Wrapping up

The countdown is on! We will be back home in less than 3 weeks now. It doesn't seem like 16 months since we came here together, but here we are!

We've entered a very lovely season here in Nepal, much, I'm sure, to the jealousy of those of you still battling snow and wondering if spring is ever going to arrive. The days are starting to get hot, but the mornings and evenings are very pleasant. It's sunny almost every day. We could actually use some rain to fill up our water tanks, as there is a severe water shortage at the moment. We have run out of water a few times in the last few weeks. Surgeries had to be cancelled over the weekend because of a lack of water. There are fights breaking out at the local water taps, where people who don't have running water in their homes go to stock up. Our large storage tanks are less than 30% full, even with getting tankers of water to truck water in and pump it into the tanks for us. Send the rain, Lord!

This is an issue every year at this time, and the solution isn't obvious. Trucking water in is expensive and not sustainable, as more and more people move to the community and also rely on the town's water supply. Our rainwater storage tanks are a great idea...when there is rain! In a couple months, the monsoon will start, and the tanks will be full to overflowing, and most will forget that we were in a crisis just weeks earlier. There are plans to build an even bigger rainwater storage tank (over 1 million litres of water), which will certainly help, although it still may not be enough during the dry season. Drilling for water may be a better long-term solution...assuming when we drill there is actually water to be found (which is not a guarantee). It is an issue that has very much been on our hearts and minds since we came to Tansen, and we continue to pray that God will make the way for us to have an abundant, clean supply of water, not just for the hospital, but also for the surrounding community.

As Jessica goes on maternity leave, the hospital is facing even more of a shortage of surgeons than there has been. This challenge is compounded by a new policy that medical licenses are not being granted to short-term visitors, so our usually steady stream of short-term surgeons coming to help is also not happening. She is leaving the department in the hand of 1 Nepali surgeon who has worked here for the last 3 years, but may be leaving in the next few months to go do further training, and 2 newly graduated Nepali surgeons who had some significant gaps in their training and are still learning the ropes. Please do pray for the surgical service and for provision of adequate coverage and support, both as we are away, and when we come back.

Our new Nepali surgeons operating together

Paul's building projects are coming along, though disappointingly, it is likely that neither of the 2 major projects will quite be finished before we leave. He's working hard to try to get them to a place where they don't need his oversight anymore. They're getting close, but we're still waiting on shipments of supplies that should have been here ages ago, as well as some other things that are outside of our control. He is sad to be missing out on the satisfaction of being able to survey the finished project, but trusting that it's all in God's hands. 

The nursing station in process

With the challenges and suboptimal circumstances we're leaving behind both on the surgical side and the building side, we're reminded that this is indeed not our work but God's, and that we need to hold onto things loosely, allowing Him to use as as He sees fit, but remembering that we are only a small piece of a much bigger puzzle. "Unless the LORD builds the house, those who build it labour in vain." (Psalm 127:1)

Our current plan is to be home for about 6 months, and then to return to Nepal in late October. The baby is due on July 11. Do please pray for us as we wrap up the last couple weeks here in Tansen for this season and prepare for the next chapter of our lives.

Leaving our comfort zone

With the increasing availability of specialists in Kathmandu who provide a reasonable quality of care, we try not to do things here in Tansen that are too far out of our realm of expertise and comfort when we can help it. These days, it seems that more and more patients are able to afford to go to Kathmandu when needed and pay for the care there, and so we often refer more complex cases there. However, Nepal is still a very poor nation, and there are many patients who could never afford to go to Kathmandu for care. In fact, their hospital fees here get paid for with charitable funds. In those cases we do the best we can, even when we are pushed beyond our usual scope of practice.

We have a visiting pediatric surgeon here right now who has been here many times before. He was asked to help with a little 6-month-old girl who was born with an encephalocele. For those of you non-medical types, that is where a portion of the spinal canal doesn't properly form, so there is a connection between the spinal canal and the surrounding tissues, and causes a leak of the fluid around the spinal cord and brain (CSF, or cerebrospinal fluid) into a fluid-filled sac outside the spine. This little peanut had a big mass, about 30-40 cm in size, coming out from the back of her neck, filled with CSF and connected to her spine and brain. Normally this would be operated on by a neurosurgeon, but this family was dirt-poor, and couldn't even afford care in Tansen, let alone go to Kathmandu. So we sent the MRI (which we sent her elsewhere for and paid for out of charity funds) to this surgeon over e-mail to get his opinion. Not being a neurosurgeon himself, and never having done a case like this, he consulted a neurosurgery colleague back home, who thought that this was probably doable, and told him how to do it.

