Sunday, February 26, 2012

Yo, Ho, Ho and a Good Night's Sleep!

Our adventure has taken a bit of a turn now that I've found a new job on the "Eye Team".  As you recall late last week in a fit of honesty the team that does screening admitted that since they aren't travelling into the bush to find patients there wasn't a lot for me to do in regard to evaluating patients for future surgeries since most of that work had been done at the huge screening done on the first of February.  Not sure what the rest of the team is doing but I was asked to help out the Eye Team. 



In addition to the hospital - which is primarily a place for patients pre- and post operations - there are other teams doing dental work, some palliative (comfort) care for patients we find that we can do nothing for but give comfort and the eye team.  Much of this work is done off the ship so until last week I had little knowledge about what they did so this past week was another in the "fire hose" learning variety for me. 


Part of the reason they felt they had a new found dire need was one of the extremely competent optometry techs from Dartmouth was leaving on Monday night to go home.  She had been here for several weeks and has a ton of experience at home in patient evaluation both pre and post op.  Apparently the rest of the team was very new in their jobs, didn't do this sort of work at home and didn't have a huge amount of patient care experience either.  So - although I know very little about eye surgery it was felt my patient care experience would be a big help. 


Eye surgery is a huge, huge need here in Africa.  I never knew that there are 45 Million blind people in the world and 90% of these people are in developing nations like here in Togo!  The World Health Organization has a program called Vision 20/20 wherein their goal is to prevent or eradicate all preventable causes of blindness by the year 2020.  This is an enormous goal since at the current projected rates, if nothing is done the number of blind people in the world will actually double to nearly 90 million by then.  I've spent most of my free time this week reading up on these diseases and how to diagnose them.  If you're interested in learning more about the Vision 20/20 initiative here is their link:  http://vision2020.org/main.cfm


So - on to the eye team week.  Everyday the eye surgeons - ophthalmologists - do surgery on the ship.  For the most part they do cataract surgeries and pterygium removal.  This is a sort of fleshy growth from the white part of the eye that can grow over the iris and eventually cause blindness.  They also sometimes do strabismus surgery on little kids that have early evidence of lazy eye.  In order to keep the surgeons operating our team evaluates as many patients as possible for operable eye cases and sees the patients both before and after surgery and refers the patients that need extra evaluation to the surgeons that operated on them.  This is very high volume work in that they do 40 or more surgeries a day and they are all done as out-patients.  The day workers lead these poor, blind folks on and off the ship conga line style up and down the gangway.  It is quite a sight to see.  I'll have to see if I can get a picture of it one of these days. 


Since the surgeons operate everyday we see all the patients the following day to take off their eye patches, evaluate their vision and determine whether they have any post surgical problems.  You can imagine the sight of 40 or more patients sitting outside under an awning with their eye patches on everyday.  So, I started telling Peter I was off to Pirate clinic, argggg!


In addition to seeing the post op patients we also go off to two large churches in Lome, Togo every week to evaluate people who would like us to help them with whatever eye problems they have.  This is somewhat similar to the big screening we had for all the surgical specialties but on a slightly smaller scale.  One of the churches had over 1000 people show up!  Fortunately for me this past week neither of our screening days was that well attended.  We have at least 10 of the local people that are fluent in multiple languages there to help us and actually perform a lot of the testing the patients go thru prior to seeing the optometrist and me.  The optometrist we currently have working with us is very knowledgeable and has taught me alot.  Unfortunately she is going home to Scotland next Friday and then we'll have a local man helping us for several weeks until the next volunteer comes.  Hopefully by then I'll be able to function a bit more independently. 


The patients go thru the stations getting their visual acuity and eye pressures done then we look at them to confirm that there's a cataract and good pupillary response and if yes, refer them for secondary screening. 


After hours of doing this we grab a sandwich in the field, screen some more until there's no more patients and then go back to the ship and see yesterdays post ops. 


On days where we're just at the ship we see the post ops and we do the secondary evaluation of the folks we saw at the churches.  During this evaluation we confirm what we saw at screening, do a mini physical exam and if all is well they are scheduled for surgery. 


The days on this team are very long and very busy! 


Fortunately, we've been sleeping better than ever!  I confirmed that my new malaria medicine is keeping me awake at night so I've divided up my pill and am portioning it out over the week so I've been able to get to sleep a little better.  More importantly - the Well's Fargo Wagon aka shipping container from Texas made a surprise appearance in Togo this week!! 


