UHMLA discovers an Oasis in the Peruvian Amazonian Jungle

Our first mission to Perú is finally accomplished with complete success.  The UHMLA group flew to Lima, then to Tarapoto and then rode a bus to Moyobamba where we checked in a hotel for the week of June 23rd through the 30th.  Another bus drove us to Yantaló every day back and forth.  Yantaló is a very small town in the Peruvian Amazon. The word “Yantaló” in Quechua means carrier of firewood on back.   Dr. Luis Vazquez, a retired cardiologist from Chicago, built a hospital complex in this remote place where his mother was born.  This is a state-of-the-art building designed by students of architecture of the University of San Diego and completed in 2015.  The physical plant is very spacious and immaculate.  It includes a large operating room with two columns of ceiling booms, three operating tables, three anesthesia machines and one laparoscopy tower.   Prior to our mission several other missions used the operating room for pediatric, plastic, general and gynecological surgery.   UHMLA was the first group that used all three tables simultaneously for an entire week. 

The members of the team were Rolando Rolandelli and Zubin Bamboat for general surgery, Michael Kuchera for gynecology and Deowall Chattar for plastic surgery. The anesthesia team was made up by Gerald Lefever, Walter Lewis and Cyrus Kapadia.  The nursing team was led by Christina Jimenez and included Carol Santana, Monica Grzelak, Ruben Milan and Lindsay Lefever in the Operating Room with Paula Lefever, Valentina Salvador, and Kathleen Kuchera in the recovery room.   We were very fortunate to also have with us Maria Kapadia and Erin McDonnell assisting us with the intake and discharge of patients and Charles Lewis managing the administrative aspects of the mission.

On Sunday we screened approximately 85 patients and selected 70 for surgery.   During the week we had three cancellations and some additional candidates screened. Ultimately we performed 67 operations in 63 patients between Monday and Friday.  Among the 63 patients six were children under the age of 10 (two 2 y.o., one each ages 3, 5, 7 and 9).  A total of 32 operations were done for general surgery conditions: 19 hernias, 11 cholecystectomies, 1 colectomy and 1 sphincterotomy for anal fistula.  Two ladies who underwent laparoscopic cholecystectomies stayed overnight with drains to be removed the next day. One of them had a gallbladder very suspicious for gallbladder cancer.  The colectomy was performed on a 35 year old man who presented with a nearly obstructing cancer of the colon.  His family history included a brother, only two years older, who already had surgery for an obstructing tumor of the colon requiring a temporary colostomy and his mother also with an obstructing colon cancer.  Although he had health insurance through his employer the process for him to get to see a surgeon was estimated to take several months.  After much debate we obtained the support of a surgeon from Moyobamba and proceeded with the surgery. We intended to do the operation laparoscopically and to that effect we mobilized the left colon and the splenic flexure. As we dissected around the tumor we realized that it was quite large, approximately 8 cm. in diameter, and firmly attached to the stomach. We had another debate including multiple family members and decided to open the abdomen and do an extended right colectomy with en-bloc partial gastrectomy.  The operation was uneventful and he recovered well without the need for any analgesics. He was started on a liquid diet on the 2nd postoperative day, which was the day of our departure.   Fourteen patients underwent surgery for gynecological pathology: 5 pelvicovaginal reconstructions including 3 cystocele repairs, one colpocleisis and one colporrhaphy, 4 hysterectomy (3 vaginal and 1 abdominal), 3 ovarian cysts, 1 D&C and one hymenal ring.   The D&C was performed to obtain endometrial tissue for biopsy in a lady with postmenopausal bleeding, the specimen was highly suspicious for endometrial cancer.  The ladies who underwent cystocele repairs stayed overnight with a urinary catheter to be removed the next day.  In the field of plastic surgery 21 patients underwent surgery: 10 for subcutaneous masses, 6 for scar revisions including flap reconstructions, 2 hand deformities, one eye lid deformity, one circumcision and one removal of subcutaneous foreign body. 

The support staff in the Yantaló clinic were excellent; especially Mery Padilla, the overall coordinator, Nino Ocampo the operating room nurse coordinator and Alberto Rivera the chef.  Wullman and Aljaz were also extremely helpful.  During our stay in Yantaló we met three first year medical students from the University of Rochester doing research on access to water in the Yantaló community.  We added to their summer curriculum a quick immersion to missionary surgery.  Overall the mission was a great success and we decided that Yantaló will become an additional destination for the annual UHMLA trips.

