Thursday, March 5, 2020 – A very busy clinic….

Standard

Yesterday had gone well with a fair number of patients and today was going to be our first day of an announced clinic in which the community had been made aware of our presence . It had been raining for days which often has the effect of decreasing our patient volume given the difficulty of getting around for both pedestrians and vehicles on the rain soaked and muddy roads. For this reason, it is often much quieter as far as patient volume in the spring or rainy season, when it is either due to transportation issues or because there is planting going on and everyone is in the fields. For whichever reason, though, our numbers have been consistently lower for patients in the spring, or wet season, compared to the fall, or dry season. If yesterday’s clinic, though, was any indication of what we were to expect, this could be stacking up to our most robust spring clinic that we’ve had.

Carrie charting and Dan working at the central station in clinic

It was also an education day so that we all gathered in the administration building for a lecture, this morning given by Dr. Joyce, our resident laboratory scientist extraordinaire who has been here since the beginning and has built the lab here at FAME. The doctors at FAME have been unable to do cultures due to the significant safety concerns and the equipment requirements that include an isolation hood, which up until now have obstacles that were unable to be overcome. After much fanfare, they are finally ready to begin doing cultures as everything is in place, though not until after having to wait 9 months to have the hood repaired. Joyce went over what the expectations should be for everyone ordering cultures and what things they could culture and what they couldn’t. It will be a new era here as we will have full information on sensitivities and resistance as well as an ID on the bug in most instances. Being able to finally narrow antibiotics will mean that patients will be on fewer unnecessary antibiotics and possibly for shorter courses. This will be a major advance in therapy here at FAME.

A father and son

I had left at the beginning of morning report to get clinic up and running, leaving Amisha to listen for any potential neurology consults in the ward that we would be requested to see or for those that had some neurologic flare to their presentation and who would be prudent for us to see at some point during their hospitalization. Dan and Marin had gone to the ward early to see their two young children who were very sick (i.e. ICU-sick) which seemed like a very good thing to do prior to our neurology clinic. In addition to the children, we did have a consult in the ward who was women admitted after a head injury with an aphasia who had also had an CT scan demonstrating multiple hemorrhagic injuries. We arrived in clinic to find a great number of patients waiting for us, all of who needed their vitals taken, but once that was done, we were pretty much rolling with three translators to help us in three examination rooms.

Patients waiting in clinic

Dan and Marin spent much of the morning working on the two children who, unfortunately, both succumbed to their illnesses later in the day despite providing everything possible short of intubation. The one young child who Amisha had done the lumbar puncture on yesterday and quite likely had an initial bacterial pneumonia that progressed to sepsis, but hadn’t responded to any of the antibiotics that she had been placed on. The child continued to have respiratory distress throughout the morning with worsening O2 saturations and increasing work to breath. Not that it would have made a difference in this case, there are no ventilators available to use in these situations, meaning that the best we had to offer was the CPAP machine which was no longer providing the benefit it had yesterday. The baby received some morphine to provide some comfort and passed quietly in the presence of her mother, who had been told that she was not going to survive. The other young child presented with what was likely pyloric stenosis and presented after prolonged vomiting and hyponatremic dehydration with renal involvement. The young boy eventually succumbed to multisystem failure.

Patients waiting in clinic

Meanwhile, what had been our decision to see perhaps 30 patients for the day, quickly was abandoned as more patients were sent our way, many of who had come from very long distances making it impossible to ask them to return the following day. We saw many patients with complaints of headache and many patients with epilepsy, both adults and children, so that everyone was happy, though the volume of patients did get a bit worrisome in the afternoon as we were approaching 4 pm, when the clinic usually stops, and had many patients still to see. We continued seeing patients as long as was necessary and finally finished our day somewhere around 6 pm, quite late considering the number of support staff required who must stay late to help us. We still had a consult to see in the ward that we had known about earlier in the day, but hadn’t had a chance to see her given the volume of patients showing up in our outpatient clinic.

Three Maasai women

One very interesting patient that Alice saw in the late afternoon was a young man who stated that he had developed abnormal movements of his right side less than a week prior to coming to clinic. He had never had the symptoms before and noted that he had been drinking alcohol excessively, but had stopped at least a week ago and prior to the movements starting. He was not encephalopathic, had no eye movement abnormalities and was not ataxic so it was quite unlikely that this was thiamine deficiency. Since the movement was acute in onset and there were very few things that could cause a movement like this to start suddenly, we were very suspicious of either some metabolic derangement or possibly something structural. We decided to send him off for labs first and they were normal we would consider getting a CT scan with contrast. Surprisingly, we found that he had a blood sugar of 599 and a hemoglobin A1c of 12.9, both very elevated indicating that he was not only hyperglycemic, but had been so for some time. He was eventually admitted to receive treatment for his blood sugar and by the following day, his movements had completely resolved!

Our busy clinic

Alice and Carrie went off to evaluate her in the ward and found a pleasant 55-year-old woman who had been struck by a bijaji (the little three wheeled vehicles from India that have slowly populated East Africa over the last several years), lost consciousness for several hours and had initial difficulty with her speech. She had gone to an outside hospital, but her family had taken her out and brought her here for a second opinion. When seen here, she was noted to have some difficulty with her speech and underwent a CT scan of the brain prior to our being consulted to see her. Her scan was quite impressive, demonstrating a right posterior cephalohematoma, a left posterior parietal epidural hemorrhage and a left temporal subdural hematoma with parenchymal hemorrhagic contusion. For those of you who are “neuro-nerds,” I am sure that you’re quite familiar with the urgency of an epidural hematoma as these are usually associated with a skull fracture and most often require surgical evacuation to prevent rapid deterioration of the patient. Given the fact that we don’t have a neurosurgeon here at FAME with the closest one being over two hours away, having a patient here with a potential surgical lesion isn’t the most comforting.

The epidural hematoma of our ward consult

This patient looked remarkably well given what her CT scan looked like and after we saw her, the first question from the family was whether or not they could take her home as they lived very close and promised to bring her back should anything change. It is so different here given the fact that patients and families are paying for their hospitalization as families want to take their family member out of the hospital as soon as possible so they don’t continue to run up a bill. In the States, the discussion is tremendously different and it requires a team of social workers to find the appropriate placement for patients, often delaying their discharge by days or weeks. True, that many patients are sent to acute level rehab which doesn’t exist in Tanzania, but family members here are taught the various exercises and stretching that would benefit a patient and then they are done at home. We had given instructions that it would be good to watch the patient for another night perhaps to make certain that she didn’t worsen suddenly, but we found out the next morning that her family remained very persistent through the night and she had been discharged home after remaining stable for the evening.

The parenchymal hemorrhage of our ward consult

I did not leave that night until after 7 pm with the ward consult having been finished and then locking up our ward for the night after housekeeping finally finished mopping the floors as there was quite a bit of dirt that had been carried in through the day. The final tally of patients was 36, not including the inpatient children that had been seen nor the ward consult of the woman with the head injury. It was quite satisfying to have seen that many patients and everyone had felt some sense of accomplishment for our first day. Given the number of patients seen today, it was clear that this spring was stacking up to a busier time than prior spring visits. Dinner tonight was the Tanzanian version of mac and cheese, spruced up by Chef Amisha with the local gouda cheese and peppers that she added to make quite a gooey and tasty concoction. That and a cold beer completed quite a successful day and the rest of the evening was occupied with work on the computer for me and various activities for the others. We each fell asleep with the anticipation of the coming day and what new experiences it would hold.

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