Blog by Justin Rome, 4th Year Medical Student, Unite For Sight Global Impact Fellow in Honduras

Semana de los Santos

Semana de los Santos (Saints Week, or Holy Week) is a week in Honduras when nobody comes to get their eyes checked, and most of the staff in the clinic vacations to las playas en el norte (the beaches up north). I'm sure it has some other significance, but maybe not. Needless to say, it was a slow day today, which was not so bad really. We were not rushed, so I was able to get to know the few ophthalmologist, optometrists, and some other staff members who decided not to go 'norte'. The clinic here is very much a family, and I mean that literally. Everyone is related either by blood or marriage. Even the attached restaurant is all family. This gives the place a real nice homey feel. I have included some pictures form my Tilapia lunch, the gate to my hotel, and the clinic right across the street. I am headed tomorrow to work at an orphanage at San Lorenzo. I will be there though the weekend, probably returning on Sunday or Monday to "Tegus" as the locals call it. I make a new post when I return early next week. Till then, adios.

(This photo is taken from the hotel, which is across the street from the eye clinic. The entrance to the eye clinic is right behind the red car.)

(ZOE Eye Clinic)

 

San Lorenzo

As I mentioned in my last post, this is 'Holy Week' here in Honduras. Semana Sanata (not Semana de los Santas and I previously noted), is the week leading up to Easter. This is a very popular vacation week, as most businesses are only open Monday and Tuesday, and some for a half day on Wednesday. This includes ZOE clinic (where I am working). In fact, on Wednesday morning, none of our morning patients bothered to show up, so we closed our doors at 8:30am. The head administrator of the clinic, Pedro, had mentioned to me the day before that I would be going to an orphanage in San Lorenzo after our clinic on Wednesday. I know Unite for Sight holds eye screenings in San Lorenzo, so I figured that's is what I would be doing. Were we going to screen the childrens' eyes at the orphanage? Then would we be screening adults in the area as well? My spanish was not good enough to determine these details, so I just packed my bag, and went along for the ride. After 10 minutes, we were outside of the Tegucigalpa city limits, and were in the beautiful countryside of Honduras. With its sprawling mountainscape, lush vegetation, and deep valleys overlooked by the mountain passes, it was truly beautiful. I wondered how many people outside of Honduras were aware of this natural beauty, seeing as Honduras is not at all a tourist destination. Alongside the roads, were occasional houses, which seemed to be hand-made for the most part - consisting of clay, and straw, with red tiled ceramic roofs. They shared one similarity with all the property in Tegucigalpa, they all had barbwire fencing and padlocked gates. I guess nobody has too much trust for their neighbors here. Nearby each house, or groups of houses, were more plastic bottles scattered about than I have ever seen in my life. Coca-Cola and Sprite seemed to be the most abundant. As you can imagine, there is no trash or recycling service in the middle of Honduras, so residents burn their flammable trash, and simply discard their plastic waste where-ever they see fit, which was often right in front, or beside their homes. I though this to be very strange, and it frustrated me to see so much non-biodegradable trash juxtaposed with such beauty - but without the infrastructure for its removal, what were they to do? Should they drink less soda? What would I do if i lived out here? That thought was fleeting.

We arrived in San Lorenzo at 10:45am. Technically, the orphanage is about 10 minutes outside of San Lorenzo. It was very hot. We were only a two hour drive south of Tegucigalpa, but I could appreciate the climactic difference. We were immediately greeted by many kids and the director of the orphanage, who seemed to be expecting us. Pedro introduced me to Roberto, the director. Roberto looked to be in his sixties, wearing kakis, a tucked in white polo shirt, bifocals and a smile. Neither Pedro or Roberto spoke a word of English. Roberto went to the kitchen to get us some water. Pedro told me that Roberto would take me back to Tegucigalpa on Saturday. I didn't realize that Pedro would not be staying with me until this moment.

