It’s over…

My last week was spent in Majuro, the capital of the Marshall Islands. It is much more westernized here and it was evident as soon as we first stepped foot on the dock. We were even working in a hospital with an inpatient pharmacy and air conditioning! Well except the pharmacy was the only room in the building that it didn't work. We did have fans and electricity though! And the American kind of electricity, the kind that doesn't require an adapter or a transformer. It's the small things….

It was interesting to see how they worked in this hospital pharmacy. The techs were allowed to fill and dispense prescriptions without the pharmacist's approval. Not much different than the last 5 weeks where we had Australian sailors and pretty much any spare body helping us dispense prescriptions, but it was interesting to see this in an actual institution. I had no doubt in the tech's abilities to do this job especially since their formulary was also severely restricted.

It is simply amazing how fast my time with Project Hope and the U.S. Navy passed. It was a wonderful experience and one I will surely never forget. I implore all of my pharmacy, medical, and professional colleagues as well as my friends to pursue such an opportunity to assist those in need if ever presented the chance. Participating in this medical mission trip has allowed me to work alongside specialists in their respective fields. It was also incredible to be able to interact with doctors from Canada, Australia, Chile, and South Korea as their kindness never ceased.

Jabwot

I had the pleasure of going to an outreach on the island of Jabwot. Our team was flown in by helicopter and my first impression as we flew over the island was that it was deserted. We soon found out that it pretty much was. We walked for fifteen minutes through a serene jungle, minus the occasional falling coconut, until we finally saw the village. Going in we were told to expect a census of 100 people. After checking everyone in at the clinic, we found there to be 54 people. Thankfully, all of the islanders received excellent care from a nurse that lived there and were generally in sound health.

After talking to one of the village elders I found out that the children have many opportunities to get off of the island and make a career for themselves. She had two sons in Arkansas and another in Hawaii. Though with 13 children, I guess some of them are bound to get around. We did see one patient who came in contact with a local predator. A fisherman had suffered a run in with a shark, was bitten in the wrist, and lost use of the tendons necessary for movement of the wrist. The doctor was able to refer the patient thanks to the Marshall's excellent referral system and follow-up care.

I was able to work right next to the two doctors and hand-deliver the medications so my job was done as soon as they had seen the last patient. The veterinary team unfortunately was up to their elbows in pig and dog neutering and soon enlisted our help. My first job, fend off the angry sow with a shovel while her male piglets were castrated. My second job, hold a piglet down while it was being castrated. Thankfully there was no third job. I figure the first two would look good enough on my resume.

Perhaps they'll let me pull teeth at the next site.

A good day

Today was a good day. We arrived in the Republic of the Marshall Islands and headed to the island of Kwajalein where an Army base is located. We didn't get hung up with passport or sovereignty issues and were allowed to take liberty on the island. I had Subway (it was a close call between that and Burger King) and the establishment across the way happened to have 50 cent Guiness Stout Bottles. The Pacific Fleet Band was there jamming out with some Michael Jackson and Jazz. The breeze off the ocean was the icing on the cake. Today was a good day, and it was much needed after the last two islands.

Kwajalein is a strategic military holding as it is home to a ballistic missile weapons intercept program, space operations support, and is one of five sites in the world with radar stations used to operate the GPS systems worldwide. The Republic of Marshall Islands is also the former home of nuclear tests conducted by the US, the most recognized atoll being Bikini Atoll. It is important to know that all the Marshallese located on Kwajalein were moved off this island to another, Ebeye. Refugees of the nuclear tests were also moved to Ebeye. One of our mission sites is located here and the population is estimated to be 12,000 living on a 0.5 mile patch of land. I've heard one of the commanders refer to it as a "little Tijuana."

Dr. Marks and I will not be participating in Ebeye MEDCAP but will travel on to Majuro in 3 days. In between, we are being flown out to two separate atolls for outreaches. Ailinglaplap and Jabwot await us with open arms, hopefully.

Kiribati – Betio Continued

On Thursday I had the great pleasure to meet Admiral Willard (http://en.wikipedia.org/wiki/Robert_Willard), a four star Admiral who commands the Pacific Fleet of the U.S. Navy. His accomplishments include commanding two different aircraft carriers, running the TOPGUN school, and has twice served on the Joint Staff among other activities. I was asked along with a representative of each partner nation to provide some feedback directly to the Admiral on our experiences and how they can be improved. Along with his wife Donna, the Admiral was personally responsible for organizing and planning this mission. It was a great honor to be able to provide a suggestion for improving it in the future, a proposal I'm sure will be considered for the next mission. After our meeting was concluded he gave us his personal military coin, which how I understand it, is an even greater honor.

We were asked to vacate the Betio Sports Complex for several days as they were holding an amateur boxing competition against rival Fiji islands. The two day event plus Sunday being a national day of rest turned into a 3 day weekend for myself. Dr. Marks and Phengphan each went to a different outreach site, an opportunity I will get to experience in the Royal Marshall Islands.

On Saturday I attended a health fair confident I could lend some support based off previous experience with APhA health fairs at the school. What I wasn't counting on was this fair being Kiribati style. Instead of having patients walk through the various stations and be screened, the I-Kiribati prefer to educate through song and dance. This made for an interesting afternoon as the Navy and USPHS healthcare providers were forced to come up with skits on the fly. Another important thing to note is the difference between the Navy's definition of time, if you're on time you're late, and the I-Kiribati definition of time, it'll happen when it happens.

On Sunday, the day of rest, some of the doctors and I went on a self guided tour of the Japanese defenses from World War II. We first passed the bunker the Japanese Admiral that commanded the island used. The building was pockmarked and overgrown but still rich with history. He died in the bunker on the 3^rd day of the invasion. As told, the bunker had gasoline pumped inside and was ignited via grenade, so deeply entrenched its defenders. Further down the road we found the Japanese artillery guns, still pointing ocean side. These gun batteries were huge and surprisingly still in great condition, though I doubt it would launch the coconuts stuffed down the barrel. The artillery shells were prepared in the pillboxes and bunkers behind the guns and transported via a rail system to the guns. Ironically, the guns were manufactured in the UK and sold to the Japanese prior to the war. All the directions on the guns are in English.

Tomorrow we start our five final days at the Betio Sport Complex before we steam ahead to the Royal Marshall Islands.

Kiribati - Betio

On Sunday morning we arrived off the coast of Kiribati (pronounced Kirabas as ti is an s sound in I-Kiribati) and were eager to get off the boat and ashore to begin set up for our first clinic at Betio Sports Complex (pronounced Besio). The islands themselves are surrounded by reefs and are nothing but spits of sand studded with palm trees. It appears the highest place on the island is about 5 to 10 feet above sea level.

We stayed on the boat all of Sunday due to a small issue between the U.S.A. and Kiribati governments concerning the Navy's sovereign right to not surrender a list of the crew linked to Department of Defense activities, i.e. the Navy and Merchant Marine crew. The issue goes from Kiribati customs agents to the Kiribati President and from our Commodore to the Commander of the Pacific Fleet, and wouldn't you know, an agreement is reached. So Monday we get on ground and instead of using the planned helo-ops, we end up having to take a 35 to 45 minute RHIB ride in. Once we arrive at the Betio Sports Complex the reason is clear; the ground is overgrown with both weeds and trash and the paved parts in are disrepair. Looking around one would think the place was 13 years old but a dedication plaque indicates it is only 3 years old.

The area itself is rich with World War II history everywhere you look. We drove past the battle-scarred Japanese headquarters, pillboxes and bunkers poke out from the ground, and the Japanese artillery guns, though rusty, still appear to guard the coasts. Even the RHIB ride in to Tarawa is historical. It is the same path the Marines took storming the beaches. Several boats are stranded on the reef just as the Marine's amphibious landing craft were stranded, forcing the Marines to swim and wade inland or face certain death under the Japanese counterattack. The water level is only 3 to 5 feet above the reef that stretches up to 500 yards from the beach.

Kiribati itself is another one of these "beautiful disaster" island nations. The scenery and people are genuinely friendly, but the conditions they live in leave a lot to be desired. The islands are small and narrow to the point you can see from one side of the island to the other just by turning your head. This leads to overcrowding and a collection of refuse. The only way they get rid of their refuse that I've seen is to burn it. The U.S. Public Health Service environmental health people have even told us of beaches that are littered with human excrement. One even joked that they don't even need to do thorough tests for choleform bacteria; they can just fill a glass up and then hold it up to the light for visual confirmation. The "Kiribati Salute" refers to checking the bottom of one's shoes for surprises.

Another interesting cultural difference is the children. They are everywhere and into everything. The children are very nice, curious to see us and what we are doing, and aren't afraid to invade your personal space. Another joke is that they seem to let their dogs and children run free, but lock the pigs up. Speaking of pigs and sustenance, due to the islands lack of space and rather dry conditions, they are only able to grow food in crops in small amounts and fishing predominates the food gathering. Kiribati is actually expected to be the first country to disappear due to global warming and the rising of the seas.

Shellback Ceremony

Dr. Marks and I began our shellback ceremony at 1800 with an announcement from Davy Jones himself! He heard about all of us slimy pollywogs, 47 in all, on board and was demanding we show up for physical fitness the following morning. The one and only King Neptunus Rex himself would be present with his court of trusty shellbacks for our physical test. The shellback ceremony is also known as the crossing the line ceremony. It is done to commemorate a sailor's first time crossing the equator and is administered by those who have been initiated.

