Costa Rica LIBERTY!!!

July 27, 2011

We continue en route to Costa Rica, with scheduled arrival tomorrow afternoon.  As soon as they call liberty, I will be on the first bus to the hotel to meet up with Scott, who arrives today!  Lots to do before then, as liberty ends at 2400 on July 31^st, and I have a hospital tour scheduled for 0900 on August 1^st, so everything needs to be coordinated before I leave the ship tomorrow.  I’ll write more if I can!

August 4, 2011

It’s funny when I write things like “nothing stands between me and liberty except 3 days at sea,” how comically ironic that turns out to be.  Some of you may know this already, but on the night before we were scheduled to arrive in Costa Rica for liberty, the entire ship was buzzing with excitement in preparation for the next day.  After an otherwise mundane ops brief that evening, the Commodore stood up and announced, without any fanfare, “I have some bad news.  It doesn’t look like we’ll be arriving in Costa Rica tomorrow.  You should probably call your spouses and let them know.”  It was an issue with getting clearance to discharge waste products from the ship into port in Costa Rica – somehow the permit had not come through in time.  Knowing the reason behind the delay in our arrival did nothing to cheer anyone up.  After the ops brief, people were just moping around the ship.  No one smiled at anyone else, and everyone just looked miserable.  The next morning, they still conducted our mandatory liberty briefs (to remind us how much to drink and the off-limits establishments), but no one really paid attention and everyone just looked dejected.  In the middle of our brief, the ship’s master came over the 53MC and announced that “we will be pulling into port as scheduled.”  The entire ship’s company erupted into applause and cheering, and all of a sudden, the liberty brief seemed a lot more relevant.  Spirits were lifted and we all started packing and preparing to get off the ship.  Unfortunately, due to a 30-foot draft and significant tide fluctuation, we weren’t able to pull into port until about noontime.  Then, the port authority came through with several new identification requirements to disembark from the ship.  After the longest afternoon in history, crewmembers on leave (me) were allowed to go ashore at about 5pm.  I had to have an escort take me to the hotel (where Scott was waiting), so I grabbed several friends (who otherwise would have spent another 1-2 hours waiting for liberty to be called).  We took a taxi to the hotel and Scott and I were reunited!  It was fantastic. 

We are in port in Punta Renas, Costa Rica, which is also a cruise ship port.  There has been one cruise ship here since our arrival.  It is fairly touristy and the hotel we stayed in, the Double Tree, was very nice.  The food was delicious – I have become a big fan of ceviche, a very popular dish in Central and South America.  Scott and I went ziplining and mountain biking as part of the ship’s tour program, and then also took a private tour of Tortuga Island – a really fun day that included snorkeling and relaxing.  He was able to meet most of my friends from the ship, and he fit right in, as I knew he would!  I got to watch some videos of the kids that he had brought from home, and that part made me happy and sad both.  I cannot wait to see them in 1 month!

The 3 days of liberty unfortunately flew by and Sunday night, I reluctantly returned to the ship at about 10pm.  The next morning, I was manifested for the Costa Rican hospital tour.  It was SO difficult to go back to work knowing Scott was still in country and literally minutes down the road.  He was able to entertain himself, obviously, but I had a hard time focusing during the tour and was pretty grouchy that day.

