Living on the Comfort

Nothing in my life before has prepared me for living onboard a navy

hospital ship. I’ll describe a typical day when leaving the ship to go

on a MEDCAP and a typical day onboard the ship.

MEDCAP: Hopefully go to bed the night before at decent time (10p).

Wake up at 4am and be at the mess hall for breakfast by 5am. Have to

be ready for muster (roll call) by 5:15am-5:30am. In Nicaragua we had

to board hospitality boats to go onshore. On most days the swells were

so high, we would have to wait by the ramp until it was safe to board

the hospitality boat. Some days by the time I boarded the boat it was well

after 6am. By this time I had already been up for over 2 hours. After

the short boat ride to shore, we would board busses that would take us

to the sites. One site was about 30 minutes away, with an incredible

view of a volcano. The other was about 15 minutes away. Patients would

already be waiting for us at by the time we arrived. After everybody

arrived at the site, muster would be called again. Patients would

start to be seen roughly between 8:30a-9a, depending on the time we

arrived. We would see patients until about 3:30p-4p. We took lunch

sometime in the middle. After “closing shop” for the day, it was

another bus ride back to the pier. On my last day there was a fishing

competition on the pier. I think the winner was a 17 pound mahi mahi.

Once again we had to wait for the hospitality boat to arrive to take

us back to the Comfort. Once onboard the Comfort, it was down to our

berth for a shower and back up to the mess hall. It really ddid not matter what was for dinner, I was hungry. After dinner there is

always a short brief about how many patients were seen and what the

weather would be like the following day. After the brief, there was

some chit chatting in the mess hall, and then back down to our berth

for bedtime. It was usually around 10:30p.

Onboard: When we don’t have to leave the ship, we can wake up slightly

later. Instead of 4am, it is 6am. Breakfast is until 7am. It is not

the best food I have eaten, but I have been able to find some things

that are edible. The scrambled eggs with pancakes have been my usual breakfast. We then have to muster by 7:15am. During the muster,

the plan of the day is given. I have found it very informative that

during the muster a little piece of naval history is given.

At the end of every muster a quote of the day is given. After that it

is pretty much free time. There are educational opportunities that are

available. They are not mandatory, but I have learned so much from

attending them. The physicians are very knowledgeable and like to

share their experiences. Then it is lunch. Everything here pretty much

revolves around food. After lunch, I could possibly go the gym or take

a nap. I’ve done both. There are 3 gyms. There is the cardio gym,

spinning gym, and the weight room. In the spinning gym, there is the

option of participating in an insanity workout. It was tiring and fun

to have such an intense workout while the ship is rocking. If not

working out, or napping, I would do laundry. Laundry days are Sundays,

Tuesdays, and Fridays. Laundry days are a workout in itself. To go

from my berth (room) to the laundry I have to climb 96 stairs, go

across one of the floors and then go down 50 stairs. The laundry room

is way too hot, so I would put my clothes in the washer; go up 50

stairs to the sym. After the gym, go back down those 50 stairs. Then

up the 50 stairs, and down 96 stairs to return to my berth. The last I did laundry Nicole told me that I was going the long way. I did not have to go up that far and then back down a different flight of stairs. Oh well, I'll know for next time. I little extra exercise never hurt anybody. LOL! To go the mess hall from my

berth it is 81 stairs. I try to take everything I need for the day in

the morning so I don’t have to go back down. I can tell that I am in

better shape now than when I first arrived. I am only out of breath

right before reaching the mess hall level. Before I would be tired and

out of breath 2 to 3 levels before the mess hall. Then its dinner, the

brief, and hang out time. Hang out time includes playing cards. Lights

out at 10pm, even though you can stay awake for longer.

After leaving Nicaragua there was a “strategic pause” on the ship. I

have never seen so many happy faces. This pause meant that muster was

not at 7:15am. We had to muster by 10am. It felt good to wake up late.

