CASIEF workshop at CAS 2019

How to Get Involved in Global Health
2019 CAS Annual Meeting

Location​: Calgary Telus Convention Center
Section​: CASIEF
Date​: Sunday, June 23, 2019
Time​: 10:00-11:30
Location​: Calgary Telus Convention Center
To register: ​Go to ​casconference.ca​, or click ​here.
Description: This workshop is intended for people who may not have any global health/overseas practice, or may already be doing some but are interested in other options. It will be an interactive workshop session, with an expert panel and lots of opportunities to ask questions.

More information, including panelists, in the promo poster (PDF).

Doctors Without Borders (MSF) is Recruiting

In the past 50 years, MSF has become a major player in the world of medical humanitarianism. When people think of MSF, many images and questions come to mind. Is it for me? Can I leave on short missions while continuing to practice in Quebec? Should I go once I have retired? After my residency? What is security like on the ground?

To sign up, see the Canadian page. The complete information package (PDF) is also available.

Lifebox Distributes Pulse Oximeters to Burundi’s Public Hospitals

Following on from our exciting developments in India and Bangladesh last month, this month we take you to Bujumbura, Burundi, where Lifebox and local partner ATSARPS (Agora des Techniciens Supérieurs Anesthésistes Réanimateurs pour la Promotion de la Santé) organized a pulse oximetry workshop and distributed pulse oximeters to each of the country’s 54 public hospitals. With 46 anesthesia providers in attendance, the workshops were covered by national media. Read more here.

Read more about Lifebox in their Global Brief (April 2019).

 

World Congress of Anaesthesiologists 2020

Abstract submission and registration opens June 2019!

Sept. 5-9, Prague, Czech Republic

The 17th WFSA World Congress of Anaesthesiologists is proud to announce four competitions!

Three of them are for country entries and one is for individuals. Winners will be announced at the Closing Ceremony besides the winner of the individual competition, there will be a chance to win two Congress Dinner tickets which will be given at the first day of the Congress. You have a unique opportunity to support your country or win two tickets to the best social evening of the Congress.

It is easy to take part! Click on the competition below if you would like to know more (this will take you through to the WCA website).

Or, visit on twitter, facebook, or instagram.

Medical Jet Lag

No matter how much international experience under your belt the initial days in a low-income country are a medical seismic shock with potential register on the Richter scale. Call it medical jet lag. A recalibration is required that necessitates a reconsideration of what you take for granted at home. My approach is to listen and simply absorb. The surgical cases are very much the same but disease processes also very different. Medical presentations are more advanced as access to definitive treatment are more limited.

A well-trodden medical maxim states that when you hear hoof beats think horses rather than zebras. It is used to illustrate the point that uncommon presentations of common diseases occur with greater frequency than rare conditions. In Abyssinia the zebras are the horses.

Anesthesiologists were in the bathroom or asleep at the wheel when job titles were being handed out. Most people can’t pronounce it, no one can agree on how to spell it and even other physicians don’t really understand what we do. We are the witches and warlocks of the medical world. “Life guard” would be more appropriate but instead that moniker was coopted by teenage babysitters in speedos. All the credit to them and the marketing firm that locked down the term. It stands to reason. The anesthesiologist’s role is to suspend consciousness, maintaining normal physiology and guard life while the barbaric acts are performed, which under any other circumstance would constitute torture. Needless to say that the invention of anesthesia is one of the greatest human achievements of all time, right up there with the domestication of fire and the printing press. I say we go toe to toe with the pool kids and let the chips fall where they may.

There is a ying and yang between surgeons and anesthesia colleagues; an interdependence that takes place through the mutual care of our patients. One requires the other and alone they serve no functional purpose. We are partners in an elaborate dance where the patient sets the tune, surgeon decides the steps, and the gas passer sets the dance floor. In high-income countries the symbiotic surgeon-anesthesia relationship has an equal power dynamic and modern medicine has finally recognized that the patient is the one ultimately in charge. In Canada, surgeons and anesthesiologists require five-year training programs alike for a sum total of 13 years of post-secondary education. We stand on equal footing in the operating theatre and frequently collaborate on choosing the best approach for a surgical journey for the patient.

