Cars, cars, cars

I once came across a blog entry describing the 50 steps required to obtain a Zambian Driver’s License. They weren’t kidding!  When I first read the blog entry, it struck a funny bone because I knew that it was quite possible that such a straightforward, mundane activity could become such a huge ordeal in Africa.  I realize that for a Zambian with all the time in the world, this might not be such an unusual process.  However, for someone who is busy, has a full time job, and is so dependent upon others to get anything accomplished while getting settled in a foreign land, it has turned out to be an incredibly frustrating and bewildering process.  From going to get our health exam, then going to one RTSA (Road Transport and Safety Agency) office, standing in lines, being told to go to another window, then standing in more lines, then going to another office…to being told that we need one form or another document or that we are too late for the practical driving test and that we need to return tomorrow…it has been quite the ordeal.  There are never clear instructions as to what steps need to be done in what order, what offices need what documents, how much to pay when or what the rules of the game are.  We actually had the assistance of a local who guided us through the whole process, but even then it was difficult.  And it wasn’t free.  Imagine if we had attempted to undergo this process alone!  I don’t think we would have survived. 

Nonetheless, we were able to jump the final hurdle this week.  Both Paul and I underwent our practical driving test under the scrutiny of the RTSA examiner.  One tip that was given to me just before we started off was, “Don’t cross your hands on the steering wheel while making a turn.”  It is a strange rule they have here in Zambia, but I succeeded in driving like a granny during those short 7 minutes on the streets of Lusaka.  It’s quite awkward…harder than it seems (you should try it sometime!).  After all was said and done, Paul and I both got a “Pass!”  =)  We even obtained our Temporary License, so in 2 weeks we should have the actual License in our hot little hands. 

Timing has been good, since we were told that our new car had arrived at the dealership this week (we had ordered it 2 months ago, but it had to be built in South Africa).  So just after our driver’s test, we were able to go to the local Toyota dealership and pick up the vehicle.  To tell you the truth, it nearly emptied out our U.S. bank account.  But since our commitment here is for 6 years, we wanted to have a reliable, sturdy vehicle suited for the African terrain which would also have a good resale value.  She is a beauty.  We look forward to many trips and adventures exploring Southern Africa in this strong but sleek 4x4.  

Hakuna Matata

After two days of traveling, we have finally arrived back home in Zambia.  It still feels a bit awkward to call Lusaka “home,” but it really does feel nice to be home.  Our week in Zanzibar, a beautiful island off of Tanzania, was both refreshing and therapeutic.  After 4 months of battling major stressors like picking up and moving to a different country as well as encountering countless frustrations in struggling to understand a culture opposite from one’s own, we decided we needed a quick get-away to relax and calm our minds.  And this was quite the get-away.
We stayed at a beautiful hotel sitting along the northern coast of the island (Nungwi).   

The white sand beaches and crashing waves created an idyllic scene as we soaked in the infinity pool, relaxed beneath the umbrellas, and ate breakfast from the beachfront restaurant overlooking the Indian Ocean.  

With 98% of the population being Muslim, most people dressed their part in conservative yet colorful clothing despite the sunny beach atmosphere.  

The sing-song chants of the frequent prayers were heard throughout the day.  The locals spoke Swahili, so the common phrases “Jambo” (hello) and “Hakuna Matata” (no worries) were often flung our way.  Tourism, fishing, and spice farming seem to be major industries on the island, and the women would daily walk to the shore with big buckets, hoping the fishermen would come back from a good catch with thousands of tiny silver fish.  When the tide was out, the women would wade into the water with their full garb.  

Children would play their part in helping contribute to the daily earnings. 

Stonetown was an interesting place, with a lively mixture of outdoor markets, mosques, artwork, and shops.  

We saw many different shapes and designs for doors.  Many had spikes protruding from them, which were intended to thwart off elephants.

The narrow roads were frequented by bicycles and scooters zooming past the pedestrians.  

