Thanksgiving at KAF

I worked all night last night, so I was actually considering just sleeping through Thanksgiving, but my Army friend, who is being transferred out to one of the Forward Operating Bases (FOBs) tomorrow morning, wanted me to go with her to have Thanksgiving Lunch at the Niagara Dining Facility (DFAC) as a sort of going away event. I have really enjoyed working with her for the last 3 months, so I thought I would be a good friend to her on Thanksgiving Day.

The Niagara DFAC served a big Thanksgiving lunch from 11:30 to 13:00 just for U.S. military service members, and then opened it up to all others from 13:00 on. With only one hour and forty-five minutes of sleep under my belt, I dragged myself out of bed, threw on my Navy sweatshirt and shorts, strapped my required glow-belt around my waist, donned my shoulder holster carrying my M9 and waited for my friend to knock on my door at 11:45. As I waited, our new ICU Department Head and her room-mate, who live right across the hall, emerged from their cocoons with their cravings for Thanksgiving fixings. Lunch for two turned into lunch for 5 as my room-mate decided to come with us as well.

As we approached the DFAC and saw the line streaming all the way out past the jersey barriers (large wall-like, concrete barriers that supposedly provide protection from rocket attacks) that surround the DFAC, grumbling from the group began. Someone said, “I’m not sure I want to wait in that line for food that will probably taste like cardboard.” I remarked back, “What else do you have to do? It’s Thanksgiving.” Just then we could hear the muffled sound of a band playing music inside the building. This lifted everyone’s spirit and we decided it would be worth the wait.

Almost an hour later, we finally reached the salad bar first. There was shrimp cocktail, which thoroughly excited everyone in our group, as we are all seafood lovers. My room-mate took a salad plate and filled the entire plate with just shrimp. There was also salmon lox and, of course, cranberry sauce at the salad bar.

At the hot counter, you had a choice of turkey, ham or both. I chose both along with sweet potatoes and macaroni-n-cheese. The stuffing looked like

regurgitated cat food, so I passed on that option. There were mashed potatoes as well, but I prefered the  sweet potatoes.

The desert bar offered up pumpkin pie, pecan pie, a vanilla custard tart and bread pudding. It was Thanksgiving so I indulged and took one piece of pumpkin pie and one piece of pecan pie!

Once I was able to break out of the crowd of people hoarding around the food, I suddenly realized that the DFAC was decorated with Happy Thanksgiving signs and paper turkeys. There was a massive center piece in the room consisting of ice sculptures, a large cake, fruit and nuts. People were congregating around, having their colleagues pose for pictures with the ice sculptures and/or cake.

We were worried about finding a place to sit, but there was a table in back with enough chairs for all five of us, so we quickly swooped in and saved it with our trays. Several of us made our way back into the crowd of hoarding foodies to grab beverages or, in some cases, other food items we couldn’t fit on the tray the first time through.

We enjoyed our time together, stuffing our faces, commenting on which items we thought were really good and which items were just so-so. I’m not sure if there was a single piece of shrimp left by the time we were done eating and everyone agreed that the macaroni-n-cheese was especially yummy! I didn’t care so much for the pumpkin pie as it tasted a little bland and dried out, but the pecan pie was moist and delicious. The turkey was pretty bland, but I ate about half of it doused with cranberry sauce. The ham, on the other hand, was excellent.

We enjoyed the music that was being played by a Brass Quartet in the far corner of the room and, at one point during our meal, the band had the entire DFAC crowd sing Happy Birthday to someone who was celebrating a Thanksgiving Day Birthday. The atmosphere was spirited and uplifting and it was nice to just sit and chit-chat. We shared stories about our Thanksgiving traditions from back home and attempted to ensure our friend who is leaving for another FOB that it will be an exciting experience for her.

By the time we were done eating, I felt like I was going to explode! I actually felt like I had finally eaten a decent meal here at KAF. They did the Thanksgiving meal better than I had expected. My tummy was happy!

I do miss my husband and my family. I have enjoyed many wonderful Thanksgivings with my family and friends and look forward to doing so again in the future. Happy Thanksgiving to everyone and thank you to those who sent decorations and Thanksgiving treats! I also give thanks for all the thoughts and support you all have provided throughout my deployment.