We did the operation on Monday. Aside from some nervous anesthetists (and surgeons!), everything went well. The mass came off easily, and the hole in the spinal canal was closed off. Baby did well. We were pretty pleased. The next morning we heard that she was doing "Dherai ramro" (very well), and we were excited to hear that. But on rounds we noticed that her fontanelle (baby's soft spot on their head) was a bit full and bulging (a sign of increased pressure in the brain). She looked okay otherwise, though, so we just watched her closely. By later in the day her level of consciousness had deteriorated, and her breathing pattern was abnormal. We knew there was a potential for this to happen. We decided to remove some of the excess fluid with a needle and hope for the best. (We understood from the neurosurgeon that sometimes it takes time for the CSF balance to sort itself out after an operation like this). But the next morning she seemed worse. Now her right eye was not focusing, and she was even less alert. A quick SMS/e-mail consultation with the neurosurgeon and we decided the best thing was to send her to Kathmandu ASAP for something called a VP-shunt (where they insert a drain that drains the CSF into the abdominal cavity). If she deteriorated in the meantime, we could insert a temporary drain here in Tansen before sending her to Kathmandu. He told us how to do this.

Enter the next set of problems. In Kathmandu at the moment, all the doctors are on strike. In fact, this is nearly nationwide, though it hasn't affected us yet. I don't really understand all the reasons for it, but only true emergencies are being cared for. Everything else is on hold. Thankfully, one of our Nepali doctors here has a brother who is a pediatrician in Kathmandu. He contacted him, and arrangements were made that we could transfer this little one today (Thursday) and someone would care for her there. I think they even agreed to do the surgery for free. Social services agreed that we would cover the cost of her getting there and for any medicines she would need.  All well and good, provided she was still alive by today. (Did I mention that we have been praying up a storm over these past few days?)

As the day progressed yesterday, she grew worse and worse and we knew we needed to put this drain in or she was going to die. Unfortunately our anaesthetist doctor is away, so we only have nurse anaesthetists right now. They are very good and very experienced, but they were understandably nervous. Fortunately (??) for them, by the time we got her to the OR, she was so deeply unconscious that we didn't need to give her anaesthesia other than a bit of local anaesthetic. We then used a central line (special kind of IV) kit...expired, by the way...as a drain. When she got to the OR she was only breathing (gasping, really) maybe 3 times a minute, and I really thought she was going to die in front of us. (Insert more fervent and desperate prayer!) We got the drain in, and a LOT of fluid came out, obviously under high pressure. We waited....

After a few minutes, she started breathing on her own. Her heart rate normalized. She started making a few...just a few...movements. We all realized we'd been holding our breath and all started breathing a little easier. She was coming back to us in front of our eyes. It was amazing...truly miraculous! Over the next several hours she started moving more, opening her eyes a bit, and her pupils, which hadn't been reacting at all, started reacting. She wasn't totally awake, but she was getting there. This morning at 5 am she was put in the ambulance and they left for Kathmandu. We pray she made it there safely and that she is able to get the care she needs. We pray for a full recovery for her. We pray for her parents to enjoy many years with her. And most of all, we pray for her and her family to come to know the One who really has saved her life. We serve, Jesus heals.

Why it's hard to get things done in Nepal

Paul has been diligently working away at a couple different building projects here in Tansen. One of them is coming along swimmingly...the one that involves a dedicated team of skilled workers from Kathmandu who have a deadline after which they will lose money on the contract. He is more of a consultant for that job. The other project, the building of a new nursing station for the medical ward, is being done by the hospital workshop staff, and it isn't coming along quite so quickly. Paul gets asked regularly how much longer it will be before it's done. If he could keep workers there for more than an hour or two at one time, it would really help!

That isn't to say there isn't progress being made. A few months ago they were working at chiseling away (by hand!) the extensive rock that needed to be removed before the building could even start. Eventually someone figured out that if they held a blowtorch to the rock for a few minutes and then poured cold water on it the rock would break faster. It was a little frightening to see the fragments of rock start flying everywhere, but thankfully there were no injuries!

