Working outside the box

I think it’s funny that I am returning from a surgical mission overseas and my biggest problem is that I might run out of money before I get home!  Never before have I had the opportunity to SPEND money on mission – nothing to buy, nowhere to go and not allowed to go even if there was.  Amman was different.  Between shopping excursions for food and drink to entertain my room-mates and neighbors; last minute expenses for taxis, Visa extensions and dinner in Paris; and a whirlwind tour of Aqaba…but I’m getting ahead of myself.

I’m writing this, the last Blog Installment of my MSF-France Mission for Iraq in Amman in the boarding lounge at Charles de Gaulle Airport.  It’s just before 6 a.m. and my day is already three hours old.  I had a bit of a “Senior Moment” when I set my alarm clock and failed to take into account the change in time-zones between Amman and Paris.  So, I had an extra hour on-line waiting for my taxi to arrive at 04:30 <sigh>.  It probably wouldn’t have mattered – I woke up an hour before my alarm was set anyway, but this explains why I never got the 4 a.m. wakeup call from the hotel desk…

I cheated a bit on my arrival time at the airport.  I know the printout says, “…three hours in advance…” but I was certain there would be few flights this early in the day.  Even the subway doesn’t start running until after 5:30 (thus one of the taxi charges – luckily he accepted VISA, otherwise I was going to have to pay him with a combination of US dollars, Euros and coins).  Traffic was light (as expected) and we got to the airport at precisely 5 a.m.  I did the electronic check-in and bag drop-off and was on my way to the gate at 05:10.  I do love European airports.  The long walk to the gate and security screening still took under 15 minutes.  Charmed life, I keep saying!

My final week of work was fairly calm.  The first Iraqi Anesthesiologist came back from vacation and the second left for his week off.  Work was light again – MSF was putting on an Exhibition at the Cultural Centre, and the Queen came for a photo shoot with our surgeons (so all surgery was put on hold for the day).

Since, understandably, I wasn’t on the invitation list to meet the Queen, I filled my day giving lectures to various groups of nursing staff on acute and chronic pain management.  No surprise that a large percentage of the patients in our program have persistent or chronic pain after being blown up.  I stopped by the Exhibition the next day – it was a smaller version of the Refugee Camp in the City program which has been so successful touring Europe, the US and last summer, Western Canada.  I found a photo in the display showing my Anesthesia Technician from Gaza last January, wearing the scrub hat I gave him on my departure – like I said before, it’s a small world!  They are bringing the RCIC to Eastern Canada this spring, so if you happen to be in Waterloo or Montreal…

There are several Expats with experience in diving (or interest in traveling around Jordan on their weekends off).  Unfortunately, due to a combination of weekend commitments and upcoming flights, no-one was able to join me on my last weekend traveling around Jordan.  Grabbing the bull by the horns, I booked a bus ticket, hotel room and series of dives in Aqaba, and headed south out of Amman on Thursday evening.  Thanks to my remaining travel companions (red wine and Gravol) I had a lovely sleep on the 5 hour trip and woke up refreshed and ready to party.  The feeling wore off quickly, but I did have a chance to stroll the streets and experience some of the nightlife in Aqaba late Thursday.  I found a great store selling fresh roasted & seasoned cashews, pistachios and a variety of other munchies so I loaded up for the weekend.  As usual, I woke up before my alarm the next morning and after a huge “Jordanian Continental Breakfast” at the hotel, I wandered around the neighborhood again.  By chance, I stumbled upon the dive shop I had booked with and arranged for two dives with all the equipment and trimmings – 25 JD per dive (ludicrously affordable after $100+US dives in the Caribbean and Mexico).

One bonus of diving in the Gulf of Aqaba is that transport to and from the dive site is by road instead of open skiff.  I never have problems with motion sickness WHILE diving, but trips to and from in high chop make me regret (and on occasion, relive) breakfast.  This time both dives were off the shore at the same public beach so I could spend my surface interval basking in the sun.  Dive #1 was on the planned wreck (for reef development) of the “Cedar Pride” now covered in a variety of corals and filled with fish.  We saw at least a dozen frilly Lion fish and half a dozen eels (two of which were in the open – a very uncommon experience on my previous dives).  I was a bit disappointed…well actually, JEALOUS when we came up and heard another group hadseen a large Whale Shark swimming near the wreck.  We must have missed it by just a few minutes!  We made up for it on the second dive coming across a large sea-turtle which hovered nearby peacefully ignoring us.

