Thursday, December 20, 2012

Treatment Dilemma

What would you do? I have a patient that has a chronic disease. This disease causes him to get lung infections and shortness of breath. In order to manage the disease (there is no cure yet), he needs to perform certain treatments at home on a daily basis. Unfortunately, he does not. Consequently, he ends up in the Emergency Department with symptoms of shortness of breath and signs of lung infection. I am usually called to admit him to the hospital. He usually ends up staying 14 to 18 days, during which he gets the treatments he should have been doing at home, gets IV antibiotics and an intensified treatment plan to treat the acute exacerbation of his disease.

While in the hospital, he is quite comfortable. He is watching tv, eating well, likes to keep the room very cold, stays up late at night and sleeps in, in the mornings. His social situation is that he lives with a significant other who has teenage kids. The house is noisy, not very clean and there is a competition for the food in the fridge. In the hospital, these problems do not exist for him.

From a physician's standpoint, I feel unable to turn away a sick patient who, without treatment could have a very serious outcome (eventually death). From the standpoint of being a steward of our healthcare resources (did I mention that he is on state insurance?), I almost feel like I should turn him away and figuratively, give his bed to someone else who will be more committed to doing the home treatments as they should. On one hand, I completely sympathize with the patient: having a chronic disease that requires a burden of treatment every day, in spite of which life will be shortened by the inexorable course of the disease is a hard reality to bear. Which of us do 'the right thing' every single day? Many people eat unhealthy, do not exercise, or smoke. Would we (or the healthcare system) punish them? At the same time, at what point do we withhold treatment from someone for not doing the right thing? Some healthcare providers 'fire' their patient. Lung transplant units will refuse to put someone on the list for a lung transplant (even if they need it) if they do not feel the person will make the necessary lifestyle changes (such as quitting smoking). These are harsh decisions made by stewards of limited resources (like a donated lung).

What would you do?

Friday, November 30, 2012

The Two Sides of Medicine

Last week, I got to attend a lecture by a PhD who has developed some revolutionary tools in medicine. He talked about the various 'omics' -- genomics, proteomics, metabolomics and others that I had not even heard of. He talked about new technology that could measure as little as 300 molecules of something in a body fluid. Back in the day when I went to graduate school, we had learned about Moles, millimoles, micromoles as the smallest quantities of something. Apparently, there is now a picomole and a femptomole (which I have heard of) but also an atomole and a zeptomoles -- newer units of measurement to keep pace with a technology that can measure them.

He spoke of a day within, say, the next 20 years when we will be able to wave a wand instrument in front of a patient and get measurements of key molecules in their system to tell us what the probability will be that they will get this or that cancer, or whether they are infected with that or that virus.

For a while, I felt I was watching star trek or some other futuristic science fiction show, as he showed us slides of the technology, the results and its potential. It was truly amazing.

Of course, at the end of the presentation, I went back to my clinic where in an examining room I used my rubber tube filled with air with a flat plastic and metal disk which I placed on my patients' chest and back to listen to their heart and lungs to make a diagnosis.

I find it curious and sometimes get culture shock when I go between the world of the future with these promising new tecnologies and the world of primary care in underserved areas where basic healthcare is still an unobtained goal. Oh Well.

Sunday, July 29, 2012


Yesterday I had a strange new experience as a doctor. I have been taking care of a young (30s) man with spina bifida for the past 5 years. I had just seen him for a physical recently. A few minutes before leaving the clinic at the end of a busy day, I received a phone call from a pathologist. My patient, who I will call Steve, was found dead in his apartment. The cause of death was not known. An autopsy would be performed. I was stunned. I had just seen him a few days ago and things looked good. He had a chronic urinary infection, but with his neurogenic bladder and paraplegia, this was not new or unexpected. He was on prophylactic antibiotics for this. I asked when the autopsy was planned for and was told it would be done the following morning. Since I was not scheduled to work or be on call that day, I asked if I could attend. The autopsy was to be performed in another town.
Yesterday morning, I drove there and found the morgue. Present was the pathologist who would be doing the autopsy, the county coroner and a med tech. I was permitted to gown up and assist with the procedure.

