Saturday, July 29, 2017

From The Airport

So Im typing this from my phone as I never did get the internet to work on my computer this week (for once I can't blame Microsoft, though-- even though I should have brought my Mac!!)  It might be shorter than usual, but let's face it-- that's probably a good thing.  I'm a rambler.  At least I have self-awareness.

I think a list of ongoing prayer requests from the week might be a nice way of summing up the kind of week we have had in the most efficient way, actually, so here goes:


  • For Francisca, Basilia, Tomasa, Juana, Josefa Toño, Juliana, Isabel, Manuela, and Josefa Chach-- continued recovery and healing I. Their homes after discharge post-op, and most of all that their old outcomes would be a dim reflection of God's glory and live for them here on earth.
  • For Rosa, our dear friend known by the Ficker family for years now--  words can't describe how lame saying call heart is or how sick her sweet body is. She has the worst asthma I have ever seen. She has now developed diabetes from all of the prednisone she has been dependent on for so long now. She has gynecology problems from all of the coughing she has done over the years. She has unstable angina. She is only 40 years old.  She has lost a child due to the horrible healthcare here in Guatemala.  it seems so very unfair and so very sad.   We will continue to treat the problems that we can, but for those that we can't, we will continue to offer prayer and fasting. I will be in fasting for her every Monday until at least October when I go back down to Guatemala. Who will join me?  This is the only woma this is the only person I know of who is Latin who has married a Mayan person. Her husband is a pastor who translates at our clinics for us and they both have beautiful hearts for the Lord!  We selfishly want to keep her with us for a long time, so will remain in prayer for her and covet your prayers too!
  • For guidance for the nursing class I taught Friday night-- that they don't go out and try to do anything crazy and outside their realm of practice after we went over breech deliveries and shoulder dystocias!
  • For the fertility of so many young women that Kelly and I diagnosed with PCOS in Canillá this weekend-- it's just as devastating a diagnosis here if not even more so as they tend to be left by husbands with no means of providing for themselves.
  • For safe transition to flying the new larger plane that the Fickers have acquired for their ministry. (A PC-6 or Pilatus Porter for those of you interested)
  • For safe and productive decisions in the opening of inpatient and surgical services in the hospital-- especially for sterile technique and instrument provision in the OR, post-operative nursing care, and paperwork keeping-- as well as as caregivers making wise decisions about staying within their scope of practice but providing what they can for patients and finding that balance)
  • For me to remember not to try this AeroMexico flight itinerary again!
  • For us all to remain grateful for the resources God has given us, and generous with the same... 
May God bless you all to His service, and tune your hearts to sing His praise!!!!



Wednesday, July 26, 2017

Pictures!

 OR Selfie!  Suzy's got serious skills... Heidi and Kelly are scrubbed in with Everaldo here.


The whole team finally in a shot together without our face masks on (we got this at the end of our last case today--)  From left to right, Micaela, Suzy, Kelly, Alma (Guatemalan scrub nurse and an institution at the Good Samaritan hospital where we work; she has been there over 30 years!), Heidi, and Everaldo


A few of our patients waiting to see us on the first day, while listening to me tell them they will all be seen if they wait patiently and they do NOT have to be fasting, followed by a word of prayer... (I like to think they are all deep in concentration, but they are more likely just wondering about my weird Spanish and accent!)


Suzy checking in on a post-op patient.  Cool Mickey Mouse sheets, huh?


The hospital courtyard-- I'll never be able to prove it scientifically, but I swear this place is good for healing!!


Suzy checking in on another patient~  she's rocking out the heart and lung exams for us since, let's face it-- we're gynecologists ;-)  She's a pediatrician so she actually pays attention to these things.


Kelly with a sweet, sweet patient that we operated on yesterday.  

Nice overview of the OR with Heidi and Kelly doing a rare open abdominal case and Suzy showing off her camera skills again.


And yes, that is Suzy (the pediatrician!) operating!  Turns out, pediatricians are darn good at suturing, of course ;-)

Kelly with "Ever" and "Mica"

 Told you we've been "paid" in peaches... by about eight different patients at least!


Unless you are a surgeon it's difficult to understand, but where we are operating is actually directly behind me here and directly to Kelly's left (i.e., the pelvis, of course)-- Seriously, difficulty level 11.5 out of 10.  I was pretty much struggling just to drive the camera while Kelly rocked this thing OUT like she'd been doing it all her life!


