R&R in Bolivia- SB2011

Tuesday March 1, 2011

My first three days in Bolivia have further opened my eyes to the realness of culture. Its hard to believe that in a world where one can be taking a medical exam in Chicago on Friday at 4 pm but arrive over 4,000 miles away less than 36 hours later that cultural difference are still capable of persisting, but it’s very real and it’s a nice surprise. While I love the American way of life, it’s refreshing to find that on a Sunday morning in Santa Cruz, Bolivia the streets are eerily empty, the stores are all closed aside from a few cafes and supermarkets, but the central plaza is filled with people of all ages sitting on park benches chatting and reading quietly to themselves. As I strolled the plaza I thought to myself, when was the last time that I had a day where nothing needed to be done? Where no textbook needed to be studied? No errand needed to be ran? No appointment scheduled? I sadly couldn’t recall. It certainly wasn’t a weekly occurrence. I thought this could be nice to spend the afternoon reading in the park. I found an open bench and opened my new free reading book- Cutting For Stone. I must have read the first 10 pages over and over again. I felt uncomfortable just sitting reading a book in a foreign country; there must be something to see, somewhere exciting to hit on the to-do list. But there wasn’t. So I convinced myself to sit and read for at least another half hour. It was refreshing.
The next morning I was eagerly awaiting my afternoon meeting at 3:00 and the patient neurology consult at 4:30. Finally, something to do! We arrived for the meeting a bit before 3 pm to find the doors to the clinic locked. We waited on the street for the next 30 minutes before being let-in by one of the receptionists. After another 20 minutes, the physician with whom our meeting was with finally arrived. However, he needed to see a patient first. We just sat and waited. It was now 4:30, still no meeting, but we had another appointment to be at. So we left, without the meeting. If that wasn’t frustrating to a timely American like myself, the afternoon just got better. We arrived about 10 minutes late to the neurology consult to discover that the patient was unsure how to get to the appointment so rather than call for directions, he just decided not to come. Therefore, the consult would be rescheduled for the following day. Two and a half hours after departing the house we had accomplished nothing. If I hadn’t been on vacation, forcing myself to embrace the culture and whatever came my way, this would have really irritated me. I learned that this is a common practice in Santa Cruz. Whether it be lunch dates with friends or business meetings, people come when they are ready and no one (but the Americans) seems to be frustrated or bothered by this lateness. I even asked one of the coordinators who had been there for months have you figured out what “late” means here? Meaning, if someone says 3pm does it mean 3:30, 3:45 or 5:00? She said it all depends and sometimes 3pm actually does mean 3:00 sharp. I think this is one cultural phenomenon that I am incapable of adopting. How does anything ever get done? It seems unfathomable in my mind, but it certainly must work for them. Imagining these exact same scenarios in the states makes me chuckle- the outcomes would have been very different.
The final cultural aspect I was bombarded with was on day number 3- Tuesday morning rounds at the hospital. We arrived a few minutes past the seven am start time and had to tip-toe quietly into the presentations that had already begun (see some things do start on time). It was a small room filled with rows of young people in white coats and what I inferred to be attendings in standard business attire. One resident presented his case and was promptly questioned and “pimped” by the chief at the front of the room. While the dialogue was completely in Spanish (so I wasn’t able to fully grasp the medicine), this meeting appeared to be extremely similar to rounds in the US. There were many doctors nodding off, some were eating their breakfast, others were coming and going and having side conversations about patients. Aside from the dialect I could have been right back at Loyola. The rounds on the ICU floor were also very similar to those that take place in the states. A resident presented the patient to their attending and was promptly instructed on how to improve. A small insight into how my third year might look. The discussion of patient care, the questions that needed to be answered, the medicines that should be dosed were all extremely similar. I sat in the lobby afterward trying to make sense of or take note of what my first few days had shown me. It took some time, but I realized that every country and every profession has their own culture and when you aren’t accustomed to it you feel uncomfortable and sometimes uncertain in how to act. While being at the hospital, I didn’t question my actions or my role. I struggled certainly with trying to understand the language, but I knew how to fit into the medicine culture. This was not so in my other adventures of the week. I also wonder at what point did I suddenly become comfortable with and accustomed to the culture that is medicine? Has it really only taken the past 18 months of medical school or did I learn this customs earlier in my life? If its true that I only learned them recently, then certainly it could be possible to adapt to a new culture or a new way of life in another country. I suppose there’s hope that I might one day be able to not feel uncomfortable without having a task at hand or be okay with a meeting that takes place 90 minutes after it was supposed to.