It is common for surgeons and anesthesiologists to complete shorter missions than other MSF volunteers.  Nevertheless, goodbyes were a bit sad for me.  It’s always bitter-sweet leaving for home…I know I’ll miss the friends I met in the field, but I do look forward to my friends and (especially) family back home!  Getting away from the noise is a benefit too – I probably won’t hear another car horn until the rodeo comes to town for the next Calgary Stampede.  Unlike Gaza and Somalia, loud noises here have had innocent causes (mostly fireworks celebrating weddings and birthdays).  I DID get a bit of a flashback walking home on my last day – the contrail might still have been made by an F-16, but at least it wasn’t going to strafe me as I lay soaking up the sun on the roof!

I certainly won’t miss the electrical connections, intermittent baseboard heating or maimed children – humans WILL continue being nasty to each other, I’m afraid…

Best wishes to my team members, especially the “Self-Professed Serial Monogomist”, the “Vegetarian Hiking Yoga Instructor” and the “Oklahoma Cheerleader”!

This week started out badly – we lost a patient (I’ll call her “Leila”), our first death since the project opened.  All the staff, patients and families have been dealing with their grief ever since.  Leila was very ill when she arrived from Iraq – in and out of ICU and suffering from severe leg infections.  I looked after her a few times, providing sedation so the surgeons and nurses performed dressing changes.  I was impressed by the compassion and skill of all the staff, taking care to minimize Leila’s pain.  Frail and cachectic, she eventually succumbed to overwhelming infections resistant to the newest (and most expensive) antibiotics modern medicine has to offer.  Her death has affected us all and provoked feelings of guilt and anger directed toward the government and armed forces responsible.

 

 

Some of the surgical procedures being performed here are truly amazing.  Facial trauma is common in our patients and requires prolonged, multi-step reconstruction (especially when the jaw is damaged by bomb blasts or gunshots).  The process begins with a complex assessment of bone and dental loss.  “Three dimensional” C.T. scans are

 

forwarded to a company in Europe which creates models of the skull and mandible the surgeons can use to plan the steps required.  An early step involves attaching a multihole plate to the remaining mandibular bone to act as a “skeleton” or framework for future bone

 

 

 

 

attachment.  The maxillofacial and plastic surgeons performed an 11+ hour free fibular flap to rebuild the mandible of a teenage boy last week.  You can see from the radiology studies, he has lost about 9 cm of his right mandible with the accompanying teeth.  Once the bone graft has healed, the plate will be removed and a dental prosthesis can be created for him.

 

There are several children in the program in addition to the boy, above.  Burns to the face and hands are a common indication for plastic reconstruction.  Contractures develop and if not treated immediately, loss of function and cosmetic distortion are dramatic.  Facial burns and trauma make my job much more complicated (a fiberoptic bronchoscope is available and frequently necessary).  Hand contractures involve both skin grafting AND digital manipulation and wiring, followed my months of physiotherapy to improve range of motion and practical function.

 

My presentation on Pain Management was well received at “Journal Club” on Thursday – so well received that I have been requested to give another lecture NEXT week.  I was also signed up for no less than three lectures for the operating room and ward nursing staff.  I never pass up the opportunity to get up in front of an audience!  Since this is my last week (and we already have 15 operations scheduled), I will have to be very efficient with my time – I can always sleep when I get home…

 

I talked most of the team into joining me for dinner and a drink at the “Irish Pub” at a nearby hotel, which I can see from our apartment.  None of us has been there before, so we weren’t even sure what they served as far as food (but hey, it’s a PUB, right??)  Imagine my embarrassment when we walk in to find all they serve is alcohol!  Even worse, as my two supervisors enter in front, the bartender looks at me and says in English, “Hi, welcome back!”  No, seriously, I’ve NEVER been in there before!  Trust me!  <sigh>  We pulled a U-turn and fortunately found a nearby Sushi restaurant a couple of the team had heard about and wanted to try.

