Pie.

This week, our Operations Director Jeff started the week by sharing something he attributed to Dr. Pete Friesen - a Coach & Trainer for the Carolina Hurricanes plus numerous Canadian World Championship & Olympic teams (I say attributed because I tried and failed to find any similar quotes online...so if anyone else can please share). 

He told us about the Rule of Thirds:

"If you're really working hard toward your goal, you should feel great about 1/3 of the time. 

1/3 of the time you should be just coasting along.

The other 1/3 of the time you will feel terrible and beaten down."

(to summarize, I made this helpful pie chart)

He continued:

"With this rule in mind, if you never feel like you've got nothing left to give, and just feel great all the time, you aren't pushing yourself enough. You're capable of more, and you're holding yourself back. 

Conversely, if you feel terrible more than 1/3 of the time, you aren't taking time to recharge or to recuperate. You're not taking the appropriate self-care steps. You're at risk of injury and burnout."

Now, I have never been an athlete of any sort at any level. I dropped out of most of my high school teams within a couple months. I have my excuses, but that's besides the point. Until 2020, I'm not sure I had ever seen this rule played out to its full extent; at least, not in myself. 

Only during the boredom of COVID restrictions did I find the drive to push myself to feel physically terrible 1/3 of the time long enough to be able to say, "yeah, I jog sometimes. I'm a jogger." And you know what? It felt pretty great the other 2/3rds of the time. 

Also (mostly) thanks to COVID I've found myself in a tightrope marathon; a seemingly endless balancing act between "things are ok right now, let's make the most of it," and "oh crap, here we go again." There have been times it was go time all the time, and the yellow slice of my pie chart took over. There was no time to recharge, no time for self-care. Other times the slices stayed the right shape, but the time-spans stretched WAAAY out: 1 week of insanity, 1 week of coasting, 1 week of feeling pretty good. Lather, rinse, repeat. 

Jeff's words came as a very healthy reminder of my limitations. That it's ok, even good, to feel like crap sometimes; that it can mean I'm working hard to accomplish something positive. It's pretty easy however, in an environment where your coworkers are your dinner buddies and your patients are your downstairs neighbours, to stray into one-half to two-thirds territory. 

So I must say thank you. To every coworker/dinner buddy/neighbour/friend who has told me it's time to leave the office/take a sleep-in day/book a couple more days of vacation. I think my pie consumption is slowly starting to come back into balance. 

And as I approach the end of the race - or at least this leg of the race - it has definitely been worth the whole pie. 

À la prochaine,

-D

Anniversary

I've officially passed the 1 year mark since I embarked the AFM in Las Palmas. 

It's a little crazy to think back at everything that has happened. 

I spent the first few months at the Reception desk, and then the Purser's office, managing the comings & goings of crew, the emergency team assignments, and assembling immigration records for sailing. 

I lived out of a hotel for a few solid months of 2021, both before arriving to the ship and after - during drydock! 

I went back to my happy place, the AFM hospital, and tackled a mountain of work trying to turn what had basically been overflow cargo storage for 2 years back into functioning wards and an ICU. I had a great team that started incredibly small, but grew and grew into a group of amazing, dependable, hard-working nurses. That group has evolved over the year, as it always does here, but I consider myself so blessed to have had such great colleagues with such a heart to serve. 

I reconnected with old friends, built deeper relationships with old acquaintances, and found new, lifelong friends. No...scratch that. New family. I walked with this family through joy, through storms, through outbreaks, through boredom, and through pain. We created beautiful things together, we laughed, and we cried. I nearly lost one of them. It was wonderful and it was hard. And it was so very worth every moment of it. 

We sailed back into Senegal - such a joyous day - and got to pick up the work we left off. Bringing back patients who were waiting patiently for surgery for 2 years through the pandemic. We got to see our sister ship, the GLM, visit the continent for the first time. We saw diplomats, presidents and ministers of health commit to tangible goals for improving surgical care across Africa. We saw hundreds of healthcare professionals from all sectors receiving training to help achieve those goals. We saw so much potential, hope, and joy for the future. 