Just a taste of the colorful Guatemalan life


Rounds tend to be a little laid-back-- kinda more like a family conversation in the living room!  Only with three or four different families.  That didn't know each other until they all got put in the same hospital room.  And are all helping each other recover now.  Such a thing of beauty in so many ways.


A better one of Suzy and Kelly in the OR


And with that, my friends, it's LIGHTS OUT for me!  Good night.

I Need a Hammer; Can I Borrow Your Shoe?

Yep, true story.  Real quote.  (Technically, specifically asked for Suzy's Dansko, since I happen to know they make good hammers...)

Sometimes mission work is all about improvisation and learning to work within the resources available.  Such as when you are in the OR and one of the nurses kind of gets the stirrup holder stuck and you need a hammer~  you use a shoe.  Then when you put the patient's feet up and find out they are size of your eight year old kid's feet~ you end up taping the feet in to the stirrups.  And when they tell you that they can't move the TV screen away from just over the patient's right shoulder during the laparoscopy because the tubing won't reach, you do ovarian drilling upside-down and backwards (like a BOSS, Dr. HOLDER!!!!)

Other events of the last two or three days? Let's see...

I may or may not have ordered a round of shots for patients this morning just before discharge-- but don't worry, they were milk of magnesium "shots".

I gave a bag of my own blood to a patient, but much more surprisingly and exciting than that was the fact that her husband actually volunteered to give the first bag!  Blood donation is just NOT a thing here that people understand or do.  It's been a horrible frustration for many years.   We basically usually end up buying a bag from someone, so I think today I may have started a "matching donations" program?!

We watched a parade from an OR stretcher through a window, which was all fun and games until we realized the wheels on the stretcher weren't locked in position and wondered how we were safely getting down...

We had the clinic curtain fall down on two different heads (mine and the lab tech's)

Oh-- speaking of the lab tech, for the first time ever, the only blood I had on my scrubs during a week here was my own!  She probably should have taped the needle in while collecting the bag of blood, in retrospect...

We've done 9 major cases, all significantly life-changing for these women.  We've been more than reimbursed by their smiles, the gratitude in their eyes, and the gazillions of bags of peaches they have gifted us with.

We've gotten to know two really cool new graduates from the nursing school that the Fickers opened a couple of years ago, and benefited from their help.  We hope they've benefited from some teaching from us as well, since they will soon be opening up the ORs in Canilla!!!

We (meaning me...) locked ourselves out of our clinic room, which is nothing new since I typically do that at least once a trip and when I call for Felipe, the sweet young man who cleans the hospital, he always knows I need him to climb in the window again~  Usually when I have him do that I find the keys on the desk inside and not actually in my pocket, though ;-)

Tonight, we finally have gotten to sit down to a nice dinner together here in town to reflect on our week together~ and what a week it has been.  I'm reminiscing on just how many crazy, wonderful, horrible, beautiful, sad, ugly, and all-in-God's-perfect-planning-and-timing memories and stories I have~  and it is such a joy to now share some of them with Suzy and Kelly.

I'll try to post some pics in a bit...










Tuesday, July 25, 2017

Wow


Wow.



“Whirlwind” doesn’t even begin to describe the last two days.  Dr. Kelly Holder (a former resident of “mine”, now all grown up and rocking out her career), Dr. Suzy Schulte (a pediatrician I’ve known since my Houston residency days that married Matt’s best friend) and I arrived safely here in Guatemala late Saturday evening.  Luckily, we rested fairly well that night.

Sunday, there were nearly 40 patients waiting to see us!  The ladies at the hospital had started a list they were turning away after the first 20, but we vetoed that plan when we caught wind of it (which in retrospect may not have been the brightest idea—we were there until nearly midnight seeing over thirty!)  It was a little frustrating that we only scheduled nine of them for surgery of the bunch, but at least we can help those nine and were able to reassure quite a few others. 

I know 30 doesn’t sound like a lot, but you have to remember that many of these patients need translation from Spanish to Quiche language, are all new to us, and are often very poor historians so it takes a while to get to the real chief complaint—here’s an example:

How can we help?

My feet burn.

OK, anything else (hoping the gynecologic complaint will be next)

Really bad—like, super bad.  I can’t sleep at night.  And all the way up my legs.

OK, anything else (same hope)

Both sides!