It was a somewhat surreal experience to be standing before someone I had known and cared for for several years and had just examined a few days ago. He lay dead on the autopsy table. The autopsy proceeded in the usual fashion with a Y-shaped incision made on the chest. The ribs and clavicles were sawed to permit up to lift up the rib cage. Systematically, heart and lungs were removed and examined. Bowels were removed and examined. Liver and gall bladder were removed and examined. When we came to the urinary system, the cause of death became apparent. The right kidney was grossly enlarged with a large extra-renal pelvis. There was frank pus in the bladder. The cause of death was urosepsis. It was estimated that Steve had been dead for at least 24 hours before he was found in his apartment. Interestingly, a nurse from the clinic had called him in the morning to give him some normal lab results and his mother spoke to him at around 3 pm that afternoon. He must have died within 6 hours of that time. There was no warning. It is unusual for urosepsis to set in so rapidly with no symptoms manifesting even 6 hours before. Some element of mystery will always remain.

I called his mother from the morgue with Steve's splayed open body still on the table. She had come to his appointment with him as she usually did, just 4 days ago. I offered my condolescences. I said goodbye to Steve and walked away.

In one sense, it was interesting to see the very organs I had palpated, auscultated and percussed from the outside while he was alive. I was able to hold and touch the kidneys and lungs and other diseased organs. I was able to see his spinal fusion beneath the scars I had seen just 4 days ago. In another sense, it was sad -- I was looking at and in his corpse. As primary care providers we do not have to go to autopsies. I went because he was my patient and I wanted as much as anyone to know why he died and as my final act of care. Goodbye Steve. You died so young! I will miss you!

Monday, July 16, 2012

Camp Angel - Summer 2012

Camp Angel is a camp held twice a year (summer and winter) for children touched by cancer through a family member. Camp Angel 2012 was held at its usual summer location: Camp Luther, Three Lakes, WI ( from July 13 to 15, 2012. If you have never been to Camp Luther in beautiful Three Lakes, it is worth checking out the pictures of Camp Luther at their website. Especially beautiful and I think, unique are the actual camp sites where the campers spend their nights. 
Noah's Ark

Pioneer Village or Covered Wagons
51 kids showed up this year. They were divided into our usual 4 groups, the 14  littler girls (7-9 year olds) were in the Bunnies group and they stayed at the Pioneer Village or Covered Wagons. The 16 older girls (10 and 11 year olds) were in the Foxes group and stayed at the Treehouse. Similarly, the 9 littler boys (7-9 year olds) were in the Wolves Group and stayed in the Tower, while the 12 older boys (10 and 11 year olds) were in the Bears group and stayed at the Fort. The photos show pictures of the Covered Wagons, Treehouse, Tower and Fort camp sites where the groups stayed.

The campers arrived at about 3 pm in the afternoon on Friday, July 13. After some games of introduction, campers went to their respective camp sites to settle in. We had our usual Friday night dinner of delicious pizza. This year, something was different. We should have known, given it was Friday the 13th. There was quite a storm during dinner and lightening cracked a tree that fell on a powerline pole and took the powerline down with it. One of our camp staff whose was driving in late was stranded on the other side of the blocked road. Also unable to get through to us was the local Harley Davidson Group. No one was hurt. We did lose power though. One enterprising biker was able to get through and he generously offered to present a show-and-tell to the kids. Practically every kid got their picture taken sitting on his bike! The camper retired to their camp site for the night where they slept…er…played and horsed around.
The downed power line

The next day, power was restored by around 7 am. After breakfast, in 2 separate groups, we took off for Eagle River where we went for a ride on the Pirate Ship ( 

Captain Steve was gracious as ever. We had a great time (aarrrhhh!!!). We came back hungry and ate a great lunch. After lunch and swimming tests, it was time to get out on the water. Kids swam, went tubing, swung from the rope into the water, fished (actually caught fish!). On shore, there was face painting, rock painting, crafts, painting driftwood and other fun activities. In the evening, DJ Dan brought his setup over and it was time to dance! This year, there were many requests for Justin Bieber. DJ Dan did not disappoint. Even though he did not have any to begin with, thanks to the internet and iTunes, kids were soon rocking to Bieber. Kids returned to their camp sites for bonfires, s’mores and (officially this did not happen) girls versus boys camp raids.
Beware the pirates!
Okay. So this is a medical blog. As the camp doctor, I treated small cuts and bruises. I did have to set and cast one displaced fracture for one little girl. Nothing serious. She came to me in tears with her broken walking stick. She left smiling with her stick bandages and set (almost) as good as new.

