Thursday, September 5, 2019 – Our first day of neurology clinic….

Standard

It’s like the first day of school for everyone, but me, of course. They have all been waiting to get started and today is the day. Mornings here are just so different than they are at home, mostly for the obvious reason that this is just different here. We have a schedule and have to be at morning report at 8 am today, but there are no pressures, no phone calls to make, no charts to close, no RVU targets to worry about. Everyone has had whatever they wish for breakfast (for me, it’s corn flakes, milk and a banana) and we head out the front door of the Raynes House (whether the front or the back door is a much debated topic here) to walk to the clinic. It’s a short 5 minute walk passing by the other volunteer houses (there are four of them) and through a gate that now leads past the new 25-bed material health ward that was just opened last month. FAME’s dedication to maternal and child health has been one of its main missions since the very beginning and this facility is yet another step towards reducing both infant mortality and obstetric morbidity. The number of deliveries has continued to increase on a regular basis ever since the first here at FAME in 2014 (attended by one of our pediatric neurology residents, Doug Smith, by the way).

The first day of “school”

Morning report takes place at 8 AM every day and where we hear about the patients currently on the ward and any new admissions that have come in overnight. There will frequently be neurology patients in the ward and it is very common that the patients who have come in overnight were admitted for neurologic reasons like stroke or headache. Today, we heard of a two-year-old child who had been admitted perhaps ten days ago and has been encephalopathic the entire time with intermittent seizures. She had undergone a lumbar puncture that was unrevealing and a CT scan that also read as normal. She had been maintained on antibiotics and anti-TB medications but had not been improving. This was definitely something that Marissa was going to look into as soon as we got to clinic.

The residents with Charlie, the FAME’s mascot

We finished morning report at 8:30 AM and made our way over to where we would be holding our neurology clinics. Since the maternity patients had previously been held in Ward 2, but had now been more to the new maternity wing, such that Ward 2 was now empty. Not only would we have three complete examination rooms, but we had a large vitals room and plenty of space at the old nurses station for Angel to check in patients and do triage. I was made well-aware, though, that having this space for now did not imply in any fashion that I would have it in the future and that I should not expect to have anything near this perfect when I came back in March. Over the prior years, we had made our makeshift home at the night physician’s office, the emergency room and the hallway in between where we would often house an additional two stations for a total of four teams working at a time if that was what was necessary. This arrangement had managed to serve us well and we were certainly able to see our patients, but I have to admit that having the entire Ward 2 to ourselves was a real treat and we all looked forward to working in this new space.

Twins!

Dr. Annie would be working with us again as she was the clinician here that had had the most interest in neurology going forward, though she also serves several other significant roles for FAME and we would have to be cognizant of that going forward. In addition to Annie, who would also be helping us translate, we had a senior medical student from KCMC (Kilimanjaro Christian Medical Center) who was on his vacation and had asked to spend time with us while also being willing to translate. Abdulhamid Shaban will be returning to help next week, so for this week we were planning to use either Angel of Kitashu (our social workers) to help as well, though they were also responsible for social work duties on campus which could be a real balancing act trying to serve both roles.

Twins!

One of the big issues for our clinics has always been triaging patients. Since we do subsidize the clinics by offering to see patients, provide them with one month’s worth of medication, and check any labs all for the flat rate of 5000 Tanzania shillings (just a little bit more than $2 USD), it becomes very important that we limit our care to only those patients who have neurological conditions or problems. It would be impossible for us to see every patient who wanted to see us for other reasons and that is not our role here. I had originally begun triaging patients with William Mhapa (who is now the incredibly accomplished head of HR here at FAME while continuing to add degrees to his name) a number of years ago, though over the last several years, it has been both Angel and Kitashu that help with the triage. We’re willing to see any patient with neurological symptoms, but not those who have simple arthritis or some other joint pain. Again, it’s not a matter of not wanting to see patients, only the fact that we have a specific purpose here and do not have unlimited funds. FAME does charge patients for their care, albeit a very small amount, and a significant portion of their operating budget is made up of patient fees. Providing a mechanism for patients to avoid paying those fees would be ultimately self-defeating to the sustainability of FAME.

