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Burger Zapf M.D., Ph.D.

Otolaryngology, Head & Neck Surgery, Facial Plastic Surgery

411 Walnut Street # 4269 Green Cove Springs, Fl 32043 USA E-mail: He has been working in our Clinic for the first time from the 17th of April until 23rd of May 2004. His second visit in Guadalupe was from March 29 until May 7 of 2005. The third visit was from November 20th until December 14th of 2005. The forth visit was from April 2 until May 18th of 2007. The fifth visit was from November 15 until December 20 of 2007. The sixth visit is from November 2 until the end of month 2008 The seventh visit was from the November 1 until 27 of 2009 Thanks you very much for your great work.

ENT Experience at Guadalupe Mission Clinic, Ecuador, in the Spring of 2004

I have to say these were an exciting five weeks, not only with the medical work but also with the entire team here at the Clinic. We enjoyed camaraderie and weekend cookouts galore. The Mission Clinic serves a large rural population. From the city of Loja four-hour bus ride away up into the mountains. Patients come the night before and literally sleep on the front steps of the Clinic in order to be first in line the next morning. The Clinic and the doctors’ quarters were built recently and are very nice even to “first world” standards. Unique electrically heated showerheads, computer with internet access, TV with a video movie collection and a large kitchen to cook to one’s heart’s desire complete the picture. The covered veranda overlooks the tropical rainforest mountains and the river. Weekends are free for exploration, sightseeing or just relaxing. The Clinic is new and spacious. A large pharmacy stocked with donated and bought drugs serves the community as in most third world clinics there is a vast amount of donated supplies. You have to wade through it to find what is useful for you. Ideally you would organize and bring with you donations of meds and supplies for your own use. That way you reduce your chance of being caught short. The OR has a good Storz operating microscope. There is a rather ancient Bowie cautery, office suction, an OR table, OR surgical stretcher, and multiple sterilizers. There are sufficient instruments to see patients all day without resterilizing. There are some old instruments for septoplasties and tonsillectomies, but no mouthgag. Any potentially interested ENT person should plan to bring all special instruments for surgical procedures. That includes prostheses, gelfoam, eardrops, steroid nasal sprays, PE tubes, etc. There were several ossicular reconstructions I could not do because of lack of equipment. I used up the entire pharmacy supply of cortisone nasal sprays. Also the chromic catgut sutures started to run low. I brought a portable audiometer that turned out to be extremely useful.

