How to Prepare For an Eye Mission

How does one prepare for an eye mission?  I do not profess to be an expert but I have written down my experiences to help myself for future attempts on eye missions.  I truthfully feel anyone who thinks they have a foolproof plan is the fool.  The goal to achieve a successful mission trip can be daunting.  The early explorers used to draw maps so they could return to unchartered lands.  My first years were very much into unchartered waters when working on eye mission projects.  After a mission trip, I documented my work so I would not make the same mistake twice.  I also documented for my teammates in case the proverbial bus should strike me down.  As a team player, I will provide my twelve-month guide for any followers who might be thinking of an eye mission.  I will also accept any information from individuals that can make this endeavor easier (send me an email on your ideas for my records).  This trip takes an estimated 12-month preparation.  Some people reading this will be shocked and say why so long?  My answer…….I have a day job.  My hours combined to facilitate the average mission trip equals 80 hours to completion.  My objective was to make the attending surgeon walk from his ASC into a surgical suite in a foreign land with all products he felt was important.  I can safely say I have failed every time!

 

January

This month will require six major objectives:

 

• 1) Confirm Date of Mission
• 2) Confirm surgeons who will be attending

Make sure surgeons fully commit since the surgical mission depends upon surgeons.

• 3) Confirm Location
• 4) Start research on Ministry of Health (MOH) organization of country you will be attending. (Completion can take 4 to 8 months)

You will need to see what rules and regulations will be required to enter and to leave the country with donated medical supplies and equipment.

• 5) If working alone or collaborating with 501C organization, paperwork will need to be completed. (This information will be required for obtaining vendor products and for entry into country (HOH). I work with 501C organizations.
• 6) Confirm all individuals who will commit to eye mission. Any late comers will be required to get own passage and hotels. Be firm!

 

February

This month you should follow up on all previous issues and now start the next objectives:

 

• 1) Create check off list of all items needed for surgery.

 

Your checklist list can be up to 50 items long and can vary as to what type of product for type of location.  You will need to prepare since surgeons may want or require certain items to be present.  I have a check off list I religiously work from and this objective requires about 6 months of diligent follow up.  This objective will cause the most ulcers for the prep team.  You will require many items and best to require from all major vendors.  You will need to require from all major vendors since product will be released from the excess of the vendors inventory (remember these are donations).  You should inform vendors you will leave November 1^st.  I will explain this maneuver later if you succeed your 6-month objectives.

 

• 2) Have firm commitment from surgeons.
• 3) Schedule airline tickets for all and get people committed. An airline ticket is best commitment.
• 4) One individual should be over products during transport.

The responsible individual should also have available designated credit card or cash for emergencies.

 

You will need to inquire from airline the weight restrictions and the amount of secondary boxes that will be allowed, on commercial flights, if you plan to take product on same flight.  Many airlines today give no preferential treatments to missionaries with extra boxes or suitcases.  The airlines have been burned in the past and airlines need to make money in today’s economy.  If traveling with large number of people, inform your fellow missionaries they need to live from one suitcase.  The surgical team may need the other suitcase for supplies and you will use fellow missionary’s names’ to transport needed supplies.  (This is when airlines approve two suitcases per person.  Our last trip we paid fines of $500 for extra luggage.  As of this writing, cost for suitcases and extra luggage may make it financially impossible to carry product via same flight).

 

Today it may be more economical to ship down products via national freight carrier companies.  Many of the freight carrier companies have ports of entry in airline terminals where your product can be waiting for you.  It is worth a bit more to have the freight carrier get it through customs and be waiting then to take a chance on commercial airlines.  My personal experience has been to lose boxes of product along the transfer of commercial aircraft to destinations.  You have no clue as to what box they might confiscate, lose or misplace and the lost box may contain your lenses!  Airline freight carriers can respond and deliver to most places in the world in three weeks upon notification to ship.  I strongly recommend working with airfreight carriers.

 

• 5) With committed team, does ANYONE have friend, relative, acquaintance that lives in country or may be working with United States government in any fashion? Send note to individuals that can help you gain access to names of government officials of the country you are about to enter. To attend the country you are to perform your mission will require all avenues of contacts and communication. The more contacts the better chances for you to succeed on your mission.