On the way to Guatemala, dolphins and a whale were seen. I didn’t see

any of them. I was disappointed. :(

En route to Guatemala, we worked in the "scullery." We gave the guys a break and cleaned the dishes for them. (They were still there to help us out). The "scullery" accepts the dirty dishes and silverware and washes them. There are 2 windows that accepts the dirty plates. Our dishes became backed up, and the guys gave us tips on how to do it faster and better. Kim was great at pushing the button for the garbage disposal. I will admit that I was a little afraid that it was going to explode in my face. Surprisingly I had fun. I think we all had fun. The music was blasting and the time went really fast. I give so much credit to the guys for doing their job and having fun while doing it.

I am excited to step onshore in Guatemala and meet new people. I’m

also excited to actually feel land under my feet. By the time I go to

the first Guatemalan MEDCAP I would’ve spent 7 days onboard. I’m ready

not to feel the rocking anymore. Even though sometimes onboard I don’t

feel the ship moving.

Almost there (to Guatemala)

We are due to arrive in Guatemala shorty, truth be told I have been told we are essentially here but going in circles waiting for our allotted time to enter the port.

During these days that we have been “underway” there have been many class offerings, meetings that review the work that was done in Nicaragua both medically and the engineering and preventative medicine work that was done. There is a huge focus on clean water, one statistic relating to clean water, or lack there of has to do with children. I forgot the exact number but diarrhea is the leading cause of death in children under 5 in these areas. We were told of children who played in the sewage drain off from their bathrooms near their school daily, and no adult knew better to tell them not to do it. I guess I should correct myself, it is not that they simply didn’t know better, there were no other options, the kids were happy playing in it, and possibly no one had ever educated them on the fact that the drainage contained feces and disease. I learned of villages where the water in the man made, hand dug wells was dark as mud, yet the locals drank from it regularly. They had to be careful not to scoop up a frog in their glass, because the frogs too enjoyed playing in the water.

There seems to have been a tremendous initiative by both the military and a group called Edge Outreach that focuses on providing clean water and making it sustainable for for the local people. There are amazing things being done in these communities, it is unfortunate that we are here for such a short period of time that follow up and continued education is limited, albeit impossible. I have to assume that the hope is that the teaching we be passed down through generations. One problem, or barrier to sustainability may be the lack of education, or the work it takes. For me, I think, wow, if someone could come into my village and teach me how to clean my water to make it potable to drink, the people will be healthier, the children will live longer, the further generations will be made possible. Water is essential to life. These people are most probably unaware of the health benefits of clean water because there communities have survived for years and generations on the existing water. They may not make the connection that babies are dying due to their water source, that so many illnesses that they suffer from may be linked back to the water.

A valuable lesson, although I am not sure what purpose it serves, is that we can’t save everyone. There are cases that have been seen, and I am sure the next stop will bring some of the same, that the collective “we” can’t save. This is heart breaking, especially since we are geographically so close to Miami, to the US in general, where life saving procedures can be done. Geographically we are close, but for these families medical treatment in the US is truly worlds away, it may as well be Mars.

I hear the words...”finish your food, there are starving children somewhere” repeat in my mind. Luckily most of the children I have seen appear well nourished, but one can be fooled by seeing a child who may be the appropriate weight but is truly lacking essential vitamins and minerals that his/her family does not have access to. I have had several children asked their mother for water while I am examining them, WATER?? I do not recall a time in the US that I have has a child essentially beg, as he/she would for candy, for water. Maybe the water we were provided tasted better than there’s, maybe it was fun because we were giving it to them in baggies as it was coming for the purified water from Edge Outreach, so it was kinda like a water balloon... despite the reasons it was a little sad to see these kids a little desperate for some water. Teaching is difficult when the family is truly functioning within their means and there is not possibility of expanding their diet or food source. Teaching really has to focus on capitalizing on what they do have available. One thing common to so many cultures is...there seems to be no shortage of candy & sweets. Just as in the US, those who are poverty stricken may eat just one meal per day.

Last night we had “scullery” duty... Luz may be explaining it in her post so I won’t go into detail. All I will say is that we were on the receiving end of dirty dishes of nearly all the 850 people on board (divided between two windows), Dr. Roark manned the one window with a fellow Hope volunteer while Kim, Luz and I were at the other window. It was an experience, I would do it again without a problem. The good thing is you get to see what people AREN’T eating, so you make a mental note of what not to eat.