The next day, Tuesday, I was the site leader at one of our 2 MEDCAP sites.  Astute readers may remember that I had been a site leader before, about halfway through our mission in El Salvador.  I had a great time that day and spent my time giving tours of a very well-organized site and putting out small fires.  This time, it was site set-up day, and I was responsible.  It was a really challenging day – a much different experience from my first day as site leader.  At 7:15 that morning, we walked into a large gymnasium where pallets of our medical equipment and supplies had been delivered the day before.  I had been given a diagram of the gym by the ACE team but was otherwise on my own.  So, in the span of 15-20 minutes, I had to determine the best locations and setup for the medical providers, dentists, optometrists, pharmacy, lab, physical therapists, and discharge planners.  In addition, with the help of 2 amazing ASLs (assistant site leaders), we set up our patient flow plan – from mass chaos outside the entrance of the site to organizing patients into 4  groups – optometry, dental, general medicine, and pediatrics, and getting them inside the gym with all their paperwork completed to see a provider.  I had never done this before so relied heavily on the ASLs.  Unfortunately, or fortunately, depending on your perspective, the Costa Rican government and ministry of health were very interested and involved in our setup plan.  As this is country #8 of our CP11 mission, we have a pretty good idea of what does and does not work for patient flow.  The Costa Rican representatives had some very specific ideas on site setup.  We tried to accommodate them, in the interest of building relationships and partnering with our host nation colleagues, but it quickly became clear that the plan they had advocated for was disastrous.  Hundreds of patients were milling around in the 100+ degree heat, going to see the wrong provider type, without any paperwork, and no one was happy.  It was difficult to change the setup once we had started, so we did what we could to make the best of it.  By the end of the day, we had a good flow going, and we managed to convince our Costa Rican counterparts that a few critical changes would vastly improve things.  They agreed, so once the patients had left, we made some significant modifications to our patient flow plan.  The next day, Wednesday, I was site leader again.  It was really rewarding to see the changes that we had implemented the day before result in such an improvement in patient flow.  It was a perfect demonstration in logistics and flexibility (ok, maybe not perfect, but pretty fricking good).  They always tell us, “It’s not about the numbers,” but to some extent it IS about the numbers.  A well-organized site means nothing if you can’t see a good number of patients.  On the first day, we ended up seeing just over 400 patients (after completing site setup by around 9am).  The second day, we saw almost 650.  Not the most we’ve ever seen, but a respectable number.  The CO of the ship visited the site yesterday, and I was actually proud to show him around.  He referred to our patient flow as a “silent drill team parade” – it was that smooth!  I give 100% credit to the ASLs, but it was still really rewarding to be a part of the process. 

In addition to the whole site setup and patient flow plan, there were the continuous small fires to be tended to.  Any unhappy patient, provider, or host nation representative gets fielded to the site leader.  In addition, there are the political introductions to be made and the hourly discussions with the ACE team and the ship med ops team about site operations.  My biggest challenge of the day came when one of the translators told a patient that (essentially) she could choose which doctor she wanted to see.  We had several Costa Ricans doctors working with us, but she only wanted to see an American doctor.  Very quickly, the other 45 patients waiting with her decided that they too only wanted to see the American doctors.   Since one of our mission objectives is to build relationships with our host nation providers, this didn’t go over well.  I ultimately had to tell the patients that they could see the next available provider or they could leave the site to return the following day (at which time they would also see the next available provider, regardless of nationality).  I emphasized that we were working side by side with our host nation providers, but the patients were NOT HAPPY about seeing one of their own doctors.  (Truthfully, I can understand where they were coming from, as most had been waiting for 8+ hours and had probably been promised by their local government that they would see an American doctor, but for many reasons, this just wasn’t a good idea.)  I stood my ground, as unpopular as that made me with the patients, and it took about 30 minutes of discussion (during which time no patients were seen, out of principle), but eventually all the patients ended up seeing providers in the correct order.  No one left the site, and it all worked out fine.  Surprisingly, this was the first time in any of our missions that this had come up.  The translator that had started the mini-riot was stationed in a different area for the rest of the day.

The next day, I once again served as the site leader.  It was a busy day, but much smoother - there were no international incidents and no injuries (our CO’s definition of a great day).  

En route to Costa Rica and the UNREP - July 24th and 26th, 2011

July 24, 2011

Adios El Salvador!  At this point, there is nothing standing between me and liberty in Costa Rica except for a 3 day ocean voyage.  Yippee!  Our liberty stop in Costa Rica has been long-awaited by everyone on the ship (just like Ecuador was earlier in the mission), and is even more so for me since Scott will be visiting!  

Since my last writing, I organized and attended another hospital tour, which went well, but the term “herding cats” came to mind several times.  I think I will restrict the number of participants in the future – it got a bit hectic.  After every tour we have managed to find a respectable restaurant for lunch.  This time, while I was asking the bus driver for recommendations, one of the senior officers said to me, “I think we can make it back to the ship for lunch.”  This was his first (and last, I’ve since decided) tour with us.  I just looked at him and said, “No, sir, I don’t think so.”  And then got an even more senior officer to agree with me. =) 

After that tour, I had another “worker bee” day at the MEDCAP site.  The heat index that day was “only” 109, but it was the hottest I remember feeling on our whole mission.  There were 6 providers in one classroom, and no breeze at all.  We were all sweating through our t-shirts and I drank over 3 liters of water.  It is not easy to muster up empathy for patients when you feel that miserably hot, until you remember that they have been waiting in those same conditions to see a provider, some of them for more than 12 hours.  That definitely put things in perspective.  Also, knowing it was our last day seeing patients before liberty helped quite a bit.  Not my most productive day at the site, but I was able to keep smiling until the end, so I consider it a success.