OK, we are here for gynecology problems. Do you have anything wrong with your uterus?

Well, “they” say it’s my uterus causing my feet to burn.  They really hurt bad (rubbing feet) And my arms. They really hurt, too!  And, oh how my uterus hurts my arms and head too!

OK, how do “they” say it’s causing these problems?

Well, they say I need surgery because of my tumors…

[5-10 more minutes of this non-sense generally passes before an ultrasound is generally presented diagnosing fibroids that are either (1) tiny and don’t need to be operated on or (2) ginormous and should have been removed years ago but the patient couldn’t afford it.  There’s rarely an in-between somehow.]

Then you also have to remember that this visit is also the initial visit, the pre-op visit, the financial counseling visit, and the pre-op labs, so it’s hard to hurry much.

And then all of that has to be fully documented.  In—you guessed it—Spanish.



We thankfully had the help of two nurses from the freshly minted class of 2017 (?) in Canilla, Ever and Mica this week—they are here to try to learn some OR nursing skills but so far have probably given more than they have received, unfortunately.  They did scrub with us today and are hopefully gaining quickly in skills so we can get the OR up and running out in Canilla soon!  They are wicked smart and have great surgical instincts.

Today, we saw about 10 more patients in clinic in between three major and quite grueling surgeries.  Everyone did great and kept great attitudes (OK, except for maybe me…) up through around 11 pm again.  We. Are. Exhausted. 

I will try to post some pictures soon; I promise!











Wow.



“Whirlwind” doesn’t even begin to describe the last two days.  Dr. Kelly Holder (a former resident of “mine”, now all grown up and rocking out her career), Dr. Suzy Schulte (a pediatrician I’ve known since my Houston residency days that married Matt’s best friend) and I arrived safely here in Guatemala late Saturday evening.  Luckily, we rested fairly well that night.

Sunday, there were nearly 40 patients waiting to see us!  The ladies at the hospital had started a list they were turning away after the first 20, but we vetoed that plan when we caught wind of it (which in retrospect may not have been the brightest idea—we were there until nearly midnight seeing over thirty!)  It was a little frustrating that we only scheduled nine of them for surgery of the bunch, but at least we can help those nine and were able to reassure quite a few others. 

I know 30 doesn’t sound like a lot, but you have to remember that many of these patients need translation from Spanish to Quiche language, are all new to us, and are often very poor historians so it takes a while to get to the real chief complaint—here’s an example:

How can we help?

My feet burn.

OK, anything else (hoping the gynecologic complaint will be next)

Really bad—like, super bad.  I can’t sleep at night.  And all the way up my legs.

OK, anything else (same hope)

Both sides!

OK, we are here for gynecology problems. Do you have anything wrong with your uterus?

Well, “they” say it’s my uterus causing my feet to burn.  They really hurt bad (rubbing feet) And my arms. They really hurt, too!  And, oh how my uterus hurts my arms and head too!

OK, how do “they” say it’s causing these problems?

Well, they say I need surgery because of my tumors…

[5-10 more minutes of this non-sense generally passes before an ultrasound is generally presented diagnosing fibroids that are either (1) tiny and don’t need to be operated on or (2) ginormous and should have been removed years ago but the patient couldn’t afford it.  There’s rarely an in-between somehow.]

Then you also have to remember that this visit is also the initial visit, the pre-op visit, the financial counseling visit, and the pre-op labs, so it’s hard to hurry much.

And then all of that has to be fully documented.  In—you guessed it—Spanish.



We thankfully had the help of two nurses from the freshly minted class of 2017 (?) in Canilla, Ever and Mica this week—they are here to try to learn some OR nursing skills but so far have probably given more than they have received, unfortunately.  They did scrub with us today and are hopefully gaining quickly in skills so we can get the OR up and running out in Canilla soon!  They are wicked smart and have great surgical instincts.

Today, we saw about 10 more patients in clinic in between three major and quite grueling surgeries.  Everyone did great and kept great attitudes (OK, except for maybe me…) up through around 11 pm again.  We. Are. Exhausted. 

I will try to post some pictures soon; I promise!