The lack of cocaine is a real drawback.There is a broad range of ENT problems here. the adults seem to hide out and only trickle in. On the last visit we did seven rhinoplasties in one day. On the way to the hospital we scoured the large indoor market for rye flour. I generated the surgeries as I saw the patients and could fill one to two surgery days per week. which I bought in Quito on my way here. We got up at 5 am to catch the bus to Zamora. Amanda was tireless in helping to translate. Even though there are many children with chronic MOE. even with conscious sedation. Initially I did some tonsils and noses with Ketamine and Versed. It is difficult to line up surgeries in sufficient quantities to keep an anesthesiologist you bring with you busy all the time. The anesthesia machine was up and running but had not been used before with gases. traumatic nasal deformities. Upon Rori’s advice I also started using Fentanyl 2mcg/ kg as sedation which worked out quite well in conjunction with Versed. we weren’t able to schedule enough general anesthesia days. My hope was to avoid bringing all our equipment to the hospital in Zamora and instead bringing the anesthesiologist to Guadalupe. I learned from Dra. I did tympanoplasties under local. The #15 blades ran out and sedation meds got used up. Despite political turmoil in Ecuador and a nationwide doctor strike. Later Padre Jorge and I went to the hospital in Zamora and arranged for surgeries under general anesthesia there. so I started doing septoplasties under local anesthesia. Rori that Halothane can easily be used in these evaporators. This includes a large backlog of needed tonsillectomies. I had a very rewarding experience. with whom I worked together with very well last year. similar to those found in the U. The anesthesia personnel at the hospital are a mixed bag. There is presently no anesthesiologist or OR nurse in Guadalupe. as well as keeping the good spirit going. tympanoplasties and ossicular reconstructions.D. The machine has an Enflurane and an Isoflurane evaporator. which has problems. I had some surgery patients appear on my last day here. . it would simplify things greatly. Bring pounds of flexibility to adjust to third world medicine. Fortunately most ENT procedures are one-person operations. Rori came on three days and we did tonsil and rhinoplastic surgeries. also the fiberglass casting material. M. If an ENT person were able to bring along an OR nurse for help. Rori Cedeño. The hospital is rather antiquated and has extremely limited supplies. I often did tympanoplasties on the spot as the patients walked in. I switched to Propofol as long as Lori was there to help me. I had to use Afrin and 5% Lidocaine ointment. The latter one would actually be better for Halothane since both gases have the same vapor pressure. carry supplies and keep the financial tap running. In order to keep the cost down Amanda organized our own meds and bought what each anesthesiologist requested. Highdose Ketamine brought of course all the known emergence problems with that drug. It became obvious that once you start doing surgeries in earnest (we did 75 cases in the 5 weeks I was there) you run out of supplies fast. The turnover time between cases was amazingly short. Because of the inevitable snafus. we were able to hire Dra. We brought everything with us. veggies and meat for our weekend feasts. and activate the donated anesthesia machine that the Clinic has. The first anesthesiologist we had was slick and experienced. organize. The Gelfoam I brought ran out on the last day. In the long run I feel it would be much easier to arrange for an anesthesiologist from Zamora to come to Guadalupe as needed. We used general anesthesia with Halothane in the Enflurane evaporator without any problems. The patients don't show up on time or are difficult to reach. Guadalupe ENT report May 2005 It was very nice to return to the Guadalupe Clinic and see progress being made. Amanda. and hope to return again next year. like some of the ophthalmologists do. the anesthesiologist. helps with setting things up and sterilization. from needles to meds to sutures to instruments.S. On other occasions it was rather slow and rough going. the clinic nurse. We even supplied the gloves. Burger Zapf.

I also noticed again the absence of vocal cord problems. They do however have a cautery and overnight stay facilities. Those cases have to be done in Zamorra. On the social side we again had lots of fun cooking.) It appears that an avalanche of ENT problems has begun to come down on us since my initial visit last year. I had to turn away 3 to 4 patients a day who were all in dire need of amplification. Initially we could use just analog behind-the-ear style instruments which have been essentially phased out in the USA. Siemens donates hearing aids if you are a good customer. Regards Burger Useful information for new ENT-Doctors: The Guadalupe clinic has essentially no surgical ENT instruments. I saw more ear problems. . We decided to allow cosmetic surgeries this year. I did all the tympanoplasties and three stapesplasties under local anesthesia without problems. There is a lot of traumatic nasal pathology. an ear mold kit and maybe a hearing aid tester need to be found. I did not see any Head and Neck cases or laryngeal pathology while I was there. and exploring the region on weekends. The ear molds can be made easily. For example: Starkey Hearing Foundation. There are a number of groups who provide hearing aids to the third world. I have a hard time getting my hands on prostheses. chronic tonsillitis and chronic ear disease. telephone 1-800-328-8602. I have been doing cholesteatoma surgery in an outpatient setting in the United States for decades. etc. PORP and Stapes prostheses were donated.sotheworldmayhear. Fred Rondo. Since I myself am presently not in a clinical setting. but the nurse Amanda has not heard about it in recent years. A portable audiometer. I extended my ear instruments for post-auricular approaches and brought a mini-drill to shape ossicular implants. The clinic is not equipped for overnight stay of patients or inpatient therapy. The instrument adjustments can be done simply by feedback from the patient (sound too tinny: adjust the lowers. Someone from one of these sources could train a local person while but charged higher fees to subsidize the indigent patients and help finance the anesthesiologist and the anesthesia drugs. Another large need that became again obvious to me is hearing aids. I ran out of TORP and stapes prostheses in the end. I plan to return in late November to continue to help meet the ENT need in Guadalupe.In response to the need for more complex tympanoplasties and ossicular implants. we even have a dental lab that allows denture production. www. hiking. Mark McCarthy. The ideal set-up would be to have a local person trained to fit hearing aids and then have instruments donated and sent to Ecuador. Rayovac also donates hearing aid batteries. If we had a mastoid drill we could also operate the cholesteatoma patients under general anesthesia as outpatient. It would be nice if some TORP. This hospital in Zamora has absolutely no surgical equipment useful for ENT procedures. I have heard that the Rotary Club or Lions Club have donated hearing aids to Ecuador in the past. yet 60% of the surgeries were again nasal. Thereare only office examination instruments and no audiometer. This is the way it is already being done with eyeglasses. It needs to be seen if that actually works out. For any case you would like to perform you have to bring your own tools and special supplies.

