” I yelled back. Great way to end the day!

But the day would be extended….. When we reached the boat ramp we came upon a group of our own that was completely soaked. Turns out that they had taken the big slow boat back to the ship, and tried to complete the exchange but the seas were so rough they had to abort the attempt and return the whole way back to the mainland. They had just spent the past two hours on the transport boat and were soaking wet! “That must have sucked!”, I said. Wet heads nodded yes.

After waiting for about another hour, we were told to board the bus again and that we were all going to be transported back to the ship by helicopter. “Yes!” An even better way to end the day. The flight crew aboard USNS COMFORT mobilized both helicopters and began transporting back and forth. We donned our flight mask and hearing protection as well as life vests, and waited our “stick’s” turn. A stick is a term for a group in a line. There were four groups lined up in sticks. Each stick would rush towards the helicopter and board when they were called and it was their time to go.

I snapped some photos as we boarded and went airborne and was mesmerized by how fast a route it was. Two minutes from ground to ship aboard the helo. Before we knew it we were back on the ship, a bit waterlogged, but safe, and full of stories to tell over some good chow.

As I looked outward at the setting sun on the horizon, I also could see the rising moon, full and looming over Colombia. Hopefully all of that Tylenol if taken correctly by the people below was rivaling the pain brought on by this orbiting piece of rock.

Prevention in Colombia

2009-06-08T21:40:00.001-07:00

“First Call for Boat Team One!” That’s what I heard blasted over the intercom at 5am as I then sat straight up in my rack and hit my head. Ouch…. Dang it’s early. Today the USNS COMFORT team of health care professionals descend upon Tumaco, Colombia and will over the next two weeks attempt to wreak as much positive health care benefit on the population as possible. With the ship being anchored a few miles off shore there are two ways to get to land- helicopter and boat- and for me this morning it would be the latter. The boat ride was appox. 45 minutes and as we pushed off I donned my IPod, watched the beautiful sun rising over the water, and looked aft at the American flag with the mighty USNS COMFORT hospital ship getting smaller and smaller in the background. Next stop Colombia.

As we pulled into the pier by the small Colombian Coast Guard base in Tumaco, I spotted armed guards, a gorgeous beach, and banana trees. What I also saw were several semi-submersible boats that I had recently seen spotlighted on CNN that were being used to smuggle drugs (cocaine) to Central America and eventually the United States. These boats are ideal because they have a very low profile (invisible to radar) and are able to be submerged for short periods of time if spotted. The drug smugglers also like them because if they are caught they can scuttle (sink) the boat with the evidence, and appear to be fallen overboard and will be rescued with no proof against them. They are constructed by the drug lords and appear to be either converted cigar boats with fiberglass tops, or built from the ground up for smuggling purposes. Interestingly, during our country brief by the Embassy attaché we learned that these boats are now illegal to even be operated regardless of what they are carrying. Also, the attitudes of the people in Tumaco were positive towards the U.S. but they were pro-drug trade, so we were instructed not to talk about this with the locals. I walked over by one of the drug boats and snapped a photo.

From the pier we were taken briskly through the small town of Tumaco accompanied by Colombian guards with machine guns hanging outside the door for force protection. An awestruck population stared at us as we sped by and waved. Scantily clad children ran though the dirt streets, as did stray dogs often times barely averting being struck by vehicles. Many of the box like wooden houses were propped up on stilts with a muddy base below no doubt from the heavy storms that cause flooding in the area on occasion. The people as I suspected had a darker skin tone than the Colombian people I have seen who come from farther north in the country near Cartagena or Bogota. This was the Afro-Colombian region.

Our medical site is located on the far side of town at the Max Seidel School, and as we approached we could see the long lines and hoards of people already there waiting for a wristband and ticket to see a medical provider. Each child and adult had to make the choice of one and only one type of specialist to see- optometry, surgery, dental, or general medicine. This was designated on their wristband and they were assigned a serial number and given an encounter sheet to be taken to the respective clinical area. I set up shop in one of the school buildings in a tarped off corner space with three chairs and a table and with rays of sunlight streaming through the small holes in the eroded concrete wall.

We set a goal of seeing at least 1000 patients today. Between 14 providers that would be more or less 70 patients a piece. Several Spanish translators, some from the Mormon church, showed up to assist with language barriers. My Spanish is fairly good, but I grabbed one of the volunteers for backup and we set out in seeing the patients- with the mantra of expediency makes most difference running through my head.

Right from the get-go I started seeing strange pathology and sad cases. My first patient was a young man who upon extending my right hand to introduce myself extended his left hand, and not his right, because where his right hand used to be was now a stump. “Que paso?” I asked. He told me how he had been injured by a land mine and proceeded to show me his lower legs where large holes were evident where his calf muscles should be as well as numerous scars upon his ankles and feet. Nevertheless, the man was cheerful and I quickly recalled the Spanish word for smile- sonrisa – because he had one. I learned the other day that Colombia has the highest concentration of landmines than any other place in the world, placed by paramilitary groups, the FARC, and the Colombian government over the years, they are a constant source of devastating and unnecessary injuries to children and adults each year. The Colombian singer and icon Juanes who would play for us later that night aboard COMFORT was here at the site today speaking out about Landmines as was the U.S. Ambassador to Colombia. Throughout the day I would see several adults and children with burns, amputations, and disfigurements due to these mine explosions and it filled me with wonder as blended right in with the rest of the society, as if it were expected or something (sort of like obesity in the U.S.)

Over time, my translator and I came up with a system by which we saw patients expediently. I would make the introductions and ask, “Cual es tu problema?” He would then listen to the details as I wrote on the patient encounter form, and he would fill in the story detail gaps that I did not catch. Then I would do an exam, prescribe treatment or medicine, and talk a bit about lifestyle and healthy behaviors. Since the translator had been living in this town for a few weeks, he taught me some of the local slang for hello (Q Bo Pey lau), and hey brother (papi), hey sista (hermana). That elicited some smiles on the faces of the patients.

