Post 2: First days in the clinic

Monday, November 17: We woke up early to enjoy an excellent and extravagant breakfast prepared by the World’s Best Cook, Lu. We also got to meet the Brazilian Audiologist from the clinic, Rildo Galucio, who was super nice and seemed excited to be working with us. Together (with Davison’s help for translations) we went over the day’s itinerary. The plan was for us to see about 8-10 patients per day, but Vanessa urged us to spend as much time as was needed for each patient. We very quickly went through the consultation rooms to familiarize ourselves with the equipment available. For diagnostic testing, there was a small single-walled sound booth with a basic diagnostic audiometer. There was also an immittance bridge for doing middle-ear testing. Finally there was a computer and Hi-Pro box for programming hearing aids.

Monday breakfast
Monday breakfast with Lu, Ellen, and Davison (Vanessa and Rildo not pictured)
Monday morning, patients were lined up by 8:30
Familiarizing ourselves with the layout of the clinic.

At 8:30, we began with our first patient at the Vivo o Som clinic, a 16-year-old boy with unilateral microtia. His audiogram from a different clinic indicated sensorineural hearing loss in the affected ear, which seemed unlikely, so Ellen completed a new hearing evaluation on him, which showed conductive hearing loss. We were able to adjust his hearing aid program accordingly, and he was happier with the way the hearing aid sounded. We discussed the possibility of a bone-anchored hearing aid, but the patient would need to go to a specialist in another town for that.

Our next few patients were adults coming in for hearing aid evaluations and rechecks. One gentleman needed a new hearing aid because while he was hunting, an animal attacked him, and during the ensuing struggle he lost his hearing aid. I’m pretty sure that was the first time I’ve seen a patient with that particular problem!

first patient
Collaborating on our first Vivo o Som patient!
New HA fit
Fitting a new hearing aid.


Lunch was a delicious meal prepared by Lu, and it included this incredible dessert she made to welcome us. We love the clinic staff—they are so kind to us!!

Welcome dessert
Our delicious “Welcome” dessert, courtesy of the best cook in Parintins (Lu).

In the afternoon, we saw an interesting vestibular/balance case, a woman whose otorhinolaryngologist had diagnosed her with labyrinthitis. However, when she described her symptoms, it sounded more like positional vertigo. We asked about the specific types of testing her doctor had done with her, and we decided to go ahead and do a Dix-Hallpike maneuver to test for a disorder called Benign Positional Paroxysmal Vertigo (BPPV). I asked Ellen to take the lead, because she’s much more current with this type of testing than I am! We cleared of the exam table in the other room, and I assisted Ellen as she completed the test. However, we had negative results! We decided to re-interview the patient for a more detailed description of her symptoms, and when we did that, it turned out that she had all the hallmarks of Meniere’s Disease (episodic vertigo, low-frequency sensorineural hearing loss, roaring tinnitus, and aural fullness). We referred her back to the otorhinolaryngologist to discuss this as a possible diagnosis. I was so proud of Ellen for confidently taking the lead with this patient—I don’t think we could have done this without her!

Completing a Dix-Hallpike maneuver on a patient with vestibular symptoms.
Getting additional case history information after a negative Dix-Hallpike.

Our other patients that day included several more evals, rechecks, and hearing aid fittings. By the end of the day we were really finding our groove as a team—me, Ellen, Rildo, and Davison. The consult room got pretty crowded at times, but I felt like we were providing great care for the clinic patients. As a bonus, by the end of the day, I felt like I could understand about 20% of the Portuguese the patients spoke. Not bad for arriving with only about two words of Portuguese in my vocabulary!

Ellen got to do a LOT of audiograms.
audiometric testing
Ellen, AuD student extraordinaire!
programming HAs
Collaboration sometimes takes a while when the computer connection is sloooow.

After a long day of clinic, we finished up around 6:30, and then enjoyed a delicious dinner prepared by Lu. Everyone we’ve met and been working with has been incredibly nice; we felt like we just fit right in. Dinner was lots of fun and joking around, but Ellen and I were so tired we went right to bed after dinner.

