Post from Beverly

July 23, 2011
Lori and I flew together from Miami to San Salvador having no idea what to expect from our adventure. We arrived at the airport and were greeted by a Project Hope veteran named Earl. Earl is a pharmacist who went on Hope’s first expedition in 1958. He now brings pharmacy students who compete for the privilege of traveling on the mission. He is retired military and so soft spoken you have to lean in close to hear him. Incidentally, Earl met his wife on his first Hope mission.
At the hotel we met several people who would be traveling along with us. Some had traveled on Hope before and had many stories to tell. All were interesting, some were sad, most were funny. The next morning we were all excited to be heading for the ship. The bus was supposed to arrive at 10:45 AM which turned into 1:00 PM. We then drove around the city three or four times picking up various other people who would be joining us. We took another trip back to the airport and then finally headed towards the port. The 1 hour ride to the port took nearly five hours!
As we drove around San Salvador the first thing I noticed was a McDonald’s. As we continued to drive we saw Subway, Pizza Hut, Burger King, KFC, Wendy’s along with Sears, Nine West, and even Wal Mart. Everything was so Americanized. Except for the housing; corrugated aluminum houses in various stages of disrepair were crammed together on hillsides and in valleys. There were forty or fifty crowded almost on top of each other and surrounded by large piles of trash and garbage. Amongst all the American retailers and impoverished citizens was the most beautiful foliage and flora I have ever seen. They have the same hibiscus flowers we have, but the colors are more brilliant and the blooms are twice as big. I really wanted to spend a few days getting to know the people of the city and find out what their lives were like; but we moved on to the ship.
The Comfort is physically much larger in person than you expect from the pictures. Brilliant white with a giant red cross on the side, it stands out more than any other in the port. Once on board, the first thing that you notice is that this is a collaborative effort much greater than the United States Navy and Project Hope. There are military personnel from the U.S. Army, Air Force and Coast Guard as well. Additionally, there are military from Canada, Holland, Brazil, Columbia, and a variety of other countries. Several private and religious organizations are also prominent.
It is an extraordinary experience to encounter such a variety of people. Surprisingly, with so many people in such tight quarters everyone remains amiable. Manners are displayed by all and impeccable. Those who have been on board longer help the newcomers find their way around (which by the way is a lot more difficult than one would expect). This is my first close encounter with military personnel. The maturity and professionalism displayed at all times is refreshing; especially when you recognize that most of them are late teens and early twenties.
We arrive too late the first night to do much but eat, find our bunk, and go to bed. Our second day is orientation to the project and the ship; which is like orientation everywhere. The third day we at last get to go out to our first medical site.
We see nearly 1000 people the first day. There are medical experts from every field working together to offer as much help as possible in such a short period of time. As a student, I am not only welcomed, but sought after. Physicians and practitioners with unusual and text book cases seek me out to show me the nuances of assessment that we don’t always get to see in the United States. Detailed history and physical assessment are the key to diagnoses in our outdoor makeshift clinics. Simple procedures are performed on the spot. Family Practice from crib to crypt is flourishing here. I have seen and learned more here in four days then I learned in nearly two years of training.
The people of El Salvador are happy, extremely clean, and grateful for all things we offer; big and small. The difficult encounters are those that could be easily fixed in the U.S. but ruin lives in Central America. A 14 year old boy who has what his mother calls “a hole in his heart” and has heart sounds suggestive of a VSD is thin, gaunt, and low on energy. Back home, we could fix his heart in less than one hour. A 72 year old woman arrives our last day in El Salvador blind in her left eye and no peripheral vision in her right. Her blindness is caused by simple cataracts; had she arrived the day before we could have fixed it. We referred her to the host nation, but in El Salvador she may be too old to have the surgery. Fortunately, there are only a few of these cases that stand out. Most of the patients present with complaints of headache, dizziness, stomachache; usually symptoms of not drinking enough water or malnutrition from parasites. We give out vitamins and acetaminophen; along with education, education, and more education. And we get back a lot more than we give.