Our first night we had to do a talent show in front of all of the trusty shellbacks. Possessing no inherent talents, I decided to "borrow" someone else's. Dr. Marks and I decided to copy Dr. Stolte's and Dr. Clements Thursday Night Live spoof from Phollies. We were imitating Craig (Will Ferrell) and Arianna (Cheri Oteri), the Spartan cheerleaders, from Saturday Night Live. We planned three cheers, my personal favorite being "Who's that pharmacist in my pharmacy" with Dr. Marks popping out and saying "It's me It's me." We also laced it with several jokes and references to what we have seen so far on this mission.

We were psyched, ready to get it over, and suddenly it was our turn to get on. We ran onto the flight deck with pom poms flying and executing perfect scissor kicks. All of our practice and hard work paid off. We got three lines into our skit and everyone stood up, and booed us off stage. Whew, that part was over.

We woke up at 0600 the following morning. I'm not sure if I am allowed to reveal the next part in its entirety, but here are some choice words. Water. Duck walk. Peanut Butter. Jelly. Calisthenics. New hairdo. Green eggs, bacon, oatmeal, and ham. Calisthenics. Oranges. Tuna fish and rice slip and slide. Calisthenics. Swab the deck. Leap frogs. Fire hoses. Bowline dragon. Row row row your boat. Make the baby laugh. Dunk tank. 2 hours later and I am now a trusty shellback.

Dr. Marks and I can now both say this with pride for having made it through. It's a great honor to be a part of this naval tradition as I imagine not many civilian pharmacists will be able to display their shellback certificates in their offices. This was another unique experience that this rotation has granted me with.

Good Samaritan Hospital

Our third and final clinic was at the Good Samaritan Hospital, donated and built by the Italians. Catholic nuns live, work, and run the hospital. Getting to the hospital itself is a nice 30 to 45 minute drive depending on how crazy the driver is. We pass through palm tree plantations which equates to 50 foot palm trees in neat rows as far as the eye can see. I hear the Solomons are the world's largest producer of palm oil. Supposedly it's also where one third of the world's tuna that is canned comes from. We also pass the island's only self-serve car wash, a shallow portion of the river the few automobile owners can drive through and splash water onto their car. This tradition was started by the United States Marine Corps back in WWII when they gained control of the islands. The hospital itself is set against a backdrop of mountains perpetually shrouded in clouds.

The view is quite soothing for the amount of volume we are seeing. Yesterday we had a personal best of 500 prescriptions! The pre-packed medications we gave the providers have certainly saved us a large number of prescriptions as well. We have also been very lucky to have a few of the Australian sailors as well as English medical students help us in the pharmacy. We are able to quickly train them to be autonomous in dispensing prescriptions. This is quite different from the U.S. where there are several checks and balances before the prescription leaves the pharmacy.

It's quite incredible what the nurses do here at the hospital. They are very well trained, love what they do, and this is a blessing for Guadalcanal. I imagine it is almost impossible to entice doctors to the island. It is one of the only islands where malaria is still an issue, healthcare reimbursement is next to nil, and the bustling city life is dirty and dangerous. The WHO lists the Solomon's as having something like one doctor per 155,000 people. The hospital is lucky enough that Sister Dolly, the head nurse, has two Cuban doctors as friends that will visit once a week. This it's self is boggling to me coming from America where Patient First's and quick-care clinics are starting to become as populous as retail pharmacies.

But now the Solomons are behind us and we are moving off towards Kiribati. The experience here has been very eye-opening and full of some life lessons. Hopefully Kiribati will be just as exciting.

Gallery of Pictures

Steve has taken the lead in writing about our adventures (and is doing a phenomenal job), since I am doing the SITREPs (Situation Reports) for Project HOPE, but I will add what I can to keep you updated. I have found that posting pictures to the blog is very difficult due to the internet capacity, so I am adding pictures to my own gallery which you can all access. Please go to http://gallery.me.com/alla.marks to view the first set of pictures from our mission. I will be posting new pictures whenever I can and will describe the picture above a little later in my blog to create some suspense and anticipation.

Tomorrow is our last day in Solomon Islands and we will be sailing to Kiribati on Wednesday (your Tuesday). Our first island has presented several challenges and accomplishments. We definitely have had to adjust to the heat, which is much more intense than Samoa and Tonga. We drink several bottles of water during our MEDCAP and sweat it all out. I found out the hard way, through an allergic reaction, that sunscreen with DEET, is not compatible with my face. So far, the mosquitos have not been bad, but Solomon Islands has the greatest prevalence of malaria, so everyone is diligently taking their doxycycline or mefloquine.

In terms of accomplishments, Steve and I have been on site every day of each MEDCAP (while other departments get work/rest cycles). The days are long, hot and busy, but very rewarding. We have had the opportunity to counsel on albuterol use with a spacer, discuss antibiotic options with the physicians, and instruct medical students from England and members of the Australian Navy as to how to dispense and counsel. I was able to assist a medical student in administering ceftriaxone IM to a patient, since she had never given an injection to an actual patient. Immunization delivery certification definitely came in handy! The team work during this mission is simply amazing. We have physicians, nurse practitioners, dentists, dental technicians, optometrists, and pharmacy staff all working together in a collaborative manner. Physicians actually ask us for advice (and even follow our suggestions) as well as step in after they are finished with clinic to help us get prescriptions out so we can pack up and get back to the ship. Pharmacy, of course, is the last stop for both medical and dental patients. The islanders are so patient...they stand in long lines to get registered, then to see a physician, then to get a prescription. If they want to be seen for more than one service, they have to get back in line to be registered again. Sometimes, it is very difficult for us in pharmacy, since we have such a small formulary of medications and we are only treating acute diagnoses or relieving symptoms. Simply giving acetaminophen to help with pain to a patient with tuberculosis or breast cancer definitely tugs at my heart, knowing that it does not resolve the cause of the pain. A lot of patients have serious chronic conditions that cannot be addressed by the Pacific Partnership, so they are referred to the local hospital without a guarantee that they will actually follow through or get the level of care that we are blessed to receive in the US.

Adjusting to military life is interesting. I, who am not a morning person at all, have started to work out before breakfast (served at 7am), since so many people do. Meals and meetings define your day. There is no training or preparation for hazardous physical activities. For example, yesterday we had to use Jacob's Ladder to get on the ship (pictured above) since the waves were too high for the regular gangway (which itself is extremely long and difficult to maneuver, especially with your heavy backpack filled with 6 bottles of water and MRE for the day). You have to time jumping off the RHIB onto the ladder as the swell rises then grabbing with both hands and climbing up one rung at a time without looking down. I am sure you can all appreciate the death-defying feat that Steve and I both accomplished (without falling into the water).

Well, it is rounding midnight and we are mustering at 0730 to go to the MEDCAP. Stay tuned for more exciting escapades.

A week on the H.M.A.S Betano

Dr. Marks and I had the great pleasure to stay on the Australian LCH's this past week. I was on the Betano and she was on the Wewack, sister ships who will be decommissioned next year. Let me just say, the Australians have been awesome and they welcomed us with open arms. Of course, there's a crew of sixteen or so on each ship and I think they were happy to have some new people to talk to.

On the Betano, we had a younger crew with a CO who knew how to have fun. The LCH's have very large tank decks for holding supplies and ours had been converted to a party deck after the first day at anchor. It was complete with weight room, pool (no diving), and a movie screen projected onto the side of a module. A module was what we slept in and it resembles an eighteen wheelers trailer, but much smaller. We were racked 3 high and I banged my head a few times on the bunk above before learning my lesson.

The Australians also were a great help at the clinics. They helped the dentists with extractions, pre-packed meds for us, handled crowd control, and all the while they did it with a "No worries mate." Afterwards, exhausted and sweat-soaked (I really want to drive in how hot it was), we would pile into the flatbed and head to the Auki Lodge to have a few refreshments, Solbrew, before heading back to the pier to catch a zodiac to the ship. From there we'd enjoy a hardy meal and cool down in the pool.

Sadly, the Australians will be heading back home after next week so we will lose a very large support arm of the mission. Cheers!

Visale and Auki

Our first week of clinic was quite the ride. The amount of sweat we shed was evidenced by the liters upon liters of water we had to drink to avoid heat related injuries. It's hot.

It's fair to say Dr. Marks and I were quite grumpy (Sorry Nicole!) at the beginning but we've adapted. We're getting closer to the equator and it will only get hotter. We're doing it the Solomon way – just sweat it out!

The clinic has been seeing 700 people a day through the combined services (optometry, medicine, dental) and we've been busy averaging 300+ prescriptions a day. We got smart very quick and had the Australian guys pre-pack all kinds of medicine to give to doctors to dispense to alleviate the burden on us. Even so, we average 200 people a day we still have to counsel in Pigin English. If you see Dr. Marks around school just ask her to show off her Pigin skills; she has learned a new language!

The islanders have shown up in full force and line up at 3am for our 9am clinics! Just about every other person has some sort of fungal infection and I've seen several cases of tinea corpus. Malaria is a problem here but we are referring those patients to the host nation for care. We're also quite lucky to be able to work with two pharmacists from the host nation. It is incredible how they've managed to deliver high quality healthcare with the extremely limited funds. They work 12 hour days and are on call during the weekends and JohnMac(enroe) travels across the Bay to get to the hospital.

