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…

May 18th, 2011

It’s been a while since I had

1) time to sit down and write, and

2) something interesting to write about. 

I’m not going to guarantee anything interesting in today’s post, but I do have some time…

We are now in Ecuador, our third of nine countries on this trip.  We arrived into port on Saturday, May 14^th, and are actually docked at the pier in Manta.  This means no waiting for hospitality boats to take us to the shore.  Instead, we wait for hospitality buses to take us to the medical sites.  Manta is a fairly large town, and is quite industrialized when compared to our previous clinic sites.  At the end of this mission we will have our first of two liberty stops here, and there are plenty of hotels, restaurants, and bars within a short taxi ride of the pier.  This is a topic of much conversation and excitement, let me tell you.

On our first day here, I was on shore at the surgical screening site, which was a local free clinic.  It was a Saturday, so the clinic would have been closed, but opened for our mission.  This was the first time we’ve had an actual medical facility for our medical mission – so we had sinks, exam tables, chairs, desks, and electricity in each exam room.  The medicine consultant (me) also happened to have one of the two exam rooms with air conditioning – and it quickly became the “I-have-a-quick-question-but-I’m-going-to-drag-it-out-and-actually-it’s-not-really-a-question-I-just-came-to-cool-off” room.  I re-learned how to play poker and looked at a few EKGs, but I felt superfluous. 

On Sunday, I was put to work at one of our MEDCAPS sites, in Rocafuerta, a 50-minute bus ride from the pier.  On that bus ride, I fell in love with Ecuador.  While the pier and the surgical site are located in downtown Manta, Rocafuerta is in the countryside and the route to get there is really scenic.  The ceibo tree is (apparently) native to Ecuador and is beautiful – I have pictures but you should google it to see for yourself.  During the bus ride that day, I put on my headphones, listened to an old Kidd Kraddick in the Morning podcast, and drank my Starbucks frappuccino on ice while I enjoyed the scenery.  As far as this mission goes, it was about as perfect a morning as you could ask for. 

When we arrived at the MEDCAPS (medical civil action program) site, I was again pleasantly surprised.  The site was a local school (again closed, as it was Sunday), and it was located in a beautiful town square, with a gorgeous chapel, several restaurants, and a few stores.  The school was much nicer than the one I described in Peru – the classrooms were still sparse but the architecture helped make up for it.  The floors were tiled with bright-colored geometric shapes, the walls were a bright yellow (but not obnoxious yellow, more of a marigold color), and the classrooms were all open-air – no windows.  Turns out they get 0.2cm of rain per month here, so keeping dry is not an issue.  Windows would have been nice, though, for the mosquitoes, which kept taunting us by landing and sticking around on our permethrin-pretreated uniforms.  Our preventive medicine guy keeps telling us they are dying a slow, painful death when they do that, but still.  Come on.

The rest of my day at the Rocafuerta site was great.  The patients were all wonderful, the translators did a fantastic job, and the flow was smooth.  We were permitted to leave the school for lunch, which never happens.  As I left with another internist, we joked that we felt like we were in Shawshank Redemption – the freedom was that sweet.  Not wanting to push the limit, we ate at the first restaurant we came to.  We had encebollado, supposedly the most popular dish on the Ecuadoran coast, which is basically a soup broth with large chunks of fish, onions, cilantro, and lime.  So far, 3 days out and I’m ok…  We each had a bowl of soup, some plantain chips, and a bottled soda (I had Inca Cola – a bright yellow Peruvian soda that smells like bubble gum and tastes like cream soda).  Our total, for the 2 of us, was $2.80.  When we left a tip, the owner chased us into the street to tell us we had accidentally left money.  I’m really hoping the rest of the places in Ecuador are similar – liberty will be a lot of fun.