We were pretty spoiled by the decadent meals Lu prepared for us, but it was so nice to unwind with everyone at the end of the day!

Tuesday, November 18: Another early start, but we didn’t mind at all because we got to enjoy another one of Lu’s delicious breakfasts first. We started seeing patients at 8:30 again, but it was a bit of a slower pace than the previous day, so we really felt we were finding our rhythm. Working with Rildo and Davison was such a pleasure! Our patients on Tuesday morning were interesting—we had three different men who had asymmetric hearing loss secondary to skull fractures! It was fascinating, and what are the odds that they’d all come in on the same day? We decided it must have been “skull fracture day” or something.

Happy faces at breakfast, looking forward to another day!
collaborating with Rildo
Collaborating with Rildo.
Davison is basically an honorary Audiologist by now. He’s so good at translating everything, and he knows when he needs to get clarifications from the patients.
Ellen was an excellent immittance-measurer.

In between patients, when there was time, Rildo consulted with us about various clinic patients. He was particularly interested in whether or not we thought some of his pediatric patients might be cochlear implant candidates. It was interesting to talk to him about candidacy criteria and what the evidence says about implantation success in various types of patients.

In the afternoon, we had two elderly patients who were blind. The first was a 90-year-old woman who had moderate to profound hearing loss bilaterally. We took earmold impressions, but decided to go ahead and fit her with open-fit hearing aids while she was there with us in the clinic rather than wait the THREE MONTHS it takes for earmolds to come from Sao Paolo. Prior to the hearing aid fitting, the woman had significant difficulty responding to our questions, but once we fit her, she immediately began responding. Her daughter was so happy! Our favorite part was when her daughter asked Rildo a question about how to tell the left hearing aid from the right, and the MOTHER (who had previously been unable to answer questions) spontaneously responded with the correct answer! It was a great affirmation that we were doing good work in the clinic.

Ellen Lindsay Davison
The three amigos (me, Ellen, and Davison), working together.
earmold impressions
Ellen takes pride in her beautiful earmold impressions.

The next blind patient we saw was an 80-year-old man who lived alone. He came to the clinic with his friend. The patient was unable to reliably respond to any of our questions or instructions, so we weren’t able to get a complete audiogram. With Davison’s help, we finally did get a general speech awareness/recognition threshold around 45 dB (moderate hearing loss) for the right ear and 95 dB (profound hearing loss) for the left ear. We discussed referring him for additional testing such as an Auditory Brainstem Response test, but the closest clinic that could do that is a TWENTY-FOUR HOUR boat ride from Parintins. I decided that we should just proceed with a trial hearing aid fitting for the better ear and see how he did with it, so we scheduled him to return later in the week.

Ellen completes tympanometry on a patient who had difficulty following verbal directions.
instructing the patient
Davison attempts to give instructions.

Our other interesting patient on Tuesday afternoon was a gentleman who indicated that a cockroach had crawled into his ear and was driving him crazy. None of us were entirely keen on the idea of looking in there, so I (very bravely) stepped up and said I’d do otoscopy first. Lo and behold: NO COCKROACH! I had Ellen look too, and there was definitely no bug or bug parts of any kind in there. I left the room briefly, and evidently while I was gone, the patient tried to argue with Ellen and Rildo about how we were all wrong, and the cockroach was probably just hiding from us around one of the curves of the ear canal. Man, what I wouldn’t have given for a video otoscope, just to show him how clean and clear his ear canal was!

Out of respect for the cockroach’s privacy, I’ve chosen to post a different photo here. This was just an ordinary evaluation– no bugs– and I was doing tympanometry. Still bravely, though.

We finished up around 6:15 and had some dinner. Ellen and I sat at the table and had some good laughs for a while before we went off to bed. That night, before my shower I was “attacked” by a giant moth in the bathroom. I think it was mad about the cockroach situation earlier that day… However, despite the moth attack, I have to say it was a pretty successful day!

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