The shortage of anesthesiologists and surgical load in low-income countries has resulted in a shift to use non-physician anesthesia providers with less training to fill the gap. Today the mainstay anesthesia providers in Ethiopia are anesthetists. They provide very good care and are technically quite skilled within their scope of practice. Some surgeons may prefer the anesthetists as they may be more willing to take direction without protest. Pesky anesthesiologists have a tendency to voice concerns and suggest elective surgical procedures be coordinated with the overall health of the patient to ensure optimal conditions and a reduction in postoperative complications. We often insist pain management strategies such as an epidural, which can be perceived to consume precious operating time and threaten case cancellations, all in the best interest of the patient.

Part of our role is to encourage collaborative decision making in concert with our surgical colleagues while demonstrating techniques and providing advice on anesthetic plans to ensure a safe surgical course. The first few days require acclimatization to the patients, their conditions, the surgeries and the flow of the hospital. Once you know where to find the bathroom with running water and remember to bring your toilet paper you can focus on clinical care.


Jason McVicar, February 25 2019

Return of the Anesthesiologist

How’s that for the next summer blockbuster? Who am I kidding, in film anesthesiologists are akin to wardens: a plot device reserved for wallflowers or villains.

I’m back in Addis on the garden terrace of the Ghion Hotel. From this little government sponsored oasis, combined with jet lag, and a St. George premium lager I could convince myself I’m almost anywhere. Except Ottawa. The polar vortex and snow squalls clearly don’t reach the northern ridge of the Great Rift Valley.

It is exciting to be back at the Black Lion Hospital and Addis Ababa University in the Ethiopian capital.  I’m working again with the Canadian Anesthesiologists’ Society International Foundation or CASIEF for short. It’s not a sexy name like Save the Children or World Vision but this charity does great work. CASIEF is a scrappy little organization built on the vision of benevolent anesthesiologists 50 years ago. The charity’s first date was in Nepal and evolved with a successful courtship in Rwanda built on the dedication of a few very dedicated souls such as Drs. Jeanne, Angela Enright, Franco Carli and Patty Livingston. Today relationships also exist with the  anesthesia programs in Guyana, Burkina Faso and here in Ethiopia.

The CASIEF model is one built on relationships: Education Development would best characterize the mission. The model primarily consists of a visiting professor program from Canadian institutions where teachers travel to assist with clinical teaching in the operating theatre and deliver lectures with a partnership to assist with curriculum and professional development.  Teach a friend to fish type thing but the learning is truly bidirectional. As trust is built the scope spreads across a variety of domains such as leadership, professionalism and research.  The mandate is to collaborate with partners to build capacity for safe, sustainable anesthesia and perioperative care through education, knowledge translation, and advocacy.  Like any engagement there are fits and starts but the long term evolution of growing yesterday’s students into today’s professional leaders is remarkable.

I didn’t forget my laptop this time. On the last visit in 2017, I managed this same trek only to leave the lifeline to all my educational materials in the seat pocket of the commuter flight in Toronto- a teacher without tools.  The residents on the trip, Sophia and Karim, came through with resources and expertise.  Having that pesky final Royal College exam at the end of 13 years of training on the immediate horizon has wide-ranging benefits both at home and abroad.  We provided operating room table-side instruction by day and crammed lessons together by night at the hotel. Often the teaching topics were requested the day before.  Our routine most evenings would consist of huddling in the hotel lobby scouring resources and cobbling to together lessons while making small beer sacrifices to Etherna, the undisputed God of Wi-Fi as she teased us with broken links to pearls of pharmacology and physiology.  It was the best of times, it was the worst of times.

Humanitarian parlance has an old adage, “This isn’t our first rodeo.”  This is my third visit to Addis Ababa. There is something special about returning to a place you have visited before. You never really go back to the same place. Change is inevitable. Development and progress relentlessly march forward.  Roads are paved, buildings fall and get put up, mostly by the Chinese in these parts. There is a growing familiarity but I am not exactly the same person on each subsequent visit.  Traveling as a wide-eyed medical student or first time faculty carry an innocence that fades with each return.  Small quotidian familiarities appear in subtle ways. The warm blast of the first breath of sub-Saharan air on the tarmac, the texture of enjera and kitfo cuisine and the thousand yard stare of a grizzled wanderer to ward off touts comes more naturally with each arrival.

There is a personal cost to being away from family. I’ll be honest, dread creeps into the last day before any overseas work travel now.  It hasn’t always been this way but every trip since we started our little family has an element of regret.  Kids change things.