Jet Fuel

When Jessica and I were children, I remember how she always loved the smell of fuel—logging trucks, snowplows, airplanes. Anytime we were around anything that gave off the smell of diesel fuel or jet fuel, she would take a deep breath in and say how much she loved that smell! Well, Jess, you would have loved the experience I had this morning, but let me start at the beginning.

I spent last night caring for two Afghan boys, one was ten years old and the other was twelve. The 10 year old was in a motor vehicle accident and suffered a skull fracture. He definitely acted like a patient suffering from a neurological injury because he would open his eyes, but would never really focus on you. Every time I tried to do anything with him, he would try to kick me away with his feet. He would also grind his teeth and spit up all his oral secretions. He was very restless and would frequently put his legs over the bed rail or he would flip his whole body around, his head facing down at the foot of the bed and his feet at the head of the bed. He was pretty cute, though, so I couldn’t get too frustrated with him. Besides, the Afghan children are much smaller for their age than American children. He was about the size of a 6 or 7 year old, so I was able to reposition him back up in bed easily.

The 12 year old boy was with us because he had gotten his shemagh, a scarf worn by Afghan men either around their neck or around their head, caught in a grain mill. In order to keep from getting sucked into the mill, the boy had to rip his head out of the scarf as it tightened around his throat. This resulted in multiple fractures of his jaw bones, several layers of skin getting ripped off, and two large cuts into his lips. These injuries lead to the swelling of his tongue and airways. When I had him two nights ago, he had to have a breathing tube, called an endotracheal tube, down his nose into his lungs so that he could breath. Tonight, he was breathing on his own, but his mouth and tongue were still extremely swollen so he wasn’t able to swallow his saliva or talk. I had to continuously suction his mouth and, even with the interpreter at the bedside, it was difficult to communicate because the boy would just point and we would have to guess what it was that he needed.

If this child had not been brought in to us, he would have died because his airway would have eventually closed off from the swelling of the injury. But, now, with the help of intravenous steroids and a mechanical form of ventilation, he will be fine. In addition, he would have been extremely disfigured in his face if it were not for the amazing work that our Ear, Nose and Throat surgeon does here. I told this doctor that he should consider going into plastic surgery when he gets back because he does wonderful work!

The two kids actually came from a different area of the country and, now that they were stable, it was time to send them back to the medical facility at the Forward Operating Base in the region where their families live. This would allow for the patients to be closer to their relatives and then be easily discharged back into their community. However, in order to get them back, they had to be packaged up and flown by fixed-wing aircraft.

Normally, a team of U.S. Air Force personnel come and pack up the patients by hooking them up to transport monitors and other equipment and then loading them onto gurneys. This morning, however, no one arrived to start prepping the patients, and when we called to find out if anyone was coming, we were told that there had been a miscommunication and, thus, no one was coming. This meant that we were going to be responsible for getting the patients all ready for the flight and that we would also need to make arrangements with our own ambulance to get the patients out onto the flight line. And oh, by the way, the plane is scheduled for departure at 06:15. It was 5:30 when we were told all of this.

Well, this began a whirlwind of activity. This was a job that was normally the responsibility of a specially designated team that is deployed here specifically to do this part for us. The packaging, the transporting, and the loading of the patients onto to the aircraft was not something I had ever been trained to do. Our Respiratory Therapist tracked down the portable monitors and equipment we needed to monitor the patients during transport. The Officer of the Day, who should have been manning the Quarter Deck (front office) of the hospital, went and brought us gurneys, while the other ICU nurses helped me load my patients onto the gurneys.

The 12 year old boy had not spoken since he had the endotracheal tube removed the previous morning, despite frequent encouragement do so, until we were just about to roll him out the door. He suddenly became wide-eyed and franticly tried to spurt out something that sounded very slurred, as his tongue remained pretty swollen. His family member, probably his grandfather, leaned close over him in an attempt to hear him better. He finally blurted out one clear word and the old man smiled. I had tucked a stuffed bunny rabbit that we had given the boy earlier in the night, down near his feet under the strap that was securing his legs to the gurney. The old man pulled it out and held it up to the boy’s face so he could see. Out of all the things to say at that moment, the boy just wanted to make sure the rabbit was going with him!