July 26, 2011
We have not been able to post anything as of yet. The internet and telephones have been down for several days. You never realize how dependent you have become on these electronics until you have to do without them. I well remember the days when long distance calling was rare due to cost and mailed letters were the only form of communication. We have been out of touch for less than a week and all of us are feeling a strain.
We left El Salvador the evening of July 24. It was a really a great experience in many ways. The people of El Salvador are warm and friendly. They have a system of socialized healthcare and have many services available to them. The problem, as was explained to me by one of the many translators, is that the services are not close to home for most people. A trip to San Salvador costs money and most of the people do not have automobiles. Additionally, once they make the trip there are no guarantees that the procedure will be performed when the patient arrives or scheduled for another day. We met a young 23 year old mother of a 7 month old who had a PAP smear result which showed CIN 2 (moderate dysplasia). She had a letter which described the necessary cryosurgery and where she would have to go to get it. She did not have the resources to travel to the city and stay in a hotel while she awaited her appointment. In some ways, the citizens have access to many services that United States citizens do not, but there are other difficult conditions that prevent access.
Speaking with the discharge planner about this same young woman she told me that many of the postsurgical patients from the USNS Comfort are discharged to a central location or taken to the port exit to await a ride. In this country people are used to a long and difficult road home. Some of them call for a taxi, some wait outside for a family member, and others have no idea how they will get home safely. In the U.S. this would be unheard of for somebody one or two days post op waiting for a ride in the street.
Today has been a very exciting day. It is the day where the ship is refueled and restocked with supplies. One would think that boxes would be loaded at the dock and fuel would be dispensed at the port. Not so. We travel out to sea and meet a ship called the Lewis & Clark. The two ships travel side by side while gas and supply lines are thrown from one ship to the other. Fuel is dispensed through these lines and palettes of packages are pushed across ropes to the other ship. The Navy’s helicopter picks up supplies from the Lewis & Clark and drops them onto the deck of the Comfort. It is a process which the military makes look easy, but it is quite difficult. The ships have to travel exactly the same route without any deviation in rough seas for close to twelve hours.
We are expected to arrive in Costa Rica on July 28. Hopefully, at that time I can post some of this info.
July 30, 2011
Well, we have been in Costa Rica for two days. The ship is on “Liberty” which is similar to vacation only you still have to get up ridiculously early and be checked in by 7 AM. We have been exploring Costa Rica a little during the down time and have seen some beautiful landscapes and beaches. I took some pictures but forgot my USB cord so will have to upload when I get home.
During our exploration of the area, we were stopped at a check point and were asked for our passports. I was not carrying mine with me, but I did have my US drivers license and my USNS Comfort pass. However, this was not enough. The police then decided to search my purse, the vehicle we were in, and were telling us we could be in big trouble. Out Civil Rights were totally irrelevant in Costa Rica. Memories of old movies where people are hauled off to jail and left indefinitely raced through my head. My cell phone does not work here and I did not have the ship’s phone numbers with me. My American sense of justice and freedom for all was causing me to feel angry, but I knew it was best to hold it back. Fortunately, someone thought to show them a picture of the ship. Their attitude changed immediately. They shook our hands, thanked us for being there, gave us all our stuff back and let us go. I am really not sure what they wanted. I hope they are trying to stop the drug trade and not blackmailing American tourists. I now have a much greater appreciation for justice system in the U.S. Even though it often makes mistakes, at least out officers are forced to respect individual rights.
Tomorrow we will all go back to the ship and begin surgical screenings. I am looking forward to getting back to work. It is such a great opportunity to fine tune my assessment skills. Hopefully, the internet and phones will be working on the ship and I can post more frequently.