Each day I am reminded of how lucky so many of us are to have access to clean water, food, shelter. Our children do not play in poo water during recess... I realize that this degree of poverty is not limited to places outside of the US.

Our trip is over halfway complete, the thought of going home is bittersweet. I am truly looking forward to our next mission stop that we are (slowly) approaching. I expect I will learn more with each patient and each day...

Fun Times!

Last day in Nicaragua

Have not been able to blog for a few days due to difficulties with the internet, I will try to catch up. So we have been out several days in Nicaragua to the med sites. The primary complaint remains to be concern about possible parasites, low weight and “kidney pain”.

I have had some interesting cases, one child who had an impressive murmur whose mom mentioned it in the history as a secondary finding, he had been seen by local cardiologist but no follow up recommended. After consulting with one of the Navy doctors it was determined that he had possible VSD, I recommended he return on a day when we would have a cardiologist and the capability to do an echo. I was thrilled to find out that he did return, our photo journalist was with me the day I saw him and she let me know that he came back to the med site as recommended on a day when she happened to be there.

I have hopefully helped some children get glasses, we have optometry on site and luckily they have been super accommodating when it comes to fitting these kids in. ON one particular day I know that the optometrist (one guy with the help of tech’s) saw over 100 patients, truly impressive. Each time I presented a case for a child I felt could truly benefit from a thorough eye exam and possible corrective lenses he agreed with a smile. Some of the schools these children attend do not have water and certainly do not have the luxury of air conditioning, yet they do the best with what they have. If I can be instrumental in helping them being able to see better which in turn will help to improve their abilities in school and potential for learning which may in the long term improve their quality of life, this is an opportunity that can’t be missed.

The way that these sites work is that a patient is registered to see just one service due to the high number of patients seen in one day they generally are not permitted to pass from one service to the next. However, there is a great deal of collaboration between the services and whenever possible a child would be referred to return the following day and given a bracelet to indicate that he/she did not have to wait in line again, people waited in lines for hours. In some cases if the condition was severe and/or the family lived at such a great distance various services would fit the child in, this was a window of opportunity for these patients to get medical care they so desperately needed. I saw a child with horribly decaying teeth, I’m no dentist but he clearly had dental caries, my concern was that in a short period of time he would have an abscess and the infection would soon enter the bone. Dental saw him that same day, unfortunately I was so busy I was no able to follow up to see what the outcome was.

There is a common theme each day/each med site, which is education,education, education... regarding the importance of remaining hydrated, proper nutrition, getting vitamins from natural sources, and education regarding appropriate height/weight for children.

I have had to prescribe albuterol to a small child, he really needed a spacer as well. Forgive me if I mentioned this in a past bog... but I will tell you again. We were able to create a spacer with an empty water bottle, tape and some gauze... it has been pretty cool learning from the experienced providers and learning to work with what you have. So I sent this mom and her child home with a spacer made of an old water bottle and some albuterol and she was so grateful.

One of the things I was really looking forward to on this trip was being able to help a population of people who truly needed help and I feel I have done that, they are appreciative of even the smallest bit of assistance. This community seems to live by the idea that it “takes a village to raise a child”, in many instances the child was brought in by a neighbor, a friend, extended family member. The children would wander in the waiting area from person to person and everybody seemed to know each other. I saw people who were at the med sites from open to close, all in search of medical care and some also seemed to be there for the social aspect of such a gathering. It was an opportunity to be provided with clean, cold drinking water and a slightly cooler environment, as we did have large fans.

I have such great respect for those people who have been on the ship for months and will remain on the ship for months after I am back home. Now that we have been here for a week I feel I have adjusted to the schedule, and to life on ship and I could (and would love to) stay on ship for the duration of the mission-scheduled to finish in Haiti and be back in the US by early september. The one thing that it difficult, lets just say impossible, to adjust to is the food... I am entertained by the creativity of those who have been on ship for months with regards to the methods they have developed to be able to create an edible meal from what is served. I have heard a grown man giggle with delight while licking up the last bit of ice cream he was lucky enough to get, apparently they had soft serve ice cream early on in the mission but it ran out very early so when there was a small amount available it was like finding a pot of gold at the end of a rainbow.