I treated some swimmers ear, upset stomachs, overheating, mild dehydration and the camp staple: homesickness. I also made sure everyone got their scheduled medications. I was a little uncomfortable given one little girl the medication that she was prescribed by her provider back home. Her medications included lithium (for bipolar disorder), Seroquel (for mood disorder), Depakote (for mood disorder) and something for sleep and ADHD. I am not a child psychiatrist. I felt sorry for this little girl being on such strong psych meds.
Free Style Four Squares: chicken feet, black magic and cherry bombs allowed!

Girl talk and ... hey, get off the roof!

Pirates of the Caribbean... okay, actually of Camp Angel

A sign in the pirate ship... hope the kids didn't notice!

Me and the First Mate

I LOVE Justin Bieber! Play more Justin Bieber!

Captain Steve made some mean tatooes...

Hanging on to the bobbing moon-thingie was loads of fun

Sliding into the lake

Our med and First-Aid room -- my kingdom

A view of the lake early in the morning

A shout-out to the awesome camp counselors we have. These young men and women, many of whom began coming as high school students and some of whom still come even though they’ve graduated college do a great job. They are aces at treating homesickness and worshipped by their campers. They carried them, played with them, colored T-shirts with them, and made the camps fun for these kids.

The camp is kept short – three days because most of these families have too much going on to spare their kids for longer. Reading through each child’s connection to cancer breaks your heart. There was one little boy at camp with his two sisters. 

He constantly acted up. Playing Four Squares, he would argue about the rules (black magic and chicken feet allowed/not allowed, we’re playing freestyle versus we’re playing four squares). Reading his notes, I realized that he and his three sisters had lost their dad about a month ago to cancer, and he was really close to him. What’s more, his death had been difficult. Childhood should be a happy time. Cancer does not respect that. Camp Angel brought smiles and laughter to broken hearts, even if just for a weekend. Every little bit helps. Hopefully, we created some sunshine memories in the dark cancer-winter  of these young lives. 

Tubing. Go faster!

Sunday, June 17, 2012

Happy Father's Day

It's June 17 -- Father's Day. I'm working Urgent Care Pediatrics.

On a day to celebrate fathers, I sure saw a lot of them. Worried, broad shouldered, holding their little ones in jammies, blankets or in infant car seats, they brought their little ones in. I walked into one room to find the baby in the car seat fast asleep and the dad sitting on a stool with his head resting on the table, also fast asleep. He wearily recounted a difficult night of sitting up with a fussy, coughing baby.

Here's where the rubber meets the road. Fathers caring for their children, no thanks needed. Selflessly, they did their duty as parents and dads. When I casually remarked to one dad of a 4 month old,

"Hey! Congratulations! It's your first father's day!"  (This was his first child).

He looked at me puzzled for a moment and then broke a smile and said thanks. He wasn't thinking of Father's Day, or presents, or a special day for him. He only wanted his little boy to be better.

In a world that has its share of deadbeat dads, irresponsible, selfish and childish men who father children nonetheless, it was great to see that there are still caring, tenderhearted, broadshouldered men out there who are doing their jobs... even on Father's Day.

Happy Birthday to You!

Working Urgent Care Peds on the weekends is lots of fun. Oh sure, some days you're so busy you don't know if you're coming or going. Yesterday was one of those days. The place was hopping! Imagine my surprise when another 8 patients appeared in my list of patients to see. Curiously, they all belonged to 2 families. Hmmm...

My colleague on the adult side was seeing a couple of adults there too, in relation to the same thing.

Here's the story. Dad had a birthday (yay!). A cake was ordered. The cake was cut, Happy Birthday was sung. Good times for all. While Mom was cleaning up, she began to wash the knife. Imagine her surprise when she noticed that a piece of the knife blade was missing. It was as if an arc-shaped piece from the cutting edge of the knife had dissappeared. She could swear that the knife was entire this morning when she put the knife in her husband's hand. Oh-oh!

The family all rushed to Urgent Care. Was the knife piece in someone's belly -- someone who had eaten the cake? Thoughtfully, they brought the cake along as well. Half of it had been eaten of course and the other half had been cut into slices, but it was still in its glass baking dish.

While we were all contemplating having to x-ray all these adults and children to look for a metallic piece in their gastrointestinal system, our radiologist had the presence of mind to save the situation. He would x-ray the remaining birthday cake. If the piece was not there, then the whole lot of them would be walked through a fluoroscopic (live-action x-ray) machine to look to see where the knife piece was.

Fortunately, the knife-piece in its enterity was discovered in the cake. It showed up beautiful on x-ray. I must say that I think this is the first time I have heard of x-raying a birthday cake but hey, anything's possible.

