A "Typical" Day at Sea

June 14^th, 2011

Happy Flag Day…

Did I mention that I have 7 roommates now?  That’s right, there are 8 of us in my stateroom – myself, Carrie (another Air Force internist), Audrey (the JAG – lawyer – for the mission), Stephanie (a Public Affairs officer), Becky (the “Fun Boss”), and 3 Canadians – Isabelle, Tanya, and Tracy (a dentist, hospital administrator, and nurse, respectively).  We are a diverse group – Carrie, Isabelle, and I are off the ship most of the time we’re in port, while Becky almost never leaves the ship and Tracy works nights on the inpatient ward.  Thankfully, everyone is VERY respectful of the extremely tight living quarters and the need for personal space.  However, 8 women in one room, no matter how respectful, is a lot (“enough,” some would say).  It is crowded and messy, especially while we’re at sea (like right now), and everyone is on the ship all day.  This morning, I counted 19 pairs of shoes on the floor – not including the shoes we were all wearing.

While I’m sure this information fascinates you, it occurs to me that if I am counting shoes and reporting on that, there must not be a lot going on.  I’ve been meaning to write for a while about a “typical” day on the ship – so here goes.

Ok, really, there are 2 typical days on the ship – shore (mission) days and underway (at sea) days.  On most grey hull ships, the shore days are low-key (liberty) and at-sea days are more stressful – but as with many other things, the situation on the Comfort is the opposite.  I’ll start with an underway day, since that’s today.  At 6am every morning, the 1MC (overhead PA system) calls out, “Reveille, Reveille.  All hands heave out.”  Yes, that is exactly what they say – I’ve checked.  No, I don’t know what it means.  There is no heaving out going on in our stateroom.  For me, it means, you have 30 more minutes to sleep.  Sometimes I don’t even hear Reveille – on occasion there is a compassionate person on the mike who announces it very quietly.  Most of my roommates are up around this time, but are quiet enough that I can usually fall back asleep.  Those who know me know that I will wake up at the last possible second.  So at 6:30, my alarm goes off and I stumble out of bed.  There is always a light on in the room (for safety in case of a middle-of-the-night egress), so I get dressed by that light – I never turn on the main light.  I am ready to walk out the door at 6:45.  And then comes the first obstacle of my day: the stairs.  It is 66 stairs UP to the mess deck (cafeteria).  There is something about being awake for 15 minutes and having to climb 66 stairs in heavy boots that is very disheartening.  One of these days I’m pretty sure I just won’t be able to make it.

But remarkably, so far, every morning, I have climbed all the stairs and arrived at the mess deck (albeit a little out of breath – you’d think it would get easier doing it every day, but it doesn’t – it’s the last flight that does me in).  There are 3 dining areas in the mess deck – the main deck, the chief’s mess (for E7s and above), and the ward room.  On other ships (“real” ships, as my Navy friends say), the ward room is where all the officers eat.  On the Comfort, there are so many officers that the ward room is restricted to O4s and above.  Thankfully, I made the cut.  The ward room is much nicer than the general mess deck.  You can serve yourself (rather than being told you can have rice OR pasta, but not both), go back for seconds, and the lines are much shorter.  The ward room is less crowded and therefore quieter – which makes for great conversations.  Also because it’s less crowded, we tend to eat with the same people every day – and since I like the people I eat with, this is a good thing.  Another advantage is that there is no one rushing us along – in the main mess deck, seats are at a premium, so when you’re done eating, you’re done.  We like to lounge around after meals and just talk.  Anyway, so every morning I head to the ward room.  Breakfast is the best meal of the day.  It’s funny, because at home I usually don’t even eat breakfast, or if I do, I’ll have a ½ bagel or an English muffin.  Here, I have to limit myself.  I usually have a pancake or French toast, 2 hard-boiled eggs, a bowl of cereal, and fruit.  The coffee is awful, so I get my caffeine in the form of fountain Diet Pepsi (not as good as fountain Diet Coke, but I’m definitely developing a taste for it). 

At 7am on the dot, the 1MC announces, “Secure the mess line.”  One of my first days on the ship, I heard that and thought they said, “Secure the meth lab” – so that’s our running joke.  “Secure” is a Navy word.  It’s used liberally around the ship, usually to mean something is closed, off-limits, prohibited, or safe.  We have to “secure for sea” (fasten down all movable objects), the ward room is frequently “secured for DV luncheon” (closed, obviously), a sign in the bathroom tells us if we keep clogging the toilets, they will be “permanently secured” (this one makes me laugh, because it’s such an idle threat – are they really going to permanently close the toilets?).  My favorite was one day at breakfast, when there was no milk.  When I asked one of the FSAs (food service…agents?  assistants? Not sure – one of the mess deck workers), he told me, “I’m sorry ma’am.  The milk is secured.”  I just couldn’t think of a reason why we were securing milk.  Anyway…

