Kruger National Park

Angie and I had a weekend away! We went to Kruger National Park in South Africa her first weekend here (Aug 29-31). We left Swaziland early on Friday morning (Jono offered to see the post-ops) and drove North. The park was only about a 2.5 hour drive from Siteki. We got  our passports stamped and crossed the border. I can only be in Swaziland for 30 days at a time, so I have to cross the border every few weeks. It was good to get my passport stamped so my 30 day period started over.



Border crossing between Swaziland and South Africa.

We had a few adventures throughout the trip. Shortly after we crossed the border into South Africa, we got pulled over by the police. The cop came over and asked for my driver's license. I handed it over. Then he told us we needed to pay 500 Rand ($50) for having a cracked windshield. (Indeed, the windshield was cracked but it was a tiny crack). Anyway, we went around and around and we asked him if it was really an offense to have a cracked windshield. We also made the point that if we paid the fine, how were we to know that we wouldn't get pulled over multiple more times for the same offense. The cop didn't speak great English, and the language barrier made it even more difficult. I even made a fake phone call to Jono (no reception on my Swazi phone) to ask if it was truly an offense to have a cracked windshield.

The cop was not budging. He then asked for my International Driver's License. Thank goodness Angie had our guide book that stated that driving in South Africa is legal if you have a valid Driver's License with a photo from your home country. So we showed him the book, and he dropped the topic.

He went back to the topic of the cracked windshield. I asked him to show me the book where it is considered an offense. He brings back this huge book and can't find the cracked windshield section, I guess.

After about twenty minutes of this, he just tells us to go on. We gave him some American fruit snacks and a granola bar and got on our way.

I really was not trying to get out of something that was truly an offense, it just seemed suspicious to us. He was telling us an arbitrary number ($50) and had no actual "ticket" to fill out for the offense. Jono had warned me this could happen (much more common in Mozambique than in South Africa), so we were prepared and knew how to handle the situation.

We finally made it to Kruger at about 10 a.m. We spent the first day driving around the park on our own and saw lots of amazing animals: black rhino, white rhino, hippos, elephants galore, an ostrich, zebra, giraffe, warthogs.  It was so incredible!

That night we stayed in Komatipoort which is just outside of the park. We stayed in a lovely little Bed & Breakfast. They had arranged a safari for us the next morning at 5:30 a.m. We went with a great guide named Jean. We were also joined by an Italian family and a German family.

Within our first thirty minutes in the park we saw all of the cats: two cheetahs, two leopards, and a pride of lions. It is really rare to see all of the cats because some of them are rare (only 120 cheetahs in the park), and the park is 414 km in length! It is hard to grasp the size of the park, it is huge.

Here are some of our favorite photos from the day:

White rhinoceros. They are actively being poached in Kruger Park, despite heavy security measures. The tusk is the only part of the rhino the poachers desire. They grind the tusk into dust and illegally smuggle it out of the country to Asia, where it is considered to be useful medicinally.

 

 

 

 

Hitching a ride on the back of a hippo :-)

 

Cheetahs. They are not many in the park and it can be difficult see one. We felt very lucky!

 

Violet breasted roller

It was a very early and very cold morning in Africa. I never thought I could be so cold in Africa!

Hippo in mid-yawn

 

The Cape buffalo. This is the male (bull).

Lioness just after making a kill. The poor impala! After this, she took it back and hid it in the brush, and soon she led her two little cubs back to eat.

 

 

 

King of the Jungle

 

African elephants. Mama and baby.

African leopard

Hyena
 

 

 

 

 

 

This one is for my dear sister

Kingfisher

 

 

After a long drive, we finally made it to our B & B...and celebrated with a glass of wine!

 

Our accommodations in Komatipoort (near Kruger)

Clinic and surgery days with Angie

I am playing catch-up from blog posts from last week, so I am post-dating this entry.  Angie and I are currently in Cape Town, South Africa for a bit of sightseeing and also to meet with Dr. Colin Cook. He is a good friend and mentor to Dr. Pons.

At any rate, last week's clinics were very busy! On Tuesday we were in Manzini, Wednesday at Good Shepherd in Siteki, and Thursday was surgery day in Siteki!

Angie was also overwhelmed by the pathology here in Swaziland.



Conjunctival lesion in 20-something male. Looks slightly atypical, so we asked him to get tested for HIV and we will do an excisional biopsy next week.