 Now the foundations have been laid, the walls built (the gaps are where large windows will go), and the roof trusses built, welded, and secured in place. The bathrooms have been tiled, and the tiles for the rest of the nursing station have been ordered. There remains the installation of windows, tiling the whole place, designing, building, and installing the cabinets, countertops, and shelves, as well as some other things. Theoretically this is doable by the end of April (when we come home for a few months...more on that later), but given the challenges along the way, we're not sure what will happen.

A typical day for Paul:
-9:30 am go down to the job site, where 2 or 3 workers are ready for the day's work. Instructions given, as best as he can give in Nepali, and work started.
-10:00 am - one or more of the workers gets called away for one reason or another. Perhaps they need to haul some oxygen cylinders somewhere, or repair a leaking pipe, or paint the house of someone who will be moving in the next week, or any number of other things. Paul is left with one worker (if he's lucky!)
-10:30 am - Paul gets called to a surprise meeting that could have been planned in advance, but advance planning doesn't seem to be a familiar concept here in Nepal. The meeting takes the rest of the morning.
-12:45 pm - Paul goes back to the building site to check in before lunch. The workers have left for lunch 15 minutes early, and Paul sees that the tiles, which had been going in straight while he was directly overseeing the tiling, are now uneven and crooked and need to be re-done.
-1-1:30 pm - Lunchtime, during which we often pray desperately for some kind of progress to be made for the rest of the afternoon
-1:45 pm - the workers come back from lunch (10-15 minutes late). Thankfully there are now 2 of them. The other one is busy with something else for the rest of the day. Paul explains to them that they need to redo a lot of the work they had done in the morning. The funny thing is, they KNEW the tiles weren't level...but maybe they thought it didn't matter.
-1:45 pm to 5 pm - Amazingly, they are able to focus on work for the afternoon (okay, so perhaps not so typical a day!), and so after removing the crooked tiles and replacing them, they are able to make some progress with the tiles.
-5 pm - Paul is explaining what the plan will be for tomorrow, when one of the workers tells him, "Oh by the way, I'm taking leave tomorrow." Again...advanced planning is a non-concept here. No wait...that IS advanced planning - they told him the evening before!

It is no wonder Paul's hair is greyer than it was when we arrived! Ideally, this project needs to be done before we leave in late April. Without his direct supervision, it may never get done. Pray that they are able to meet the deadline.

Why the deadline? Well, our exciting news is that we're expecting a baby in July, so we will be returning home for a few months to have the baby and adjust to being a family of 3 before coming back to Nepal, Lord-willing, in late October. Jessica is now into her second trimester and is doing well. We do appreciate prayers for this time of transition, and for a safe and healthy pregnancy and delivery.

A sad day

I (Jessica) was on call yesterday and I must say it was one of the sadder days I've experienced in awhile. Started with rounds, and once again, our burn ward is full of tragic stories. On the pediatric side there was an 18-month-old boy who'd been burned by hot daal (the lentil soup that Nepalis eat every day). The burns weren't particularly deep, but they were extensive, covering about 50% of his little body. He wasn't doing so well yesterday morning, and was starting to show signs that he might not make it (unfortunately, I've seen enough of these burned kids now to start recognizing these signs which to the casual observer might not seem like such a big deal).  We did what we could and moved on. I was hopeful, but not optimistic, that he would improve.

I've already written about electric burns. Currently we have 2 patients with electric burns. One is a man I wrote about before who has huge wounds on his chest and back from the current passing through. He is actually improving, and many of his wounds have been grafted and done well. His finger, however, hasn't done well and it's being amputated today. He was discouraged about that. However, looking at the bed next to him, he has reason to be thankful. The young boy who was in that bed previously who lost one arm at the shoulder and eventually went home has been replaced by another young boy, 9 years old, who has lost BOTH arms at the shoulder because of an electric burn. He was playing in a power station! In the bed next to the kid is a middle-aged man who has a seizure disorder who rolled into the open fire in his home while having a seizure. His burns are all quite deep, and cover about 20% of his body. I think he will make it, but he has a long way to go. Finally in the corner is a young girl, about 20 years old, who poured tar all over herself and set herself on fire. Sadly, this is a common way for young women in Nepal to attempt suicide, and it is all too often effective. Just before she came we had another young girl in the same bed (incidentally with the same first name as this one) who had done the same thing, only with kerosene instead of tar. She didn't make it. But this girl seems to have regained her will to live, and is quite motivated to get better. I think she will do okay in the end.