Humanitarian work, if that is what I am going to call this, is rather incongruent to family life.  The demographics of the volunteers or aid workers are very bi-modal: pre and post children.  The challenges of leaving a family with household kids at any age are a significant barrier. You often have to call in supports from friends and extended family. I am certainly grateful to those in our lives who have helped us get through these strained times.  I just video called home and my 4-year-old son refused to acknowledge me. The two year old was genuinely happy to see me and had the inquisitive instinct to ask again where Ethiopia was. The debts incurred will have to be repaid.

Back into the theatre tomorrow.  All the world’s a stage…


Jason McVicar, February 15 2019

Dr. Livingston returns to Rwanda (7th and final edition)

Final Reflection – Saturday, February 2, 2019 (from Patty)

Our team is dispersing: most of us are returning to Canada but Dave will stay on with Emma for a few weeks in Addis Ababa before going back to Rwanda to help with the foundations simulation curriculum.

Although I am tired after the long flight from Addis Ababa (as I wait for the final flight to Halifax), I can’t help reflect that our last month has been enormously productive, energetic and rewarding. We’ve had great teaching moments, watched learners blossom, seen trainee facilitators become confident teachers, contributed to sustainable simulation-based teaching in Rwanda and Ethiopia and had fun doing so. Our team has shared many laughs and lighthearted moments as well as serious discussions. We resolved challenges creatively and with care.

I am grateful to all the learners and colleagues in Rwanda and Ethiopia who have been so generous. Thank you to the members of the Jan 2019 team (Dave, Stephen, Chris, Jon, Mary, Julian and Emma). Although I will miss you, I hope our paths will continue to cross as the caring anesthesia network around the world grows richer and richer.


Visit Dr. Livingston’s blog at < https://simcentreopening.blogspot.com/ > to see the original posts, including photos.

Dr. Livingston returns to Rwanda (6th edition)

Nyamirambo – Saturday, January 26, 2019 (from Patty)

I brought the team to Nyamirambo last night to walk down memory lane. We took Christophe and headed to the Green Corner for delicious fish (tilapia from Lake Victoria) that is eaten using one’s fingers.

This came with Rwandan french fries, so possibly the best fish and chips ever. We wandered down the main street of Nyamirambo – full of people, shops, bars, music and joie de vivre. It had not reached full 2:00 AM fortissimo levels of noise yet, being too early. We stopped at the door of the Guma Guma bar to check that the chairs were all lined up in front of the TV (like church) for the next Premier League game. Indeed, life is unchanged in Nyamirambo. The old apartment building was dark and rather ghost like. Enough of that, we returned to the new apartment and chatted late into the night exploring Stephen’s vast knowledge of esoterica.

We are at another transition point. Tomorrow we fly to Addis Abba, Ethiopia to run a VAST Course. CASIEF has a new program in Ethiopia and we look forward to learning more. Chris is the only one of us who has been to Addis before (outside of airport transfers).

As our time in Rwanda comes to a close, I reflect on the visit. It has been productive in so many ways. There is a hunger for our continued involvement, yet at the same time there is a sense of enormous progress. The anesthesia program is well launched and able to function without us. Many people around the country have received extra training and plans are underway to embed the VAST Course as a frequent offering for continuous professional development.

On a more personal note, I reflect on time. Life is always too short but it is possible to have a rich life where time is enjoyable, meaningful and memorable. That is the gift that Rwanda has given me. Even though we have only been here a few weeks, it seems ages ago that Chris and I were wandering around for our first lunch, we cycled the dirt roads in the northern province, our first Jeopardy game with the residents, watching the fishing boats on Lake Kivu. All marvellous, all rich experiences.

My future involvement in Rwanda is an open question. I will no longer come as a CASIEF volunteer (too old and no longer practicing anesthesia at home) but I suspect I will return in some other capacity, perhaps a family visit with all the people who consider me their Canadian mum.

On to Ethiopia – Monday, January 28, 2019 (from Patty)

Our final night in Kigali, we were invited to the home of Francoise, anesthesia program director and a good friend. It was a warm gathering with family and friends. Francoise gave us a lesson in the African method for carrying a child. Chris and I both made the effort but clearly Francoise is the only one of us who looks perfectly at home with a baby on her back.

