 Surprises are gifts. You're minding your own business and a snowball hits you in the head. It stops your mind. You catch the moment of total bewilderment. It comes once a year when I step off the plane on the steamy tarmac of the tropics in Sierra Leone. I smell palm oil and breathe the red dust from the company. By a team of very talented surgeons and nurses, they know trauma. Many of them work in a war zone called Newark. They leave their antiseptic air-conditioned, highly regulated and well-supported ORs to go to a Bush hospital, nine grueling hours from the Capitol, where neither the well, the generator, or the ambulance survived the 12-year brutal Civil War. We did over 150 operations in two weeks, and this is what surprised us. Sierra Leone ranks on nations on the UN average life expectancy. It is estimated that only one out of four people is in need of surgery. 25% of the reported deaths last year could have been averted by timely surgical care. Hernias are left untreated, holes in the stomach from too much hot pepper, amputations for both bone infections, and untreated diabetes. The Dalai Lama once said, if you think you are too small to make a difference, try sleeping with a mosquito. This infection was the result of a mosquito bite that Muhammad had been treating with honey. He didn't seek medical care until he heard on the radio that the doctors were in town. We actually, we breathed it pretty well, but anyway. A hernia repair means a farmer goes back to work. This 35-year-old man, shockingly, was working in the field the day before his surgery, even though half his digestion was taking place between his pelvis. While gallbladder surgery is common in the United States, perhaps the results of our super-sized meat diets. In Africa, they are rare. Instead, we see huge hydroceals like this one here, a fluid-filled sac. It's a condition which would never be allowed to get to this stage in the United States. But for most of our cases, we use spinal anesthesia. Our anesthesiologist, who happens to be a Sierra Leonean, once told me, when you see a slight wince, you know the pain is a 10. Post-op, we give only Tylenol. Working in an environment without reliable power infrastructure requires creativity. We supplied oxygen by hand often, and used a Jerry Rick pump to rinse a patient's abdomen because the sterile water was in short supply. One of our docs made an incentive spirometer from an empty water bottle. These same bottles came in handy as sharp containers. And lawn furniture, not treat. We cannot treat goiters since there is no thyroid replacement medication in the entire country. Even after we amputated a young man's foot, we couldn't give him a system. It is a parasite that carries a bacteria. This condition is treatable. It's preventable if treated early. This 21-year-old man will never work on it. The second most common cause of blindness in Africa is river blindness, which can be prevented by simple antibiotics if these children live in a school full of blind and caught. But for those we are able to treat, the gratitude is heartwarming. I mean, I complain if I wait in a doctor's office for 30 minutes. This man walked 40 miles, waited six hours, I think he even brought it back. In states, the expression of gratitude is rare as too little time for our patients. This robotic surgery is where a doctor interacts with a computer, maybe the ultimate expression of technology over time. In Sierra Leone, our efforts to provide care, some do what you can, where you are. The biggest surprise I always have is to a healthcare system which emphasizes treatments over prevention where creating a crisis. We often suffer from open treatments and there's an African proverb saying, small, small, and if many little people in many little places do, for more information you can go to issueglobal.org.