Soon after we accepted the offer to come here last fall we decided to do a small test of the shipping to the ship system by purchasing two, very nice, egg crate foam mattress pads.  We knew that depending upon how the International center got them to us we might have to pay a hefty, by weight freight charge so a high volume, low weight item wouldn't cost too much and if they never arrived it wouldn't be the end of the world. 
Peter couldn't wait for it to be on the Bed!

See how happy Peter is?
So, for the past six weeks Peter has been increasingly worried that our mattress pads were appropriated by someone, lost in the mail or floating aimlessly at sea somewhere.  But NO!  We now are sleeping on cloud like comfort since they were on this latest container!!  Whooo-wheee! Before plopping down on the new pads Peter was dancing around the cabin 


This has been great for both of us since he's been working very hard since we got patients on board and has been taking call every couple of nights.  He's also the senior medical doc here so he's often asked for his opinion regarding patients that the other doc works up.  

We got two new surgeons here this week so Peter and Dr. Fiona had alot of admissions and post op patients to take care of this week.  The maxillo-facial surgeons here are quite amazing.  The senior max fac guy has been on the ship for about 20+ years and many surgeons come here to work just to learn from him.  Peter said he did an amazing surgery this week where he completely rebuilt a man's nose from his forehead as his own had been destroyed somehow.
Here are a few pictures taken when Peter and I were doing the initial goiter patient work ups. 

Ann telling Dr. Fiona a story





So that's about it for this past week.  My eye is better so I started wearing contacts again today.  We got off the ship for a lovely dinner out with our friend Dr. Fiona and ended up getting the name and phone number of a cab driver that is willing to come pick us up when we need him so our mobility may improve from here on out. 

Thanks again for all your kind comments and most especially for the phone calls from  both of our sons.  Please say some prayers for our younger son, Tommy as he has a horrible case of the flu and has missed some classes this week.  We spoke with him last night and he's going to visit his grandmother this coming weekend (I think) but I'm sure they would both be happier if he was completely on the mend by then.  Have a blessed end of February and we'll send out more news in March!  

Sunday, February 19, 2012

A Week of Some Ups and Some Downs

Hello to our friends and family around the world.  The weeks seem to be floating by a bit faster and Peter has been asking me if I was going to sit down at the computer and compose a blog entry and I was thinking I didn't have much to tell for this week.  But maybe there were some notables here and there.

So, on the work front we've had some changes.  After over 30 days of wandering around the hospital, horning in on Peter's workspace and letting people know I "didn't really have a job" my local boss finally admitted what I'd been saying for these past four weeks in that she really had no work for me to do.  What?  You might be wondering -   There are patients lining up outside the hospital, patients nearly two to a bed and there's nothing for me to do?  Kind of.... 

My official title on my name tag is: "Assistant Screening Coordinator".  Sounds like a job.  Doesn't sound too "doctorly" but sounds like there's something I'm supposed to do.  Apparently in long term planning Mercy Ships is looking to send teams out into the hinterlands of the country to screen the patients prior to sending them to the ship in addition to the all day long, huge screening that they do at the beginning of a field service.  Since this service is only 5 months long and piggy-backs onto the previous trip here in 2010 there's litte need to go out and find more patients since we have more than we can handle.  So - no trips to the bush...no need for a screening doc.  Told ya so. 

Peter and his compadre Dr. Fiona share the ward duties and the ward admissions and they were happy to have me tag along and share the load as well as consult with each other so we were all on the same page.  Apparently our exhuberance and Peter's and my reparte' was a bit much for the nurses so like  elementary school teachers I think they wanted to send us to some separate corners...or something like that. 

On Thursday my boss admitted that there was no work for me to do in screenings and would I be interested in working with the uber busy eye team? It seems they were having some key people leaving to go home and needed some clinical person to sort of herd the rest of the team in their efforts to find patients as well as take care of patients post op.  Although I am somewhat ignorant regarding diseases and examination of the eye, having nothing else to do with my remaining 4 months here I said "Sure!"

So - now I'm on the eye team.  I've had a half of a day with them thus far so I've not got much to tell regarding how they work or what I'll be doing but I'm figuring I'll be busy since they typically do 40+ surgeries per day.  Yes, no typo - that was 40, 4-0, I'll even spell it out....FOURTY or more per day.  That's what I get for grousing about having not enough to do.  So - if I don't blog again until I get on the plane back home in June you all know the reason why. 

