Days of Being in Clinic

A few days into my time at the Dembi Dollo Eye Clinic, an elderly man came in wearing a musty jacket and carrying a bag on a stick over his shoulder.  The flies which had been swarming around him as he entered continued to do so as he sat in the exam room, and it soon became apparent that his hearing was beginning to go as well.  After examining him and scheduling him for cataract surgery the following month, I led the man out the door to the gate of the clinic.  As I placed a hand on his shoulder, he grabbed my hand and fervently shook it.  At that moment I felt something I have experienced quite frequently over the past few weeks here- a reminder of why I wanted to become a doctor.

entrance to the clinic

Working at the eye clinic has been an enlightening, sometimes strange, yet often affirming experience.  Many of the rules of American medicine have been thrown out the window- whether because of culture or necessity.  Medications which would be standard treatment in the US are unavailable in Dembi Dollo (and sometimes in Ethiopia, for that matter), the power frequently goes out without warning, on occasion female patients will breastfeed their children during their exams, and once a man blessed me for simply taking his blood pressure!

Having the privilege of working with great Ethiopian coworkers has made the experience all the better.  The first day I met Alami, one of the assistants at the clinic, she laughingly told me she thought I was 18 and that I looked just like "Dr. Larry."

me with the man I'm a "doppelganger" of, Dr. Larry Thomas

Alami proved to be an extraordinarily kind and helpful coworker- one of the nicest people I've met in Ethiopia, in fact- which was made all the more remarkable by the fact that she suffers from podoconiosis, a form of elephantiasis which causes one's legs and feet to swell up and often makes walking painful.  Tamima, another assistant, and Getahoon, one of the clinic guards, also provided many interesting conversations and did their best to make sure I felt at home.

Tamima, Getahoon, and Alami

A 15 year-old girl with a remarkable command of English named Hawi has worked as my translator at the clinic.  After her mother died from complications due to HIV and her father essentially disowned her, she moved to Dembi Dollo to live with the Daughters of Charity at their hostel for girls.  An Australian woman who regularly works with the Daughters of Charity has been applying for guardianship of Hawi, in hopes that she might move to Australia to fulfill her aspirations of becoming an eye doctor.

One of the most exciting aspects about working at the clinic was being able to recognize in real-life patients the ocular disorders and conditions I had learned about in my Physical Diagnosis course in the first year of medical school.  These included (described in layman's terms)-

Allergic conjunctivitis (pink eye)

Inflammation of the conjunctiva, or covering of the white part of the eye and inner part of the eyelid, due to some allergen rather than a bacterial or viral cause.  A large number of the patients at the clinic are affected by this, and usually have itchy eyes and sometimes tears.

Glaucoma

An increase in pressure in the eye leading to damage of the optic nerve, which transmits visual stimuli to the brain.  Patients with glaucoma lose peripheral vision before losing their central vision.  Typically in the US, applanation tonometry is used to ascertain a patient's eye pressure, but at the clinic the Schiotz tonometer, a mini handheld plunger-like apparatus, is commonly used instead.  When screening patients for glaucoma, clinicians here will often feel a patient's eyeballs through their eyelids- a healthy eye should feel like the fleshy part of the hand below the thumb whereas a glaucoma-affected eye will feel considerably harder.

Cataract

A clouding of the lens which causes a decrease in vision, and also one of the main reasons I'm here in Ethiopia.  Cataracts are one of the major causes of blindness in Ethiopia, and the eye camps run by THAF in conjunction with the Daughters of Charity aim to restore vision by providing cataract surgery in regions where cataract surgery is not readily accessible.  Cataracts can be caused by aging as the lens gets larger or by trauma, and has been associated with exposure to UV light and smoking.


Keratoconjunctivitis sicca

Dry eyes which typically occur in post-menopausal women.  It can also be associated with autoimmune disease called Sjogren's syndrome.

Pingueculum

A harmless raised area on the conjunctiva of the eye

Pterygium

Derived from the Latin for "wing," a pterygium is a harmless growth of the conjunctiva (covering of the white part of the eye) horizontally towards the cornea (clear front part of the eye).  These can prove problematic when they grow so much that they cover the cornea and block the patient's vision, and are associated with exposure to UV light.

the eye clinic

As much as I thought I had learned about and memorized in first year, there were still many more conditions patients came in with which were completely novel to me-

Vitamin A deficiency blindness

Vitamin A plays an important molecular role in the eye in converting photons of light into signals to the brain.  A lack of Vitamin A has also been linked to a decrease in secretions which would normally keep the eye clean, putting those afflicted by the deficiency at increased risk of eye infection.

Macular hole

What I observed in clinic was likely a pseudomacular hole since the patient's central vision wasn't affected- a real macular hole is a break in the macula, or the part of the retina (back of the eye) responsible for central vision.

Phlyctenulosis

A raised area on the eye commonly associated with Staphylococcus infection or tuberculosis.  Phlyctenules can occur in the conjunctiva- the covering of the white of the eye- or the cornea- the clear central part of the eye.

Ocular rosacea

Ocular rosacea typically occurs in older fair-skinned people, which made it all the more interesting when a young, dark-skinned Ethiopian girl came into our clinic with this condition.  She had patches of dry, discolored skin on her face, neck, and back, and burning and tearing in her eyes.  Interestingly enough, she also had the phlyctenule described above, a common symptom of ocular rosacea.

Hematoma

The boy in the picture above came into clinic one day and pushed a mass, which was tucked into his lower eyelid, completely out of his eyelid as seen in the picture.  The ophthalmologist, Dr. Samuel, suspected the boy had a mass of blood (hematoma) and sent him to the hospital to have it removed.

One non-ocular infection I learned about at the eye clinic is called noma.  When I first saw the poster for Noma posted on one of the clinic doors, I assumed that it was depicting uncorrected embryological defects in children and adults.  Yet upon doing more research, I found that noma is actually a gangrenous disease which has largely been eradicated except in poorer regions of the developing world, and which causes rapid destruction of facial tissue.  Click here to see a picture (warning- image may be disturbing).

The clinic not only provides the requisite medical care a clinic should provide, but also provides a sort of societal benefit as well.  Clinic patients pay a deeply discounted rate for their procedures and medications, and exams are completely free of charge.  Poor members of the community are identified by the clinic staff, and these patients simply pay whatever they can.

An elderly woman with bilateral cataracts came in one day accompanied by her young grandson- she had essentially lost her vision aside from the ability to detect light.  Her and her grandson's clothes were old and beginning to wear down, and when Sister Evelyn served the boy a plate of food, he ravenously scarfed it all down.

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On another day in clinic, an 11 year old boy who couldn't stop smiling came in with his grandma.  He eagerly listened to all of my conversations with his grandmother, peeked at everything I wrote on her card, tried to help with her eye test, and even listened as the nurse gave the medication instructions.  I discovered that he wanted to become a doctor, so I let him take the eye test himself, listen through the stethoscope, then look through the ophthalmoscope.  It was a remarkable thought that, should this boy continue pursuing his goal of becoming a doctor, he could not only raise his own economic level, but better the lives of other Ethiopians as well.