The journey to Ethiopia had a prolonged detour in Bujumbura, Burundi, long delays in the visa line, and what felt like an interminable wait for the shuttle to the hotel. We rolled in around midnight last night, tired and punchy.

First impressions of Addis – fewer trees, busy, fast paced, lots of concrete, tall buildings, enormous hospital complex, people wearing traditional clothing. We jumped right into a VAST facilitator course today with 3 staff anesthesiologists and a senior resident. Our team expanded to include Emma, an Ottawa resident, and Julian, the CASIEF-Ethiopia lead. Our Ethiopian hosts had arranged a bright airy teaching space and assembled the course materials. We quickly began rolling out the scenarios and were delighted at how well the group picked up the key ideas.

We finished the evening with a traditional Ethiopian meal – communal meal on injera eaten with fingers. We have one more day of facilitator training tomorrow before welcoming 14 participants to the VAST Course on Wednesday.

A VAST success – Wednesday, January 30, 2019 (from Patty)

Day one of the VAST Course in Addis. The participants are on time, the space is bright and cheery, the food is more or less on time, the day is bright and sunny. My concerns about people being too quiet during the first session were quickly put to rest – by mid-day people were jumping in with comments and insights and we had to curtail discussion to keep on time. We have a mixed group of anesthesia residents, NPAs, nurses and surgeons. The four facilitators we trained on Monday and Tuesday have exceeded expectations by a huge margin. They are now running and debriefing scenarios with some prompting from our team. It is a huge luxury to have a big team (to say nothing of the talent!). Dave is now a VAST Course pro. An additional bonus is the the level of English is strong and where needed our local facilitators quickly translate into Amharic. Other great moments: Laurence, the sim coordinator from Rwanda, coaching Haben, the anesthesia admin assist. My heart melted to see them sharing a chair and chatting away. I truly hope this is the beginning of a journey of simulation in Ethiopia.

Strong Women – Thursday, January 31, 2019 (from Patty)

Many of the leaders in the anesthesia department are strong, talented women. How great! The head of department and the head of the Ethiopian Society of Anesthesiologists are both female. Three of these skilled women are helping to facilitate the VAST Course. Watching them engage with participants and pull out the best performance, is inspiring. Day two of VAST is scenario heavy with 7 challenging OB anesthesia scenarios. We are tired but smiling.


Visit Dr. Livingston’s blog at < https://simcentreopening.blogspot.com/ > to see the original posts, including photos.

Dr. Livingston returns to Rwanda (5th edition)

Resident Academic Day: Humility and Obstetric Hemorrhage – Tuesday, January 22, 2019 (from Patty)

Yesterday we completed our final Academic Day with the Rwandan residents here in Kigali. It’s been a tremendous honour to spend time with this passionate group of people, who despite incredible odds, are persevering at delivering high quality anesthesia care. I’ve never met a more engaged, enthusiastic group during a teaching session, and our various approaches to teaching were heartily welcomed. A highlight is always Anesthesia Jeopardy, where trivia relevant to the week’s teaching is covered, complete with cheers and (many!) jeers from the opposing team. It’s an understatement to say that they residents “really” get into it.

This week’s topic was obstetric hemorrhage – an important topic to cover in a country where maternal mortality remains at 210/100,000 live births (compared to just 7 in Canada), and postpartum hemorrhage (PPH) remains a significant cause of morbidity and mortality. Throughout my time here, I’ve striven to understand some of the causes at the heart of the issue.

Following medical school, graduates work as General Practitioners (GPs) in rural hospitals; there, they are responsible for all manner of obstetric care, including Caesarian sections, amongst other routine medical and surgical care. Formally trained Obstetricians are not readily available (there is a severe shortage across the country) and when these GPs run into issues with PPH or massive obstetric hemorrhage, they are often left to deal on their own. Add to that the incredibly limited supply of blood available for transfusion and stock-outs of common medications used to treat hemorrhage, and you have a perfect storm of factors leading to unnecessary loss of life.

In Kigali and Butare, two larger cities where the majority of anesthesia residents in Rwanda train, doctors receive patients transferred in from these rural District Hospitals for further management. Often these patients are still actively bleeding and are in a critical state. Yesterday, one resident discussed at length how she had spent much of the day and night last week dealing with one massive obstetric hemorrhage case after the next – something that would be unheard of in Canada. The cases that the resident described represent some of the worst PPH a Western physician may see in their careers, and here we have residents trying to manage these patients in challenging, under-resourced settings with only limited backup.