I have heard people excited about the “smell of lettuce”, lettuce is another scarce resource around here, on most nights salad is actually chopped cabbage with various salad bar like toppings, including hard boiled eggs- we are in close quarters, as a public service a beg people not eat eat the combo of cabbage and hard boiled eggs!!! Fresh fruit is also worth standing on line for, the line forms quickly and the fruit goes fast. Lets talk about milk, we do not have fresh milk on board so they use this milk-ish substance that is kept cool in the one of those rotating slushy machines, the consistency varies daily, some days it comes out in chunks, other days you can actually convince yourself it is milk and ok to drink. I drink it in my coffee (another necessity when waking at 4am) daily and I have survived thus far.

This continues to be an amazing learning experience, it has been such a rewarding experience to work with/collaborate with such knowledgeable practitioners. One thing that I have realized is that working in the conditions we are in, the heat, humidity, lack of resources, tremendous number of patients being seen, morale is always up. Our team is smiling on the way out in the morning and still smiling on the way home, we all may be exhausted but the reward from these patients is so much greater than the sacrifice. I truly do not feel as if I have sacrificed anything to be here, I feel honored and lucky to have this opportunity and I only hope what I am learning here will stay with me throughout the years. It is an exercise in being able to work with in the means available to me as a practitioner and within resources available to the patients. I saw a patient who had an appendectomy 5 years ago and was coming in for follow up because they were not able to make it back to the doctor for follow up after surgery, this just gives you an idea of the limited access to care in some of these communities. I have learned a tremendous amount in such a short period of time. We will be leaving sometime in the next 24 hours for Guatemala, I am sad to leave this beautiful country but looking forward to the next stop. If I have positively impacted just a handful of the hundreds of patients seen, I did what I came to do. It has been an even exchange though, I have taught them about medicine and they have taught me a little more about humanity.

Pictures

I am so excited that this is the first day that I have had wireless access long enough to actually post pictures! Hope you enjoy!

Nicaragua Mission

We are on day 9 of the mission and it has definitely been an unforgettable experience. Life on the ship gets a bit tough at times because of the tight quarters and inability to “escape” for privacy. However, the military personnel as well as the other civilians have all been extremely welcoming and their passion for humanitarian is contagious. On the days that we go to the clinical sites, the buildings are extremely hot and it does get exhausting at times. On the other hand, our sacrifice is nothing compared to what the natives experience on a day-to-day basis. The natives have deeply shared their appreciation for the care that we are able to provide for them. They treat us as if we are “royalty” and they cherish all of the advice that we have to offer. I have been fortunate to care for and educate many families about basic dietary/nutrition needs as well as disease process and primary prevention. Much of which we take for granted in the US. It is amazing to see the natives standing in line for hours in the hot sun and/or rain just to have an opportunity to get a few moments of “quality care” from the Americans. It is also sad when we encounter patients with significant health problems that we identify, and then have to refer back to their host nation’s providers for follow up. I often wonder if they feel “disappointed” that they are placed back into the same local healthcare system (or lack thereof). Although, I wish we could address more of the major concerns, it is definitely rewarding to see the impact that we make on so many others. Just the simple courtesy and respect that we give to our patients is enough to make a lasting lifelong impression for those that are less fortunate! Until next time……

Post from Luz

Hello everybody it's Luz. I am having trouble logging in and this post is under Randy's name.