 

Always do your home work and be prepared, the best-laid plans can go awry at anytime.  To be understanding is a critical component.  You are working with no pay as well as all of your counterparts.  To criticize will only lead your team of charitable workers into camps of dissent.  Upon arrival, you will be working with few hours of sleep and in strange settings so your team should consist of team players and few glory seekers.

 

 

March

March has roared in upon us.  If you have completed all objectives to this point, you are ahead of the game and maybe you should go into this line of work.  This month our big objective is to go over again, number one objective of the month of February.

 

• 1) Follow up on Check off list.

 

You will also be following up on cancellations of other surgeons or individuals who were 100% going on an eye mission who now need to cancel.  Note to all; Make sure you have at least three surgeons agreeing for any major surgical mission.  One surgeon will usually cancel (my calculation of 10 years experience) because of an unforeseen reason.  You do not want to burn your surgeons out or cancel because your surgeon cannot attend.  Surgeons participating on first mission will seek to conquer the world in first days and it will become difficult to maintain their happiness.  So much to do and so little time will swallow up your surgeon.  The first time mission surgeon has left their well-oiled organizations back home and will expect the same.  An experienced missionary surgeon understands to perform to the best of their abilities and take in consideration the location and effort of the team.  A great friend and surgeon of mine said once, ” If you help just one individual you have succeeded, everything else is icing on the cake!”

 

April and May

This month you will need to move your objectives to all at least 75% complete.  Catch up on every goal or start to reconsider departure date or cancelling.  Reviewing your objectives and hitting your goals should be paramount.

 

June

This month is the deciding period.  If you DO NOT have your MOH issues 80% resolved and if you do not have 80% of all other objectives completed you should seriously consider cancelling mission trip.  Remember the Ministry of Health (MOH) of your proposed missionary country is a Government and ALL Governments run on their time frame not yours.  This is the hardest objective to satisfy.  You may work this objective until the day you depart because of a single unanswered issue.  If you depart without all issues resolved, they will meet you at the airport and you should settle in for a few hours of negotiations.

 

Most entry through MOH governing bodies, require many individuals to sign off on volumes of paperwork.  Be prepared upon arrival to also be asked to pay entry fees (bring extra cash) which are not stated by any Governmental departments.  Some countries still work with an accepted practice to provide monetary entry at local levels.  It is good to know which countries may still perform these types of practices.  We consider these practices in the United States as kickbacks.  Know the issues of the country you are to enter.

 

July August September

We have now jumped forward into September and we have had a much time.  I have found these months to be flooded with emails and communication to  MOH.  Emails will not stop during these months and it is important to stay in touch with all team members on ANY issue.  Your contact in the foreign land you will be visiting will now be like an old friend or pen pal from all of your email questions and request.  You will be looking forward to meeting the individual(s) upon your arrival.  We are cleaning up small miscellaneous issues, which often lead to more small and important issues.  We look to leave in December. 

 

October

I now need to remind you of the warning comment stated back in February!  I will explain this maneuver later if you succeed your 6-month objectives.

We have departure date for our team leaving in December BUT we informed our vendors that we actually were leaving November 1^st.  My answer for this warning is from my terrifying experience of years prior, please read;

 

We had product requested on donation orders to our vendors.  Vendors replied that many if not all products were available and would arrive, a checklist was supplied by vendors and I felt secure.  We supplied all 501C papers in February and vendors assured us they would send one month PRIOR to departure date.  Our plan was to leave in December and all products would arrive the first week of November.  We received product November 1^st, but the bill of ladling informed us that product had been cancelled due to low inventory from mission department.  One month from departure and I did not have product needed for our mission.  The product was phaco machine cassettes.  My answer was to scramble and bring down a different phaco machine.

 

This is why I stress to provide a premature departure date.  The extra time will be essential to scramble and plead to your reps or other vendors for product that was not provided. 

 

• 1) Review products received and now confirm what you CANNOT leave without. Begin to beg, borrow, and beg again.

 

The extra time will give you a chance to get the products you need.  Remember you have been working your day job so why bring on ulcers that are not needed.  Be prepared to think on your feet because once you land you will be continually be thinking on your feet to make things work.

 

November

Product is in and 95% complete to inventory request.  Now we need to pack!