Saturday March 5, 2011

I'm now at the clinic and its more fun than the city of Santa Cruz, but it certainly comes with its challenges. Yesterday I saw a man who had come to the clinic in November and was diagnosed with kidney stones. He was sent on a consult with a nephrologist in Santa Cruz. For various complicated reasons between x-rays being lost, translation errors and not being able to reach the gentleman by phone he was told that he 100% needed surgery to remove the stones in early January, but he had returned to the clinic in March not aware of this. Can you imagine? I certainly cannot. Consistent painful, destructive kidney stones for four months! Obviously, all of us understood the importance that he needed to get this surgery as soon as possible. Well, the difficulty became that once we spoke to the Nephrologist he was able to see the patient that afternoon and potentially perform the surgery the next day. If not, then it was Carnivale and the nephrologists would be out of town for the following month. In the US you'd simply drive your car to the doctor have the necessary pre-operative tests at the hospital and be set for surgery; that was not the case here. Someone had to drive him to a nearby town (ie about 50 minutes from the clinic) for the xray and ultrasound and then we had to give him money and directions to take a bus to the doctor in Santa Cruz (another 90 minutes or so from that hospital). It was not the easiest plan to execute, but it was done. I don’t even want to think about what happens to individuals suffering from these ailments who are without an advocate from a clinic like this.
In the afternoons I have been traveling with Alice, a clinic coordinator and Maria, the clinic nurse, to the various towns that the clinic serves to help implement a new de-parasitization program. We spend the first few minutes presenting proper food handling and safety to avoid contaminated their food with parasites and then Maria discusses the importance of and the meaning of proper nutrition. We then proceeded to get the heights, weights and ages of all children who attended and provide them with albendazole and Vitamin A. On our last afternoon we treated over 80 kids in the afternoon ranging in age from three to fifteen. It was also Carnivale starting that weekend so the younger children were running around the school wearing homemade masks, painted on beards and banging on improvised drum sets. At the end of the afternoon I was beyond exhausted and ready to head back to the clinic for a cold shower and a nap when we were invited by one of the families to stay for dinner. I should have been elated and grateful, but instead I was irritated. I grudgingly (not visibly) drove to their home where they were preparing a homemade sopa for us. As we sat outdoors under a large collection of trees, dogs and roosters milling around us, listening to them discuss local politics and concerns my irritation quickly dissolved. Here I was a guest in their country and their home and I was being ungrateful because I wanted to what, sleep? Ordinarily being a conversationalist I tend to monopolize conversations in the states. However, with my fatigue and my sadly deteriorating Spanish skills I spent the next hour mainly listening to the conversation. It was a nice change. It was interesting to hear their thoughts and concerns. I feel blessed that these individuals had been willing to allow me to be part of their lives. Needless to say, it was a fulfilling day on so many levels.

Chronicles of the DR

We arrived to the DR around 9 oclock local time and basically spent the first few hours of our visit waiting in various lines: $10 entry fee, immigration, baggage, customs and even a queue to leave the airport in the car because of an airport exit fee. I was rather convinced I would arrive to the DR to find that my baggage was still in Miami. Fortunately, this was not the case. My luggage actually arrived yesterday without me even though the American Airline peeps were resolute about my luggage needing to travel with me and this being the reason they would not allow me to fly standby. I was able to pick up my luggage from a rather shady storage area and we were on our way to ILAC. When I arrived several people expressed concern because they noticed my large suitcase I packed with ENT supplies arrived without me. I told them they should have opened the bag – I was inside the whole time. This received a few courtesy chuckles.

ILAC is located about 20 minutes from the airport and my first impressions of the grounds were very positive. It is very open with a courtyard in the center. There is also good security with a barbed fence and a guard dog – hopefully he will not need to pounce into action. There is wireless available so I have been able to email and even make a few calls. However, there is no air conditioning and Ill be sleeping under a mosquito net on a thin mattress – not to bad for roughing it in a developing country.

Breakfast starts at 6 am tomorrow followed by OR set up around 6:30 and the first case running at 7. This will be my first taste of surgical work in a developing nation and I am truly excited, though a bit nervous for the experience.

It's now day 2 of cases and I am completely exhausted. The fact that I have probably only slept about 7 hours total in the first two nights may be contributing. The first night I was unable to fall asleep not only because I slept for 10 hours the previous night but there were children and roosters making noises throughout the evening.

