"Relationships, relationships, relationships"

This morning I had to get all my “paperwork” in order. I definitely feel for those that were not born in the United States, but live and work there. There is a lot of governmental red tape to cut through, and it isn’t easy. And for how “difficult” I am finding it, I can only imagine the process is 100 times more daunting, complicated, and time consuming in the U.S.

Don’t worry. I am in the country legally. I can be here for thirty days before I need to exit. Then I can come back for another thirty days, and so on. So I have my calendar marked! It is a good thing Swaziland is so small, as I can be in South Africa in very little time to get the passport stamped.

Rather, the paperwork I am talking about is my “Swaziland Medical License”. Jono (pronounced “John-O, and short for ‘Jonathan’) assures me that, for how complicated it may seem here, this is the easiest international medical license I will ever obtain. Anyway, on Friday I went to the hospital office to turn in my papers (notarized copy of medical license, notarized copy of medical school diploma, notarized copy of passport, notarized copy of residency completion certificate…you get the picture). Anyway, apparently I needed “police clearance” from the U.S., which I never obtained. I was so frustrated because on the front page of their application, they have a list of the “necessary documents”. And there is NOTHING listed about obtaining “police clearance”. Apparently what this translates to in the U.S. is “background check”. So I went home on Friday very frustrated. It was my first “bad day” in Swaziland. I ended up calling the U.S. via Skype (thank goodness when it is nighttime here, it is working hours at home), and was able to contact a person at Dean McGee, who was able to scan a copy of my background check and send it to me today. (Isn’t the internet amazing?!)

Meanwhile, this morning, I had to purchase two “stamps” that are affixed to my paperwork, which then needed to be signed and stamped with an ink stamp by a commissioner. It all seemed very complicated. But the job is done, all the paperwork finished, and I think I can turn everything in tomorrow.

 

Paperwork!

After I finished running around to these different offices in Siteki, Jono picked me up in the truck and we drove to Manzini to do surgery at St. Theresa’s. At any rate, on the way there, we had our “entrance meeting”, about my goals and expectations, as well as his goals and expectations. During this time, he made it very clear that he would like me to spend some time at the Mbabane Government Hospital, and he would like to set aside every Monday for me to travel to the city. Mbabane is the capital of Swaziland, and is located on the western side of the country (Siteki is on the eastern side). Luckily, since Swaziland is only 115km across at its widest point, one can drive from Siteki to Mbabane in about 2 to 2.5 hours.

Well, there is no time like the present! And since it was a Monday, Jono felt like today was the day to get started on my work at the government hospital, by driving in and introducing myself to the eye clinic! About ten minutes before we arrived in Manzini (about 2/3 of the way from Siteki to Mbabane), Jono proclaims that I should drive myself into Mbabane. I was just a little nervous for a few reasons: they drive on the left side of the road here with the steering wheel on the right, I am great at driving a manual but every car is different and this was a big truck AND all the shifting is done with the left hand, I had no “google maps” to navigate me to the hospital, nor did I have a paper map. So Jono whips out a piece of paper and starts drawing me a homemade map. Now, I must tell you Jono draws incredible maps. I swear he has every stoplight memorized in this country. So his map was actually quite good, and I made the trek without much difficulty. (All the while thinking, “What would my mom think of this? It sure is a good thing she has no idea what I am up to today.”)



The Map
(the dots represent all the stoplights!)

 

The Ride

The City (Mbabane)

When I arrived at the eye clinic in Mbabane, everyone was very nice. They asked me if my “navigator” was good in helping me get to the hospital. I pulled out the little piece of paper that was Jono’s hand-drawn map, and they started laughing. I think they thought I had a GPS or something.

 

Mbabane Government Hospital. The eye clinic is the building located directly in front of the blue car.

 

At any rate, I met with Sharon, who is an optometrist and also has her MPH. She is very intelligent and capable, but I get the feeling that her creativity has been quelled by government inefficiencies. There are a lot of problems with funding for eye care here in this country, and it all stems from the fact that Swaziland does not have a National Eye Care Coordinator. Apparently no one wants to donate funds unless they know there is a specific person in place to account for all the money. Which, makes sense. I guess awhile back, the government (Ministry of Health) was interviewing people for this position, but the position was not filled for some reason. And now, it can’t be filled because the government is broke and there is a hiring freeze (or something to that effect). So the position is not filled, but no longer available, which makes everything difficult.