 

Packing should be in sturdy boxes that can withstand the rigors of travel.  You can obtain boxes from some freight companies with no cost or minimal cost by working through their companies.  Individuals who will be shipping via the aircraft they fly should research the approved weight of a suitcase.  Many airlines have different weight parameters per bag.  Weight is an important issue that can lead to expensive penalties if not prepared for properly.  Be prepared.

 

• 1) A sturdy large box is important. Remember we deal with weight for each box if we fly commercial or your product flies via freight. You may need to experiment packing many items to achieve the least amount of boxes to optimal weight.
• 2) Strengthen angled corners of each box with duck tape. Today’s duck tape comes in neon colors and makes each box easily visible coming out on baggage pickup. It is also easily visible in large warehouse of boxes when picking up from Airfreight Company. Duct tape should also be packed for mission. It has been used on the space shuttle and I guarantee you will use it on a mission.
• 3) We are not shipping clothes and we need to remember to consolidate our product in many boxes. What am I speaking about? If you place all of one product in a box and that one box is lost or stolen, your eye mission could end.
• 4) Label your boxes 1 to whatever number with large bold numbers on outside of each box. This informs you or another individual when picking up total number of boxes all are present just by scanning from a distance. This also eliminates us to walk up and read labels on each box to confirm ownership if other boxes are present. You will be moving boxes multiple times before you arrive and making things simple and easy on front side will be welcomed when you are tired and run down on the backside.
• 5) Each numbered box should have contents of each box on inventory ledger sheet, which travels with person over product. Upon final arrival, you will be unpacking multiple boxes containing similar products; the inventory ledger will make less work for the many hands that might be available for warehousing your product. The inventory ledger should also carry all-important information. This information could be serial numbers of equipment going down but coming back into the United States. This sheet should also contain what is to be left down in mission country. The more formal paperwork you carry will be less time spent in entering each country. Proof of ownership is easier if you carry paperwork. Receipts of purchase and serial numbers are valid for equipment movement between countries.
• 6) If you need certain drugs, make sure your MOH have been advised. Remember viscoelastic is NOT a drug. Any product that is not a drug should have its labeling available. A description of the product in the language of country you enter is helpful to have inside the box if inspected. You can find many labels on line by supplier of the product. Cut and paste the words from label into any interpreter program on line and print out. This paperwork is proactive and seldom used. However, past experience has kept me from many hours of standing in line. Just as our country does not like illegal drugs, other countries do not. Be proactive.

 

Summary: the first patient you witness on post op day will reward the many hours you have slaved for this long arduous project.  There is no other feeling like it and the bug of Eye Missionary work may have just bitten you.

I Care, U Care, We All Care For Eye Care

Most of those who came to Guatemala’s grandest-ever eye jornada were born in a war zone, or in its cooling aftermath. Some were refugees daring to re-don traditional garb that was once considered subversive. Some had rarely even seen eyeglasses, much less seen through them; the eye-tingling splendor of the Western Highlands was for them as much a blur as had been, for years, the hope of peace.

Peace has its dividends, and war, its levies; one levy was a stunt on progress so acute that in 2006, ten years after the close of the 35-year Civil Conflict, all of Sololá province lacked a single optometrist. Today there are four and, for one week in April, triple that. They, and a company of other volunteers, brought light into eyes dimmed by war and its lingering privations. One did not need a month’s wages – nor even a minute’s – to own glasses.

The jornada (health fair) idea began with Dr. Patricia Cole, headmistress of Panajachel’s experimental Chinimayá school, and her friend, Chicago optometrist Philip Ortiz. Dr. Ortiz is the co-founder of ICareInternational, a California-based foundation that dispatches optometrists, surgeons, support personel – and mounds of eyeglasses – to wherever they are needed in Latin America.

Trip organizer Lance Kinney, who chronicles ICare missions with his camera, was personally recruited by Ortiz while doing contract work on the latter’s house. “I asked Phil what he did. When he told me about his ICare teams, I enlisted.” Like everyone else, Kinney had to travel light to Guatemala in order to leave room for his share of glasses.

Social Worker Dave McClure, a 20-year veteran of ICare jornadas, was another personal convert. “I grew close to Phil, my own optometrist, after getting a cornea transplant. I discovered that he was making these trips on his own nickel, helping people who otherwise had no hope of seeing well. So I started going along.” McClure’s role is operating a gadget that identifies the parameters of donated eyeglasses.