The other reason could be I've just got too much empathy.  Hard to believe but yes, less that 24 hours after joining the eye team I got an eye infection.  Nothing too fancy - just some pink eye but I thought it a little weird so I'm getting a double dose of empathy every four hours as I attempt to hit my eye with some antibiotic drops from an itty bitty dropper. 

Just glad I didn't start operating on those goiters or the giant hernias is all I'm saying....

The other fun thing that happened this past week was also a personal medical thing.  I got a rash and started throwing up.  OK -sorry, TMI  (To much information for you non-text or twitter junkies). When I first got the non-itchy rash all over my arms and back I asked Peter, the internist if this might be a drug rash from the doxycycline I'd been taking everyday to ward off Malaria?  He assured me it wasn't so I began to lament the lack of my favorite non-toxic laundry detergent left behind in California figuring that to be the cause.  A week later as the rash was spreading my GI tract joined the party by letting me know that this pill was no longer welcome, so Good-bye!  When I let the live-in doc know this latest development all of a sudden the rash was "classic" drug reaction and I must never take the drug again.  I'm still shaking my head about this.

For those of you that are not Infectious Disease physicians I'll let you know there are only three drugs on the market to prevent malaria from the wonderful mosquitos here that think sunset is an invitation to an epidermal smorgasboard.  I was now deemed allergic to one of the meds, the second is too expensive to carry on board and only the well heeled, short term crew buy enough to bring to the ship with them.  The third drug is all that is left to me now.  Down side is that a not uncommon side effect is bizarre, vivid, disturbing nightmares.  Lovely.

So far I've not encountered any Steven King episodes at night but for the first four days after my first dose of this once per week medication I discovered that insomnia is also a side effect.  Indeed, after four days of two or three hours of sleep per night even Peter wasn't happy he diagnosed my drug rash. We have a few things to try to lessen the side effects so hopefully next week I'll be better rested and a bit more cheery about things in general. 

We did get off the boat a bit over the past few weeks.  Peter traded call this weekend so we went into town to the craft market again and he bought a shirt.  He also went to a going away party for the current crew physician as the new guy showed up Friday night.  He also went to a German church service at the German Seaman's mission this morning.  I begged off of both since I'm trying to catch up on my lost sleep so I don't have much to share about those adventures. 

We've no pictures to share this week since we've neither gone anywhere new nor have we done anything noteworthy enough for the ship's photographers to catch us in the act, I guess.  So, there's news from the frontlines but nothing too terribly interesting it seems.  We are working on our British accents since we think that our sweet Fiona sounds infinitely more educated than we do and since there's no TV to watch pointing out the differences in how we say things passes for entertainment here.  You say potato, I say po-TAH-to sort of thing.  Cheerio... 

Thanks so much to those of you that have sent us notes of encouragement and especially to our sons who both dutifully called us yesterday.  We are most grateful. 

Sunday, February 12, 2012

Off the Boat and Into the Past Century….Or Two.

I hope everyone is enjoying their weekend as much as we are happy for the break.  This past week proved to be almost as busy as last week and we are happy to be of use. I have to first issue a huge note of thanks to Peter’s mom who has thankfully waded through pounds and pounds of our mail every week!  She not only lets us know what’s important she makes sure any checks or bills that have arrived are appropriately taken care of.  Without Brigitte’s help we would certainly be at loose ends. 

Let me apologize in advance for the length of this posting.  Much has happened this week and I wanted to share it all with you.    
Peter at screening day
Monday, Tuesday and Wednesday were filled with many, many goiter patients that as you recall from last week means their thyroid glands have grown to enormous proportions and require surgery.  The criteria for surgery in this country under the limited circumstances we have are very different from what we are used to in the United States or any developed country for that matter.  As I mentioned in the entry regarding the mass screening day, the general surgery slots for hernia repair were filled on a first come, first served basis.  This was done to maintain order and avoid rioting by those that had waited the longest.  This, of course made most of us on the medical side unhappy when we would encounter someone late in the day with an enormous problem and all we could offer was prayer and the hope that we’d have enough surgical spots to get them off of the waiting list.

Fortunately, due to the need for lab and x-ray evaluations we had time to sort through the goiter patients and have more of an opportunity to determine who gets a surgical slot based upon medical need.  Sadly, during this week we heard that one and then later two general surgeons have cancelled their time with us in the near future so we have no knowledge at this point how many of our surgical candidates will now go without their badly needed surgeries. 