I see it as that cyclical problem: we can’t get funds until we get a National Eye Care Coordinator in place. We can’t get a National Eye Care coordinator in place because the government is broke and we have no funds. Therefore: WE HAVE NO FUNDS!

I have to realize that this problem has been a long time in the making, and I am not going to solve it during my three months here. There is a lot to be done though and most of it right now involves making connections. As Jono puts it, “there are three words that are the most important words to know when dealing with Swazis. They all start with ‘R’ and end with ‘ship’. Relationships, relationships, relationships.” So, I will be an ambassador for the Dean McGee Eye Institute, which is committed for the long haul for helping Swaziland develop their eye care system. I know this will take time and we are talking on about “years” as opposed to “weeks or months”.

But the “problem solver” part of me wants to just “fix” everything now. And I am realizing that change takes time. Progress takes time. And for now, I will just have to do my best with the resources that are available.

The plan for Mondays at this point is for me to drive into Mbabane every Monday and help the Government Hospital Eye Clinic work out some of the kinks in their system. I will help them however I can, and I will work on building “relationships, relationships, relationships” amongst the different groups here: Jono at Good Shepherd Hospital, myself/Dean McGee Eye Institute in Oklahoma City, and the Government Hospital Eye Clinic. After all, we are all working for a common goal.

After my meetings, I drove back to Manzini to pick up Jono and Sister Senani, who were finished with their surgeries for the day. We did some quick shopping (much more selection in Manzini grocery stores compared to Siteki), and then made it back to Mabuda Farm by 4:30. It was an exhausting day!

As I was getting out of the truck, I asked Jono if he ever got frustrated with all this red tape, government inefficiency, lack of infrastructure, etc. He really is doing more than his fair share of the work here in Swaziland in regards to eye care. And he basically has built the whole program himself. And he said, “No. I just don’t give up hope. We must never give up hope.” This will be my mantra here.

After work, Angela and I went on a walk around the farm to decompress and talk about our days. She is so great. We took some great photos from the horse pasture as the sun was setting.

Animals grazing on the farm at sundown

 

That is all for now. More soon.

Sunday in Swaziland

Today I got up and attended church with Pons’. It was about a 30 minute drive to Simunye Christian Fellowship.  On the way to church, the road cuts through Hlane Game Reserve. It just so happened that we saw an elephant and a monkey on the way to church. I am definitely NOT in Iowa anymore! It was a really nice service. There were a lot of expatriates that attended, in addition to myself and Angela. I met a really nice girl from the Peace Corps who has been here for two years already. And the pastor was a female pastor from Indiana, and I must say, it was nice/comforting to hear the American accent!

 

Simunye Christian Fellowship/The Grapevine Church

 Later in the day Angela and I walked the 1 km into Siteki to return a hair dryer. I had purchased one here as it is “winter” and I don’t want to leave for work with a  wet head. The only reason I mention this story is that it was quite an event to get it exchanged for a new one. Just after my first use, it no longer blew out hot air. It turned on, but it was cold, cold, cold. Fortunately, when I had purchased it, they wrote a “3 month guarantee” on the inside lip of the box.

I thought it would be easy to return. However… first I asked a cashier, who asked another cashier, who called over her supervisor, who summoned a lady in the back to help. The lady took the hairdryer, grabbed a plug adaptor from the shelf (there are even two types of plug-ins here in Swaziland itself), and then proceeded to the end of the rice aisle, where she knew that way down along the floorboards, there was an electrical outlet. She plugged in the defunct hairdryer, and in the middle of the store we tried it out. She agreed, that indeed, it didn’t work properly. But then she had to call over her manager, who had to again verify for himself that the hairdryer didn’t work correctly. Next we grabbed a new one off the shelf for comparison, and he was finally convinced that it was broken. So, twenty minutes later, I had a new hairdryer in hand.

I certainly don’t want to sound critical, because I am a guest in Swaziland, and I certainly respect their rules and culture. It was just so foreign to me to go through all of this, especially using the hairdryer in the middle of the grocery store aisles, to get my purchase exchanged!

Photo for the day:

Cows grazing in the morning fog on Mabuda Farm

 

Mlawula Nature Rerserve

Today Angela (from S. Africa, recently hired as the clinic manager) and I went to Mlawula Nature Reserve which is only about 15 km outside of Steki (pronounced “Stegi”). We took the long route on the way there, stopping off in Simunye for lunch. I have not eaten out since I arrived (there are only two restaurants in town and apparently it is slightly risky to eat there). We went to the Country Club and shared a pizza. Next, we continued on to the nature reserve.



