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Radiology Afloat: The Impact of Diagnostic and Interventional Radiology during the 2005 Tsunami Relief Effort Aboard the USNS Mercy

2008; Elsevier BV; Volume: 20; Issue: 3 Linguagem: Inglês

10.1016/j.jvir.2008.10.026

1535-7732

Stephen Ferrara,

earthquake and tectonic studies

AT approximately 9 a.m. local time on December 26, 2004, an earth-shattering event took place in the Indian Ocean; it was to become one of the worst natural disasters the world had seen since the eruption of Mt. Krakatoa in 1883 in Indonesia. While thousands of Acehnese families made their ritual Sunday pilgrimage to the seaside to enjoy a relaxing family outing in the setting of their region's immense natural beauty, a massive 9.2-magnitude earthquake shook their island's foundation, unleashing a merciless tsunami that would claim an estimated 150,000 lives from this single, humble province. Although Aceh's capital city, Banda Aceh, was the world's most severely affected location, the devastation was felt vastly throughout Asia and even as far away as Africa (Fig 1). Millions were affected in 14 nations and as many as 300,000 were killed (1US Geological Survey Most destructive known earthquakes on record in the world.http://earthquake.usgs.gov/regional/world/most_destructive.phpGoogle Scholar). Inhabitants of this part of the world, known as the Ring of Fire because of its intense seismic and volcanic activity, are no strangers to natural disasters. However, nothing could have prepared them for this. As Americans celebrated the holidays, the media streamed home images from the disaster, generating a tremendous outpouring of sympathy for the victims of this horrific tragedy. National governments and private civilian aid organizations (identified as nongovernmental organizations, or NGOs) mobilized financial, materiel, and manpower aid in an effort to ease the suffering. The United States led in this initiative, both as a government agency and through its citizenry. By December 31, the US government had pledged $350 million (eventually $950 million was pledged by the American government and an additional $1 billion was donated privately) (2United States Agency for International DevelopmentUSAID Earthquake and Tsunami Reconstruction.http://www.usaid.gov/locations/asia_near_east/tsunami/ngolist.htmlGoogle Scholar), but perhaps more importantly, it mobilized one of its greatest assets to lend assistance: the US Navy. The USS Abraham Lincoln had been performing its normal patrol work in the Indian Ocean when the tsunami struck; within a matter of days, the ship arrived on station off the coast of Sumatra and began providing critically needed food, potable water, and sanitation. The ship and its support vessels shelved their original mission and stayed on station for more than 1 month. During that time, thousands of helicopter sorties were flown to ensure that the initial survivors of the tsunami had the best possible chance of continued survival without falling victim to the harrowing threats of dehydration, disease, and starvation. With millions of US aid dollars committed and the Lincoln on station providing tons of food and thousands of gallons of potable water, a final piece was yet missing: American medical expertise. On New Year's Day 2005, 6 days after the disaster had struck, one of the Navy's two hospital ships, the USNS Mercy, was activated and began making preparations to leave her home port in San Diego, California. The Mercy was constructed as a wartime casualty receiving and treatment facility, and designed with the care of trauma patients in mind. The ship is a floating tertiary care center, now tasked to take world-class American medical know-how to the neediest of third-world nations. It is an impressive medical platform. Converted from the oil tanker S.S. Worth in 1985, Mercy is a 1,000-bed hospital complex complete with 12 operating rooms (including a converted angiography suite), 80 intensive care unit (ICU) and 20 postoperative beds, a full laboratory and pharmacy, a blood bank, and a complete radiology department (Table 1). A helicopter pad is adjacent to a massive open casualty receiving bay (CASREC) via a bank of three elevators. Patients can be triaged and resuscitated in CASREC, where portable x-ray units are used to obtain images that are loaded onto the picture archiving and communication system right in the treatment bay. Three compact, portable ultrasound (US) units (SonoSite, Bothell, Washington) can also be employed by radiologists, emergency room physicians, and surgeons to perform "fast scans" to look for free intraperitoneal fluid. For more advanced imaging, patients can be brought to the main radiology department directly adjacent to CASREC, where they can undergo imaging in any one of four radiography/fluoroscopy rooms or they can undergo a computed tomography (CT) scan or formal US examination. From the radiology unit, the patient can go directly to the neighboring main operating room complex, followed by a seamless transit to the postanesthesia care unit or any one of the ship's three ICUs or its isolation unit.Table 1Specifications of USNS MercySpecificationDetailsCommissionedNovember 8, 1986, San Diego, CaliforniaLength894 ftBeam106 ftDraft33 ftDisplacement69,360 tonsRange13,420 nautical milesSpeed17.5 knots (20.13 mph)AircraftHelicopter platformBed capacity1,000/80 ICU/20 PACUOperating rooms12 (including angiography suite)Auxiliary servicesRadiology, laboratory/blood bank/histopathology, burn unit, pharmacy, dental, physical therapy, optometry/lens fabrication, central sterile receiving, biomedical repair, engineering services medical gas production, laundry servicesWater production300,000 gal/dNote.