The irony was not lost on me that our Academic Day was spent teaching residents about a topic they have far more experience in dealing with than I ever will (hopefully!). What’s amazing is that the group was so interested in hearing about “my own” experiences and what I would do in their situation – coming from a major tertiary care hospital in downtown Toronto, seemingly endless resources and assistance is available when I need it. That’s not, nor will it likely be the case here anytime soon. The more time I spend in Rwanda, the more I realize how important it is to tailor our teaching to the clinical context in which we are working. While there may be gold standard treatments and buckets of evidence demonstrating one approach over another, we must think creatively how that may apply in different environments. At the end of the day, I couldn’t help but think that it was truly I that received the bulk of the education.

Hiking Nyungwe Forest – Wednesday, January 23, 2019 (from Patty)

From our time in Kigali, to our visits throughout the countryside, and the countless small hamlets whose jostling for space earns Rwanda the title of Africa’s most densely populated country, it is clear that this place is old. Rwanda’s roots run deep. The people, the language, the culture have shaped and been shaped by this place for time beyond measure. As a Canadian of European descent, the sentiment is almost foreign. This sense of agelessness thrums strongest in Nyungwe.

Nyungwe National Forest covers nearly 1,000 square kilometres in Rwanda’s south west. It encompasses the largest expanse of montane rainforest in Africa and may well be Africa’s oldest rainforest. It is the source of both the Nile and Congo river and provides Rwanda with more than 80% of its freshwater. It is home to 13 primate species and 300 species of bird, many found no where else. Its importance can’t be overstated.

Needless the say, we were very excited to arrive and explore! We arrived late at night, driving a winding road through utter darkness and at times torrential rain. Feeling small in the face of such a primordial expanse was a feeling that would only grow over our time in Nyungwe. The next morning dawned bright and clear as we set out on a 10km hike. Amidst foggy vistas were heard the distant calls of one of the resident chimpanzee troupes. We had the chance to walk amongst waterfalls, towering ferns, and mahogany forests. The photos below hardly do the experience justice. The day finished with yet more torrential rain but it was no hardship as we were by then cosily settled into our guest lodge for the evening.

Our second day in Nyungwe saw us once again trekking into the wilderness but this time with a specific goal in mind – a sighting of the rare black and white colobus monkey. As was the theme of the entire weekend, we were not disappointed. We saw a troupe of nearly 40 of the monkeys within short measure! Amongst them also were at least two newborns, completely white unlike their mature black and white coloured counterparts.

Nyungwe is vast. Clearly our own experiences, incredible though they were, barely scratched the surface of this ancient place. Rwanda has made the preservation and protection of this place a high priority, that its woods and their inhabitants be protected from destructive incursion. Long may it stay that way.

People Moving – Wednesday, January 23, 2019 (from Patty)

When I first came to Rwanda in 2008, there were few private cars. Most roads were dirt, there were few sidewalks, no street lights and pedestrians had to navigate their way over mounds and around pits. Now much of Kigali is paved with sidewalks and good street lighting. Private car ownership is growing, with a resultant deterioration in air quality.

But Rwanda is always innovating. I read in the local newspaper today of plans to install a cable-car network in Kigali. The study designers argue this will move people efficiently and will reduce greenhouse emissions, noise pollution and collisions. Furthermore, the study recommends transportation corridors for pedestrians and cyclists. Wow! This visionary thinking is what is helping transform a tiny landlocked African country into a significant regional player. Could we please have efficient public transportation and corridors for pedestrians and cyclists in Halifax?

Meanwhile, we make do with other transport options.

Excuse me. Come again? – Thursday, January 24, 2019 (from Jon)

Being a geographically small country, Rwanda is linguistically (and culturally) very homogeneous. Day to day most Rwandans speak Kinyarwanda, but due to Rwanda’s French colonial past, most Rwandans grew up also speaking French. Elementary school instruction for most of the country’s independent history was in French. However, in 2009 Rwanda intentionally became a member of the commonwealth and the official academic language became English in schools and colleges. This means that most Rwandans are fluent in Kinyarwanda, and at a somewhat lesser extend English and French.

That being said, many of the difficulties in communication are most complicated than simple linguistic misunderstanding. Let me give you a few examples.