I was so enamored with Ecuador after my day at Rocafuerta.  I should have stopped there (not that I had a choice).  The next day, Monday, I went to a different MEDCAPS site, this time at Montecristi.  Montecristi is apparently famous for their Panama hats.  It is another scenic town, located up a tremendous hill.  The school that we took over for the mission was not surrounded by civilization – it was surrounded by hills.  There was no breeze.  To get the site, patients had to climb (walk) up steep roads for miles – usually carrying their kids (and sometimes their parents) or not feeling well.  Many of them arrived at 4am or earlier, and the clinic didn’t open until 8am or so.  Once we opened the doors, we had a set number of patients we could see, and there were many more than that waiting in line already.  You can imagine that the tension in the line outside the site was high, and there have been riots every day that site has been open. 

Some days things just seem to go well, and other days not so well.  This was one of those “not so well” days.  My translator, while nice, was not great at following instructions or directing the patient interview.  The patients – hot, sweaty, and sick – were anxious to talk about their problems and didn’t want to leave.  As opposed to other sites, where the complaints were usually straightforward and easy to fix (UTI? Here are your antibiotics, have a nice day), it seemed like every patient at Montecristi had fatigue, weight loss, abdominal pain, and trouble breathing.  I was definitely suffering from “compassion fatigue” – which, as you can probably figure out, means I was losing my ability to care.

That day, I ate lunch on the second floor of the school and looked out at the valleys below us, as well as the hundreds of patients in the school courtyard still waiting to be seen, and tried to muster up some compassion to get me through the afternoon – after that, I had 2 scheduled days off, so that helped.  One of my first patients after lunch was one of the saddest cases I’ve seen in a while.  I’m pretty sure he had Huntington’s disease, a progressive, invariably fatal neurological disorder that can hit anytime in life with symptoms of involuntary limb movements and tremors progressing to spasticity and dementia.  This patient was 45, and came in with his wife.  He could barely walk and leaned on her with most of his weight just to make it into the room.  His entire right arm moved involuntarily around his head and body, almost like he was doing stretching exercises.  His left arm had a substantial resting tremor.  His speech was extremely limited, although he was able to talk in 2-3 word sentences.  According to his wife, this had all started acutely 2 months ago.  By her report, he had undergone an MRI which was “normal.”  Unfortunately, even in the US, there is no treatment for Huntington’s, but I was able to get him a wheelchair and some physical therapy education.  He was ecstatic, and so thankful.  He was able to operate the wheelchair and I think we really made a difference in his quality of life.  The sad part is that it will inevitably progress and he will likely die from this disease – as will all of his children, at some point, as it is a disease that is inherited (in an autosomal dominant fashion, for all you medical readers).  I didn’t tell him that.  I’m not sure if that was the right decision.

Anyway, after seeing that patient, my ability to care was rejuvenated.  The rest of the day went better and I have recovered somewhat over the last 2 days back on the ship.  As it turns out, I won’t be going out again until Saturday, so I’ll have more time to recoup.

Not to totally switch topics, but I realized that I never wrote about the week of miracles on the ship.  It was Easter week, interestingly.  Here’s the scenario.  Prior to that time, we had been instructed that PT gear was only to be worn during actual PT, and going to and from the gym.  And while Navy personnel could wear civilian PT gear, our Air Force commander had decreed that only the Air Force PT uniform was authorized.  We had all bitterly complained (given the ship’s laundry turnaround time and the overall unattractiveness of the AF PT uniform), to no avail.  Then, for some unknown reason, on Easter Sunday, we received an email from our commander authorizing civilian PT gear for PT – we were elated!  It was an Easter miracle.  The next day, the ship’s commander (known as the Commodore) set the policy that PT gear could be worn outside on the flight deck, for reading or just hanging out.  So, instead of being in full ABUs outside, we could wear normal-looking shorts and t-shirts.  Miracle #2.  THEN, later in the week, I was shopping in the ship “store” (which is 2 aisles wide and 20 feet long), when I spotted, out of the corner of my eye, a cooler/ refrigerator.  Inside were several dozen bottles of Starbucks frappuccinos – coffee, mocha, and vanilla flavor.  I think I’ve lamented enough about the coffee here for you to understand my excitement at this discovery.  For those who don’t know, I’m not even a huge Starbucks fan.  However, it so vastly exceeds the alternative coffee option that I immediately bought 8 bottles.  From that point on, I was back to my normal, functional self in the morning.  Miracle #3.  These may sound like small events, but trust me.  They are evidence of a higher power. =)

Una cerveza por favor...