We faced challenges. And boy, were there a lot of them. We faced destructive weather, electrical fires, COVID, COVID, and even more COVID. We faced the unique problems of finding safe ways to continue working on a ship in the middle of an outbreak, and trying to remember how things worked even in the before, "normal" times...2 years prior. Every department on the ship has pulled together to get us successfully through the field service thus far. 

We can and we have "done hard things" (this was the Academy's motto for the year, one that became the brunt of a few jokes as things just seemed to get harder and harder)! We have journeyed towards healing alongside hundreds of surgical patients this year. 

We welcomed women who had suffered through painful, prolonged labor, then lived with the shame of incontinence for years as a result. We got to celebrate healing for many of them. And for those who continue to live with this burden, we got to show them that their condition does not define them. That they are still valued and loved.

We welcomed men, women and children from all walks of life with hernias - often massive, painful and limiting. There are so many of them - hundreds - and they don't stay long, so we often don't get to learn what is on their hearts. But we get to see their many smiles as they come and go.

We welcomed dozens of kids with crooked legs, and got to see them walk back off the ship with them straight.

We welcomed many with masses or gaps on their face, so many wearing their disease where the whole world cannot help but notice. So many, who have felt monstrous for many years, leaving feeling beautiful and whole.

We welcomed scarred, burned, devastatingly injured patients whose healing drew their joints inward, locking out their mobility. We forge deep relationships with these reconstructive plastic surgery patients, as some of them take months for their grafts to fully heal. But their joy is all the more deeply felt as we journey through the pain and healing together with them. 

It has been...a journey. That's for sure.

-   -   -

Right now I'm on a journey back home, for the first time in over a year. It is a strange feeling, more like leaving one home to return to another. Like my heart is in a few different places, and sometimes I need to leave one piece behind to retrieve another. 

I thank you all again for walking with me through this ongoing journey. 

It's a team effort. 

Niofar (we're in this together). 

À la prochaine,

- Danita

A Tale of Two Kidneys

I had a lazy morning in my cabin today. While I was sipping my tea and pondering a certain patient's situation, I started thinking about Hemodialysis. 

I've never worked directly in a Dialysis setting, but back home a decent number of my vascular surgery patients had some kidney function problems. It wasn't unusual for one once in a while to be on dialysis, and three times a week we would wheel them in their hospital bed down the hall to the outpatient dialysis wing. I started thinking about how wild it is that someone can have completely non-functioning kidneys and be kept alive by spending a few hours every couple of days plugged in to a machine. Blood goes out a tube, through a contraption (which I barely understand) where toxins, excess fluid and other waste materials are removed, and 'clean' blood is returned back to the patient. 

That such technology exists--that we have figured out a way to replace the work of such a vital organ--is pretty mind-blowing. 

Quite a few people in Canada live productive, relatively normal lives sustained by this technology. Sure, there are some limitations. You can't really travel without being sure there's a dialysis facility where you're going, and arranging treatment there. There are medications and other precautions you must take. But over 23,000 Canadians rely on dialysis treatment to live.1

---

My mind went on this tangent because I was a little worried. 

One of our patients was having rather odd symptoms, and one of the more likely explanations was that his kidneys weren't functioning properly. 

I wondered what it would be like, compared to what I've seen in Canada, to live with kidney failure in a place like Senegal. 

Dakar is a big city with a number of pretty top-notch hospitals. And indeed, there are a smattering of other hemodialysis treatment centers around the country. Treatment is even free(ish). I say 'ish,' because you are often required to pay for physical resources (i.e., medications, implanted access ports, etc), even if a procedure itself is 'free.' Just over 1000 people currently rely on chronic dialysis treatment in Senegal. Well over 1000 are on wait lists. About 75% of those on the wait list will die before they get treatment.2

The biggest barrier, as with so many aspects of healthcare in West Africa, is resources. There's simply not enough specialists. Not enough machines. Not enough nurses trained to use them. Surgery must be performed to create an access port before treatment can happen, and that can only happen at one hospital in Dakar.2

---

Fortunately, in the case of our patient, it is not his kidneys that are the problem. The mystery of his symptoms has been solved, and, for him at least, my worries have eased. 

