VOSH Southeast (of the USA) has been sending a team of eye specialist to Chinandega semi-annually since 2005. The 2009 eye team was composed of three qualified optometrists from the States, an optical dispenser, 17 third year optometry students from Chicago, and myself. We were split into two teams, imaginatively named A & B, and sent to different locations each day. I was assigned to team A (A for Australia?) along with Dr Nelson Rivera (who made himself available to the team for the first two of the five working days). We were responsible for all the boy students (three in total) and all the Asian students (A for Asian?). Both teams were equipped with translators (most of whom were local to the area) and non-trained assistants who helped with the vision testing, auto-refracting, and dispensing stations.
In five days of examining eyes, some of which were significantly longer than others, over 1375 patients were seen, predominantly by the students, as the qualified optometrists (with the exception of one hard worker) assumed supervisory and administrative roles. Team B used a rotating ‘assembly line’ approach to seeing patients, who were seen in the following seven stations: registration (case history), vision measurement, auto refraction, preliminary examinations (pupils, extra ocular movements and external observations), refraction, fundus examination, and dispensing. The team I was managing (A for Arkapaw?) preferred to have the same students see the same patient after the vision testing stage through all the intermediate procedures before handing them over to the dispensing team. This strategy was chosen in a bid to improve the students’ ability to integrate all the information they collected themselves so as to arrive at a diagnosis and treatment plan; it also served to minimise the need for patients to repeat themselves (through a translator).
In all but one location we were working out of local church buildings. The spaces that we worked in varied considerably: one in particular was large and almost too bright (on account of the white walls and big windows); the others were rather small, quite dark (especially when heavy rain was falling on the tin roof, which also made hearing hard) and very hot. (The hottest room we worked out of caused considerable problems for the female Muslim students in my group who were covered from head to toe with clothing.)
Filling the prescriptions that we generated was made arduous by the fact that the vast majority of spectacles we were distributing were of the donated ('pre-loved') variety, which made me super-glad to have volunteers with us who had the time to sift through the many wrong pairs of glasses to eventually find something that was ‘near enough’ to what was needed and in a suitable frame. To their credit, VOSH is in the process of establishing an optical lab in Chinandega that will hopefully remove, or at least diminish, the need for donated spectacles in future visits (at the same time as provide job opportunities for a few locals who will learn to work in the lab).
Referring our patients for further care was also problematic. Referrals needed to be made for all the usual suspects: cataracts, glaucoma, pterygia (though less often than anticipated) & cardiovascular disease. There is no resident ophthalmologist in the area and the one who makes infrequent visits is expensive to see. As such, many patients who required ophthalmological care were simply not going to be seen. Fortunately, those requiring surgery for cataract or pterygia could be directed to the free Cuban clinic in a nearby town. The most heart wrenching moment of the week was learning that the vast majority of patients who we thought to have glaucoma were not in a financial position to afford the drops even if they did see the ophthalmologist. We had a limited supply of glaucoma medications with us, which meant that the students had to decide: who to give the drops to; whether to recommend that the drops were used in one or both eyes; and whether to recommend that they be instilled on an everyday, or every second day regime. These measures were being made in the hope of saving some sight until the next team arrives in 2010 with more medication to give away.
Three of the more memorable patients were: 1) the male builder in his third decade, who claimed to have never worn glasses before, for whom we are making a pair of -15.00D spectacles; 2) The malingering girl who had a history of head trauma (baseball bat to the head) which took the whole of Team A about half an hour to work out; And 3) the elderly lady who had recently lost all the vision in one of her eyes who just needed to cry and be comforted (you can forget how traumatising vision loss is, especially when lost without explanation, until you sit through an experience such as this).
The main organiser of the tour, Suzy Bamberg (who performed her role with precision and grace) is also a member of a Lutheran Church in Florida. She was therefore able to organise a small number of church members with building skills (or just a willingness to help out ) to join the expedition so as to aid in the construction of a few houses over the week that we were in town. The Floridian church has been fostering a relationship with the local community in Santa Patricia, a refugee camp established nearly ten years ago as a result of Hurricane Mitch, throughout the last decade. Church members sponsor children through school (they must have a uniform in order to attend classes) and provide the funds necessary to build concrete brick house for their chosen family (thereby replacing tin shacks). This unique mission with its dual focus afforded members of the eye team to visit the community (and in some cases to even enter the homes) out of which many of the people who were presenting for eye exams had come. This yielded the opportunity to witness first hand the basic living conditions of those we were serving with our professional skills in the clinics. It was a moving experience for all who took the time to visit the camp. There was also a welcome, and a farewell ceremony, complete with cultural performances, held in the camp for the teams benefit at the beginning and end our time there. I took the chance to provide an extra set of hands at a couple of the building sites on the rest day while other members of the eye team visited places that I had already been.
Personally, I had one of the best weeks of my life while working with the team. I really like teaching, and prefer to teach the practicalities of optometry more so than the theory. To be able to interact with the third year students in the capacity of a tutor was highly enjoyable. They did incredibly well, seeing far more patients than they would normally see in a day, and managing to adopt an alternative modality of practice necessary to meet the challenges that arise when practicing in unusual circumstances. Watching them develop confidence and clinical skills over the course of the week was immensely satisfying. I was a little uncomfortable being referred to as Dr Luke - the students insisted on it as they believed it to disrespectful to call me Luke or Lucas as I was requesting - which just goes to show how much a victim to the tall poppy syndrome I am as a result of living all my life in Australia and New Zealand. I also really appreciate delivering optometric services to those who would not otherwise have access to them, working in large teams, and living in community. (I was guilty of trying to be the last one to bed each night in an attempt to soak up all the good conversation that was to be had with such an interesting and fun collection of people). All of these loves combined, made for a wonderful personal experience that simultaneously bettered the living circumstances of many Nicaraguans.