The boy who lost one arm went home. He was a really sweet kid and always made us smile.

Metal ladder, multiple wires, bare hands...no wonder we see so many electric burns here!

So that was our morning rounds. In the afternoon I had to do an emergency C-section for a lady with twins who had "fetal distress" (indicated by an abnormal heart rate of the babies). Both the babies I pulled out were "flat" (i.e. really floppy and not showing many signs of life), but thankfully were resuscitated and seem to be okay now. Mom, however, bled a lot, and I had to resort to almost every surgical maneuver for post-partum hemorrhage that I know. Thankfully it stopped before I had to do an emergency hysterectomy. So I guess that story had a happy ending.

Not so the next C-section, which was for a lady who was 31 weeks pregnant and had come in with bleeding. Baby seemed okay, and the bleeding wasn't too extensive, and so the team had decided to give the mom steroids to help mature the baby's lungs and just observe her closely, hoping to be able to wait a couple days before delivery so that the baby would have a better chance of surviving. Things went well for several hours, but then at the early evening check, there was no heartbeat. An ultrasound confirmed that baby had died. She was breech (head up instead of head down), so needed a C-section. It's an awful feeling to pull out a dead baby! The operative findings confirmed the suspicion: that the placenta had separated from the wall of the uterus (placental abruption for all you medical types). All in all the mom seemed to take it well. I can't imagine!

Finally, just before I went to sleep I got a call that my little burned boy had died. I could hear wailing in the background while I talked to the resident on the phone. A sad day on many counts!

Thankfully the weather these days gives us reasons to smile. Daytime temperatures are lovely, and the views have been very clear. It's hard to believe that the mountains, which are so clear these days, are hidden much of the year by clouds and haze. It won't be long before it starts to get cold, but we're sure thankful for this season while we have it.

The "nice" season

One of the language teachers in Kathmandu says that there are 5 seasons in Nepal. There is the cold and dry season, the cold and wet season, the hot and humid season, and the hot and rainy season. And then there is the "nice" season, which, sadly, is the shortest season in Nepal. We THINK the monsoon is done now and we are into said "nice" season, though we were again hit with rain a few days ago. But most of the time, the skies are clear and it is sunny and beautiful. We are seeing the mountain peaks again, though certainly not every day. It's still quite hazy. We're hoping things will clear up even more in a week or two. In the meantime, we certainly are grateful for the drier weather!

The blue skies and mountain views are starting to come back!

We are also coming into festival season. Nepal's 2 biggest Hindu festivals come almost back-to-back in October and early November. Dashain...the biggest festival...is coming up next week and lasts 5 days. Tihar comes for 3 days in early November. During these festivals the whole country is shut down...including almost all the hospitals! Which means that we will likely get all the emergencies in the area, as people will have nowhere else to go. We won't be doing any clinics or elective surgeries for a few days - nobody wants to be in hospital during festival season. As far as important festivals go, it's the Christmas of Nepal. (As a side note, in contrast to this season, Christmas is really a minor occasion for most people here...it was only declared a national holiday a couple years ago, and most don't celebrate it. We will have Christmas Day off work but otherwise the hospital will run as usual)

Because of the upcoming festivals the hospital has slowed down a bit. Fewer people are coming to clinics for non-urgent problems, and most people ask to have their surgery scheduled after the festivals are done. We still have our share of emergencies, though, and the pediatrics ward, in particular, remains swamped from all the late-monsoon illnesses (typhoid, pneumonia, gastroenteritis, meningitis, etc).

One of the pediatric patients "namaste"-ing me in clinic

On another note, I (Jessica) have decided that there are few injuries that are worse than electric burns. I wrote about Sonu a few months ago. Hers was by far the most extensive and devastating of the injuries we've seen recently, and she eventually succumbed to them. But we've had several other bad ones, and each time I see them I find myself angry that these injuries happen with such regularity, and to young people. Recently I cared for a 27-year-old young man, an electrician, who was handling wires when something happened and he was shocked. He lost his right arm, up to midway between his elbow and his shoulder. He has a wife and a child, and probably won't be able to do electrician's work again. He had the most incredible attitude of any patient I have ever cared for, I think...much better than I would have had in his situation. Because of this, I really enjoyed seeing him every morning on rounds, but his right arm stump was a constant reminder of the tragedy he had suffered.