Although Zanzibar is mostly Muslim, it’s a very peaceful place, and the Christian church seemed to coexist just fine next to the mosque.

The highlight of our trip was the opportunity we had to learn to SCUBA dive.  We ventured out into the hotel pool, then out into the open sea to learn the basics of diving down to the depth of 50 feet.  What a thrill it was to learn to breathe underwater, to feel weightless and neutrally buoyant in the Indian Ocean, and to admire the whole new world of sea vegetation and God’s wonderful ocean creatures on our exhilarating open water dives.  Now that we’re PADI-certified for open water diving, we hope to get more opportunities to explore the underwater world throughout the world.  Hopefully by then we’ll have an underwater camera.

Another highlight was meeting Conchester, a local masseuse, who induldged us with an hour long massage session each day for 4 consecutive days.  I also enjoyed reading some books from the Reading Room.  We certainly got our R&R this holiday season.  

Now back to reality.

December update

The last few weeks have been a blur of activity.  Here’s are a few snippets of what our lives have been like in the last 2 weeks:

1.    I’ve had some variety of viral sickness that has migrated from one part of the body to another – causing a sore throat, generalized malaise, then a runny nose (but, strangely, only the right nostril), then a congested eustachian tube (I’ve suffered from decreased hearing out of the right ear for the last two weeks), a week of loose stool, back to a sore throat, then nasal congestion.  I’m almost back to normal, but I still can’t hear properly! 

2.   My role has changed suddenly and dramatically at the Lusaka Eye Hospital.  As of November 29^th, I’ve officially been named the Medical Director and Administrator of the Lusaka Eye Hospital.  This has meant that all of a sudden I am in the position to make important decisions for the running of the institution and managing the 42 employees on payroll.  Although I feel inadequate for this position, I know it is not by chance that all of these changes have occurred.  I just hope and pray that I will be able to help lead this hospital in the right direction (and hopefully out of the red). 

3.   Dr. Mumba has left Lusaka Eye Hospital for greener pastures.  He’s served as the ophthalmologist here for the past 3 years, and we appreciated his years of service.  We bid farewell to him with a simple party and cake.

 

4.   LEH’s 10^th Anniversary.  November 2011 marked the 10^th anniversary of the Hospital’s birth.  We had a celebration and ceremony, characterized by a PA system that wasn’t functioning properly, a tacky blue and white tent, and many awkward moments on stage.  Nonetheless, it was a happy occasion to celebrate the decade of eye care service this hospital has contributed to the people of Zambia.

5.   By virtue of my appointment to a position of leadership at my Eye Hospital, I was at the last minute invited to attend Zambia’s National Prevention of Blindness Committee Strategic Planning meeting.  So for three full days I sat in meetings with about 10 ophthalmologists (mind you, there are only 22 ophthalmologists in the whole country) visioning, discussing, and planning the strategic national plan for eye care in Zambia for the next 4 years.  It was a blessing to be able to take part in such a committee and to get a better understanding of the “big picture” in terms of eye care for the country. 

6.   Two weeks ago, we had a chance to visit Riverside Farm Institute for the 3^rd time since we arrived in Zambia.  RFI is a self-supporting institution that has a farm, a mill, a school, and a wellness center.  It’s a beautiful area, about 1 hour’s drive from Lusaka, and it’s always nice to hang out and hike with fellow Americans. 

7.   Last week, we had some visitors from the Eastern Province – Dr. Verna Peduche and her husband, Gem, who are missionaries out at Mwami Adventist Hospital.  It was a historic few days, as they were our first set of visitors here in Zambia.  Now that they’ve warmed up the house, we’re now open to more!!!  If anyone wants to visit Zambia, you know where to stay!