The Solomon people are very friendly and intelligent. They live off the land and farm for themselves. The islands as a whole are very poor and they crowd our clinics because the healthcare is free and they may not have the funds to afford it otherwise. Besides betelnut, I've noticed another odd behavior of the Solomon people. They litter indiscriminately. As soon as they are finished with something it's either thrown on the ground or in the water. From afar, the beaches are beautiful, but as soon as you get close you'll notice trash is just below the water. Tomorrow we retrograde (pack-up) and head to the hospital in Honiera.

Opening Ceremony – Solomon Islands

This is the hottest weather I have ever been in. It feels like you are walking through water and the sun is but a mile away. It's even hotter on the flight deck of the USS Mustin. We were on the deck to celebrate the opening of the medical, engineering, and veterinary clinics that would be held through the islands. Several high ranking officials from various armed forces were there. I had the distinct pleasure to meet Rear Admiral Robin M. Watters who is Chief of Staff for the U.S. Pacific Fleet. Also among us was a two star Australian Defense Force General, Solomon's Prime Minister, U.S. Ambassador, and members of the Solomon Parliament.

Riding in from the Byrd to the Mustin, we were met with stares from the islanders who packed the piers to watch our arrival. Looking back out into the bay, the Byrd struck an imposing figure among the smaller fishing vessels. Walking from the pier to board the Mustin I saw my first case of the long term effects of chewing betelnut, an anxiolytic and stimulant. The telltale sign of betelnut: rotten teeth stained a bright blood red. To say the least, that was an experience but probably less traumatizing to me than to the dentists with us. As a quick side note, the USS Mustin is a guided missile destroyer and is quite the impressive piece of machinery to have the opportunity to tour.

Tommorrow we leave for our first clinic via helicopter. We will stay 7 nights aboard an Australian LCH (Landing Craft – Heavy). Think of the ships in Saving Private Ryan with the front loading door. Expect to hear more about our experience upon our return to the Byrd August 14.

Iron Bottom Bay

Today we have arrived in the Solomon Islands. Another beautiful island with sapphire blue water set against mountains. We arrived in the Solomon's between Savo and Guadalcanal islands, escorted by the USS Mustin, a missile guided destroyer. The destroyer was mainly for show as several high ranking military officers were stationed. They were here to celebrate Guadalcanal day with a welcoming ceremony onboard the Mustin.

This time of year 67 years ago U.S. and Australian navies were pulling into the Guadalcanal region to battle the Japanese forces. Allied forces engaged in naval, aerial, and ground battles starting August 7, 1942 against the occupying Japanese Forces. The naval forces were engaged in the middle of the night and the superior nighttime warfare of the Japanese naval forces dealt heavy casualties. Twenty nine Allied cruisers and destroyers sunk to the bottom of the canal. Thus the name, Iron Bottom Bay.

Even though Allied forces sustained heavy casualties, the Japanese sustained even heavier casualties attempting to reinforce their ground troops. The Japanese lost 38 ships and 31,000 lives (compared to the 7000 Allied). This was the turning point for the Pacific front as the Allies now were pushing the Japanese forces backwards.

It is quite the honor to be here at this time and traveling the same route the Allied forces used in their assault.

Hope you enjoyed the history lesson. Dr. Marks and I just found out we will be putting boots to ground in a couple of days so look forward to hearing about the clinics we will be participating in.

Culture Shock

Today two of our many orientations dealt with culture shock. These presentations were geared towards the armed forces that were present, which by the way is everyone but the 6 civilians. They were teaching about how to identify and prevent one's self from becoming culture shocked. I then realized I was culture shocked but not by the Pacific Islanders. I am now living with the Military culture. Everything the military does is, not surprisingly, very structured. We all meet at our pre-arranged times every day at the same time even if there is nothing much on the agenda. I soon found myself planning around when my next meal would arrive (0700, 1200, and 0530). As the chaplain said today "You may not be military, but for this mission, you are."

All of this aside, the people I am living and working with are wonderful. I've made friends of French engineers, Canadian dentists, a South Korean dermatologist, Australian engineers, and a variety of healthcare providers from the armed forces. The Commodore and his crew have gone out of their way to make all of us "newbies" feel at home. The majority of officers on the ship do practice a certain medical specialty.

The ship itself is about as large as a cruise ship with a helo landing pad where the pool should be. I find it very akin to staying in a hotel. The major exception is that this hotel has a tendency to sway back and forth. The second busiest parts of the ship behind the mess halls are the fitness rooms. Everyone is encouraged to participate in daily physical fitness in order to prepare for the intense heat and humidity of the islands we are visiting. At 2100 it was about 90 degrees and humid enough to make it feel like you were breathing in water. I guess this is to be expected as we are now nearly on top of the equator.

Dr. Marks and I eagerly await our turn to go ashore either aboard the helicopter or the rigid hull inflatable boat. The next couple of sites they are predicting upwards of 750 people a day. Reports have even come back from the advance echelon team citing instances where people will travel for days for medical aid and patients will often show up by the truckload.

Final thoughts on Tonga and PP09

I've been putting off the writing of this post for some time now. We left Tonga on a Sunday and spent three days sailing to New Caledonia, PP09's only liberty port. We were working while we were underway, preparing medications for the Solomon Islands, but I had time to write. I guess that, subconsciously, I associate the writing of this blog entry with the end to what has been a truly remarkable experience. Even now, as I stare out over tarmac, it hasn't fully hit me that my time with PP09 is done.

My last week in Tonga was probably the most memorable. In addition to the adventure that was Tuesday, on Wednesday I was called upon to prepare some IV medications for a trauma patient. I had prepared sterile medications under far worse conditions while in Samoa, so doing sterile work in the Tongan hospital was a walk in the park. The fun began after I delivered the medication. The local nursing staff had not used this particular medication before and was unfamiliar with its administration. After our surgical tech tried several times to convince the nurses of the proper technique, I was called in to defuse the situation. I would like to say that I was my calm, authoritative demeanor, my natural leadership ability, or my irrefutable charm that made them believe me, but I suspect the flashy drug reference I showed them on my touchscreen iPod may have played a role.

On Thursday, things got interesting when we had a patient present with typhoid. Technically she didn't list that as her chief complaint, but the bloody diarrhea in Dr. Ho's office gave it away. True to form, Dr. Ho wanted to give chloramphenicol, a drug rarely used in the US due to its toxic side effects. Thankfully Dr. Newman, our fearless cardiologist, was there to suggest something a little less toxic.

Friday was our last day of clinic in Tonga and my last day of clinic for PP09. We were only open for a few hours in the morning with the rest of the day being allocated to packing up our clinic (the Navy calls this process "retrograde", but I refuse to use retrograde as a verb). When we had seen our last few patients (I'm happy to report that the lady with typhoid was responding well to treatment) and finished packing, the hospital staff held a closing ceremony for us. In Tonga, the traditional way to say goodbye is by sharing kava. Kava is a plant whose roots contain a chemical known for its anesthetic and anxiolytic properties. It is brewed into a tea and served in a coconut shell. You don't savor kava, you chug it…a feat that is difficult to do gracefully.

Sitting on the floor in an elongated circle, they served us one at a time. Using a half of a coconut shell, a large Tongan nurse scooped up the kava from a vat and walked over to me. She towered over me as I sat cross-legged on the ground. Given the inherent elevation differences of our positions, the coconut shell was presented directly to my face. She gazed down upon me impatiently as I hesitated, but for an instant, to inspect this mysterious concoction. It was a watery, light brown mixture with no apparent odor. Without a moment to lose, I grabbed the shell and slurped it down. Now coconut shells are not like bowls; their edges are rough and inconsistent, so a certain amount of spillage is unavoidable. Handing the shell back and trying to slyly wipe my chin at the same time, I began to wonder why they drink this stuff. It does not taste bad, but it's not good either. It is a little earthy, but ultimately it is quite flavorless. Then it hit me…I couldn't feel my lips…or my tongue! I even had a slightly numb spot on my chin where it dripped. It was quite fascinating really…something akin to drinking lidocaine. I'm not sure I'd like to adopt this custom, as I found the lack of sensation more unsettling than relaxing. Nevertheless, I felt honored to be included in the ceremony.

After the kava ceremony we exchanged gifts. We presented each of the hospital staff with certificates of appreciation and they gave us each a trinket or souvenir of some sort. I was given a lali (pronounced La-Lee) a sort of percussion instrument. It is hand carved from piece of wood and really quite beautiful. Apparently these were used in place of church bells. When the gifts were all given the dancing started….and everyone knows I love dancing. Like a fish to the frying pan…or an Irishman to a tanning bed…you just can't keep me away…

The ceremony officially over, everyone was standing around, talking, and taking photos. A bunch of local children where there and soon became the life of the party. At the sight of a camera, they'd cluster together for the shot then swarm you to see how it turned out. The remarkable thing about Tongan children is that they are all tough. At the pharmacy we had several 3 year old children that could swallow pills. Even during dental extractions, very few of the kids would cry…and our dentists were scary ;) After the ceremony, the kids were literally climbing all over us. Dr. Farwell and I decided to have a race, each with a kid sitting on our foot. Farwell is huge…a sort of Arnold SchwarzenDoctor…so he won by a mile, but the kids had fun.