Angela (our clinic administrator)  and our Hawaiian Pizza, Swazi Style: Ham, bacon, pineapple, and banana. It was delicious!

Country Club in Simunye

 

 

 

The area was proclaimed a reserve in 1980. There is a lot of wildlife on the reserve, but the animals are pretty skittish, so it was hard to get good views or photos. It is a beautiful area with the Lubombo mountains forming the eastern border of the park.

We took some fun photos of the wildlife we did see.

 

 

 

All in all it was a great day!



Angela happy that we found our way out of the African bush!

 

Orbital Cellulitis

I am happy to say that our patient with the severe left-sided orbital cellulitis is much improved! The patient continues to be in the hospital for IV antibiotics, but hopefully can be discharged next week.

 

Left orbital cellulitis on day of presentation

 

Attempted right gaze on day of presentation. The patient was unable to adduct the left eye. There was no relative afferent pupillary defect.

Day 2



X-ray 2 days after presentation. There is complete opacification of the left maxillary sinus and significant opacification of the left ethmoids.



Day 5. Patient is much improved!

 

Friday Post-ops

Today we saw our post-ops. When Dr. Pons does cataract surgery, the patients stay upstairs in the clinic. They often travel long distances, so included in the price of the surgery is two night’s lodging at Good Shepherd. They come in for their pre-op visit and biometry (lens calculations) the day before surgery (Wednesday). They stay overnight on Wednesday night, have surgery Thursday, spend the night on Thursday and are seen in clinic for post-op on Friday. They are then free to travel home.

 

On Fridays, post-operative day #1, the patients are brought down to clinic at about 8 a.m. The morning starts with singing and prayer, led by a local pastor. Then, Sister Senani gives a lecture to the room full of patients about post-operative instructions. She instructs them on proper use of their eye drops and tells them when to return for follow-up visits. This is all done in siSwati, one of the official languages (in addition to English) of Swaziland. So, I understood nothing. However, Q (short for her full name which starts with a “Q”), helped translate. Q is a nurse in the clinic, and she is young and fun. I asked what all the murmuring amongst the patients was and she said they were saying things like, “It is too expensive for me to come back. I cannot come back to clinic. I didn’t know we had to come back to see you after surgery…”  Of course, this was all explained to them pre-op. Jono said he thinks the follow-up rate for post-ops (seen at Day 1, Day 10, and post op Week 6) is about 10%. That is to say about NINETY percent do not come back to see us after post-op Day #1!! And, he said, this is important for two reasons:

1. It stresses the importance of the Post-op Day #1 visit. We have to presume we may never see the patient again. Therefore, this visit is vitally important to make sure they are doing well and that there are no signs of infection.

2. This poor rate of follow-up indicates that the patients are doing well. He said, “Do you know why the patients don’t come back?  It is because they are so happy!” Of course, we would like to see them back, but it is often not feasible for the patients.

 

Post-op patients singing and praying with the Pastor

Sister Senani (in orange) giving post-operative instructions to the group

 

Consent for surgery complete with the fingerprint "signature". All identifiers (except, I suppose, for the fingerprint) have been removed :)

 

A few more photos:

Bustling metropolis of Siteki. My grocery store (ShopRite) is on the right with the big red lettering.

Another view of Siteki

 

My new wheels for the next three months. I had better get used to driving on the left hand side of the road...

 

Surgery!

Happy birthday Jono! Dr. Pons (Jono) and his wife made it back to Swaziland safe and sound. We spent the day in surgery. Jono usually does about 20 cases in a day, but he had a lighter schedule given he just got back into the country. He did one phacoemulsification (standard cataract extraction procedure in the U.S.), seven manual small incision cataract surgeries (“MSICS”, the most common procedure for cataract surgery in the developing world), three conjunctival lesion excisions, an emergency lid laceration repair in a patient that was involved in a motor vehicle collision, and excision of multiple eyelid cysts.

 

Operating Room at Good Shepherd

Sister Senani preparing for the next case. There is a wonderful television screen for medical students and visiting surgeons  to watch the surgery live. It is fantastic quality and a great learning tool. In this photo, Dr. Pons has finished removing the cataract and is placing the intraocular lens (IOL).

  

Dr. Pons at work

It was quite an efficient day with no mishaps. Two of the cataracts were traumatic, and those can be a bit difficult surgically. Jono handled them with great skill and ease. We took a group photo to document Dr. Tim's last day in Swaziland. We sure will miss him!