8.   We finally bought a car!  For the last 4 months that we’ve been here in Zambia, we’ve had to rely heavily upon others for our mere survival.  Getting to work, coming back to work, going to church, running errands, and buying groceries all involved calling up a driver or begging for a ride.  But as of 2 days ago, we have our own set of wheels!  How liberating it felt to be able to get behind the wheel of a car and drive ourselves to buy groceries!  We even treated ourselves to an Indian restaurant for lunch.  Mind you, the car is old (1996ish Toyota Corolla Saloon), tan, and small, but it will suffice for now.  At least until we get our 4x4 truck. 

9.   We almost fired our helper.  We found that our levels of sugar were being depleted quickly.  Our cooking oil was running low at an abnormally fast rate.  The shampoo we had left in our guest bathroom was newly purchased, but we found that it was almost 1/3 empty.  Our laundry detergent was half empty, and we had only done 2 loads of laundry.  Our dishwashing soap and other floor cleaners were disappearing quickly.  And there were at least 2 rolls of toilet paper missing.  At first, we assumed she was simply being careless and using the supplies without discretion.  But then our suspicions were aroused, and we confronted her.  In fact, we nearly fired her that same day.  But she pleaded for a second chance, so we agreed to keep her on the grounds that she does not take or use any of our supplies or food.  Talking to other locals who have maids, this behavior seems to be the norm rather than the exception.  But what do you do when these lovely people need a job and food so desperately?  We decided to give her a little additional money to purchase food and discourage her from taking our food/supplies.  Hopefully, she has gotten the message and we won't have to fire her after all.  

10. Our garden is slowly growing.  We’ve only eaten spinach from the garden so far, but hopefully the eggplant and other veggies will start to produce soon. 

So that’s it for updates thus far. 

By the way, if anyone feels compelled to send us a Christmas card from the U.S., our address is:

Janie & Paul Yoo

Lusaka Eye Hospital
Post Net Box 674. Private Bag E891
Lusaka. Zambia 10101                 

The mail might take a month or so, but it’ll probably eventually get here.  Unfortunately, we won’t be sending out Christmas cards this year from Zambia. I hope you’ll forgive us! =) 

Happy Holidays!!! 

Evisceration + Enucleation

Two weeks ago, a lady came in with a horrible looking corneal ulcer of the right eye.  It was large, necrotic, and causing a great deal of pain.  Her vision was light perceptions only.   

Her left eye was fine.  I started her on frequent antibiotic eye drops, but told her she would likely need a tectonic graft in the near future.  I saw her again last week; the nasty redundant necrotic tissue had cleared slightly, and now I could see that there was a large desmetocele centrally with iris poking forward.  But I had a dilemma.  The only corneal trephines I have are one size (8.5 mm for the donor, 8.0 mm for the host cornea).  I have been attempting to order other sizes from India, but they have been slow in coming.  This lady needed a limbus-to-limbus transplant in order to make this tectonic graft work.  Her ulcer was just way too large.  I told her to come back in 3 days while I tried to find a large trephine. 

Apparently, I was too optimistic about how long the desmetocele would hold.  The next morning, she presented stating that last night she felt a “gush of fluid” and felt like “there was a hole in the eye.”  I knew immediately that she did indeed have a hole in the eye.  And I realized that I did not have the technology or resources to fix her.  I explained to her the imminent need for an evisceration (scooping out the contents of an eyeball), and we proceeded to the operating theatre.  

I haven’t done an evisceration since my residency days, so I felt a little rusty, but the surgery itself went smoothly.  Unfortunately, we don’t have orbital implants available at our facility, so I had to leave the scleral shell empty.  Nonetheless, closure was straightforward and hemostasis was obtained with time and pressure.  

That same day, we also did an enucleation on a poor little 2 year old child with leukocoria of the right eye.   

The week prior, we had performed an exam under anesthesia and determined that she had a large intraocular tumor very suspicious for retinoblastoma.  I had the honors of cutting the optic nerve.  

 

This globe will be sent to pathology at the University Teaching Hospital in Lusaka, and we will be able to determine whether or not it is retinoblastoma. 