A young twenty-two year old girl really got to me mid-morning. She told me how for the past 11 years she suffered from constant headache, and it was unbearable. I queried her on whether the headaches waxed and waned, if anything made it better, or worse, and to all she said no, it is constant. I then asked her if she had ever taken any medication for it, and she replied no. I said, ok, well then let’s try some “pastillas” (pills) of Tylenol or Aspirin. I was optimistic that they would help. However, at this the girl began to shout and said she didn’t want the pills, but instead wanted me to “fix” her headache. I became frustrated as did she and she started swearing at me. I pleaded with her to just try the Tylenol and see if it helped. She finally gave in and with tears in her eye shouted back again, “Yes doctor, I will take them if they are free, but what about when they run out, what then? I cannot afford any of these pain pills and my headache will come back! Hoder! (Spanish obscenity)” Wow. I was stunned. She was right. That was the reality. I apologized and realized again how we take things as simple as Tylenol for granted in the United States. The woman quickly collected her things, said gracias and left the office, leaving me stunned and speechless sitting there with my Mormon translator.

Late-morning a gentleman came into my “office” and right off the bat I noticed a bulge in his pants. We did the typical question and answer in Spanish and then I put on my gloves and proceeded to the exam expecting to find a fairly significant inguinal hernia (protrusion of intestine through the inguinal canal into scrotal sac). However when the man dropped his drawers what I saw was incredible. This man had an enormous “bladder” like protrusion from his lower abdomen. I had never seen anything like this before. As I lifted the mass of skin and tissue, urine came trickling out from below. Wow! An external urine tract from the external mass. Upon further questioning it turns out that the man had had a prostate removal through his abdomen over 14 years ago, and the incision site had not been closed effectively. Years later the man experienced a herniation of his insides (tissue, bladder area) out of the scar site and external to his body. It had scarred down and he had been living this way for over a decade, with the mass filling up with urine, and then when he went to the bathroom deflating somewhat. Unbelievable. “Le Duele?”, I asked. (does it hurt). “No” , he replied. “Not at all.” And he smiled as if he were proud of his condition, as if it gave him an identity amongst his people. “Como puedo ayudarte?” (How can I help you?), I asked him. He replied that what bothered him the most was the pain in his knees and shoulders and that he wanted some vitamins. When I gave him some Tylenol and Multivitamins he was overjoyed. When I took him over to see Dr. Donahue the head of Surgical Services to see about an operation for his neo-bladder, the man could care less. It turns out that a surgery to fix this condition (which Dr. Donahue, a urologist, had never seen before either) would take several steps and be extremely involved. We couldn’t do it with our capabilities here anyhow. Bottom line- the man left happier than he came- even with urine dripping out of his lower abdominal “appendage.”

By lunchtime my translator and I had seen about forty patients, referred some to surgery, given some pain medicine like Tylenol or Aspirin, some anti-worm medicine, and largely given all positive reassurance and healthy recommendations. I ended each encounter prescribing smiling- sonreirse. It was exhausting and despite my best efforts to remain unaffected, I felt the compassion fatigue of seeing a lot of suffering and not being able to do anything about it. It was time for a break and some lunch. Outside my exam hut, and down the way the Official Opening Ceremonies were going on with dignitaries from both countries. I plopped myself down on the ground in the shade, opened an MRE (meal ready to eat) and watched the ceremony. The Tumaco mayor spoke, as well as the U.S. Ambassador to Colombia. Special guest Juanes emerged and the crowd went crazy. The media was all over him and the mob moved where he did, getting autographs, photos, etc. It was nice to be on the other side of things and for the most part anonymous just doing my job as a doctor.

Back to work and a whole afternoon of patients to see. My Mormon translator had abandoned me to go work in Physical Therapy, so I tried to have a go at it on my own. Let’s just say that a lot gets lost in translation, even if you do speak the language fairly well. My friend Michelle (an ICU nurse from Puerto Rico) stepped in to help when I needed it and I was grateful for that. Throughout the afternoon I started to realize health trends of the people here in Tumaco. First- there were a significant number of patients (more than a dozen that I treated) over the age of 80 and many in their seventies who were in good health save for their complaints about arthritis and generalized body pain. Therefore longevity of life was comparable if not more than a 1^st world nation like the United States. What was notably absent was chronic disease as we know it in the U.S. – there was very little obesity, heart disease, diabetes, high blood pressure, or lung problems. Why you may ask? Well, I began to ask a lot of questions of my patients. Drug/Alcohol/Tobacco use? Nearly every single patient I interrogated did not smoke, consume alcohol or use drugs. In fact the way they answered the question so emphatically no, made me realize that it was almost “taboo” to do such a thing in this community. There was a social stigma against those who polluted their bodies, did not work hard, eat healthy, and drink a lot of water. What an inverse relationship to the United States! It was especially striking in light of the work I have been doing lately with the U.S. Surgeon General fighting childhood obesity. There was one particular gentleman in his mid-70s who had been born, raised and lived his entire life here in Tumaco. He prided himself in working construction, and came with a complaint of rotator cuff tendonitis in his right shoulder that was preventing him from lifting and doing construction. He wanted some pain medicine. He was so excited when I gave him some simple Tylenol and Aspirin to help with the pain as well as exercises to do to strengthen the rotator cuff muscled. This guy was 75 and couldn’t wait to get back out there in motion and action!