Then there is a 10-year-old boy currently in hospital who also suffered an electric burn. How does a 10-year-old get a bad electric burn? Well, if you saw the complete jumble of electrical wires that we see around Nepal, you might not find it such a surprise. He was climbing a wall and grabbed a wire, and was frozen to the wire for almost 1 minute before he was released from it. His right hand immediately was in a "frozen" position, never again to move. We had to amputate his right arm all the way up to his shoulder. He also has severe wounds on his abdomen and chest, which will need to be grafted. Thankfully he's doing quite well, but his life will never be the same.

This morning there was another patient who had arrived...a young man in his 30s. I don't know his story, but I do know that he has huge, very deep wounds in his chest and going through to his back, as well as in both hands. We are hopeful that he will be able to keep his hands, and that his heart and chest haven't suffered too much damage from the electric shock. Time will tell.

I would sure love to see some prevention going on as far as electricity is concerned, but I'm not even sure where you would start. In the meantime, we continue to see these devastating injuries, and I am grieved every time. It's hard to make sense of it all sometimes, but I am grateful for the chance to care for these ones, and pray that in the midst of their suffering they would come to know the God who loves them and cares for them far more than we ever could.

Catching Up

Our apologies to anyone who believes we have fallen off the blogging planet. How is it September already?

After a short but good trip back home for a family wedding, we have been back at it again here in Tansen for a little over a month. There was no time for jet lag, either going or coming back here. Things continue to be extremely busy, and we find ourselves being involved in many different things and being pulled in many different directions. The challenge remains finding a balance between the many very real needs here, and knowing what we're called to take on.

Monsoon

The rains continue here in Nepal, and we're all getting pretty tired of it. There are definite perks to the rain - like a more abundant water supply and greener fields - but for most people the constantly damp, mouldy clothes, the constant need for an umbrella, the mud and puddles everywhere, the grey skies, and the unsafe travel, are enough to make them look forward to the end of monsoon. A few weeks ago the skies cleared and for 3 days we even saw the mountains! But then the clouds and rain came again, and we're still in the thick of it.

A few weeks ago...a brief hiatus

The same view. Are there really mountains out there?

Paul

Paul has a few major projects on the go, and is also regularly being called upon for input into one or another building or maintenance issue. A few of the main things he is working on are...

A 3-storey residence and classroom building. Fortunately there are outside contractors who have been hired to do the work, and so Paul is mainly there to ensure things are getting done properly and that things are moving along smoothly. There have been many bumps and hiccups along the way, and we're still looking at approximately another year's worth of construction and work before it will be finished inside and out.

A new nursing station for the medical ward. Paul designed this building, and is overseeing its construction. The first (and perhaps biggest) challenge has been to break up the rock that is where the nursing station will be. There are no jack-hammers or dynamite, so this is being chipped away at painstakingly by guys with hammers and chisels. Amazingly, they're almost done...after more than a month's worth of work! Notice the tarp over the area to allow for work to continue in the rain.

The project that has consumed most of Paul's time in the last few weeks has been a cart to house our new laparoscopic equipment for the Operating Room. (We recently received a high definition camera, LCD screen, and light source to replace the very outdated ones we have been using) We are looking forward to actually being able to see what we are doing when we are doing laparoscopic surgery, or cystoscopy, or arthroscopy! Of course, the equipment that arrived needed to be assembled along with the old pieces that we will still need to use. It is still a bit of a hodge-podge, but it will be a huge improvement on what we've been doing. Paul had to design and build this cart from scratch, with the help of some guys in the workshop. It should be up and running by tomorrow. We're both excited...Jessica to finally be able to use it, and Paul to finally be done making it (everything takes longer than anticipated here)!

Before (minus the machines)

After

Jessica

With only 2 general surgeons here currently, life is very busy, and Jessica often has to work late or go in when she isn't on call. We are excited to report that 2 new Nepali general surgeons will be arriving later this month, and they plan to be here for a few years, at least. They have just completed their surgical training, and haven't yet been registered as specialists with the Nepal Medical Council. As such, there will still be a few months where they cannot work as independent surgeons, but we look forward to their coming, and hope that it will help make the workload a little less.

