Hektoen International

A Journal of Medical Humanities

Beyond the scope

Nathan Cannon
Hershey, Pennsylvania, United States

Retina Group slit lamp (side view). Ophthalmoscope photo by Ben Schumin on Wikimedia. CC BY-SA 3.0

Hushed hum of voices. Open, dimly lit room. Slit lamps gliding, knobs turning, lenses gently flashing. Clinical officers hard at work, diagnosing, assessing, treating.


I am seated beside the attending, a retina specialist. Together, we have been seeing his patients, who have had a remarkable array of corneal transplants, tube shunts, and muscle alignment surgery. These procedures are valuable anywhere, but maybe especially here—a place where clocks and calendars are overrated and communal chai predictably slows the morning. Here the temperate highland climate nourishes sprawling emerald tea fields, radiant patchwork quilts draped over rolling mountains. Most patients live in mud or tin huts but somehow manage to scrape together fifty shillings to visit the eye daktari, evidence of the trust this hospital holds among its neighbors, the Kalenjin, inhabitants of the highlands of Kenya’s Great Rift Valley.

“Look up. Angalia juu. Down, chini. Straight ahead, mbele. Good, your allergies are improving. Keep up your current medication and follow up in three months. Next!”

A father and two boys walk in. The older child looks to be around seven years old, the younger not more than five. Is that a limp? My attending’s brow furrows. “I remember these two.”

As they approach, the older boy stows his crutches and negotiates the precipitous transfer from father to armrest, fumbling slightly before sliding into the exam chair. I look down. His scarred and misshapen lower limbs twist unnaturally, like a doll when its joints are overmanipulated.

“They’re brothers,” my attending explains. “A few months back, they were playing in a field and found a metal object. Curiosity got the best of them, and they picked it up.” He hesitates, glancing at the boy still seated calmly in the chair. “Or tried to.”

“And?” I ask.

“It exploded.”

I swallow hard and try to keep from picturing the scene.

“Apparently, there were military drills in the area, and a grenade hadn’t detonated. I don’t quite understand how they survived. They have already had the ocular shrapnel removed. It took me nearly an hour each, can’t imagine what it took for plastics. No globe penetration, except for his left,” motioning to the younger child, “which we had to remove.”

I fend off the questions that begin to surface. What was the military doing carrying out drills in civilian territory? Who throws a grenade and forgets when it doesn’t go off? Why do these crazy things seem to only happen here?

“Would you like to perform their exam?”

I bite my lip as discordant waves of dismay and curiosity wash through me. The latter sentiment rallies, and I nod and sink into the chair, swing over the slit lamp. The boy sits forward expectantly. I can see the pockmarked scars scattered across his face, smaller but more numerous than I expected. I wonder what the other kids his age think?

I think of myself as a child, playing in my backyard. What are the chances I would have stumbled upon a military grade explosive? Practically zero. Not even a question. What other parts of these people’s lives am I missing?

“Come forward. Kuja hapa.” I motion with my hand toward the chin rest. He scootches closer, brushes his forehead against the frame and startles backward.

“He doesn’t see well.”

“Right.” A wave of warmth washes over my face. Deep breath. Focus on the patient in front of you.

This time I help guide his head into the frame with my hand. For a second, I almost imagine the faint flicker of a soft forgiving smile, and then it is gone. He opens his eyes wide and looks expectantly out, as if he has done this a thousand times before. I adjust my chair, lean into the eyepiece, and focus the beam.

Lids and lashes clear—wait—no, distortion of upper and lower lid margins from complex scarring. And how scarred would I be, I wonder, if my familiar childhood surroundings suddenly blew up in my face. How much has he had to grow in these last months?

Angalia juu, chini, mbele.

Sclera without injection. But so many miniature craters, bordered by faded brown. My stomach churns. I’ve never seen burnt sclera before.

I redirect the beam centrally, and my breath catches.

The cornea is a starry sky. Scars and thin white ringed opacities throughout, visual axis occluded.

“Those are called Coat’s rings. From metal foreign bodies.”

I suddenly remember to breathe. The seven-year-old in front of me wears the singularly most terrible and beautiful battle scars. One would think I were peering into the eyes of a seasoned veteran.

Incongruent emotions resurface, and with a brief headshake I return my attention to the landscape behind the whorled fray. I think the iris is okay. Hard to say about the angle. I won’t even try for cell.

Left eye… I am lost again in a symmetric tapestry, both unsettling andmesmerizing.

They switch, and it is the younger brother’s turn.

I marvel at the level of cooperation for his age. He has to stand because his torso is too short to reach while seated. He has a little trouble looking in each direction, but manages with his father’s encouragement.

Similar, but a larger scar inferonasally.

I shift with the scope to his left eye and almost jump.

“You forgot it’s gone.” My attending wore a wry grin. “Still good to take a look.”

I purse my lips and return to the eyepiece.

Dysmorphic pink tissue. Clean and moist without discharge.

I sit back and my shoulders sag. The enormity of these boys’ challenges, past and future, crashes down. How will they function in school and society at large? Will they grow up begging on the streets? All because of one traumatizing accident? At the same time, it is not lost on me how calm and poised they have been throughout the exam. Clearly, they possess maturity beyond their years.

My attending breaks in: “At this point, his wounds are fully healed, so we can extend follow up to two months. He has protective eyewear, and his brother is on the wait list for corneal transplant. I don’t think we have anything else to offer.”

My ear catches the warm chatter of street venders outside the window, and a soft breeze sweeps through the acacia trees. A heavy sigh escapes me. How is it that among these beautiful surroundings and warm people there exists such suffering and struggle? The problems are so much bigger than myself, and extend even beyond the scope of medicine.

As the attending explains, the father listens with rapt attention, hands resting on the heads of his two boys, hanging on every word. “We will do what it takes to help my boys see as well as possible,” he responds.

They turn to go, and I see the younger boy take the brace he had been clutching with both hands and extend it towards his brother. A smile softens my face, and I become aware of the tension throughout my body. Relax.

Father and sons hobble together towards checkout, and I catch a whiff of familiar chai. Teatime already?

Please come back and teach me again soon.


NATHAN CANNON is a fourth-year medical student at the Penn State College of Medicine in Hershey, PA. He holds a Bachelor of Science in Physics from Roberts Wesleyan University and plans to pursue a career as an ophthalmologist. This work is based on his experience on his most recent medical missions trip to Tenwek Hospital in Bomet, Kenya. 

Summer 2023



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