Probably every week will have a taste of roller coaster action and this week was no different.  We saw a few patients this week that sadly there is nothing we can do to help.  We thank God that He brought a wonderful Togolese woman to the ship – Clementine, who gently informs these people in their own language about their either malignant or equally untreatable medical condition.  She is also the person that informs the many, many people we discover to be HIV positive of their new found diagnosis.  I don’t know how she does it and still she is the most positive person I’ve met on the ship it seems.  Say some prayers for our dear Clementine. 

Each morning we three doctors go on rounds with our surgical colleagues and a gaggle of nurses to determine what each patients needs are.  Pretty routine stuff for a hospital.  What is not routine is that each small ward is packed with five beds on each side facing the narrow aisles in the middle.  There’s approximately a foot in between the beds.  The wards are completely mixed with men, women and little kids. Even more impressive, most patients bring a family member with them as their “care giver”.  This is always done in the local hospitals so we honor the practice here.  These loving folks literally sleep on a mat underneath the patient’s bed!  So, 10 patients in the ward, nearly that many care givers, translators, nurses, surgeons and we docs trying to sort out who needs what, when and why.  Yup – it’s a circus!  What is most impressive is how stoic the patients are and how happy they are as soon as they get out of surgery.  Big smiles and thumbs up from people mummy wrapped in gauze is commonplace.  It is very uplifting and that’s even before the band arrives for the singing and the dancing.  Part circus – part party.  

I spent part of this week digging in my brain archives for my pathology training.  Not only did I assist with a fine needle aspirate of an enormous lesion, I did the slide prep, stained and made multiple attempt to get cover slips on those slides without making too much of a mess.  It’s been over 15 years since my slide making days – so give me a bit of a break, here!  I spent much of the day screening and putting dots on the slides for review by the esteemed cytopathologist that was here in early Feb. for our screening day.  Yes – he’s no longer on the ship but via the magic of modern technology we have what is known as a “Coolscope”!  This amazing microscope transmits not only slide images via a website but Dr. Ed can completely control the microscope remotely from his computer in England after we put the slide in the machine!  Fabulous! 

Ann on first boat
So, on to this weekend’s adventure story.  Yesterday we had the privilege of travelling to the quaint village of Togoville on the beautiful Lake Togo, about 40 km away.   With a friend we met at the Partners reception here onboard a few weeks back.  She is an ophthalmologist with an NGO from Germany and Peter stuck up a conversation in German with her and they hit it off immediately.  She and her driver (!) picked us up and he drove us to a boat launch that one could take a ferry of sorts across the lake.  One can drive to the village but our friend, Irmela thought this a more picturesque method of travel.  We gladly hopped in the boat with about 10 other Africans.  As her driver was negotiating the price things got a bit heated.  It’s not uncommon for whites to get charged more for things and we accept that as we do have the means to pay.  Apparently it became clear that price wasn’t the issue-  they did not want us IN THAT BOAT!  If we wanted to go across the lake we’d have to hire our own private boat.  We thought it interesting and sort of part of the day’s adventure but her driver, a local guy, was incensed.  
We did not hire a private boat from them but went to a lovely resort a short distance away and hired a different boat and had a lovely ride, gondola style.  We felt transported almost back to biblical times when the sailor unfurled two long bamboo poles with a scrap of cloth attached with two strings.  Voila!  Our sail!   
The ride across the large lake was very peaceful with a gorgeous, cooling breeze.  As we neared the shore we saw a dozen young men run down the long dock toward the shore and I thought, hmmm a welcoming committee.  We figured they saw us as easy marks needing a tour guide and thought a simple “no” would suffice.  You can imagine our shock when they ran into the water and offered to carry us to shore!  We, of course, said “No, no, no!!”.  When I glanced over my shoulder and saw two men had hoisted Peter out of the boat and were hauling him to shore I knew I didn’t have a chance.  Next thing I knew I was suspended above the water hoping this young man hadn’t over estimated his strength since I’m significantly above my “bride going over the threshold” weight.  Suffice it to say the man had to work for his few francs that Peter reluctantly doled out.  So, that was weird.  Africa – land of the entrepreneur. 

We then went for a peaceful walk to a school for the blind that Irmela wanted to visit since her organization partners with many clinics and other agencies that work with vision needs throughout the world.  We met with the nun that runs the school; saw about 40 kids that live at the school who then broke into an amazing song for us, complete with gorgeous harmony.  The school struggles with funding and rarely has anyone with her experience to see to the vision needs of these kids so she offered to come back next week and do eye exams.  We’re hoping to see if there’s any way the eye team on the ship assist her. 