The kava finished, the gifts given, and the goodbyes said it was time to leave. For most of the medical team, Tonga was just a stop on their journey. For me, it was the end. I rode to the pier on the back of an old flatbed truck with the last of our supplies; trying to soak up as much of the experience as possible. My time with PP09 has been amazing from the start and is an experience I won't soon forget. I am saddened that it is over, but moreover I'm grateful for the opportunity and forever humbled by the experience.

New Caledonia – Sat-Mon

What an incredibly long series of flights to get to New Caledonia. As a first time international flyer, I found 24 hours of flight time to be quite tasking. New Caledonia is beautiful when you fly into Noumea's airport, flanked by mountains on one side and water on the other. The airport terminal was small and getting through customs, baggage claim, and out the door took all of 50 feet. H1N1 is a big concern in the area and all incoming passengers are screened via a thermal imaging device that looks at the eyes for elevations in internal temperature.

From the airport it was an hour's drive into the actual city of Noumea through some of the 1500 odd mountains in New Caledonia. The city itself is very busy, filled with a quite diverse mix of poorer Pacific Islanders, Chinese and Japanese business owners, and well-to-do French citizens. Everyone speaks French and touring the city has been quite the challenge being on the other side of the language barrier.

On our first day, the U.S.N.S. Richard E. Byrd moved from anchor in one of the bays to portside at the cruise ship marina. This ship is humungous! It has been drawing quite the crowd from the locals and to get back to the ship with a taxi driver all I've had to say was take me to the big American ship.

Tommorrow, Monday, we are leaving port and getting underway to the Solomons. We've been hearing about the impact John Nett (Big John) and John Hammill (Little John) have had on the missions thus far and we are very excited to begin our work in 3 days times.

Time to try and get on this sleep schedule….

July 21th Strange day in Tonga

The day started out normal enough. As usual, our clinic was the most popular place in town and patients were coming in by the busload. My preceptor, John Nett, was given the honor of being the sites Officer in Charge (OIC) and was kept pretty busy with both pharmacy and OIC duties. We broke for lunch around 1230 and enjoyed a delicious MRE under a tree on the beach. It was a rather agreeable setting until the rain came. In typical tropical fashion; it was sunny once moment and raining the next. It was as if someone tripped a switch and turned on the rain. Not being the type to allow a little rain to ruin a perfectly good meal, I simply grabbed my stuff and continued to enjoy my pouch of vegetable lasagna and my bag of osmotic cranberries under an awning of the hospital. Not as nice as on the beach, but still quite agreeable. Seeing as the rain has cooled things off a bit I opted for coffee…Field Joe to be precise.

For the uninitiated, MREs often contain a small packet of Nescafe instant coffee powder. To make Field Joe, you simply pour the powder in your mouth and follow it with as much water as your cheeks can hold. Then simply shake your head side to side and presto…fresh coffee, brewed right in your mouth. Sadly, I did not invent this wonderfully creative caffeine delivery system; the art of Field Joe was passed down to me from the all knowledgeable Dr. Cota, CDR, USN when we were on Savaii. For those of you wondering…it's awful and worse yet, the taste seems to linger for an unnaturally long time. But it served its purpose and before long I had all the energy I needed to finish the day strong.

As we were putting the finishing touches on our final prescriptions of the day (354 in total), word came that the weather was too rough to run the RHIBs. This meant that, for the moment, we were stuck on the island. What do you do when you find yourself stuck on a tropical island with no way home? Simple, you remember your Boy Scout survival training and seek out the necessities: food, water, and shelter. So we went to the bar.

The Mariner Café & Bar is literally the only establishment on the island. It is a small outdoor café/bar with 5 tables under a covered patio. Our entire medical team that day was around 25 people. When we pulled up the Mariner we realized that we were not the only ones stranded on the island. The engineering and veterinary teams had beaten us there…about 50 people in total. Needless to say, the place was packed and we soon ate nearly every bit of food in the place.

It was now getting late and word again arrived that there was no chance of getting back to the ship that evening. We now had to find accommodations for 50 plus people on an island without a proper hotel. Luckily we had the mission commander there to help. Through a herculean effort, he somehow found a place for everyone to sleep. I was lucky enough to get a rack aboard one of the Australian LCHs that was docked at the pier.

No sooner than I step inside the LCH do I hear "Safeguard! Safeguard!" go out over the Australian PA. It was very dark on the pier and one of the girls coming aboard the LCH missed her step in fell between the ship and pier and into the ocean. The people immediately behind her said she simple disappeared in front of them. She managed to fall through a gap no more than 18 inches wide without hitting a thing and without making a sound. Luckily, one of the tallest people on the entire mission was right behind her and was able to pull her out quickly. It was absolutely amazing that she was able to walk away from that with no more than a wet uniform.

The Australians were great. Not only did they find towels and dry clothes for the girl who fell in, but they really went out of their way to make us all feel at home. We had warm, comfortable beds and a hot meal in the morning. They even played Born in the USA over the PA as the morning wakeup call. The only bad part of the night was the lack of a toothbrush, for I still had the taste of Field Joe in my mouth.

July 18th Kingdom of Tonga

It's Saturday night and with help from a frosty cold, supposedly formaldehyde laden, but none the less delicious Tongan beer, I've finally caught my breath. The Tongan clinic is a hit. Each day we get busier and busier. We are bringing patients in by the busload…literally! In five days we've seen roughly twenty five percent of the islands population. Today was a half day and we still managed to fill 180 scripts. Friday we churned out 411. I'm not going to sugarcoat it…we're pretty awesome ;)

But don't get the impression that we are just a prescription factory…mindlessly turning out script after script. Much to the contrary, this has been the most clinically oriented pharmacy of the entire Pacific Partnership mission. Every day I'm talking to the physicians; discussing dosing or drug selection. For example, we have seen a lot of tinea type skin infections in Tonga. Because we lack the medications indicated as first line treatment, each physician took a different approach initially. However, after some discussion we were able to agree on a treatment and standardize our approach to the problem.

Perhaps the biggest contributor to the clinical orientation of our pharmacy is the location itself. We are setup in the hallway in front of the hospital's pharmacy. The local pharmacist, Salome, has been terrific. She is very knowledgeable and has been helping us with translation and counseling. She has also allowed us access to her pharmacy and her medicines. This has dramatically increased our ability to provide care. The drugs that the Navy purchased for PP09 are all for treating acute illness. We have virtually nothing for chronic conditions. The pharmacy at Nui'ui on the other hand is stocked with a respectable selection of medications for a variety of conditions. Our physicians are now able to prescribe medicines for diabetes, heart failure, hypertension, and a variety of other conditions that we could do nothing for in Samoa. Furthermore, we will remain at this site for two weeks. This allows us to conduct follow up care; something that was impossible in Samoa. We can bring patients back to check the efficacy of their therapy, for routine wound care, or to complete a complex procedure. From the patient's perspective this lends credibility to our operation and makes us easier to trust. If they have questions or are unhappy with the care we've provided, they know right where to find us.

Working so closely with the physicians here has been one of my biggest challenges, but at the same time it is what I've enjoyed the most. One physician in particular, Dr. Ho, has been particularly challenging and fun to work with. Dr. Ho is a partner nation physician from Singapore. His style of medicine is noticeably different than that of the US. As soon as I started receiving his scripts, I knew I would find him interesting. One of the first things he wrote for was Ponstan tds 2/52. Now I could figure out that 2/52 meant two weeks and I reasoned that tds was equivalent to TID, but what the heck is Ponstan?

Now if any of my professors are yelling at their computer screens saying that I should know this drug, let me first say that I checked…I searched every PowerPoint and every note that I ever took in pharmacy school and the word Ponstan, or even its generic name, does not appear anywhere. But I digress…

Apparently it is an NSAID of sorts that works well for menstrual pains and is commonly used in Singapore. Who knew? Well it wasn't long before I was a familiar face to Dr. Ho. We were persistent thorns in each other's sides. He would use an abbreviation that I didn't know or would opt for an uncommon treatment approach and I would be right there in his office asking questions. I learned quickly that you need to be prepared if you are going to challenge Dr. Ho on a therapy choice. He's good, he knows his stuff, and he is always prepared to defend is position. A few times I came into his office, Sanford Guide in hand, thinking I had a superior approach to therapy; only to find out that he'd already considered my idea and dismissed it. He always seemed to have at least three good reasons to back up his position. Even when I'm wrong, I have found that I enjoy these encounters because I have never left his office without learning something.

Tomorrow is, by Tongan law, a day of rest and we all can use it. Monday morning we start back up again and, as tired as I am right now, I find myself anxious to see what the next week brings.

July 13th – 14th Pangai, Kingdom of Tonga

We had a smooth sail from Samoa. Our two day journey to the Kingdom of Tonga provided us with some much needed rest and some time to prepare for our Tongan mission. Having offered up Saturday as a sacrifice to the International Date Line, we arrived on Monday and I was anxious to get ashore and start working. Two Australian LCHs (Landing Craft Heavy) had joined us and will be used to bring our gear ashore. Unfortunately, Mother Nature had other plans on Monday. Heavy rain and rough seas tossed the flat-bottomed LCHs about too much to transfer our gear aboard. Instead we spent all day Monday in a constant state of readiness…waiting for the green light that never came.