 

A few of us took advantage of the good weather last weekend to make a day-trip to the Dead Sea.  Because it is landlocked, technically the Dead “Sea” is a salt-water lake.  The only significant water entering it comes from the trickle of the Jordan River, but during the rainy season a lot of water rushes down the wadis into the Dead Sea too.  Because of the ongoing drought, the Dead Sea is gradually drying up – the water level has dropped substantially over the years.  Because the water continues to evaporate and the salt has nowhere to go, the concentration of sodium chloride (and many other elements and compounds) is over 30% (compared with the more usual 3% in ocean water.  This is why the lake is really DEAD – nothing grows in it or near the shores.  This is also why it is much more buoyant than fresh-water

 

 

 

 

(or even usual sea-water).  Swimming is really impossible – you don’t dare get water in your eyes or mouth (I dipped a finger in and touched it to my tongue as an experiment, and the area burned until I generated enough spit to dilute it).  You cannot submerge enough body parts to really swim – anything but paddling around on your back causes your legs to flop about uselessly in the air.  Quite amusing, really!

 

 

It was sunny and warm so there were lots of families at the beach resort we chose (which had the added advantage of fresh-water showers and two swimming pools).  The “Lake” water was warm (probably 21 degrees or so) but the pools felt icy and refreshing after lounging about in the sun, eating ice cream.  On a clear day, you can see the West Bank of Palestine on the other side, but it was hazy (either from smoke or sand & dust in the air).

 

We concluded the afternoon with a short walk up one of the nearly-dry wadis, where several large plumbing pipes were laid to collect a few drops of the remaining run-off.  It wasn’t as challenging a hike as the ones at Petra and happily, I have been keeping up with my exercises and long walks in Amman (mainly home from the hospital when the weather is good).  My skipping rope has been ignored until recently, but with the deluge of rain we’ve seen the last few days I’ve been making more use of it.

 

Just as long as the rapid heart-rate only occurs OUTSIDE the hospital!

It really is like a small club of friends in MSF – everybody seems to know everybody!  This week I discovered that our Psychiatrist worked with Elena (one of our psychologists in Gaza who also Blogs for MSF), Anne knows Michelle (Post-op Clinic Manager from Gaza), Debra was providing Anesthetics in the Sri Lanka project which I was originally hoping to join last summer, and Anne was working in the Yemen project (my alternate plan) which was suddenly closed, leaving me with the sad duty of golfing and fishing at the lake all of August.

I have agreed to extend my mission a bit to allow both Anesthesiologists here to take some vacation time.  Those who know me will agree that I believe strongly in rest and relaxation.  The interesting thing is that in order to extend my Jordanian Visa past one month, the government requires that I take an HIV test!  If the result comes back positive my Jordanian Visa will be the LEAST of my problems.

As I mentioned last week, I was given a tour of the Hotel where patients remain during their convalescence.  In the well-equipped Physiotherapy department, the staff has put up a poster demonstrating hand and finger movements (which I think is an ingenious maneuver to avoid confusing translations).  I took a photo, partly for interest in the rehabilitation positions, but even more so for the title.  You gotta love the French!

Our Plastic Surgeon is back from vacation so our relatively quiet operating room is now hopping – seven cases today in two operating rooms.  I got here nice and early so that we had two small operations finished in the first 30 minutes.  Unfortunately, our best efforts to move along failed miserably.  The combination of a late surgeon and missed critical blood-work left one operating team cooling their heels for over an hour and the other two and a half hours behind <sigh>.  As they say in the armed forces, “Hurry up and wait.”  Happily, the test results were eventually obtained and we went ahead in our room – this poor guy was injured in a bombing in Iraq over 3 years ago.  He had his humerus and tibia repaired but fell in 2009, refracturing the tibia.  He has been on crutches ever since.  He cruises around the ward with a big smile on his face practicing his English and is just happy that he’ll be able to walk again.  If only I had been able to talk him into a spinal anesthetic!  I still remember how to DO a general anesthetic, he woke up with a big smile, thanked me and gave me a kiss (a sign of great affection and friendship in Jordan – and please, no comments about disinhibition and erotic dreams from the propofol).

Our Pharmacist is into the full mind & spiritual health idea.  She is a vegetarian, practices advanced Yoga, enjoys regular Chinese massage, avoids pharmaceuticals (showing true restraint, being a pharmacologist) and even dabbles in acupuncture.  So when I heard the sound of birdsong coming from her room a few mornings ago, I naturally assumed she was playing a meditation soundtrack.  It sounded just like the Ashley & Franks albums I acquired from a friend back home.  You know what I mean – the sound of a dozen tropical birds twittering in the trees, making you imagine you are high in the Cloud Forest of Costa Rica.  Turns out it was REAL birds in the eves outside her window.  They must be celebrating the warm weather as much as I am!