After the mess line is secured, we all get in line to put our trays away, into the “scullery” – the dish cleaning area.  In front of the scullery are 3 bins, where we separate our trash into paper, plastic, and metal/ glass.  This is done everywhere on the ship – all trash must be separated.  This is because paper can be incinerated on the ship, but plastic and metal/ glass are held “on deck” until we are in a country where we can pay to recycle or dispose of it.  After we turn in our trays, we head to “quarters” or “muster,” which is held daily at 7:15.  Muster is another Navy word – and they love it.  We muster constantly.  Basically it is roll call, and is done to make sure no one has fallen overboard since the last muster.  We have a fairly large department (85-90 staff), but have gotten the muster down pat and are usually all present and accounted for by 7:17 or so.  Then we are read the POD – the Plan of the Day, which includes any useful information about training, activities, or secured offices for that day.  After that, we usually have an internal medicine meeting and a brief lecture among the internists.  After THAT, the day begins.  While we are at sea, there is usually some kind of training or lecture scheduled in the morning and one in the afternoon.  We also have fire drills and abandon ship drills after every mission.  In the mornings, I try to find a computer where I can check email or work on my computer in my stateroom (on blogging, lectures, etc.).  I also do laundry twice a week (we have assigned self-service laundry days, so if you miss your day, you’re out of luck until 3-4 days later, so I do it every time just to be safe).  The ship’s laundry will do most laundry for us, but I’ve gotten one too many still-damp and smelly towels back and I just prefer to do it myself.  If I can find a functional TV (no small task), The Daily Show and Colbert Report are on AFN (Armed Forces Network) from 9-10am.  Lunch is served from 11:30-1pm, and I like to go as early as possible so I can be hungry again at 4:30, when they serve dinner (no, I’m not kidding).  After lunch it’s usually more internet time or meetings, then a workout after lunch has digested. 

At 4:30, it’s “Dinner for the crew” over the 1MC.  As much as I try to hold off, the response is Pavlovian, and I am hungry about 5 minutes after I hear the announcement.  Lunch and dinner are remarkably similar meals (both much heavier than I would eat at home), and I try to have a salad for at least one of them.  Unfortunately, we have run out of lettuce (or maybe it’s secured), so they’re serving cabbage instead.  For those wondering, cabbage does not equal lettuce.  Not even close.  Not even with a lot of ranch dressing, and not even if you cut it into lettuce-sized pieces instead of thin strips.  If I never see cabbage again, I’m ok with it.  For a while, they were also serving extremely under-ripe green tomatoes, and calling them tomatillos.  They weren’t.  We knew this when, after refusing to eat them for 2 weeks straight, they started turning red and delicious.  That was pretty funny.  My other favorite Comfort recipe came this weekend.  Saturday night was pasta night (my absolute favorite meal on the ship), and Sunday, they served “tomato soup,” which was, as it turns out, pasta sauce.  They didn’t even try to dilute it or add milk or spices or anything.  So when I get home, that’s going to be my new meal – pour some Ragu in a bowl and tell the kids it’s soup.  For all my complaining, I will say the food is, well, actually, it’s pretty bad.  Once again, my Navy friends tell me that the food on a grey hull ship is amazing.  They have all done tours on other ships and can confirm that the Comfort meals are not typical of Navy meals.  Thankfully, there is a seemingly endless supply of peanut butter and jelly, so I have made more than my fair share of sandwiches (on stale Wonderbread, but this is still better than some of our lunch options).

After dinner, as I mentioned, we all kind of hang around the ward room until they once again secure the meth lab.  We kill time for about 30 minutes (usually hanging out on the flight deck, where there’s a nice breeze and sunset), then we meet back in the ward room for “Internal Medicine Peer Review” – one of my favorite parts of the day.  I’m not sure if this is a Navy thing or what, but 4 of the 6 internists, and several of the radiologists and the dermatologist, are big-time gourmet tea drinkers.  So they started having tea time, and of course the rest of us had to join in.  And now it is our nightly ritual, to sit and drink tea after dinner.  Around the same time this started, we were told we had to have some kind of peer review program in place, so we decided to call that tea time (so now it’s an official meeting and we can’t be forced to miss it for other, less important/ fun meetings).  We usually discuss patients for about 5 minutes then resume other conversations.  After that, it’s the COPS brief (the Current Operations brief).  This is a source of entertainment if not information.  Every night, the brief consists of the weather report (hot and humid), current events (usually one story relevant to the country we’re visiting), the plan for the next several days (more of the same), the medical summary for the day (how many patients we saw at the sites and on the ship), the Navy band report (they continue to play music), the Public Affairs Office report (where they tell us how many Facebook friends CP11 has), and a message from the CO (the hospital commander) and the Commodore (the ship’s commander).  When we pull into a new country, we get a cultural brief, a legal brief, a safety brief, and a brief about the upcoming MEDCAP sites.  On a good day, the COPS brief lasts about 15 minutes, but sometimes it can go on for a full hour.  My favorite part is the band report (just because I think it’s funny that we’re getting a report on the band) and of course the medical report, where we get to impress everyone by showing how many patients we saw that day.  A typical day at the MEDCAP is 700-900 patients – Colombia was a bit less as we had fewer providers out there.  The guy in charge of the medical brief is pretty funny and is one of the internists, so frequently joins us for tea time.  As is common in group conversations, we come up with some key phrases that turn into inside jokes – and he manages to work these into the ops brief seamlessly.  So far he’s used “Danish butter,” “Jamaican handshake,” and “hot jungle popsicle” – which are all very benign phrases (in origin) but end up being hilariously funny when the origins aren’t known.  Makes us all laugh to hear how they are worked in.