On Tuesday, I awoke to calm seas and a busy schedule. Monday was supposed to be our setup day. Now we have to setup and open our clinic on the same day. At 0700 I raced from my room to the galley to see how much food I could pack away in the 10 minutes I had to eat breakfast. It turns out that I'm a remarkably slow eater. By 0715 I was on a RHIB headed to the town of Pangai, on the Tongan island of Lifuka.

I arrived on shore with my stomach growling and was disheartened to learn that my haste this morning had been in vain. Due to some miscommunication, our gear would not be ready for offload until 1000. 'Hurry up and wait' is a concept I've become quite familiar with during my time here.

Lifuka is a fairly small island; only 5 kilometer long and less than a kilometer wide in most parts, but it is beautiful. The beach is lined with coconut palms and small wooden boats are moored just off shore. It looks delicate on approach; the island is basically a low mound of sand atop a massive coral reef. It would take little more than a heavy rain or strong wave to wash it into the sea. In fact, that is a major reason why we have come to Tonga. In addition to medical care, we will be conducting emergency preparedness drills and helping them prepare for a natural disaster.

Our clinic site this time around is Nui'ui Hospital. It is the island's main hospital and is, by far, the nicest medical facility I've seen since joining with Pacific Partnership. The hospital is a one story building shaped like a T. Although not laid out like a US hospital, it does have all the major components. There are recognizable patient rooms, a dentistry clinic, a surgical suite, a laboratory, and a pharmacy. It even has an ambulance garage.

John and I made short work of setting up our pharmacy. We spent a good amount of time before we arrived in Tonga redesigning the formulary that was built for this mission. Our resulting formulary is much more compact and optimized for this mission. In no time, we were setup and ready to fill prescriptions. We saw 64 patients in our first day and filled 132 prescriptions. Not bad for a half day and an empty stomach, but tomorrow will be the real test.

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Additional ways to follow the Pacific Partnership Mission

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The official blog, http://www.cpf.navy.mil/subsite/pp09/index.html

US Navy updates online, http://www.navy.mil/local/pacificpartnership/

From the USNS Richard Byrd

July 8th – July 9th Final Days in Samoa

On Wednesday I celebrated my birthday in style: by filling 533 prescriptions for 252 patients! Media exposure of our clinic over the past two days has really gotten the population excited about what we are doing here. Thursday was our last day of clinic and we were only open from 0800 until 1300. The local news station, however, told the public that we would be there all day. There was nearly a riot when we closed registration. A few hundred people were crowding the registration desk in the building's entryway. Another 20 or 30 people were loitering around the back door of the pharmacy, looking for a way to enter the building. The police had to be called in to disperse the crowd and thankfully the situation resolved without incident. While the situation could have ended badly and I do feel bad about having to turn people away, I hope it serves as an eye opener for the local healthcare system. I hope they are driven to improve their system and restore the public's faith in their abilities. I also hope that the public stands up voices their concerns. Our presence in Apia has exposed the public's desire for quality healthcare. Let Pacific Partnership 09 serve as the catalyst that transforms the healthcare system of Samoa.

Tomorrow we set sail for Tonga. I'll leave Samoa with fond memories that will last a lifetime. I've learned so much here, done and seen things that I couldn't have imagined just a few short weeks ago. We may not have transformed their healthcare system, but we have sown the seeds. If I'm lucky enough to return to Samoa in the future, I'm confident that I will witness the fruits of our labors.

July 7th Apia, Samoa

On the second day of clinic, we changed our hours from 0800 – 1600 to 1200 – 2000 to accommodate the work crowd. Business was good: 230 patients and 442 prescriptions, but I'm starting to notice a trend in the type of conditions we are treating. In Sataua, we were serving an immediate need. The people on the island of Savaii have very limited access to healthcare and the conditions we treated reflected that. We saw several conditions or disease states that were the result inadequate healthcare. I wrote earlier about the patient with elephantiasis. This condition can be completely avoided if the filariasis is treated early. We also saw a lady that had a large cyst on her upper leg that prevented her from sitting properly and dramatically decreased her quality of life. The examples go on and on, but if it was not for our clinic many of the patients on Savaii would still be suffering.

In Apia, healthcare is much more accessible. The city's main hospital is in the center of town and care for Samoan citizens is nearly free. Samoans need only pay a $5 tala administration fee to obtain their medical record. The actual care is free. As a result, the conditions we saw in Apia were much more acute. Gone were the progressive complications of long neglected diseases; replaced with simple cold symptoms or muscle aches and pains. On the whole, this is a good thing. Such basic conditions reflect a fairly healthy society, but we are missing a golden opportunity.

Each day we saw more and more patients. When asked why they waited in such long lines to be seen by us instead of going to the hospital, the nearly unanimous answer was that the quality of care we were providing was far superior to the local hospital. This is the opportunity we are missing. We are setup in a community center. All the local translators and helpers are volunteers with no medical background. Instead of treating simple conditions that the local doctors are already capable of treating, we should have been working alongside the local healthcare providers. Had the local medical community been represented at our clinic two things would have happened. First, we could have had a tremendous exchange of knowledge. There were several tropical skin conditions that our physicians had never before seen. The local physicians would certainly know better how to identify and treat these diseases. Furthermore, we could have taught them more advanced treatment procedures and diagnostic techniques. Secondly, the peoples' faith in their local healthcare system would be strengthened had they seen their physicians and nurses working, as equals, alongside our team. We could have helped them identify why the public views their health system as inferior and helped them improve. By treating only short term conditions in total isolation from the local health system, we have set ourselves up to achieve only short term goals. The people in Apia clearly need our help, but a more lasting contribution would be to help them improve their health system thus rendering our services unnecessary.

July 5th – July 6th Clinic in the Capital

Returning to Apia, I was pleased to see that the Byrd was pier
side. This would make it much easier to get on and off the ship. We got back on board with just enough time to shower and grab some food before we left again to set up clinic in Apia. The site chosen for the clinic was a large community center near the center of town. The main part of the building was a massive open room with a stage in one corner and a kitchen in another. With Apia being the capital as well as the most populated city in Samoa, we were expecting to see larger numbers than what we encountered in Sataua. However, I was still shocked to see just how many chairs had been set up in the waiting areas. It was a sea of plastic. Hundreds of chairs…we were going to be busy.

The building's kitchen opened up to the main room through a series of windows that could slide to one side to allow for the serving of food. It seemed the natural choice for the pharmacy location with one exception: It was overrun with ants and cockroaches. A call went out to the Navy's preventative medicine team and they responded with a backpack sprayer of permethrin. I have to admit, I was a bit skeptical at first. After all, permethrin is what we use on little kids to kill lice. I expected to return the next day to find a room full of angry cockroaches, alive and ready to fight. Thankfully these bugs capitulated to the chemicals and I returned the next day to find massive cockroach casualties.

With the roach problem behind me, my focus returned to how to deal this onslaught of patients that had been predicted. In Sataua, John Nett and I were alone and making it up as we went along. Here in Apia, we had help from a Navy pharmacy tech and series of lessons learned from our experience in Sataua. Before long we had the pharmacy organized and a workflow established. We saw 180 patients the first day and filled 270 prescriptions. We were busy, but it was smooth sailing all day. Never did I feel rushed or overwhelmed.

July 5th Update on Savaii

We've packed up our gear and sent it ahead to the Samoan capital of Apia on Upolu. We have a bit of down time now as we wait for the ferry to Upolu, so I've had time to tally our pharmacy numbers. In 3 days the pharmacy saw 368 patients and dispensed 689 prescriptions!

July 2nd – July 4th Sataua Clinic

We opened the clinic at 0800 and it became immediately apparent that we have some rather large holes in our formulary. We're missing some key antibiotics, we have almost no GI meds, and our selection of antifungals is painfully limited. But on the plus side, we do have enough 100 count bottles of pseudoephedrine to start several meth labs and enough bisacodyl to keep the entire island on the porcelain for several days. Joking aside, I find that I rather enjoy these oddities. It gives me the opportunity to work directly with the physicians and challenges me to find creative alternatives for therapy.

Most of our patients speak very little English, but it's clear they are grateful for our help. The lines, in every part of the clinic, are long, but I have yet to hear one person complain or see anyone get upset. In the pharmacy, we are hand writing all of our prescription labels on small stickers or plastic bags. This takes time, but the people here are nothing but understanding. If it wasn't for the 90% humidity and the lack of internet access I might just open a pharmacy here.

Our medical clinic is busy, but dental and optometry are at capacity. Access to healthcare is limited on Savaii, but it is still possible to get care. The hospital is staffed by nurses and a doctor visits the hospital once a week. The same is not true for dental and eye care. These services are virtually nonexistent on the island and travel to Apia, the capital city, is too expensive for much of the population.

As the days progress, the clinic gets more and more interesting. We had a patient with a severe abscess requiring IV cefazolin. Under normal conditions, this would be prepared in a sterile environment. Under our conditions, it was prepared on an old weathered desk sterilized with Purell. Later we had a patient with elephantiasis resulting from lymphatic filariasis. He had been suffering from the condition for over three years. The origin of the name, elephantiasis, was clear. His legs were massive, at least 8 inches in diameter at the ankle. And his skin had become thick with callus and hyperpigmented. It was an amazing sight; one that evoked both fascination and sympathy.