There's no quick, band-aid solution to the healthcare gap in low-income countries, but while I'm holed up in the hospital helping with hernia repairs and tumor removals, our Medical Capacity Building (MCB) teams are around the continent doing the real work that will make this a safer place to live. You may have heard about the visit from our enormous-brand-spankin-new sister ship, the Global Mercy, here in Dakar. While her hospital isn't quite ready for patients yet, she did draw in crowds of healthcare professionals to participate in a range of training courses--courses that can and will save lives. And our participants are quickly becoming champions of these essential skills in their own workplaces, multiplying the impact. 

Since I've rambled on for long enough now, I'll shut up and let them tell their own stories. 

The crews of the GLM & AFM assembled together after 6 weeks of service side-by-side.

The Global Mercy has since sailed back to the Canaries to do a little more prep work before her hospital doors can open, and I'll be joining her there in a few more months. 

In the meantime, we'll carry on doing our best for each patient who comes to us needing surgery. 

À la prochaine,

-D

MVPs Pt 5

Banna's eyes are full of joy. 

The first time I met her, she was walking in to the ward with one of our chaplains, and though she wore a mask she clearly carried a broad smile underneath! She entered, greeting each nurse, day crew and patient. I was holding paperwork in my hand, anxious to get it signed, but did my best to patiently respect this custom. 

Let me back up a minute. Banna's name first came up in discussion with a patient's brother. This patient, a teenage girl, needed surgery to remove a large lipoma - a fatty tissue tumor - on the back of her leg. Anyone under 18 has to come to the ship with a caregiver. Usually a close family member, this person takes responsibility for medical decisions for the patient, as well as helping with their daily needs. This girl's older brother came with her as her caregiver, however, once on the ship, he told us he had to leave for an interview at the end of the week. Back in their hometown. 15 hours away.

Now, this put us in a bit of a sticky situation. The girl's recovery would take at least 3-4 days in hospital, with outpatients follow up for a week or two after that. She needed someone who could stay with her 24/7. We asked, "Is there any family here in Dakar who could come help?" 

Yes, a sister, but she was too busy with work.

"Is there any way you can delay the interview?"

No, he would lose the job if he didn't go. 

"Can any other family member come to stay with your sister?"

Yes, but they wouldn't be able to arrive until the weekend, and then they would still need to quarantine for a week. 

The surgeons who could do this surgery would only be here until the end of the week. We couldn't delay, or the surgery wouldn't happen. 

A lot of prayer had already been answered for this patient. She required a CT before we could proceed with surgery, to determine if the tumor was even operable. Our scanner, a bit past its prime, decided to throw a bit of a hissy fit that day and not function. Our biomedical technicians worked through the entire day trying to get it functional again, and we worked on a contingency plan to transport the patient to a local hospital where the scan could be done. 

Her surgery was delayed by a day because of this, but in the end we did manage to kick the old beast into gear and get the pictures we needed. The surgeons reviewed them and decided it was safe to proceed with surgery. 

That just left us with this caregiver conundrum. 

The patient's brother had mentioned a name - someone who was at the Hope Center who they trusted -  who might be able to step in to help. 

Her name is Banna. 

We were discussing all of this with our preoperative team, and they immediately said, "That isn't going to work - she's a pre-op patient."

Slated to have hernia surgery the next week, it would have required Banna to wait until this patient was home, or until another caregiver arrived to take over, before she could have her own surgery. What's more - Banna hadn't been seen by the surgeons yet. We weren't even sure if she could have surgery. She might stay all this extra time to support another patient and then end up not being able to have surgery with us at all.

A Silver Lining

The same Friday all of this deliberation was taking place, I got an email about a surgeon's departure date. My coworker nudged me, "I guess you knew about that already?" 