He smiled showing his crooked and missing teeth and said “Muchas gracias. Vaya con Dios.” A similar joyful female patient stood out to me when she invited me over to her casa (house) to have a home cooked Colombian meal of fish, coconut rice, and bananas. I wish I could have taken her up on the offer. In lieu of that she was content with a photo together, in fact she was so overjoyed she tried to walk off with the camera too. No camera for you senora! This diet and habits that these two patients spoke of was consistent across the board for these coastal people- a diet rich in fish, fruit, vegetables, and a lifestyle that involved much activity late into life. These people had hardships of a different kind. What they lacked in access to specialty care for problems like the trauma, burns, birth defects, hernias, infections and arthritis, they made up for with an obvious lack of chronic disease states (due to lifestyle) that ironically is what plagues us (the U.S.A.) the most. As we come in with our big ship, and our big guns to help this “health care deprived” population, we as the United States ironically can learn a thing or two from them, especially with our looming health care crisis. Tumaco with its limited “sick care” resources and its socioeconomic predisposition toward healthy diet and activity, is in reality a case study demonstrating how important and effective prevention is in limiting chronic disease. Perhaps the United States (and Congress) should pay attention.

Day 1 finished. 70 patients treated. 152 surgeries scheduled. Total of 1500 seen by all.

3rd World Care Glasses

2009-06-06T11:23:00.000-07:00

It is the 65^th anniversary of D-Day, the historic amphibious invasion of Normandy, the largest of its kind in history- 2700 ships and craft. As we approach the Pacific coast of Colombia, hundreds of newly minted Shellbacks aboard, this is nothing to the scale of courage and fear that those brave men faced decades ago. We should all take a moment to give thanks to those thousands of men who gave their lives that day, and thank any veterans and servicemen and servicewomen you know. Onboard COMFORT there is a feeling of optimism and excitement as we get mentally prepared to work for approximately ten days straight caring for and treating patients in the rural and impoverished area of Tumaco, Colombia. Many of the Afro-Colombian villagers there have never seen any type of medical personnel, and have little to no health and prevention education. Last minute preparations are taking place, manifests being made for the helicopter transits, medication being stocked, medical Spanish being practiced, guns being loaded for force protection against insolent parties ashore. The sequence in way things work once we get to a location is this- setup of central location for treatment (such as a school), force protection does a bomb sweep and then sets up positions of cover, preventive medicine does safety checks on the site, screening of potential surgery patients first which fills the surgical schedule onboard the ship, then basic urgent care needs commence with gusto for the remainder of the time.

An interesting discussion was had this evening at the Medical Indoctrination Brief. In the Wardroom (where the Officers eat), CAPT Cole explained the mindset that one must have in order to make the greatest impact in a country like this. Cole, a seasoned veteran of this type of work is an athletic middle-aged doctor who doesn’t say much, but when he does he speaks with wisdom and authority. He is the kind of guy who listens and observes- those who talk too much, those who often have no clue what they are talking about, those that are making a concerted effort to help- then intervenes with leadership to guide the way. I like the guy. He’s a great mentor.

A non-governmental organization volunteer doctor stated that she would prefer to take a half of an hour with each patient and see twelve patients total for her day and see them back the following day with lab results and x-ray.

This sparked a great debate about requesting follow-up care for the patients that we see, and Cole insisted that we cannot stand to do this in most cases. “These people have never had any medical care. They all are plagued by malnutrition, parasites, and many may have terminal medical conditions. Be prepared for what you are about to see and manage your expectations accordingly. You are not going to single handedly go in there and save the country. We are not in the U.S. any more folks. You are providing urgent primitive care. That’s it! “

“The more people we see, the more basic aid we give, whether it is Tylenol or Motrin for pain, Albendazol for parasitic worms, or even just Multivitamins- the more impact we have here.”

“What about a patient with lung cancer, or breast cancer,” the woman asked.

“We can see what we can do to get them to the ship for surgery if it is early enough, but in many cases that is not possible. I know it sounds odd, but in this environment we are actually working ABOVE the standard of care by providing pain medication to allow them to be pain free for several months before they unfortunately pass away. That is the reality here. They have no standard of care to begin with, and are overjoyed to get any aid possible to make their lives a bit better. That is why it is important to see as many patients as possible.”

As I sipped on my coffee and sat back and thought about it, he was right. We all needed to shift our lens from a 1^st world view to a 3^rd world view and set our expectations accordingly. I remember witnessing this in my humanitarian mission to Laos in 2006. One patient that stands out in my mind- a short (they all were from worms and malnutrition) man who came to me in the jungle with a big smile on his face and I asked him what was wrong. He told me that he had constant rash and itch all over his body. His friend that was with him kept telling the man to pull down his drawers and show me something. The patient finally complied and when he dropped his pants the left side of the man’s scrotum was hanging way down due to a large mass. I palpated it and at first touch began to think it was a testicular tumor. But I then switched my 1^st world lens to a 3^rd world lens and realized that what this gentleman had was a massive hernia with a loop of his bowel in his private parts. In the United States this is a medical emergency because it can cut off the blood supply to that part of the bowel and if it dies can lead to death. I immediately put my stethescope on the area to see if I could hear any bowel sounds. There they were- Gurgle gurgle. Wow! I asked this man how long it had been like that. He replied nonchalantly- 4 years! I stepped back and thought. Here we were in the jungle. There was no way that I could get this guy out of there for surgery and I surely couldn’t do it there in the dirt. That is a complex operation. What this guy really wanted was some relief from his itching. So, I looked past this condition, which would have taken priority in the States, and gave the man some simple Benadryl, and Cortisone cream for his rash. Upon doing so his smile got even bigger and he came forward to give me a hug. “Pull your pants up man!”, I shouted.

As we go forth into this impoverished area of Colombia, I am making sure that I have my 3^rd world doctor glasses on. The more patients we treat the more smiles (and hugs) await.

From Pollywog to Shellback- Crossing the Equator for the 1st time on the high seas

2009-06-06T11:17:00.000-07:00

At supper last night the word began to spread that we were going to dip South and cross the Equator. This is a big deal in the Navy. The right of passage ceremony that one must go through from Pollywog to Shellback is steeped in lore and Naval history.