July 1st Hitting the ground running.

0030 Climb Jacob's ladder to board the USNS Byrd.

0100 Finish check-in and receive room assignment

0115 Scare roommate as I burst in carrying a backpack and large duffel bag

0130 Receive a quick ships tour

0200 To bed (or cot as it were)

0500 My roommate is up…so I am as well

Our team musters in the helo hanger at 0630. We have five providers on our team: a general physician, a pediatrician, an optometrist and two dentists. All told, there are 12 of us on this mission. We are going to a hospital in Sataua, Samoa on the island of Savaii, where we will establish a clinic.

The scenery on the helo ride in is amazing. Savaii has but one road. It circles the island near the shore. The islands center is mountainous and bathed in shades of green that I've never before seen. We are only a few hundred feet above the jungle, but it is so thick that individual trees cannot be distinguished; they simply blend together as if one giant organism.

We land at a small air strip where some vans were waiting and drive to the clinic site. The hospital is on a beautiful piece on land; a small peninsula with a bay on each side. The hospital itself…not so beautiful. It is an open air building consisting of several small rooms all joined by covered walkways. The facility is old. Several windows are cracked or missing all together. The paint is peeling and what little equipment they have has been neglected. It is immediately apparent that we have a huge opportunity to really help these people.

Within hours, we've transformed the facility. It now has two dental bays, two medical exam rooms, a surgical suite, and optometry room, and a pharmacy. I have only worked in a handful of pharmacies in my time, but unless there is a Walgreen's on top of Mount Everest, I'm pretty sure the pharmacy we setup in Sataua has the best view of any pharmacy in the world.

From behind the pharmacy counter (built out of a series of old lecture podiums) I look east, over a bay filled with crystal blue water. Waves break over lines of coral exposed by the low tide. On the far shore are coconut palms swaying gently in the wind. There are no other buildings in sight, just nature…it's absolutely beautiful.

As I take in the view, fatigue takes hold. I'd been running on adrenaline for hours now. The meager three hours of sleep I've achieved in the past 24 hours are finally catching up to me. I'm exhausted, but excited for tomorrow and the opening of our clinic.

July 3 Nicaragua Here I come

We dropped anchor at 6:30 this morning in the waters surrounding Nicaragua. When I headed out to the deck for my first sight of Nicaragua, I was surprised to see just how close we were to the shore. We were still a little out to sea, several miles, but I could clearly see buildings and other structures on the coastline. It was a different side of Nicaragua than I had seen before.

I had a late call away around 8 this morning to take me to shore since we did not drop anchor until this morning. This would be our first day in Nicaragua and the site needed to be set up. Now, the military sends out an ACE team who will do all of the prep work before we actually get on site. They will scope out where we will be and create a plan for where to set up and how the flow will work. This usually is done a few days in advance of the boat’s arrival.

To get to shore in Nicaragua, we took at hospitality boat for about 30 minutes to the Corinto seaport. This was the first tim,e I had been at such a massive port. There were huge ships in the harbor. Some of them were as big as the Comfort. When I asked why we couldn’t bring our ship into the port, I was told that it would be very expensive for us to pay to dock the ship for 10 days and with our ship anchored where it was it can be seen for miles up and down the coast.

Once we arrived at the port we were told to show our IDs to be allowed in the country. This was a bit of a problem for me because the ship’s admin department had collected all of the civilian’s passports the night before in order to get them stamped. Since we had entered the country by sea, we were told that there would be a problem at the airport if we tried to leave without proof that we had entered the country. After consulting several of the officers, it was determined that no one but the lead officer would show their ID at the gate.

It is a 30 minute bus ride from the port to the first site at the Ministry of Health Clinic in Chinandega. I really enjoyed the ride because it gave be a chance to see the beautiful rocky coastline and gave me a majestic view of the white hull hospital ship that I call home. The ship miles out from shore was a awesome sight to see against the deep blue sea, bright blue sky and the dark brown boulders of the shoreline. I am sure that I will remember it for the rest of my life. I can only imagine what it is like to be a citizen of Nicaragua seeing the ship for the first time. I know I was never prouder to be part of an organization that has such a beautiful symbol of promise and hope.

As we drove down the streets and through towns, I couldn’t help but compare Nicaragua to El Salvador. There were things that were very similar and things that were very different. The bright colored buildings are the same in both countries but in Nicaragua fewer houses are what I like to call “finished. When I say finished, I mean that they have be stuccoed and painted. Another difference that I could see right away is there is a feeling of poverty that was not noticeable it El Salvador. The buildings weren’t finished, the people’s clothes were not as clean and there was liter in the streets. In addition, the roads are not marked an paved as nicely as El Salvador. One thing I will say in favor of Nicaragua is that there is some beautiful scenery. Volcanic mountains are magnificent and the coastline is unbelievable. I am impressed at where there is poverty beauty still abounds.

After our short ride to Chinandega, I was ready to get to work. I was glad to have a chance to get a good workout moving boxes around the pharmacy and unloading the pallets, but when we arrived around 10 there were no pallets to be found. The pharmacy had a total of 19 pallets to go to both sites and I know there were plenty of other departments that had pallets as well. It is a long process and takes quite a bit of time to move that much product by helo from the boat to the shore and then get it sorted out by site.

While we waited Lt. Baidoo bought us a coke from a local vendor and we explored the clinic. After we had gotten the layout of the place and developed a plan for our pharmacy room we ventured right across the street to a little store. One of the guys bought some bread. This bread was folded into triangle and filled with something very sweet. The bread tasted a bit like a Danish here. I also tried what looked to be a sugar coated emanpanada, but it was empty on the inside. It tasted like a sugar cookie and was very good.

Once we were told that they hadn’t even loaded the pallets, we sat down across the street and began to play with some kids. A small little girl appeared with a coin cordoba in her hand, and she went to purchase some candy at the store. She seemed very curious as to what we were doing. I went over and took her picture. After that, we were instant friends. I asked what her name was in Spanish. From that point on, Anita thought that I understood Spanish, and we had a very long conversation (I have no idea what she said). I took her photo again, but she told me that she wanted to fix her hair. Then she introduced me to her brothers and their friends. We played with them for a while and then Carl Caluya bought everyone some ice cream from a street vendor.

About that time word came that some high ranking officials were going to view the site, so we had to move 10 feet to be inside the clinic gate. While they waited, Anita’s brothers kept us entertained with a very fast paced game of marbles. These kids were good. I think one of the soldiers told them that he would buy the winner some candy and gave both of them their choice of candy when the afternoon was done. Once the officials arrived around 2pm, we were told that we had to leave to catch a helo back to the ship. None of our pallets had arrived so we couldn’t do what we were supposed to do. A bit frustrated, we headed to the air strip.

Nicaragua is a very interesting country in that the waves get really rough around the middle of the afternoon. For that reason, all of those making the daily commute will arrive on shore by boat and will depart by helo. Luckily, the air strip was only 6 minutes away by bus.

When we got to HLZ (Helo Landing Zone), I was surprised to see a bus full of Operation Smile patients. On July 2, the Comfort joined forces with Operation Smile for this country. For those of you who are not familiar with this organization, it is a group of medical providers and surgeons who specialize in cleft pallet surgeries. Eighty-seven patients were already identified prior to our arrival today and were waiting with their escorts to head to the ship.

The ship was using both its Navy helicopters as well as several Army Black Hawks that were loaned to us from a military base in Honduras to transport patients. Since there were so many patients and only 11 seats per helo, we waited for several hours to get back to the ship. We also had to wait until the Black Hawks were clear to fly on and off the ship. (I was told they had to qualify, not sure what that means, but they didn’t actually take people flying for several hours until their paperwork was complete).

After waiting for such a long time, we were rewarded with the first Black Hawk ride of the day. This was a great experience because it was the first time I had ridden with the helo doors wide open. The trip took about 10 minutes and the feel of the air against my skin was refreshing after a long hot day. I had so much fun and like a tourist that I sort of am I took tons of pictures from the air.

We didn’t get much accomplished today, but it still was a great experience. I was able to try some local food, had a chance to get to know some of the other soldiers on board the boat, and made new friends with the local kids. In fact, we still refer to the day as our COMREL day. COMREL stands for community relations and usually consist of a group of military and civilians who go out into the community and perform community service deeds. All in all it was a great day.

July 6 - USNS Richard Byrd Update

This is an excerpt from a Project HOPE e-mail concerning student John Hammill:

Regarding the subject of the email, I wanted to pass along an update on John Hammill. I received a satellite phone call from his preceptor, Dr. John Nett, and all is going very, very well. The most important thing he wanted to emphasize was how impressed he is with John and how thrilled he is to have him for a student. It sounds like they are working out very well together and, if things continue on course, should be a great experience for all. You have provided us with excellent students (as I'm sure they all are!).