Meanwhile, the lead officer from the Tactical Operations Center for the hospital gathered up a group of Corpsmen from the Hospital Ward to drive the ambulance and help load and unload the patients. We wheeled the patients out to the ambulance, hoisted the gurneys up into the back, placing the 12 year old up on the designated gurney shelf in the back of the ambulance and the 10 year was placed on the floor of the ambulance, because normally this ambulance is meant to carry only one patient. These are not ambulances like the nice fancy ones back home. These are military vehicles that have been converted into make-shift ambulances.

I climbed up into the back of the ambulance with the patients and waited while one of the Corpsmen brought me a portable suction machine so that I could ensure the two kids wouldn’t drown in their secretions on the ride out to aircraft. Several people kept yelling that we had to go because the aircraft was running behind schedule. I yelled back that we couldn’t drive off until I had the right equipment to ensure the safety of my patients. Meanwhile, someone threw me a pair of goggles and told me to put them on when I got out to the flight-line, otherwise the jet fuel would burn my eyes. I was handed the suction machine and then the heavy ambulance doors were slammed shut, leaving me in the back of the ambulance, very dimly lit only by the daylight shining through the two small windows in the back. There was no interior lighting like in modern, American ambulances.

The ride out to the aircraft was somewhat bumpy and I was glad to have the suction machine because the younger boy required it’s use a couple of times. After a few minutes, I felt the vehicle change direction and then begin to move backwards until I heard someone yell, “That’s good. That’s good!” It seemed as if the double doors blew open on their own as I suddenly felt something burning my eyes. I remembered the goggles from earlier; they were still on top of head. I quickly pulled them over my eyes just as they were starting to water. Then as I climbed out of the ambulance, the smell hit me hard, that smell that reminded me of my sister’s obsession—jet fuel. Boy would she have loved to just stand out there on that runway this morning and taken in the fumes of the majestic C130!

Then back to reality as several people quickly pulled the two patients out of the ambulance and ran them up the ramp into the bowels of the aircraft. I walked up the ramp, hoping it would be quieter inside than it was outside, but was sadly disappointed. I had to yell my report to the medic who was taking over care of the boys and hope that he at least heard the most important parts. I then knelt down next to the 12 year old and boy, touched his head and smiled at him, hoping to make him feel more comfortable about the trip he was about to take. He seemed to understand everything that was going on and, once the Air Force personnel were done frisking his family member, as he slid in behind me and smiled at the boy, the boy finally smiled back.


Fall In A Far Away Land

I can feel winter encroaching, trying to steal away the last of the desert warmth, bringing darkness earlier and earlier each day. During the day, it is still warm enough that I break out into a sweat when I walk the mile from the NATO Dorms to the Hospital, but as soon as the sun goes down, the chill sets in. People can now be seen donning jackets, caps and even gloves from around 4pm to 10am.

This is one of my favorite times of the year back in the States. I love  the crisp mornings and the colors of the season, especially the bright reds of the maple trees in my yard.  I miss the scent emitted from burn piles as people attempt to rid their lawns of dead leaves and pine-needles. And most of all, I miss planning for Thanksgiving dinner, making green bean casserole with the crunchy onions on top, stuffing and my mother-in-law’s southern-style macaroni-n-cheese and corn pudding.

Now that the cold nights appear to be here to stay, we have been experiencing an influx of burn patients from the local community. As there is limited electricity, especially in the smaller villages, the Afghans use kerosene lanterns and oil stoves to keep their families warm. We have cared for several children that have been burned from kerosene lanterns and, unfortunately, the oil stoves can be very dangerous as the Afghans often attempt to refuel them while they are still burning.

Just this past week we admitted five out of ten family members to the ICU who were burned when the stove exploded while the mother attempted to refill the oil. Dad had 25% burns, mom had 40%, their 10 year old girl had 65%, their 7 year boy had 70% and their 3 year old boy had 40%.  Within less than 12 hours of admission, we had to let the 10 year girl and 7 year boy go. With more than 60% of their bodies burned, their prognosis for any sort of positive outcome was almost non-existent.

In the states, we would have been able to resuscitate those two children and after months of hospitalization and multiple surgeries, they would have been discharge to begin a long and difficult rehabilitation with intense physical therapy and probably more skin grafts. This would be possible in our country with the health care resources we have, but even if we could have kept those children and performed the multiple surgeries they would have required over the next several months, our hospital doesn’t have the rehabilitation resources required to provide the quality of life necessary to survive in this culture. It was a difficult decision for our doctors to make, but after a lengthy discussion among every single doctor in the hospital, the Commanding Officer and the Director of Nursing Services,  the decision to provide comfort care only was made and that is what we did.