After the COPS brief is the FOPS (future operations) brief, aka “the hot wash.”  Not sure why it’s called that.  It’s where the down-and-dirty logistics planning takes place for the next day – who goes out on which boat, how many buses will be needed, etc.  The only time I’ve had to go to the hot wash was when I planned the trip to the oncology hospital – that’s where I got confirmation of my transportation, security, local cell phone, and translator.  Most of the time during the hot wash, we go back up to the flight deck for some fresh air.  By this time it’s dark out and we can usually do some stargazing – I got to see the Southern Cross!  There have been a few days on this deployment that for some reason, I haven’t gone outside at all.  That is a huge mistake, I realize now.  Being stuck inside the “skin of the ship” all day makes time go by much more slowly and makes me feel sickly.  Being outside in the fresh sea air is much better (except in Peru, where the smell outweighed the benefits of the sea air).  After our time on the flight deck, we’ll either watch a movie, check email, or call it a night, depending on what the next day’s schedule looks like.  And that is a typical “at sea” day for me.  When we’re in port or at anchor (during missions), my off days are pretty typical, except there’s less outdoor time, because the helo’s are flying missions and the flight deck is secured.  And now you know what that means. =)

Anchors Aweigh (again…)

13 June 2011

Back at sea as of yesterday morning.  We were all happy to say goodbye to Colombia.  As it turns out, our presence in the country was not universally welcomed.  I mentioned before that we had 900 security personnel at the MEDCAP site in Tumaco.  This meant a large influx of Colombian police and military forces (from outside the local area), which resulted in the capture of one of the key FARC leaders (the narcotrafficking group).  In retaliation for this, on Friday night, there was another explosion/shooting in Tumaco.  There were several casualties, and the Comfort was once again asked to assist with medical care.  For logistical reasons (leaving anchorage less than 36 hours later), the command elected not to accept these patients.  I have mixed feelings about this (I feel we could have stayed anchored for a few days longer to help out, as our medical care is clearly far superior to the system in Tumaco, and we have 2-3 extra days that we could eliminate in our next country), but obviously it was not my call.  I know there was a lot of information that was factored into the decision (much of which I am not privy to), but I can’t help but think we could have really made a difference in those patients’ lives – our ability to provide trauma care and resuscitation far exceeds Colombia’s – especially in Tumaco, where, as I mentioned, most of the physicians are on strike.  Well, everyone said Colombia would be our most challenging mission (so far), and they were right.

Saturday I was scheduled to take part in a doctor-to-doctor exchange (the SMEE), where we were to meet with local physicians to discuss medical practices.  Per routine, we awoke “in the fours,” (this should give you some foreshadowing here – nothing good can come from waking up that early), mustered for our boat at 5:30am, and arrived at the SMEE site before 7am.  No more than 45 minutes later, we were informed that all shore activities for the day had been cancelled, due to security issues from the previous night’s events.  We were then bus’ed back to the BLZ, where we were told no boats would be running until 3pm.  So then we drove to the HLZ, where, after a 2+ hour wait, we were able to catch a helo ride back to the ship.  The helo ride was fun, but did not make up for the early wake up call or the 6+ wasted hours – not to mention the supposed “risk” we faced by being off the ship due to security issues.  Our instructions for the mission are to “be flexible and keep a sense of humor” – two commands that I was unable to follow after our exercise in futility on Saturday.  After returning from the site, I had lunch and a nap.  When I woke up, I still felt inflexible and humor-less.  Later that day, one of my fellow internists mentioned that his 3-year old daughter had refused to talk to him on the phone, because she was mad that he had missed her birthday last week.  It struck me that Abi will turn 3 in a few weeks (and I obviously won’t be there) and I started thinking about how big the kids are getting and how I’m missing so much by not being home and I just started to tear up.  It was right in the middle of our nightly COPS (Current Operations) brief, so not too many people noticed, but I was still embarrassed.  The guy who had told me his story (that set me off) felt terrible for upsetting me – so then of course I felt terrible because, well, he was the one whose daughter refused to talk to him.  The nice thing is, we have a really great group of people in my department.  We’re all in the same boat, so to speak (get it? – that joke never gets old), so after the COPS brief, my fellow internists and other friends were all more than willing to lend a sympathetic ear, a hug, and their own sad stories.  That night also happened to be the Commanding Officer’s birthday, so after the COPS brief, they served delicious cake (unlike the regular dessert cake, which is the opposite of delicious).  It was a mellow kind of night – for everyone – but the cake helped.  After that, we all hung out on the flight deck, enjoying our last night off the coast of Colombia, and watched a movie.  I finished up the night by watching every video I had of the kids – sounds like torture but it actually cheered me up.