ICare collects tens of thousands each year, more than they can give away. Some come through the Goodwill and the Salvation Army; others are seconds, discontinued styles, or “blems” (perfectly functioning frames with minor flaws.

“The average retail for eyeglasses is $150,” says Dave’s wife, Colleen. “But on this trip we’ve given away Christian Dior, Prado, Calvin Klein and the like, for which the frames alone cost $400.”

Colleen’s coworker, Laura Gekeler, says the important thing is “seeing joy spread over the face of someone who’s seeing well for the first time in years – or the first time ever – whatever the frames are worth.” The volunteers have seen people marvel at seeing things like clouds for the first time.

In addition to prescription glasses, sunglasses and reading glasses were given out. “They’ll help farmers who toil at high altitudes,” Dave says, “where ultraviolet radiation is intense.” He adds that reading glasses were also given to women who cannot read, “but have to thread needles, for their livelihoods.”

Every volunteer could recall memorable cases. Optometrist Chuck Tribbey treated a child who could resolve nothing beyond her arm’s length. And there was a teacher “who was so farsighted, I don’t know how she was able to teach.” Both were helped.

Megan Chilton, majoring in International Relations, noted that “kids and adults are always happy with their glasses. They’re not self-conscious. But teenagers often are, and we’ve seen some reject free glasses because they’re too big. They’ll settle for a smaller, better looking pair, even if the prescription is a little off.” For unlettered patients, Chilton’s eye-chart station featured charts of arrows, fingers, pitchforks and high-pitched houses all “pointing” in a cardinal direction.

Ron and Michelle Reed, an Illinois couple helping out with logistics, recounted one case that needed a second take. “An elderly gentleman received his first-ever glasses,” Ron says, “but seemed disappointed as he left. He returned the next day with a letter typed by his son, saying that the glasses gave him headaches and eyeburn.”

“Sure enough,” Michelle says, “they weren’t at all in line with his exam results. So we found some that were. They were huge and ugly. But this time the guy left happy and excited.”

High-school seniors Danny Brooks, Matt Margolis and Stephanie Riley, manning the autorefraction station, were touched by seven-year-old Madalín. “She was so thrilled with us, and her glasses,” Margolis says, “that she ‘adopted’ us and hung out with us for most of a day.”

“She went around hugging the volunteers,” Riley adds. Brooks remembers a man who, at 94, was “too old for treatment. But he at least got sunglasses.”

Duane and Eunice Wakeman, married 57 years, have volunteered for 14 ICare expeditions. They are, they say, the high point of their retirement. They brought their daughter, Sue Bea, on this one. Sue and coworker Joan Sable managed a database of the eyeglass inventory. Whenever glasses were given away, Sue and Joan deleted them from the database.

“We don’t find a perfect match for everyone,” admits Sable, “so we give the closest we have. Sometimes, we find we have the lens for the right eye, and another for the left – but on different frames.”

In such cases, it is often possible to mate the lenses into one of the original frames, or into another, in spite of differing shapes or dimensions. For this there is a frypan full of seasalt where frames are heated to malleability for refitting. Lenses, too, can be modified on the spot by filing. Frame arms can be recurved, to fit their new owners.

Klaus Schumann, a German lawyer who immigrated to the United States and became a truck driver, spent part of every day for three months prior to the jornada sorting the glasses. They are always indexed by the right lens, then divvied further according to refractive parameters. At the end of the jornada, Schumann and wife Jay turned over some 2300 undelivered eyeglasses to the Lake Atitlán Rotary Club, whose president, Rufino Caniz, began pondering his task: to find owners. “It won’t happen quickly,” Jay says, “because some of the glasses are for relatively weird prescriptions. But there’re still many for people with commoner vision problems.”

Before the event, Rotarians distributed flyers and posters, and asked local mayors to inform their townfolk of the jornada. One Rotarian business, Panajachel’s El Horno Bakery, donated a day’s worth of meals to the volunteers and provided another three days at cost. Seven sharp students of English from nearby Del Valle University showed up to translate. Some Atitlán expats also entered the translating fray.

“Foreigners who live here need to give something back,” says American Myron Klein, of Santa Cruz. “That’s why I’m here.” Klein’s presence was rewarded in a special way. “A nice seamstress who did work for me 25 years ago popped up in one of the lines. She remembered me, if not my name.”