We are expected to get underway from El Salvador in the next hour or so.  I’m going to check on the preparations!

July 26, 2011 – The UNREP

Our big lament over the last 4 days was the fact that the ship’s communications system failed – or, in ship lingo, “comms went down.”  This happened abruptly on Friday and was apparently a failure of the “whiskey-8” (I have no idea what that is).  Once the site of failure was identified, the replacement piece was urgently shipped to meet us in Costa Rica, where we arrive in 2 more days.  (At least, that is the information we received originally – as it turns out, the replacement part arrived today, so comms is now back up – I’ll get to that later.)  The information technician was flown down to El Salvador, where he boarded the ship, ready to receive the missing part.  You can probably imagine that a complete loss of contact with the outside world creates some problems.  For the first 2 days of comms being down, we were still pierside in El Salvador, and some people were able to use 3G on their cell phones.  I was able to at least email home using this feature (on someone else’s Kindle) to tell Scott why I couldn’t call or send or receive emails from the ship.  However, once we left El Salvador, the 3G disappeared and so did every connection with the rest of the world.  The ship does have a limited number of satellite phones, which were available for 1-2 minute “morale calls,” basically enough time to tell our families we were safe and incommunicado.  After that, the only need for computer use was for intra-ship email, or use of the intra-net.  Since we finished our El Salvador mission on Saturday (the day after comms went down), there wasn’t a whole lot of intra-ship information to pass.  The people responsible for medical operations (Med Ops) were able to use the satellite phones to talk with the ACE (advance) team who are already in place in Costa Rica, but otherwise, not much got done.  I would never admit this to anyone except you, my loyal blog readers, but it was a teeny tiny bit liberating and relaxing not to have any outside communication.  Instead of everyone heading to the phones or computers after dinner, we all hung out and watched movies, played games, and talked.  As the days passed (4+ full days without comms altogether), the lack of communication got more and more frustrating, but there’s something to be said for complete lack of control over these things, and the fact that everyone (to include the Commodore and ship’s crew) was in the same boat (ha ha ha).  So how did the piece arrive early, you ask?

Well, today was my first (and probably last) Navy UNREP.  This stands for Underway Replenishment, and is actually composed of a COMREP (Communicating Replenishment? – not sure on this), and a VERTREP (Vertical Replenishment).  After much coordination, preparation, and briefing, as well as fancy maneuvering and velocity changing, the Comfort met up with the USNS Lewis and Clark (supply ship) at around 6am this morning.  I was sound asleep for this part, but basically, the two ships were connected by a fuel line (to take on fuel) and a zipline-looking apparatus.  After that, hundreds of pallets were transferred from the Lewis and Clark onto the Comfort via the zip-line (COMREP).  In addition, the helos that are stationed on the Comfort ran back and forth from ship to ship all day transferring additional pallets through the air (the VERTREP).  The very first item to come across the COMREP: the whiskey-8.  Within a couple of hours, the IT folks had it installed and outside emails came pouring in.  They kept the internet restricted to command and operational personnel, though, given the 4 days of backlogged work that needed to be accomplished.  However, by late last night, we were back to full-speed (i.e., slower than dial-up) internet ship-wide.  A huge morale booster, since Scott would be coming to visit me in Costa Rica in 2 short days, and we had no way of communicating!

In addition to the whiskey-8, the UNREP provided us with a fresh food supply, real ice cream (a fantastic treat which we already enjoyed last night), more paper towels (we were completely out), and a number of pharmacy and lab supplies that were badly needed.  Overall, there were over 600 pallets transferred over about 10 hours, so I’m sure there was other stuff delivered, but food, ice cream, and paper towels have been the most obvious replenishments so far.  I was able to watch the UNREP from the bridge (the control area for the ship) and talked with the ship’s Master (a civilian mariner) during the process.  It was wicked cool. =)

I mentioned that with no communications, people were sort of forced to spend time together.  These ended up being some of the best nights we’ve had on the ship.  It has been weeks since the sky has been clear enough to see stars at night, and the first 2 nights we were at sea (after leaving El Salvador), there was not a cloud in sight.  On top of that, there was no moon, and we were in the middle of the Pacific with not a single light around us – even the flight deck and upper weather deck were completely pitch black.  This made for some amazing stargazing.  I have never seen so many stars, and the Milky Way was unbelievably bright.  We saw 15-20 shooting stars over a few hours – and all around the flight deck you could hear people laughing and shouting when one crossed the sky.  It’s surprisingly easy to have deep conversations when looking at millions of stars and nothing else.  In an interesting coincidence, when comms came back up, a cloud cover set in and no stars were visible at all.  Maybe the communications failure was strategically planned…