"Crossing the Line" is a time honored tradition in the United States Navy that has in the past been characterized by a celebration that marks, inducts, and honors an important and significant event in the maturation and seasoning of young (and some not so young) Sailors.

This celebration will mark a day in their lives which, when remembered later, will become a reference point used to gauge the passage of time. With this celebration we seek to rescue them from interminable, unhappy ranks of miserable "pollywogs" and induct them into the ranks of trusty, crusty and honorable "shellbacks". This ceremony will be a positive experience to all who are involved. It will seek to honor the rich legacy and lore of

the mystical Davy Jones, His Majesty King Neptunus Rex and his court while reinforcing our Navy Core Values of HONOR, COURAGE, and COMMITMENT.

Ask anyone who has ever served in the Navy if they are a “Wog” or an honorable “Shellback” and they will know what you are talking about, and most likely have a a memorable story to tell. We were not supposed to get near the Equator on our way to Temaco, Colombia, but we got a call yesterday from a U.S. Submarine in the area needing to medically evacuate one of their patients to us, and therefore we steamed full speed to the SouthWest to meet the patient (who after I examined him thoroughly turned out to just have case of gastritis. TUMS and SITFU for him. Anyhow, with that change in course we were close enough to the Equator for the Shellbacks to convince the Commodore to dip down overnight to cross the midline of the world. Knowing that this was coming, the Pollywogs among us (the majority of the crew that had not crossed the Equator before onboard ship) got ready for battle. We were to dress in white T-shirt and long pants (both inside out and backwards) with clear designation that we were Wogs. The Shellbacks dressed as Pirates. Much scheming was done this night and although the Wogs were ordered to our racks at 8pm. My roommates and I stood with solidarity and maintained the Shellbacks from entering our Officer Stateroom. Even the Murse (male nurse) from Canada contributed. The rumor was that the Shellbacks would start our initiation at 5am the following morning, so we hit the sack and some (including myself) wore our Wog attire to bed.

At slightly before 5am we were awakened by yelling and pounding on the doors by Shellbacks. My roommates and I sprung out of bed, threw on our boots, posed for a quick photo, and went forth to face the gauntlet. Up on the casualty receiving floor we were placed face down on the floor and sprayed down with water and soiled with maple syrup, ketchup, and mustard. We gave kisses to a royal cat stuffed animal that was referred to by a different name. On my shirt was written “Diver Wog” and I was made to lead our group in physical exercises like pushups and flutter kicks until we were about to throw up. We sang songs- Jingle Bells, Beat It by Michael Jackson, Row row row your boat, Anchors Away, and In the Jungle the Lion Sleeps Tonight. They even fed us breakfast- pink pancakes, purple eggs, and green hashbrowns. The only difference was we could not use our hands and had to eat it with our mouths off the tray. Back to exercising….. A pirate with a large beard, a knife and a whistle had written on his shirt Physical Trainer, and he put us through a workout of running, pushups, and throwing ourselves on the deck to wipe the floor with our bodies. We were doused with flower, and soaked again, and then feathers came out. We were blindfolded and in a single line train made our way up to the flight deck following the Wog in front of us. I could not see what was coming next, but it sure smelled disgusting. Down on our knees we climbed through a tunnel full of something like spaghetti or soup or meatballs mixed with water and Tabasco I think. On the other side of the tunnel we took our blindfolds off and climbed over a large net and into a barrel filled with fluorescent green water. Our whole body had to be submerged in the lime green water, and I took a big breathe and went for it and stayed under for a good 2 minutes or so. I wanted to give the Shellbacks a scare and after these two minutes they grabbed my hair and pulled me out of there. Ha ha. For this they sent me to the “Toilet Bowl”. A john stand alone and filled with something red and filthy. I stuck my head in there after some prodding and tasted a combination of root beer and ketchup and something in there stung my eyes. It must have been some Tabasco. The firehose came out and we were doused with water as we did pushups on the flight deck and tried to blow the water out of the starlet holes on the deck to no avail.

The theatrics continued with dousing by more flour, eggs, and mustard. We were placed on stretchers and hosed down again. The final part of the initiation is to kneel before Lord Neptune. Neptune had a crown with jewels, sunglasses, a white beard, and looked a bit like Gandolf from Lord of the Rings. He even had a Jester running around him screaming insanely. He asked us if we were ready to be Shellbacks and we answered Yes, Your Majesty. One Wog didn’t and they had to do the whole thing over again. Dumba#* Filthy, soaked, exhausted, it was only 830 in the morning and me and my roommates had made the crossing of the Equator and survived the right of passage and were now officially Shellbacks. Our room now smells a bit “gamey” as the Canadian Murse describes it, but our boots and pants will air dry eventually. Until then, I am stuck with my flip flops. On to Colombia!

Abandon Ship!

2009-06-05T09:36:00.001-07:00

Last night I tossed and turned and could not fall asleep. It may have been my fascination with the words- A MAN, A PLAN, A CANAL, PANAMA which spells the same thing forwards and backwards. Or it could be because the seas are becoming rougher and I find myself shifting back and forth in my bed with the rolling of the waves. I have found over the years that this rockin either puts me to sleep, or keeps me up for hours. Argh…. It must have been 3am by the time checked out, and luckily today we were ALLOWED to sleep in. I woke up at 9am and the sea state was even rougher. We must have been taking on a ton of water, because the ship was leaking everywhere, and as I made my way up topside, I saw outside that we were in monsoon conditions. Wow it was raining hard. The deckhands had things under control, and so I figured I’d go partake in an acrobatic spin class taught my roomy LCDR Dave Bacon. Bacon is a microbiologist and a salty guy, the last person I would have suspected to be teaching a spin class on a hospital ship, but he was darn good. Hard charging music and a great sweat to start off the day. Dipping side to side with the waves on a bike on a ship gave it an added degree of difficulty.

