This was our last day of mobile clinic, as we would be providing the remainder of our patient care and education at FAME rather than in the villages. Upper Kitete would be our last visit for the week and it is the furthest away of all the clinics we currently provide. Yesterday, Neena had commented that Kambi ya Simba is a very remote area because of how far down a single dirt road you must travel to get there. Well, Upper Kitete travels down the very same road, only it is at least twice as far if not more. I guess that makes Upper Kitete doubly remote. It is a long way out, but well worth the drive if not just for the beauty of it all. It is the second to the last village on the plateau with the road ending at Lostete, and despite this, there are still multiple buses daily that ply this route.
Before leaving for Upper Kitete, though, both Whitley and Neena had volunteered to give short lectures on CT scans and CSF analysis, respectively. It was probably silly for us to think that it could have been done in one session (45 minutes), so in the end, they covered everything in a little over an hour. But since it was so important and everyone from the lab and radiology had also come to hear the session, Gabriel felt that it should be completed today and not run into another day’s session. They were both very good lectures considering it is always a bit difficult to decide just how in-depth to make them considering we are not giving it to neurologists, but to general practitioners, many of whom have never worked or been instructed in neurology before.
After rounds we went to see the boy with tetanus who had been doing much better overnight. He had looked better yesterday evening with an increase in his symptomatic medications, but he still hadn’t received the tetanus immune globulin, as they hadn’t been able to find it yet in Arusha. Thankfully, though, he was more comfortable with the additional muscle relaxants and sedation so that he wasn’t continually crying out like he had been. His urine was also much more clear rather than the dark brown it had been when we first saw him.
We finally got everyone corralled into the Land Cruiser and we were off for Upper Kitete with George driving again given the rough road and long distance. Also, Upper Kitete has no cell service so having a breakdown there means you would have to send word with someone heading towards home and hope that rescue would be coming before nightfall. It’s not happened to us in the past and I will continue to do my best to prevent it from ever occurring as the accommodations there would be difficult at best. We secured lunch in town yet once again and were then fully provisioned for our trek into Mbulumbulu and the far reaches of Karatu district.
We’ve been using the same dispensary at Upper Kitete since I started going there in 2011 (Kambi ya Simba’s dispensary had been fully updated a few years ago prior to a visit by the prime minister), and the facility could use a good revamping. There is an outdoor alcove where we’ve set up our pharmacy in the past, but today it was being used for well baby visits by the clinical office (more in a minute) so we set that up at the end of the outdoor walkway outside of the labor room. The labor room that has served as one of our exam rooms in the past was now unusable for us as there was a patient in labor in the room (I guess that makes sense) with women running in and out during our clinic. That meant that we only had two exam rooms to use. One was the nurse’s office that I affectionately call the “bat cave” as there is a square piece of the ceiling missing in one corner of the room and one can often hear the squeaking of bats during the day and the room has a faint smell of bat droppings that is at first a bit unnerving. This was Whitley’s room for the day and though it wasn’t something she cherished, she stood in there like a trooper and didn’t complain. The other exam room was the clinical officer’s room which actually worked out quite well and it was gracious of him to allow us to use it for the day. Sara and Neena worked out of this room and alternated on patients.
Whitley worked with Dr. Jacob for the day and Baraka translated for Sara and Neena. Dr. Jacob is new to FAME and had never worked with us before, so Whitley was again working with him on the neurologic examination along with how to take a good neurologic history.
When we arrived at the dispensary, there were many, many patients there which was certainly encouraging, but it would have also been quite a handful for us to manage there in a day since we’re usually starting at around 11am by the time we get everything set up. Thankfully, about half of the patients waiting were for the well-baby clinic where they all get their weights checked along with a general checkup. The baby’s are weighed on a simple mercantile scale and each baby has their own handmade, unique sling for them to sit in during the procedure. Most babies are fine with the process, swinging contentedly as their mothers attach them to the scale and then there are others who scream bloody murder as they’re weighed. I brought Sara out to watch as it was certainly something she had never seen before and certainly wasn’t how things were done at CHOP.
Once we finally figured out who was there to see us, we were able to begin triaging patients and making a list. We had old notes with us for patients who had been seen there previously, as it is obviously imperative that we maintain some sense of continuity. Once the list was made and it was checked to see if we had old notes for those we had seen before, it was clear to begin seeing patients. As the day wore on, the list seemed to always have the same number remaining, as patients seemed to show up throughout the day. Regardless, it was not overwhelming and we were able to see all the patients necessary, that is except for a gentleman who showed up after 4pm and it was impossible for us to see him and still get back to Karatu in the daylight hours.
All patients were interesting, but Sara saw a young girl with cognitive impairment since birth along with generalized weakness, hypotonia and very myopathic looking facial features that were very suspicious for some form of congenital myopathy. She had been brought in by her grandmother so it was difficult to look for any hereditary features and her grandmother wasn’t very helpful in giving us any details of her past history or developmental milestones. We are unable to check muscle enzymes here so we wouldn’t have that to help us and it was decided that she would come back to see us when we returned in March.
The clinic finished late, which was unfortunate as I had hoped to show the residents “The Overlook” which has become somewhat of a tradition – it is a spot in Upper Kitete that sits high on the escarpment and provides an incredible view of the Rift Valley below. I’ve been there many times, but today was a bit hazy with all the dust being driven into the air so it probably wouldn’t have been as spectacular as normal and missing it wasn’t such a tragedy. We didn’t arrive home until well after 6pm with the sun going down quickly. We were planning to head for the Central Serengeti tomorrow after morning report barring any complicated consultations in the wards. We spent the evening packing, but did have to run down to the clinic for one late night outpatient consult on an expat. We all slept well that night with the anticipation of going on safari for the weekend.