The next day I woke up feeling better but not normal.  It was Sunday, and was deemed a “semi-down day” (our second one of the mission).  At church last week, the chaplain said, “On the ship, every day is Monday – except Sunday!”  This is partly true.  When we are in port, both Saturday and Sunday are working days, so although church services are held on Sundays, many people cannot attend due to mission requirements.  So far, we have only had 2 Sundays at sea, when we haven’t had to work.  A semi-down day means that instead of mustering in uniform at 7:15am, we could muster in uniform at 10am.  For some reason, though, they moved church services to 8:30 (instead of 9), so I wasn’t able to sleep in for too long (and, inexplicably, they still called “Reveille, Reveille” at 6am).  They served “brunch” from 10-12, which consisted of grilled cheese sandwiches and rice, with a side of bacon (guess that was the “br” in brunch).  Not sure who comes up with these menus. I kept waiting for the mimosas and eggs Benedict to come out.  After that, it was a relaxing day, followed by our second scheduled “steel beach picnic.”  A steel beach picnic is basically a cookout on the flight deck (our “steel beach”).  At our first steel beach picnic, right before we crossed the Panama Canal, everyone wore PT gear and sneakers (instead of the hot and uncomfortable full ABU or NWU uniforms and boots that we usually wear), and there were lounge chairs set up on the flight deck, along with games, contests, and a live performance by the Navy band (who were INCREDIBLE).  Unfortunately, yesterday, the weather didn’t cooperate, and so they moved the steel beach picnic inside to the mess deck (cafeteria).  And made us wear our uniform.  And there were no games or music or lounge chairs.  So, we ate hot dogs on paper plates on the mess deck.  Not much of a picnic – I wish they had just postponed it to another day.  We finished up the day by watching a movie and then we all went to bed early – everyone was sort of disappointed in our much-anticipated “down day.”

I realize this particular post is not as uplifting as some of my previous ones, but this is as much a memoir for me as it is a chronicle for my friends and family, and I want to be honest with myself and you all as to what is going on.  In general, this deployment is not terrible – the people are fantastic, my job is not too strenuous, and I am almost never concerned about my safety.  It could definitely be a lot worse.  But it would be lying to say that we’re never homesick or that we don’t drive each other crazy sometimes, or that I don’t get frustrated with the mission and lack of communication and feelings of futility with day-to-day and month-to-month operations.  I try not to think about it too much, because it’s a short journey from thinking about how much I miss the kids and Scott to thinking about how much I REALLY miss the kids and Scott and then getting through the already grueling mission days is that much harder.  I’ve made some amazing friends and we’ve had hours upon hours of conversations – some deep, some just entertaining and fun.  The ship is small enough that most of us know each other – at least by face if not by name.  But the smallness of the ship can be a source of frustration, too.  People who start to get on your nerves keep showing up – 3 meals a day, plus musters, meetings, mission sites, etc.  In the deployed setting, when 900 people are in a confined space, eating together, working together, living together, working out together – there are no secrets and no escapes.  When you’re feeling frustrated, you can’t just stay away from the people who frustrate you.  There is no private space (other than your bed, if you close the curtains around you) or place to vent without possibly being overheard – especially when, for example, the friend you want to vent to is roommates with the person you want to vent about.  Even a phone call home takes place in an open hallway, in a bank of 10 pay phones, with conversations open to everyone.  And while talking to Scott and the kids is the highlight of my week, I don’t want to waste precious phone time complaining about life on the ship – when I know things are much harder at home.  So, I’m grateful to have friends here and a blog to voice my frustrations to… =)

Colombia - June 8th, 2011

Colombia has been a different mission, to say the least.  First of all, we are anchored approximately 6 nautical miles off shore, so the boat ride to the BLZ (the boat landing zone, you remember) is about 45 minutes (we call it “the slow boat to China”).  The BLZ is located on a Colombian Navy base, which is a 10-minute bus ride from the MEDCAPS site.  The most remarkable thing about the bus ride is the presence of heavily armed police guards along the street – at least every 100 yards.  There are also armed military guards stationed in towers looking out over the streets.  At the MEDCAPS site, we have 900 Colombian military and security personnel, for our protection and for the protection of our patients.  Makes me feel scared and safe at the same time.

The high level of security is due to the fact that the area of Colombia we are in, called Tumaco, is one of the highest cocaine export areas in the world.  Cocaine eradication is THE topic of conversation down here.  There is a local group called the FARC that is very active in exporting cocaine.  They are apparently a violent group which actively resists the CNP (Colombian National Police) and the Colombian Navy. 