Instead of being too 'in your face', I decided to 'play it cool' and let them come up to me. I didn't want to come on too strong and have the kids fear me. One boy, about 15 years old, tells me in spanish that it is time for lunch and to come with him. I followed him to the cafeteria. There, two women, likely in their sixties, were preparing the meals. I would quickly learn that the staff of the orphanage consisted of Roberto, the two women in the kitchen who were responsible for cooking and cleaning the clothes, and two other women in their twenties who's responsibility was mainly to tend to the younger kids. The orphans were all boys ranging from 5 years old to 18 years. There were about 25 of them. I picked up my plate of beans, eggs, and tortillas and cheese and my oatmeal drink - a meal I soon became accustomed to. It was delicious. The eggs were so fresh, and the tortillas nicely stemmed. I need to eat this more often at home, I thought. So simple, so healthy, and so good.

The orphanage was founded in thirty years ago by a man from the States who is currently living in Budapest, Hungry. He even set up a school on the property, which is no longer used. Instead the kids attend a school in San Lorenzo proper - however, they are off for the holiday.

After dinner, I was impressed to discover that everyone washed their own dishes. Later, I would find out that that all would make their beds in the morning as well. What discipline! Some of los pequenos (I'm not sure how to make that symbol over the n), or the little ones, grabbed my hand and told me in spanish that they were going to show me around. It just hit me that nobody here speaks a word of english. I have taken six years of spanish, but it had been a while - 10 years in fact since I last studied the language. But as we walked, words I thought I had forgotten crept from my subconciousness into my conciseness. It is so strange how that happens. During my neurology rotation this past year, I learned that everything you ever learn, or even read for that matter has imprinted permanently in your brain. It is not always easy to access however. Apparently, researchers were able to stimulate the brain of a man using electrodes, and he read off a newspaper from 30 years ago, only he had no paper in front of him. It was word for word to the original periodical. Maybe this is true indeed. Being forced to speak only spanish, really improved my ability to do so. When I didn't understand what the kids were saying, I would ask them the significance of a particular word, and they would explain it to me in spanish until I understood. I was impressed by their wiliness to help me get them. What great teachers, I thought. They showed me their large farm of plantains, yucca, mango, lemons, papaya, and many other fruits whose names I cannot recall because I had never sampled them before. Some were very acidic/citric and other mild. I met their six year old black lab, Luna, who we bathed because she was hot and dirty. They took me to see their bulls (toros), cows (vacas), chickens (pollios), chicks (pillitos), ducks (patos), roosters (gallos), horses (cabillos), and sheep (ovejas). They even had a fish (pez) farm - specifically, that of talapia. We saw lizards (goboros) which liked to eat their chicks.

The kids all accepted me right away, and we had so much fun playing together. They would teach me spanish, mainly by accident when I didn't understand what they were saying, and I tried my best to teach them some english. They loved posing for pictures and seeing the digital images on the display. And they really loved my iPhone games. More than a few times they drained the battery fully playing the three games that I have installed. After dinner, when the sun started to set, we would play soccer. It is much too hot to play during the daytime, so such activities are reserved for the night. Thinking I was coming to San Lorenzo to screen for eye diseases, I left my sneakers in Tegucigalpa, and only brought my walking shoes. After two days of soccer they were destroyed. But it was well worth it. These kids were very good at soccer, and although I had size on them, they gave me a good run around. In fact, the first night, I almost vomited from the amount of exercise. But, thankfully I didn't. The second night, I fell trying to seal the ball, and scrapped my arm pretty good. I didn't make a scene of it, so nobody noticed, but later when we were watching TV, they all asked me what happened to my arm. I told them it was from when I fell playing 'futbol'. They took my minor injury to be a right of passage in becoming like them, like someone form Honduras, which I readily welcomed. Later at night, before we would go back to the rooms to shower and go to sleep, we would take a dip in their shallow pool. Maybe 3 feet deep at most, it was mainly for cooling off and floating around in.

I did not see Roberto very much other than early in the morning, and at mealtimes. Although he was not visible, I had the sense that he was always nearby, and that the kids always knew where to find him if they needed something. They affectionately called him 'Pappi', and the female staff aunts, or "Tia". They were brothers to each other, affectionally touching and grooming one another, and sharing food, and toys. Not once did I see any fights or arguments.