We were very saddened for not being able to meet Dr. Luis Vazquez who had planned on being there but was recovering from a medical emergency in Chicago. We wish he has a speedy recovery and is present in Yantaló  when we return next year. 

February 2018: LA ESPERANZA, HONDURAS

The decision to embark on the Honduras 2018 mission trip was delayed due to concerns of violence after the presidential election. The final decision was made on January 27th, 2018. We held two Thursday evening meetings, February 1st and 8th in preparation for our departure on February 10th. A team of attending surgeons and anesthesiologists with prior experience on UHMLA trips in La Esperanza was assembled. The team included Ted McLean, Rolando Rolandelli, Isaac Spiteri, and Dan Chung. We also had a third anesthesiologist already ticketed to travel, but unable to attend due to a family emergency. Since we were already planning to travel without recovery room nurses, this loss was devastating. Fortunately, Gerry Lefever, with less than 24 hours’ notice, boarded the plane with the rest of the team. Two chief residents also joined us on their first mission trip: Lyly Nguyen and Anand Shah. Operating room nurses included Kristyn Fabyanski (UHMLA Guatemala 2017), Lorene Caroleo, and Carolyn Neier. Furthermore, I was approached by Yuri Jaramillo and Dayanna Grau, two young nurse assistants who work in Surgical Access in the Main OR at Morristown Medical Center. Both had just obtained their degree in nursing but had never practiced. We welcomed them into the group, trained them in circulating functions at MMC, and planned on Baptism by fire. Four additional members completed the team: Susie Kaye, Maggie Claudio, Suki Dewey, and Mercedes Rolandelli; all four had prior experience in UHMLA missions.

The trip from Newark to La Esperanza was relatively uneventful, without any incident of violence in Tegucigalpa. On Sunday we made the usual transfer of duffle bags with supplies from the hotel to the Hospital Enrique Aguilar Cerrato (HEAC) and began setting up the equipment while we screened the patients scheduled to undergo surgery on Monday. Upon unpacking we realized that we had left behind the light source for the camera. Fortunately, we were able to replace it with one available at HEAC. Since we only had one tray of laparoscopic instruments, we had to interpose a smaller case in between cholecystectomies so we could sterilize the set of instruments.

The schedule Monday through Thursday consisted of three cholecystectomies along with two minor cases in room 1 and five open cases in room 2. By Friday, we were left with a number of cholecystectomies but no smaller cases to interpose, so I decided that we would only complete one cholecystectomy in room 1 and remain available for any special cases in which our team could offer a distinctive advantage over the local team (for example, cases involving pediatric anesthesia). We also participated in the care of an acute emergency on a physician colleague.

With two prior trips to La Esperanza under our belt, we had the advantage of knowing the hospital, the nurses, and some key physicians. We even had some returning patients. Every phase of the process went very smoothly. Patient selection, movement in and out of the operating room, surgery, and recovery were flawless. All physicians and nurses performed at their usual high level. The team members that stood out in this trip were Yuri, Dayanna, Maggie, Suki, and Mercedes. Yuri and Dayanna absorbed a lot and really began to connect the dots between nursing school and clinical practice. By the second day both looked as if they had been practicing nursing for many years. Maggie successfully filled her usual role of social worker and scheduling officer. Suki continued her charge of turning over instruments between cases with professional expediency. Finally, Mercedes has really become an effective troubleshooter between the UHMLA team and the hospital employees. Nurses, secretaries, sterilization technicians, and many others relied on her mediation.

All operations were accomplished as planned without any complications. We finished the week with the usual ceremonies: Shoulder to Shoulder expressed their appreciation for our work and we recognized the great effort they make to support us. Typically, at HEAC there is only one or two elective general surgery cases; during this particular visit we increased this amount to 10-12.

After all our hard work we even had the opportunity to enjoy some sightseeing on Friday afternoon. Luckily, on Saturday morning, we left Honduras just ahead of a snowstorm. No matter how many of these trips one makes, there is always a great deal of emotions to “unpack,” as well as luggage. Our next mission will take place in Yantaló, Perú June 23rd through June 30th, 2018.

