March 30, 2017 – Our last neuro clinic and The Golden Sparrow…

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Rounding in Ward 1

As we walked to our last day of clinic here at FAME we were all a bit sad that the month had gone by so quickly and it was last time that we’d leave our house with the excitement of a new day of seeing patients. There was a soft drizzle, though we knew it wasn’t something that would last and it was likely to be another beautiful day here with the sun shinning. Each of us had different emotions that morning. For Chris and Nan, it would not be likely that they would return, at least for a very long time if at all. For Jamie, she would be flying to South Africa to meet up with her boyfriend for two weeks of vacation there and in Namibia. Her reality would be delayed by two weeks before she, along with Chris and Nan, re-entered the world of Philadelphia, HUP, CHOP, Presby and whatever rotations they have left in their residencies. For me, it’s different. Each time I leave, it’s merely “baadaye,” which means “later” in Kiswahili as I know that I’ll return six months with another group of eager residents. Another group who will get to experience what all those in the past have, now along with Chris, Nan and Jamie, which is a reaffirmation of the practice of medicine for most, but to all has been a truly rewarding time intertwining medicine, cultural awareness, nature, teamwork and, perhaps most of all, friendship. That I have been able to, at least in some part, assist them with this adventure, has been gratifying, to say the least, and in a more personal way has been life defining for me. But, hey, we still have a full day of clinic to get through.

One of the pediatric in patients with a scalp IV

Nan meticulously writing notes while Chris supervises

Morning report was held in the same small night office with all the doctors and clinical officers “smooshed” together, some sitting, some standing, but all happy to be here in this remarkable place. Dr. Lisso made a point of recognizing that it was our last day at FAME and thanked us for all for the work we’ve done while we were able to say a few words about how much we’ve enjoyed our time here. Then it was off to rounds which we spent a little more time on today just to make sure there weren’t any loose ends on our part. We rounded on the little three year-old boy whose been here the entire month with horrible burns over his entire back and legs after having backed into a fire on which sat a pot of boiling food. He’s so much better than when we first arrived and though we haven’t had to care for him, we’ve watched as he has been wheeled daily to and from the OPD where the procedure room is so his wounds could be dressed and redressed.

Dr. Brad checking out our young burn patient

Dr. Brad taking a walk with our burn patient and mom

We rounded on the woman who had suffered second and third degree burns over 60% of her body from ignited kerosene in a somewhat mysterious manner that really never mattered to those caring for her. She has amazingly improved, despite her odds, with the thoughtful care of Dr. Elle, a surgical resident from North Dakota who departed yesterday, but reinforced with everyone here how to continue her wound care. We also rounded on the 16 year-old girl with the likely osteosarcoma of the knee who would be sent home to die with only palliative care after her case was discussed with the oncologist at Muhimbili Hospital. Neither the family nor the patient had been told yet of the decision as the plans were to have a family discussion later in the morning. How sad it is to know that she would not have encountered the same issues that did in receiving care early on and would have had at least the possibility of surviving this cancer rather than what we know will be a certain death.

Abbey listening to the lungs of the young girl with the osteosarcoma of the right knee

Rounds with the team

At clinic, we had a number of follow up patients which is always good as you never know that they will show up as requested considering the difficulty many of them have in getting here which includes the equivalent of one or two USD bus fare. Jamie’s patient with HIV and the brain lesion came today as requested as we had wanted to evaluate him after 10 days of therapy to see whether he was responding to the toxoplasmosis therapy we had him on. Unfortunately, his examination was unchanged which was the least helpful option for us. Had he gotten worse or better we would have know whether the therapy was working or not and would have been able to make a decision to continue his medication or not. We lobbied with Frank that a CT scan would be helpful in making some sort of decision as it might offer additional information (improved or worsened), but alas, it was also unchanged to our eyes. We left it that he would remain on the medicine which he had been already and we would have the scans read in the US by someone to make sure that we weren’t missing anything subtle and would then make a final decision. If it’s not toxo, then the next candidate is lymphoma which, without a biopsy, would be very hard to treat and the other possibilities, crytococcosis or TB would also be tough without special labs and/or biopsy, neither of which was a option here.

Jamie, Chris, Dr. Badyana and Dr. Jackie

Daniel and Onaly operating the CT scanner

During the midst of our clinic, we also had a debriefing for our neuro team that consisted of me, Alex (who is the new project manager), Sokoine, Angel, William and Dr. Brad. Susan was not feeling well and couldn’t make it and Frank was home caring for her. The meeting lasted an hour and was very productive, identifying the things that worked well this trip and those that hadn’t as well as future directions and development for the neuro project. I had been very hectic this trip due to a doctor shortage at FAME as one doctor had given late notice and several were on their annual holiday so that we didn’t have the maximum exposure with the medical staff for the teaching that we have done in the past. This was an aberration and something that we will work on preventing in the future. The good thing is that we know have a list of things to work on in the short term as well as long range. When I returned to the “neuro wing” (the night office, ER and small outer office) everyone was working just fine in my absence and no significant difficulties had been encountered.