I noticed a stark difference in the way that the Afghan parents dealt with the death of their two children compared with how parents in our country deal with death. In our society, we tend to want to remain with our dying loved one not only until the very end, but even for a period of time after they have passed. However, these parents chose to say goodbye to their children early in the night and did not want to see them again after they said their goodbyes. We kept them separate from their two dying children, but pushed the couple close to one another so that they could pray with each other and cry with each other. We also moved their 3 year old son, who did have a positive prognosis, next to the mother so that she could reach out and console him whenever he cried.

The couple went through a roller coaster of emotions through out the next two nights as they remained under our care. Having heard so much about the repression of the Afghan women, I was surprised to see this couple relate in much a similar way as any married couple in the U.S. They seemed to have a mutual respect for each other as they spoke to each other and cried with each other. The woman cried openly while the man tended to cover his face and weep into his blanket, although not always. Even though I could not understand the language, I could decipher that they were reciting prayers to Allah frequently throughout the night as well.

At other times, when they may have been experiencing feelings of denial, they actually spoke in tones reminiscent of a regular day-to-day couples chat. I’m not sure what they were saying, but it seemed pleasant. At one point, the woman was trying to ask me something and after pointing at or holding up every single object in the area, the couple actually started laughing at me because I couldn’t figure out what she was asking. When I finally had the translator come over and help me, he told me that she wanted to get up and sit in a chair. The three of them tried to teach me to say “ksseenawem” which essentially means ”I want to sit up” in Pashto. After laughing at my pronunciation a couple times, I finally got it, but by that time, she no longer wanted to get up. Oh well. At least I tried my best to communicate with them. They were very patient with me and, via pointing and other gestures, we were able to figure most things out.

Then, later in the night, the mother heard one of our other pediatric patients crying on the other side and she suddenly became convinced that it was another one of her eight children. She would not stop crying until we decided to roll the child’s bed over where she could actually see for herself that it was not her son. This then resulted in a long period of prayers from the mother and more tears from the father.

The translator told us that they do not tell them that their children are going to die, when the doctors ask them to like we do with loved ones in the States, because that is not how they prefer to deal with death. They prefer to be told once it is over and, in the meantime, just tell them that their lives are in the hands of Allah to decide what He will. I think there is a much stronger acceptance of death in their culture than in ours as well. These people live a hard life and their society is used to premature deaths from accidents and illness that we otherwise have the means to prevent, fix or cure. The average life expectancy for the Afghans is only 44 years of age. Our life expectancy in the U.S. is 78 years of age, almost double.

Veteran's Day Poppies placed at memorial on the Boardwalk remembering
those who sacrificed their lives while fighting terrorism in Afghanistan

Clif Bars

Clif Bars have become a huge commodity here at KAF. There is one dining facility in South Park, the one that you have to walk more than a mile to get to down an extremely dusty, dirt road. By the time you get there, your legs and clothes are completely covered in dirt.

One windy day, when I got back from eating in South Park, I could actually run my nails across my scalp and tons of dirt came out. It can be pretty disgusting. You have to shower as soon as you get back because you don’t want to drag all the dirt into your room.

Needless to say, Friday and/or Saturday nights are reserved for the long, chalky trek to South Park for American greasy-spoon type food and the coveted Clif Bars. One is only allowed two Clif Bars per visit to the Dining Facility, however, I know of many people the wear the Navy Sweatshirt with the big pocket in front in order to cram in full of Clif Bars until the women look pregant and the men look like they have a beer gut!

Every night at the Hospital, sometime between midnight and 1 am, food is delivered from this Dining Facility to feed the staff that has to work here all night. These dinner left-overs are referred to as Midrats. Occasionally, Clif Bars are delivered along with the take out containers of food. This results in a frenzy of staff members almost climbing over each other to grab their favorite bars from the box. Within the first five minutes of the arrival of the food, there is not one Clif Bar left to be found. People have to beg each other, or trade other desired commodities for these bars.