We had a lecture by one of the local toxicologists last night, which described the methods used to eradicate cocaine exportation, production, and farming.  The local authorities attack the process at each step.  The Colombian Navy is responsible for preventing exportation by boat.  The Navy has dozens of boats which are extremely fast and heavily armed, to chase down the exporters.  The Navy base where the BLZ is located is full of confiscated narcotrafficking boats (and even a submarine that was captured!), with the engines detached and the fuel tanks emptied – to be re-commissioned for good instead of evil.  To combat production, the CNP investigate local farmers and attempt to limit the sale of chlorhydrate which is mixed with coca to create inhalable cocaine (the most addictive form, apparently, and the cheapest to produce – so the farmers actually give this form away to people, in order to get them addicted to the more expensive crack or powder cocaine).  At the farming level, eradication is accomplished through aerial spraying of, essentially, Round-Up.  We’ve been told that the FARC try to shoot at the airplanes during this process.  For any coca plants that survive the pesticide, the CNP hires civilians (for $20 per day) to dig up the remaining plants by the roots.  This seems like a fairly easy task, except that the coca farmers (the FARC) plant IEDs and land mines in with their crops – so explosions and severe injuries of these workers are common.

Extremely unfortunately, we got to witness the results of one of these IEDs yesterday.  Approximately 20 miles away from the Navy base, one of the IEDs exploded and injured 4 Colombian civilians.  Three were only minor injuries, but the last patient, 21 years old, was closest to the explosion and seriously hurt.  The CNP requested the Comfort’s assistance in caring for these casualties.  Since the ship is designed for disaster response as well as humanitarian assistance, it was actually very easy to take these patients on.  The four patients were flown in by helo, and transported immediately to CASREC (our Casualty Receiving area).  I happened to be on board the ship yesterday, so I was a part of the “mascal” (mass casualty) response.  The most severely injured patient was taken immediately to the OR, where he underwent bilateral lower extremity amputations (one above the knee, one below the knee) and a left arm amputation.  He also has a fractured left femur and right forearm.  He is currently in the ICU and is certainly our most critically ill patient.  I started my MOOD call at 7pm last night and didn’t leave the ICU until almost midnight.  Once we had the patient stabilized, the true horror of the situation sunk in for me.  He is 21 years old, and had taken the job that day for less than $20.  In fact, he wasn’t even hired to dig up coca plants.  He was the “water boy” – the person charged with bringing water to the other workers.  Apparently, one of the workers missed a plant and asked our patient if he would quickly dig it up – and that’s when the IED went off.  The patient has been unconscious/ sedated since he arrived on the ship, and we don’t know his phone number, so his family has no idea where he is or if he’s even alive.  He does not yet know about his 3-limb amputation and serious injuries.  I came extremely close to tears when this all hit me last night.  I’m sure my military colleagues serving in Iraq and Afghanistan see this every day, unfortunately, but I wasn’t expecting it and it really sucks.  He does appear to be stabilizing and will go back to the OR for another surgery tomorrow.  After that, he will be air-evac’ed off the ship to a Colombian military hospital.  He has no medical insurance but reportedly the President of Colombia will be paying for his med-evac off the ship.  Also, according to reports, because he was acting as part of the CNP, he will be eligible for medical care and should even get prosthetic limbs once his wounds are healed.  But I can’t help but think he’s not going to consider that good news. 

Other than that incident, Colombia has been fairly quiet.  Because of the extremely long transit time to get to and from the MEDCAPS site, most of the providers only have 2-3 days on shore.  Although going on shore makes the time go by faster, most of us are not complaining.  The first boats leave at 5:30am (requiring a wake up time “in the fours” – which should be illegal in my book) and don’t get back until after 6pm usually.  The patients seem to be much sicker – and much poorer – here than in the other countries we’ve visited, so the clinic visits are longer and more challenging.  The air temperature is about the same as Ecuador or Peru (high 90s to low 100s), but the humidity here is about 90% and there is no breeze, so it feels much, much hotter.  There are lots more mosquitoes, so my first day back from the MEDCAPS site, I was covered in 6 coats of DEET and about 42,000 coats of Purell. 