Friday, February 10, 2017

Wrapping up and More Craziness

So Thursday morning, Adele had to leave us for a flight out and back to work in Wilmington-- boo!  We will totally miss her, but Chris and I were able to round on the patients and discharge most of them.  All of them were doing well, even (sort of to our surprise) the lady who had retained over a liter of urine the night before :-/

We were able to discharge all of the patients Wednesday that we operated on Monday, and then able to discharge all but the surgeries from Wednesday before Chris and I left Thursday afternoon to head out here to Canillá.  Canillá, as many of our longer-term readers know, is one of my favorite places on Earth~  mostly because of the missionaries who live there full-time, who are some of my favorite and most wonderful people on Earth!

The Ficker (extended) family, and the other missionaries who have joined them now in the ministry, are an amazing group.  Tony has been out here working on installing WiFi as well as a camera security system at the hospital all week, so it was a happy reunion for him and Chris!

And speaking of the hospital~  holy moly!  It's amazing how close to finished it is physically.  We are still working on training up nurses and other staff~  and still wondering how we are going to fully staff it with doctors (could really use a pediatrician, an OB/Gyn, a surgeon, and an anesthesiologist!)~  but we know that God is in control of all of that even though He chooses not to reveal the full plan yet.

So we are just sitting around the table now chatting it up and telling stories... and oh, the stories we have to tell!  So many memories in this place, but we'll try to stick to the medical stories~

Today we saw several handfuls of patients in clinic, which is always fun since there are usually some patients here specifically for a gynecology consult.  The most interesting (and sad) one today was a young lady who delivered a stillborn infant last year.  She believes that she herself is lucky to be alive, as the doctors told her that in two more hours, she would get cancer that she would die from when the baby was delivered!  Usually when I hear a crazy "what the doctor said" story, I'm able to at least formulate a guess as to something the doctor might have said that maybe, somehow, could have been interpreted that way by the patient.  But this time, I've got nothing.  Any ideas?  At least the patient was happy and grateful, though.

Another first I had the other day was a patient's family member asking us if we were going to use mesh for her mom's vaginal surgery!  I forget that people here don't see the US daytime TV commercials that all are recruiting folks for lawsuits over vaginal mesh... I was so baffled by the question at first that it took me a second to answer.

I do also have to brag on the local gynecologist at the Hospital Buen Samaritano, though-- we actually had a patient that had been to see him with a small vaginal cyst and he had told her she DIDN'T need surgery for!!!!!  I've rarely been so excited.  Really.  (see previous "me have mass; me operate" post if you don't understand this)  Score one for Dr. Gil!

Those of you who are inclined, PLEASE, please, PLEase, please, PlEaSe be in prayer for our sweet friend Rosa here-- she used to translate for us in clinics, but is now married with one child and has been quite happy with her sweet husband.  They have one little boy, but miscarried a set of twins last year.  She was so excited to be pregnant again, but we were all a little mortified to diagnose her with...  TRIPLETS?!??!!  Really?!  Two of them are sharing a placenta, and they are already showing signs of having unequal blood supply pretty early in the pregnancy.  This is likely a situation where the only treatment available in the states is fetal surgery-- only offered at a few hospitals nationwide.  Clearly here, the only treatment available is prayer.  So let's pray it up, friends!  Please?

You can also continue to pray for our patients~  especially Gilberta and Magdalena, who have had some urinary issues post-op.  I'm trying now to upload some more pictures, but the cord I'm using may not work... I'll try to do so soon though!

I'll be back the first week in May, so please read and pray with us again then...


Monday, February 06, 2017

Pictures as promised, finally

For some reason, these uploaded in relatively random order, but here goes!

Adele helping a patient to put her socks on-- we buy these slipper socks and bring them down with us for several reasons (to help protect and pad patient's feet in the OR, as a nice gift for them from us, and-- importantly-- to help us during the surgery with the patients whose feet sometimes smell a little bad ;-))


Adele giving a gift bag to a patient-- we fill these with toothbrushes and toothpaste, combs, chapstick, and other things we hope the patients will enjoy having to help with their post-op recovery and hopefully make them feel cared for a little more than usual.


Our exam table in the clinic!  Complete with a sheet that needs to be straightened here... You can also "appreciate" our elegant speculum system-- clean ones on the left, dirty ones on the right in the red bucket for washing and bleaching later!  Oh, the glamorous life we lead, right?


Heidi offering the different sock colors to the patient to choose from...


Adele and Chris goofing off in clinic~  a rare moment, let me tell you!


Chris in front of the street with market going on in Chichicastenango.