July 21st, 2011 - Guatemala to El Sal

Guatemala came and went, and we are now in El Salvador.  Truthfully, Guatemala was fairly unremarkable.  My most distinct memory was the overpowering, suffocating heat.  The humidity was near 100%, and the average daily temperatures were in the low 100s.  The MEDCAP days were uncomfortable and long.  On the plus side, we were “nearly pierside,” which meant that although we still had to take a boat to get to land, the ride was 2-3 minutes, tops.  We probably could have rigged up some way to just walk from the ship to the pier, but skilled Navy personnel much smarter than me decided it wasn’t feasible, due to drafts, lines, ladders, walkways, and other terms I still don’t quite understand. 

On the plus side, the pier in Guatemala was a “cruise port” – meaning commercial cruise ships docked there and so it was slightly more interesting (and safer) than our other piers.  During our 10-day stop, we did not see a single cruise ship, but supposedly they do dock there.  What this meant for us was that we were allowed to spend time off the ship, at the pier, on 3 nights during the mission.  And on one of those nights, the command sponsored “beer on the pier” – during which time we were each issued 2 beers (I’m not kidding – the beer was provided by the Navy and we had to sign saying we received it).  Naturally, we still had a curfew (9pm), and alcohol accountability was extremely strict (had to show ID and have each beer marked off on a master list), but it was a morale booster nonetheless.  On the other nights, we were able to eat at the local restaurants and shop at the marketplace, but alcohol was strictly forbidden.  In fact, I personally know 3 people who lost all future liberty privileges due to ordering alcoholic drinks at the restaurant – they were caught by the ever-present shore patrol personnel.  The fact that 3 Navy officers (an O-4 and 2 O-6s) were formally reprimanded for drinking 2-3 drinks of alcohol absolutely astonishes me, but such is life on the ship.  Despite the regulations and strict policies regarding our time on the pier, it was a welcome change from the Groundhog Day routine we have become accustomed to.  I was able to sample some amazing local cuisine, to include tacos pollos, el carne, and ceviche camarones.  For those wondering, eating uncooked seafood in a third-world country is not the wisest idea.  The shrimp single-handedly knocked out a good 25% of the ship’s crew, myself included, for several days.  I am now a believer in the healing powers of Cipro and Imodium.  Traveling truly broadens the mind and loosens the bowels…  (And for the record, the ceviche was totally worth it.)

After Guatemala, we left for El Salvador (or “El Sal,” as we like to call it, although the locals dislike that term, apparently).  We managed to squeeze a 9-hour journey into 3 days.  Truly, we are probably 50-60 miles south of our last port, but the time needed to replenish our medical supplies and prepare for the next mission necessitates that the trip last at least 2.5 days.  This is nice downtime and allows everyone to prepare physically and mentally for the next mission stop.  During the voyage, we had the Comfort Open Mic night.  I have become friends with some very talented singers/ guitar players and joined them for the show – it was so fun to sing again, and the performance as well as the rehearsals once again provided a welcome change from the otherwise mundane daily routine.  Also during the transit from Guatemala, the DMS (Department of Medical Services – my directorate) hosted Cigar Night, where I learned that I am not meant to smoke cigars.  Maybe it’s an acquired taste – at least, that’s what I’m being told, in preparation for our next cigar night.

We arrived in El Salvador on the 14^th – a full week ago.  It has been a very busy week.  I mentioned that I am responsible for coordinating hospital tours in each country that we visit.  Usually this involves two tours – one of the local/ regional hospital and one of the military hospital, which is usually in the capital city.  There is an advance team that precedes our arrival by approximately 1 week in each country, and they usually provide me with a point of contact for the tours.  However, then it is a matter of arranging a tour date, finding someone to conduct the tour, locating translators, transportation, and force protection (security), deciding on participants from the ship, getting all the participants manifested, and then composing a report of the tour when it is all complete.  This is all manageable, but there are always unforeseen obstacles.  In El Salvador, on the day that we had arranged to tour the local hospital, there was some kind of political demonstration outside the facility and the tour was cancelled due to concerns for safety.  The demonstration lasted less than a day and the tour was rescheduled – twice.  This meant going through most of the above steps on 3 separate occasions.  Flexibility is one of the most important attributes on the ship, and I consider myself fairly flexible, but I was about ready to pull my hair out when I got the email notifying me of the third date change.  If all goes well, we will be touring the hospital tomorrow, so keep your fingers crossed.  Our military hospital tour (in the capital city of San Salvador) went off yesterday without a hitch, and we even managed to work in a nice lunch and some shopping, so these visits do have some benefits.