—PACU = postanesthesia care unit Open table in a new tab Note.—PACU = postanesthesia care unit In addition to her substantial medical capabilities, Mercy can produce 300,000 gallons of potable water per day, as well as medical-grade oxygen, and perform any number of biomedical repairs or part fabrication. Although she had not deployed in the nearly 14 years since Operation Desert Storm, a rapidly assembled hospital staff and ship's crew worked around the clock to make ready for her first-of-a-kind mission. On January 5, 2005, Mercy sailed from San Diego bound for Indonesia. "Operation Unified Assistance" (OUA) had begun. As capable of a medical platform as Mercy was, her greatest limitation was glaringly apparent: manpower. Stretched increasingly thin since 9/11, the Navy medical department continues to support fighting Sailors, Marines, Soldiers, and Airmen around the world—not only in Iraq and Afghanistan, but in Africa and Europe as well. For Mercy to accomplish her mission of providing world-class support to the tsunami victims, the Navy tried something completely novel: it called on the American civilian medical community for help. It responded in force. Partnering with American nongovernmental organization Project HOPE, a call was put out for doctors and nurses to volunteer to spend terms of at least 30 days aboard Mercy rendering aid to victims of the tsunami. Volunteers flew to Singapore, where they would meet the already–under way ship and then complete the two- to three-day sail to Banda Aceh. Because of the chaos of the situation on the ground, particularly in the initial days after the disaster when resources were being mobilized rapidly, no guarantees could be made to volunteers regarding how they would be used within their specialties: needs were still undefined. Volunteers could be certain only that they would be working extremely hard, in an unpredictable environment, helping people in desperate need. No assurances were necessary, as an overwhelming flood of volunteers eagerly and unhesitatingly came forward—a deluge that exceeded the roughly 100-person volunteer capacity the mission required and could accommodate. Volunteers came from academic and private practices; some were newly trained and others were "semi-retired." Massachusetts General Hospital responded en bloc with nearly 40 doctors and nurses over two 30-day sessions. Some dedicated volunteers like pediatric intensivist Dana Braner and nurse practitioner Gabrielle Bergmann signed up for 4 weeks but couldn't bring themselves to leave when their "tour of duty" was over and eventually stayed on for many extra weeks. The crew of Mercy was hailed as a "Team of Teams," made up not only of the aforementioned Navy and civilian personnel, but Army and Air Force personnel. The Public Health Service also loaned expertise from the National Institutes of Health, Centers for Disease Control, and the US Coast Guard. Once on station, Americans worked side by side with medical teams from the International Committee of the Red Cross and various international militaries including units from Germany, Australia, Singapore, and host nation Indonesia. Independently, many other international civilian organizations also provided assistance and sent medical teams (Table 2).Table 2The "Team of Teams"UnitPersonnelTotal military personnel450⁎Numbers are approximate as actual numbers of military and civilian personnel varied during the mission.Medical officers (MDs)12Medical Service Corps (Allied Health Services/Administration)18Nurses17Supply officers2Warrant officers2General duty corpsmen70Specialty corpsmen80Nonmedical personnel247Project HOPE180 (91/89)†Civilians volunteered for either of two 30-day "tours of duty."Physicians45 (22/23)DMD/OMFS2 (0/2)RN/NP/CRNA115DVM2 (1/1)Optometry2 (1/1)LCSW3 (2/1)RD2 (1/1)Administrative9 (6/4) Numbers are approximate as actual numbers of military and civilian personnel varied during the mission.† Civilians volunteered for either of two 30-day "tours of duty." Open table in a new tab After the 8,000 nautical mile journey across the Pacific and Indian Oceans and picking up her augmentees in Singapore, Mercy arrived on station in Banda Aceh on January 31, 2005, where she relieved the Abraham Lincoln and made final preparations to receive her first patients (Fig. 2). The question remained, however, as to how a behemoth such as the Mercy, built for treating combat casualties, could best be used in this humanitarian assistance/disaster relief environment. The international medical teams that had set up field hospitals ashore were clamoring for Mercy's diagnostic capabilities. Each facility had dozens of patients whose treatment had been stymied by an inability to make definitive diagnoses. In some instances the problem was an inability to characterize bacteria in the myriad infected patients because of the lack of a