We did not have to x-ray anybody.

At the end of it all, we were left with one problem (By the way, the family took the cake home). In this day of electronic medical records and billing, how do we record the x-ray? Our drop-down menus all had anatomy locations to choose from (chest, abdomen, thorax, upper and lower extremities, etc). Cake was not among them.

Some problems we can live with.

Sunday, March 25, 2012

In Memory of Harry

Harry W. Kuse (1922 - 2012)
It's a Sunday evening. I have a new (to me) patient with cystic fibrosis on the floor. I was not supposed to work this evening, but whenever a cystic fibrosis comes in, plans change and I round on them daily. As I finished doing that (circa. 7:30 pm), I thought to go and see my patient and friend, Harry. Up until Friday, we had been trying to treat him and he was not responding. The plan was to transfer him to palliative care's service by Monday if he did not turn around. I looked up his name on the computer and found that he had already been transferred to their service. Things must have taken a turn for the worse, I thought. I walked down to the unit to see him and his family -- a doting daughter-in-law and son. The bed was wiped clean. Harry was dead. He died around 5:30 pm today.

I first met Harry way back when I was still doing residency training. I still remember entering the exam room to find this pleasant elderly gentleman reading a western novel without any reading glasses. Through the years I came to know Harry well. He probably read every western novel he could get his hands on. Towards the end, the only westerns he could find that he had not read were western romances so he began reading those too.

Harry had become quite deaf but absolutely refused to wear hearing aids. We communicated with him by writing things on a whiteboard and he would reply back verbally. In the beginning, his daughter-in-law had to 'translate' everything he said to me because I could not make out the words in his near mumbling, rumbling voice. Towards the end however, I was surprised to realize one day that I no longer needed her help. I understood him well enough.

Harry was a tough old guy. He would flirt with the nurses and aids at the nursing home and hospital and had a great sense of humor. In the last 3 weeks he took a turn for the worse and began a slow decline that failed to change despite antibiotics, breathing treatments or whatever we did. We began to see this coming.

I remember walking away from the hospital last Sunday reflecting that for the first time, perhaps, I was losing my clinical objectivity with respect to a patient. I did NOT want him to die! I was not ready for comfort measures and found myself suggesting to his hospital doctors that we try this or that treatment. They looked at me sympathetically, but puzzled and a little dissappointed. I was supposed to be on their side in telling the family that it was time to let Harry go and I wasn't helping. It gave me pause. When does a patient become a family member or a close friend so much so that clinical objectivity is lost? Can I truly do right by my patient if I become emotional towards the inevitable decline?

On Friday, I saw Harry for the last time. He would open his eyes when I called his name but close them seconds later. I confessed my struggle with objectivity to the family with a trembling voice. However, I did put my heart aside for the moment and told them that I thought Harry had fought long and hard and his body was giving up. It was time to stop the treatments that weren't helping and keep him comfortable. They agreed. His daughter-in-law had in fact already begun to assemble photos of Harry in a slideshow and shared some of them with me. We all shed tears as we smiled at Harry's mischievious smile and twinkle in his eye as he rode his little tractor in their garden, as he played with grandkids, and wore a valentine heart on his last valentine day. I was paged out of the room and had to rush away. That was the last time I saw Harry.

They say you're not supposed to get attached to your patients. How is that possible after taking care of them for years and going through thick and thin, near misses with death and some emotionally charged painful experiences together? Sometimes all even a doctor can do is shed tears and bid farewell to a patient who becomes a friend.

Goodbye Harry! I will miss you! I still got your kids to take care of. Know that they are in loving hands.

Saturday, March 03, 2012

Tension in the room

It was the last patient of the day. Why is it always the last patient of the day?

It was a well child exam of a beautiful toddler. She was in the room with both of her parents. She saw me enter and smiled. Mom gave her a photo to hand to me. It was a picture of her all dressed up looking so-oo big. I smiled and thanked her, giving her a hug.

In the room were mom and dad. When they looked at her or talked to her or to me about her, they beamed. Their eyes lit up as they proudly recited all the words she could say and the new things she was doing. They did not have any concerns. But...

When they looked at each other or exchanged a few words, the tension could be cut with a knife. I knew they were divorced. I knew they shared custody. They obviously loved their daughter. They showed their committment to her by both coming to the appointment -- or did they not trust each other to relay anything that may transpire at the doctor's to each other?