The days have been very full. We are waking up at 5:45, setting up the O.R.s by 630 and the first cases are starting by 7. Although the schedule only goes until 430 most cases have been going over. I am assisting with anesthesia for the T&A's which I like because there is quick turnover time and therefore more action for me. I have intubated more in the last 2 days then I did an entire month at Loyola. I feel myself becoming more comfortable, especially since I had never intubated a child before this trip. I have lost track of my overall record but I think I am about 60-70% success on the first try at this point. I really appreciate being involved in surgery because there is a real sense of accomplishment. You are part of a team that corrects a very practical problem to improve a patients life and more rarely save a patients life. I don't think there have been many life saving procedures here but we are certainly improving individual's quality of life. Patients are also very thankful and most have never undergone anesthesia or surgery before, unless they were treated by the medical mission last year.

We pick patients up in preop and as we walk them back to the OR there is clapping and cheering which is great fun. I am sure the patient feels famous for a brief moment.

We finished our last day of cases today and I am completely exhausted, still. We assigned one call night to each student and mine was last night. Although I had an uneventful night checking on the thyroidectomy cases (just changed an IV bag and emptied some drains), I still had to be up every two hours and I already had a sleep deficit. Nevertheless I made it through our final day in the OR without succumbing to death by exhaustion. I was even able to take a short nap tonight before we head out for dinner and drinks in Santiago. In total we completed 122 surgeries in 3 operating rooms over 4 days. The vast majority of cases were tonsilectomies and adenoidectomies but there were also thyroidectomies and 7 or 8 vascular procedures which take a much longer time to complete. Despite the hard work, the days have gone quickly and I have enjoyed gaining new experience in anesthesia.

Yesterday I had a “moment.” I saw in the eyes of several patients great trepidation about their pending surgery. I tried to place myself in their shoes – we walk them back into a strange room with several cumbersome machines and pieces of equipment, there is loud music blaring in the background and they are surrounded by doctors and nurses wearing masks and head gear speaking a language they don't understand. I felt very privileged to be part of the team that would help minimize their fear and help get them through the process safely. I think I have chosen a field where I can really feel satisfied in my work. However, in some ways I felt our work was not sufficient. The majority of us had limited Spanish and without a translator around we were not able to effectively communicate encouraging and calming messages during induction and wake up, though I think I did a better job preparing patients and walking them through the steps when I had a translator to work with in preop. Even so, I would have liked to better convey a soothing, calming message just prior surgery.

We had a couple close calls of nearly completing the wrong procedure on the wrong patient. There are several factors contributing to these near mistakes. First, the language barrier. Many patient have multiple, very similar names and because most of us don't speak the language all that well this sets up a high risk situation. Second, we are trying to treat as many patients as possible so the turnover time is very fast. Although we are trying to keep things very similar to the way things operate at Loyola there were times when we did not do a time out to ensure correct patient, correct procedure before first incision. I am thinking of speaking to Dr. Hotaling about attempting to implement the WHO surgical checklist during future trips to help avoid some of these difficulties though I am not sure of the feasibility/ challenges that may be associated with such action. One example where this checklist may have helped avoid confusion involves an incident where we completed a second priority operation when consent was for priority number one. A discussion was had with the family and in the end they were ok with both operations occurring at this time. I could tell that our thorough discussion of risks and benefits was something very foreign to the patients in the DR when receiving health care in their own country. This practice in our country has likely been greatly influenced by the legal climate in the US. Although I believe informed consent is important, there are times when one could argue informing patients of the 1 in a million risks that are associated with a surgery or anesthesia can cause more harm then good as a patient mentally prepares for an already very anxiety-provoking surgery.

Overall, I had a great time in the DR. I think I learned a great deal and this trip set a solid foundation for residency and future global health trips.

Research underway

Research Study Update: Please see previous blog for related information...

So,
I received word that a retroactive IRB will be possible for my study.
Now I just have a lot of international e-mails and phone calls with my organization in order to get all the paperwork in. Hopefully, sooner-rather-than-later. It's going to be a pretty interesting experience- this "international study on global health." Almost an international experience on its own.

I will keep you updated!