This is probably the driest orbit I have ever seen in an enucleation.  Fortunately, we were able to find a single orbital implant...the only one in the hospital.  But it was a size 20.  It seemed far too big for this young patient, but fortunately for this orbit, it fit perfectly!  

Last week on Monday, I did another glycerol corneal transplant on a patient with another horrible corneal ulcer/desmetocele.

 Although we still don’t have all the supplies that we need (corneal block and trephines are currently on their way from India) and I have to punch the tissue on an eye shield, at least the eye looked intact postoperatively.   

And on postoperative week #1 she was already counting fingers at 1 meter!  Unlike the first patient, she avoided an evisceration,...at least for the time being. 

Random snapshots

For those non-medical readers who do not enjoy my persistent ophthalmology blog entries, here are a few random photos.  

With a few staff members and their family at our recent retreat to Siavonga.

A visit to the crocodile farm

Lounging, mouths wide open

"Downtown Siavonga"

Back at home, hang-drying at its best

Glycerol: a much-appreciated medium

Case #1

It was a Wednesday about 2 weeks ago when a 71-year-old male presented to me complaining of decreased vision in the left eye for 1 month.  His wife stated he had suffered a “stroke” about 2 months earlier.  He then developed pain and blurred vision in the left eye. 

His chart stated his vision was “NLP,” or no light perception in that eye.  However, upon rechecking his visual acuity, I determined that he did have some light perception after all.  He was unable to close his left eye at all, and his left face drooped, confirming my suspicion of a 7^th nerve palsy.  A large, ~5x5 mm desmetocele flaunted itself prominently and precariously on the inferonasal cornea.  The anterior chamber was flat, and the iris was adherent to the cornea, making a nice solid seal to the then-perforation.  He also had a typical Zambian dense cataract.  

Although the eye was not leaking now, the extremely thinned protrusion in his cornea made me quite uncomfortable, so I decided to perform a tectonic corneal graft the very next day, utilizing glycerol-preserved corneal tissue provided by Global Sight Network, a humanitarian branch of the Alabama Eye Bank.  My tissue was from a 56-year-old who died in 2009 from anoxic brain injury; the glycerol preservation method gave it a shelf life of 5 years, making it suitable for urgent situations such as these. Ideally I would have wanted a slightly smaller graft, but I chose an 8.5 mm trephine...because that's the only size I have here in Africa.

The surgery was not like a straightforward PKP.  It was a combined procedure – much like I had grown accustomed to at Massachusetts Eye & Ear Infirmary – a corneal graft, sphincterectomy to open the tiny pupil, open sky extracapsular cataract extraction, intraocular lens placement, and temporary tarsorrhaphy.  

Postoperatively, his cornea was hazy (expected for this glycerol-preserved cornea), but his eye was intact and no longer at high risk for perforation.  At least upon checking him on postoperative day #1, he was already counting fingers at 1 foot. 

Case #2

A similar situation happened just 10 days before this in which a 61-year-old female presented with a horrible corneal ulcer with perforation, flat anterior chamber, and light perception vision.  The referring ophthalmologist had attempted to provide tectonic stability with a scleral patch graft and tarsorrhaphy but sent the patient to me when this did not provide an adequate solution.  

In order to stabilize the globe, I elected to perform a tectonic corneal transplant with the glycerol-preserved corneal tissue.  I emphasized that this was not for vision, but rather for stability of the globe.  Her iris was completely scarred to the cornea and cataractous lens, making it impossible to remove the cornea without also removing the iris and lens.  I elected to leave the patient aphakic, so after a limited anterior vitrectomy I simply sewed on the cornea.  This was my very first experience with the glycerol cornea.  It was much firmer, whiter, and more edematous than normal Optisol-preserved tissue.  After struggling with the initial suture and bending the first 10-0 nylon needle, I quickly learned how to handle this thicker donor tissue. 

By postoperative week #1, I was surprised to see that the cornea was clearing a bit.  I had a hazy view into the anterior chamber and surrounding structures.  The epithelial defect was closing in with a triangular shape centrally.  And the patient was counting fingers at 1 meter!  