Main altar in Notre Dame du Lac
We continued our visit of Togoville with the beautiful Notre Dame du Lac church that sits overlooking the lake.  Apparently John Paul II visited this church on one of his visits to Africa.  There were many, many pictures of him around as you can well imagine. 

On the trip back across the lake we managed to convince our previous hi-jackers that we would walk the 10 paces thru the water to the boat and we managed to return to the other side of the lake with as much pocket change as we did when we entered the boat.  Whew! 

We then visited a most disturbing museum that apparently housed slaves from the region prior to hauling them in the holds of the slave ships travelling to the Americas.  The house itself appeared quite nice however we soon learned that the captured men and women were made to crawl thru a three foot hole on the side of the foundation to their new quarters under the house where 100s of them would stay for a week or two until the next ship arrived.  The height of the space was about 4 feet!  The slave traders lived in luxury in the rooms above.  Apparently it was a couple of Americans that came researching their roots in the slavery that actually discovered this house was still there and how it was used as the locals had no knowledge of its significance!  This area was, during those awful times known as “The Slave Coast”.  Words fail me here. 
Slave holding quarters.  Small slave entrance


We finished the day at a lakeside retreat with some drinks and water before heading back to the ship. 
Today we’re sort of hanging out, resting up for the week to come.  Peter is on call next weekend so we’ll be ship bound and our adventures will be curtailed.  So – I’ll try to find something interesting to write about next week but it will probably not be the lengthy missive you’ve been given to wade through this time! 
We hope you’re all well, happy and keeping warm.  It is hard for us to remember that it is winter there but we think of all of you often and would love to hear from you.  Particularly our elusive sons…hint, hint.  Until next time….

Saturday, February 04, 2012

A Drink From A Fire Hose

Wednesday felt a little like trying to take a sip from a fire hose or maybe learning to swim by being dropped off in the midst of the ocean.  What a day!  What a week!

But first, many, many thanks to all of you that have written such kind comments about my meager offerings in these blog posts.  We also treasure hearing from you and knowing that you are holding us close in your hearts and in your prayers.  We also have to send a huge thanks again to our friend Brian and my sister Jenny for keeping an eye on our home.  Apparently the large rain storm that hit southern California did some significant damage to our swimming pool so we’re thankful for our trusty, albeit slow internet connection to manage things at home.  I’m also glad that on a lark I decided to give Peter a handheld scanner for Christmas.  It’s come in handy a couple of times in the past few weeks when we had to send a copy of a document back to the states.  No idea how people would negotiate their lives from 1000s of miles away without the ease of technology.  One of these days I’ll write up a list of the best stuff we brought with us here. 
hospital crew
If you recall we’ve spent some time grousing about being underemployed since our arrival here.  All of this changed this past Tuesday.  We had official Hospital crew pictures taken and had a crew and hospital evacuation drill to satisfy the maritime inspectors.  Then Tuesday night after dinner there was a work party to make peanut butter sandwiches for the following day.  When we made well over 1500 sandwiches I started to get a sense of the enormity of what we were going to face on the following day. 
By this time the first group of pre-pre screeners had left for the enormous Togo International stadium to meet with the eager patients that we knew would arrive the evening before the screening day started.  Even though it made for a very long day for those out overnight I was glad to know that people who got in line with problems we were not going to be able to help would be sent home right away so that they would not spend hours and hours waiting to be seen only to get bad news in the morning. 

Hours and hours went into the planning of the screening flow due to some horrible results that happened last year in Sierra Leone.  Apparently the line into the screening site doubled back on itself so people taken in were not always the ones that waited the longest so a riot ensued. Sadly, many got trampled and one patient even died!  It was clear that the folks in charge at the ship took great pains to make sure that a similar incident had no chance to recur and the patient queues, the security and the set up for each station went better than anyone expected.   

The pre-pre screeners went through the line outside the stadium with pictures of the types of maladies that we were planning on offering surgeries for.  If the people in line had something other than what we could treat they were asked to go home since there was no need for them to stay.  I’m glad I didn’t have that job.  These folks were out in the sun all day long, mostly giving people the bad news that they couldn’t be helped by us. Approximately 3500 people came to stadium on Wednesday.  Of these only 1600 were admitted for further screening. Once these people entered the main stadium entrance they were met by a screener that then confirmed if they had a problem we were going to screen for that day. After this they were told to wait to be seen by a nurse that would do their initial history.  For each person that we had talking to a patient we had a local interpreter to help make sure that the patient understood what they were being asked.  There were probably 30 nurses with interpreters doing history screening.  There were rows and rows of people patiently waiting to see a screener.  I can’t begin to tell you how amazing it was to not only see so many people but to see how patiently they all waited.