Today is Sunday, June 26, 2011, or I am told it is Sunday. The days blend together and I am not quite sure why. I have been onboard the USNS Comfort for one week. I can't believe time has gone by that quickly. We (Kim, Nicole, Randy, and I) have gone out 4 times this week. There were two sites that we would go to see patients. One was a civic center (Centro Civico in San Juan del Sur) and a school (Escuela Humberto Mendez en Rivas). The Nicaraguan people came to be evaluated by professionals in specialties that included general medicine, family medicine, women's health, pediatrics, dental, and optometry. They were truly grateful that we were there to provide them with free services and medicines. I have had some kids that have been wheezing. The 1st thing I wanted to do was find a nebulizer machine and give them a treatment. Here the only thing I had was an Albuterol inhaler, or so I thought. I was taught by the very knowledgeable physicians and nurse practitoners how to make my own aerochamber for the little kids. All I needed was a pair of scissors, a water bottle, tape, and the inhaler. To my complete amazement my makeshift aerochamber worked surprisingly great for my asthmatics. After 2 puffs of teh inhaler my little asthamtics were no longer wheezing. I was so happy that I was to build something so very useful. I was touched by how the parents would dress up their children to come see us. The little girls would be in dresses and the little boys would be in button down shirts and pants. I was saddened by the fact that we couldn't provide all services that were needed. I have found that the Nicaraguan people are sweet and loving. We sail away later today, and I will miss this country (especially the slice of avocado that was heaven sent during one of the MEDCAPs). God Bless Nicaragua.

Leaving Nicaragua

Finally our internet is back working. Poor Luz spent hours last night trying to post pictures without any luck. Today is our last day in Nicaragua and it has been a great and busy first week. Today one of the pediatricians came up to me to let me know specifically what a great job that Luz has done when working with him. He said beyond seeing more patients that most of the other providers, she spent more time doing education with them than others and was the first provider he has seen who walks their patients to pharmacy, etc. The other providers have had similar comments about Kim and Nicole. Okay, as for the other stuff. Wish we had a picture getting off the transport boat on Friday. Many people got sick on the short ride and then the actual getting off was pretty scary. They have had to cancel functions because of the danger involved in being transported to and from land. The food, well what can I say. Luz has a great picture I hope she can post soon.

Hello

Hello from Nicaragua. As you may have read in the blog from the past few days it has already been an adventurous trip, including the always exciting task of getting on and off the ship to go to our clinical sites. It was never that difficult last summer. Luckily no injuries so far. Kim, Luz, and Nicole have been real troopers. It can be hard to adjust to this setting but I’ll let them tell you about that. The noise, the food, the lack of privacy, etc. I will tell you that we all went out together for long clinical days at very hot and humid sites both Monday and Tuesday and we all will go out again tomorrow and Friday. They all have been doing an amazing job and that isn’t just my opinion but also the opinion of all the other providers at the sites. The providers are very impressed with their knowledge, skills, hard work, and positive attitude. The internet is again a source of major frustration. Well, just have to accept that one. I’ll write more as we go along but I will let the students be the primary bloggers as it is their experience that is most interesting.

Today was our second day out onshore (MEDCAP). To go onshore we had to navigate the swells and go onboard a hospitality boat waiting to take us onshore. It was once again an indescrible experience. We thankfully made it onshore safely (only a camelback fell in the water... it was rescued very quickly). We made it shore, and arrived at Escuela Humberto Mendez after a bus ride. . The students were sad we took over their school for a week (not really). In total 544 patients (in different specialities) were seen today. The temperature with the heat index was 106F. HYDRATE was the word of the day. The return trip was uneventful(very thankful again). It was the quickest offloading of people I've seen so far. It was probably due to fact I was in a boat full of military personnel that jumped of the boat like little bunny rabbits (I don't think they will like that comparison). It was a bit difficult to take the patients to shore (especially after surgery) due to the Helos not flying today and the high swells. My hats off to the crew of the Comfort to safely take the patients to shore.

First few days in a nutshell

We arrived to the town of San Juan del Sur via bus on Saturday. Along the drive the poverty was apparent as was the beauty of this country. We drove along shore for a bit with a picture perfect view of a volcano, I will have to look it up to see which one it was.

Everything has been great so far, truly an experience. Boarding the
ship from a smaller boat in the large swells was a mission in itself, truly hard to accurately describe the experience- adrenaline pumping to say the least. The timing of each persons disembarking the boat is carefully timed by the Civilian Mariners, it is like a choreographed dance with fancy footwork to be able to safely land safely on board the USNS Comfort. Nearly lost some people between the ship and the smaller boat...but we
all survived!! The boarding/check-in process is… a long process. We were met my Faye, a representative from Project Hope who made sure we all were fed and led us to our rooms.