September 2017: Guatemala

A team from UHMLA returned to Guatemala City for another surgical mission in September 2017.  This mission was carefully planned by having local doctors and organizers working on the ground months before our arrival.  Our team was led by Drs. William Diehl and Gerald LeFever and the site had been inspected prior to our arrival to ensure the operating rooms and facility would be adequate for the needs of our prospective patients.  

The Guatemala team members included a full nursing staff for circulating, OR assistance, and PACU care: Rachel, Carmina, Arlene, Francesca, Kristyn and Lindsay.  The Anesthesia team comprised Drs. LeFever, Chung and Spitieri.  The OBGYN team was led by Dr. Kuchera and PGY3 resident Mina Ayyad.  The general surgery team was Drs. Diehl, Bamboat and PGY5 resident Ben Schroer.  

Our group met on four occasions in NJ before the trip to collect materials and medical supplies including meshes, sutures, laparoscopic equipment, and OR instruments. The anesthesia team coordinated OR medication and Dr. Bamboat was able to procure 90 vials of donated Exparel - a long-acting local anesthetic that was crucial for post-operative analgesia.  One of the great aspects of this trip was our local colleague Ariel Marroquin.  He worked with local physicians to generate 65 patients ready for surgical screening on the day after our arrival.

The team arrived in Guatemala City mid-day Saturday without incident.  Our 14 oversized medical supply bags made it through customs without a glitch and were loaded onto vans for transport to our humble but clean and safe quarters in Guatemala City.  All day Sunday, the teams separated to maximize screening of prospective patients.  The nursing staff worked tirelessly to prepare the three operating theatres while Anesthesia and the OBGYN/surgery teams interviewed, examined and discussed surgical care with prospective patients. Local college students volunteered to help with medical translation.  In all, 53 patients were selected for surgery.   The hospital was only a few blocks away from our residence and our group was able to walk together to and from the hospital safely.

The next 5 days were spent in our element, the operating room.  The spectrum of cases included ovarian cysts and tumors, inflamed gallbladders, soft tissue tumors, and pediatric and adult hernias. The hernias ranged from small umbilical defects to giant inguinal hernias.  The most memorable hernia case was a gentleman who had been living with a huge inguinoscrotal hernia for more than three decades.  Though local doctors had offered to fix it, he had declined out of fear because his own father had died as a result of inguinal hernia surgery. He was no longer able to work as much of his small bowel and part of his colon was in the hernia.  When he had heard of the UHMLA team coming, he was able to overcome his fear of surgery by having the faith and trust in our surgical and anesthesia expertise.  His surgery was challenging but successful and the patient’s emotional appreciation for not just the repair, but surviving surgery cannot be understated.  The patient was able to go back to his village outside Guatemala City and resume working to support his family of 6 children. 

Another interesting case involved a 32 year old woman who presented to the clinic with what was initially thought to be a soft tissue tumor involving the helix of her ear. By growing her hair and covering the affected ear for years, she tried to lead a “normal” life. Soon it became too difficult to hide the “tumor” from friends, family and her employer. She lost her job as she feared going out in public. Careful examination of her ear revealed hypertrophic scarring from earrings in that area when she was younger. We resected the hypertrophied tissue and reconstructed the ear to resemble her contralateral unaffected ear. Her gratitude was priceless.

The local hospital was clean, safe, and nicely set up.  The local staff at the hospital helped us clean instruments and took care of patients who stayed overnight.  Every morning before surgery, we performed rounds in the wards on the patients from the day before. This involved teaching the local nurses about post-operative surgical care, analgesia management as well as basic medical management of problems like diabetes and hypertension.  A Canadian volunteer named Joe was hired as a 3rd party technical support for the OR.  His expertise was critical as he fixed multiple equipment failures and kept the laparoscopic equipment and anesthesia machines/monitors functional.  

Each day the gracious staff at our residence quarters prepared meals for us which were well received after a long day of operating. We visited some local restaurants on a couple of occasions in downtown Guatemala City. On our final day, we drove to Antigua about 1.5 hours outside Guatemala City and visited the hospital of our surgical mission the previous year. The Antigua medical facility is being renovated and will hopefully be ready in 2019 for another UHMLA visit. 

We are grateful to the entire UHMLA team who volunteered their time and expertise to make this trip a success. The facility in Guatemala City with the onsite local staff and medical coordinators is an asset to UHMLA’s future missions.  Guatemala has an abundance of people living in true poverty with a huge surgical burden of disease. We are already planning and looking forward to our next trip in September 2018.