That day, I also won the award for seeing the world’s grossest wound – a distinction I would gladly pass on to someone else.  The patient was 91 years old and lived alone.  He reported having “worms” about 20 years prior, which caused his left leg to swell massively (a condition called elephantiasis).  Because of the swelling, he got an infection in his leg, which he told me had been there for 20 years.  When he came to me, he was sitting in a wheelchair, and his leg was wrapped with a dressing.  From across the room I could smell the dead tissue and see the flies and gnats buzzing around and feasting on his skin.  The smell alone had me nauseous.  One of the nurses offered to help me change the dressing, otherwise I probably wouldn’t have considered it.  We both donned masks to help shield us from the smell.  As I peeled back his dressing, the full extent of his wound became clear.  His entire shin/ calf was necrotic and the most disgusting thing I have ever seen.  I literally started gagging behind my mask.  When I looked at my translator, she had turned away and was crying – I told her she could leave the room if she wanted.  We irrigated his leg with sterile water and the drainage we collected at the end was filthy – with pieces of skin, dirt, and flies floating in it.  We then re-dressed the wound, but not before taking several pictures – I’m sure you all can’t wait to see.  The patient was very grateful to have a clean dressing, but was less pleased when I told him I recommended amputation of the leg.  He said that another doctor had recommended that before, but that he was concerned that surgery might kill him.  I told him that yes, that was possible, as he is 91 years old, but that the infection eating his leg might kill him too.  In the end, he agreed to at least consult with a local surgeon to discuss amputation.  In the meantime, I gave him one month of strong antibiotics and a few extra dressings, along with strict instructions to clean the wound every day (instructions that I am 100% certain he will not follow).  When we got back to the ship that night, the story of my patient had already spread.  A colleague had taken pictures of me irrigating the wound, and those pictures had made their way around my department.  Someone mentioned that they had had a similar patient in Peru – to which an eyewitness quickly responded, “No, I saw that patient too.  Melissa’s was a thousand times worse.”  In the medical world, seeing and treating a disgusting medical condition inexplicably gains you a certain amount of respect and admiration from your peers.  Again, an honor I would rather not have had.

Believe it or not, I haven’t been out to the MEDCAP site since that day.  I head out again tomorrow and Saturday.  The physicians in Tumaco have all been on strike since March, so the local hospital here is being run by residents and medical students.  Specialists are especially lacking, so I have been asked to see about 20 oncology patients tomorrow.  I have no idea what to expect, but I am excited to be able to use some of my oncology knowledge out here.  I am, admittedly, a little intimidated about seeing 20 new cancer patients in one day – usually we see between 25-35 patients at the site, but they are not as complicated as your typical oncology patient.  Should be interesting.  The next day, we have a meeting arranged with some of the local physicians (some of whom are on strike, and some of the residents that are working the hospital).  The meeting is referred to as a “SMEE” – a subject matter expert exchange.  Typically, these SMEE’s are less of an exchange and more a passing of information from us to them, but they specifically requested an oncologist, so I’m heading out to answer any cancer-specific questions they may have. 

Give me liberty...

I’ve mentioned before that liberty has been a very popular topic of conversation on the ship.  It got more popular as the date drew closer.  Unfortunately, the Commodore (ship’s commander) and the admiral in charge of the “4^th Fleet” (of which the Comfort is currently a member – it switches depending on where we are in our journey) had some pretty strict rules about liberty.  The first (and worst) was that we needed a skeleton crew on board the ship at all times – “in case of emergency.”  The skeleton crew was to consist of 25% of the ship’s crew – I’m not sure what kind of emergency would have necessitated us leaving 75% of the crew on land with the other 25% on board, but don’t get me started.  We’re pretty sure this rule was in place purely for crowd control – the Manta liberty area was small and we brought 900 thirsty American sailors to it.  So they split us up into 4 duty sections, and I was in section 1.  Unfortunately, since there were technically 5 liberty days, those of us in section 1 got to “stand watch” (sit on the ship looking longingly at the shore) on the last day as well as the first.  Sigh.  Thankfully, many of the staff in my duty section were friends, so we made the best of it – we watched movies, sat on the flight deck talking, and even ordered pizza from a local Godfather’s Pizza place (got it delivered to the quarterdeck).

The second rule for liberty was that it expired every night at 1am.  This meant that we had to be back on the ship or in our hotel rooms (if we were approved by our commander to stay out overnight – and this was only for E-7 and above) by 1am.  AND, the third rule was that we had to be back on the ship, in the uniform of the day, by 8am for muster.  This meant waking up at 6:30 or so at the hotel to make sure we wouldn’t be late.  After muster, it was a matter of waiting around for the Commodore to call for liberty.  Some days this was as early as 8:45, but others it was as late as 1pm.  So, our “5 days of liberty” ended up being much, much shorter (about 40 hours total of actual free time).

Other liberty rules included the requirement for “liberty buddies” – we had to travel in groups no smaller than 2 and no larger than 5 (and the groups were documented on the ship and could not be separated under any condition).  In every liberty group, there had to be a “DND” – a designated non-drinker, for the full 24-hour period.  Some of the skeleton crew served as “shore patrol” – members dressed in civilian clothes making sure there was always a DND and that groups were not too large.  It was hardly “liberty” as I pictured it.  Which is not to say that we didn’t make the most of it…

Thankfully, many of the people that I hang out with are FIPs (fairly important people) on the ship.  We had a couple of section leaders and the equivalent of some squadron commanders in our group.  No one cared that we took a group of 15 to dinner, given who was in the group.  That was pretty nice, since we all have a good time together.  And the DND thing was actually not hard to enforce, as there were always a few people who had no interest in drinking after the previous night’s activities (and very little sleep).  By the end of liberty, I was actually happy for the 1am curfew and 8am muster – no one in their right minds would have been up at 8am otherwise, but this way no one wasted any of their precious liberty sleeping in.  And given that none of us had working cell phones, mustering everyone together at breakfast time gave us an opportunity to plan our day.

