Service trips add valuable experience for life and practice

An ophthalmologist reviews the benefits he has received from helping others.

Issue: May 1, 2006

ByRichard P. Wilson, MD

Nathan G. Congdon

I’m delighted to introduce a new feature in Ocular Surgery News entitled “Thinking Globally.” The focus will be on the burden of blinding disease in the world, particularly in the developing world but also in underserved areas of our own country. The column will also discuss potential solutions to these all-too-common and unnecessary causes of blindness.
In this month’s piece, Rick Wilson speaks directly from the heart about the satisfactions that come from the restoration of sight in underserved areas. His words remind us of those of Sir John Wilson: “People don’t go blind by the million. Each of them, as a human being, goes blind as a personal tragedy.”

It is appropriate for this column to begin on a personal note, with stories of the alleviation of blindness patient by patient. Over the months we will explore other perspectives on the problem of world blindness. What are the best approaches to cataract or pediatric eye disease in the developing world? What solutions are sustainable over time? What is the appropriate role of the ophthalmologist?

Vision loss can be limited or cured by surgery or the latest pharmacological wonder, but it can also be prevented with face-washing or a 2-cent capsule of vitamin A. “Thinking Globally” will explore a range of blinding problems, some of them with elegant solutions, others with workable approaches and some for which good answers are still needed. In all cases the message is the same: Much is being done, but much remains to be accomplished as well.

Nathan G. Congdon, MD, MPH

Richard P. Wilson

As an Army brat who was born in Germany and grew up around the world, traveling came naturally to me. However, taking time away from a busy glaucoma practice for service trips required two a priori decisions. The first came with the realization that, as Reed Kindermann, a frequent Surgical Eye Expeditions participant, puts it, “This is not a dress rehearsal.” One does not get a chance to replay missed opportunities. The second decision was that my goal, if I am fortunate enough to live that long, is to be able to sit in a rocker on the porch of my old folks’ home, perusing a lifetime of unforgettable and exceptional memories.

These early decisions led to 3 months in Australia in community psychiatry and 2 months on the Hope Ship in northeast Brazil in internal medicine before I graduated from medical school. The experiences were so rewarding in terms of education (treating patients with tetanus, rabies, kala-azar, schistosomiasis and Chaga’s disease), places (the Great Barrier Reef, Machu Picchu) and people who have remained friends, that a life-long pattern was established.

Life lessons in Kenya

During the last 6 months of my glaucoma fellowship at Wills Eye Hospital, I explored multiple options for working in Africa. I settled on a Presbyterian Church of East Africa hospital called Tumutumu, more than a mile up the slope of Mount Kenya. I raised $45,000 in equipment and medication and obtained six volumes of Duane’s Clinical Ophthalmology. Shortly after July 1, 1979, I arrived in Kenya, 5 days before the team I had recruited, allowing time to obtain a Kenyan medical license and a waiver of the duty my supplies would normally elicit.

The license was easy.

I went from agency to agency and back again trying unsuccessfully to get the duty waiver. If the authorities demanded an onerous duty beyond my limited means, my mission would be over before it had begun. Inexperienced in the art of baksheesh, I did not even try to offer a bribe. With a sinking feeling in my stomach, I returned to the airport to meet the volunteer team: a scrub nurse, the event coordinator for Wills Eye and a pharmacist on loan from Alcon. I waved to them as they descended the stairs of the plane, but then they disappeared. My dread intensified.

Suddenly, an Air India employee asked me to follow her out a side door and down the street. There I found an Air India van loaded with my team and all our supplies ready to take us to Tumutumu. It turned out that Peter Chan, the Alcon pharmacologist, called the local Alcon representative to see what help he could offer. The representative’s wife worked for Air India. My worldly education was just beginning.

One-hundred eight-five patients were waiting in the hospital courtyard to see me the morning of my first clinic. Some had walked 2 days to get there. One out of every three had active trachoma or evidence of previous infection. The Kenyan legislature annually set aside enough money to acquire sufficient tetracycline ointment to treat the country’s trachoma. Due to graft, supplies rarely lasted through May. At Tumutumu, I was impressed that the hospital administrator’s lifestyle seemed well above his salary. On my return to the United States I related this to Presbyterian Worldwide Ministries. Six months later he was in jail.