5 May 2011

Happy Cinco de Mayo!  In honor of the occasion, we had Mexican food for lunch.  Of course, every Thursday is Mexican, so that may have just been a coincidence.  They don’t actually celebrate Cinco de Mayo in Peru, you may be surprised to learn.

Yes, that’s right, we are in Peru.  We arrived on Saturday morning and were welcomed by the absolute worst stench I have ever smelled.  We are anchored not at one of the lovely coastal beach towns, but outside the Peruvian Navy Base located in Piata, Peru.  The Navy base, our boat landing zone (BLZ), is home to a large fishing port and squid processing plant.  Fish processing is an odiferous process.  Truly, if the wind is blowing in the wrong direction, it is actually painful to be outside on the ship (which is an 8-10 minute boat ride from the shore).  And the BLZ (where the hospitality boat drops us off to wait for our buses) smells awful 100% of the time.

On Sunday, I was part of the team to set up one of our clinic sites.  The site that was chosen by the ACE team (not sure what it stands for – but it’s the advanced planning team) is a local school in a poor, small town called La Huaca, in the province of Piura, Paita.  La Huaca (pronounced by all of us as La HWAH-CAH! with lots of emphasis on the HWAH) is a desert town with a small river running by it.  Because of that river, they have several rice paddies and can grow sugar cane.  That is their main export. 

The school actually closed for the 12 days that we are here so that we can run the clinic.  So as I mentioned, Sunday was set-up day.  The school is situated in a large, sandy courtyard with several trees in the middle, so there is a good amount of shade.  There is also a nice breeze, so it hasn’t been too hot.  Before we started set-up, we got a quick tour.  The classrooms contained anywhere from 30-40 student desk-chairs (you remember, those, right? from elementary school) and one only slightly larger desk for the teacher.  There were chalkboards on 1-2 walls and basically nothing else in the classrooms – no decorations, pictures, drawings, letters, numbers, or anything.  A couple of the rooms had a crucifix on the teacher’s desk.  Some of the windows had makeshift curtains (usually sheets) to keep some of the glaring sun out. 

I wanted to cry when I saw those classrooms.  I remember when Meghan (my sister) started teaching in San Antonio, and Mom, Dad, and I went to her classroom a few days before school started to decorate.  We plastered the walls and bulletin boards with colorful paper and cutouts to make an inviting, exciting, interesting environment.  We sorted through dozens of boxes of educational toys, games, and books so that the kids would WANT to come to school.  The only decoration in the classrooms here was on the kids’ desk chairs – some of them had their names written on a piece of paper, which the kids had (I assume) decorated, and then the paper was taped to the chair.  Part of our set-up job was to take all the desk-chair sets out of the classrooms to use as seats for the waiting patients in the courtyard.  I must have been really emotional that day, because as we were all hauling desk-chairs out of the classrooms, all I could think about was how heartbroken the kids were going to be when they came back to school in a week and a half to find their beloved decorated chair missing.  There’s no way we’ll get them all back into the correct classroom.  I just really couldn’t get past that.  Still haven’t.

I perked up a little bit when I saw a separate building, next to the principal’s office, with the sign “Biblioteca.”  Sadly, there were very few books, and still no decorations, but a couple of teaching aids, like an aquarium (empty), a human skeleton (missing several bones), some white boards (cracked in several places), and some more desks and chairs.  I thought about all the stuff we have sitting in our attic at home, that could decorate the school and fill the library.  I don’t know why the stark minimalist décor affected me so much.