As you may know, the "Johns" and one Navy pharm tech are the only pharmacy specialists on the mission, so they are really the subject matter experts on board and are being leaned on heavily, which is a very good thing. The team has been working ashore everyday since 1 July and it sounds like they actually spent several nights ashore away from the ship in a remote area. When Dr. Nett called me today, he was talking under a palm tree on a pristine Pacific beach, so I don't think there are any complaints! The Medical Officer on board said they are installing a wifi system, so hopefully they'll be able to access the Internet soon. Once we start receiving our Situational Reports, I'll forward to you. Dr. Nett didn't have his notes with him when he called, but said they've written over 700 prescriptions and have seen over 300 patients in just the few days they've been working.

July 2 Sailing on the High Seas

We are moving today. At 11:00 am this morning, we heard the call to hoist the anchor so that we could set sail for Nicaragua. We were so excited that Lt. let us go to the bow of the ship and watch them bring up the anchor. The anchor is massive and has to be hauled up by a large machine. As the links of the anchor’s chain are brought up there are certain markers on how deep the anchor has gone. With each marker they will ring the ships bell to announce how many feet deep the anchor is coming up from.

In addition to watching for the markers, the sailors also have to wash the muck from the ocean off the chains and the anchor. That is a lot of hard work. The fireman’s hose they use has a great deal of force behind it so you have to be pretty strong to hand on to the hose and still be able to wash the chain off. Lt. Victor, one of our pharmacist, gave it a try. It took about 30 minutes to raise the anchor and for them to declare “Anchor’s Away.”

Because this was our only day to pack for Nicaragua, the pharmacy was frantically trying to count medicines and label them. Even though we had roughly twenty volunteers at any given point during the day, we ran into a few snags along the way. The first problem was that we ran out of plastic bags to put the meds in. Nicaragua is our last stop and unfortunately some of our supplies have run low with no chance of restocking. Once we found some paper bags we began to run out of staples to close the bags. Then we realized we only had to small packages of labels left. However, with a little ingenuity from the Chief and HM2 McSherry we were able to use the IV label printer to make more labels and some packing tape to close the bags. When all was said and done, we ended up packing 19 pallets and 10,000 pounds of medications for the people of Nicaragua.

NIcaragua is slightly different then all of the other countries we have visited so far because it has mandated that whatever medications that we take into the country have to be left there. To many, this seems like an unusual request, but my past experience with this country tells me that the Ministry of Health does not have the money to provide healthcare to all of its people. We weren’t opposed to this plan because we are not heading to any other humanitarian assistance ports for this trip but this might have limited exactly what came ashore if we did have to go to another country after this.

In the middle of the transit day, we had two scheduled events to look forward to: a bridge tour and the abandon ship drill. Tracy, the Project HOPE coordinator, set up a bridge tour for us. Third mate Joe was the person who gave us a tour and explained how things worked. He is part of the MSC (Military Sealift Command). Joe took time to explain our route back to see and then over to the Coast of Nicaragua. On the maps it looked like we made a backwards J to get to the coast. We have to go back out to sea to “exchange” some water on the ship.

Meg asked if she could drive the boat for a little while and the helmsman agreed. After Meg finished, I asked if I could drive. It was really easy since the seas were not rough at all. In fact, I barely had to move the rudder 2 degrees in the 10 minutes that I was driving the boat. According to Joe, we were going about 18 miles an hour and to be honest, I couldn’t even tell that we were moving at all from the bridge. I am grateful for the bridge tour because it gave me a chance to learn a bit more about sailing and to see all the equipment that is involved in making a giant ship move.

Another scheduled item for the day was a fire drill and an abandon ship drill. At 3:15, the call went out that this was a fire drill. Two of the pharmacy personnel, McSherry and Chief Bone, are tasked with fire duty and are firefighters for the ship. For this drill, everyone will go to the place that they normally muster, take roll, and wait there until the drill is over.

Right after this drill, we roll right into the abandon ship drill. For this drill, we go to the pharmacy put on our long sleeve shirt, life jacket, and hats. We need to have the long-sleeve shirt and hat to protect us from sun exposure in the event that we needed to stay in the lifeboat for an extended period of time. Once fully garbed, we hurry to the flight deck were several sailors are holding signs with numbers. Since I muster with ancillary services, my number is 3 and will be placed into lifeboat 3 in the case of an actual abandon ship. It is really neat to observe the blue and orange sea of people everyone from the whole ship piled onto the flight deck around the helo waiting for those in charge to account for everyone on the ship. Once it is confirmed that all were present and accounted for, the drill is over, and we head back to the pharmacy for the rest of the day.

One of the other things that Project HOPE set up for our day of traveling was to serve in the galley. I was really excited about this because I wanted to see how the kitchen worked to prepare enough food for hundreds of people. However, when I got there I found out that I was serving on the mess deck. This is a thankless job for anyone who has ever done it.

For the 2 hours that food is being served, these men and women stand alert waiting for someone to spill something or make a mess on the salad bar. To be honest, until I did this job myself I didn’t know that these people existed. They simply appear out of nowhere to supply extra bowls, sweep and mop the floor, do anything to keep the area clean. If that is not enough, after dinner, they must wash down all of the tables, put away the napkin holders and salt and pepper shakers. Then, they will sweep and mop the floor. It really is a hard job.

Working in this humbling capacity taught me a great deal. The first thing is that I should always appreciate the people who work behind the scenes. They work very hard and seldom get credit for their long hours. Second is to take a few minutes out of my day to tell them how much that I appreciate all of their efforts. The last thing it taught me was to become more observant of my surroundings. There many, many people who have seeming insignificant jobs around the ship but without them the Comfort would not run smoothly.

Today has been long and full to the brim with new and exciting experiences. There is always something interesting to do or see on board the ship. Each day brings an adventure and when I close my eyes to rest, my mind always begins to wonder what the next day will hold.

June 30th It feels good to be needed.

The journey from Washington Dulles to Apia, Samoa was long and arduous. Between the time zone shifts and crossing the date line twice in one day (is that possible?) my total travel time was lost to me. Nevertheless we arrived at the pier in Apia around 2330 Tuesday, June 30^th. The ship was anchored about a mile off shore. While waiting for the RHIB boat (rigid-hulled inflatable boat) to collect us, we were exchanging introductions with the Navy personnel and others that had just arrived to Apia. When I mentioned my name, Petty Officer Akins' eyes widened. "You're John Hammill? We've been looking for you!" he said. He then presented me with a piece of paper that contained orders to pack a small bag with clothes and supplies for a 3 day RON (Remain Over Night) mission and report to the helo hanger at 0630.

We will be traveling to the village of Sataua, Samoa on the island of Savaii. My preceptor, John Nett, and I will be the pharmacy contingent for this mission. In fact, with the exception of a single Navy Pharmacy Technician, we represent the entire pharmacy team for the whole Pacific Partnership. It feels good to be needed.

July 1 Fun on the Comfort

This past week has been a very busy week for the pharmacy. Most of the time we will have a 3 or 4 day prep time when moving from one country to another; however, since the Nicaraguan port is only a few miles away, we only had one day transit time. I am told that what normally happens between countries is all of the medications that were used in the last country are brought back to the pharmacy where they will be sorted and counted. Then the pharmacy will create new pallets for each of the sites that we will visit. This process usually will take all of the 3 days en route to another county. Since we didn’t have that time, we have worked really long days and recruited many other volunteers from different departments throughout the ship.

After prepacking and labeling 19 pallets of medication and several long days, we are ready for some fun. The galley pulled out all of the stops on one of our last days in port and they served us steak and lobster one night for dinner, topped off with a delicious slice of blueberry cheesecake. Keep in mind that cafeteria food is never that great but that dinner was not bad. It was a welcome surprise after a long hard day.

One of the other ways we have to relax after a long day is to participate in any of the many exercise classes that we have going on throughout the day. There is a yoga class held on the flight deck around sunset. It is so beautiful. The sky is brilliant and the stretches really do a lot to help you unwind those tensed muscles. For those looking for more intense workouts there is the PX90 class. Now I haven’t been that tempted to go to that class after Julie told me how hardcore that turned out to me.

The class that I love to attend is Zumba. This exercise class is based on Latin dance steps which fits well in ouand is quite fun. Instead of being in a gym, everyone gathers in CASRAC (the triage, staging area). Our instructor turns on the Latin music and class starts. With this class you are constantly moving but it is so much fun since each person adds their own little dance step into the mix. We usually have a few onlookers stop as they pass by to see and to enjoy the class for a brief moment. The class is a really great aerobic workout and surprisingly enough, I wasn’t sore in the least the next day.

In addition to the exercise classes, the Fun Boss also sets up evening events for our entertainment. One night we played bingo. Some of the prizes were really nice but others were funny. The one person who won the ipod also won the portable DVD player as well but Lt. Victor did win a tee-shirt. All in all it was a fun night. Some of the other events that the Fun Boss set up are movies on the flight deck, Comfort Idol, and karaoke. It is a great way to meet other people in other departments as well as keep up the moral.

One other interesting thing of note is that we do have a celebrity on board (which I didn’t know about until I had already met him). I sat down to dinner with a few ladies from Project HOPE who were having dinner with one of the Navy physicians on board. We had a lovely dinner, and it was nice meeting his acquaintance. It was only after dinner that one of my other friends came up to me extremely jealous. I couldn’t understand why until she told me that the Navy doctor that I had just ate dinner with was Andy Baldwin from The Bachelor.