Divorce is such a sad part of our society. With more than half marriages ending in divorce, there are many children in shared custody. Most parents love their children even if they can no longer share a marriage with their child's parent. I hurt for the parents and the children in this situation. As a doctor who sees children, interacting with the adult parents is part of the equation. As a doctor to adults too, I feel the pain of both the parent and the child and want to help them both. But how?

I have seen this child since she was born. Her parents were married then and not now. I will continue to walk with her and with them doing what I can for all of them. One day, one visit, one situation at a time.

El Salvador Mission Trip 2012 - Part 1

From January 20 to 29, 2012, a group of 56 people, including 4 doctors, 1 dentist, 7 nurses and others travelled from Marshfield, WI to El Salvador to work, pray, love, repair and build. In 4 days, we visited 4 different underserved sites in the country and delivered medical care to 800 people. Here are some pictures from that trip.

On medical missions, if you'll need it, take it with you!

Every morning, we'd have breakfast at 6:30 am. About an hour later, we would load our two buses with people and equipment. Pretty tight fit! Most of our trips involved 2 to 4 hours of bus travel each way to the places we worked at.

To get to some destinations, it was necessary to transfer everything to smaller pickup trucks.

Sometimes, the roads were too narrow for a bus, so we'd transfer everything to small pickup trucks and go the rest of the way

Let's make bubbles!

We had a lot of fun and I think, got back more than we gave. Here is one of our high school volunteers (Olivia Heegeman) teaching a little girl how to blow bubbles.

Blowing bubbles is fun!

It worked! Laughter is free.

removing an infected ingrown toenail
One of doctors -- Princy Ghera-- was a Med-Peds resident from our (Marshfield Clinic's) combined residency program in internal medicine and pediatrics. She finishes her residency this June and is going on to become a pediatric pulmonologist. Here she is removing an infected ingrown toenail while I looked on.

Here's the patient (mom) holding onto her daughte for comfort.

Interestingly, while she worked on the patient's toe, the patient, a mom, held tightly onto her daughter, while the second one looked curiously at me trying to comfort her. Usually mothers comfort their children during medical procedures. But who says the roles cannot be reversed?
Our team purposely went to the poorer parts of the country. Our goal was to provide free medical care and services to those without access.

Some of the houses nearby where we worked

El Salvador Mission Trip 2012 - Part 2

Counting pills
 A regular ritual before we can hit the road to visit the places we go to provide medical care is counting pills. We pre-package 30-days supply of pills in little plastic bags that have symbols of a rising sun, mid-day sun and setting sun. We pour out volumes of syrups and liquid medication into one-person size bottles. This takes quite a while and by the end of night, not many of us are left smiling as we are here at the start of the activity.
In the background you can see our evangelism team learning street skits and dances they used to reach people on the streets while we saw patients.

Are they any more left?
 Basically, the evening before our 'work week' begins is used to set up and package all our meds and plan what we'll take.

on the road
 Once we're all packed, we hit the road. Our daily bus ride took 2-4 hours each way. The roads weren't the best. Because of constant use, these vehicles often lose their shocks and their suspension gets shot. One of the teams that came down with us were a dedicated group of auto mechanics that stayed behind at the center and overhauled, repaired and maintained all the vehicles and equipment.

Onto a smaller pickup where our bus could not go

For me personally, it was fun to load the bus, then unload the bus and load the pickup truck, then unload the pickup truck and set up everything in the places we provided care. We all worked hard to do this. It was good exercise.

Setting up
 Here we are outside a church in Las Delicias. We set up our clinic inside that church and saw approximately 200 patients that day.

Dr. Boris Magana 'checking in'  a patient.
  Once we were set up, there was a system. People in the area were told beforehand that a medical team would be coming and they could come and get free care and medication. They were given coupons (free) ahead of time. Once they showed up, they filed into Dr. Boris' station. He took down a chief complaint, filling it out onto a medical form on which the next station could write down vital signs, blood sugars.

Checking blood sugars
  This year, thanks for donations from the makers of OneTouch, we were able to check blood sugars. We diagnosed several new cases of diabetes and some known cases with uncontrolled diabetes. One patient with a blood sugar of 600 (normal: 70 to 100) told us that he knew he had diabetes. He said the local hospital was out of insulin. We are trying to build a clinic where patients can come and receive continued medical care. For now, Dr Boris sees them rotating visits through the various places we were about once a month.

Checking vitals
Once patients had checked in, the stepped to the vitals station where nurses checked vitals.