I stayed with 2 other girls (2 of my roommates) at a local hotel called the Oro Verde.  Many of the officers stayed there.  It was a 3 minute taxi ride from the ship and was right on the ocean.  There were several small oceanfront restaurants and shops within walking distance.  The hotel also had a very nice pool area where we spent most of our time.  On our first day of liberty, I went with a friend to the hotel’s “beauty saloon” – where, despite the name, they don’t serve drinks.  We both decided to take the plunge and get our hair done.  I was very nervous – trying to pantomime “natural-looking highlights” wasn’t easy.  Fortunately, a girl from the ship (who speaks perfect Spanish) was getting a pedicure, so she translated for us.  The stylist then told her to tell me, “it’s going to be very blond” – ack!  So after a little bit of back and forth, I went for it.  Both of our highlights came out fine – pretty good, in fact.  We didn’t get cuts, though.  Just didn’t want to risk it.

After the saloon, a group of us went to dinner at a fantastic steak/ seafood restaurant called Martinica.  Service in Ecuador is very slow and relaxing.  Dinner took almost 3 hours.  When we were finally done, we made our way to a dance club called Paparazzi.  Dancing to South American/ Latin music was entertaining, but we were happy when they put on some more recognizable songs.  Of course, at about 12:30am we headed back to the hotel so as not to be caught out after curfew by shore patrol.  I haven’t had a curfew in a really long time.

The next morning, we headed back to the ship for breakfast, and some people for their duty day.  When liberty was called that day, we all headed right back to the hotel where we slept and hung out at the pool.  There were a few non-Americans staying there, but we definitely overtook the place.  We had another relaxing lunch and then dinner at an Italian restaurant.  A note for future trips to South America: they are not known for their Italian food.  My chicken parmesan was terrible.  I did have some fried octopus, and every place serves “chifles” (fried plantain chips), but overall not my best meal.  After dinner we again explored the local bars and nightclubs – but only until 12:30am or so. 

By the next day, Sunday, we were all starting to get tired.  For many of us, though, it was our last day of liberty (back on duty on Monday), so we wanted to make the most of it.  My amazing translator Rosa from Jaramijo (the one who set up the hospital tour earlier), had arranged for some of us to have a spa day on Sunday.  Normally, the spa would have been closed on Sunday, but a friend of hers owns the business, and so she opened it up just for us.  We had mani’s, pedi’s, and an hour-long massage, for $40.  Although I would have paid much more just for the day of pampering.

After our spa day, we once again headed back to the hotel.  In Ecuador, it is illegal to purchase or drink alcohol in public on Sunday, so we had stocked up on a few beverages and snacks the day before.  Our room party started at about 2pm and went until, you guessed it, 12:30am, when we headed back to the ship.  I have to say, I don’t think I could have handled another day of liberty.  In 67 consecutive hours, I slept 3.5 (the 1am curfew didn’t necessitate going to sleep at 1am, and many of us stayed up all night playing cards, talking, and trying to use the internet at the hotel).  Monday, my “duty day,” was spent napping and relaxing on the flight deck.  And as much as I complained about having to end liberty a day before everyone else (or at least 75% of everyone else), most everyone came back early that day.  I think everyone was exhausted. 

The days since liberty ended we’ve all just spent catching up on sleep, stories, and pictures.  I like to say that if nothing else, liberty provided us with something else to talk about besides how stale or soggy the French toast is in the morning.  It was good to get out of uniform (especially these awful combat boots) and eat normal food (you know, like fried octopus).  A couple of glasses of wine didn’t hurt either.  And it brought us a lot closer as a group.  Of course, we are all already looking forward to our next liberty stop in Costa Rica.

Tuesday morning we pulled away from Ecuador and headed back to sea.  The local food finally took its toll on me that day and I took my first dose of Cipro.  I was one of the last people to suffer from Montezuma’s revenge, so I really can’t complain.  We arrived in Tumaco, Colombia this morning and sent a small crew out this afternoon to set up the medical site.  I am on MOOD duty today, so got to spend the afternoon catching up on email and blogging.  Hence the two blog updates in one day.  If you made it this far, congratulations.

Manta, Ecuador

June 2^nd, 2011

The mission continues.  We docked this morning off the coast of Colombia, after spending approximately 4.5 months in Ecuador.  Well, it seemed that way, anyway.  The 12-day mission was our longest so far, and was followed by 4 days of liberty in Manta.  Liberty was, of course, the highlight of Ecuador, but a close second was the opportunity to visit a large cancer hospital in a local city.