After a quick shower and brunch (no bloody marys here) the medical crew assembled in the medical spaces for training. My other roommate Dr. Mike Berretti mentioned the link to pancreatic cancer incidence. Given the fact that Mike is currently smoking a pack a day, and he is applying to a pulmonary fellowship I find very disconcerting and I have made it one of my mission goals to get him to quit.

At 1300 we hear an alarm go off aboard the ship announcing a fire in the forward engine spaces. The medical response team jumps into action with the stretcher, medical kits, and radio. The next sound over the intercom is Abandon Ship, I repeat, Abandon Ship! Followed by six short blasts by the ship’s whistle and a long continuous blast from the horn. It was a mad rush to the door as we scrambled for lifejackets and made our way up to the flight deck and our life raft positions. It was a sea of orange on the flight deck with close to 800 people from all walks of life ready to abandon the COMFORT. Good thing this was only a drill and there was not a real fire. But if there had been, no doubt we would have made it off the ship safely. The orange life jackets had a nice way of making you look pregnant as my friend Dr. Karen Jacobson found out. She held her bun in the oven with pride.

Even aboard the USNS COMFORT, just north of Colombia, in the open seas of the Pacific Ocean- my Navy Medicine recruiting efforts continue. CDR Hartzell and I assembled a group of about 30 pre-professional students, members of Project Hope, and other NGOs for a presentation on the Navy Health Profession Scholarship Program. Again I was struck by the intelligence of these young UCSD students and their unending amount of questions. It was fascinating on two levels to talk with students who study right by where my condo is in La Jolla, and also to describe Navy Medicine to them and have them actually onboard and experiencing a Navy humanitarian mission. The Navy Health Professions Scholarship is an incredible deal which pays for ones medical or dental school in return for the commitment to serve in the Navy as a health care provider for the equivalent number of years. It is the best decision I have ever made, allowing me to achieve a professional medical education, travel and adventure, the opportunity to work with outstanding selfless people, and most importantly to wear the Navy uniform and serve my country proudly. I find that when giving this talk, and especially when taking questions, there are two types of people- those that are service minded believing in sacrifice and teamwork for the common good, and those that are selfish and see the world through a “ME” lens constantly asking the question how will this affect ME?

The answer. We don’t want the latter. Enough said. Go NAVY!

Panama Canal Crossing

2009-06-04T13:38:00.001-07:00

Watch us Cross: http://www.pancanal.com/eng/multimedia/index.html

The Panama Canal is one of mankind’s greatest architectural feats. Creating a passage for ships, goods, trade from the Atlantic Ocean to the Pacific Ocean without having to make the lengthy trip around the entirety of the continent of South America was first thought of in the 1500s, and attempts were made in the late 19th century and into the beginnging of the 20th century. Ultimately close to 25,000 people died in its construction, largely from malaria. The Atlantic Ocean is actually higher than the Pacific, and with a lake in the center, a series of locks needed to be constructed to isolate the ship and either fill or drain to meet the water level on the other side. Today we passed through several locks with the ship coming within inches of the sides. This is because vessels over the past century are built to “Panamax” standards meaning that they can fit through the canal lock system. The first lock occurred around 6:30 today (while I was (over)sleeping). The beauty of the large lake was seen in the background during the Memorial Ceremony for Chief Branum. As we approached the next set of Locks we passed under the Centennial Bridge completed around 2004, this suspension bridge looks very similar to the Skyway bridge in Tampa and also the bridge in Boston. It was built to commemorate the century of the canal’s existence and also the handover of the Canal in 2002 from the U.S.A. to the country of Panama. As we passed under the Centennial Bridge many of the crew clamored to the top of the flight deck and bridge to get a good picture. It was really hot out today. The sun was scorching as we had our full uniforms on sweating profusely (I sweat a lot for some reason). But it was a special time to see all the smiles of the crew who were making one of the world’s greatest passages. We each will receive an official certificate from Panama stating that we have made the crossing. I was mesmerized by the lock system, how deep the canal must be to handle the keels of some of these massive ships, and how the water pressure differentials work. When we were “locked in” to one of the compartments, mechanized cars dragged the ship through with cables, and then the distal gate was let down and you could literally feel the ship sink, and could clearly see the level change when you peered over the side. Then we passed through and out of the lock. That lock was closed, the other end opened again, and water poured back in. In the distance we spied Panama City’s highrise and knew we were getting close to the grand Pacific Ocean. I was already sweating bullets, so I figured I would go for a run and a bike in the gym. So I threw on some running shoes and got even more sweaty. Good to get the heart beating. The only trouble was that after I was completely soaked, and went to take a shower I realized that the ship’s captain had turned all the freshwater on the ship off! While in the Canal all the water is freshwater, and the intake tank and distillery on the ship can only work off of salt water, so I was SOL. No PT (workout) gear is allowed topside (on deck) so I was subjected to sitting in my room soaked until water was restored. That was a bit malodorous and wet. I hope my roommates don’t mind. Glad that laundry is tomorrow.

By the time water came back on, and I got a quick shower, I had missed dinner, so I visited the vending machine and got some peanuts and a Gatorade. The nightly brief was long this evening, but packed with a great review on the crew’s work in Panama and a preview of the work coming up in Colombia. In Panama close to 20,000 people were treated and hundreds of surgeries done, engineering projects completed, lives touched. To hear some of the stories got me excited about getting our there and making a difference in Colombia. We will be receiving hazardous duty pay during our time in Colombia due to the terrorist threat levels there. The area we are going to called Tumaco is near the Ecuador border and is very rural. The majority of people in this region are Afro-Colombian with darker skin, and also there is a large Indian tribal populations. Tonight’s brief by the Official from the State Department based at the Embassy in Bogota was fascinating. He delved into the progress that has been made in Colombia under Presdient Urebe. Crime and terrorist threats are down, potential for socioeconomic growth and free trade with U.S. are all hot topics. We will be transiting from the ship in teams by helicopter and small boat to set up our worksites for dental, surgical, medical, and preventive medicine care. Some nights we may have to camp and stay over. It is going to be hot, hard going, but I am ready. Just so long as Juan Valdez is there with his donkey and some good Colombian coffee.