Pendleton Community Clinic, WV

Pendleton County, West Virginia is the third poorest county in the United States and is still recovering from a devastating flood a few decades ago. Throughout this trip I was bombarded with the inequalities of health services in Pendleton County depending on an individual’s geographical location. I became aware of inaccurate stereotypes that were associated with certain diseases that affected the entire livelihood of individuals infected. It was difficult to see the disparities in infrastructure, health services, and education in our country that is considered to be a highly developed nation. When deciding what service trip to attend, I wanted an experience that would provide the opportunity for me to understand the different aspects of society that contribute to creating health disparities in a community. I decided to travel to Pendleton because I believe there are important health disparities in the United States that have been forgotten because of the vast inequalities worldwide. By meeting and speaking with community leaders, our goal was to better understand the needs of the county. My desire is to have this initial experience be developed into a longer relationship ultimately serving this rural community.

Eat, Pray, and Love Ghana

Disclaimer: I have neither read the book nor seen the movie, "Eat, Pray, Love." Let's just put that right out there. So if you were expecting a beautifully written synposis, Roger and Ebert style, my apologies...you will read no such thing. However, as the much anticipated (self-proclaimed) blockbuster of the summer hit theaters last weekend after one too many previews on the television, the words started to sink in...and take on a new, perhaps more reflective meaning - very pertinent to the ISI and GHF experiences. I feel like the words EAT, PRAY, and LOVE can represent the 3 legs of the ISI/GHF tripod.

EAT - when we travel to foreign countries with a heart to serve, a part of our service to the people is to learn about their culture...and this definitely includes the local food (well, at least it did for us in Ghana). Eating is a mode of universal communication and it can often open the door to the culture of the people with whom we are interacting, so that we may better understand who the people are that we are serving.

PRAY - prayer was a huge component of my GHF experience. As we experience an up close and personal view with human suffering (maybe some of us for the first time), we are also confronted with some deeply profound questions that require us to communicate with someone or something greater than ourselves. In addition to questions, we are often deeply moved by the people whom we serve - their attitudes of gratitude, their humility, and joy despite homelessness, hunger, and no access to healthcare touch our hearts in a way that we find ourselves struggling to understand. Throughout my experience in Ghana, prayer served as an ongoing conversation with God in which I asked countless questions, apologized for my ignorance and arrogance, and shared words of praise and thanksgiving for the people of Ghana and the many lessons provided by their albeit brief presence in my life.

LOVE - In 1 John 3:18, it says "let us love not in word or speech, but in truth and action." One of my favorite, most convicting verses that continues to stir within me the desire to serve. As we participate in ISI and GHF trips, we are called to serve. In our service, we are acting upon the love that we have for others. We are moving beyond "the talk" and begin to "walk the walk." Of course it is a challenge - we are in a completely foreign place, may not speak the language, may have no idea what we are supposed to be doing...but I think if we go back to the basics - EAT, PRAY, and LOVE - we find what the ISI/GHF trips are truly meant to capture.

Bolivia

When I got off the plane in La Paz, my chest felt the same sensation it had 3 years ago. We had just landed at 13,325 feet, and I could tell that there was less oxygen in the air. It was my second time in Bolivia, one of the only international locations I’ve been able to return to more than once, and thus there was an odd sense of familiarity when we landed—the same majestic, white-capped mountains illuminated by the morning sun, the same outside walk from the plane to Immigration, the same dark olive green uniforms worn by the immigration officers.

Ultimately, however, while many of the sights and sounds reminded me of my stay in Cochabamba, Bolivia a few years ago, I truly enjoyed getting to know new cities. Each one has a distinct character. La Paz is an eclectic mix of the traditional and modern, with 'cholitas' in bowler hats, colorful skirts, and shawls, alongside people in suits and ties, or name brand clothing. In order to cross the street, we learned to dart in between minibuses and taxis, and quickly realized that a red light is more of a suggestion than a requirement. Santa Cruz, in contrast, has a far more relaxed pace. There are no high rises or crowded streets as one might expect to see in the 'economic powerhouse' of Bolivia. It is also not the 'plastic city' that our teachers and host families in La Paz warned us about before we left. Palacios, the small rural village where the clinic was, consists of a few small houses, a store, and the clinic, which is essentially where the road ends.