Chris and Sokoine evaluating a patient

Perhaps the best of our follow ups today was the little Maasai baby, Frank, who returned with his caregiver (recall that his mother died shortly after childbirth) and had actually gained some weight. He had been feeding well on formula which was verified during his visit today as well as the technique that his “mom” was using to mix it. Nan was the happiest to see him, of course, but everyone involved was very pleased considering that it was a very likely possibility that he wouldn’t make it to today’s visit. He labs looked great and he looked better as well. At the end of the day, though, when we were finished evaluating him, it turned out that the last car had left to where they live (several hours away) and they didn’t have money to stay in town so Angel was meeting with them to figure something out. Little Frank was a success story so far, but he has a long way to go to be completely out of the woods and will need his formula for good bit longer. Just mixing it with clean water isn’t something that’s guaranteed so it remains to be seen how this will play out. This is just one of so many cases here like this and we always have to remind ourselves of this. But Frank was the one we were involved in caring for, so somehow, for us, he’s different.

Nan and little Frank

Angel, Nan, Frank, Rehema and “mom”

Chris’ last case of the day was a young 18 year-old Maasai woman who was accompanied by her husband and brother-in-law and had been having seizures for several years and were best described as generalized, but with a significant myoclonic component. The decision was to begin lamotrigine which is always a bit of a challenge due to it’s complicated titration schedule that is not always the easiest to communicate to someone. Chris did an excellent job of having them repeat the directions back to Sokoine to make sure they understood them. As an interesting note, the family of this patient had also been attending FAME as their younger children all have rickets and are receiving vitamin D supplementation. The video of the young girl is a classic example of a rickets “waddle.”

Sokoine and Chris evaluating the young Maasai woman with epilepsy

Soja had called just as we were finished with our patients which was perfect timing so I had Alex drive me down the hill to pick up the vehicle. He had fixed the four-wheel driver that required a new relay under the dash, fixed the emergency brake and welded a new brace for the pop top. He had also put in a new headlamp as the one before had water that filled it half-way up. The total for parts and labor came out to be 230,000 TSh, which is a littler over $100!! I don’t think you could drive a car into a service center in the US for less than that just for them to take a look at it.

I was back in a flash and sat with Chris as he finished logging the last of our spring 2017 patients into our database. It hadn’t been our biggest clinic here, but we ended up seeing at least 226 patients during our visit at FAME as well as the four different mobile clinic sites. There were plans to go out to dinner tonight with the possibility of dancing afterwards, but we were leaving early in the morning so had to do our packing first. We had plenty of time to get the packing done, though Nan managed to fall asleep prior to dinner despite our upbeat packing music playing on the bluetooth speaker I had brought along for just an occasion. It was to be a night at The Golden Sparrow which had taken the place of Carnivore, a dive restaurant and pub that served only grilled chicken, chips and drinks. The owner, Martha, had built the Golden Sparrow, then closed Carnivore with the intention of capturing the old clients plus some new. The Golden Sparrow was a far cry from Carnivore 2.0 which was easily recognized the minute you entered this outdoor cafe as the floors were not dirt and uneven and the chairs and tables were level, a fact that was much appreciated after a beer or two so you didn’t feel like you were listing long before you felt the beer.

The Golden Sparrow certainly did not disappoint this night as it served for our final get together that included Sokoine and Angel along with several other volunteers from FAME. It takes quite a long time once your dinner is ordered, but when the roasted chicken finally arrived, it was the same delicious dish that had been served at Carnivore and which we had longed for. After dinner, several of us went into the lounge where there was a DJ taking requests and a small dance floor. This was also a significant upgrade from the tight quarters of Carnivore and we took full advantage of the situation by putting the dance floor to good use despite the fact that we had lost half of our group who were calling it a night and heading home. We had set a limit to how late we’d stay out and each of us stuck to this witching hour of 11pm as we had planned to leave on safari by 6:30 the following morning and still had to make our lunch and finish last minute packing. Jamie, Abbey and myself, who had taken advantage of the lounge got home to find that Chris and Nan had actually taken care of making our PB&J sandwiches (Jamie was heartbroken that there was no Nutella left, of course) that we’d eat on safari the following day as well as extra sandwiches for the flights home since both Nan and Chris both complained that there no snacks on the flight to Doha. We were safe in bed by around midnight and looking forward to the following day.

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