Loss of a Shipmate

2009-06-04T13:34:00.000-07:00

2 JUN

Awake at 0600 to the call over the 1MC (main intercom) to reveille, reveille. I must not have slept well, because my roommate Mike asks me why I look hung over, but he was the one who was out on the Pier drinking Coronas last night, not me. We head up to chow, and just after sitting down we see two Corpsman and the on-call physician literally run out of the chow hall and know something is wrong. As there have been several medical rescue squad calls over the past few days for minor injuries, we expect this is nothing more, but the sense of urgency worries us. It was not until quarters in sick-bay at 0800 where we would learn of the tragic loss the crew had suffered.

I cannot write about the details, but we all are shaken by the suddenness of events and prayers and tears are ever present. The mission must continue and we proceed on with our powerpoint briefings and humanitarian aid to the Panamanians. It is a quick reminder of how fragile life is and how some are lost despite us as health care providers doing everything in our capacity to prevent it. God has something better in store, and I pray that this is the case in this situation.

2 JUN (cont.)

It has been a very emotional past day and a half. I am writing this in memory of Navy Chief Pamela Branum who passed the evening of June 1, 2009 of natural causes while asleep in her bed aboard USNS COMFORT. I had been emailing a lot with Chief over the past few weeks getting ready for the mission and spent quite a bit of time with her the past two days and witnessed her true care and devotion to the Navy mission and her shipmates. Two days earlier she was the one who picked us up at the airport in Panama and took us to the ship. While there we witnessed a changing of the guard, the goodbye to the Reservists who had served the past few weeks and a grand welcome for us newcomers. There was a moment of cheers and Chief Branum was front and center. I remember thinking that this was such a special moment and so high energy, that I whipped out my camera and set it to movie mode and recorded the moment. Today while I look back at that clip it truly captures Chief Branum’s energy and how the sailors and troops felt about her. I am watching it as I write this and can’t hold the tears back. I hope that her family and the crew get to see this video as it captures the spirit of this special person.

Hundreds of us gathered in uniform on the Pier to see Chief off as she was taken by helicopter draped with American flag back to her family. She was treated with high honor and dignity. As we saluted and TAPS was played, you could hear nothing but the chop of the helicopter blades, the gentle breeze, and the heartfelt thoughts of a hero gone too soon at 41.

3 JUN

This morning at 5am the USNS COMFORT pulled out of port in Colon and made way for the Panama Canal. I must not have heard the humming of the motors starting up, or the Reveille call, and evidently didn’t hear my alarm clock either as I rolled over to wake up and looked at my watch which read 8:33am. Dang nab it. Overslept right through breakfast. And right through muster (morning meeting at 7:30). For all they know I could have been man overboard. Everyone on the crew was so pent up with emotion last night we had gone out on the pier and had some suds of beer. It was a lot of fun and our last chance to do so for the next month and a half. So that may have had something to do with my deep slumber.

I threw on my uniform and hurdled up the ladder to the Medical Dept. to let them know I was present and ok. No problem they said. “We’ll have to have your roommate Murse (male nurse) make sure you’re up on time from now on.” Roger that Sir. But he is Canadian.

There were two very important events today. One is the transit of the Panama Canal- effectively going from the Atlantic Ocean (which is higher) to the Pacific Ocean (which is lower). The other is a special Memorial Service for Chief Branum which could not have been more beautiful and well done by Chaplain Overek. We gathered on the flight deck, the ship moving at a speed of about 5 knots and the green landscape of Panama passing by in the background. Several members of the crew who knew Chief very well spoke, and we heard some very moving verses from the Bible. We also sang two very moving hyms- “O Beautiful for Spacious Skies” and “Amazing Grace” in memory of Chief. The Chaplain related a story of how Chief Branum came to him a few days ago after experiencing a dream. “She told me how she was wading through a river of water and on the bottom she spotted shining Silver coins all around her. She bent down and picked up some coins filling her pockets and she felt rich in life and wealth. She then related how she next came upon a village where she encountered some people that for some reason felt that she had done something wrong, but how she knew in her heart that she was good, she was one with the Lord.” As the sun beat down on the ship, Chaps finished this story and it was hard to tell from looking around if those were beads of sweat or tears on people’s face. Chief Branum was in heaven, and as we started the final hymn- Eternal Father Strong to Save, three birds descended upon the flight deck and chirped away in song, as if a sign from above. The words of the hymn could not be more fitting:

Eternal Father strong to save
Whose arm hath bound the restless wave,
Who biddst the mighty ocean deep, its own appointed limits keep,
O hear us when we cry to thee for those peril in the sea.

And when at length her course is run,
Her work for home and country done,
Of all the souls that in her sailed let not one life in thee have failed
But hear from heaven our sailors cry and grant eternal life on high!

