Having settled into the Raynes house yesterday evening, it was everyone’s first morning waking up in this paradise, save me of course. It was a beautiful morning with full sunshine quite early as the sun rose behind our house and cast long shadows towards the hills to our west. The sky was as sparkling clear as one could imagine and the songs of the many bird species fill the air with a lightness that is so very special here. There are no sounds of the city or civilization here other than the occasional vehicle or groups of children that come along the road from the coffee farms down the way. FAME sits six kilometers high out of town on a dirt road that is in decent condition as long as it hasn’t been raining much, but can become a bit of a slip and slide at times. It is literally beyond peaceful here and you have to pinch yourself almost every day to make sure you’re not either sleeping or in heaven. At least that’s how I feel about it here which must be pretty obvious as this will be my 18th visit to FAME.
Everyone fared for themselves for breakfast (either eggs or cereal) and then readied themselves for the short walk to clinic and morning report at the start of the day. Morning report became a daily feature here once the hospital opened necessitating overnight coverage on the ward, and hence morning report where the overnight doctor gives everyone and update on the ward patients and any overnight admissions. Dr. Jacob, one of the newer clinical officers at FAME had been on overnight and went through the ward list of patients giving updates on each. There is always some discussion on many of the patients along the way and, at times, this can become quite vocal, but it is always for the purpose of educating and never degrading. Clinicians here come in three flavors; medical doctors, which is obvious, clinical officers, who are similar to an advanced practitioner or nurse practitioner, and assistant medical officers, who are somewhere in between the other two. FAME started with few MDs and mostly clinical officers, but now employs four MDs, five AMOs and five COs, all Tanzanian. All of the clinicians are generalists, though a number of them have extra training in certain areas that enable them to provide additional services to patients here at FAME.
During morning report, we listen intently for any patients that may need our services so that we can see then in the ward during the day providing our consultative services and often managing much of their care if they are primarily neurological in nature. This morning they presented an unfortunate case of a one-year-old child who had presented overnight with a prior history of cough who had been taken to an outside dispensary and given some treatment but sent home. The child hadn’t improved and the family decided to bring the child to FAME, though she had a prolonged respiratory arrest (perhaps up to two hours) prior to arriving and was resuscitated when she got here. The child had been intubated and was being bagged now (meaning someone sitting at the bedside constantly squeezing a bag to provide air to her lungs) as there are no pediatric ventilators here. She had also had a seizure in the morning and was given diazepam at the time. It was unclear what we were dealing with, though was most likely a primary respiratory process and not neurologic in nature, and given the history, we weren’t expecting much in the way of neurological function. With clinic starting for us and already having patients waiting, we decided that Jon would head over to the ward to see the baby and do an assessment while the others would begin seeing outpatients.
Our assessment of the little baby was not very encouraging, but we really hadn’t expected much more. She had no respiratory drive, and the only brainstem reflexes we could find were bilateral corneal reflexes. She had no response to pain, no oculocephalic responses and her pupils weren’t reactive. This was certainly consistent with a severe hypoxic injury as we knew had occurred and there was very little that we could see that was positive. Unfortunately, we were concerned that the diazepam she had received that morning could cloud her exam and we felt strongly that we should continue to watch the baby for approximately 24 hours. Later that day, she had recovered one pupillary response, but was otherwise unchanged and Jon went to have a “goals of care” discussion with the family, something that is always difficult when a child is involved and that much more complicated when dealing with the cultural considerations that must be considered. It was decided to continue watching the child overnight, but our expectations were grim regardless.
This was an unannounced day for clinic meaning that we had not made an effort to let the community know that we were here, but rather we would see patients who had been called to come in and were either follow up patients we had seen previously or were those patients who had been recommended to see us when we arrived. There were a fair number of patients already waiting for us and I had wanted this to be a slow day so that everyone would have the time to get their feet under them and learn the system here. Though the documentation in the chart is universal, writing prescriptions, requesting labs and radiology and just about everything else is very much different than what we do in the States. It doesn’t take long, though, for everyone to get up to speed and we were through our morning patients in no time. We were working with Dr. Anne who I have worked with for a number of years now and a fantastic clinician. She was an amazing clinical officer and is now an even more amazing assistant medical officer. At least half of the patients today seemed to be children which was unfortunate given the fact that we’ll have two pediatric neurologists here with us beginning on Monday. Later in the day, I was over in the OPD where they were checking in a very small infant who had obvious developmental delay and seemed to have an episode while in triage that raised concern for a seizure. Dr. Ken asked if we could see the child, and when I learned that they were from Karatu, I immediately suggested that they return next week to see to one of the peds folks.
We had planned to head downtown to pick up sim cards for the residents immediately after clinic, but of course, nothing works to plan. We were asked to see a woman who had just arrived this afternoon with a history of having given birth one week prior and had eclampsia with high blood pressure. She had been discharged home and the day prior to presenting here had developed a headache, then intermittent right sided weakness and finally confusion. Her blood pressures were moderately elevated and she was completely encephalopathic on examination, being unable to follow all but a single verbal command. She had roving eye movements and did not seem to track or blink to threat. She was moving all of her extremities, but seemed to move the right side less easily. Though FAME has had a CT scan for the last several years, it has been out of commission since our last visit here and is awaiting the blessing of the atomic development commission in Tanzania so that it can be switched on and used to scan patients.
Without the CT scanner, though, it meant going through a laundry-list of diagnoses and not beginning any treatment that might be harmful for any one of the top diagnoses. The main concern would have been whether or not we felt that she might have a hemorrhage given her headache, but the leading diagnoses were PRES, or posterior reversible encephalopathy syndrome, or RCVS, or reversible cerebral vasoconstriction syndrome. A third diagnosis, that being venous sinus thrombosis was also a consideration, but her presentation wasn’t as classic for that entity making it less likely. All of these entities are more commonly seen in the setting of pregnancy or being post-partum, but PRES remained our leading diagnosis and, luckily, treating her blood pressure (normalizing it) was the most important treatment at hand. For venous sinus thrombosis, the treatment would have been placing her on anticoagulation, but without having a CT scan to rule out hemorrhage, that was entirely not an option. We ordered magnesium and blood pressure control and hoped for the best.
Despite our emergent patient at the end of the day, we were still able to make it to town to purchase the sim cards and at long last, the residents were now back in touch with the rest of the world through their phones and all was in balance again. There was plenty of daylight remaining for us to do some shopping in the vegetable markets here and we managed to pick up everything we needed for some good guacamole other than the cilantro, though I’m not sure how hard we really searched. It was back to home for dinner, which tonight was comprised of a delicious meatloaf and mashed potatoes. It was Wednesday night which is the evening that all of the volunteers in Karatu get together at Happy Day pub and so I drove everyone down to enjoy the warm company of others from many countries who have come to this part of the world for one reason or another, but everyone with an interest in helping others less fortunate. It’s a wonderful feeling to be part of such a club.