Anyway, after the Biblioteca, we were shown the restrooms.  There is no running water in the school.  To flush the toilet, you have to take a bucket (already mostly full with filthy water) and pour some of it into the toilet bowl, then pull the lever to empty the bowl.  Turns out, the school (and all the homes in the surrounding villages of La Huaca) gets only 2 hours of running water per week.  This made our Jamaica clinic (at the National Sports Arena) look like the Ritz.  This was real-deal poverty.  This sounds selfish, but I was ecstatic to see that someone had procured port-a-potties to be used during the mission.  (No, I never thought I’d use ecstatic and port-a-potty in the same sentence, either.)

After moving all the desk-chairs out of the classroom and into the waiting area, there wasn’t much setup to do.  We took the teacher’s desks (about 2x2 feet) and covered them with Chux pads, to make them look more doctor-ly.  We set up our privacy screens (that we transported from the ship) so that 2 or 3 providers could work in the same room.  We worked for a long time to get a 1000-lb generator across the sandy courtyard so the dentists could run their equipment (our first attempt at using a forklift ended up in it getting stuck in the sand, and I have a great photo of a bunch of us playing tug-o-war with the forklift/ generator combo).  Partway through the day, we got a visit from a local village band (consisting of about 8 or 9 members).  They paraded around the school and stopped out front.  We all took a break to watch the performance.  There was a trombone, a couple of horns of some kind, a few drums, some cymbals, and a woman with a 2-liter soda bottle with a rock inside.  Several of the women and children from the village right next to the school came outside to dance with us.  All of the kids wanted us to take their pictures with them, and then look at the camera screen to see themselves.  They were too too precious.

After the band, we finished what little setup there was, and boarded our buses to get back to the BLZ (boat landing zone, remember?).  The bus ride from La Huaca to the BLZ is only 17 miles, but takes about 60 minutes.  Most of us sleep the whole way.  At the BLZ, we usually wait 20-60 minutes for a hospitality boat to bring us back to the ship (each hospitality boat holds 35 people, and it’s a 20+ minute ride round-trip, and sometimes they only have one hospitality boat running).  This wouldn’t be so bad, except for the smell.  It’s not the kind of smell that you get used to.  It’s indescribable.    At the end of the first day, I just couldn’t wait to get in the shower.  Thankfully, they have nighttime laundry on the ship for “mission personnel.”  I never used this service in Jamaica, but definitely couldn’t wait to get my uniform into the laundry after my days in Peru.

Monday and Tuesday I saw patients at the clinic in La Huaca.  When we got off the bus on Monday (the first day the clinic was open), there was already a line of probably about 150-200 people.  They all started clapping when we got off the buses and kept clapping as we walked past them and into the clinic.  The kids were giving us high-fives and I’ll admit it, I had tears in my eyes.  What a nice welcome.  In Jamaica, there were riots outside the gates with people fighting each other to get inside.  I immediately decided that I love the Peruvian people.

Ok, more later.  Today’s my day “off” and there’s lots to do.  Specifically take a nap.

We were assigned translators to work with us in clinic.  My translator was a 24-year old Peruvian – he was a mechanical engineer who wanted to improve his English.  He was sweet sweet, but his English needed a lot of work.  We worked together though, and managed to get by.  The second day I worked with him, he came in and told me that he had looked up some terms on the internet that we couldn’t translate the day before.  I was impressed with his initiative and his desire to learn.  And he quickly learned my teaching points and recommendations for the very common problems we encountered.  About 80% of the patients we saw had “kidney pain” – which meant anything from back pain to stomach pain to hip pain to trouble urinating to actual kidney pain.  The other 20% of patients had “gastritis” – which meant heart burn, gallstones, chest pain, or constipation.  There were a couple of patients with other issues, who were much more complicated.  Unfortunately, our lab testing was extremely limited (we could check a UA or an iSTAT) and we had no radiology capabilities at this site.  So I handed out a lot of motrin, tylenol, zantac, and antibiotics.  The patients were all so grateful, because they had been suffering with pain for decades but couldn’t afford to buy pain medication at the pharmacy.  It’s amazing how simple interventions (mostly over-the-counter medications) can make people so happy.