Lucia when he still had his practice. Nigsch is . He is a problem-solver. and during that time he saw a variety of patients. When he still practiced here. Nancy.. sailing. Aside from those kinds of cases. usually from the indigenous population of Saraguro and Shuar Indians. he knows how to adapt to new situations and make the best out if it. "There. in retirement." Dr. Dr. Zapf and his wife. "We really appreciate him a lot. flashing a smile. the Annapolis ear. Nigsch especially well because of their heritage. So. the director of the clinic. Zapf's previous stints at Clinica Misonal "Nuestra Senora De Guadalupe" have lasted four to five weeks. Many of the medical issues he encounters with patients aren't that different from those in America. The 58-year-old has already made two trips to a clinic in the Amazon region of Ecuador to help the region's poor. The volunteering is interwoven with his other passion. Dr. although he's also done other kinds of treatment there." They also admire his dedication." the Rev. This is in addition to work he's already done in Mexico and other volunteering he did in Jamaica and St. "He is very generous. The vast majority of the work involves nasal and ear problems. it doesn't matter where you are. a hard worker. Staff Writer Like many physicians. dealing with insurance companies took up lots of time. so language barriers aren't a problem.. Zapf was born in Germany and the Rev. Zapf said. it all falls away. Jorge Nigsch. Dr. he said. wrote in an e-mail. nose and throat specialist saw no reason to stop. They are examined on a first-come. with good humor and an excellent doctor. "It fits my personality. Zapf said he gets along with the Rev." Dr. first-served basis and pay $1 per visit. will continue a protracted sail around the world after he completes his latest stay at the South American mission clinic. Dr. . A nurse translates Spanish for him. one of the major differences in medicine is the lack of red tape that exists at the clinic. Burger Zapf got into medicine because he wanted to help people. There's clearly a need." Dr. He is fun to be with.Retired Annapolis doctor helps the poor in Ecuador By THERESA WINSLOW. and will depart for another stint there next month." he said. "People need you. He spoke of one patient who made a return visit to him after surgery and had 13 fullgrown maggots living in his ear. Zapf said. though there are exceptions. "If you can help someone.

