Our first real day of neurology clinic here at FAME can often be a challenge. It is unfortunate that we are only here every six months as it is long enough not to be routine, though it feels like it should be. Sokoine has spent the last months preparing for the next several weeks by advertising throughout the district for our clinic here at FAME as well as in several villages for our mobile clinics. In a way, though, it’s now like game time. All the preparation and effort that has gone into making our work here possible will now be put to the true test.
Monday morning clinic
Mondays are always the busiest day of clinic at FAME with patients lining up long before the clinic’s opening. And that is without the neurology clinics. Coupling that with our presence where we have far more patients than we can possibly see in one day show up for the first few mornings is always a recipe for some degree of chaos regardless of how much planning and preparation we have made for this event. We are unable to schedule appointments as that is not how Africa works. The frame of reference is in days or even weeks so when you tell someone to show up on a specific day, they may come today, tomorrow or the following day.
Dr. Mike and Dr. Msuya discussing a case
For the last several trips here we have seen patients in the night office next to the emergency room and the emergency room itself, both of which are at the opposite end of the complex and across from the outpatient clinic and registration. It has always been a bit unwieldy as the patients coming to see us must not only register on the other side, but they also have to wait to have their vital signs taken and then come across to where we’re seeing patients. We have a separate waiting area outside the night office and ER for our patients and that is often overflowing into the garden. Combining that with the fact that we have to attempt to screen patients to make their problem is neurologic, it becomes complicated. Since we subsidize the neurology visits, meaning that patients pay a single small amount (5000 TSh or $2.50) for the visit, medications and labs, the neurology clinic can become quite popular even if they don’t have a neurological problem. Sokoine does his best to educate everyone when he makes his announcements prior to our arrival, but it’s often not enough. Mary, who is in registration, also begins making announcements early to the throngs of people waiting to register to make sure they are aware. It is still not enough. So after we begin clinic, Sokoine will bring the patients in briefly to screen them one final time to make sure their problem is truly neurological. Few patients are turned away at this point in the process, but since we are often working only with an interpreter, we can’t really be providing general medicine care in our clinic and we’re using neurology funds to do this.
Dr. Kelley evaluating a longstanding patient of mine
Clinic began in earnest a bit late with all the logistical issues, but we were finally seeing neurology patients and I had Laura and Kelley all set up. Laura was working in the night office with Dr. Ken and Kelley was in the emergency room with Salina providing translation for her. Sokoine and Angel, who also helps with our clinics and is a social working by training, were keeping things running smoothly all day and managing the patients coming over from registration. It was clear from the onset that we wouldn’t be able to see everyone on the first day that had come, so they began to give patients numbers for the following morning to have them come back. They try to be sensitive to the distance that people have traveled, often more than a day to get here, so it is often those who are local that may have to return. In East Africa, though, even if someone were from far away, they would merely walk into town and they would be able to find a family to stay with as that is the culture here. If you have room on the floor for someone to sleep, you are obligated to share it with another member of your “community.” There is little sense of personal space or wealth here as very few have much and what little they do they will gladly share. To do otherwise for them would be unconscionable. That is what is so special about East Africans and one of their incredibly endearing qualities. It is also so very opposite of our Western culture.
Dr. Kelley and Salina
Kelley and Salina evaluating a dementia patient
A young microcephalic patient with developmental delay
Our patients for the day were a mix of returns and new and all with interesting pathology. Many seizure patients returning for medication adjustments or often doing very well and needing only a quick checkup. A number of psychiatric patients that we end up following here as we are the closest thing to a psychiatrist here and someone has to provide them care. Many children so that both Kelley and Laura were getting that extra pediatric experience neither of them bargained for. All in all, it was a great day of patients and getting their feet wet with how the clinic runs. Everything is new for them, from the medications to use, to how to write prescriptions, and having to document everything in handwriting on a paper chart. And not the least of which is having to work through a translator for virtually every patient they see. But this is how medicine is meant to be practiced and what we all went into medicine for. No computers, no coding, no typing, no insurance companies and no big brother. Just you and your patient and your clinical acumen. To say that it is refreshing would be an understatement. Both Kelley and Laura were absolutely fantastic, of which I had absolutely no doubt they would be, and we worked until late with a brief break for chai in the morning and lunch in the mid afternoon. Things ran smoothly after our morning setup and it was a great day.
I had to drive Sokoine, Salina and Dr. Ken home as the FAME bus to town had already left since we were working late in clinic. We were all beat and definitely ready for a bit of down time. We worked in the volunteer office for a bit on the Internet, catching up on charts and emails, and then went home for a very much deserved, and equally refreshing, beer and dinner. I think we all slept incredibly well that night.