Back in Tegucigalpa

Today was my first day in the OR here in Tegucigalpa, Honduras. It was a very different experience than what I have observed back in the States. For starters, the OR is in the clinic, not in a Hospital. The 'pre-op', and 'post-op' waiting areas, are the chairs right outside of the OR. The room itself is fairly similar to any other I have seen, but the equipment was a bit older. The other thing that struck me was that there was no anesthesiologist. Back home, most ophthalmic cases are done with an anesthesiologist administering a mild sedative to keep the patient calm and relaxed, and to prevent pain, numbing eye drops are given. Instead, here they use a parabulbar block (by injecting an anesthetic with a long needle alongside the eye) which prevents any sensation of pain, vision, or the ability to move that eye. It is safe, and I've seen it done back home, but it's not so common except under certain situations. And when it is done back home, its usually preceded by a dose of propofol (a short lived hypnotic agent, yes, the one MJ was on) pushed by the anesthesiologist so patients don't have to be conscious when a 3-inch needle comes at their eye. The other difference was the way the ophthalmologists take the cataracts out. In the States, the standard of care now is using Phacoemulsification (sucking out the lens with a tiny ultrasound probe). This procedure allows for very tiny incisions to be made since the cataract comes out as a liquid. They do have a "Phaco" machine here, however it is rarely used for two reasons. One, it is much more expensive then doing the older method called an extracapsular removal which involves making a larger incision and taking the cataract out whole. The reason it is more expensive is that the "Phaco" machine uses disposable equipment that is costly. The second reason, is that unlike back home where most people come to see an eye doctor when they notice early changes in their vision, and cataracts are removed at earlier stages, here, most patients will not present until they no longer see out of an eye. When a cataract gets this advanced, Phaco has no utility. In fact, the only time I saw an "extracap" back home, was in a very advanced, opacified cataract. Patients, if candidates, can opt for having their surgery done by phaco, but they have to pay extra for it. Already, the cost for an extracap procedure is 3,000 Limpira ($160), which is quite a bit here. If they cannot afford the surgery, like the patients we recruit from the villages, Unite for Sight pays for the cases, which is supported fully by donations (thanks again to everyone who donated!)

(the ophthalmologist and the scrub tech starting a cataract case at ZOE Eye Clinic)

(cataract removed)

(inserting IOL)

The Other Central Park

Today was the first day I got into a taxi and was quoted the local price for a ride. Finally. I attribute this to my ability to explain where I want to go fully in Spanish - something that I could not do two weeks ago. I still bargained for the best price; however, because, I don't know, I just feel like I have to. It seems almost expected by the driver. I have come to realize that I can get a ride anywhere in the city for 40 L, which is about $2. When I got here, they would ask me for 100 L ($5) for a ride, but today he started at 50 L ($2.50). I still refused to get in the car until he agreed to take off that last 50 cents. It seems ridiculous to bargain in cents, but when cents can actually buy you things, you find yourself doing it. I remember in SE Asia doing the same.

The taxis here do not have meters as you can expect, so you best settle on a price prior to hopping in. Taxis are everywhere in Tegucigalpa, with the taxi to personal car not unlike that of NYC. Unlike NYC however, they are all white, and easily identified by their 'flair'. Some have rims, some are lowered, and some have windows so tinted you cannot see inside at all. They all have one thing in common though; they yield the car's name in large white decaled lettering on the top of their windshields. I got in "The Gift of Jesus" (El Regalo de Jesus) this morning. My favorite taxi so far has been "Carlitos" because it reminded me of my good friend in NYC.

I started this post about taxis, not because I had the intention of rambling on about them, but because I started out the day in one heading to Central Park. Yes, there is more than one Central Park. Who knew? Today was the first day I had the chance to venture into the city center. My hotel is quite close, maybe two miles away, but the journey is long with all the traffic. Tegus is a mountainous city with the downtown area being in the valley. The driver dropped me off at central park, and I began walking around. Immediately, the area reminded me that of Bucharest, Romaina. Like both cities, electrical wires dominate the cityscape, and stray dogs run around asking people for food.

I walked down the main shopping street of Tegus, which is a pedestrian way. Lots of people were out today, enjoying the weekend, and the nice weather. I received some strange looks when I would take my camera out, I think because people are not used to having someone walking snapping pics of their city. I tried to be subtle about it, but that's not the easiest thing to do on a busy street. One woman when noticing my camera kept posing for pictures.

The storefronts on this street mainly showcased cheap clothes, electronics, and fast food chains. In fact, when searching for a place to eat lunch, there was no other option than fast food. This seems to be the norm here in Tegus. To avoid eating fast food everyday, I've been doing a lot of shopping at the grocery store, getting fresh fruits and veggies.