Rubber skirts under the front door keep out snakes. He retired about four years ago. This time. The Rev. A nurse told him she found a pair of the spiders in another room." He finds his time at sea just as rewarding as his time at the clinic. Mrs. Annapolis. --Published October 30. Zapf first found out about the clinic after searching the Internet for volunteer opportunities." Creature comforts While the clinic is the jungle. 2005. to making a homemade prosthesis for the inner ear when one wasn't available. wanting to devote more time to volunteering and sailing. Zapf said. The Capital. there's no air conditioning. Copyright © 2005 The Capital. Md." Dr. Dr. adventures. Still. who relishes the problem-solving aspect of the clinic work. . Halekai. Zapf said. because she said she got to spend time at home working on taxes while he was at the clinic. The problem-solving can involve everything from improvising his own medical instruments. His past trips to Ecuador have worked out great. So is Dr. Things like this are never easy. he'll fly to Ecuador first and she'll join him in December.. "I like to solve problems. "I like . Zapf. Dr. like a specialized suction machine. since there isn't always the same kind of equipment he had at his disposal when he practiced here. Md. Nigsch said the staff is looking forward to the physician's return next month." she said. He said the accommodations are fine with him and shrugged off any suggestion that his time there represented any kind of hardship. and we just solve problems as they arise. who serves on the board of the Seven Seas Cruising Association. They then plan to travel the country and nearby Peru before setting sail for the South Pacific. Annapolis. sitting in his home and showing pictures of the clinic on his computer. The name is Polynesian and roughly translates to "home on the ocean. Zapf. is already in Ecuador. "I like it." he said." or "houseboat. said she recognizes his need to help people and doesn't worry about his trips to remote regions to do the work. and he has a picture of a tarantula he found one day in his bedroom. staying there isn't exactly roughing it..from Austria. "He's very self-reliant. Their 50-foot sloop.

motorcross racing. slaughter and butchering in the town square of the poor animal and finally beef soup cookout for the whole town. chronic tonsillitis and chronic middle ear disease. Often for clearly unnecessary surgery. early in the morning. I showed padres niece how to bake German rye bread hoping this will finally sink into the cooking operation at the mission. Gyrus ENT was extremely helpful in providing scores of middle ear prostheses. My approaches to the Catholic Mission Board turned out to be frustrating. The hospital OR has now a new anesthesia machine. TMJ. Rori Cedeño was again hired for procedures under general anesthesia in the clinic OR. PE tubes and a new sinus Gel. The festival included car racing. This also included.fall 2006 To prepare for this visit I approached several companies for help. The clinic-office set-up was now done in a flash and almost routine. great hiking and great cooking.a group of scantily G-string clad girls singing and dancing .Third ENT visit. During the marching the first question of every passer by was: how much did the steer cost( $250. which we presently don´t have. public dancing and at the end Las Chicas del Fuego. She is a very experienced and amazingly slick anesthesiologist who can do Halothane cases with instant wake up! Due to scheduling problems we did one surgery day at the hospital in Zamora. payed for by the large organizing committee). Sterilization is done with dry heat process! Watch the wraps! The nurses seemed very competent and cooperative. A fair amount of patients came from afar (4 bus changes) for a second opinion. the marching into town of a steer behind a brass band. I was lucky to witness the festival for the Madonna de Guadalupe. The patient mix was again similar to previous visits: Lot of stress related throat pain. They also donated the drugs and materials for the surgeries that allowed the nurse Amanda Anderson to give refunds to the patients. Dra. which I was able to operate in the clinic OR) and some otosclerosis. Hyoid syndrome. traumatic and cosmetic nasal and septal problems. A large crowd of pilgrims (including the volunteers) wandering 23 km through neighboring towns carrying the Madonna in front. They were also willing to give us a mastoid drill but I ended up on the number 2 spot on the waiting list. With the new Peruvian president a new hospital administrator came in and is very interested in a cooperation with the Guadalupe clinic. On the social side we again had lots of fun. fireworks. fruitless and a total waste of time. The concept of doing some cosmetic surgery to finance the indigent patient procedures under general anesthesia seems to work out and we came out financially clean at the end. The anesthesia (Fredy) is more geared to long cases and not so much for fast outpatient turn over.The existing full complement of office examination instruments was put aside by Amanda and we just had to open the box to get going. Scores of sensory neural hearing losses in need of hearing aids. some pretty bad (one very large cholesteatoma. nice cautery and suction. I updated my middle ear instrument with great discounts from Gyrus ENT and arrived in Guadalupe ready to go. Again a dizzying amount of high school teenage boys who wanted cosmetic nasal surgery and required serious talking to.