Munasim Kullakita "Love Yourself, Little Sister"

In La Paz, each morning, we had Spanish class from 9 am- 1 pm, and then return to our host family's home for lunch. In the afternoons, we were able to volunteer four times with a local organization called Munasim Kullakita, or 'Love yourself, Little Sister' in the Aymara language, that works with girls who live on the street and have been victims of sex exploitation and trafficking. The organization runs two houses for these girls. The girls begin/ return to school, and also learn skills such as knitting so that they can eventually gain independence. The second part of the organization's mission is outreach. They have 'recruiters' who continue to go out and build relationships with the girls who are still living in the streets. They encourage them to take care of themselves, remind them of activities that the organization has three times a week, and notify them of days when they can get medical attention and/or a hot shower.

The second time that I went, Alicia and I walked around the streets with one of the organization workers. He told us there were three rules that we had to follow when we were with him: 1.) Don't carry any valuables or money on your person. 2.) Don't let yourself be pulled away from the group. 3.) Wash your hands thoroughly when you return. With those admonishments, I was nervous about how we would be received as foreigners, and did not know what to expect.

Initially, as we walked the streets with the organization worker, I actually couldn't tell which girls were living on the street until they flocked over to the worker to say hello. Most of them were high on some sort of toner, paint thinner, or nail polish remover, I’m not sure which. They would pour some on a ball of wool or yarn, and bring it up to their faces to inhale, all while talking with us. It was difficult to hold a conversation with them, and when they kissed us on the cheek in farewell, the odor was overwhelming. According to the organization worker, one of the largest barriers for the girls to leave the streets is their addiction to drugs.

While we were standing with one group, a girl stumbled out into the street, sat on the edge of the sidewalk and began wailing, her cries echoing down the street. The organization worker tried to see if he knew her by calling out to her and asking what her name was, but she would not respond; and none of the other girls seemed to recognize her. He told us that it would be better if we did not approach her since we were not sure how she would react. I looked back at her as we were walking away, and the image of her was burned into my memory-- her slight, hunched figure sitting on the sidewalk made no more than a silhouette by the bright sun. By the end of our experience that day, I grew to appreciate how much progress each of the girls in the house had made after leaving the street.

Trans Copacabana

Before we left for Bolivia, we were warned that we would have to take a 10 hour overnight bus ride to Santa Cruz from La Paz to meet up with the rest of the team. Little did we know at the time that, that number would continue to grow as we talked to people in La Paz. By the time we left for Santa Cruz, the number had grown from 10 to 15... to 17, until one kind woman told us that we should be prepared for 19 hours on the bus. Ultimately, our bus ride on the Trans Copacabana bus line was not as bad as it could have been, but it was certainly not one that I would necessarily want to repeat in the near future. Due to our fear of the bus bathrooms, none of us dared to try the bathroom even after more than 12 hours on the bus. Only when we stopped at a checkpoint the following morning did we venture outside to pay a couple bolivianos to use some squatting toilets in a small hut by the side of the road.

El Centro Medico Humberto Parra

In the clinic, the patients we served could be categorized into three groups. First, there were the patients we could help immediately. These were the ones who came in for medication refills, parasite treatment, UTIs, and other manageable illnesses. On the other end of the spectrum, there were the patients who had more life-threatening illnesses such as patients who needed a pacemaker or radiation treatment. In those cases, the clinic was able to write referrals. Although the cases would then have to be sent for approval, there was a good chance that the patient would be able to receive a life-changing treatment. The most difficult cases for me were the cases in between where we didn’t have enough resources to make a definitive diagnosis, but the patients’ quality of life was not affected enough such that a referral to a specialist would be approved. It was frustrating that we could not offer any assistance, and that they would likely return to the clinic with the same symptoms over and over again. At the same time, I did find it rewarding to be part of the continuity of care for many patients with hypertension and diabetes. It was encouraging to know that they would continue to have access to care even after we were gone.

“Usted tiene Cancer”

In PCM-1, we learned how we should give patients bad news. We learned that it is important how you deliver the message, that we should be sensitive to the patient. However, my Spanish capabilities never felt more inadequate than when we had to deliver bad news at the clinic. How do you tell an 18 year-old girl with an 11-month old baby that’s she pregnant again when you’re not sure whether or not she wants another baby? How do you tell someone that they need a pacemaker because their heart might go into ventricular fibrillation at any moment? How can you explain to someone that they have cancer when all the words you know seem equally harsh, or scientific?

The patient came in with lab results from a hospital in Cochabamba for ‘follow up’ because she was still hemorrhaging. The lab results stated that she had cervical cancer, but no one had told her. I was working with Alicia that day, and when we went out in the hallway, we tried to plan how we would tell her. It was all for naught, however, because when we walked back into the room with the clinic coordinator and physician to explain the situation, the coordinator walked in and said, “Usted tiene cancer.” Just like that. I remember looking over at Alicia, both of us horrified, but it could not be undone.