Beverly Griffis

Explanation of pics

I meant to label the pictures I just posted but didn't. The first two pictures are of Lori and Owen, our interpreter in El Salvador, and Beverly getting sage advice from Faye, our Project Hope leader and pediatric NP. The next two pics are the stadium site where we set up our clinic and our protection. The other three pictures are from Costa Rica liberty, one of the beautiful beach, one of Lori and Gary and Jeff, two ER docs and HOPE volunteers, then me roughing it on the beach here. My pics do not do the beach justice. It is gorgeous.

Costa Rica Liberty pics

More El Salvador pics

El Salvador pictures

Internet finally

Hi Everyone,

Well, it has been awhile. Unfortunately soon after Lori and Beverly arrived and we started our mission in El Salvador, our internet went out for some time. I had a few posts prepared that I was going to put up as soon as the internet (as did Lori and Beverly) came back on but that didn't happen. Anyway, suffice it to say that El Salvador was an excellent experience. I'll let Beverly and Lori post more about it since it was their first mission stop. I will say that they came on board, got oriented, and went right to work without missing a step. Currently we are on a short liberty break in Costa Rica before starting the mission here on Monday. It is a spectacular country from the little I have seen. We are all staying just north of Jaco Beach in a resort in the rainforest. I'm posting a few pictures but they don't do it justice.

Adjusting to Civilization

Today is day 5 of being back to civilization and it seems that it has been the hardest by far! I never thought that I would actually miss life on the “Comfort”. Of course, I am grateful to be home with my family as I missed them terribly! However, there just seems to be emptiness in my heart. I miss having fulfillment from pursuing the daily mission of caring for the less fortunate. Although, I certainly have my own missions at home, it just doesn’t provide the same satisfaction.

Taking part in Continuing Promise 2011 has made an incredible impact on my life! I feel blessed to have the experience to meet such wonderful people, discover a new meaning to life, and learn such valuable information at the same time! I have always been told that “the most valuable things in life are often the hardest to achieve”, but I never fully understood the true meaning of that saying until now. Undoubtedly, the mission was physically and mentally exhausting, but the reward that is gained far outweighs the challenge. Not only was it rewarding to help others; it was reassuring to work alongside so many others who provide selfless care day after day in such desperate circumstances.

Unfortunately, I didn’t get to post on the blog as much as I wanted to due to poor internet connection and lack of time. Therefore, I wanted to take this opportunity to give a synopsis of my overall experience. Furthermore, the last 3 days of the trip I was bedridden with a food borne/viral illness which left me feeling extremely weak. Thankfully, some of the same providers that work so hard in the clinics, made themselves available to nurture me back to good health. I never thought I would be so sick that I would need 3 liters of fluid bolus over 2 hours!

I will cherish this experience for the rest of my life and want to thank everyone there who helped make it a memorable one! To anyone else considering embarking on a similar journey; I would highly recommend it!

El Salvador

Beverly and Lori arrived last night and are currently having orientation (a long, tedious process). However, tomorrow we will go out for our first clinic day and I am sure they will find that much more interesting. I'm glad to have them on board and am looking forward to another excellent rotation with FIU NP students. They should soon have internet (sort of) access and they should start putting their thoughts and experiences on the blog. Kim, Luz, and Nicole, hope you will also continue to write as you process the experience now that you are back home.

Guatemala Pictures 2

Guatemala Pictures

Nicaragua Pictures 2

Nicaragua Pictures

Mission Complete

I am writing this post from a lounge chair in my backyard with tears in my eyes. I am extremely happy to be home, surrounded by my family and pets, yet I still have a heavy heart. Guatemala was different and more difficult for me than Nicaragua. The heat and humidity in Guatemala was oppressing. The MEDCAPS were held in 3 elementary schools. A breeze was hardly felt in any of the sites. I am not sure if the lack of a breeze was due to how the schools were built. Even though the heat was unbearable, I hardly heard any of the providers complain about the heat. It was something that you had to deal with by drinking lots of water. On some days I became slightly dizzy and had a headache. This was my body telling me to hydrate. I would educate parents on the importance of drinking water, and the consequences of not drinking enough. I had to use my own advice on myself. The heat was not the only factor that made Guatemala different than Nicaragua.

