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).