Also Ethicon donated large amounts of GELFOAM for my tympanoplasties. My contribution to the festival was selecting a big piece of beef on site and cooking a real gourmet goulash soup for the organizing committee. stapes prostheses and TORP ceramics. Burger Zapf. In preparation I approached my old friend Mike Canary. He graciously dedicated two hours of his time to allow me to brush up on mold making and simplified fitting of analog aids. Successful stapesplasties on patients living at the coast in El Oro started a local initiative.D. A thankful patient began a radio advertising campaign and literally a busload of patients hard of hearing Burger Zapf. The annual ENT conference happened to be held close by in Washington. All of this served for lunch with crusty rye bread and beer. Amanda explained to them that the hearing aids were used by other people before and not of the latest technology. They appeared very interested but in the end the contacts petered out. In summary it was again a successful visit and progress was made again. This invariably let people .and multiple hearing aid fittings. Cheep instruments abound to complement my typla set. Fifth Visit in November/December 2007 My fifth visit was dedicated to bring the hearing aid service in action. I approached Starkey the hearing aid company who organizes hearing aid jornadas all over the world.D.April/May 2007 Here a slide show reference for interested parties to look at and get a feel how to reach Guadalupe.shaking their behinds at the cheering crowd. I brought the hearing aids donated by the Madison Lions Club through the initiative of Richard Borner and we went over their characteristics and the different modalities for adjustments.DC and I took the opportunity to approach Gyrus ENT who generously donated a mastoid drill system. M. After my arrival in Guadalupe things were getting soon into full swing. Fourth ENT visit. Without too much advertising the patients started flowing in. This generated 6 stapesplasties. To separate the needy patients. http://picasaweb.there must be a nest of otosclerotics living in this area.(Not sure of their tastes I cooked a trial version first). I connected to the University of Connecticut ENT staff to generate interest for future missions and to have a university and residents getting involved. an Annapolis hearing aid dealer with experience in fitting aids in the third world. M.

The concept of doing some cosmetic surgeries to finance the whole operation appears to be solid now. hone her surgical skills on the many minor surgical cases and even learn how to intubate. So we scheduled him for the second half of the jornada with the idea to collect general anesthesia cases for him. numerous tympanoplasties. I was able to have plenty of suture material very generously donated by Ethicon that helped to solve our chronic 5-0 . All this kept Amanda reeling. the ENT program seems established to the degree that 92 patients showed up on the first day! Some patients all the way from the Peruvian border literally camped out in front of the clinic. I ended up doing 9 in a row on one day. MD . The referral of general anesthesia cases to the last 2 weeks backfired in that we again ended up doing 12 hour surgery days to finish all these procedures. a German anesthesiologist who was willing to spend two weeks with us. After Padre Jorges attempts to get the military anesthesia involved failed. Overall I saw 382 patients for consultations and did 92 surgical procedures that included 45 septorhinoplasties. The new fan on the microscope solved all the lamp burn out problems and we got to enjoy the new air conditioner in the OR. I gave her some lessons and left my audiometer behind for her use. lots of nasal trauma. Burger Zapf. MD . good hearing and rhinoplasty results that will lead to more patients in the future for sure. PhD . a mastoidectomy (Thank you Gyrus ENT for the drill system) and numerous assorted septoplasties scar procedures TE etc. Interesting cases. 10 Stapesplasties.of means seek out their local hearing aid dealer to buy the latest digital aids. Our resident medical student Sarah Milgrom got the opportunity to learn to start IV's. For this November my good dentist friend Ekkehart found Thomas. Our supply of hearing aids dwindled rapidly and Amanda agreed to learn to fit aids after I left.Rori the anesthesiologist from Loja who agreed to spend her weekends with us to do all the general anesthesia cases. 6-0 suture shortage. we again hired Dra. cosmetic cases and more chronic ear disease and otosclerosis than ever. That of course let to mammoth 14 hour surgery days. PhD Sixth Visit in November 2008 I spend all year sailing the pacific which left me with little time to prepare for my 6th visit. This made me painfully aware again how many teaching opportunities are lost to ENT residents who would greatly benefit from these many interesting clinical and surgical experiences. I neglected to procure more hearing aids and ear mold material and we again stood sorely by unable to help the numerous deaf people needing amplification. Again lot of second opinions for unnecessary surgeries. I'm confident that I could keep an anesthesia person busy through out the entire jornada with general and conscious sedation cases. Again an endless line of rhinoplasties emerged. a mid face bone on lay. a cleft palate. Burger Zapf. That would spread the daily load to more tolerable hours. Well.

