Friday, March 13, 2020 – A knock at the door….


Life here at FAME is indeed very comfortable for us in the Raynes House as it has been in other houses I’ve stayed. I will have to say that it hasn’t always been that way as it probably took several years before the hot water situation was ever sorted out which mean cold showers during that time. Now, hot water is supplied by Kuni boilers, which are essentially hot water heaters that must be fired once or twice a day to provide us with the hot water necessary for everyone, or almost everyone to shower. That means that the boilers must be filled with wood or some other combustible material in order to be lit and that can certainly be a choir. The boilers are each shared by two houses, and how much hot water you have in the morning depends on how many people are sharing the house and wanting to take a hot shower at any particular time. Everyone taking a shower at the same time here means the hot water will run out very quickly and chances are there will very likely be many unhappy people that morning.

Marin, Amisha, Frances and Angela

Breakfast for us is usually whatever we want it to be since it’s the only meal that we are responsible for ourselves. It will vary from something fancy, like scrambled eggs (ala Carrie), or less complicated like a bowl of corn flakes and banana (ala Dr. Mike). I can even be simpler, such as a granola bar which many of us will do if we’re running late in the morning. I can often be found sitting at my desk in the wee hours of the morning, typing on my blog, so my mornings are most often the cup of tea and a granola bar later at clinic. On rare occasions, someone will run to the Lilac to pick up coffee for several of us. Though I have offered to Carrie that she can work on entering the patient data in the morning at the Lilac and have breakfast, she has opted to do them in the afternoon/evening and spend the days with us observing in clinic.

Africanus, Carrie and Alice evaluating their patient

So, this morning, as I was sitting at my desk pecking away on my blog, I was a bit surprised when, at 7 am, my thoughts were disrupted by hearing that there was someone at our door insisting that two doctors were needed at the hospital to help manage a patient. There are certainly neurological emergencies here at FAME that require our immediate assistance, though it is very rare for us to be summoned in this manner, and, there are no stroke alerts here as there are at home where we have TPA and mechanical thrombectomy to offer, neither of which are available here. Meanwhile, Molly felt that it was a nice throwback to medicine as it once was, receiving a knock on the door to politely request our presence and not some beeper or alarm. There was something about it that made her think of house calls and the days of all small town doctor, I believe. Whether or not that was the case, though, both Molly and Carrie volunteered to come up to the hospital with me, where we found Dr. Julius, who had been on overnight, in our emergency room (which also doubles for the endoscopy suite) with an acutely psychotic and very combative patient who was wresting with one of his family members.

Amisha and Anne evaluating their patient

We were told that our patient, a 31-year-old gentleman, had a similar episode a year ago and had been seen at an outside hospital and given Valium for a week and, after that, he had apparently returned to normal (for him). Unfortunately, though, he had not been placed on any long term medications nor sought psychiatric evaluation anywhere. From our perspective, we were most concerned that he would hurt himself or someone else, and we needed to get some control of the situation, which meant giving him a strong intramuscular sedative, in which case he probably wouldn’t be awake for some time. We were unable to access the haloperidol that I had brought in the past as it was locked away, but we were able to located some chlorpromazine (Thorazine), a powerful antipsychotic, which we proceeded to give the patient along with some lorazepam (an anxiolytic) to get things working more quickly. He continued to fight with us for several minutes, but it was only a matter of time before he fell rather suddenly fast asleep with all of standing there and very happy that the wrestling match was over. During the height of his psychosis this morning, he was having very clear visual hallucinations, but it was impossible for us to gather any history from him so it was unclear if he was having any auditory hallucinations in addition. He was transferred to the medical ward and later in the morning, the team went to gather more history, but it was very difficult as his wife was a rather reluctant historian and, other than the episode from one year ago, was not willing to admit much more, meaning that we wouldn’t have much more to go on from a standpoint of making a diagnosis. Our suspicion was that we were dealing with schizophrenia and were just not getting the straight story from his wife, but either way, he would be put on a chronic antipsychotic for now (olanzapine), and would have to be re-evaluated in the future to determine how long he would remain on the medication.

Presenting to Dan

Having finished for the moment with our psychiatric patient, it was almost time for morning report so the three of decided to run down to the Lilac Café and order coffees to go. We received our French presses of wonderful Ngorongoro Highlands coffee just in time to head to report and hear about a patient in the maternity ward who was a few days over 36 weeks and had very significant pyelonephritis that had been causing her to be febrile. A very brisk debate ensued among all the FAME doctors, the nurse midwife in charge, and the volunteer ob/gyn regarding whether the child should be delivered early or not. I will not burden you with the details of the discussion since I had very little understanding of what was actually being said given that my last journey into this realm, other than my own children, was over 30 years ago and it was not something that I had planned to pursue at the time. I’m not certain as to what the final decision was on the matter, but either way, it didn’t involve us.