The high point of the week (and of the Mission, so far) was our trip to al-Petra last weekend.  Truly one of the most impressive sights of my long(ish) life!  We made our way south from Amman by tour bus along the desert highway.  I was a little worried about the bus-ride since I’ve been known to get a wee bit of motion sickness (read:   Mallory-Weiss tear of the esophagus in the Caribbean) but I needn’t have worried.  Once you leave Amman the highway heads due south for two hours,

then makes a hard right toward the Israeli border with only the occasional speed bump to slow traffic down at rest-stops along the way.  We arrived at the bus station which stands right between our hotel and the main gates and had checked in, unloaded our bags and made it through the gates before 11 a.m.

Petra is a marvel of ancient settlement culminating in an advanced, wealthy trading civilization called the Nabateans, who eventually partnered with and

succumbed to Roman influence.  The main city centre, consisting of several

temples and other buildings, is now reduced to rubble by earthquakes and the elements.  The amazing feature of Petra is the Tombs carved directly into the mountain face (instead of the more traditional free-standing assembly).  The entire valley is teeming with elaborate facades, sometimes with tiny crypts where bodies were laid to rest, occasionally with large multi-room chambers large enough to hold feasts or religious ceremonies.  The

tombs appear to have been commissioned by the wealthy, powerful or famous to be built after their deaths as a tribute (or perhaps to provide a more comfortable afterlife).  Because of their proximity to the surrounding rock many have been protected from the weather and resisted 2000 years of erosion.  The most notable

(and the most well-known, in part due to the filming of “Indiana Jones and the Last Crusade) is the “Treasury”.  This glowing work of art is the first thing a visitor sees when emerging from the 800 m long Siq (or gorge) entrance to the valley.  Breathtakingly beautiful, the sandstone glows in the morning light like a beacon to travelers.

On our second day, we got up at 5:30 and passed through the gate even before the security personnel arrived.  This enabled us to take an alternate route into the ancient city, following the Wadi Muthlim stream bed (impassable during the rainy season due to flash floods).  We picked up two companions at the gate – dogs presumably belonging to the local Bedouin clan.  While dogs are unpopular with (and even shunned by) most Arab communities, the Bedouin frequently keep them.  The dogs who joined us had some of the distinctive markings of border collies (which explained why they nipped at our heels and bounced around like delighted children when they realized we were going for a walk).  The hike in was somewhat challenging what with the walls closing in to less than one metre in places and boulders blocking the way.   At low points, residual water from last week’s snow and rain formed pools which had to be leaped, skirted or (once) waded through.  “Lonely Planet – Jordan” was quite positive about the route, but my “Rough Guide” advised against wading due to the water snakes… I guess I should have read that BEFORE the trip!  Our companions left us at an obstruction made up of two boulders and a 3 m expanse of water – we reluctantly left them behind, realizing they would have to find an alternate route home at the end of the hike (as would we).

We came out into the valley above the Royal Tombs, found a quiet place to sit and ate our Bedouin breakfast overlooking the glory of Petra.  Not a soul was about – it was just after dawn and not even the local traders in jewelry, postcards and tea had come down from the town.  The rest of the tourists hadn’t made it as far as we had yet, so we had Petra to ourselves (at least for a little while).  Eventually the earliest Bedouin   overtook us and we were invited by a lovely lady on donkey-back for après breakfast tea at her “shop”.  I had to laugh when two young men in traditional Jordanian attire passed us while listening to Bob Marley on their portable Boom Box.  The music matched their dreadlocks (and strangely enough, their long black shirts and baggy trousers) perfectly!

Next we made our way up to the “High Place of Sacrifice” (al-Madhbah), 170 m above the valley floor.  The Royal Tombs are even more breathtaking from above, and from this vantage point cliff tombs & carvings spread out in all directions as far as the eye can see.  To put things in perspective, the dark opening you see in the bottom of the tomb farthest to the right, is about 2 m tall (and in the following photo, the small white speck in the doorway is a tourist!)