I did a double take on the departure date. 

It was today's date. 

This was the surgeon who had just arrived; who was just supposed to be starting surgery Monday. Who would have been doing Banna's surgery. A family emergency had come up, and no one could fault them for leaving, but it sure came as a rough blow.

This meant about 30 patients had to be rescheduled for later in the field service. There was no backup surgeon who could fill his place. 

It did mean one good thing though: Banna would be able to fill this need. She happily agreed without hesitation to fill in as a caregiver; understanding that there was still no guarantee she could get surgery herself. We were, fortunately, able to secure a tentative surgical space for her just 1 week later, when the next surgeon arrived. 

Another family member was able to come eventually, and Banna had her hernia repaired without complication. Her smile before and after surgery was the same - even if she was in a little bit of pain. 

I hope I've managed to express even a little bit how bold and beautiful the culture of community is in this part of the world. How a complete stranger will step in, giving a week of their life so that someone can have their own life transformed. The sense of 'Niofar' (we're together, we are one). Every day I learn a little bit more how valuable that perspective is, and how much further I have to grow in it. 

My amazing team of nurses & day crew from around the world. I'm hiding behind PPE in the back row.

From the land of hospitality and dust...

À la prochaine,

        -D

Senegal 2.0

March 13 passed a couple weeks ago.
That might not mean much to most people--other than it's vaguely the time of year COVID started to be a real and present danger. 
To anyone who was on the ship on that day two years ago, however, it's quite a momentous date. 

March 13, 2020 was the day all crew were called into the International Lounge on the AFM and told, "We aren't doing any more surgery in Senegal. International travel is becoming increasingly challenging; flights are getting cancelled; borders are being closed. Our surgeons can't get here. Our anesthesiologists can't get here. We're going to send our patients home, and if you want to go home too, start making plans to do so."

We knew very little about the virus at the time, but we knew that anything that transmissible would wreak havoc on a tightly-packed ship like ours. We had enough trouble with GI bugs and colds already. 

That meeting ended with a promise: "We don't know when, but we will come back and complete the surgeries we have promised." We shared that promise with each post-op patient as we sent them on their way, bags bulging with nutritional supplements and dressing supplies. We shared it with each pre-op patient when we had to share the news - 'I'm sorry, your surgery is cancelled.' We shared it with each Day Crew who joined us in our bubble, sleeping on a mattress on the floor, until there was no more need for translators and we said our goodbyes. 

We are back. 

And boy are we facing some challenges. Fighting this infuriatingly contagious disease at every corner. 

But we are here. And we are fulfilling that promise.

Let me give you the Cole's Notes on what the last couple months have entailed.

January

The year started in a complete whirlwind. As with so many parts of the world, after months of relative security and fairly lax precautions, Omicron hit and it hit with a vengeance. Within days of two separate, isolated cases cropping up, both related to travel, we found almost 15% of our crew were testing positive. Another 40% ended up quarantined as they were high-risk close contacts. It was a nightmarish couple of weeks, and the tiny handful of medical staff we had on board at the time (myself included) were run ragged trying to stay on top of contact tracing, testing, and checking in on our positive cases. Just about anyone who wasn't in quarantine was spending all day every day supporting the crew who were; delivering meals, doing laundry, and turning over vacated quarantine cabins for the next poor soul. Quarantined crew in critical safety positions could leave their cabin for essential work wearing N95s and yellow, 'stay-away-from-me!' safety vests. When we ourselves ended up in quarantine, we kept working remotely to support the others, because...well, there really wasn't any other option. 

My Manager and I on a 'rapid-test-ALL-THE-CREW' day.

We were so close to our departure for Senegal, and we had to be COVID free by that date. 

In the midst of all that, I somehow managed to cram, write, and pass 2 exams! So, there's that. I'm now the proud holder of a Professional Diploma in Tropical Nursing from the London School of Hygiene & Tropical Medicine. Bring me your tapeworms, your amoebas, your plasmodia falciparum that I may diagnose thee!