I remember during, my teenage years in the mountains of Southern Oregon, my father bringing home an experimental health bar that one of his former students had created. The first taste test I recalled involved eating something that looked, and tasted, like bark shavings held together by molasses. Little did I know I was eating something that would eventually evolve into one of the most popular energy bars in existence! I got to be a part of the creation of something that is now lusted after by coalition forces here in Afghanistan! I find that pretty amazing. Thank you Gary Erickson for making the Clif Bar. I eat one every day before I go to the gym for my workout.

And, I just ate one this morning before I ran another 5 K here on base! This time I ran the U.S. Marine Corps 235th Birthday Run, the one in which we ran in memory of a fallen Marine. I am very honored to have run in memory of CPT Trevor Yurista, who died in Afghanistan fighting in Operation Enduring Freedom in Fall of 2008. I believe he was there with me in spirit as I crossed the finish line just as the sun was coming up this morning!

Miracles and Frustrations

Recently, we have had several reporters from various newspapers here at the Role 3, however, we have yet to see many worthwhile articles on what we are doing here. I’m not quite sure if it’s because what we are doing here isn’t news worthy or because it’s not controversial enough. We recently had a soldier who was shot through his lung and, in order to save him, our surgeons spent 5 hours operating on him. They eventually determined that the only way to possibly keep him alive was to remove half of his lung. Amazingly, the patient survived the operation and came to the ICU afterwards. In the ICU, our nurses and doctors spent the next 14-16 hours, carefully monitoring and treating him, keeping him alive and waiting for a team from Germany to arrive with a special heart-lung bypass machine which performs ECMO, or extracorporeal membrane oxygenation. In the past, this device has been primarily used on neonates and children and seldom on adults. During ECMO, the blood is removed from the body and circulated through a machine outside of the body where the blood is re-oxygenated and then is infused back into the body. The blood completely bypasses the heart and lungs.

Here, at KAF, was the first time they have ever brought ECMO into the combat zone, so this case will make the medical history books. And if this patient survives, he will be a miracle. Unfortunately, the article ( says that the team from Germany operated on the patient for 5 hours, when it was really our surgeons who operated on him before the medevac team even arrived. I know that I shouldn’t be upset, because the most important thing is that this soldier will most likely survive. I’m just frustrated because we have yet to have a really good article about what we are doing here despite so many reporters coming through.

I have also been dealing with another frustrating situation, one that is heartbreaking for our unit. I have been caring for a 3 year old Afghan girl for the past few weeks who was injured when her family’s vehicle hit an IED. Not only are coalition troops being injured by the Taliban’s IEDs, but so are innocent civilians. Unfortunately, this little girl suffered not only two fractured legs which now lie flaccid with large external fixators protruding out from her skin, but she suffered brain damage as well. She will occasionally open her eyes, but she does not focus on anything and she only barely lifts her arms in response to stimulation.

Despite this little girl’s poor prognosis for any recovery from her brain injury, we have done everything possible to make sure that she is comfortable and well cared for. Sadly, we had to send her out to the local Mir Weis hospital because there was nothing more we could do for her. We hope that she will receive the care necessary to prevent her death, but they have limited resources and the staff does not have the same work ethic as medical staff in our country (they only show up for work when they feel like it). There, patients are only fed if the family comes in to feed them and the family has to bathe the patients and do the dressing changes as well. The nurses provide very limited care and they do not always have the oxygen and tube feedings available that this little girl will require.

The Role 3 hospital here at KAF is a combat trauma hospital whose main mission is to care for the injured coalition forces. Our admission of these children and all the surgical procedures and nursing care that we provide is purely humanitarian in the hopes of winning the hearts and minds of the people. Which I believe we are doing, even if it is just one Afghan civilian at a time. The parents of these children are very grateful for the care that we provide. One of our translators was telling us that they are glad to have the coalition forces here doing what they are doing because the majority of the people really do want democracy. As more and more civilian casualties are reported daily and more and more children are brought in to our unit, I hope the Afghan people continue to feel that way.

I have signed up for another 5K run. There is at least one a month around here, because there is nothing else to do. This next one is to celebrate the Marine Corps birthday. As part of this run, each person is given the name of a Marine whom has lost his/her life here in Afghanistan since the war has started. I will be running in honor of 1st Lieutenant Trevor Yurista, a 33 year old from Pleasant Valley, NY. Yurista was a ground intelligence officer with the 5th Marine Regiment, 1stMarine Division out of Camp Pendelton, CA. He was killed Oct 27, 2008 by an IED. Just last month, an intelligence compound at Camp Leatherneck here in Afghanistan was dedicated and named after him. I am honored to be running in memory of this Marine.