Mission Jamaica: Complete

April 21^st, 2011

Jamaica MEDCAPS (Medical Civil Action Program) complete!

April 22^nd, 2011

Ok, didn’t have much time to write yesterday.  That’s because we had our last day of clinic at the National Sports Arena, and we were able to borrow some free WiFi from the office building next door.  WiFi = Skype!  So I got to see the kids and Scott for about 20 minutes – the connection wasn’t great but it was better than nothing!  I’m told we will probably get WiFi again in Haiti, but until then, I’m planning on the archaic internet connection on the ship.

There’s an email going around the crew here called “My Donut of Freedom.”  It’s a pie chart (donut, get it?) that someone created in Excel, charting the percentage of deployment completed to date (it also has a second-by-second countdown).  As of today, we are 12% done!!!  It sounds awful, but actually 12% seems pretty good to me.

Getting back home is definitely a prime topic of conversation around the ship.  Another hot topic: liberty.  I can definitely see why the sailors on liberty port may go a little crazy.  You would think we had all been away from civilization for months, the way we are planning our 4 days of freedom (which, by the way, is still over a month away).  For many of us, one of the most anticipated parts will be the ability to wear civilian clothes – for me, the prospect of just wearing anything other than combat boots is making me happy.

Today is our last day in Jamaica.  For those who have asked, we are anchored in Kingston, the capitol of Jamaica.  There is a very good reason why cruise ships and tourist airlines don’t fly into Kingston.  It is poverty-ridden and dirty.  There are no Caribbean blue beaches nearby, just brown-black water with lots of floating trash.  To get ashore, we take a small “hospitality boat” that holds 35 people.  It’s about a 2-3 minute ride to the BLZ – the boat landing zone.  The BLZ is in downtown Kingston, with office buildings, banks, and street vendors close by.  You can see the Blue Ridge Mountains from the ship.  I’d love to come back and see the rest of the island, as a tourist.  Who’s with me?

April 24^th, 2011

Happy Easter!  We are back at sea, en route to Peru.  We left Jamaica on Friday morning and have had a quiet “holiday” weekend, with a relaxed schedule (got to sleep in until 6:45 yesterday morning, woo hoo!).  Today, I attended the Easter Sunrise service on the flight deck, somewhere in the Caribbean, southwest of Jamaica and northwest of Peru.  Pretty cool.

When we first got underway in Portsmouth, I wasn’t sure how I would handle the rocking of the ship.  It was definitely an adjustment, made much harder by the fact that I had a nasty cold and was very, very congested.  I spent several days with a feeling of “disequilibrium” – even after we anchored in Jamaica I had the disconcerting feeling of falling backwards, and found myself leaning forward in my chair, and even in bed.  My abs got a workout those few days.  Once I stepped foot on land, my disequilibrium went away (coincidentally, so did my cold).  So I was nervous to restart the journey – especially when the ship’s master (the civilian mariner in charge of operating the ship) sent an email telling us about the Pacific swells that were to come.  I will say, now that we have been back underway for 2 full days, that I LOVE the rocking of the ship.  It is so soothing and comforting somehow.  It’s funny to walk through the halls and see people leaning to one side or the other without thinking.  We all look like we’re failing a mass sobriety test.  And like I’ve mentioned before, there is nothing like being on a treadmill while at sea – it’s really a cool feeling though.

The bad part about moving again, is what my Navy colleagues refer to as “hull chatter.”  Hull chatter describes the seemingly endless variety of random noises that the ship produces as it cuts through the water, at all hours of the day and night.  I have gotten out of my bed on more than one occasion to find out who in the hell is banging on our lockers with a hammer in the middle of the night.  Well, obviously, no one is banging on our lockers with a hammer in the middle of the night – somehow this noise represents normal ship functioning.  My roommate Carrie (another Air Force internist) is convinced there is an elf who scratches on the wall above her head continuously.  And there are apparently crewmembers upstairs from us who repeatedly throw their bowling balls on the floor.  Of course, some of the noises ARE explainable – when the ship rocks side to side, it opens and closes doors and lockers, so there’s a “creak-SLAM-creak-SLAM” rhythm to enjoy too.  Hull chatter. 