The poverty level was increased and the educational level was decreased. This could have been due to the areas that were selected for the medical sites. Some of the reasons that parents (the majority were mothers) brought their children to be evaluated were the same. They included headaches, not growing well, and the need for parasite medicine. Guatemala was harder for me because I saw sicker children that needed more help than what I (we) could provide. I saw children with failure to thrive and congenital anomalies that had to be referred back to the community for treatment. Not being able to give immediate help was more frustrating to me than the heat. I know that I did the best that I could under the circumstances, but that does not make the sadness of not being able to help go away any easier or faster.

My last patient of the mission was one of these cases. It was a 15-month boy that had had fevers for 7 months; with history of seizure and taking depakene. The parents brought all the imaging and the results of all the exams that had been done prior. I desperately wanted to help this family. He was a healthy 15 months old upon examination. If I had not been told that he had had a fever, I would not have been able to tell. This was a very complicated case. I consulted with 3 physicians about this child. It was decided to draw blood at the site, and run the labs back at the ship. I explained to the parents what we wanted to do, and asked them if they could come back the next day for the lab results. They told me they had left their house at 2 am, arrived at the site at 6 am, (I saw them at 1:30pm). I offered to call them by phone to give them the results. They chose to come back the next day to receive their results in person. I was impressed by how involved the father was in the care of this child. Up to this point I had primarily seen mothers bring in their children. The labs were drawn and I waited till 11:30pm to get the results and get copies to give to the parents the next day. I unfortunately was not scheduled to go out the next day (it would’ve been my 8^th straight day) to give the parents the results. All the results came back negative. The parents were told that he probably had drug fever and he should go back to see the neurologist. I was told that the parents were happy with the care their child received. I should be happy that we were able to give the parents some kind of diagnosis for their child. I wish I had some way of following up on this patient to see what happens. I wish I could follow up on all my patients I referred back to the community.

My experiences were not all bad or frustrating. Even though I speak Spanish, I still learned some new words. I learned new Spanish words for milk, baby bottle, candy, junk food, right now, military hospital ship, and diarrhea. I was thanked and blessed by many mothers for taking care of their children. I could see in their eyes how grateful they were for everything we did for them. Even it was just providing reassurance that they were doing things correctly. I could see a mother’s love for her child or children with every child that I saw. A mother’s love is the same in every country. I have met some incredible people on this mission. All the physicians were knowledgeable in their area of expertise, and wanted to share their wealth of experience. I admired the military for everything they do before this trip, now I admire them even more.

I had some sad times, and I had some wonderful times. I might not have been able to fully express my feelings in this post, but it is an experience that I will never forget. I am grateful to FIU and to my job for giving me the opportunity to participate. I have made new friends, learned new things, and visited new places. Participating in Continuing Promise 2011 is a decision that I will never regret.

Now I have to transition to life back on land. My room last night was so quiet it was difficult to sleep. I had not realized how quickly I had gotten accustomed to sleeping with the engine noise. I have not driven a car in over 3 weeks, and now I have to drive in Miami traffic.

I look forward to reading the posts from the next two students.