A new mother and her baby with one of Mildred’s blankets

For our first morning, which was also unannounced, we had a fairly large group of patients show up to be evaluated. In the end, we did see 25 patients in clinic and another three patients on the wards – mostly children or newborns who were evaluated by Marissa. Everything worked incredibly smoothly and there were no real hitches that occurred throughout the entire day. The residents were incredibly efficient and the stack of charts for the waiting patients was decreasing in height very quickly. After lunch, though, Mike was seeing a patient who we had been treating for epilepsy, but who had apparently run out of her medication several weeks ago. While he was taking her history, she began to have what looked like shivering to him, but within a few moments, she developed a very loud ictal cry that reverberated off of the walls. She began to have a very clear cut generalized convulsion and was unresponsive. Several of us walked into the room to see what was up and if we could offer any assistance, but she began to have tonic stiffening of her entire body with an arching back such that she was very quickly launching herself out of her chair. Our main focus at that time was to lay her on the floor as quickly as possible while protecting her head and keeping her from aspirating by turning her head to one side. Her seizure lasted for about for about two minutes and she didn’t have a long post-ictal period, but there was very little question about what we had just witnessed (a generalized convulsion) nor was there any question regarding what needed to be done. We restarted the patient’s carbamazepine and stressed the importance of remaining compliant on the medication so something similar would not happen again. This is often not as easy as it sounds (convincing the patient to take their medications) despite the obvious results of not doing so. This is no different here than it is at home.

Our seizure patient of the day

When Marissa went to see the young child that had been mentioned at morning report, she had found them having a focal seizure and was probably in status. This required her giving diazepam to the patient and also maximizing her phenobarbital dosing which eventually broke the seizures, but the child remained quite lethargic and our concern remained that it was whatever had been causing the seizures and the child’s presentation to begin with. We had little to go on so would very likely have to begin repeating tests that might have changed.

A new baby in their blanket

Another fun thing for the day was giving out baby blankets that I had brought from home to the new mothers and their babies. Mildred Staten, a wonderful women who I know from home has been knitting baby blankets at home with a group of friends (she recently told me they were called the knitwitts) for new mothers in some of the nearby hospitals in Philadelphia and had asked me some time ago whether this is something that might be appreciated at FAME. She took my very enthusiastic “yes” literally and has given me a large number of blankets on two occasions in the past, and had contacted me about a week prior to my departure this trip with news that she had accumulated another large group of blankets for me to bring. It is truly an act of love and goodness to pass on your own creations such as these blankets to travel overseas to a far off land to be given to those who you do not even know or have never seen. Today, I had asked Katherine, FAME’s communications director, to distribute some of these blankets to the mothers and their babies and to take photos of them as long as they were agreeable.

A new mother and her baby in a blanket

Since we were finishing on time today, we had decided to go downtown so that everyone could see what Karatu looked like, but then we had also decided to visit Katherine’s tailor, Teddy, who I have visited on a few occasions in the past with residents so that they could have her make items of clothing for them. The fabric here is just spectacularly colorful and beginning with my first trips here I have fallen in love with the nearly unlimited patterns. Those who have accompanied me have also loved these fabrics and have chosen to make many different pieces of clothing from skirts to shirts, pants to aprons, bowties to bags, and even a sport coat. We went to the fabric store first and then visited Teddy where everyone gave her orders and she took personal measurements to make sure that everything fit perfectly. All I was having made were some shoulder bags. Mike Baer was having perhaps the most unusual item of clothing made, though, that anyone has asked for on my trips. He was requesting that Teddy make him a jump suit, tailored to fit. I must admit that I hadn’t expected that, but we’ll just have to see what the finished product looks like when it is done. I’ll be sure to have him model it and share those photos with you.

A little cutey…..

It was now after dark and we made our way home from town up the FAME road that I have now driven hundreds of times. We were all starving as our dinners were waiting here for us at the Raynes House and we were all exhausted from the busy day in clinic and shopping afterwards. We would continue our work in the morning and all looked forward to the new and interesting patients that were awaiting us.

Kyra at Teddy’s shop having clothes made

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