After a patient had their history form done they were directed to the specialty screening for the different types of surgery being done.  Peter and I started out with the Maxillo-facial team as many of the surgeries that are done on the Mercy are head and neck tumors.  We had three oral surgeons evaluating the patients and determining if they had something they could surgically correct.
In the same room a visiting cytopathologist did needle aspirates of tumors if the surgeons wanted more information to guide them. I was surprised to learn this wonderful man takes his vacation time every year and comes to this massive screening for Mercy Ships.  His lovely wife assists him by staining and labeling the slides and doing the paperwork.  I spent much of the morning with him doing aspirates and looking at slides.  Yes, this was a blast from the past and I never expected that any of my path skills much less long lost cytology facts would be dragged from the mothballed areas of my brain during this mission trip.  Who says God doesn’t have a sense of humor? 

Peter was assigned to do the physicals on these patients with two other doctors but within 30 minutes he saw that the poor crew physician was inundated with the general surgery patients and he moved over to that room to see the multitudes that presented with anything that wasn’t to be cured by the head and neck guys.  There was also a plastic surgery room for some burn patients and a few other maladies but I never got in that room during the day. 
We had a steady but not unmanageable stream of patients and the cytology was very interesting.  We worked from about 7am until 11 and broke for a quick peanut butter sandwich.  As soon as I left my room I discovered that the room Peter was working in was overrun with patients and had a line out the door.  Probably at least 100 patients were waiting to be seen and there were many, many more on the way!  So- after my sandwich I moved over to the general surgery room to help with the screening there.  Most of the patients here came in two types – either a giant goiter (very enlarged thyroid gland) or very, very large hernias.  Since we were primarily just screening to see if we needed to see these patients back at the ship at a later date for lab tests and other work up we spent very little time examining them.  In all we estimated that about 500 patients came through that “clinic”.  All of them seen by two and later three docs. 

After the patients were accepted as a surgical candidate some were sent to have labs and possibly x-rays on the ship at a later date.  They were also sent to the scheduling people to determine when they could be set up with a surgery date!  These were the ecstatic, fortunate ones.  Sadly, many, many more patients were told they would be put on the waiting list as we are only here in Togo for 5 months and have a limited number of docs and nurses that will be coming for this mission. 
I can’t tell you how heartbreaking it is each time I would see someone I felt desperately needed surgery and the best we could tell them was we prayed more surgeons would come and open more spaces for surgery.   

We finished up around 5pm for the long, very dusty ride back to the ship on the crowded, bumpy roads.  In a future entry I’ll write some about the local city of Lome’ and what it’s like to be here.  I think we were a bit dehydrated along with being exhausted as we both had a headache and felt sort of spacey.  Fortunately nothing was scheduled for Thursday as I took most of the next day to sort of “reboot”. 
Today – Friday the 3rd, the first wave (30) goiter patients came to the ship for intensive physicals, blood work and in some cases ultrasounds to determine who will be put on the surgery schedule and when.  There are three more screening days for these thyroid patients and the operating rooms start taking care of the patients we saw last week on Monday so well be really in the thick of things then and I’ll write more about those patients later. 

Well – that was lengthy but so was the day!  It was sort of what you’d expect on a day where nearly 4000 patients from three or more countries have come for surgery to correct a lifelong problem.  It was very hot and kind of humid but at times there was a nice breeze that blew through the building that seemed like the gift you always wanted.  The flies were pretty out of control but that same wonderful breeze sort of sent them on their way.  The people were amazing.  The crew, the entire crew from the school teachers to the engine room guys to every sweet nurse was thrilled to be a part of this amazing day.  The patients were inspiring in their hope and trust that we could fix their problem and incredibly gracious when they were told, “I’m so sorry.  We can’t help you.”  I just wish there was more we could do.  More I could do.  In addition to wishing I remembered more cytology I also wish I’d paid better attention in creative writing as I would love to give you all more a sense of the spirit and the aura of the day.  I guess it’s one of those things you call a “once in a lifetime” sort of experience.  Then again, maybe it won't be….