While staying at the Gisakura guest house, we decided to plan the rest of the weekend and upcoming week. I turned on my computer and noticed a Gisakura wifi network. I walked to the desk to ask for the password.
Somewhat timidly I ask, “Excuse me, can you tell me the wifi password?”
The desk clerk replies, “I don’t think the wifi is working very well right now…” looking down at the unplugged wifi router sitting on her desk.
I, not realizing this – in retrospect very obvious non-verbal que – persist. “Well, I see the wifi network on my computer. Can you give me the password to try?”
The clerk again looks at the very obviously unplugged router with a very long pause and a slightly confused look on her face… then reaches for a piece of paper and writes down the password – I imagine deciding that it is just easier to avoid conflict by quietly leaving with the router for the night rather than to argue with this somewhat slow muzungu. By the time I realized that the password supplied was not going to solve the problem, I also decide that just using a cellular hotspot was easier than arguing about the wifi.

The following morning, we enter the Nyungwe park office to be greeted by a friendly park ranger. “Good morning. You are welcome!” he says gesturing to a single chair. I look at the chair and the other three people with me and decide to stand. We all shake hands and exchange pleasantries. Now with all four of us standing near the desk he more emphatically says, “Please, have a seat” again gesturing to the single chair. I decide he really wants at least one of us to sit down so I sit. Proudly he explains “We have many activities in the park: monkey tracking, hikes, nature walks, the waterfall hike, the canopy trail.” Given that we came solidly unprepared and really open to any outdoor park related activity, we attempt to clarify our options.
Chris offers “I hear there are some packages for the trails. Is that true?”
“Yes, sir. You can enjoy many trails with the package. There is a package for short trails and a package for long trails.” A long pause clears the fresh mountain air.
Chris tries “which trails are included in the package.”
The ranger helpful says “the waterfall trail leaves from here at 9am.”
“So, the waterfall hike is included?”
“Sorry, no, sir. The waterfall hike is an additional fee.”
“Oh” Long pause while recalculating… “So, can we do the waterfall hike in the morning and then go on some other hikes in the afternoon?”
“Sorry, sorry. As you can see (gesturing to his watch reading 9am on the dot) you have missed the waterfall hike today”
Being that we had no firm plan, we were undaunted at this point. “Ok, that’s fine.”
“Thank you, sir.” Smiling
“Can we go monkey tracking?”
“Very good. We have 13 different species of monkeys here in the park!”
I break in at this point. “Great! How many Colobus monkeys are there?”
The guard looks up and appears to be counting in his head, responding after some time “37.”
“Ok, when can we see the colobus monkeys?”
“Tracking for colobus leaves 8, 10, (thoughtful pause) 1 and 3.”
“Great. Can we go at 10?”
“Yes, sir. May I please have your passports.”
We hand them over and begin to chat while he carefully writes down our information. Then we he is almost done registering us, he says “The ranger tells me the colobus monkeys in the trees now. They may be somehow difficult to see now. Maybe it’s better not to go now”
Now admitted becoming disappointed and somewhat comedically frustrated, “Ok, fine. Can we go on a nature hike?”
“No problem, sir. They leave from the Uwinka office. You can register for them there.”
“They can’t use the information you have here”
“No sir”
Now trying forcefully to remain upbeat, “Ok. Thank you for your help. Do they accept visa cards at the Uwinka office?”
“Yes, sir. Only visa.”
Upon arriving at the Uwinka office (13 windy mountain road kilometers away), the ranger there informs us that they only take cash.

This kind of miscommunication and misunderstanding is endemic in global health work either in or outside of the operating room. It plagues our ability to be effective and the fault does not clearly sit with one person or group of people. It can be at times comical or mildly frustrating, but at worst it can lead to conflict, destruction of long fostered relationships and even medical error resulting in harm. The most concerning aspect is that Canadian and (even more so) Rwandan culture tends toward being polite, overlooking perceived minor missteps. This means that miscommunication can go unnoticed until too late. The answer is likely that miscommunication decreases gradually as we understand each other’s culture, the words we use, our verbal ticks, and we strength our relationships between people. We can improve things but miscommunication will remain an ever present reality of working cross culturally.


Visit Dr. Livingston’s blog at < https://simcentreopening.blogspot.com/ > to see the original posts, including photos.