February 4th-11th, 2017: LA ESPERANZA, HONDURAS

UHMLA returned to La Esperanza for another surgical brigade with Shoulder to Shoulder at the Hospital Enrique Aguilar Cerrato (HEAC).  Being the second trip there were many things we prepared for; however, as it is common in these trips there are many other things that we cannot prepared for, and we deal with them as they come.  Last year it was Shoulder to Shoulder that selected patients from us from La Frontera (border with El Salvador).  This year the HEAC publicized broadly our coming; and no patients were screened. As a result we found ourselves screening over one hundred patients until we filled the slots of our surgical schedule and had to stop.  The other incident was that one of the members of the team fell ill the day before our departure.   Therefore, we had more work and fewer hands; nevertheless, the team step up to the plate and did a spectacular job. 

Another new experience for us was bringing complex gynecological surgery in the hands of Dr. Michael Kuchera.  The rest of the team were: Diane Krutzler and Rolando Rolandelli for General Surgery, Gerry Lefever, Nancy Schultz and Meagan Judge for Anesthesia, Susan Kaye and Sejal Jain for Family Practice; Christina Jimenez, Mary Quinn, Tara Gonzalez, Paulette Garcia, Valentina Salvador and Cyprienne Lacaden for Nursing and Maggie Claudio, Suki Dewey and Mercedes Rolandelli for coordination and support.

 

Upon our arrival we met with our support staff from Shoulder to Shoulder, led by Kate Clitheroe and Paul Manship, and we distributed Spanish speaking people with each screening station: general surgery 1 and 2, gynecology, family practice, anesthesia and scheduling.   The hospital had undergone a major renovation and was really much improved from last year.  One problem was that the only radiology equipment in the hospital broke down.  We had several young doctors in their “social service” internship who were extremely helpful and fully staffed clinics and laboratory.  We completed the marathon scheduling 10-11 surgeries every day from Monday through Friday and made it back to Hotel to watch the half time of the super Bowl.  Maggie and Gerry had decorated the room and provided all of us with NFL paraphernalia.   We relaxed a little bit and got some rest to get the week started.

 

We tackle some hard cases first: in one room we removed an arterio venous malformation from the chest wall of a very cute 7 y.o. girl while in the other we did the first vaginal hysterectomy. Typically, it takes a long time to get started in this setting, but were finally underway and the patients did fine.  By the end of the day our nurses had to spend hours washing instruments to be sterilized for the next day. We did not finish until 9 PM and therefore, decided that as of the second day Suki and Mercedes would keep washing and drying instruments as we were finishing the surgeries. That was of great help; however, we kept running into difficult problems and saw daylight pass again; we made it back to the hotel at around 9 PM.  We decided that we would leave for Friday any possible tour into the center of town.

 

In total we did 5 vaginal hysterectomies, 6 total abdominal hysterectomies, 3 cystoceles, 2 oophorectomies, 1 diagnostic laparoscopy, 10 laparoscopic cholecystectomies, 5 hernias, 8 fistula in ano, 3 hemorrhoidectomies,  1 sphincterotomy and 1 excision of anal skin tags, plus the excision of the vascular malformation of the chest.  We also removed a port that was placed in the US for chemotherapy on a patient with rectal cancer.  In addition, we did 5 colposcopies and 10 ligation of internal hemorrhoids in the office.   We also saw several patients in follow up from last year and consultations in the emergency room.

 

On Friday we went into the town by 5 PM, most shops were closed except for some street vendors in the square of town. Those who were there for the first time got to climb up to the Gruta and get a panoramic view of Intibuca. We were hosted by Shoulder to Shoulder to a nice dinner and got back to the hotel to spend the little energy left in packing.  The fifteen duffle bags we had brought in were reduced to 7 by us either consuming or leaving behind the disposable supplies.  We packed the laparoscopic equipment using our scrubs for protection.   

 

On Saturday we were picked up at 5:45AM for a 4 hour drive back to Tegucigalpa.  We went through the checking in process quite smoothly and stood in long lines through customs and airport security to finally arrive to the gate.  As soon as we sat down we hear Suki’s name being called in overhead speakers.  She needed to be present to open her duffle bag by the Honduran “TSA”. That meant running back and forth through all the incoming crowds to find out that there was some stainless steel vaginal retractor that had gotten the attention of an agent.  We cleared customs through Miami with just enough time to board the next plane and arrived back to a frigid Newark all team members and the luggage safe and sound.   At the Friday dinner Gerry said: "we become so close in this short week that the day after we are back home we wonder where did everybody go", and that is the exact feeling. 