Heidi and Adele operating!  (Also known as, "Chris totally busting Heidi for stealing a surgical step from Adele"!)  Yep-- busted.  But I PROMISE I gave it back to her as soon as we got those stinking' high uterosacrals identified!



Heidi's turn to touch feet!  Putting socks on our second patient from the day.


Dr. Iris Gamez, our awesome anesthesiologist, likely answering a text from someone else wanting her services...


Half of our nursing staff!  On their morning rounds...


The anesthesia machine in the OR, with Iris's tackle box of meds and supplies with it.


Chris busting me taking photos of our OR schedule which is taped to the OR door, so that I can remember what cases we are doing (and maybe also which cases we DID when we go to do morning rounds!)


The available sutures in the OR...


Chris and I playing tourists in Guatemala City on Saturday~


Our ultrasound machine is not bad at all, but it's not exactly great, either...


"Me have mass; Me OPERATE!"

It's so funny how many times I think of Dr. Bob Maier, one of my professors in residency, down here~  he used to really drive us hard during our pre-op conferences where we discussed our patients that were coming up on the surgical schedule.  He would make us really "defend" our decisions to operate, give a credible differential diagnosis, and tell him what we expected to find.  If we couldn't do so, he would usually resort to saying he didn't want to graduate a lot of surgeons that would go out "like monkeys" and just say "me have mass, me operate" (and thus take out every cyst or fibroid that we saw!)

Like everyone who has ever been pushed hard as a learner, we all hated it at the time.  But as I see the effects of some surgeons who apparently DID grow up with a lower level of training, I am eternally grateful.

We often spend more times in a clinic day explaining to patients why they DON'T need surgery (that another doc here has told them is necessary-- and expensive!) than we do setting folks up for surgeries!  Our latest example today was a real gem...

"Naomi" came in with an ultrasound result in hand stating that she needed a hysterectomy.  We reviewed her results, saw a single fibroid less than 2 cm way up high in the uterus where it rarely bothers anything, and clearly asked for a little more information.  It turns out, she has had long-standing complaints of pain in her legs and feet-- especially her left foot.  Apparently at some point, someone figured this must be her gallbladder and ordered an ultrasound of that.  Turns out she did, indeed, have gallstones (which were asymptomatic), and she was prescribed some type of natural herbal medicine to dissolve those (which, to our knowledge, doesn't exist).

So when that treatment didn't work, they figured it must be her uterus or kidneys, and thus ordered a lower abdominal ultrasound.  They saw the small fibroid and went with, "me have mass, me operate".  For a mere $1,000.00 or so!  Which she clearly didn't have, so now was in our office asking for a more discounted surgery.  This is usually where us Southerners throw in a "bless her heart"!

So after hearing the sad news that removing her post-menopausal uterus would NOT help with her foot pain, she went away with some ibuprofen and likely a bit of disappointment.  With low levels of professional accountability, however, this is unfortunately quite common here.  And not even the worst we've seen.

But on to happier news~  Things went quite well in the OR today!  Four cases (one was a minor case, but still!)- all went well, Adele got some great experience, Heidi even got to get some blood on her gloves once or twice (It's more and more exciting when you get to do it less and less, it seems...), and Chris just loves to operate so she pretty much rocked the whole thing out while I sat one or two cases out to finish up in clinic.  It's a great team effort, as usual.

We saw another 11 patients in clinic, and 2 will likely be surgical cases for May (my next trip)-- who wants to come with me?!  The rest were a usual mix of infertility, menstrual complaints, and incontinence or other concerns.

We are now at dinner tonight, and one patient that I operated on in 2013 or so just came in a recognized me~  #feelingfamous -- Good thing she looks like she is doing well...

I'll try to get some pictures up in a little bit-- Chris was nice enough to take some today since I usually forget anymore!

Until then, good night to all~


Sunday, February 05, 2017

Fiesta en su Vagina

You probably don't want to ask about the title; Chris made me do it based on some counseling/teaching that I did for one patient today ;-)  She may have been somewhere around the 23rd or so of 27 total patients, and I "may or may not" have been a little loopy by that point.