Jessica has spent a lot of time on various administrative activities lately: organizing the surgical teaching for interns and residents, designing and implementing new paperwork and updating the protocol for the burn ward, putting together a teaching schedule for our daily morning reports, and most recently, working on creating an evaluation form for us to use for our trainees.

The burn ward has remained quite busy, but thankfully no patients have died recently of burns. We have had a few success stories. Two young ladies who were both burned on approximately 30% of their body surface area, who both required skin grafting, both did well and have been discharged. We still need to work on their mobility and preventing the stiffness that is so difficult to deal with in burns patients, but we are making some progress. There was a gentleman in his 40s who had both his hands badly burned, requiring grafting. He did really well and has gone back home with relatively normal hand function. We've had children who have also done well, including this little one who burned his hand and needed grafting. There is a sad story of a 27-year-old man, an electrician, who was electrocuted while working with wires and had to have his right arm amputated as a result. Electric burns are awful!

We have a urologist visiting us at the moment, who is helping us to update some of our urology protocols, as well as teaching us a few new skills that we will hopefully be able to use after he goes. He was also helpful in the operation on a 70-year-old lady who was having quite a lot of pain when passing urine. No wonder. Here is her X-ray showing a 7 cm stone in her bladder...and the stone, which we removed yesterday!

Please continue to pray for us, for strength for the many demands, for wisdom to know what to take on and how to prioritize, and for ongoing grace for living in a culture that is not our own. There are days where it is very challenging and frustrating, and other days where we love it. But we know that this is where we are to be at the moment, and so we carry on.

Monsoon

It’s been awhile. I suppose sometimes the more mundane things in life overshadow the “blog-worthy” stories, and so here we are in the middle of July already! Amazing how time flies.

It’s monsoon season right now, which means that everything is wet and everything (including our clothes and towels) stinks like dampness and mould. Our feet are often wet and muddy from walking outside. You can't leave home without your umbrella, as it could start raining at any time. Fortunately the sun does come out now and then, so we do get a bit of a respite at times. This is the only time of the year that our water storage tanks are overflowing. They sit dry for much of the year, which leaves us with a water shortage a lot of the time. But right now the tanks are bursting at the seams, and for now we enjoy abundant water. As you drive along the road, all the rice fields are flooded...perfect conditions for growing this Nepali staple.

The sun does come out occasionally. Last week it brought this rainbow with it.

In the hospital, monsoon brings a bit of a slow-down of patients, as travel is a bit of an issue (more on that in a minute). However, it also increases the number of admissions for things like meningitis, snakebites, typhoid, and other GI illnesses that all seem to come at this time of year. This doesn’t tend to affect the surgical side of things too much, though we do remain quite busy in surgery, as well.

Travel is always an adventure during monsoon. Flights are unpredictable, as the weather often causes delays or cancellations, sometimes at the last minute. Recently, someone we know was almost in Bhairahawa (the airport near Tansen) before the plane turned around and went back to Kathmandu because of poor landing conditions! Fortunately, the 2 visitors we have had during monsoon made it here with no problems.

Then there are the roads. The rain often makes them very muddy, makes potholes worse, and the roads can be very slippery. Add to that the risk of a landslide, and road travel also provides no guarantee you’ll be able to get where you want to go. Landslides happen more frequently as monsoon progresses. You just hope you aren’t directly under them when they do happen! And if one happens, the traffic can’t get through, resulting in more delays. We came across this landslide the other day while out for a walk. 

We are thankful to have the opportunity to take a break from monsoon, as we are on our way home for a couple weeks for a family wedding. We made it out of Tansen without any problems, either on the road to the airport, or on the flight itself, and we are enjoying a day of rest in Kathmandu before heading on the long journey home tomorrow. We are ready for a change of scenery. As much as we love Tansen and know that it's where we're to be right now, we are tired, and looking forward to being home where (barring unforeseen disasters), you have consistent electricity and an ample supply of water, you can drink the tap water and eat what you like without worrying about getting sick, speak English, drive a car, go out for coffee, see friends and family, etc. The time will go quickly, but we are thankful for it. Please be praying for our safety, as we have a lot of travelling to do in the next few weeks. We will be back in Tansen in early August.