Tomorrow we’re back to our regular at-sea routine.  This means a 6:00am wake-up call (“Reveille, reveille!  <<crackle crackle something>> all hands on deck <<something something>> - I’ll let you know if I ever figure out what they’re saying).  Of course, for those of you who know me well, you know that the wake-up call is simply alarm #1, and that there are plenty of snoozes to come.  I will finally crawl out of bed around 6:30, get dressed in ABUs, and head to the mess deck for breakfast.  Breakfast is the best meal of the day, and would get 5 stars if they only had decent coffee.  After breakfast, we muster in our duty stations at 7:15 – my duty station is the Sick Bay, although I don’t usually work there.  We take roll call, hear the POD (Plan of the Day), and get specific instructions from our specialty leaders.  I think I’ve mentioned there are 6 internists here, and we have a really good group.  We each take MOOD (Medical Officer of the Day) call one day out of six, and there’s otherwise a lot of downtime when we’re in transit (when we get in port, we are usually doing shorework when we’re not the MOOD).  As an aside, there’s also a POOD (Pediatric Officer of the Day) and a DOOD (Dental Officer of the Day) – I think we got off lucky with the MOOD title.  Tomorrow we are having an M&m conference – for the non-medical folks, this stands for morbidity and mortality, and is an opportunity to share possible adverse outcomes and lessons learned.  We will be doing this once at the end of each mission site.  Thankfully, there are no “big M’s” (mortalities) to present, and it will primarily focus on frustrations and possible areas of improvement for future missions.

After the M&m conference, my day is free.  The funny thing is, most of my at-sea days start off completely free, and usually by 8:00 or so, are 100% booked.  People are pretty good about taking initiative to schedule various informal teaching sessions, formal training classes, group workouts, Bible studies, movie matinees, and administrative meetings.  Throw in time for email and phone calls, as well as lunch, dinner, and a nightly Ops Brief, and the day fills up fast.  Every night there is an evening prayer over the “1MC” (ship’s audio system), and then at 10pm, it’s “Lights Out.”  It’s only a little bit like being in prison, I promise.

We also have a great MWR (Morale, Recreation, and Welfare) department on the ship – the “fun boss,” as she’s called, is one of my other roommates.  They hosted an ice cream social a few nights ago (with lots of toppings – very well received) and have arranged for a Bingo night tonight.  On Tuesday, we’ll cross through the Panama Canal, and will have our first “steel beach picnic” – a picnic on the flight deck, so we can enjoy the view passing through the Canal.  Sometime this week, we will also cross the equator.  Some of you may have heard of the Crossing the Line ceremony – we are apparently doing this on the way back up (since there’s already quite a bit going on this week).  I am a little nervous about that but I think it will be fun – and then I will no longer be a pollywog, but a mighty shellback!  I’ll let you know how it goes…

More Jamaica...

April 17, 2011

We are halfway done with the first mission stop in Jamaica.  We got here on Wednesday morning and I spent the last 2 days at the Northside Arena clinic in Kingston.  What an experience.

When we arrived into port, I was so excited to get off the ship (after 5 long days at sea with nothing to do).  This excitement was tempered somewhat when I discovered I’d have to be ready to board a “hospitality boat” at 5:20 am.  This meant a 4-something o'clock alarm in order to get dressed, eat breakfast, pick up my MRE (meal “ready-to-eat” – as unappetizing as it sounds), and muster up.  There’s a lot of mustering in the Navy.  I forced down some coffee (suffice it to say, I really miss my Keurig), knowing it would be a long day, and was ready to go by the appointed time.  Turns out the Navy is just like the Air Force in its HUAW mentality – that’s hurry-up-and-wait.  We finally left on our hospitality boat at 6:15 or so.  As I mentioned previously, the Comfort is not docked in Kingston, but actually anchored several hundred yards offshore, so it was a quick ride.  Once we arrived on land, we boarded buses which took us to one of 2 clinic sites.  Like many places in the Caribbean, driving in Jamaica is terrifying – narrow roads, fast cars, opposite-side-of-the-street driving.  On top of that, we had a police escort with sirens and lights, and didn’t stop at a single stop sign or traffic light.  Not sure if this was for safety or celebrity status – I’m choosing to think the latter. 