 

February 20th-27th, 2016: LA ESPERANZA, HONDURAS

In planning for Honduras we had to consider several uncertainties: how many patients had been preselected, how many patients we would find eligiblefor surgery, how many patients could be done each day, how much help we would find from the hospital, and what kind of equipment and supplies we would find in the operating room.  In order to confront any eventuality we decided to carry our own essential tools: anesthetics, trays of instruments, multiple supplies and the entire set of laparoscopic equipment (monitor, insufflator, and camera unit).  We ordered duffle bags, stamped them with “UHMLA Medical Supplies” and off we went.  

The team was made up by surgical faculty: Rolando Rolandelli, Ted McLean, and Billy Diehl; surgical resident Omar Ahmed, anesthesiologists: Gerry Lefever,, Isaac Spitieri, and Daniel Chung; OR nurses: Imelda Jimenez, and Arlin Fidellaga, PACU nurses:  Cyprienne Lacaden and Valentina Salvador, and surgical nurses Monica Grezlak, Ruben Millan,  and Carol Santana.
We were anticipating some objections at customs but we crossed without even a single question.  Kate from Shoulder to Shoulder was waiting for us in Tegucigalpa with a minibus.  We began the process of renting a truck while waiting for Susie Kaye to arrive from Houston.  Once Susie arrived and all the luggage was loaded we departed to La Esperanza with a stop in Siguatepeque.  In spite the dense fog that hid the huge potholes in the winding road we made to the Apart Hotelwithout incidents.

We began early on Sunday at the Hospital Enrique Aguilar Cerrato (HEAC) where we found about 60-70 patients waiting for us and many hospital employees and trainees volunteering time on their day of to help us.  At the end of the day we made up the schedule for the entire week in the two operating rooms that were made available to us; one is an active OR which only needed from us the addition of our laparoscopic equipment. The other one had never been used as an operating room, we made it work as such and use a room next to it as a recovery room (Cyprienne was extremely resourceful to make this happen).  One problem we faced was that the two ORs were separated by a Labor and Delivery Unit, the busiest any of us had ever seen in our lives.   The HEAC provides the obstetric care for women in the immediate region and for all those with high risk pregnancies and/or deliveries in the state of Intibucá of 250,000 people.  One number I hear in terms of yearly births was 17,000 which seems high but based on the ones we saw in just 5 days I believe it is totally possible.

We used the “main” OR for all cholecystectomies, children and any other major cases. In the smaller room we did all the anorectal cases. Hernias fill the gaps in either room.  During the weekdays we saw many more patients either in the clinic or the OR.  The HEAC normally functions with an anesthesia technician and without intensive care unit.  Therefore, patients who are too sick; e.g., any one who may require mechanical ventilation after surgery was transferred out.  While we were there we were asked to assist in some of these difficult cases and of course we did what we thought was safe: one elderly woman with acute cholecystitis but we referred out another very malnourished lady with gastric outlet obstruction. 

The trip had several highlights for us.  First, the collaboration with Shoulder to Shoulder was invaluable; they did an enormous preparatory work and they kept doing it all week long and took responsibility for our patients when we left. Kate who has a Masters in Public Health coordinated everything: patient selection, transport, communication with patients, families and referring physicians, and most important: kept us well fed, hydrated, healthy and happy.   We were also fortunate that we had a Board Member of Shoulder to Shoulder Dr. Kaye as part of our Brigade.  Susie has more than 15 years of experience in Honduras and with her expertise in Family Practice we were able to sort out issues that exceeded our limited capacity as surgeons.  Maggie, who back in New Jersey functions as Dr. Kaye’s administrative assistance came along and offered all of us all kinds of assistance by communicating with patients and families.