Navy Showers

2009-06-04T13:17:00.000-07:00

1 JUN

Beep beep beep beep. It’s 5:50 and my cell phone alarm has been going off for about 20 minutes muffled in my locker. I jump out of my rack trying not to fall in the darkness and promptly remove the battery from the phone to shut it up. The phone doesn’t work down here in Panama anyway. Good break from the Crackberry. We’re running low on fresh water aboard so the Captain has called for “Navy showers.” This consists of quick splash to wet up, water off, soap and shampoo up, then quick splash to rinse off. No Hollywood showers the Captain says. Haha. I do the deed and am off to breakfast at 0600. Panamanian fruit and yogurt, with French toast and grits. Not too bad. Mixed with some good conversation with the folks from Anesthesiology the morning is flying by already. At 0730 we gather in Sick Bay for the Medical Department meeting (muster), take roll, and go over the plan for the day. Those of us that just checked on board have some further paperwork to complete, and give our introductions to the crew. Since it is the final day of operations in Panama we will have to wait until Colombia before we start seeing patients. With some spare time I feel the need to get the blood pumping, so lace up my orange shoe laces and hit the gym. It’s well air conditioned and with plenty of cardio equipment. I did some cross training with elliptical, exercise bike, and running on the treadmill. Worked up a good sweat and let my mind wander. Still trying to decide what route to go – Preventive Medicine or Family Medicine. One of my roommates is David Bacon, a Navy microbiologist who spent 4 years studying Malaria and Leishmaniasis in Peru. He is a very frank guy, gruff as they come, and tells me why he loves Navy Medicine- the people, the travel and the benefits you can’t beat anywhere else.

Early afternoon meeting with the PrevMed team. CDR Maleen and LCDR Wells talk to a joint group of us from the Navy and the Public Health Service about what we can expect in Colombia, El Salvador and Nicaragua. We will not be pier side for those countries and will have to be taken to land by helicopter or small boat. LCDR Wells is leaving to El Salvador tomorrow to start planning for a preventive medicine project on a small island there offshore. After the meeting I run into a tribe of older Panamanian women dressed in the most ornate and colorful dresses. They are short in stature, very nice, and pleasant to speak Spanish with. They each tell me how many “hijos” (kids) they have and it ranges from 4 to 11! Next stop is the pharmacy to pick up some doxyclycline. Every crew member must take a pill of this medication each day as prophylaxis for potential malaria. I make quick friends with the Pharmacist LT Butaa who agrees to give me the orange pills instead of the blue which are a bit easier on the stomach. We will be getting our uniforms sprayed tomorrow with permethrine- an insect repellent also commonly known as DEET.

Mid afternoon I retreat to my room and being reading Forgotten People, Forgotten Disease by Dr. Peter Hotez. It is an insightful book about how Neglected Tropical Diseases plague millions of people in this world, and the link they have to downfalls of governments, social injustice, poverty and mortality. And we can have a serious impact on this outcome as treating these diseases are extraordinarily cheap. For just 50cents per person per year we can eliminate these neglected diseases through oral medication. Dr. Hotez along with Kari Stoever formed the Global Network for Neglected Tropical Disease at the Sabin Institute (www.sabin.org) a few years ago with help from Bill Clinton and the Bill and Melinda Gates Foundation. The impact they are having on global health is remarkable. More on this later…

After dinner my Navy Reservist friends from Hawaii and I took a stroll off the ship where many local Panamanian Indians had set up makeshift stores with trinkets, jewelry, and hand-woven bright colored cloths. I got some postcards, and a nice rosary made out of volcanic rock crystals from Panama. It is HUMID! Sweaty walk back wearing coveralls to the ship in time for the Confirmation Brief. Tonight we heard from the ship’s Navigator about the plan for Panama Canal Transit. The brief had excellent photos and history of the building of the Canal. Wednesday’s crossing is going to be eventful with some stellar photo opportunities.

Destination Panama

2009-06-02T17:51:00.000-07:00

31 May

Homestead Air Force Base to Panama

Woke up at 6am to buzzing alarm and freezing room (darn thermostat was broken). Look outside and everyone is up and at ‘em and in their uniforms. I dig through my sea bag and pull out my camouflage uniform and steel-toed boots. When I put on the “utes and boots” I am instantly taken back to where I was a year earlier in Southeast Asia, with my dive team. Operational. Feels good to be back in the saddle again.

There’s a thing in the military called “hurry up and wait”. It’s let’s go, let’s go, let’s go! And then when you get there you sit around waiting for the next step of the evolution. That would be the theme of the day. You just have to be patient. Semper Gumby as they say. Max Flex.

Our group mustered (gathered) at 0730 outside the lodge and boy were we a hodgepodge- docs, dentists, public health service, social workers, medical students, pre-meds, and engineers. Most of he folks are Navy Reservists from all over the United States. I am thrilled to get to know these talented and service-minded individuals. Everyone is teeming with excitement to get to Panama. First we had to weigh-in – literally getting on a big scale with our backpacks and combat boots. I came in just under 2 bills. Whew. The next announcement came that we would have no food or water until reaching Panama. This gave me instant concern and I pulled the Chief aside and told him to go to the quicky mart right now and get three cases of water. Yes sir. Yes, that’s what I’m talking about. That’s the last thing we want to be- dehydrated on arrival.

Finally after a few more hours of waiting we are hydrated and enter the tarmac. So fascinating how relaxed the rules are when you’re flying military air. The aircrew mention they need some strong hands to load bags, so a Public Health Service optomotrist and I roger up. We don the gloves and earplugs and start the conveyer belt and climbed up in the belly of the plane loading sea bags. It was fun.

The plane is a Boeing 737 like any other commercial jet, but says U.S. Navy on it. Pretty cool. The pilots (decked out in flight suits) are Navy Reservists (Bo flies for JetBlue, and the other for American) and the aircrew are active duty out of Jacksonville. Really nice people. It is at this point that I am regretting not eating breakfast. After we are airborne, I strike up a conversation with the Aircrew Chief in Spanish about her hometown in Dominican Republic. Through and through I come to find out that she likes to cocinar and has some food stashed away. Gracias Dios. Blueberries and Chicken with Green Beans.