The jornada ran nearly five days, with most of the first spent logging symptoms and identifying surgery candidates. Over the week, surgeons led by Dennis Deters performed 46 operations in Sololá’s public hospital, with Guatemalan medical students assisting. Another ophthalmologist, Roger Ewald, remained at the jornada site to evaluate additional candidates, and perform post-ops of the work of his colleagues laboring in Sololá.

The hospital also received a donation of a $250,000 Alcon Phaco Emulsifier, a surgical appliance from Vantage Technology, where Dr. Deters’ wife, Ann, is CEO. The gift puts this provincial hospital on the map of vanguard treatment.

The event’s most compelling volunteer might have been retired optometrist Lenny Sable, who filled in wherever needed. Dr. Sable wore a paper Burger King crown all week, and encouraged and entertained everyone with his self-effacing humor. On the final day, he won a kiss from a young translator.

“I can’t wait to come back,” he says.

Mission Trip Photo Journal

Most of you may know already that my son and I were traveling to Guatemala during the Month of April. As this trip was full of adventure for both of us, we have shared our journal with you our readers, now enjoy the photos of our journey

Day 9 April 12th

Birds are still recording the same old song but for some reason today I am not despising their songs. I guess I realize I will not hear them again until another visit to a tropical country. We had a very enjoyable evening with a great meal and friendship. The evening was filled with remembering the events of the last days of surgery. Many comments of how they miss the teams of eye care professionals they work with and how they appreciate there talents. The last week has been very tiring and laborious. The endeavors by us all have produced a friendship which we now cherish.The surgical team came to this country seeking to help people who are enslaved in blindness only by a cataract. Our goal was to teach of the technique that is used in the United States. Our goal was not totally achieved in ways of teaching a local ophthalmologist but we did achieve the gift of sight to many.

We leave behind a phacoemulisfier that can be used for future surgeons, be it local or missionary, so we do declare some victory in our efforts. At the end of this day we will start to make our way back home to the United States. We came from five different states not knowing each other but to serve and help those less fortunate. Mission accomplished Sololá Guatemala 2008.

Day 8 April 11th

Slept in until 7am today, actually tuned out the birds or I am starting to get accustomed to them.Walking up to the hotel dining hall for breakfast and I am startled to see about 5 post op patients waiting in chairs along the hotel. We informed them all that we would see post-ops at 9 am. I guess many had to take certain buses into our village so they are waiting.

Surgeons meet me for breakfast and they are also surprised to see all the post-ops. We down our breakfast quickly start viewing post-ops in the beautiful outdoor office we have set up. The surgeons are quite concerned about many of the procedures but they are all smiles as the post-op procedures all look very good. To work under such draining circumstances and now to witness the result is very gratifying to them. I enjoy their happiness as well since I too, felt such frustration while trying to help the surgeons in any fashion during all the procedures.

We close out the last post-ops around 11am. We pack the slit lamp up and decide to walk around the beautiful village. Upon our arrival back to the hotel two more post-ops are waiting. Again the eyes look good according to the surgeons and we bid them farewell. The surgical team will go out this evening for a celebratory meal.

Day 7 April 10th

Many of the U.S. optometric members from clinic below attend surgery to witness surgical procedures. They have heard of our stories at the breakfast table and all want to experience the issues of our surgical team.Some post op patients have started to filter into the optometric site from first day surgeries. The patients coming in are ecstatic with their new vision. We are to see the majority of our post ops tomorrow.

Our one joy we heard from the optometrist below was a post-op patient who arrived at the optometric site and was complaining of his sight. We performed cataract surgery on his left eye and upon his visit to the optometry clinic he was complaining of poor sight. He was promising that the surgeons had done something to his right eye since he did not see as well from his right eye. The optometrist asked if he could see from his left eye. He could see everything, it was all so beautiful but his old eye was not correct anymore and he remembered that some fluid had fallen into his right eye. He was convinced that his right eye was harmed. The best Spanish translator was having a hard time convincing him that his right eye too needed cataract surgery.
We finish early today around 4 pm and we head down the mountain leaving all of our product and equipment behind. We pack all of the equipment which will need to return to the states. I do feel a sense of remorse leaving an area so underserved but this has always been my feeling after a medical eye mission, the feeling never changes.