The Negev of Israel lies to the west but due to the heat haze (or dust and sand) we were unable to see it.  On the bus-ride back to Amman I  realized this was the first real hike I have been on while on any mission with MSF and I was especially grateful I brought good hiking boots.  Up until now, I have been satisfied with my Birkenstocks, which fill the role of hiking boots, shower flip-flops, house slippers, and occasionally operating room clogs.  I even hiked to the top of Red Mountain once or twice to pick Saskatoons, not to mention wading through the flooded O.T. Tent in Gaza last February…

It’s nice to be busy again – lots of plastic surgery and combined maxillofacial-plastics free flaps booked the next few weeks.  I managed to have a senior moment and completely miss didactic rounds last week, so I was “volunteered” to give the next one.  Between lecture preparations, 10-hour operations, shopping and cooking I now have full days.  I even helped move a few cases of I.V. fluids around in the Pharmacy (now that I have pretty-much recovered from my New Year’s Eve hernia repair – I have been waiting for an opportunity to comment on the “comb-over” and self-imposed “Hemi-Brazilian”).  Over-share alert!

Speaking of over-share – if you ever find yourself in a country with slightly tighter restrictions on personal attire than that in the West, try not to pull one of these…

The End.  So Far.

First the Bad News – the heat went off in our apartment last week, so it remained 12 degrees in our bedrooms as well as in the common area.  The Good News – it was corrected before the snow came on Thursday.  It was brutally windy and cold for awhile, rattling the shutters in the middle of the night – it felt just like home!  It snowed on & off for a couple days, but despite warnings and staff fears it never accumulated and it vanished rapidly when the sun came up.

Lucky thing because I missed the instructions to turn the hot water heater back on in the evening, resulting in a “refreshing” morning shower.  On a positive note, the freezer compartment of our refrigerator is cold enough that I’ve had ice cubes to go with the lemon twist in my drinks.  I keep saying I lead a charmed life!

My sleep cycle is finally back to normal…I get up around 5:00 and have a nice leisurely coffee and breakfast with time left over to “work” online before we are picked up at 7:30.  Jet-lag had been getting ridiculous – I began waking up earlier every day (at 02:30 the night after posting Installment-I).  I was feeling pretty exhausted – I figured it was at least in part because there is no inhalational gas scavenging system in the operating theatres.  Exhaled nitrous oxide and volatile anesthetic is vented into the room.  Then I realized we had performed spinal anesthesia on all the patients that day, so no gases were present <sigh>.  Trying to “catch up” by going to bed early seemed only to make it worse.  The combination of exhaustion, winding roads and heavy smoking in the operating room lounge was causing serious nausea for awhile, but all is good now.  Fortunately, I don’t have to take malaria prophylaxis, so I don’t have to deal with the bizarre dreams and insomnia I experienced in Somalia.

Much to my chagrin, I have developed a taste for the instant coffee packages provided to us in the operating room – a sickly-sweet combination of Nescafe, Coffee Mate and sugar.  I still prefer the Arabic coffee cooked on the stove (with cardamom) but I have to admit the instant stuff is simple and portable and it’s easy to find hot water.

It has been fairly quiet in the operating room – one of the surgeons is away on vacation.  He is scheduled to return on Sunday, so we might find things picking up.  We have only been running one theatre so far, which has allowed me to get used to the procedures, meet the staff and give a few lectures ( I do love a “captive audience”).  MSF has outdone themselves with the anesthesia and surgical equipment.  The surgical and patient complexity requires live X-ray (fluoroscopy) and advanced airway equipment (flexible fiberoptic bronchoscopy).  Multi-tissue flaps and complex maxillofacial reconstruction are common and we have access to monitored postoperative care beds and even ICU ventilation.

Many patients have injuries which are several years old.  Osteomyelitis is common and multi-resistant bacteria are the routine instead of the exception, so isolation protocols are rigidly enforced.  It was explained to me than one gentleman in a private isolation room had both Pseudomonas and MRSA (a resistant staphylococcal strain) cultured from his wound on arrival in the program.  Infections must be eradicated (or at least controlled) before considering implantation of tissue expanders, bone grafts or internal fixation devices.  Some patients present with serious systemic illness from their wound infections (why it is advantageous to have a good working relationship with a facility with an intensive care unit).