After being driven through countless poverty-ridden neighborhoods, we arrived at the clinic site a little after 7am, with maybe a hundred patients already waiting in line.  My clinic site was actually not a clinic at all, but the city’s sports arena – a large indoor building with lights, some air-conditioning, and fixed plumbing – all luxuries that we were told not to expect.  Of course, the tradeoff was that there were no actual medical facilities, so everything we needed we had to bring ourselves.  There were several privacy screens, that we set up between long tables, kind of like this:

Hmm.  It took me a really long time to make that little drawing, and it doesn't appear to have copied into blogger.  Damn.  Actually, looking at it now, I’m pretty sure you would have had no idea what it was supposed to be anyway.  I’ll post pictures if I can.  Basically, there were 5 rectangles next to each other at the top of the drawing, and 5 rectangles next to each other at the bottom, with little lines in between.  There were 3 other rectangles on the far right of the drawing.  Each rectangle on the left 2/3 of the picture represents a table.  The top row was for adults, and the bottom row was pediatrics.  The three rectangles to the left were our Physical Therapy/ Back pain station, our mobile lab, and our pharmacy staff.  I put an X on my table, which you can't see.  That clarified things, right?  There were 2 providers at each table, and we each saw patients on our side of the table.  There was one private exam area set up outside this picture, under a staircase, with a privacy screen surrounding, but detailed physical exams were the exception, not the norm.

The only equipment we had at our table was a blood pressure cuff, an ear/eye scope, a stethoscope, and prescription forms.  We also had Purell at our table and a hand washing station close by.  It didn’t take long to familiarize ourselves with the “clinic,” and we started seeing patients shortly after we arrived.  The next 8-9 hours are kind of a blur.  Prior to seeing the medical provider (physician, nurse practitioner, or physician’s assistant), the patients were screened outside to determine their chief complaint.  They were given a wrist band with one of 4 categories – medical, dental, optometry, or pediatrics.  The hard-and-fast rule was ONE CATEGORY PER PATIENT PER DAY.  This was very difficult to explain and enforce.  I saw, obviously, patients who requested adult medical care.  We had a limited number of medications we could dispense.  We could also check a very small number of labs – Hemoglobin (only), iStat, fingerstick glucose, urine dipstick, and pregnancy tests, along with tests for malaria and HIV.  Labs in general were discouraged.  The first day I was there, we had no radiology capabilities, but the second day, we had plain films and ultrasound.  Radiology studies were generally discouraged too.  At first I didn’t really understand why, but after seeing a few patients, it quickly became clear.  There was really no way to follow these patients up.  I’ll get to that more later.

Patients came in for a variety of reasons – acute illness, chronic medical problems, second opinions, free medications, “to meet an American doctor,” routine check-up, and a variety of other complaints.  As it turns out, Jamaica actually has a decent health care system – the best of all the countries we’ll be visiting, apparently.  Health care is free to the public, but because of this, the wait list for most specialists or radiology studies is 1-2 years.  Patients who don’t want to (or can’t) wait that long have the option of going to a private clinic, and paying out-of-pocket.  One patient I saw came to me with the diagnosis of “cervical polyps,” and was scheduled for polypectomy in a few days at the local private hospital.  She was wondering if it could be done on the Comfort instead.  When she showed me her paperwork, I understood why: the operation, a relatively minor procedure performed in a same-day surgery clinic, was going to cost her nearly $20,000 Jamaican.  I contacted the ship to see if one of our gynecologists could perform the procedure, but the surgery schedule was already completely full.  Very frustrating to have to tell her that.