Day 6 April 9th

We were so happy to have local Ophthalmologist attend procedures with us today. This local Ophthalmologist was attending the hospital for a procedure of a local individual. We thought that he had been informed of our arrival and came in to learn the new equipment but he was never informed of our visit and had no clue we were performing cataract surgery. The young surgeon brought in his own equipment, which consisted of his own microscope, nothing else. The local Ophthalmologist said he would loan to us his microscope, after my request, so we could pick up more speed. Working with two beds helps the surgeons stay focused on continual procedures but also requires us to keep up with supplies and movement of patients. Most procedures in the States the surgeon is dictating to patient the “Do’s and Don’ts” after the procedures as patient is leaving but we always need our translators to make sure they understand.We informed the local Ophthalmologist that the equipment and all products would be left behind and we would enjoy teaching him on the techniques of phaco. He had practiced somewhere before with phaco but not in Guatemala. He was surprised we were working on such hard cataracts. The young ophthalmologist watches the surgeons performing phaco on the patients. He is impressed with the equipment but appears to be standoffish to the technology. We keep informing him this will stay behind and he will be allowed to use the equipment but his body language reflects that he feels no need.

The day continues and young local surgeon witnesses our crew perform extra capsular technique. He explains that this is his caliber of surgery. We accept the fact that not all phaco is worth the effort on some of the lenses we have witnessed. The day grows long and we work slow and steady. We are treated by an elderly patient with another super cataract. The amount of time to perform capsulorexis takes minutes not seconds. The surgeon is finally through the capsule and starts to phaco. The surgeon stops dead in his tracks. He informs us that the tip of his chopper has just snapped off into the lens. Our surgeon works through the unique situation but we term the cataracts “super cats”.

Day 5 April 8th

Same birds plus a thunder clap in middle of night before rain storm. The thunder was similar to dynamite explosions I witnessed as child with my father. The explosion and then the rumble down the valley was startling. At the hospital we have new wave of patients. Our other surgeon arrived yesterday during cases and performed unbelievable since he had been up for 18 hours straight. Crazy flight times required 3 am flights and he had an additional 3 hour drive through the mountains to Sololá. Today he has a headache and is sleep deprived.We look for things to roll along OK as yesterday. The flow is starting to pick up for us but the procedures are still hard and consuming. The surgeons pray for their stools back home and cherish for a 4+ cataract. The vision blue has been a hot item and even this will be rationed before we finish. All patients are stoic while on the table. They except the fact they need to sit many hours and are always courteous and thankful upon departure. Completed 12 procedures and we walk out by 10 pm. It appears we are slow but everything feels in slow motion. We just keep pushing on.

Please continue to read our Journey on Monday the 26 of May. Have a good Weekend.

Day 4 April 7th

Same birds waking us up and up the hill we go by 7:15. We captured some extremely bright young people to help us translate from the optometry group. The local people were quite prepared for our lack of Spanish skills and prepared young students attending small private school to take us under their wing to translate. Even though we have surgeons who speak fluent Spanish we find that the local people speak 3 other languages inside the Spanish language making it difficult for even the local people.We work hard getting the system into place but it took us until 11:30am to get first patient on the table. We are working with one surgeon at this time and have many more procedures to go before the end. Our second surgeon is yet to arrive and will be in later today. Everything is double slow since all missions contain individuals who have never performed in surgery or worked for other surgeons or hospitals. Every body performs differently so we now all need to re discover how and what we can all do to make this endeavor work to the best and most efficient manner. First day is slow. We complete 14 procedures but it is 11 PM. Back to bed.

Day 3 April 6th

My word these tropical birds are loud! The volumes of the birds are the same as watching the National Geographic channel only on high volume. Sleep was great until the slightest break of light initiated the call of the wild to awaken. I can see now that I will not be in need of an alarm clock. It took until 11 am to get out of the optometry clinic. They had 200 people waiting the instant we turned the corner to the clinic and all hands were requested to set all stations for the optometrist.We arrived at hospital about 12 noon and walked into deposit all of our product and equipment. The 15 boxes of product that will remain at the hospital after we complete our 4 days of surgery will be stored in a temporary break room storage room we have been given during our stay. Upon unpacking I realize that some product was not shipped. Making note for next trip that person packing needs to also confirm the inventory list to all product per each box before leaving for destination. Assuming never changes and I assumed the product requested had been sent. This caught me off guard on some products and I know this will not make my surgeons happy.

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