From left: Dr. Jono Pons, Dr. Tim Fetherston, Q, Sister Senani, me, Camille, Sister, Angela

 

Tonight we had a birthday party at the Mabuda House (Jono and Helen’s house). It was a lovely party. They are definitely taking very good care of me here!

 

Jono's Birthday party. Front row: Me, Charlotte. Middle row: Viv Fetherston, Milly, Angela, Linda, and Linda's mother. Back row: Dr. Tim Fetherston, Ashley, Camille, Ciaran, Helen Pons, Dr. Jono Pons. We all had a good laugh that Dr. Pons had inadvertently positioned himself right in front of the antlers!

Tomorrow Dr. Tim and Viv leave to go back to the UK. Now that Jono is back, it will just be the two of us in clinic.

One of my dearest friends, Angie, who is also an ophthalmologist (we did our residency together at Iowa), will be coming to visit me in Swaziland for two weeks. She arrives here at the end of August. She is going to help out in the clinics and keep me company J I can’t wait! It will be nice to have a friend to travel around Swaziland/South Africa with me.

Photo for the day:

My bedroom at Mabuda Farms, complete with a mosquito net, which I have been finding very handy. There is plenty of room for Angie when she comes to visit!

 

Wednesday Clinic

We have a set schedule every week that we follow. Dr. Tim kindly outlined it for me the first day I arrived.

Weekly schedule

 

Wednesdays, we have clinic here in Siteki at Good Shepherd.

Dr. Tim and I made it into clinic about 9:15 this morning to an entire waiting room full of patients. We immediately set to work. Again, it was a very interesting day, but there is always some frustration. The visions that are checked by the technicians seem to be an “estimated” vision. In fact, I had one patient whose vision had miraculously improved in the right eye from longstanding “hand motions” to nearly 6/15 (equivalent of 20/50 in the U.S.)! Amazing. And then, when I looked at her, it was clear there was NO WAY she could see much out of the eye. The pupil was completely blocked with “scar tissue” from old anterior uveitis secondary to syphilis. At any rate, I rechecked her vision, asking her to cover her left eye, and it was clear she was peeking. So I covered the eye myself and realized her vision was “NLP” (no light perception). I love the technicians, but clearly things like this slow me down.

And today, I finally understood how useful it is to check for an RAPD. I had many patients who had been previously diagnosed (by whom, I have no idea) as needing a cataract extraction. But upon exam, the cataract did not seem to correspond to the vision (i.e. vision was much worse than could be explained by cataract alone), so I did a quick pupil check and determined that there was an enormous RAPD. Upon dilation, it was clear it was NOT a cataract, but rather end stage glaucoma with a completely cupped nerve that was responsible for the visual decrease. It makes quite a difference: for a cataract we would operate, for end stage glaucoma, we put the patient on drops to try to preserve what tiny amount of vision he or she has remaining.

Other interesting things seen today:

-          Interstitial keratitis from syphilis

-          Bilateral chronic angle closure glaucoma with mid-dilated pupils, decreased vision, and intraocular pressures in the 30s.

-          Many patients with end-stage glaucoma

-          A patient with very mild cataract, who didn’t want to buy glasses until we “took her lenses out and cleaned them” (she wanted cataract surgery when all she really needs is glasses).

-          Pseudoexfoliation glaucoma

-          Tractional retinal detachment secondary to long-standing proliferative diabetic retinopathy

 

Clinic at Good Shepherd Hospital. Dr Tim's/Dr. Pons' slit lamp on the left, my slit lamp on the right of the photo

 

A quick note about patient privacy. Many of the patients we see in clinic are HIV positive. When we examine the patients, it in one large room, with both myself and Dr. Tim sitting at one end. There are two long benches in front of our slit-lamps, and the patients just scoot down the bench until they reach us. At that point it is their turn to be examined. Obviously, given this set-up, privacy is NON-EXISTENT. And oddly, everyone is okay with this. Dr. Tim told me my first day is was perfectly acceptable and even considered appropriate to ask the patient in front of everyone else if they are on “ARVs” (anti-retrovirals). The patients don’t even bat an eye and will share this personal information. I can’t even imagine this in the United States—asking patients this extremely personal information in a room full of other patients. But, I guess it probably has something to do with how incredibly prevalent HIV is in this population; it isn’t considered abnormal to have HIV—it is just a fact of life that 1 in 4 deal with here in Swaziland. And I am sure we would give them more privacy if we had the ability. The clinic is literally four rooms: the examination room, waiting room, office, and a bathroom.

Photo for the day:

Swaziland from above