The coolest part of the flight was the ability to go into the cockpit. One can’t do that very often since 9/11, especially in a 737. The pilots explained the automatic pilot features, told me about the charted course, and took some photos. On approach to Tocumel International airport in Panama we could see dozens of cargo ships below between the haze of clouds and thunderstorms. Safe landing and again we exit and are made to offload our bags from the belly of the aircraft. By this point it is raining cats and dogs, but we don’t mind. It actually feels nice against the thick humidity. We hear noise coming from the Terminal. It is the Reservist crew that we are there relieving and they welcome us with cheers, high fives and flag waving. I can’t tell if it is a welcome or they are just excited because they are going home. Probably a bit of both.

We load onto buses that take us on about an hour and a half drive from the airport to Colon where the Hospital Ship is docked. The ride is a bit cramped, but everyone is in good spirits and talkative. I strike up a conversation with a guy named Joe from Missouri. Joe is in fighting shape and with a sharp jaw and quiet way about him he stands out as an intelligent and thoughtful young lad. The Harvard Medical School shirt he was wearing didn’t give it away though J After talking with him for some time about Health Care Reform, Russian viewpoints of the U.S., and the current quagmire in the Korean peninsula, this guy has his stuff together. I ask his age- 22 years old. Tried to remember where I was at 22 and if I was anywhere close to the wisdom this guy had.

When we arrive at the port terminal the mighty USNS COMFORT comes into view for the first time through the mist of pouring rain. Sporting its big red cross on the port bow, the converted oil tanker now hospital ship is a truly massive- 1000 bed patient capacity, operating rooms, Intensive Care Unit, and so much more. It is truly a beacon of hope and humanitarian aid throughout the Americas. Proudly we board, salute the American flag, and are welcomed by the crew of close to a thousand people already aboard. First stop- the mess decks (chow).

Surf and Turf is the meal this evening. Something tells me that these frozen lobster tails (not so bad with some Tabasco sauce) are not something to get used to for supper. Perhaps it was the Joint Staff Surgeon and Deputy Undersecretary for Health Affairs making a special visit today that prompted such cuisine. In the food line I see my office mate from back in D.C.- LT Marcy Morlock. A familiar face in the crowd and lovely lady. She’s been on board already for two months, and just gives me a smirk and “Welcome to the Sauna”. I also run into my Duke classmate (now Infectious Disease physician LCDR Todd Gleeson. Gleeson was my platoon commander at Duke, and taught me much back then. A Johns Hopkins medical school grad, Todd is sharp, cunning, funny, and an incredible athlete. Since Duke he has gotten married, and has three children. Very pleasant surprise to see him.

After chow we are inprocessed (lot of paperwork), and I am taken to my officer berthing and rack (bed). There are five of us in a stateroom of sorts, with lockers outside and the bunks in the back. My roommates are the head of IT for the ship LT Sean Kelley, LCDR Vic Diaz a nurse anesthetist, LCDR Dave Bacon a microbiologist (and spin instructor), Canadian male Nurse (murse) LCDR Dave McClean, and LT Mike Berretti a Navy Internal Medicine doc.

I go on exploring mission to find the gyms and other nooks and crannies of the ship. Over the 1MC (the intercom) there is a call for mandatory briefing for next day’s events and talk by the Admiral and the DUSHA. Interesting speeches by both, and even more impressive questions about the future of humanitarian assistance missions for the United States Military. Bottom line- it shall continue and is becoming a discipline, a specialty, all in of itself. We need to have training programs for medical diplomacy and continue to integrate and partner with the State Department, the Dept. of HHS, and NGOs.

During the speeches I see my good friend CDR Dave Hartzell (Navy dentist) dozing off. He looks exhausted and so I got him a cup of Joe, and a punch to wake up. CDR Harzell is the head of the Dental Team aboard USNS COMFORT. He is married to a Navy dentist as well. Once the brief is finished Dr. Harzell shows me the Dental Treatment spaces and technology aboard COMFORT. Extremely impressive ability by a machine to take a 3-D image of a tooth and send that information instantly to a machine that will construct a crown to the perfect size and shape for insertion. Wow!

It’s been a long day, and there will be many more to come. Tomorrow morning I meet with the Medical Services Team led by pediatrician CAPT Anderson. It’s the final two days of treatment occurring in Panama. So far over 15000 patients seen. T minus 2 days until we cross the Panama Canal!

The Journey Begins- Embarkation from Miami

2009-05-29T11:38:00.000-07:00

30 May 2009 DC to Miami- I left this morning a bit tired after the send off at Clydes last night. Thanks Angie Goff! It's an absolutely gorgeous day in D.C. On way to Reagan National Airport the air was filled with white wisps from windblown Dandelions. Definitely can smell summer in the air. With my seabag and camoflauge backpack in hand, cabbie asks me where I'm going. I answer Panama (not Costa Rica). He proceeds to tell me that he is from Somalia and that he is a pirate, but a good pirate. A Pirate Cab Driver in D.C. Interesting. I asked him if he heard about the new Pirate movie. He said no. I said it's rated R. Arrr... He doesn't get it. But he did go on to say how he tried to tell his pirate cousins in Somalia not to f#$ with the U.S. Navy. Wise man. They should have listened. Flight is uneventful aside from the stewardess asking me mindless questions about being on TV. Once in Miami Aiport I trekked to the USO lounge and met up with a medical team from all throughout the U.S.A. We proceeded to Homestead Air Force Base. My vanmates are a recent Harvard grad/Spanish major, Navy Corpsman (Hooyah!), Master at Arms Navy Petty Officer, and Physical Therapist from Duke (Go Blue Devils!). The Chief driving the van makes a few wrong turns and bumps the van into the car in front of us at a tollbooth. Thank goodness for rubber bumpers. Harvard linguist got her first diplomatic tasking with this incident. Homestead is not all that bad. Air Force has the best lodging out of all the services. Went for a run in the rain. Plan is for NALO flight to Panama on 31 May for rendezvous with USNS COMFORT. Now to find some food......and figure out how to get into this jet.....