Waking up at FAME is a beautiful thing. The mornings are soft and quiet, other than the sounds of the many birds outside and the soft rain falling on our metal roof. Our house is nearly full with the six of us and Dan and Marin are in the Neill House which is one of the original volunteer houses here that I have stayed in many times before until our Raynes House was built three years ago through the generosity of a donor. It again rained through the night, but as heavy as before and remained as only a light rain through the morning, not even enough to have us put on our rain jackets for the five minute walk to clinic. Everyone grabbed something for breakfast and it was off to clinic for us. Our room and board here includes not only our housing, but also dinners made for us during the weekdays (we fend for ourselves on the weekends), lunch for everyday that we’re here, groceries for the house for our breakfasts and whatever else we would need, laundry done every day and wireless serve in the house (when it’s working). All FAME volunteers pay a daily fee for room and board no matter how long you’ve been coming or whether you are on the board of directors or not. It is the only way that FAME can operate and is necessary for the volunteer program to run as close as possible to a zero balance sheet.
Morning report begins at 8 am daily, and we usually do our very best to make every report as is often the place where you learn about patients that came in overnight and any possible neurology patients that may be in the ward for us to see. On Tuesdays and Thursdays, we have education at 7:30 am, which we are usually responsible for when we’re here, so those are early mornings. Morning report is run by the night call doctor, which each of them take on a weekly basis in rotation. During our month here, though, Dr. Anne, who has worked with us for several years now and is training to be our community neurologist at FAME, will again work with us for the entire month and will have no call scheduled so as to make sure she remains available for us.
Today’s clinic would be unannounced, meaning that we would see mainly patients referred by a physician here at FAME, or one that they would have called to come in for follow up with us. Tomorrow would begin the busier announced neurology clinic meaning that our advance team has gone to the community and made announcements about our presence and what conditions we treat lessening the chance that we have non-neurological patients in our clinic. One problem that we run into over the years is the fact that our neurology clinic has been subsidized, meaning that the patients pay a flat fee of 5000 TShillings (a bit more than $2.50), and for that they will receive our consultation, a month’s worth of medication and any labs necessary for their evaluation. As this is far less expensive than most people will pay for a visit, many patients will do their best to be seen in our clinic even if they do not have a neurological problem. We have worked on triaging patients for this reason, but somehow that doesn’t always work effectively and patients will slip through.
Our clinic staff is coordinated by Angel and Kitashu, both social workers by training, who have worked with us for several years now and have a perfect understanding of the needs of the clinic and our purpose here. When seeing patients, it is necessary for us to use translators, and sometimes two depending on the languages spoken, as there are many patients here who do not speak Swahili. I have always strived to use translators with a clinical background such as the MDs or clinical officers here, as then we are leaving something behind in the neurological knowledge we’ve conveyed, but that has not always been possible given the growth of FAME over the years. As I’ve mentioned, Dr. Anne is the clinician that we are training and, in addition, we’re working with two new clinical officers who do not yet have jobs to help us. Though they are hired as translators, they are also clinicians and it would be impossible for them spend this time with us without absorbing a great deal of neurology. I am in the process now of finding a fourth translator so that Marin would be able to see some patients on her own with us, but finding a well-trained translator here can be quite difficult. It can be very frustrating at times as the patient volume continually grows along with the need for qualified translators which just don’t seem to exist here in any overabundance.
Patients are seen on a first come, first serve basis as there are no appointments here and patients will often spend the entire day waiting to see us. We try to separate the children for our pediatric folks as this is the most appropriate, but we have no control over the mix of patients that will be seen on any particular day and often there can be a disparity in either direction. Patient visits can either be rather simple, such a neuropathy or a well-controlled seizure follow up, or they can be incredibly complex for us and this is not helped in any way by the lack of documentation available when we see our patients. They have very often been seen somewhere else and may have even received medications, some of which may have worked, there is no record to refer to and often the patient is completely unaware of what had been done in the past. On occasion, showing the patient a selection of tablets, such as anti-epileptics may spark their memory, but more often it is a guessing game in which you must weigh how confident you are in the history you’re receiving and decide going forward. Considering all of the obstacles that are encountered throughout our day, the residents do an incredible job with the patients that are seen in both regard to diagnoses and treatment plans.
During this visit, we are also very lucky in that we have a physical therapist working with us who is from Ireland and has a huge interest in neurological cases. Frances Marron had found out about the work we’re doing through the FAME website and my blog and, after spending some time in New Zealand, decided to come to Tanzania and coordinate here visit here with ours. What a luxury of having our own physical therapist who can sit in evaluation with the doctor when it looks like it’s someone who might need her services and then she can work with the patient and family after our visit. She’s also happy to see our dizzy patients to help with vestibular therapy which is a great advantage for us. I am quite certain that we will have many patients for her to help during her time here and, better yet, that’s what she is looking forward to.
We started the day with morning report and quickly found that the ward had a number of extremely sick children or, more accurately, intensive care level children, who were in dire need of Dan and Marin’s care as that is their specialty. One of the children in the ward appeared to be septic having not yet responded to antibiotic therapy and was having serious difficulty breathing. We have no ventilators to use here, or course, but we did have an older CPAP machine with a host of masks there were able to be sized for this child so that her struggle breathing did seem to improve once it was placed, though how long this benefit would last was anyone’s guess. When they had originally seen this young child, Dan’s comment was that he didn’t think the child was going to last the hour, but after getting the CPAP mask on, the child seemed to stabilize and look a slightly bit brighter. Regardless, it was going to be an uphill battle. There were also other children who, unfortunately, were equally critical such that Dan and Marin spent most of the morning and part of the afternoon working in the ward service non-stop to assess them and come up with a game plan for each that would hopefully help.
The rest of the group spent the morning seeing a few patients and becoming acclimated to the system here that is very different than what they are used to at home. The clinic was actually to begin in the afternoon, but given that patients were there and ready to be seen, we took the opportunity to begin early and possibly lighten the load for the day. Carrie, the medical student accompanying us spent the entire day, but beginning tomorrow, she will take each morning to work on the data bases, entering all of the patients into it along with other data from demographics to specific diagnoses and medications that they were prescribed. In keeping this type of information, we have already accumulated a plethora of information that has helped us to recognize the distribution of illnesses seen in the various tribes we treat, the distribution of gender and ages that we treat, and, finally, the medications that we use most frequently. In addition, a very high percentage of the patients we treat here at FAME have an underlying diagnosis of epilepsy and we have shown that these patients are more likely than any other to follow up with us and are most likely to be adherent on their medication. They have also reported that their seizure frequencies have either improved or remained the same for by far the majority of patients that we’ve seen.
Our clinic today was a steady stream of patients, though by no way unmanageable. It gave everyone a chance to get fully oriented with the clinic flow and the system here without becoming overly stressed by the volume. We were able to get home at a decent hour and in plenty of time to relax before sunset, some with a hammock, some with a beer, and others with just the comfort of our home away from home, the Raynes House. It was an awesome start to the month, similar to what I have done many times in the past, and I very much look forward to sharing this wonderful experience that is FAME with the rest of the group.