So yes, 27 patients today~  We are tired.  We scheduled ten surgeries, though, which is awesome-- especially for Adele, who will get some amazing surgical experience this week!  I'm just hoping that maybe she'll get tired enough to share after a while ;-)

So we have scheduled 6 "vag-a-thons" (our affectionate term for repair of severe vaginal prolapse-- or for our more medically inclined, a TVH with anterior plus-or-minus posterior repair, high uterosacral ligament suspension, and perineoplasty), 2 vaginal hysterectomies without other repairs, 1 abdominal hysterectomy, and a D and C for a suspected endometrial polyp.  Not a bad haul for our efforts on the day.

Let's see about some stories from the day... Every time I come down here, I experience another "first"-- just when I thought I had seen it all, today there was:


  • the young lady who was recording me on video while I was giving my little welcome talk to everyone waiting-- letting them know they didn't have to be fasting all day for anything, and also that we would see them all as long as they were willing to wait their turn (often clinics here will close before seeing the last patients...)
  • A patient's family that brought us all cold Gatorades to drink towards the middle of the day-- this has happened once or twice before but it's always awesome!  And I think this is the first time they were cold...
  • A father who was very worried about his 18 year old having appendicitis-- or a kidney stone-- or a gallbladder problem-- because the left side of her back had been hurting for two days.  (A pain which, by the way, we were unable to illicit on exam... but hey!  At least he cared about her, right?)
We are now thankfully enjoying a nice dinner before retiring for the night~  Sure to be a long day tomorrow, with four surgeries to do and likely plenty more patients in clinic.  Wish us luck and let us know who won the Super Bowl!

Saturday, February 04, 2017

Meet the Team

Ah, the ever-creative title of the week's first blog... as the long-time readers (both of them) yawn.  But let's face it~  not much has happened yet.  We just got here this evening after the several hour ride up through the mountains from Guatemala City.  After a quick run to the grocery store, we now have our beds made and rooms moved in to for the week.  Now it's time to sit back, relax, fix a cup of tea, and light the pilot light for the hot water.

Oh wait~  we also have to spend half an hour trying to get Chris's phone to recognize the Guatemalan network so she can talk to her baby!  It's funny, though-- we were pretty tempted to get irritated about that, and then I remembered that on pretty much every single trip, there is some kind of internet or phone technology that needs troubleshooting-- but every single trip, we have all the phone and internet service we need!  I have called in to plenty of conference calls or over-internet meetings from here, I've stayed up to date on email, and I've caught up on patient charts in the EMR.  All pretty amazing technology making the world smaller and smaller -- and taking away our excuses not to travel it!

Anyway, I promised to introduce you to the team so here goes:  I'm Heidi, the arguably craziest of us as this is somewhere around my 33rd trip back down here for a week after moving back to the US in 2008 (my husband Matt and I lived here in Guatemala from 2006-08).  I'm an OB/GYN, and it's kind of a long story, but this is the only place I actually practice clinical medicine anymore.  I'm starting to miss it more and more, so these trips are an amazing privilege and blessing every. single. time.

Chris (DeLuca) Schwering many of you also know~  she was a resident at ECU when I was an attending there, and this is now at least her 8th trip back since going with me as a resident!  So very cool to now be taught by my former student many surgical skills she has picked up since then... never stop learning, right?  Her husband Tony flew down with us but rode out to Canillá this morning to install some WiFi, security cameras, and other generally tech-y stuff for the new hospital there.  They left their 3 year old sweetie, Caitlyn, and an 11 month old foster baby, nicknamed "Bubbles" for privacy, in very capable hands at home~  but still, it's hard to be away from each other and the tiny ones, so please pray for comfort for them this week!  (I should also mention they have a beautiful 21 year-old daughter also-- but they're pretty used to her being away at college ;-))

Adele Moser is a third-year OB/GYN resident in the Wilmington, NC program.  She is actually the fourth resident to come down from that program in the last couple of years, but the first one that I actually knew before traveling together!  We met when she was a third year student, and I have adored her ever since.  I'm really looking forward to seeing the amazing amounts she has learned in the last four years and hopefully getting her some great operative experience.

It's only about 8:00 here, but a group picture will have to wait until tomorrow-- some of us (i.e., Adele) had been up since before 2 am local time and thus didn't make it far in to the evening!

Tomorrow we will spend just a bit of time in the market, then set up and run clinic all day.  We will have a better idea of what's in store for us once we get through usually 20 patients or so tomorrow, so clearly we will keep you posted and try to get some pictures up.

Thanks for following along with us and praying for health, wisdom, and safety this week for us all.