I walked down a bit further to eventually encounter El Museo para la Identidad Nacional, or the National Identity Museum, which you probably could have figured out without my translation. After paying my entrance fee of $3.00, twice the local fee, I wondered around the large museum. I was very impressed to find a museum of this quality in the city. It served, as a natural history museum with bones of giant bears and strange looking birds that once lived in Honduras, a cultural history museum with Mayan artifacts from the north of Honduras, as well as early Christian ornaments, and a fine art museum with some paintings and wood carvings from local artists. There was even a virtual reality exhibit of the Mayan Ruins in Copan, which was very interesting, even though I could not understand all of the Spanish commentary.

Tomorrow, one of the ophthalmologists from the clinic invited me to join him and his family to spend the day at a village 30 mins away, which is known for the local craftsmanship. I am looking forward to going, and will report back with full details. With that, I will leave you with more pics from the OR, this time from a strabismus case where the doctor operated on the extra-ocular muscles that move your eye.

Valle de Angeles

I spent today in an old colonial village called Valle de Angeles, or Valley of Angeles, which is located about 30 minutes east of Tegus. One of the ophthalmologists from the clinic and his wife had invited me to join them, and picked me up early this morning. The village is very well preserved with its original architecture, and has successfully fought off all fast food, chain stores, and neon lights/signs. This gives it a very different feel from the nearby city. Many people live in Valle de Angeles, and commute to work in Tegus, since the area is much safer, and they enjoy the small town feel. Valle de Angeles is known for its craftsmanship, especially that of wood, but also straw, ceramic, and leather. We walked the hilly streets, and enjoyed espresso. Then we walked through the park, which brought us to an old church, and a historical museum. The museum showcased items from the 1800's through the 1980's. It was interesting seeing some items I grew up, such as Polaroid cameras, and VHS rewinders, behind glass in a historical museum. What was the purpose of those VHS rewinders anyway? If you had one, you certainly had a VHS player as well, which was fully capable of executing the simple task of a rewind. I think they were faster, though. But maybe I'm missing something. Anyone?

After walking around for a bit, and sampling sweet and sour tamarind candy, we went to lunch, which was very good. It was nice to eat at a real restaurant, an amenity hard to come by in Tegus.

It was a very relaxing Sunday. The next two weeks of work will be really busy with a lot of traveling, so it was a nice break.

Los Brigadas

I'm am now back in Tegus after a packed full week of outreach brigades, or brigadas en espanol. This is what Unite for Sight is all about. In a typical month here, the team goes out 3-4 days per week for 3 weeks straight on such brigades. The fourth week is spent bringing cataract patients here to Tegus for their surgery, putting them up for 3 days to ensure proper immediate post-op care, then taking them back to their villages. On average, 900-1,000 patients are screened by the team every month. The team travels to all regions in the country. Of these patients, about 70-80 have cataracts, and since not everyone wants the surgery, 50-60 end up being operated on. The rest of the patients are provided reading glasses for free or for a donation of up to $2 if they can afford it, or prescription glasses if needed at an affordable price. In fact, every patient gets a refraction, and if they want glasses made, they choose from the frames we bring, and we have them made in the optical shop which is part of the clinic. The price for these glasses is less than $20, which is much cheaper than if they were to go to a store.

Our first brigade was at an elementary school here in the city. In fact, it was a two day event in order to screen all 600 of the students. Anyone child whose vision was less than 20/30 earned themselves a refraction, which was a considerable amount. It was amazing that some of these kids were even able to go to school with such poor vision. Of course, none of them had glasses, because their family's could not afford them, or didn't know their children needed them. Next week, we will be going back to the school to meet with the parents of each child that needs glasses, to take orders for affordable pairs. It was fun screening the kids, who treated it like playing a game.

Here are a couple pics from the school screenings:

(visual acuity screening)

(outreach vehicle)

(ophthamlic staff using autorefractor)

(Visual acuity chart)

(Optometrist Victor Montoya)

(Optometrist Victor)

We reached Goascoran Valle after driving down a rocky dirt road off the main road for about 20 minutes. This road used to be packed dirt with a water repellent shell of lime to keep the road preserved in the rainy season. The street was recently dug up to transform it into a very rugged off-roading experience. The reason for this was that politicians running for positions promised villagers that they would pave the road if they would vote for them, and they showed that they were serious about the efforts by making the first step to dig up the road. Once they got elected, they abandoned the project leaving the road in worse shape. My understanding is that this is a common practice here. Now people are concerned that when the rainy season begins, the road will become a four mile stretch of mud.