My time in Bolivia demonstrated how easy it could be to become complacent by treating each patient with a cookie cutter method of counseling, and simply writing a prescription rather than addressing the root of the problem; however, I also learned how vital it is to remain vigilant, to treat the individual, and to give the patient a space to share their distress and pain, even when we, as medical care providers, might not be able to provide a treatment. In the end, it is the kindness and compassion that we show that is remembered.

Haiti

It is like looking through a dark woven blanket to bright light above. The night sky surrounds us, envelopes us as we gaze at the stars and planets. Fires flicker on hillsides around. Dozens of shootings stars streak through our vision. What wishes to make?

Morning comes early; the roosters are the only ones who arrive on time in Haiti. Bright sun heats up our concrete room, the light is blinding. Bread, peanut butter, and pineapple prepare and strengthen us for the final clinic day. Our truck, the beloved White Whale, bumps and winds its way to Dandann.

On my own and many patients to see, my excitement and nervousness brings energy for the day. The patients that have become routine to us in five days file in – cases of acid reflux, headaches, anemia, joint aches, hypertension, dental problems, vision impairments, malnutrition, vitamin deficiencies, dehydration, worms, scabies, and earwax impaction seem to be the major ones. My confidence increases as does my speed.

One man hobbles in using sticks as canes. He thinks that he is 69 years old, his eyes sunken, cheeks hollow, and bones poking through thin, outworn clothes. Asking what brought him to the clinic, he tells me, through my translator Louis, that he has pains in his stomach and all over his body. Haitians are a proud people, surviving through community and hard work so what he says next is difficult to hear. He openly admits that he knows these pains are from hunger. He eats only when people can bring him something, because of his limited mobility. He is unable to work, to support himself in any way. He has no family, his parents died many years ago and he never had children. His neighbors try to help, but they too struggle. He is not alone in his experience, but many do not share their stories. The pain on his face is apparent, I fight back tears. On physical exam, his belly protrudes, each of his ribs and spinous processes hard, sharp against my hands. Our ability to help is limited. We invite him to stay for lunch, share crackers and pretzels with him in the meantime. Tylenol and Tums are the best we have to send him home with. Louis is not only my translator, but a community leader and vows to look after this man.

The day is not done. I see dozens more patients before a father brings his children to my station; my penultimate patient. He is dressed in polka-dot pants and a wide brim straw hat with a ribbon tied around it. He is 32, his children are 8, 5, 3, and 13 months (and one more at home). Johnna, a missionary familiar with his family, explains to me his story. His wife died several months ago from an apparent ear infection, leaving him with the children. He has no money or source of income. The 13 month old has a cough and fever and the 3 year old something entirely different. He says there is something on her back, so we examine her by lifting up the large t-shirt that is her only clothes. A bony mass protrudes out, Dr. Buchta thinks it might be some sort of rib malformation, but cannot know for sure unless an x-ray can be taken. We tell the young father that he must take her to St. Boniface Hospital in Fond des Blanc so that she can be examined with better equipment. He nods understandingly and explains that the hospital is where his wife died and knows that he must take his daughter there, but has not been able to summon the courage to see it again. Again, I am overwhelmed with emotion as the struggles of my patients become clear. They are not simply medical, nor are they economic. The depth of hurt in this country is great. Each family, each person has a story. We are but a small piece of their lives, trying to make a positive change.

For this man and his family, we equip them with all of our vitamins that we have left, toothbrushes and toothpaste, antibiotics, stickers, and encouragement to have his daughter seen at St. Boniface.

At the end of the day, I am emotionally and physically drained. The White Whale brings us back to the orphanage, stopping to see a homebound patient on the way and pick flowers from the flamboyant tree. The children greet us with hugs and smiles. I relish in those times when I can see the joy through their eyes, see Christ through the light so apparent at the Mission. Dinner is a feast of rice, bean sauce, and chicken. We take for granted the provision of clean, safe water and gulp it down.

The sun sets in the hills and mountains that surround us. We debate on whether that planet is Mars or Jupiter, or maybe Venus. Darkness falls, twinkling stars replace the sun. Heat lightning strikes in the distance. It becomes quiet. A falling star blazes through the sky.

What wishes to make?