Same patient as above, side view



Classic eye injury: Metallic foreign body in the cornea
Public service announcement: Please wear safety goggles/glasses!



Congenital nasolacrimal duct obstruction (bilateral). The child is about 6 years old and has had tearing and "whitish discharge" from the corners of her eyes for her entire life! This is a very common problem in babies, which usually will resolve spontaneously in the first year of life. If not, we do a probe and balloon or stent of the lacrimal system, which usually corrects the problem. Luckily, we have the tools to do this! Dr. Pons and a visiting pediatric ophthalmologist from the U.S. will do the procedure next Monday.

Eyelid cyst in a young girl



Corneal blood staining in a 6 year old child who recently sustained a traumatic blunt injury to the right eye. He had an eight-ball hyphema, which eventually led to the corneal blood staining. He has a large RAPD on the right, so visual prognosis is very poor for the right eye.
 

Vernal keratoconjunctivitis in a teen male.

 

Central corneal opacity (ulcer) in a man in his mid-thirties  (in this photo it is yellow because the photo was taken after instillation of fluorescein). Unfortunately, it is bilateral in this patient. We do not have the ability to do corneal cultures here in Swaziland, so the working diagnosis is bilateral fungal keratitis. He has been treated with antifungals, and has not had much improvement. Fungal keratitis is typically very difficult to treat and often these patients require eventual corneal transplant.

Clinic in Manzini



Learning from Dr. Pons (in background)



Angie and me tag-teaming in clinic

Doing cataract surgery at Good Shepherd, while Jono watches on

Cataract surgery (manual small incision cataract surgery or MSICS) is finished and without any complications!



Angie doing a pterygium excision with conjunctival autograft while I assist her



Angie assisting me while I remove the pterygium on the second eye

Removing the head of the pterygium from the cornea with a crescent blade.

We did a bilateral pterygium excision with bilateral conjunctival autografts....it was perfect: Angie did one side, I did the other!

Jono inspecting (and approving of!) our handiwork

Angie and Sister Senani preparing an intravitreal ganciclovir injection (to treat CMV retinitis)

The OR scene: Angie preparing the injection in the left corner and Jono operating on the right
 

Angie giving an intravitreal ganciclovir injection for CMV retinitis. The patient has already lost all vision in the right eye (no light perception) from previous CMV retinitis. I have blurred the face for privacy purposes.

Angie doing panretinal photocoagulation (PRP or "laser") for proliferative diabetic retinopathy.

 

We stopped for a snack of grilled corn on the cob on the way home.

One final story: on our way to Manzini on Tuesday as we were reaching the city limit, we noticed there was a police stop. No sooner had I told Angie that Jono had related to me that we were unlikely to be pulled over (obviously expatriates in Swaziland), when the cop motioned me to pull over. He approached the car and asked for my driver's license, which I gave to him. He looked at it and handed it back. He then walked around the car to the passenger side...Angie and I were CERTAIN that we were going to be in trouble (yet again) for the crack in the windshield. The cop said to us, "When you get back to Siteki, you need to do one thing."  We listened intently, waiting for the fine. He said, "You must wash your car! It is so dusty!" And then he gave a huge laugh. I told him I had been wanting to wash the car for the past five days (it got very dusty in Kruger Park), but hadn't been out of work before 5 or 6 p.m. any night, by which time the sun was setting. He was SO nice, but Angie, myself, and the medical student, Charlotte, got a huge laugh out of it too. I am sure he just wanted to find some reason to pull me over to check my license and to make sure I was legal. But it was pretty funny after our not-so-fun experience with the cop in South Africa (more on that in a future post).



Dirty Swazi car.

Umhlanga (Reed Dance)

This past Monday it was a national holiday: Umhlanga, or Reed Dance. It is a Swazi (and Zulu) cultural event that occurs at the end of August or early September every year on a date set by the King. It is held in Ludzidzini (near Mbabane), and about 80,000 female Swazi virgins dance for the King. It started in the 1940s, and the tradition continues today.

I asked Jono if Angie and I should attend, or if we should stay in Kruger Park an extra day. Jono said, "You musn't miss it!" He and Helen also suggested that Angie and I dress up in Swazi attire. Helen even went so far as to suggest that one of her housekeepers, Mpumie, leave work for an hour (paid) and go into Siteki and help me pick out outfits for me and Angie!