Many of the patients I saw came in with relatively minor complaints that were easily fixed with a couple of medications (that we were giving out for free): allergies (Claritin), constipation (Dulcolax), headache (Tylenol), or UTI (Bactrim).  Unfortunately, a lot of patients came in with more complicated problems – abdominal pain, chest pain, cough, shortness of breath, or back pain.  In the US, some of these problems wouldn’t really be considered “complicated,” but would definitely warrant further investigation – either with labs, EKGs, or X-rays or CT scans.  None of that was really available – and even if it was, scheduling follow-up for the results was next to impossible.  We were instructed before we went ashore to try to abandon the practice of “evidence-based medicine” (a concept taught to us since medical school), and instead to practice “empiricism medicine.”  Fever and a cough should be treated as pneumonia – no need to get a chest X-ray.  This was a hard concept to adopt – until we realized there was really no choice.  For a few patients, where I simply couldn’t treat anything without further evaluation, we had local discharge coordinators, who would assist with placing referrals for necessary tests.  However, for these patients, the same wait list or out-of-pocket expense applied, leaving me doubtful that the problem would be managed in a reasonable amount of time, if at all.  I was frustrated that we couldn’t do some of this evaluation on the ship – but then I realized that even if a CT or lab test revealed the diagnosis, the patient would not be able to get necessary follow-up care.  Even for the patients that we could treat, for example, Claritin for allergies, the prescriptions we gave will only last a month at the longest – so our help is only temporary.

We were also told before we went ashore that the “street value” for some of our free medications was fairly high – and that some of the patients would probably not take the medications they were given, but would sell them instead.  For this reason, we were advised to try to limit the prescriptions we gave to 2 per person.  I don’t know about street value, but I definitely had a lot of patients requesting certain medications by name, although they had never taken them before.  The other problem I ran into was that patients would see their friends receiving other prescriptions and would come back requesting those too – they weren’t supposed to be able to come back in, but somehow many of them did.  At first, I tried to help out and give them what they asked for, but eventually I felt like I was being taken advantage of – and for every patient who came back and asked for something else, that was one new patient that had to wait longer or possibly not be seen.  So by the end of the second day, I got good at telling patients, in an apologetic-but-firm way, that they had already received treatment and that they would have to wait in line again if they had other problems they needed addressed.

That was my other problem.  At home, in my oncology clinic, my standard practice is to ask, at the end of every visit, “Anything else?” and to keep asking that until the patient says, “Nope, that’s it.”  Many of my physician friends groan when they hear this, as it is a sure-fire way to extend the visit and run late in clinic, but I’ve found, as the sole oncologist, that it actually serves me well.  If I don’t do this, patients will remember something they forgot to tell me the next day, and will call the clinic to leave me a message.  Or, they’ll come in for chemo (in the middle of another busy clinic day for me), and stop me in the hall (“I forgot to ask you the other day…”).  So I like to try to take care of everything in the scheduled clinic visit.  In Jamaica, asking, “Anything else?” is a HUGE MISTAKE!  There is ALWAYS something else!!  And while we are trying to provide good, personalized care to every patient, there are literally hundreds more patients waiting to be seen.  We are trying to see 40+ patients per day, per provider – that translates to 10-12 minutes per patient.  I quickly realized that “Anything else?” should not be part of my repertoire, but old habits die hard.  I made that mistake several times, to the amusement of my partner provider across the table.

I could write about my patient encounters all day, but this has already been a pretty long post.  Thankfully, I have the next 2 days off, so I’ll continue to regale/ bore you with stories, I promise.

Here's my first attempt at uploading a picture - but I only have 20 minutes before church, so not sure if it will work.  No, I'm not kidding or exaggerating.  Ok, it didn't work.  It was going to be a kind of boring picture anyway, so I'll just show you when I get home. =)