Navy Birthday

Happy Birthday Navy!

Today we celebrated the 235th birthday of the United States Navy. The U.S. Navy began as the Continental Navy , which the Continental Congress established on October 13, 1775 and consisted of two whole ships which were utilized to search for munitions ships supplying the British Army during the War of Independence. In 1972, Chief of Naval Operations (CNO) Admiral Elmo R. Zumwalt authorized October 13 as the official day of recognition for the Navy’s birthday. Every year since then, the current CNO has ensured that the tradition of celebrating the Navy’s birthday has been carried on.

Part of that tradition involves the cutting of the birthday cake by the most “seasoned” (oldest) member of your unit along with the youngest member of the unit. And, it is also tradition to reveal what year they were born! Our most seasoned member was born in 1949 and our youngest in 1990.

Can you believe they mad such a beautiful cake here at KAF? It was made by the ice cream shop on the Boardwalk! After the cutting and eating of the cake, each department of the hospital gathered together for group photos that will go into a Cruise Book which is like a High School Yearbook and will capture our experience here.

Today we also said goodbye to one of our ICU doctors as he is being moved to one of the Forward Operating Bases. We are really sad to see him go as he has been with us since we all met up for training at Ft. Dix. I know he will do a great job running the ICU where he is going, but he will be missed here at Role 3.


Care Packages and Letters

Moon over hockey at the Boardwalk



I just wanted to say thank you to everyone who has sent me care packages. I have received a lot of wonderful things to make life easier here! Recently, I have especially enjoyed the Halloween decorations from my Bellingham neighborhood. Most of the decorations are currently hanging in the ICU and they look great! I have also received lots of yummy Halloween candy that I have been sharing with my coworkers, making everyone very happy.

I have received a couple packages as well as letters from people involved with the Soldiers’ Angels organization. This organization is a non-profit, volunteer-led organization whose moto is “May no soldier go unloved.” Anyone can adopt a soldier through this organization. Thomas signed me up and I have now been adopted by a young Croatian woman who is working on her graduate degree in Cairo, Egypt. I have also received letters of support and encouragement from several other people associated with Soldiers’ Angels as well as a package directly from the Soldiers’ Angels headquarters and one from a young woman in Michigan. If you are interested in adopting a soldier or finding out more about the organization their website is

Two days ago I received a package from my sister and in it were approximately 30 letters from her 5th and 6th grade students. They arrived on a morning right after we had just packed up three injured American soldiers and sent them on their way to Landstuhl for further surgery and care. The staff was in much need of a pick-me-up when I opened the package and discovered the letters. I started reading one letter after another to two people sitting near me, and the next thing you know, I had a significant gathering of people listening to the letters. Some of questions in the letters indicated a morbid fascination with shooting and death by some of the children, mostly boys, but most of the letters were very entertaining and put a smile on our faces. The most common question among the letters pertained to what I eat or how I eat.

Below are some of the most entertaining quotes from the letters I received:

“Do you miss the taste of gum?”

“Have you flown a jet?”

“When there’s a war do people have to wake up fast? Are some people lazy?”

“How much do they pay you?”

“In what country do you live in outside the arited estate?

“Do you even like your lunch over there?”

“If you know someone is sick, what kind of soup do you make?”

“Your sister looks too pretty to be a teacher but she is.”

“One time when my mom was pregnant before I was born, my brother was born first.”

“My name is Chris, but I’m not the one that gets in trouble all the time.”

“Man, I bet your brave by going over there in the Jungle! Your lucky because maybe you could take some pictures of the jungle!”

“How is it in Afghanistan? I have heard that it has been a pretty chaotic war. Do you like Taylor Lautner?” (Taylor Lautner plays Jacob in the Twilight vampire movies, for those who don’t know.)

“Is the nurse thing huge or small and do you guys have a soda machine?”

“Do you think you would ever come here. It will be fun. I will sit up in front. I will help you out.”

“I hope you like this letter.”

Thank you, Jessica, for having your students write those letters. My co-workers and I have thoroughly enjoyed reading them several times over and they have put many smiles on many faces.