microbiologic laboratory; in other cases no one could determine what was really wrong with many of these terribly ill victims. It became immediately clear that proper medical imaging was an absolute necessity if we were to provide quality, "first-world" medical care. But before any of this could be addressed, the mission needed a clear understanding of the patients. The military mission the ship's planners had in mind assumed that the medical care would come from doctors treating military personnel of a substantively identical culture. OUA was not that kind of mission at all. Success required creating and implementing solutions to challenges that were not found in a training manual; first and foremost, this meant gaining a sensitivity to the Muslim culture of the Acehnese people and to the immensely alien nature of an American hospital ship. The Mercy would call for a Muslim chaplain, a culturally sensitive diet, and placards translated into the native dialect (one of the many services provided by a small army of tireless Indonesian translators hired by the Navy). Part of that adaptation was allowing each patient to bring a family member to the ship to stay with them during their entire hospital course. Although this created a crowded and often strangely aromatic atmosphere on the wards (astutely skeptical of hospital fare, family members would often prepare local recipes right at the bedside), it was an essential part of gaining the trust and confidence of a people who had minimal, if any, firsthand knowledge of Americans—and who were meeting us under the absolute worst of circumstances. Advanced party liaisons who had met with medical and governmental officials on the ground in Banda Aceh had determined that Mercy would be most helpful by serving in a dual capacity: she would be the tertiary care medical facility for the sickest patients who exceeded the capabilities of the field hospitals, and she would deploy primary care and preventive medicine teams to outlying villages to serve those unable to make the trek to Banda Aceh. Three primary categories of patients needed our assistance: (i) those with injuries and illnesses caused directly by the tsunami; (ii) those with chronic medical illnesses who could no longer receive medical care as a result of the devastation of the local infrastructure (including the destruction of local hospitals and the death of many local physicians); and (iii) those who suffered acute trauma or had become ill after the tsunami had struck but who had nowhere else to be treated. What Mercy's radiology department lacked in manpower, it made up for in attitude (Table 3). The initial queue of critically ill medical and surgical patients requiring CT scans was nearly 50, and dozens of other orthopedic patients who had been bedridden for nearly a month required innumerable plain radiographs, lower-extremity Doppler images, and C-arm intraoperative fluoroscopy. Ultimately, many orthopedic patients went on to receive inferior vena cava (IVC) filters as well (n = 12). Because of the high prevalence of tuberculosis, every patient, as well as his or her family member escort, required a screening chest radiograph before they could be dispositioned out of the CASREC. This would have created a bottleneck in the flow of patients had it not been for the incredibly hard-working young x-ray technologists who unselfishly pooled together for the common good regardless of subspecialty expertise.Table 3Radiology Department Aboard USNS Mercy: OUA 2005PersonnelNo.EquipmentRadiologist (IR trained)11 GE LightSpeed 16-slice CT unitLead Technologist (Chief Petty Officer)12 GE MPH digital radiography suitesRadiology Technologists52 GE Digital Legacy radiography/fluoroscopy suites Diagnostic radiology21 GE Tilt-C angiography suite Angiography11 Acuson Sequoia US unit CT13 SonoSite portable US units US13 GE OEC 9800 portable C-arm fluoroscopy units5 GE AMX 4+ portable x-ray unitsAGFA PACSNote.—The Radiology Department was comprised of US Navy personnel only. IR = interventional radiology; PACS = picture archiving and communication system. Open table in a new tab Note.—The Radiology Department was comprised of US Navy personnel only. IR = interventional radiology; PACS = picture archiving and communication system. For the medical staff and crew that had been with the ship since San Diego, a seemingly endless number of planning meetings and reviews of possible scenarios had taken place. For teammates who had joined us in Singapore, the service they had pledged weeks earlier was finally about to be realized. So many people clearly needed our help, and so much good was waiting to be done—our eagerness and optimism were peaked. And although no one was really sure what to expect or just how well we would perform, when the first inbound patient-laden helicopter was announced over the 1-MC (a Navy ship's public address system), the anticipation was palpable. Deluged with patients, every clinical service scrambled to triage individuals who represented (it seemed) every combination of age, sex, and diagnosis. Yet despite this frenzied atmosphere, each patient found a way to make a personal impact on each of us who participated in his or her care. One of the first and most memorable patients was a 13-year-old boy named Iqbal who had lost both his