Dr. Baldwin is very popular on the ship. People are always stopping him to ask him to pose for a photo. Off the ship, he is highly sought after as well. One of the other Project Hope ladies, Diane has the pleasure of working with the patients and sending them to see the next available doctor. There were 3 young teenage girls who were waiting in line and were called next to see one of the women physicians. Diane went to escort them over to her, but they shook their heads and pointed at the Dr. Baldwin. They wanted to be by the “handsome doctor.” He really has made quite an impression.

Although we have worked very hard each day, we have had some fun and a chance to relax. The days are long and the work may be a bit tedious at points, I remind myself that I am still in the middle of the Pacific Ocean surrounded by blue waves and emerald green islands with dazzling sunsets and the gentle rocking to and fro each night as I close my eyes to sleep.

June 25-28 Loma Larga

My RON mission was at Loma Larga at a school. To get to there, you either have to take an hour and a half boat ride or 10 minute helicopter ride to the landing zone. Then you load up on a bus and travel for about 45 minutes through beautiful mountain scenery. As you can see from my last posting, I was able to get a helo ride.

On the way to the school , there were several interesting things of note. One of my favorite things was the cow crossing signs. These signs are created just like our dear crossing signs except they have a picture of a cow on them, and truly, cows are everywhere. You will see them just walking down the road finding their own spot to graze for the day. I think that in this country the cows have free range. In fact, most of the time when there are traffic issues causing the bus to slow its steady pace, it is due to the cows in the road.

Another interesting thing that I saw was a woman waiting at the bus stop at the corner of Loma Larga. She had her arms crossed at her waist seemingly carrying a small bag in her arms while waiting for the bus. As the bus drew nearer, I was amazed that the bag was alive. The woman had a live chicken neatly folded against her stomach, patiently waiting on the bus to arrive. I thought it was so interesting that the chicken seemed very content tucked into her arms. It obviously didn’t know that it was going to be dinner that night. That was definitely something that I was not expecting to see.

Once we arrived a Loma Largo, I was amazed at just how big an operation this mission was. There were already several lines of hundreds of people formed outside of the school. Each line was labeled as to what type of medical care those in line would receive. We have general medicine, OB/GYN, optometry, pediatric medicine, dentistry and many more. I had expected to see one school building with a few doctors and nurses set up, but our operation took up several buildings. There were even tents set up where kids could color and play while parents were seen. This was a massive undertaking.

The pharmacy was already set up when I arrived. Several of the pharmacy staff who had been on a RON mission in San Alejo had transferred the meds from their site and set up the pharmacy for us to take over. In the pharmacy, we have several Cardinal totes that are labeled with the contents on the outside. All the medications inside are already counted, bagged and labeled, so the process of filling the prescriptions can go smoothly. All we have to do is grab the bag, place a name on it, and fill in the blanks. For example, the amoxicillin label states, “Tome___mls cada___horas por ___dias.” Using this method 3-4 people can fill anywhere from 1,000 to 3,000 scripts in one day.

To help make our process run more smoothly, El Salvador has provided us with translators from a university. They were a lot of fun as well as a good source of information about local customs and cultures. Jennifer was a student who was studying to be an English Teacher. Castillo, who always made me smile, suffers from scoliosis which could have been fixed had he grown up in the States. Claudia was full of energy and laughter all day long. All the translators were so helpful, and they helped make the slow moments entertaining.

One of the El Salvadorian translators from the Latter Day Saints group made a special trip over to the pharmacy at the end of the week to tell me that I had beautiful eyes. I thought he was talking about my blue eyes since that is unusual for this country so I told him that everyone in my family has the same color eyes. Then he corrected me and told me that the form, shape, eyelashes, todo… was very pretty. I was quite flattered and really didn’t know what to say at that point, so I told him thank you and then went back to work. That was another highlight to my week.

For those of you who don’t know me too well, I am a people watcher. I love sitting and watching people go by. One thing that I have learned is that every country has its own unique customs and clothing. El Salvador is no different. They have the “apron.” All of the older women have big fancy aprons that they tie around their waist. They remind me of the aprons that you would see hot dog venders using at a baseball game only way “girlier.” Each apron is unique in that it is covered with embroidery, ribbons, and lace. Some of them are really beautiful while others are so busy with colors and ribbons that you wonder what the creator was thinking. After asking one of the translators about the aprons, she told me that all of the women have them and that they are really handy to use. She said that you will see all of the vendors at a market with them because they are a great place to keep change when people make purchases.

The people of El Salvador are a proud people. When they came to clinic, the first thing I noticed was how well everyone was dressed. All the little girls were dressed in their finest “Easter” dresses and all they boys had on clean clothes. The adults too would have on nice clothes as well. For them, the Comfort visiting their country was a big event and they wanted to look their best.

You could also tell that the people were proud of their country because they wanted everything to be nice for our visit. One day, during clinic, the site director noticed that there was some trash in an alley near the school. By the time he had gotten up a work detail to clean up the trash, it had already been cleaned by the people of the village. In addition, the country had transported in Port-a-Johns to the site for the clinic staff as well as the people waiting to be seen. They kept several potties just for the workers and every day they had someone come and clean them out. It was a really nice jesture for the host country to make sure that we were taken care of for us.

The thing that I loved the most about my visit to the school was the people. One of the very first people to make an impression on me was a little old lady. After giving a try at a Spanish counseling session, the woman I counseled said that she understood what I had said. I went to leave and she grabbed my arm, then gave me a big fat hug and kiss on the neck. Then she gave me several blessing in Spanish and told me how grateful that I was there. I was a very humbling and rewarding experience.

Another experience that moved me was a little girl who was given a pair of glasses by the optometry site. She came over to the pharmacy with a worried face and asked one of the translators if she needed to pay for the glasses. When they told her that she didn’t need to pay for the glasses and that they were hers to keep her face broke out into the most beautiful smile I had ever seen. The people here can really touch your heart. That is why we are here. They are the whole reason we are here.

June 25 Helo Ride

Helo Ride!!!
Today was the big day!!! After checking the travel manifest last night, I discovered that I was going to be one of the lucky few who travelled to their site by helicopter. I was consumed with excitement as I lay down to bed last night. I woke up several times during the night because I was so excited and also afraid that I would be one of those people who overslept and held up the flight (even though I was still getting up at my regular time). It has been stressed repeatedly that you must be at the flight deck on time or you will be left behind.

My call away time was at 7:10 this means that an announcement over the ship’s com reminds everyone on that call away must be at the flight deck within 10 minutes. Once you get to the flight deck, you pass a table usually stocked with MREs and water. Because of the food shortage we had a boxed lunch containing ham salad kits, chips, and soft batch cookies. Once you have grabbed you meal for the day, you will head to the waiting room.
Normally, you will sit in the waiting room for about 20 minutes. One of the officers told me that you have to have long sleeves in order to fly in the plane. I have learned that it is always good to keep a light weight long sleeve jacket or shirt near you at all times since you will need it for abandon ship drills and helo rides. After donning my jacket, we were called to the prep area.

In the prep area, a soldier briefed us on how to enter the aircraft, how to get in and out of your seatbelt as well as what to do in both an overland and oversea crash. The soldier giving the brief had done it so many times before that it took less than 3 minutes to cover all the basics. Once properly briefed, we are given a weighted floatation device to place over our heads and around our waist as well as a helmet with goggles and ear protection. The helmets are stretchy, so they will fit almost any head and have enough pressure to drown out most sounds.

As soon as we were fully garbed, we headed to the helicopter. Once we were all settled in and the doors closed, we went straight up into the air. After riding in so many planes, it was a strange sensation to just lift straight up into the air. The ride was smooth and surprisingly quiet. The scenery was magnificent. El Salvador is a very mountainous area with lots of islands dotting the coastline. Since this is the rainy season, the whole country is covered in a blanket of lush vivacious green. It is a beautiful country.

Riding in a helicopter is an amazing experience. You can see for miles!! The country is so beautiful words can not describe it all and pictures can only say so much. There are huge green islands that populate the vast seas. You really cannot get a perspective at how many there are or how big they are from the deck of the boat. It is awesome to see this country from the air.

Our flight was about 10 minutes long which was slightly disappointing because the experience was so neat. I was grateful for my ride in more ways than one. To have the experience was awesome, but it was also great not to have to ride a boat for an hour and thirty minutes on rough seas to reach the same destination was also a blessing. We have had a great deal of problems with the transportation at this port.

Since we are not at our original port, we must find alternate ways to get our supplies, meet officials, and move personnel. With the recent tropical storm, the sea has been a bit rough. In addition, the helicopters have been up and down in the hanger with fuel issues due to cost and supply issues. On several occasions there have been trouble with the hospitality boats in the rough seas. Several people have gotten sick and a few people have been thrown into the floor of the boats on more than one occasion. These transportation issues are at the heart of the reason why so many people are doing RON missions at this port.

Once we arrived at the helo landing zone (HLZ) we were boarded on an air-conditioned bus for our 45 minute journey to Loma Larga School. The ride was really nice because it gave me a chance to see the beautiful countryside. Like I mentioned earlier, the country is awash in a brilliant green. Every now and again there a these beautiful trees that are covered with bright orange flowers which makes beautiful contrast with all of the green surrounding it. These trees are called “Arbor del fuego,” which means “Tree of Fire.” After such a neat bus tour of the country, I was ready to get to work.