Carrie, Amisha, Marin, Dan and Angela discussing things

Our patient who had been admitted yesterday with the question of Paget’s vs. osteopetrosis was now on IV antibiotics and was going home as he had family in the area that could continue to provide him his IV medications at home over the next week before being placed on oral medications for a month or more. This seemed like a very good plan as he had plenty of support from family, a number of who were actually in the medical field so could manage his treatment in the future as well. We believe that we had mostly come up with a solution for his chronic osteomyelitis, but there had still been no resolution regarding his underlying condition that was causing the continued deformity of his skill along with his difficulty opening his mouth. Treatment for Paget’s would have been one of the bisphosphonates which they do not have here and treatment for osteopetrosis, a hereditary disorder would be stem cell transplant which is certainly something that is not available here.

We had decided to go out to Happy Days tonight since it was Angela’s last day with us and she would be leaving in the morning. We had forgotten to have everyone say goodbye to her at morning report meaning that we would have her show up tomorrow to do so before leaving FAME. I can’t recall whether I had explained Angela’s connection in the past or not, but she had first come as a global health scholar to Penn last summer where she spent a month taking some short epidemiology courses and also was able to spend time with me in clinic both at HUP and CHOP. She is a board certified pediatrician in Ghana who has a keen interest in the various development disorders in children and, as such, pediatric neurology. When I discovered this, I had her meet a number of the peds neuro residents as well as the adult neuro residents. In the end, she would very much like to do further training in pediatric neurology and is looking into the various options to pursue this in the future. She had heard lots about my work here in Tanzania during her time in Philadelphia and had asked at one point if it would be possible for her to come observe us here. She had some vacation time at the beginning of the month and the stars seemed to align, enabling her to travel her to spend the two weeks with us. I believe it was a fantastic experience for her to have spent the time with us and was equally valuable for us to have spent time with her.

The young Maasai boy with TB meningitis improving every day

Happy Days (or Happy Day which it was originally known as) is a pub that is frequented expats here in Karatu and which has been around since I first came in 2010. It also has cottages that pretty minimalist, but adequate, and over the years have housed a number of volunteers throughout Karatu as well as some FAME volunteers. Peter Schwab stayed at Happy Days in September 2018, and was very happy there. It came under new management about two years ago and received a significant makeover in regard to both its ambience and its food. Where there used to be large picnic benches on the covered porch, there are now low tables with sofas and chairs loaded with pillows that are incredibly comfortable for lounging and eating. On Wednesday nights, which is the traditional expat gathering night there, they now have wood fired pizzas while on other nights their menu has more traditional pub food that includes a wonderful mac and cheese along with lots of other dishes and even a few burgers. I’ve never sat inside, which has also now received a similar makeover, since it is so pleasant outside, even in a rainstorm as the roof is covered.

Carrie, Molly, Frances, Marin, Dan, Amisha, Angela, Alice and me

Since it was Angela’s last night in Karatu, we all decided to take her out to Happy Days for a celebration dinner. The one thing that hasn’t changed about Happy Days, is the time to receive you meal once it has been ordered. It will usually take over an hour to get your food once you have placed your order and that’s just the amount of time you have to wait. No questions, no apologies. Thankfully, the food is very good and, in most circumstances, well worth the wait. And besides, it is like paradise living here in East Africa, so having a few beers with your fellow expats on occasion is well worth the wait. And besides, living here in East Africa, which is essentially like living in paradise every day, isn’t a bad place to relax and have a few drinks together with your friends. The evening was rainy, but under the covered porch we were dry and the air was cool. It took nearly forever to get our food, but no one cared for we were all among friends and, as they say, life is good!

Relaxing with a wonderful kitty on my lap at Happy Days

Despite the fact that life has been normal here, though, much of our focus did remain on the ensuing Covid-19 pandemic throughout the world and the fact that life was not normal over much of the globe and would very likely soon be affecting us as well. Angela was flying through Nairobi tomorrow and Kenya had announced their first confirmed Covid-19 case today. She had a layover there of 16 hours before her flight to Ghana and had anticipated going to a hotel, but was not thinking otherwise about leaving the airport and somehow not being able to get back in. We also knew that it was only a matter of time before we would be affected also and this inevitability did loom very large over us.

One thought on “Friday, March 13, 2020 – A knock at the door….

  1. Karin Verrier

    Thank you for sharing all of the wonderful things you are doing at FAME. I thoroughly enjoy reading your blogs. Truly, KARIN VERRIER

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