Goascoran Valle is a quaint old village with dirt roads, and all sorts of animals roaming the streets. We pulled up into an outdoor restaurant whose space was cleared for us for the day. We set up our equipment and went to work. We ended up screening 64 patients, gave out many glasses, and encountered 4 people who were candidates for cataract surgery.

This is a man who I met who had cataract surgery 15 years ago in his right eye, developed a complication that could have been treated, and never had any post-op care leading to the loss of vision in his eye. This is a big problem, and it is one that Unite for Sight recognizes, so all Unite For Sight patients are given proper post-op care. Other surgical missions are starting to realize the significance of this now, and are trying to provide such care to the patients they operate on. However there still are some surgical missions that visit countries, perform surgeries, then leave, and its not uncommon for patients to end up worse then they started. While the intentions were good from the doctors, without post-op care, the surgeries are useless.

This other woman, came in with her left eye taped up to keep it open. She didn't think anything of it, since it's been going on for about two years, and she has learned to live with it. She just came for glasses. When I looked at her eyes, I noticed that she had anisocoria (different sized pupils) with the left one (the side with the ptosis - or lid lag), being smaller than the right. These signs together, suggest Horner's syndrome, which is a dysfunction of a nerve in the sympathetic chain. There is a good-sized differential diagnosis for lesions that can cause Horner's Syndrome, and if it has been present since birth, it is usually secondary to birth trauma during delivery, and no work-up is needed. When it suddenly develops in adulthood, it is more concerning. One well documented cause is apical lung cancer, which can compress the nerve around the neck as it passes through the region. On further questioning, she told me that she has had a cough for a while, so I was able to set her up with a chest x-ray at the local hospital for the next day.

Well, that's it. I'm back in the city of Tegus now, and have one more week here before flying back home on Friday. We have a busy week coming up with lots more screenings, so I will make one last post before I leave.

A Final Post From Honduras

These four weeks have gone by quick. I really enjoyed this experience, and was able to get much more out of it than I had even hoped to. My conversational and medical Spanish are considerably better. I feel much more prepared to take care of Spanish-speaking patients during residency. I also made great relationships with many members of the clinic including the three ophthalmologists. In fact, I have been over to one's house, went to a village over the weekend with another, and out for beers to watch the Honduras vs Venezuela soccer game with the third. I was welcomed in the OR with each of them, and they all taught me so much. The pathology here is not like most of what we see back home. It is really end stage. Cataracts are so dense, patients are blind. Glaucoma is so advanced, little vision is remaining at the time of diagnosis. Pterygiums are so large they grow over the visual axis. And with this, the resources here are much more limited. The workups are not as through simply because the newest technology isn't at their finger tips. But with this, patients in general here are much happier with the healthcare they receive. I am not sure exactly why this is, but it's hardly subtle. Every patient comes in excited to see their doctor, and hugs are exchanged. The conversations throughout the session are light and enjoyable, even though the same time pressure exists to see a ton of patients in a very short period of time. Not once, did I witness any arguments or attitudes from any patients or doctors. It is just a different mentality here, and we can learn how to be better doctors and patients from this sort of a culture. With that said, I will quit my rambling, and post some pics from this weeks Brigadas.

The first one was here in Tegus at a general medicine clinic. We had a great turnout.

And the other one was about 2 hours out of the city in a village called Cedros. Sitting atop a mountain at 6,000 feet, we drove up in altitude the entire time from the already elevated city of Tegus. Cedros is an old, well preserved village with great views of the mountainscape, wonderful architecture and stone roads. We had a great turn out here too screening over 100 patients, and setting a few up to get their cataracts out so they can soon reclaim their vision.

Thank you for reading! I have enjoyed sharing my experiences with you all. I would recommend working with Unite for Sight for anyone, even if you are not in ophthalmology/optometry, or medicine for that matter. It is really rewarding to have such an impact on people.