There were 4 different MEDCAP sites in Ecuador – Rocafuerte, Montecristi, Jaramijo, and the local free clinic in Manta.  I wrote previously about Rocafuerte and Montecristi, and the day I spent at the free clinic.   Toward the end of the mission, I worked at the MEDCAP in a very small town called Jaramijo.  Per the usual routine, our site was set up at a local school.  The school was very small and on one day we had 5 physicians (plus translators, patients, and family members) in one classroom – very cramped and not ideal. 

The Jaramijo site was where I met a fantastic translator named Rosa.  She grew up in Ecuador but moved to Spain several years ago, and was back in Ecuador visiting her family.  As with most South American families, hers was huge.  As we were talking, she mentioned that one of her nephews was a surgeon at a large oncology hospital nearby.  She asked if I’d be interested in a tour of the hospital, to which I obviously immediately said yes.  She made a quick phone call and it was arranged – on her end. 

On my end, the battle of the century had just begun.  My direct supervisor happened to be at the site that day, so I ran the idea by him – he was thrilled and pointed me in the right direction to get it arranged.  Little did I know what I was in for.  I emailed who I thought was the right person.  The next day, I received a visit from NCIS (the Navy equivalent of OSI – the Office of Special Investigations – people you generally want to avoid).  They had received a copy of my email and had consequently visited the hospital earlier in the day to assess security and “Force Protection” – a term that all my military friends are very familiar with.  They met with the medical director of the hospital, who had no idea about our planned visit but was very happy (by their report) to give us a tour.  They instructed me that when we went to the hospital, we were to use the back Emergency Room entrance, as there were 3 security guards there, instead of just the 2 at the front.  They explained the alternate route to the hospital in case the roads were closed or barricaded.  Overall, they gave their stamp of approval.  First obstacle cleared.  The next hurdle was finding transportation.  After making enemies then friends with the right person (who was offended that I hadn’t contacted him in the first place – sheesh), I secured a chartered van with a driver and security guard.  Check.  The last step was to make sure all the appropriate people knew of and approved of the trip.  Without boring you with details, let’s just say this was a learning process for me.  The email chain is laughable – everyone wants to be in the loop.  The funny thing is, everything was arranged and approved without about half of the “required” people knowing or helping.  After this ordeal was over, a friend remarked to me, “I always say you can tell the greatness of a man by the importance of his enemies.  You must be pretty great.”  I would say I’ve mended all bridges at this point, but it was a stressful few days.

Totally worth it, though.  The hospital was called SOLCA (Sociedad de Leche Contra el Cancer) and is part of the National Cancer Institute of Ecuador.  There were 9 of us that ended up on this trip, plus Rosa, our translator.  The director of the hospital was ecstatic to have us there and took us on a 3.5 hour tour.  The hospital was beautiful and huge.  Totally state-of-the-art equipment and medications.  Bright, airy waiting rooms and friendly staff.  Their population base is approximately 2 million people.  Their annual operating budget, which includes staff salaries, chemotherapy, radiology studies, labs, equipment, medications, and radiation, is…are you ready for this?  Nine million dollars.  Yes, you read that right.  Nine million dollars per year to care for all the cancer patients in an area bigger than my home state of RI.  Consequently, they are EXTREMELY short-staffed – the night shift on the pediatric ward has 1 nurse for 9 patients (day shift has 2 nurses) – the parents are given a lot of responsibility on that floor.  They obviously don’t pay as much for medications and chemotherapy as we do in the US, but they also do a lot more with less.  Their biggest backlog is in cancer surgeries – and this is because they don’t have enough anesthesiologists at the hospital.  Amazingly, they follow our same oncology guidelines (NCCN) and use fairly new drugs for nausea and pain.  They were very proud of their radiation suite, which is able to deliver modern radiation techniques.  The hospital is government funded, but patients have a 10% co-pay (so I guess technically, their budget is $9.9 million).  It was incredible. 

At the end of our tour, the medical director asked us to sit down with him and give him recommendations on what he could do to improve his hospital.  It was really touching that he valued the “American doctors” so much to ask for this.  He really wants to start a bone marrow transplant at SOLCA, so we talked about the feasibility of that.  We asked him what WE, the members of USNS Comfort, could do for his hospital that would help.  His response: surgeries, radiology readings, and Pap smears.  The number one cancer killer for women in Ecuador is cervical cancer.  This is in the day of Gardisil, the cervical cancer vaccine, and Pap smears, which detect cancer in its earliest stages.  Unfortunately, the vaccine costs $200 which is completely unaffordable for most Ecuadorans.  And the health care system is so lacking that annual or even bi- or tri-annual Pap smears are not even remotely possible.  Such easy interventions that would make a tremendous difference.  So we talked about those as well.  Overall the trip was amazing.  Scott and I have talked about trying to come back here with a group of doctors in the future.  Who’s with us?

The tour of SOLCA was our last mission day in Ecuador.  The next day started liberty.  To be continued…