but it’s much more effective to prearrange visits. Getting there involves an hour-long flight from Quito to Loja. The Guadalupe Mission Clinic serves the rural population in the southeastern province of Zamora-Chinchipe. such as anesthesiologists and OR nurses to assist me. is from Austria. internists. general surgeons. including microscopes. but volunteers usually bring donated supplies for their own specific needs. it isn’t very effective to just dinghy ashore and visit the local clinic. Mexico and Ecuador over the past decade. my plan was to combine our circumnavigation with medical volunteerism in the third world countries that we visit along the way. and many patients come the night before. followed by a four-hour bus ride through the Andes Mountains to the Amazonian highland village of Guadalupe. a lab and a regular stream of German dentists and lab techs. for ENT residents to train with me. nurses and dentists come mostly from Germany and the United States.conditioned operating room has an anesthesia machine and modern equipment. An air. It has an established dental service. I am now on my seventh such visit. to be found by researching the Internet.Sixth Visit in November 2009 To see more about this visit. This schedule lets me fit in a month-long volunteer stint at a medical clinic in Ecuador once or twice each year. and it’s rewarding to be welcomed by some of the same staff and see some of the same patients and their families in follow-up. and. In addition to establishing contacts individually. gynecologists and other specialists.This can work sometimes. and to try to find other volunteers. so far without success. St. Lucia. But as I’ve discovered. The word spreads fast when visiting specialists are scheduled. The clinic is a modern building complex funded by the Roman Catholic Church in Austria and the United States. especially since our grandchildren were born. I’ve been bringing my own surgical tools and supplies with me each time. There have been visits by dentists. The pharmacy is stocked with donated and bought drugs. Our cruising mode has changed over the years. the parish priest in charge. ophthalmologists. and the volunteer doctors. camping out and sleeping on the front steps of the clinic in order to be first in line the next morning. As the reputation of . There’s no need to be Catholic to participate. some of whom return every year. click here Seven Seas Cruising Magazine under volunteering (after the 7th visit in November 2009) When I retired from my Annapolis ENT practice in 2001. This is mainly how I came to volunteer in Jamaica. there are a host of nonprofit organizations with volunteer opportunities worldwide. My time in the States gives me time to seek donations of medical supplies needed at the clinic. near the border of Peru. Padre Jorge Nigsch. We now leave the boat during cyclone season to do some land travel and to return to the States for a few months each year. The clinic is fairly new and unusually well equipped for such a remote location. please.