Mpumie helped me pick out some fun Swazi attire and then she washed, dried, folded, and ironed our outfits because she stated, "I want you girls to look beautiful!"  She and Mavis (the head housekeeper) came by my apartment early on Monday morning (Sept 1) to dress me and Angie.



With Mavis and Mpumie




Swazi attire for the Reed Dance

We had a great time, and they enjoyed every minute of it too. Angie and I were then on our approximately 2 hour trek toward one of the royal residences. When we neared the site, we weren't exactly sure where to go. There was a very sophisticated looking your Swazi woman walking in the direction of the dance. So we asked her if we were on the correct route. She offered to direct us, so we gave her a ride. It turns out she works for the Swazi Board of Tourism. She was really sweet and gave us great directions.

Angie and I were a huge hit at the Reed Dance. Swazi people kept coming up to us and asking us for our photo! We were even interviewed by a Swazi newspaper.

Jono had told me that the ceremony is said to start at 1:00p.m., but usually doesn't get started until the very late afternoon. When the spectator stands opened at 1:30, I thought to myself, "Boy, Jono sure doesn't know what he is talking about!". And then, Angie and I waited, and waited, and waited some more. Finally at nearly FIVE in the evening, His Majesty King Mswati III and the Queen Mother arrived. I guess Jono was right after all.

The crowd roared when the King arrived. Swazis are very proud of their monarchy.

When the King was seated in his chair in the stands, Angie and I went over to take a photo. After I took his photo, he looked over, smiled, and waved at me. Angie and I thought that was hilarious.

King Mswati III

Second from left: Prime Minister of Swaziland (appointed by the King--he is not an elected official), King Mswatii III, and the Queen Mother all watching the Reed Dance.

Next, the girls paraded across the field (probably about the size of a football field in America) so he could see each girl/woman. The women are notably topless. All of them. I guess a woman's breasts are not a big deal here (and men prefer hips and thighs). So yes, there were 80,000 topless Swazi virgins dancing in front of the king. After they have all danced past him, he comes down from his "perch" and parades through the field of females to assess each girl. If he finds one he likes, he may choose her as his next wife (he currently has about 12 wives). You'll be interested to know that, although he chose a wife last year, he did not choose a wife this year!



HRH Princess Sikhanyiso dancing

Swazi princesses (with the red feathers in their hair) dancing for the King



Swazi virgins dancing for the King
 



There were over 80,000 Swazi virgins dancing

With two guys dressed in Zulu attire





Angie and I ran into the Minister of Health and the Minister of Tourism. I am supposed to meet with the Minister of Health in the next two weeks, so we can discuss eye care in Swaziland.
 

After the event was over, we headed back to Siteki via Manzini. It was dark out and we were tired and hungry. So, when we reached Manzini, we decided we had better stop and get food. We eventually got headed the wrong way down a one-way street. We both said, "Thank goodness it is dark and we are in Manzini and no one knows us!".
We ate at Nando's which is a South African fastfood chain that I had always wanted to try. It was tasty, and we were in much better spirits after some food.

Fast forward to clinic on Wednesday of this week. We were talking to Sister Senani about how we went to the Reed Dance two days prior. She gets this funny look on her face and in her monotone, very dry way says, "I heard that you girls were driving the wrong way down a one way street the other evening". (I figured she was referring to the quick "illegal" right hand turn we make on our drive to work in Siteki). She shook her head and said, "My friend saw you in Manzini (remember that is a much larger town and over 1 hour away by car) and he said that he saw Jono's car with two white females in the front seat." She said, "Yes, he saw you going the wrong way on a one-way street...and you guys were going to eat at Nando's." I was so embarrassed, although it was an honest mistake. Angie and I shared a knowing look...news travels fast in Swaziland!

Beautiful Nina

Angie and I went to round on our little girl with retinoblastoma this morning. We walked into the ward, and her bed was empty. (Bad sign #1.) We asked the morning nurse where the child was and she gave us a blank stare. (Bad sign #2.) She then gave a look of recognition and said the child had passed away at 10:30pm the night before (the day Angie and I admitted her). Apparently she started seizing and her respirations became very labored. They did call in the on-call doctor who tried to save her. It was just her time, the disease was far too advanced. 

I am devastated by the news.

"No child should die in the dawn of life."

As most of you have probably gathered by now, my friend Angie is visiting me from the United States. She and I completed our ophthalmology residency together in June. She is a dear friend and is also interested in international ophthalmology. She decided to come visit Swaziland for awhile to help out in the clinics. Dr. Pons is very grateful for her help!