El Salvador has also provided me with my first opportunity to serve as one of the MEDCAP site leaders.  The responsibilities of a site leader include ensuring efficient patient flow, averting (or handling) disasters that may arise, providing tours for distinguished visitors, and in general just keeping the site running smoothly.  I was “voluntold” to lead the site at Polideportivo (say that three times fast) on our 3^rd or 4^th day here.  Thankfully, I was a worker bee at that site the day before (seeing 40-45 medicine patients that day – a very busy site), so I was able to get an idea of how the site would work.  I was a little nervous about being site leader – this is usually a job reserved for senior officers and there is quite a bit of pressure.  They always tell us, “it’s not about the numbers” – but every evening at the ops brief, they review the number of patients seen that day at the various sites.  If the number seems low for a given day, the person briefing usually makes an excuse or explanation to the Commodore of the ship on why that was the case.  So the numbers matter – despite what they say – and the number of patients seen at a site is generally a reflection on the site leader.  So, while I truly DO NOT CARE about the numbers, I knew I’d have to answer to someone at the end of the day, and I was a little nervous.  With that said, the day before (when I had seen 40+ patients), all the providers were angry at the site leader for pushing too hard.  So I didn’t want that problem either!

Let me say, being a site leader was fantastic!  I loved the behind-the-scenes planning that went on, dealing with minor catastrophes throughout the day, and in general keeping things running pretty smoothly.  I provided a tour to the embassy attaché and 14 local military professors (all “Distinguished Visitors”), who were very impressed with the care that was provided.  I gave 2 television interviews (via a translator) and met several local mayors.  (As an aside, by the third mayor of the day, when I was introduced in Spanish, I must not have looked sufficiently impressed, because then the person introducing us told me, in English, “No, this is the MAYOR” – at which point I tried to look appropriately deferential – but truthfully, there are a lot of mayors in the Sonsonate area, and it had been a long day.) 

My favorite part of the day came when I went to the front gate of the site – something that as a mere provider, there isn’t time or reason to do.  As site leader, I needed to check on patient flow and make sure the people working were doing ok.  At the gate, I got a reality check.  By the time the patients get to us as providers, they have passed several checkpoints and are well-organized, with wrist bands, scantron sheets, and baggies of water (for hydration) that have been provided to them by one of the NGOs (non-governmental organizations).  At the front gate, it is mass chaos.  As I walked up, I saw 5 or 6 El Salvadoran police officers, as well as several local and US military personnel.  They were all there for crowd control.  The gate was closed and separated us from the waiting patients on the other side.  The gate crossed a rather wide dirt road, and on the other side of the gate were hundreds of patients crowded together and pushing on the gate.  Right about when I walked up, we called for 10 additional pediatric patients.  The El Salvadoran guards opened the gate less than 12 inches and started pulling parents in with their children.  Before I knew it, there was a swarm of people shoving each other to get in and the other guards immediately stepped in for backup.  They over-pushed the crowd and closed the gate – almost catching a patient’s hand in the process.  I wanted to cry.  I had no idea how desperate these people were to see the American doctors.  When I talked to our gate guard (from the ship), he told me it was like this in every country, every time.  Most of the patients start lining up at 1am for the gates to open at 8am.  Hearing this, and seeing the desperation and hope in the patients’ eyes at the gate, made it infinitely easier to find a smile for these patients late in the day, when we had already seen dozens of patients and the end was nowhere in sight.  I wish I had done the gate visit sooner in the mission.

Anyway, at the end of my site leader day, morale was still pretty high, and we saw a respectable number of patients.  The biggest compliment came at the end of the day, when several of the medical personnel from the site came up to me and told me what a fantastic MEDCAP it had been.  This was despite working almost 45 minutes later than the day before (the day that everyone was grumbling about).  I felt bad, but we did make it back to the ship in time for dinner, and no one seemed upset, so overall a successful first day as site leader!  I have 2 more site leader days scheduled in Costa Rica, our next stop.