Treatment challenges offer experience

My ophthalmic education proceeded apace with my worldly life lessons. I was amazed to find the occasional Indian immigrant, but no Africans, with refractive error. Had the lions eaten all the myopes, or would this phenomenon be seen in an illiterate population anywhere? Everyone presented with 20/20 vision or a serious condition like cataract, trachoma or glaucoma. My 2 months in Kenya produced not one case of angle closure in an African, although later in Ghana I saw an unusually high prevalence of silent, progressive angle closure.

Patients presenting with bilateral serous retinal detachments and infectious or inflammatory conditions challenged my knowledge (Figure 1). I had just come from the womb of Wills Eye Hospital where, if I did not know what to do with a problem patient, it was easy to take the patient to the appropriate specialist. On Mt. Kenya, I was on my own, spending time with my Duane’s, doing major marginal lid rotations for trachoma with the textbook open beside me (Figure 2).

Patient screening and registration at Tumutumu was performed by Peter Chan and Lucia Manes.

Patient with total inversion of lid secondary to trachoma following textbook-assisted marginal lid rotation. Prior to this procedure, she had not opened her eyes in 17 years because of the pain of her lashes rubbing on her corneas. Inferior scarring is visible.

Images: Wilson RP

My first surgical patient was a young girl who injured herself taking the hem out of a dress. She stuck the point of a pair of scissors through her cornea, iris and across the eye through her retina and choroid. Without a vitrector or retinal cryo and using loupes, I did the best repair I could and was amazed to hear from a doctor who was there 6 months later that she was seeing 20/50 with that eye.

I quickly learned that although male patients could undergo surgery as usual with a retrobulbar block, women required general anesthesia with intravenous ketamine, the only available agent. This was because severe cervical arthritic pain prevented them from lying still on the operating room table – a result of carrying huge bundles of sticks and other goods on their heads when they were younger.

In addition to my duties at Tumutumu, every Thursday I would drive 2 hours to Kenyatta National Hospital in Nairobi. I went to share my knowledge of glaucoma but ended up learning much in return. Being taught to do an erisiphake cataract extraction without gloves left an indelible memory. You never realize how much sterile gloves blunt the sensation in your fingertips until you do surgery without them. Washing with lye soap and then alcohol seemed to add to the sensitivity as well as the erythema.

Each trip a new lesson

My Kenya experience has been repeated many times in various countries over the years, each time with important lessons learned from new friends in memorable surroundings. Even after 25 years of busy surgical practice in the United States, there is much to learn in a day filled with congenital cataracts, glaucoma and partially couched lenses in Africa, or dense lenses in small, cramped eyes with limited exposure in China, especially when you add paper gowns that have been repeatedly steam sterilized and unfamiliar instruments to the surgical experience.

Teaching others while struggling with a case has increased my capacity to multitask. My service experience has greatly improved my ability to solve surgical problems with whatever instruments are at hand and with a minimum of help.

The greatest benefit is obvious: the incredible feeling of restoring sight to a woman after 17 years so that she can see her grandchildren, or taking a man who has required someone to lead him around and returning him to tending his cattle. The faces of joyous mothers whose children have had their sight saved or restored appear before me as I write this and it brings tears to my eyes. Having a son or daughter assist you on a service trip by registering outpatients, helping out in the clinic or operating room, or just observing (Figure 3) enables you to share this feeling of enthusiasm for helping others. It also graphically convinces your offspring how lucky they are to be growing up in a well-off community in America, a world far different from that of the majority of the world’s population.

Philip Wilson (right) observing his father perform surgery at the Emmanuel Eye Center in Accra, Ghana.

Clearly, my service experiences have enriched my life and that of my family. In years to come, while I may not remember what I did yesterday as I rock back and forth on the porch of the old age home, I will not suffer from a lack of memories to enjoy as I page through them in my mind.

For more information:

Richard P. Wilson, MD, can be reached at Wills Eye Hospital, 840 Walnut St., Philadelphia, PA 19107; 610-664-8880; fax: 215-928-0166; e-mail: wilson@willsglaucoma.org.