Today we had another busy clinic. Angie was also impressed by the pathology here, and we were diagnosing things we have only encountered before in textbooks. As she said, it is very humbling to work here and you realize that, despite an amazing education in ophthalmology at the University of Iowa, there are still many things we haven't seen/don't know.

We diagnosed:

- CMV retinitis

- Ophthalmia neonatorum (gonococcal conjunctivitis in a 3 week old baby)

- Many squamous cell carcinomas

- Molluscum contagiosum in an older male (usually seen in children, but in setting of an adult, may indicate immunocompromise, so we ordered an HIV test)

- Removal of two corneal foreign bodies

- An open globe (stellate corneal laceration and traumatic cataract) in a 2 year old boy who had trauma to the eye yesterday

- Posterior scleritis


And, the worst news of the day...my retinoblastoma child came to the clinic. I posted about her last week. I didn't even recognize her at first.

As we last left it, I was able to obtain the globe (eyeball), and we mailed it to the UK for pathology read. I was successful in this endeavor, with Jono's help. Unfortunately, the pathology will take a week or two to come back, given the logistics. Well, today the family showed up (mother and father) with their child. The father was holding her and she was listless. The tumor was even larger, and I honestly could not believe how much it had grown in just 8 days time. I asked the father how she was doing and he said, "She stopped eating four days ago and she is in so much pain she cannot sleep at night. I came here, doctor, because she is in so much pain, I thought you could help us."

I felt nauseous and sick and angry and a million other emotions. I discussed with Jono, and we think it is likely palliative care at this point. I admitted her to the peds ward (under the eye service), and we are giving her fluids and morphine for the pain. I ordered a CBC, a chest X-ray, and an ultrasound of the abdomen (liver) to check for any sign of metastases, which may help us figure out how advanced the disease is. MRI is not available and South Africa cannot help her until they have a formal tissue diagnosis. Plus, I think she is too sick to travel at this point in time.

I explained to the father that I wasn't sure how this was going to turn out, but that I fear she is dying. He had a quick look of shock and fear on his face, and then he said, "I understand, doctor." 

I have brought a "polaroid" camera with me (the 21st century version...the Instax Mini), and I have been using it to take photos of kids in clinic, which I then give to them to keep. They LOVE watching the photos appear, and the parents love having a photo of themselves with their child. At any rate, I didn't want to stick a camera in this man's face, especially with his child looking so ill, but he must have heard I had a camera because he asked for a photo. So, I took a photo of the little girl with her parents.

When Angie and I went by to see her on the peds ward this evening before leaving clinic, she looked peaceful and did not appear to be in pain. The mother was sitting at her bedside. My heart breaks. This is life, but it is devastating and never gets easier. Especially when it seems that more could have been done earlier.

When I was in high school, I loved the story of Danny Thomas and how he came to start St. Jude Children's Research Hospital in Memphis, Tennessee. He decided to build a pediatric hospital for catastrophic illnesses because he said, "No child should die in the dawn of life." I love that quote, and that is exactly how I feel in this case.

My first American patient

Angie and I are having a great time in Swaziland. This past weekend, we went to Kruger Park in South Africa and went on safari. During the course of the safari ride, Angie felt something fly into her right eye. Her eye immediately started tearing and she became more photophobic throughout the course of the day.

It continued to hurt the next day, and of course, without a slit lamp I couldn't tell exactly what was wrong with her eye. As luck would have it, she was traveling with an ophthalmologist (me) and staying as the guest of yet another ophthalmologist (Dr. Pons). If a health issue had to arise on our trip, what luck that it would be an eye problem!

We drove home to Siteki Sunday night, and I drove straight to Dr. Pons and Helen's house. I apologized for dropping in unannounced, but asked Jono if I could borrow the keys to the eye clinic (just down the road) to examine Angie. He replied, "Well, why don't you just use the slit lamp here at the house?!"

Angie and I laughed...somehow it did not surprise me that Dr. Pons has a slit lamp at his house. Albeit old, it still functions well. Our clinic here is NOT one to waste resources, and something that may be considered "old", "out of date", or "useless" in the States is cherished and well-used here in Swaziland.

It was very handy. I examined her, determined she didn't have a foreign body, but rather a significant corneal abrasion (scratch on her cornea) and it was healed by the next afternoon.

All is well again.