As our ship-wide quarantine bubble drew to a close and the sail approached, we just crawled out of one spin-cycle of stress and into a different one. The hospital had to be ready for patients in 1 month. We scrambled to do everything we could to make it ready, then had to put a pin in that to cushion, cling-wrap, and strap everything down to get it safely across the sea. 

The chaotic month ended with the respite of a 4 day sail. 

A prayer walk was held on our last night in Granadilla.

Impromptu sunset jam session during the sail

Worship on the bow - always a highlight.

We were pretty excited.

Arrival Day!!

February

Days of endless tying-down and securing was followed by days of untying, unstrapping, and scrubbing and scrubbing and scrubbing. New nurses began pouring in, and within a few days our hospital staff had grown tenfold. The insurmountable task of turning overflow cargo storage into a functioning hospital began to seem attainable, and inch by inch, ward by ward, our Deck 3 space was transformed. 

Endless scrubbing...

To get from this...

And this...

To this!!

Literally as the ship was pulling up to the dock, our ground-based team was also arriving to set out palates, tarps, and roll out our dockside tents. It quickly went from a big, dusty, empty concrete pad, to a bustling hub for covid testing, patient selection, admissions and outpatients, as well as our transportation and supply staging area!

A couple of days before our first patients arrived, we had one last chance for all the non-hospital crew to see what the hospital is supposed to look like. It was quite a change from the cargo storage and contractor break rooms they were used to seeing for the last 2 years.

Some of the academy kids learned how to take a blood sample...from an orange.

One vial of orange juice, all ready to deliver to the lab!

And some got a ride in the CT scan!

Another pretty cool thing happened in those weeks of start up: we had four generations of General Surgery Team Leaders on the ship! Myself and my 3 predecessors! Two of them are now over on our sister ship, the Global Mercy, working to get the hospital up and running over there, and one of them was here with us as a ward nurse for a few weeks. 

(L-R) Tammy (pre-2015), Jane (2015-2016), Brittany (2017-2020) and me (2022-?)

Let me tell ya--I'm very grateful to have had all this wisdom and experience surrounding me during this time. 

Start up is always a slog, but it went by like a flash. And just like that, we were ready to open. Patients were already being screened on the dock. Senegal 2.0 was a go!

All crew on the dock after the mock hospital evacuation drill - the last key event before we can open.

March

Our first few patients embarked and surgery began almost exactly 2 years after we last sailed away. 

We started out the field service running Women's Health surgery (which includes obstetric fistulas and other gynecological surgery), as well as Maxillo-facial. As no one else was available to fill the role, I ended up stepping in as the Women's Health team lead for the first month. 

It was challenging, to say the least. Not only were ~95% of our nurses brand new to the AFM hospital, they also had to learn their way around caring for fistula patients; not really something you're exposed to in a typical high-income country's healthcare system. And although I have worked with fistula patients a number of times on the ship, it had been over 5 years and I certainly wouldn't call myself an expert. 

For anyone who isn't familiar with obstetric fistula, this website explains it well, but the short of it is: it's an injury acquired during childbirth that causes incontinence. Repairing this damage is tough, it has a relatively low success rate, and the women who live with this condition are often hardened by years of isolation. We work just as hard in this specialty to make our patients feel loved and whole emotionally as we do to heal them physically. 

Dance parties - a quintessential element of post-op care. In more ways than one!

Morning rounds with one of our women's health surgeons, Dr. Liz.

March is nearly through, and we are into our last week of women's health surgery. I'm starting to shift my brain into gear for the general surgery program which starts soon, and getting ready for many hernias, lumps, bumps, and goiters. 

If you're the praying kind, please hold up our fistula patients - they are all survivors of trauma, and some still face a difficult road of recovery. Pray too that we continue to be able to catch any COVID risk before it causes harm, and that we are able to continue to do surgery safely. 

Thank you all for your ongoing support and prayers.

From Senegal, 

À la prochaine,

-D