parents in the tsunami and had been found after having clung to a piece of driftwood for days. On death's doorstep, he suffered severe aspiration pneumonia, complicated by dehydration, malnutrition, and chronic anemia (Fig 3a). Admitted to the ICU, he was intubated for nearly 1 week, but showed steady improvement until he eventually transitioned to the ward and ultimately on to the normal activities of a 13-year-old (Fig 3b). Iqbal's tragic family story, unfortunately, was more the rule than the exception. What made his case so unforgettable was that it was our first unequivocal success with a critically ill patient, otherwise certain to die, who lived and could go on to thrive because of the Mercy. Not only was Iqbal a clinical success on an individual basis, his illness represented the first of many pulmonary syndromes we would see so frequently in the ensuing weeks. Although the massive aspiration of sea water was lethal for so many, a number of children and teenagers had the pulmonary reserve to survive the initial insult. The virulence of the marine organisms, however, wreaked havoc not only in the lung but in the central nervous system as well. Several patients referred to the ship after Iqbal had primary neurologic diagnoses such as hemiplegia with associated fever, cough, and shortness of breath. Most had already received short bursts of a variety of available oral or intravenous antibiotic therapy with limited success. Referred to Mercy primarily to undergo head CT examinations as part of their neurology workup, screening chest radiographs revealed a more complicated and sinister process. Cavitary lesions, consolidations, effusions, and even pneumothoraces were found in the setting of multifocal brain abscesses (Fig 4a,b). This process, initially referred to colloquially as "tsunami lung," was a condition in which a polymicrobial mix of aggressive marine bacteria eroded through pulmonary parenchyma and sometimes pleura, ultimately gaining access to the left circulation and on to the cerebrum (3Kao A.Y. Munandar R. Ferrara S.L. et al.Case records of the Massachusetts General Hospital Case 19-2005: a 17-year-old girl with respiratory distress and hemiparesis after surviving a tsunami.N Engl J Med. 2005; 352: 2628-2636Crossref PubMed Scopus (23) Google Scholar). Fortunately, a clinical conundrum that had frustrated the physicians ashore became readily elucidated with the assistance of modern imaging techniques—including contrast-enhanced CT. Effective treatments ensued: prolonged intravenous antibiotic therapy with imipenem or meropenem, as well as percutaneous chest tube drainage in some cases (Fig 4c), yielded uniform improvement with significant progress in pulmonary status and neurologic function, often with a dramatic reversal of paralysis within days of therapy. This sustained antimicrobial regimen was made possible by the importation of a simple interventional procedure taken for granted daily in the United States, the lowly peripherally inserted central catheter. Peripherally inserted central catheter placement came to represent a fundamental example of first-world medicine. Because of the lack of facility, expertise, or equipment, this simple procedure was not available before Mercy's arrival, yet it became a mainstay of therapy and the turning point for numerous patients with polymicrobial infections. Another interventional procedure that saved the lives of several critically ill patients was the percutaneous tube thoracostomy. Not surprisingly, given the mechanism of catastrophe, a vast number of near-drowning patients who had survived were suffering from large empyemas. On several occasions, particularly in children, these patients experienced decompensation into respiratory failure on the helicopter flight inbound and underwent drainage percutaneously in the CASREC, obviating intubation or prolonged ICU stay (Fig 5). Again, with appropriate medical therapy and adequate drainage, excellent clinical outcomes were routinely obtained. All in all, approximately 300 interventional procedures were performed; they ranged in complexity from venous access to neuroembolization. Eighty cases were performed in the ship's angiography suite and generally represent the higher-complexity vascular cases, whereas the remaining 70% of cases were performed at the bedside or in the CT suite. More than 2,700 additional radiology examinations were also performed, making radiology the "nerve center" of the medical treatment facility (MTF). Every patient received a radiographic examination, ranging from screening chest radiography to CT angiography to renal artery stent placement. One of the most remarkable features of this experience was that it definitively proved that imaging is what truly defines first-world medicine; and less intuitively, although interventional radiology services are casually perceived as a high-tech luxury in the delivery of health care, they are actually integral to the most basic community standard we have come to expect in every facet of American health care. This became astonishingly apparent as specialists and subspecialists from every facet of clinical medicine clamored for minimally invasive, innovative solutions to the unique and often incredibly difficult clinical challenges this mission routinely