Case #3

Exactly one week ago while I was in the operating theatre, a clinical officer (C.O.) popped his head into the room.  “Doc, there’s a corneal laceration that might need a patch graft or something.” 

“Can’t we just put a few sutures in?  Or does it really need a graft?” 

He hesitated, “Uh, there might be too much astigmatism with just sutures.”

“Bring him in, let’s take a look,” I replied. 

Sure enough, there was a crescent-shaped area of peripheral cornea inferotemporally with about 90% thinning.  Iris was right up to the wound.  The accident had occurred almost 1 week prior, so the perforation had sealed on its own.  But the area of corneal instability was too big for primary closure.  The C.O. was right. 

We talked about the various options.  A conjunctival advancement would afford no stability for this defect.  A scleral patch graft could work, but we’d have to painstakingly harvest it from the patient’s perfectly healthy scleral tissue.  In the end, I decided to perform a patch graft with a glycerol cornea.

I eyeballed the size of the defect.  It needed to be roughly crescent shaped, maybe 5 x 1.5 mm.  I asked the nurse for some heavy scissors to cut the tissue, which she didn’t have.  I opted for the #15 blade.  These versatile, disposable, razor-sharp blades cut precisely, but my only complaint was the resultant triangular edge rather than the smooth curved shape.  Nonetheless, it worked like a charm.  A crescent blade was then used to create an anterior lamellar dissection in my triangular/crescent shaped patch graft.  Nine 10-0 nylon interrupted sutures did the trick. Finally, a small paracentesis was placed, and LR effectively inflated the anterior chamber with no leakage from the wound.  Success.

Today the patient returned for his one week visit.  He was happy!  His vision after the accident was counting fingers, but one week after his graft his vision had returned to 6/18!  The epithelial defect in the graft has resolved, and all the sutures are intact.  We’ll have to remove these sutures in the future when things are better healed. 

These glycerol corneas are pretty amazing.  Their shelf life of 5 years makes them so easy to transport and store.  I have come to appreciate these tissues greatly in my first operative month in Zambia.  Thank goodness for glycerol.  And thank you, Global Sight Network!

Outreach

Today's dental and eye screening at Woodlands.

This is Africa

Last Thursday as I was operating, I went to stick my empty syringe into a small cup of Lactate Ringers (LR) solution so that I could fill it up in order to repressurize an eyeball.  But as my gloved hand was hovering over the fluid, my eye caught a glimpse of a small black critter with 8 legs swimming frantically in the cup.  Inadvertantly, I let out a yelp.  I admit: I have arachnophobia.  The other surgeons peered over from their microscopes and chuckled softly as they saw what caused my distress.  As the theatre nurse hurried over to remove the spider-flavored LR from my sterile tray, she smiled and stated, “This is Africa.”  

Later that same day, I saw a patient in clinic whom my colleague referred to me for a corneal problem.  He was a young, 20-year-old male who had an obvious corneal problem.  As he closed his eye, I saw a prominent bulge from under his right eyelid.  

And when he opened his eye, a big ball of white and gray seemed to jump out at me like a costumed mummy from a Halloween haunted house coffin.  He had apparently had a bad corneal infection, likely a fungal ulcer, about 2 years ago.  And his eye went on to develop this horribly large anterior staphyloma involving the entire cornea.

This is Africa.

When I see corneal processes this advanced and this horrific, I can’t help but think to myself: “Why does it get to this point in Africa?  Lack of appropriate eye care?  Lack of funds?  Lack of resources?  Is it even fair that in the U.S. we have such wonderful access to world-class research, beautiful hospitals, cutting-edge technology, and efficacious medications while much of the rest of the world does not even have access to basic eye care?” 

This is Africa, indeed.

p.s. For the ophthalmologists reading this blog, any suggestions on how to proceed/treat this case would be appreciated.