Nurses wrote the vitals onto the patient's 'char' (a single sheet given out at the triage station above).

Getting busy
 To keep people amused and occupied during the several hours wait it took to process and see everyone, we had a couple of volunteers entertain. Zip (Fran Davis) sews her own clown costumes and is a great hit with the children every year.

Zip (Fran Davis) with a couple of fans

A family waiting to be seen

El Salvador Mission Trip 2012 - Part 3 -- Seeing the doctor and dentist

Once processed, patients take their seats in a waiting area and are seen by a doctor and/or dentist. If referred, they are sent to a station to get their ears flushed, get an injection, get sunglasses or get their teeth varnished (for the kids).
towards the end of the day, there were few patients left to see

Seeing a patient in El Salvador in a medical missions environment is different than seeing them in the office in the States. It is noisy, busy and there is little or no privacy. There is no exam table. Most patients give their history using terms that would mystify most internists. If you ask them "How can I help you?" they look at you confused and say "I don't need any help!" In El Salvador, doctors ask "Que tiene?" -- What d'you have? That magic phrase gets them talking and interestingly, they all begin with "Fijarse doctor, es que tengo..." (Focus on this doctor, it's that I have...). They used expressions like "tengo nervios" (literally, I have nerves or nervousness), "Mis ojos arden" (my eyes burn) or "me duele mis canas". Through the years, we have figured out that there is a lot of dehydration, dry eyes, fatigue, and perhaps parasite-related complaints.
Getting a history -- the key to a diagnosis

Dr. Dave Heegeman seeing a patient
 More scary though was that they would use medical terms in their description of symptoms like "cuando tengo cholera..." (when I have cholera...) or "tengo mucho parasitos (I have a lot of parasites...) or "siento mucho malaria" (feel malaria). This can be quite bewildering in the beginning.

Dr. Thao Trinh, a pediatrician seeing a patient

Dr. Princy Ghera checks a thyroid
One learns to adapt and ask different questions until one is satisfied that one has a story that makes sense.

Thinking it through -- the internist's job

What are we going to do next?
 Dr. Boris and myself are talking to Oscar and his mother about what to do for him after I debrided necrotic stage 3 pressure ulcers.

Rick Mueller (our dentist) and Amy Neumann assisting
 Our dentist Rick Mueller has come with us every year. He brings along a portable dentists chair and a pump compressor unit for suction and a whole slew of instruments. Assisting him here is Amy Neumann who is actually a violinist and information technology specialist, but she learned on the job quickly enough.

El Salvador Mission Trip 2012 - Part 4 -- Eye problems

Eye damage from a chemical spill
Something that has struck me on previous trips to El Salvador (this was trip 3) is the number of eye problems we see. Sometimes we arrive too late to make a difference. This gentleman worked in construction and was applying a chemical to a ceiling (without safety glasses). A drop of the solution fell into his left eye. Miraculously, he can still see from some parts of that eye

Nevus in eye
  I saw a lot of congenital nevi in the eye (see the one in the right eye lateral to the iris in this little boy. Interestingly, I have seen more eye nevi in the eyes of my hispanic patients even here in Wisconsin.

Another Nevus in the eye
  Here is a close up of another patient's eye showing a nevus there. In all these cases, the nevus was present since birth and did not cause any visual changes.

bilateral pterygia
  Every year we go to El Salvador on these trips, we see a lot of patients with pinguecula and pterygia. Here is a middle-aged lady with bilateral pterygia (see the white stuck-on appearing growth spreading from the medial canthi towards the iris). If this continues, it will cut off her vision -- and we have seen examples of that too. Since surgery was not possible (we did not have an ophthalmologist with an operating microscope and operating room), we did the next best thing. A simple was to prevent spread of these is to protect the eyes from the sun. We took as many sunglasses as we could and gave them away, prioritizing patients with pingueculas and pterygia.

pterygium in left eye
  Here is another example of a middle-aged man with the pterygium in the left eye.

spreading pterygium
 In this example, the pterygium had already spread to the pupil and vision was being obstructed.
pterygium in left eye
Yet another example of a pterygium in the left eye.

cataract in right eye in a 90-something year old
Okay, to end on a slightly cheerful note, I had this spry 90-something year old female come in with complaints of decreasing vision in her right eye. She had a cataract, but hey, she had no other complaints. She was feeling just fine! Just because you live in a third world country in poverty does not necessarily mean you can't make it to 90.