500 patients and performed over 500 surgical The clinic’s website is www. a 501c charitable foundation. Burger Zapf.guadalupe-ec. has been formed to accept U. Each one covered part of the visit. There’s a communal kitchen for cooking and camaraderie (nuns provide meals during the week). Interplast Germany sent My.S.D. M.the clinic has grown since its opening in 2001. while enjoying the satisfaction of seeing lives improved and being appreciated for my efforts—while meeting interesting people and experiencing different cultures. most appreciated by Padre Georg Nigsch! The covered veranda overlooks the tropical rainforest mountains and the river. Beate and Gerd to be there for the whole “jornada”. with unique electrically-heated showerheads. hiking in the cloud forest of the nearby National Park (with exotic birds. even to first world standards. and trips to indigenous Saraguru and Shuar Indian villages—once known for their shrunken heads! I’ve been able to witness the elaborate festivities of Easter Week in April. One of the benefits of third world volunteerism is the lack of red tape. I relish the challenge of creative problem-solving. I’ve put together a photo slideshow with captions about my trips to Guadalupe: http://picasaweb. and over the years I’ve treated approximately 2. One of my specialties is German sourdough bread.. and the Festival of the Madonna of Guadalupe in December. computer with satellite Internet access and a DVD movie collection. but volunteers organize their own Halekai Report of 7th visit in Guadalupe. tax-deductible donations and allow U. Weekends are free for exploration. Room and board is gratis. All Souls Day in November. nose and throat cases. I’m still working to establish regular donations of hearing aids and to train a staff person to fit them. volunteers to claim their travel expenses. The Friends of the Mission Clinic of Our Lady of Guadalupe. Padre Jorge Nigsch had a clever radio ad campaign started well ahead of time and it . sightseeing or just relaxing. The volunteer medical staff quarters were built recently and are very I can just focus on patient care and surgery. with no paperwork or hassles with insurance companies. orchids and waterfalls galore). such as improvising medical instruments or making a homemade prosthesis for the middle ear when they’re not available. I see the full range of ear. Similar to the need for selfreliance when cruising in remote areas on a sailboat. The mostly indigent patients are seen on a first-come. Popular excursions are visiting a commercial frog farm. seeking second opinions and surgery. some patients come from distant parts of Ecuador. Occasionally I perform cosmetic nasal surgery for higher fees to help fund our other operations. November 2009 My musings after my last visit of having general anesthesia from the start became reality. My Spanish is rudimentary so a bilingual nurse translates for me as needed. first-serve basis and pay $1 per consultation.

was running throughout my entire visit. I therefore contacted Prof. our first anesthetists. The ear care necessary for cleft patients was missing in Portoviejo. This led to me seeing 82 patients on the first day and about 60 patients showed up every day there after. After I finished my visit in Guadalupe I went to Portoviejo and joined the group looking for ideas and pointers. We can establish that right here in Guadalupe. Padre Jorge’s nephew. Of course mainly thanks to Amanda’s ever present organization and the skilful help of Johannes Nigsch. was suddenly saddled with huge numbers of patients keeping him busy into the evening hours. They finally made it to Guadalupe. I myself saw 512 mainly in between surgeries. The drama unfolded over several days and involved the German consul in Quito all the way back to the Ecuadorian embassy in Germany and the bishop in Quito. I did several Furlow type cleft palates and a forked flap for a lip revision after previous cleft surgery. had to go thru a Customs ordeal in Quito in order to bring in their supplies. Poor Serle. . Instead of working in a leisurely pace it became more frantic than ever. My and Beate. We increased our surgeries by 70%. Jorge Palacio from the University of Guayaquil who has been running this for many years. We then had a delightful cooperation. The demand for rhinoplasties again was increasing to an alarming rate and I started to think about setting a quota. Over 140 cases in all. However I thought it was time to get serious about it. US interplast was cooperating in a venue in Portoviejo EC for cleft surgeries. It was a very successful stay and I’ll return to Guadalupe in April to join Interplast Germany for more intensive cleft work. Most under general anesthesia using a larynx mask type. Next November I would like to advertise for clefts as well to shift the emphasis away from nasal surgery if possible. At the end Johannes was my skilled OR nurse for ear cases. My “great idea” had backfired. With the help of our internists we saw about 750 patients. I also wanted to include cleft lip and palate surgery into future visits. our founding internist who came for his yearly two-week visit to the clinic. This reduced the surgery time by 20 minutes per case. The OR ran smoother than ever.