Most patients expect to be in the program for several weeks to months.  A hotel nearby the hospital has been leased and patients and their caregivers live there while recovering and awaiting their next surgical procedure.  The building houses an advanced physiotherapy program, a psychology department (and even several kiosks in the Atrium).  Patients are transported to and from the hospital for some treatments and for follow-up appointments with surgeons in the attached Outpatient Department.  Recently, the project was featured in a television news program (www…….) – putting MSF in a very positive light.

The quiet days have allowed me to explore the city quite a bit.  After Grand Ward Rounds on Saturday, Jorg and I went for another “Long Walk”, a combination of shopping and rubbernecking.  We descended the hill the hospital is perched on, weaved through much of the downtown markets and into the Coliseum.  It has been partially restored and contains two museums with artifacts and displays of traditional apparel and weaving equipment.  From the Coliseum we climbed up toward Al-Rainbow Street, managing to climb the wrong hill and having to backtrack several hundred meters (in distance and altitude).  We made it eventually, also discovering a great restaurant for a greatly appreciated sandwich (shawerma) and bottle of water.  Deciding discretion was the better part of valour, we hailed a cab for the remaining trip back to our apartments.

Jorg’s enthusiasm for walking (and his reassurance that the walk home from the hospital was only about 90 minutes) encouraged me to walk home after work on Sunday.  As promised, I entered the Shmesani district and approached the apartment after an hour and a half.  Maneuvering around the two tunnels along my route was “interesting”…mainly trying to avoid being run down in the traffic circles at ground-level.  Jordanians drive quite aggressively, treating lane markings more as guidelines and using the car horns to mean anything from, “yes, please go ahead,” to, “hey Ahmed, nice to see you again,” or the more common, “What in the name of Allah are you doing?”  Despite this, they ALWAYS stop before running into each other or into pedestrians.  I’m certain their reflexes are better developed than ours in Canada.  Cellular phones, while everywhere, seem to be used less commonly while driving.

Tomorrow, Jorg travels back to Europe – a going-away party is planned and will be well attended (he seems to make friends everywhere he goes)!

Live Large…

My Shirt Now! – the day before departure I participated in the Calgary Flames Charity Poker Tournament, knocking out Brent Sutter and thereby “won the shirt right off his back” – he was a good sport and even signed the front for me.

It is Saturday morning and I’m sitting up in bed in a comfortable apartment in Amman, Jordan.  As usual, my current mission was not confirmed until days before my departure.  The disaster in Haiti threw another wrench in the works – but the combination of my embarrassing French and more extensive clinical experience and diplomatic skills (?) convinced Paris to send me to Amman and their Iraq Surgical Project.  MSF was forced to pull Expats out of most of Iraq in 2004 due to security risks despite injured civilians suffering from the weakened healthcare system and fleeing of many physicians out of Iraq.  Thus was born the idea of transporting patients who required complex surgical reconstruction and rehabilitation to the capital city of Jordan, where MSF has contracted

operating room, ward and clinic space from the Jordan Red Crescent Hospital.

And so on Monday, I left at about 10:30 a.m. for the Calgary International Airport, arriving well before the lines formed.  My only request to the T.O. office when booking my flights was to avoid Air Canada, if at all possible (I’m bored with their poor service, depressed & grumpy staff and inflexibility).  Unfortunately, Lufthansa’s airplane coming to Calgary was delayed due to snow and bitter cold in Europe, so I started my adventure with a five hour wait.  With the delay, my connection time in Frankfurt was too short, so they moved me onto a later flight to Paris, thus providing me with another three “free” hours in Frankfurt <sigh>.  I dragged my butt into the MSF office in Paris Tuesday afternoon, 21 hours after leaving my house.  I did manage a few hours sleep on each flight (hamdu lillah – thank God – for Zopiclone and red wine) so I only felt HALF done in.

An advantage of the late arrival was a VERY efficient briefing schedule.  No-one wanted to hang around after 18:00, so I didn’t have any long waits.  I was out and on my way to the hotel in short order – I even had time to help the communications department with an English voice-over on a couple video clips from the emergency project in Haiti.  Wednesday morning I went straight back to Charles de Gaulle Airport for my noon flight to Amman on Royal Jordanian Airlines.  I planned lots of time to buy duty free (cheese, chocolate, magazines, etc.) for the team in Jordan.  Most everything is actually available in Amman, but the Paris office suggested real French cheese might go over well.