presented. We were constantly faced with unusual circumstances, such as the necessity for extremely short hospitalizations as a result of logistical reasons or host nation limitations that precluded patients from continuing their medical regimen after the ship departed. An example of the latter involved several crush victims from Nias Island with massive and complex orthopedic trauma. Many of these often young patients would require weeks of immobilization with a typical need for prophylactic anticoagulation. However, given the circumstances, no enoxaparin would be available after they left the ship. Fearing the short-term orthopedic surgical success would be complicated by the catastrophic long-term complication of pulmonary embolism, through a rigorous multidisciplinary approach we opted to place prophylactic IVC filters in these patients (Fig 6). Although no data could support such a practice, this mission frequently required "out-of-the-box" thinking: where a shipboard treatment, if unanticipated, could create a worse potential outcome than no treatment at all. This chess game–like approach to medical practice, however, is one of the many things that made this such a professionally fulfilling experience. Further examples of interventional radiologic procedures that elevated the level and complexity of care in this austere environment to "Western standards" are depicted in Figure 7, Figure 8, Figure 9, Figure 10, Figure 11, Figure 12, Figure 13.Figure 8Reproductive-aged woman referred for evaluation of large abdominal mass. (a) Coronal reformatting of contrast-enhanced abdomen/pelvis CT shows a large mass arising from the pelvis consistent with large fibroid uterus. (b) Axial contrast-enhanced CT shows engorged pelvic vasculature secondary to mass effect. (c) Left uterine arteriogram before embolization shows significant hypervascularity and mass effect. (d) After preoperative particle embolization, marked reduction in uterine vascularity is seen.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 9Images from a 15-year-old female patient with abdominal mass and abnormal serum creatinine and potassium levels. (a) Axial contrast-enhanced CT reveals marked bilateral hydronephrosis, right greater than left. (b) Coronal reformat suggestive of bilateral congenital ureteropelvic junction obstruction. (c) Late phase of intravenous pyelogram reveals markedly dilated left collecting system with no apparent right-sided renal function. (d) Left nephrostogram (prone) after percutaneous nephrostomy tube placement.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 10Images from a 58-year-old man with 1 week of anuria and a serum creatinine level of 31 mg/dL. (a) Kidney/ureter/bladder radiography reveals extensive urolithiasis with several stones forming apparent "casts" of the ureteropelvic junction. (b,c) Longitudinal sonographic images demonstrate massive bilateral hydropyonephrosis, left greater than right, and nephrolithiasis. (d) Spot fluoroscopic image after bilateral nephrostomy tube placement. (e) Right-sided (prone) antegrade nephrostogram after left nephrectomy and right pyeloplasty. Residual stones were removed percutaneously.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 11Portable US units were heavily used to provide primary and obstetric care ashore.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 12A patient discovered to have transverse myelitis was brought aboard the Mercy in Dili, East Timor. Logistical challenges including limited helicopter availability sometimes required ship-to-shore transport of patients by small boat operations.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 13The Mercy's pathologist, LCDR Mike Favata, prepares a slide during a CT-guided spine biopsy.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Figure 7 shows one of many Mercy patients who presented with advanced head and neck carcinoma, in this case papillary thyroid carcinoma, who were able to undergo successful resection for at least palliation and perhaps increased survival (we did not have the ability to give I-131 or other systemic antineoplastic therapies) because of the ability to perform preoperative embolization. In this nation in which the populace had minimal, if any, access to health care, the number of untreated benign and malignant neoplasms we encountered was staggering. Figure 8 depicts a young woman with a massively protuberant abdomen who was referred for imaging evaluation. Contrast-enhanced CT revealed a giant fibroid uterus, and upon seeing the engorged pelvic vascular channels, the surgeon was initially reluctant to operate for fear of life-threatening hemorrhage. Reassured by the ability to have the tumor preoperatively devascularized, however, the patient underwent an uneventful hysterectomy after uterine artery embolization. In the treatment of another young woman with an abdominal mass, this time a teenager (Fig 9), we found a congenital ureteropelvic junction obstruction. At presentation, the patient's serum creatinine and potassium levels were markedly increased, but after image-guided percutaneous nephrostomy tube placement, her chemistry values normalized to the extent to which she could safely undergo a unilateral nephrectomy and contralateral pyeloplasty operation. Presumably because of the heavy