Our clinic today was to be the first of the announced clinics here at FAME for this trip, meaning that the community was given a schedule of the days that we would be seeing patients and it was announced in the churches and public events, as well as fliers being placed around town the adjacent communities. This is accomplished by our outreach team at FAME which is currently made up of Angel and Kitashu, both of whom are social workers at FAME in their normal day jobs, but handle this task for us and have done so over the last few years. In addition to the announcements that are made in Karatu and its environs, they also travel out to the villages where we will be holding mobile clinics and the nearby villages for the specific dates that we’ll be visiting them. It is mostly a very successful process and FAME also has other programs that are similarly announced, such as cervical cancer screening, with all the programs benefiting from the lessons learned as these announcements are being made. There is also sweet spot as to their timing so as not to make them too early or too late in which case they become much less effective.

Following morning report, I must admit that it’s always a bit anxiety provoking as I walk down the walkway between the hospital and the operating theater and first look upon our neurology clinic “waiting room.” It can be a mob scene, especially on the first day of one of these clinics, but for some reason, today was not such a day and the crowd appeared to be quite manageable. When we have far more patients than I know we can see comfortably in one day, we will begin to hand out numbers for the following day and ask patients to return in the morning. We do have to sort through those patients who have traveled far, though, as it’s difficult to ask someone who lives seven hours away to come back in the morning. Surprisingly, though, patients can usually find a friend or family member in town who they can stay with and come back in the morning.  It is a different culture altogether here in this regard as one is considered to be related as long as you come from the same village and, as long as your related, then it is perfectly appropriate to expect things such as a meal or a place to stay for the night.

The “Neuro Crew” – Anne, Sheena, Daniel, Adys, Jon and Me

So, our first full announced clinic did not turn out to be quite as crazy as they normally are, but then that clinic is typically reserved for the first Monday that we’re here and that is the second week. The lower than normal volume may have been related to that or it may have been related to other factors such as the time of year and whether it is planting or harvest time. Whatever the reason, I was actually a bit relieved given the prospect of having some semblance of sanity for the day. It was also a blessing given the fact that I agreed to give up our ER bay (one of “clinic” rooms) to Dr. Gabriel for a few hours this morning so that he could endoscope a patient. That meant that we’d be down to two stations for seeing patients until he was finished with his procedure. In the end, we actually used the room while the patient was recovering behind some curtains as we did need to get started using it.

Sheena evaluating a patient

The day was made of the usual suspects – headaches, anxiety, and GBM. The later abbreviation, which strikes fear in the heart of any knowing neurologist, definitely threw me off here when I first ran into it. Thankfully, it does not stand for glioblastoma multiforme, a highly malignant brain tumor with a very prognosis and short life expectancy, but rather generalized body malaise, or someone complaining of basically total body pain and very likely without a unifying diagnosis. Not a patient that excites us at all as this is rarely secondary to a neurological condition meaning that it’s not something I want to be treating here to begin with. One of my long-term patients who I have been seeing since 2011 did return with her mother (also a patient of ours) today for follow up. She has been on anticonvulsant medications, doing well for many years, and it has been a pleasure to watch her grow up while under my care. Overall, the day was rather nondescript from a patient perspective and other than an inpatient consult that Adys did later in the afternoon, it was pretty much bread and butter neurology; that is, the usual suspects mentioned at the beginning of the paragraph.

Adys’ patient had undergone a procedure with spinal block a week or so ago and had developed a severe headache that was worse when he stood up. This was particularly concerning for a post LP headache, or low pressure headache and which we would treat with a blood patch, where a small amount of the patient’s own blood is placed into the epidural space and essentially patches the leak that is presumably the cause of the problem. Unfortunate for us and the patient, though, was the fact that the person who performs these blood patches was not around. The other option was to give the patient caffeine sodium benzoate intravenously, but the only IV caffeine that was available here were 5 mg vials of caffeine citrate and, though I could find a reference on how to convert the two forms of caffeine, I didn’t feel comfortable injecting something into a patient’s vein only to find out that it would cause some unexplained condition considering that we weren’t treating a lethal condition to begin with even if it was bothering him so severely. So, in the end, we chose to give the patient a high dose of IV dexamethasone, a corticosteroid, that could possibly decrease the inflammation and potentially reduce his headache. I did seem to actually work as later he reported that his headache was improved, but it was decided to keep him in the ward overnight to continue him on IV fluids and just to make certain that he was actually getting better.

Daniel and Adys charting on the veranda. We enter all the patients into our database to keep track of things

I certainly can’t leave out the fact that today was also International Women’s Day 2019. The theme as noted by the UN for this year was, “Think Equal, Build Smart, Innovate for Change.” Here in East Africa this is so very apparent as education for so many years has been reserved only for men as it is in so many other parts of the world and efforts to change this have been ongoing, but are still so necessary. There are many non-profit groups that have been trying to change this by offering scholarships to young girls so that they can continue in school and these should be supported wholeheartedly for it is often through these programs that change will occur as we’ve seen in so many other areas. My good friend, Barbara Poole, has been active in this arena for many years, as she has been in the US, and has had programs here in Tanzania just to focus on this need. She has had programs that have taught women to organize into groups to better market their trade and also programs to sponsor girls in secondary school where they are very underrepresented and it is very expensive for families to send their children to these schools that are only partially supported by the government. It is through these initiatives that society will eventually achieve equality for women and I celebrate all those who are working for this cause. Today at FAME, Katherine, our communications director, spent the day visiting all the women working here to allow them to express their gratitude for this movement and the need for continued vigilance until there is full equality.

Now for full disclosure. A beer on the veranda in the equatorial sun makes the work much less painful

Since we were actually able to get back to the house at a decent time, I decided to work on the guacamole that I had bought the ingredients for a few days before. The avocadoes here are quite large and were just perfect so Sheena and I worked on concocting a Tanzanian version of the traditional Mexican dish that contained onion, garlic, lime juice, salt and pepper in addition to the main ingredient. We had it with chapati and chips of all sorts other than potatoes. There were casaba chips, plantain chips and sweet potato chips that when perfect with the dish. Dinner that night was a version of a BLT with the lettuce, so essentially a BT, that was on very thick homemade bread that was just a bit much for the sandwich. I tried putting on some of the guacamole and cheese, but even then, it was difficult to eat due to its dryness so I ended up just eating the parts of the sandwich separately and it was all fine.

Later that evening, we had the most magnificent display of lightning and occasional thunder. The entire sky was lit up continuously to our east with cloud to cloud lightening that would occasionally result in an intense bolt of lightning shooting across the sky looking like a mad scientist was preparing to create another Frankenstein. It was just another awesome display of nature here that reminds us of the uniqueness of this part of the globe.