Good bye

Yesterday was a sad day for me as I had to say good bye to Kim, Luz, and Nicole. They brought so much energy and fun to the ship and I already miss it (despite their claims I would feel otherwise). Each brought something special to the mission and I got really lucky in having them as my students. Quite frankly they made my job extremely easy. I think now that they have or will soon have good internet access they will catch you up on their experiences and perhaps some reflections on it and also some picture which are so hard to upload from the ship. Oh, the rocking just started which means we will soon be out in open waters (and I hear rough ones). Time to get the dramamine out. In a few days I will post my own reflections on Guatemala. In some ways a really tough mission both of because of what we saw, what we could and couldn't do, and the conditions we worked under.

farewell

Today is our last day and it is with mixed emotions that I write this. Tomorrow morning I (we) will be disembarking from the ship, The time has passed so quickly I am not sure I have truly been able to appreciate what I have had the opportunity to be a part of. I have been honored to work along side amazing practitioners who have been committed to teaching me even when it was over 100 degrees outside, 10 hours into a 16 hour day, with lines of children and families still waiting to be seen. I won’t go so far as to say I have gotten my feet wet with regards to practicing independently, maybe just my toes, but the experience will stay with me for a lifetime.

I have seen so many truly needy families, adolescents who work instead of attend school, or for some, in addition to attending school. Families torn apart by illness, I saw one family- a grandmother and three young children whose mother had passed away just 8 days prior to their visit with me. Unfortunately all of their ailments seemed to be related with the pain of heartache and mourning, I told the grandmother that there wasn’t a pill a could provide or a treatment I could suggest that was going to ease their pain, they just needed time to heal. She began to cry and I could see the strength drain from her face, she was alone with the children. As she wept she was holding her 3 year old grandson on her lap, when he saw grandma cry his little bottom lip began to quiver and he began to cry, I wanted to sit and cry with them because it was breaking my heart to see them. I think she just needed to cry and someone to listen, I sat with her for a while and just allowed her to talk, that was the best, and only, medicine I could provide.

I went out for 7 days in a row and all the days have blurred into one. Luz and I had the chance to go out to one of the local hospitals to help teach/translate NRP updates and a lecture of therapeutic hypothermia and perinatal asphyxia. The lectures were intended for the physicians and med students but due to an emergency patient that needed to be tended to only the nurses were available, we gave the group the option to hear the lecture or not as it may be beyond their scope, they requested that the lecture be presented anyway because they felt that they provide care at times that is intended to be done by a physician. The lecture was presented and the nurses were great, made me proud to be a nurse... they asked insightful questions and seemed to be soaking up all the information to the fullest. There is some horrible statistic in this country regarding the number of babies that die each year, I can not remember the exact number but they seemed to grasp the enormity of it and were interested in learning simple life saving measures, if just one baby is saved we/they have made a difference.

There is a program put out by the AAP (i think) called Helping Babies Breathe, it was created in response to the fact that in many countries if a baby does not take a first breath spontaneously they are set aside and pronounced dead. The class teaches proper drying and stimulation of the baby, how to use an ambu-bag properly and deliver good breaths and proper suctioning of the nose and mouth. We were taught the basics on teaching the course, it seems like such basic care but to many babies and families it is life or death.

The most difficult part of this mission, for me, has been the limitations on what I can really do. The children who so desperately needed care were the ones who could not be helped directly at our med sites. I saw a child with CP whose mom was told that the cause of the child’s malformation of her feet was due to a seizure she had 6 months ago, we spent some time discussing CP and the associated physical and possible cognitive sequelae. I treated an 11 year old boy who had one leg longer than the other which caused him to limp and have pain, I referred him back into the community to see ortho and for possible corrective shoes, maybe surgical repair. But what I have heard is the most likely solution is a trip to a local carpenter and have him construct a shoe lift.

One case that really surprised me was a 5 year old girl, cute as can be, and the complaint listed by triage had to do with her ear, I could not really make out exactly what the issue was. Once the child sat down with me I immediately realized that she had a malformed ear, with just the lobe on the right side and she was missing her thumb on her right had, mom was concerned that as she grew she would have problems with the internal structures of her ear and wanted to be sure she would be ok. What surprised me was that mom not once mentioned anything about cosmetic concerns, she told me about how the girl had learned to write with an adapted way of holding the pencil when I spoke to her about the possibility of having a ear molded and surgically attached she looked at me like I had three heads, the service is available on the sister ship the Mercy (I have been told).