Myself and the other students are in the "overflow" area since we are
here as students, large room, lots of bunks... nice people though. The
ship constantly rocks due to our position in the water, this is
calming at times and other times it feels as if you may roll out of
bed or sustain a head injury in the shower. We are finding our way
around, everywhere we go requires a series of steps, unavoidable diet
plan.

Yesterday we had general orientation and spent some time orienting ourselves to the ship, this continues to be a work in progress, Luz has been the best so far at keeping us from getting lost. Last night we attended the debriefing for the day regarding the activities of the day and the progress so far. Made me appreciate and little bit more the work being done in these countries.

Went off ship to one of the clinics set up on shore, (pictures to follow).Up at 4am, Luz and I were first to arrive to the muster site, unaware that they called for each boat overhead, oh well, lesson learned.
I was paired up with a wonderful pedi NP and we saw about 30 kids, some
with primary care issues others with major medical problems. The
challenge is turning people away with little to no treatment after
they have waited for hours for care. Sometimes they simply do not need
care beyond a kind word and reassurance that all was ok and normal
with their child, other times we don’t have the resources to care for
them at the level they needed. There were a great many who did benefit
from the medications and services we have available.

One child in particular that stood out was seen by a practitioner for double ear infections and discharged with meds, on the way out he began to seize, one of the military personnel came to get the PNP I was working with as they were unsure of what was happening with the child. Together we went to assess the child, when we approached it was clear that he was having a seizure, blank stare, unresponsive to everyone around. Due to our limited supplies the usual suspects, supplemental oxygen, IV start kit, IV or rectal meds… were not available. The pharmacists was quickly at the patients side and offered meds not on the formulary, for use in an emergency, luckily we were able to administer Diazepam, unfortunately with little to no effect. He remained in what seemed to be a postictal state with short intermittent seizures. The local ambulance was called and the patient was taken to the hospital. The sad part is, this patient had a history of this since the age of two (he is 6 now) with seizures that occur frequently, the treatment of choice has been NS bolus and discharge. It was gratifying to be able to diagnosis this child along side such a wonderful medical team, we can just hope that he gets the treatment he needs for further care.

Aside from the scorching heat (96 outside, 116 degrees inside with humidity) and lack of circulating air, today was a good day.

the anticipation

Waiting in the hotel for the bus to arrive to take us to the ship, finally. I have been told to get used the the hurry up and wait mentality, I'm trying, it will be an adjustment.

I have met some wonderful people, all here for a common purpose. No one is "doctor" or "nurse", just call me by my first name... Takes away a bit of the anxiety as I am in a limbo, professionally.

Luz and I took a cab ride this morning to market area with local vendors... got offered some mysterious food that looked yummy but neither one of us could really identify it, so needless to say we skipped it.

There is still so much that is unknown, the anticipation lingers, as does the excitement. Looking forward to getting settled into my new (temporary) home.

Arrived in Managua

While descending into Managua, Nicaragua, I had a magnificent view. I saw mountains and craters filled with water. Seeing the beauty of this country eased my anxieties. I was nervous, anxious, and excited about participating in Project Hope, but now I am only excited. In the hotel lobby we (Nicole, Kim, and myself) ran into volunteers from rotation 2. They gave us some pointers and explained some things to us. They alleviated my anxieties even more. Now I am ready to board the USNS Comfort tomorrow.

Off to Central America

FIU is teaming with Project Hope again this summer and this year we have 5 nurse practitioner students going to Central America for Continuing Promise 2011 on the USNS Comfort. Luz Gomez and Nicole Navarre (Peds NP students) and Kimberly Harris (FNP student) and I will be flying to Nicaragua tomorrow to catch the ship for the first leg of the mission in Corinto. We will then head to Port Quetzal,Guatemala. After that we head to El Salvador where they will leave and two other students will join me, Lori Brown (adult NP student) and Beverly Griffis (FNP) student. We will be in El Salvador for a few weeks then on to Costa Rica, first for 4 days of leave time, then the final leg of our mission before returning to Miami. I expect as was the case last year, the internet will be spotty, but hopefully we will still be able to post regularly and include pictures.