Numb Thumb

It didn’t occur to me until the end of the day on Tuesday.  My left thumb felt numb!  I reviewed the events of the day, trying to put my finger on why this sensation persisted.  Then I realized the answer to my question rested in 5 letters: Simco. 

In the United States, we generally use an ultrasound machine called a phacoemulsifier when performing cataract surgery.  As a resident, this was my bread and butter surgery.  One that I took joy in learning and performing.  It was the standard of care for treating cataracts.  The corneal entry wound was 3 mm or smaller, and the results of this surgery were fantastic.

Enter: Zambia.  Here, the patients are different.  The standard of care is different.  The cataracts are much more advanced and complex.  For cataract surgery, we routinely perform “small incision cataract surgery (SICS).”  This is a manual technique in which a 6 mm self-sealing incision is fashioned in such a way that a suture is not necessary to close the wound.  Instead of an ultrasound probe breaking up the cataract within the eye, the entire lens is milked out in a single piece.  Afterwards, a small “Simco” needle is attached to a lactate ringer’s bag and a 10 cc syringe allowing for aspiration of the remaining cortical lens matter before a new artificial lens is placed in the eye.

During all of residency, I only performed 6 such operations.  And these were done in Bolivia, not in the U.S.  However, I am happy to report that I have already done 8 SICS during the last few days.  I am not yet the fastest surgeon, as there is a bit of a learning curve for this technique. Also, they were not all straightforward cases.  The most typical story went as follows: “50- or 60-something year old farmer from such-and-such village who has been blind in both eyes for a few years, light perceptions or hand motions vision in both eyes, with completely dense white or brunescent cataracts.”  Dozens of these patients had been brought to our eye hospital throughout the week as a special outreach effort through an organization called SightSavers in celebration of World Sight Day. What a blessing it was to partake in helping these poor souls see.  And thank God that all our patients are doing well.  Nonetheless, the aspiration syringe action has taken a toll on my poor left thumb.  It still feels numb. 

She's a keeper

Great news!  We have received word that our work permits have finally been approved.  After 5 weeks of waiting for these government workers at the Immigration office to process the paperwork at a pace comparable to that of a snail, we can see the end in sight!  Who knows when the official documentation will actually be ready, but once we have them in our hot little hands our container can receive the authorization to be shipped from the U.S.  We are told we can expect it to arrive in Zambia 3 months after it leaves the U.S. port (hopefully by January 2012).  What a blessing it will be to receive our beloved container; living out of a suitcase is getting old. 

A new recent development also includes the hiring of two employees to our home.  It seems that wherever we go, people are constantly asking us if we have a job for them or if we have need for a maid.  While Americans are lamenting the high unemployment rate of 9%, Zambia is also facing a crisis with an unemployment rate that is significantly higher.  So it seems everyone is trying to seek a stable job. 

We agreed to hire a maid. Not necessarily because we absolutely need help in the home.  More so to contribute to the Zambian economy.  Regina is a petite, young mother of three.  She was referred to us by our gardener, who grew up with Regina and knew she was in need of a job.  Previously she had been employed by a Lebanese family of seven.  She was not happy with that job because her hours were long (12 hours a day, 6 days a week), her wages were low (~$2/day), she had a lot to clean (the house was big), she had to wash a lot of clothes (for seven people), and she had many mouths to cook for. We told her we’d start her at almost $3/day, working 8 hours a day, 4.5 days a week.  Then, if she proved to be reliable and hard-working we could increase her wages.  At least there are only 2 of us to cook/clean/wash for.  Today was her first day on the job.  It was clear she was a professional cleaner.  She's definitely a keeper.  Hopefully, she can grow to become a part of our family.  

 

The other individual we hired was our gardener.  Triwell is already employed by our landlord to keep our grounds around our house.  He asked for $1/day to build and upkeep our garden; this will supplement his salary.  Hopefully once our garden gets up and running, we’ll have our own organic fruits and vegetables.  Can’t wait!