This has been a lesson in learning that I can’t fix everyone, sometimes education is all I have to offer, sometimes just listening is all I can do and all a person needs. This has been a humbling experience, a lesson in humanity and humility. All we need to survive are the basics, the rest is fluff. Parental love and concern are the same in every country. Children are resilient, families adapt and communities come together when the need arises.

I am sad to go but of course looking forward to going home, I will always carry with me the experiences I have had here, the knowledge I have gained. At the end of each day the exhaustion would take over but I had to remind myself that this was just a moment in time for me relatively speaking, soon enough I will be home with A/C, access to medical care, a cabinet full of snacks, essentially all the “luxuries” of home. At the end of the day for me I found that laughter was the best medicine, I enjoyed sitting around with our group sharing the good and bad of the day and if I was lucky I went to bed with a belly ache from laughing.

Many people said this trip would change my life and it has. I have made lifelong friends. I have learned more about medicine that I thought possible in such a short period of time, I have relearned the art of a thorough physical assessment and exam. I have learned a little more about myself and my strengths. I will try to appreciate all that I am blessed to have. When I think that things are bad I will remember the children who had the strength and courage to keep smiling in spite of it all and the mothers that keep it together. I will draw strength from them and remember things could be worse. I will eat all the food on my plate because there truly are starving children somewhere, in far away lands and in our own backyard.

First few days in Guatemala

This is going to be a short blog as I have been off the ship at med sites for the past two days and on again tomorrow, and exhausted. The days are long, extremely hot, dusty and did I mention hot??

The people we are seeing in Guatemala are very different than those in Nicaragua, there is a higher poverty rate, people appear to be in more need. The chief complaints are very similar, nutrition, weight concerns, parasites, everyone seems to have a belly ache and headache, especially after school. Most of the children are chronically dehydrated and truly have no idea about the importance of hydration, this is a catch twenty-two though, the water probably isn’t clean & most probably contributes to the GI complaints, yet dehydration introduces new problems. I have been talking to the families about boiling the water, but for most families it is not practical.

Interesting day yesterday... the locals brought a cow to the center of the area we were, slaughtered it, and prepared it to be cooked... cooked it and most people enjoyed a meal. I did not, I chose to eat chicken, I assume plucked off the street somewhere and cooked, but 24 hours later I am here, no issues. Local food is a part of the experience and learning the culture.

I saw a child yesterday who has all symptoms pointing to Ehlers-Danlos syndrome, the unfortunate thing is that I believe his mom had some handicap herself and truly did not understand the condition that he may have. I fear that he will not get the follow up and care I recommended for the best outcomes.

Today was long but I didn’t have a case that sticks out though, could just be related to my exhaustion but between all of the providers we did see several derm cases, unfortunately dermatology was not on-site today so some were asked to come back for consult with dermatology.

Well, I am off to the evening brief and probably bed, yes it is only 7:15.

Guatemala

Hello from Guatemala. Sorry it has been a few days since I posted. First it was internet issues then very busy out at clinical sites in Guatemala. On Thursday morning, Kim, Luz, and Nicole did a great presentation on Chagas Disease. It was very well received. They spent much time on it and it showed. Great job! We also ported in Guatemala that day. Not quite docked but a much shorter, much smoother small boat ride in. The site I went to the first few days was quite a distance though. It is also very, very hot and humid so I've been soaked by the end of each day. The people here have been really great and are very gracious when we see them. There seems to be much more need here than we saw in Nicaragua and it reminds of last year in Indonesia. Especially today when saw a woman with blood sugar of 550, severe diabetic ulcer on toe, and no sensation in front half of her feet and then the woman who has an ischemic stroke 2 years ago and her blood pressure today was 220 over 140. Yikes! A number of other serious cases and a lot let visits for general aches and pains. Okay, off to bed as another 4am morning tomorrow.