Another highlight of the trip was the opportunity to teach.  In Honduras students enter Medical School right after High School, the same way as in many other countries of Europe and South America.  Medical School then spans a total of 8 years.  All graduates are then required to domandatory rotatory internship in different parts of the country .  HEAC takes about 10 of these interns, Doctores Sociales (doctors doing social work).  We interacted with many of them, in the clinic doing preoperative assessments and in the wards doing postoperative care. More importantly in the operating room we took them through surgery and we were extremely impressed with their fund of knowledge and surgical skills.  Adding medical education of local doctors to the caring for patients in need expends our mission in such a wonderful way and makes these trips so much more rewarding.

At HEAC we counted with the support of the one and only surgeon, Dr. Renee Ratliff, who kept up with his routine responsibilities in addition to making sure we were able to accomplish our mission.  He and his wife, the one and only pediatrician Dr.  Mene Banegas were very generous and welcomed the entire team of 17 people at their house for a Honduran barbecue.  The recently appointed Director of the HEAC , Dr. Benitez, was there as well, and told us that Dr. Ratliff saved the life of his nephew who had sustained a gunshot wound to the torsum that lacerated the inferior vena cava.  

We definitely established a bond between UHMLA,  Shoulder to Shoulder and HEAC which will keep us going to La Esperanza every year.

ANTIGUA, GUATEMALA AUGUST 2015

The Mission to Guatemala was a great success. We operated at the Hospital Obras Sociales del Hermano Pedro in Antigua, Guatemala.   We screened about 75 patients and did surgery on 48.  All surgeries went well without complications.  The hospital is extremely efficient with an OR turnover of 5 minutes and electronic medical record.   We did laparoscopy with many disposable instruments reprocessed on site.  All local personnel is highly skilled and extremely devoted to their job.  Part of their skills and efficiency comes from the fact that every week there is a different group coming to do a totally different type of surgery. As we were leaving a group of Orthopedic surgeons from Syracuse came in through a Foundation “Operation Walk” ($6M operational budget) to do 100 hip replacements.  The hospital houses 240 chronic patients with cerebral palsy that, for the most part have been abandoned by the family. They take great care of them from nutrition and physical therapy to dental health (while we were there a group of odontologistsfrom Spain was doing work on them).  We paid a fee to Asociacion Companero para Cirugia, part of which is used to bring the patients and house them in Antigua and part is for the Hospital to subsidize the operations of the hospital. Once we made a tour of the hospital we realized that it was money very well spent.

The team was made up of Billy Diehl, Ted McLean, Ankit Dhamija and I doing the surgeries; Marina Debanich and Lauren Minotti scrubbed with us, Monica Grzelak (Halina) and Ruben Milan circulating, Carol (Cassé) Santana did the access, Cyprienne Lacaden  and Valentina Salvador did the recovery, Jordi Pineda was the troubleshooter and my daughter Florencia took photos and videos.  They all returned to the US by Sunday the 23rd while I headed to Tegucigalpa, Honduras.  In the airport I met with Susie Kaye, Chair of Family Practice at Overlook and long time founder and supporter of Shoulder to Shoulder in Intibuca, Honduras. This organization runs about 20 clinics in the most remote places of the most impoverished areas of Honduras.  The clinics offer primary care including Ob and pediatrics as well as dental care. They have been in operations for about 14 years but they have never done surgery.  Before climbing up to “La Frontera” (border with El Salvador) we stopped in La Esperanza at their Hospital and in the municipality. We met with the hospital director and the only surgeon and the only gynecologist. This is the only hospital in the entire Intibuca, what does not get resolved there goes to Tegucigalpa.  There are only two ORs and the possibility to make another one.  They have very rudimentary equipment for laparoscopy and work with nurse anesthetists who do general and regional anesthesia.  I was told that there is only 3 colorectal surgeons in the entire country and all three are in Tegucigalpa. When they heard about the possibility of addressing colorectal problems they became very interested.

After La Esperanza we drove to La Frontera through unpaved mountain roads and reached Concepcion, Camasca and Agua Salada (a village of 50 families).  I learnt that Honduras is the second poorest country of the Western World after Haiti, and this particular area, La Frontera, is the poorest of Honduras.  I met great people from the US working full time there as well as Hondurans.

We set as the date for our Surgical Mission in Honduras February 20th through the 27th, 2016 where we will follow the model we applied in Guatemala.  We are also planning to return to Guatemala in late July/early August, 2016.

I would like to thank everyone who supported us in this mission. I feel that we initiated a new tradition for the Department of Surgery which will bring the excellent care of Morristown to the most impoverished areas in The Americas.