Wednesday, October 7 – A day to finish charts and documentation…

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The primary role of our work here at FAME from my very first visit and including the present has been to work with the doctors and nurses to provide them with all the necessary skills to evaluate and treat neurological illnesses in the residents of Northern Tanzania. By doing so, we would be fulfilling one the main missions of FAME and improving the health of the community relying on them for their medical care. Early on, though, we also realized the need to keep internal documentation of the types of patients that we were seeing and where they were coming from, to what tribes they belong, the diseases that we were treating, and what medications we were using to be certain that we were addressing their needs and would have the necessary resources available for each of their visits. Beginning in 2015, that internal documentation became an organized database that now contains well over 2500 patient-visits and provides an incredible cross-section of the neurological health of a large community in Northern Tanzania and a wealth of information that will enable us to not only continue to provide this care, but to do so in a more efficient and effective manner over time. Furthermore, the knowledge that is gained from this record may well translate to other similar communities in Tanzania, and even throughout Africa, as well as to other specialties beyond neurology.

This database has been continually maintained by the residents who have accompanied me here and, more recently, by a select group of medical students from the University of Pennsylvania who have not only demonstrated a keen interest in neurology, but have also shown their desire to pursue it as a career. Though it has never been the intention of FAME to provide medical students with a global health experience, the volume of data that we have been collecting has made this role very helpful, if not essential. Despite the fact that I saw far fewer patients than we do on a normal visit (140 as opposed to 400), I would still be responsible for making sure that we have all the necessary documentation to input each patient into our database, both new patients and return, as well as additional information for all of our epilepsy patients concerning their seizure control. My plan for today, of course, was to spend as much time as would be necessary to complete that task which was slightly more complex given the new EMR (electronic medical record) that we had just started using the first day I began seeing patients this trip.

Thankfully, FAME had seen fit to actually hire their own IT person who would be managing the EMR internally and that made my life tremendously easier. The EMR that FAME selected would have to be one that would be usable in Tanzania for Tanzanians and was not being developed for the volunteers who are coming, most of whom are very familiar with systems such as Epic that cost millions of dollars to install and would have been total overkill. The main problem that I encountered with the new EMR actually had to do with the report feature as I wanted to be able to pull up all of the neurology patients we had seen for the month and that feature just didn’t exist when I began to play with it. Thankfully, though, Valence, FAME’s new IT specialist, was able to go into the system and find the report that I was looking for which saved me an incredible amount of time. As with every new system, though, there are often oversights that weren’t anticipated and a glaring one that I discovered, at least from neurology’s perspective, was that the data regarding tribe and village was not being recorded in the patient demographics in searchable field. Some of the questions that we had been looking over the last several years had to do with whether there were differences in neurological disease, rates of return, and demographics between the various tribal affiliations and locations throughout the region that we draw from. This information, which had been included in FAME’s older demographic database and on the paper charts, would now require that I go back through all of the paper charts to update our records and make certain that we would have the necessary information to input into the neurology database, otherwise, it would be incomplete.

I came up to clinic around 8:30 am as I knew that Kitashu was going to be there to help me gather all the charts together. Then, I was able to create a list of all the patients we had seen in the EMR which allowed me to tell if one of the paper charts was missing as often happens if someone comes and takes it for various reasons. I sat down to start the process of going through about 120 charts (quite a big stack) when Kitashu came in to ask me if it was possible for me to see a young man whose father had brought him to clinic today as he could not find the boy yesterday. This was somewhat of an interesting excuse and I wasn’t quite sure whether to take it totally seriously, but in the end, it turned out to be very legitimate.

I invited the young man, who was about 24-years-old, and his father to come into the exam room where I had all of the charts strewn across the desk and table after finally getting them chronologically organized. Dr. Adam was there with me to translate, though it turned out that both the son and the father spoke very good English. Despite this, I typically want to have a Swahili speaking person in the room as certain things can be lost in translation and just to be careful, I have always stuck with this practice. When I asked what I could do for them, there was an initial bit of a silence, and then began a very long and saga that involve the son being away at college several years ago, becoming mixed up with other youths smoking marijuana, being sent home from school and the father taking him to the hospital not once, but several times for what sounded mostly like psychiatric admissions rather than just for drug rehab (which is really hard to find in Tanzania for the most part).

Over the last several years, though, the son had been following with district mental health officer and had been on a fairly strong antipsychotic medication, chlorpromazine, that had actually worked very well for him and it was only when he went off of the medication that he would become agitated or aggressive with others. The father was blaming the marijuana for his son’s issues, and even though this might be partly true, after I had clarified that the son did indeed have auditory hallucinations and paranoia, I was completely confidence that this young man, whose issues began initially when he was 18-year-old, had a pretty run of the mill case of schizophrenia that had been well controlled on the chlorpromazine. Though the marijuana may have temporarily made him acutely psychotic, or, should I say, more psychotic, it was not the underlying problem and marijuana or no marijuana, the boy would have had the same issues and needed to be on medications.

The father, meanwhile, had done a remarkable job of not only keeping his son safe, but also doing what was clearly the best for this boy by taking him to the hospital on several occasions to try to find help for him. Unfortunately, there are no psychiatrists around to manage these case, which is why we are often seeing them in our clinic, but I did know of a psychologist in Arusha who Frank has referred patients to in the past, and I promised the father that we would reach out to get that information for him as he was willing to do whatever was necessary for his son. Hopefully, we can make that connection for them and find some relief for this very caring father. In the US, the son would undoubtedly be in a group home as he was very well dressed and appeared to be functional on his medications.

I was finally able to get back to my charts, and other than meeting with Susan and Kitashu for a debriefing meeting, I spent the rest of the afternoon working on them and was able to complete perhaps just over half. I had wanted to get in my last bike ride of the visit and was determined to do so as this would be my last opportunity. I hopped on my bike and pedaled down the FAME road into town, paralleling the tarmac along the Tumaini School Road and then connected up with the main road out of town towards Rhotia. It was actually a bit cooler than I had expected, even with the late afternoon sun bearing down on me, and it was great last day for a ride. I returned home, showered and met Abdulhamid in town for my last nyamachoma dinner, one of my favorites here. I took care of a few more charts before bed and knew that I still had a few hours of work to do in the morning.

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