On arrival in Amman, it took me a little while to get through Passport control (since I had no clue the address or phone number of where I was staying – not to mention I still have TWO Yemeni visas in my passport), but once I thought to show the copy of my MSF Mission Order, all problems went away.  I was a little stunned with jet-lag and managed to tip the guy who insisted on helping me with my suitcase 5 Jordanian Dinar (nearly $10 Can) – I figure I made his day.  JD have Arabic writing on one side and English on the other – I’ll have to look a little closer from now on.  Since I’m still healing from my hernia repair on New Year’s Eve, I didn’t really mind him schlepping my 30kg suitcase up onto the X-ray belt leaving the airport.  It was dark by the time we left with our driver, so I didn’t get to see much of the city on the ride to our apartment.

Each MSF surgical mission can be radically different from the last.  In the short time I’ve worked with them, I’ve looked after acutely war wounded, obstetrical emergencies, delayed obstetrical complications and (most recently) delayed reconstructions from violence or burns.  As in Gaza, the patients I will look after here in Amman will be having (semi-) elective reconstruction of injuries – many of which were sustained years ago.  Their caseload includes complex maxillofacial reconstruction, orthopedics and plastic surgery.  They run two operating rooms with two Iraqi Anesthesiologists – my arrival provides them the opportunity for well-deserved vacations.  There are also two anesthesia assistants, so we have lots of hands available for procedures and monitoring.  Since many of the maxillofacial patients require awake fiberoptic intubation, the extra help will be welcomed.

My accommodations are, again, similar to those in Gaza.  We have an apartment in a residential area close to a large grocery store (Safeway!) and produce market.  There are no security risks so we are free to walk throughout the city and to travel around Jordan in our free time.

The Expat team is small and I only have two room-mates, our Psychiatrist and Pharmacist.  The apartment is some distance from the Hospital, so we commonly car-pool with Arielle (Field Coordinator) and Jorg (Medical Director).  Yesterday, the five of us spent the day starting

with a huge breakfast at the landmark Books@Cafe on Al-Rainbow Street, followed by a

Temple of Hercules

walking tour of Citadel Hill (Jebel al-Qal’a) and surrounding shops.

Street names and addresses are a relatively new invention in Amman, and most people completely ignore them.  Instead, you have to ask the taxi to take you, “across from the Royal Jordanian Hotel,” or,

“up the street from the King Abdullah Mosque.”  Taxis and food are relatively cheap:  the 20-minute ride from the hospital to the apartment runs ~ 1.5 JD and I stocked the fridge with milk, eggs, cheese, bread, cooking oil, spices and a litre of pop for 10 JD.

Hiking up and down the narrow streets and stairways helped with the guilt (and calories)

associated with our 5-course breakfast – and allowed us to justify dessert and coffee at the end of the day across the street from the beautifully maintained/ restored Coliseum.

All in all, a fascinating collection of old and new – Amman will be a lot of fun to explore.

Arriving home near dusk I had just enough energy for a few quick Emails before falling unconscious into bed at 9.

I finally had a drug-free sleep, waking a few minutes before the 04:30 call to prayers.  The voice, acoustics and speakers nearby are excellent, so it isn’t a bad way to wake up.  We have internet access (although I have been unable to get WiFi to work and have to sit out in the cold living-room…don’t cry too hard for me), so I will finish editing photos and start the Blog-posting clearance process ASAP.  Tomorrow we start the new week, but today I can be lazy and hedonistic (a new experience for me –LMAO) .

Dr. Mark Kostash is an Anesthesiologist living in Calgary, Alberta, Canada.  This Mission to Gaza with the Emergency Desk in Paris was his third surgical MSF mission.  Previously, he spent three and a half months with MSF-CH in Belet Weyne, Somalia and a month with MSF-F at a VVF (obstetric fistula) program in Jahun, Nigeria.

He is a Clinical Associate Professor with the University of Calgary and between MSF missions works in a teaching hospital in Calgary.  He specializes in pain management and regional nerve blocks and coordinates this area of training for the anesthesia residency program.

Outside of Medicine, he enjoys woodworking and spends much of his leisure time in his basement making children’s toys.  He donates most of these to hospitals in Calgary and abroad.  He is an avid cyclist, fisherman, down-hill and water-skier, sailor and music enthusiast.

Bloging is new for him…