mineral content in the drinking water, exacerbated by the baseline state of relative dehydration suffered by the general population in this equatorial climate, obstructive urinary calculi was a frequently encountered condition. An even more remarkable example involved a middle-aged man who presented with clinical evidence of uremia and a 1-week history of anuria (Fig 10). In addition to the obvious radiographic findings, his serum creatinine level was greater than 31 mg/dL. A trial of bilateral percutaneous drainage was performed, which resulted in marked improvement in serum creatinine level, decreasing to 1.5 mg/dL after 3 days. The cause of the anuria was an obstructive urethral stone that was successfully removed surgically in conjunction with open stone removal with right-sided nephrectomy and left-sided pyeloplasty. The remarkable nature of this experience cannot be summed up by simply recounting the scores of medical successes. In reality, the medical victories serve merely as a symbol of the greater success—the experiment that proved that a vastly diverse group of professionals could be thrust together halfway around the world, united by nothing more than their passion to help others, and accomplish amazing feats. Additionally, the Mercy mission further confirmed that advanced diagnostic imaging is what defines first-world medicine while the ability to perform image-guided, minimally invasive procedures defines what we have come to expect from routine American medicine. Simply put, the addition of a well-rounded interventional radiologist elevates the standard of care like no other single physician can. I had never experienced such a sense of camaraderie among physicians in my career. Maybe it's because this mission of mercy had subselected for a certain type of personality, at least among the civilian volunteers (Navy personnel were not volunteers), or maybe the living environment—which was like a large fraternal camp, living in squad bays, sharing meals, and weathering rough seas together—brought a sense of unity. Maybe it was the fact that we were practicing medicine for desperately needy people that made us all feel so dedicated to the mission and each other. Or perhaps we were having the professional time of our lives because we were liberated from the economic and administrative burdens that can distract us from our everyday practices, and this allowed us to focus on our real passion—doing sometimes straightforward, sometimes complex, but always amazing procedures for people who desperately needed our help. It was medicine distilled down to the most basic, pure, and beautiful concept: that of providing excellent care, unencumbered by external influences so readily apparent in the practice of modern medicine today. The beauty of "medical diplomacy" is the mutual regard it engenders. It is even capable of lifting the political barometer. According to Pew Global Research Associates (4Kohut A. America's Image in the World: Findings from the Pew Global Attitudes Project.http://pewglobal.org/commentary/display.php?AnalysisID=1019Google Scholar), America's approval rating in Indonesia, the world's most populous Muslim nation, was only 15% before the tsunami, it more than doubled to 38% after Mercy's 2005 visit. Although America is far from being popular there, this kind of positive movement is quite hard to achieve with the use of traditional diplomatic methods, and the US government has clearly taken notice. During Mercy's return home from Banda Aceh, the previously distant Indonesian government requested Mercy's help after another massive earthquake, this time afflicting Nias Island off the Sumatran coast. Mercy immediately steamed to assist, and no sooner had OUA ended when OUA II begun. Since that time, the Mercy and her identical east-coast counterpart, USNS Comfort, have made subsequent humanitarian missions to Asia (in 2006) and South America (in 2007). As subsequent missions occur, we continue to strive to improve and refine our methods of providing the most effective humanitarian assistance possible. The mission of humanitarian assistance varies greatly from disaster relief, however, and each journey presents its own unique challenges. Simply defining the goals of the mission can be a daunting task, requiring modulation of a host of variables including individual skill sets, equipment, and time on station—not to mention trying to meet the goals of those we have been charged to help. It is important to remember that the 2005 mission in Indonesia marked the first time this form of civilian/military collaboration had occurred, placing this sort of initiative in its very infancy. The good news, nonetheless, is that the US government (through the Navy) has made a commitment to this effort, and through continued collaboration with the civilian community, the process will undoubtedly mature and improve. For further information on how to volunteer for your own "experience of a lifetime" medical humanitarian assistance mission, visit www.projecthope.org. There is no sign that this strategy to reveal the "gentler side of America" is going to disappear anytime soon. Mercy's 2008 trek is already planned, and whatever its geopolitical payoff, the medical benefits for some needy peoples in these far-off lands will be tremendous.