Thursday, September 9 – Our first day of neuro clinic….

Standard

Having arrived the evening before and fully moved into the Raynes House, everyone settled into life here. The Raynes House was built several years ago, through the generosity of Stephen and Lisbeth Raynes, as the fourth and final volunteer house on FAME’s campus and a home for the Penn Neurology team during our time at FAME. The house would be used by other volunteers at times that we’re not here, but will always be reserved by us during the months of March and September, as well as other months that Penn faculty and residents may come. The house is incredibly comfortable with four bedrooms (three double and one single, the latter for me), each with its own bathroom. We have a large living area centrally and a kitchen with the best view in the world looking out over the coffee fields to the west to watch the wonderful sunsets here. We have a small veranda in front of the kitchen windows with a beautiful garden courtesy of Annie Birch, a long time ex-pat resident here and jack of all trades. I have three hammocks set up across the front of the house for that occasional day we get back to the house early to enjoy the evenings. As I mentioned before, life is good.

The first day of school – Emily, Denise, Phillip, Cat, and Akash (left to right)
An ant colony on the move

Our daily schedule here is clinic from 8:30 AM through 4:30 PM with tea time at around 10:30 AM (a British colonial holdover) and lunch usually around 1:30 PM. Lunch is made by the kitchen for all the workers at FAME who eat together, though now it is outside during the pandemic where it used to be inside the small cantina at picnic tables. We have rice and beans complimented by mchicha (a spinach like vegetable) on every day but Tuesday, when we have ugali and meat plus mchicha, and on Thursday, rice pilau with beef (most everyone’s favorite, though I am partial to the rice and beans). Lunch is served seven days a week for anyone on campus. The kitchen prepares dinner for us on Monday through Friday, serving it in hot pot containers, one for each of us. The dinners are basic, though adequate, and after a long day at the clinic, we’re usually so tired that the dinners more than suffice. There are lots of vegetables, prepared in every way imaginable, with a smattering of beef or chicken complimented by occasional chapati. We are on our for breakfast, but are supplied all the basic groceries such as cereal, eggs, bread, veggies and fruit. Trust me, we are never wanting for something to eat here, that is for certain.

Akash and Cat evaluating a child
A good view of our outdoor clinic
Revo and Emily

For our first dinner here, they had unfortunately shorted us on dinner, which was not a major problem as it included meat sauce and Akash is a strict vegetarian. Sean and Kerry came to the rescue, though, as they had been here for a few days and had some salad fixings that worked just fine for Akash. We all sat out on the next door veranda (Joyce’s house) which is much larger than ours and in between our house and the one Sean and Kerry are staying in. Thankfully, they also had some beer and wine to bring which made dinner that much more enjoyable.

Morning lecture on chronic subdural hematomas and burr holes
Dr. Sean demonstrating on wood

Perhaps it would helpful for me to introduce the cast of characters for this trip as that might be helpful for those of you who are not family members or unfamiliar with the group. The neuro team consists of three adult neurology residents – Cat (Catherine here as the nickname Cat is not well understood), who will be going into epilepsy; Emily, who will also be going into epilepsy; and Denise, who will be pursuing training as a neurohospitalist. Our pediatric neurology resident is Akash, who will certainly discover how indispensable he is, though we would never tell him that 😉. Phillip is our medical student, whose role it is to keep our database of patients current and, when he’s not doing that, work with us in clinic to observe as he’s not allowed to officially offer any treatment or touch a patient, a common rule for medical students going to foreign countries and imposed mostly by the home institution, in this case Penn, rather than the host country.

Dr. Ken and Dr. Sean

Sean (Dr. Sean Grady) and Kerry (Dr. Kerry Vaughan) represent an entirely new effort here at FAME and that is neurosurgery. Not to bring highly technical procedures to FAME, but rather to train the surgeons here how to do a rather simple, lifesaving procedure to treat a very commonly seen problem here in East Africa and other parts of Africa. Traumatic head injuries are significantly more common here in Africa (and all low to middle income countries) and often result in bleeding outside of the brain called a subdural hematoma, or, less commonly, an epidural hematoma. Having a CT scan available here at FAME, we’re easily able to identify when these events occur, but we have no mechanism to treat them effectively other than giving some medicine to reduce intracranial pressure and shipping them off to Arusha for a burr hole or craniotomy to remove the blood and relieve the pressure. The problem is that time is of the essence, as one can certainly imagine, and very often the patient may suffer significant injury or death prior to or en route to Arusha, where there is a single neurosurgeon.

Kerry preparing the femur

Sean has accomplished similar efforts in the past during his time in Seattle, Washington, where he trained general surgeons in lower Alaska how to do these procedures successfully so that these patients could be treated on site rather than having to be shipping down to Seattle with many of them suffering complications along the way. Kerry, who is actually a pediatric neurosurgeon and just about to start a new job after her fellowship training, trained at Penn under Sean and has done extensive global health work in many locations, including nearby Uganda. We are so excited to have them here with us and this will be a huge new step for FAME, equipping them to deal with these neurosurgical emergencies in the appropriate time to save lives. They will be here for two weeks and, though it would be an excellent opportunity if one of these patients presented during our time here, it is not entirely necessary as they will prepare the surgeons and the operating rooms either way.

Gabriel saving a femur’s life

Sean and Kerry had arranged to give the educational lecture today which would be an introduction to the hand drills that were brought here to use for this procedure. Not having a ready, or willing, volunteer to undergo a burr hole (essentially the same as trephination that was practiced by many cultures in both prehistoric and ancient historic times), they had arranged for Dr. Ken to boil down a few cow femurs to remove all the soft tissue and these would serve as surrogate skulls to provide the feel of drilling through the two layers of the skull – the harder outer and inner tables and the softer cancellous bone center. After some introductory slides for orientation, the practical exercises began and our two neurosurgeons instructing the FAME doctors on the fine points of using a hand drill, or brace, to bore a hole through the two layers and note the feel of the drill bit as it was about to perforate each of the harder layers, the outer leading to the cancellous center, and the inner leading to the cranial vault with the brain and the fluid collection that was the target.

Gabriel working with the drill

After the educational exercises, we had a brief morning report to go over the inpatients and any new patients that might need our expertise, as well as the maternity patients. There was also one patient in the COVID isolation ward that was being taken care of. Once finished with morning report, the first piece of business for us to take care of would be for everyone to be instructed on the reasonable new EMR used at FAME. This is a rather bare bones system designed to primarily capture the necessary data on patients, as well as to track medications and payments. In addition to orienting everyone on the EMR, they were oriented on the work flow of the clinic and introduced to our translators. Revocatus, or Revo, who has worked with us on multiple occasions previously, is a medical intern at Kilimanjaro Christian Medical Center and is a superstar. He is a fantastic clinician who has learned a tremendous amount about neurology working with us. He has reinforced the power of our program in regard to training those frontline clinicians who will go on to care for their patients now armed with a full complement of the knowledge necessary to provide basic neurologic care where there was little before. Dr. Anne would, of course, be working with us again as she has for the last eight or so years. She is FAME’s neurology provider in our absence and has done a remarkable job of this over the years. She works with us for the entire month each time that we’re here. Dr. Leeyan, who is Maasai and a relative of Kitashu’s, is new to our clinic and working at FAME for the first time. We will give him time to get up to speed and make sure everyone is comfortable as working as a translator is not always the easiest job.

Dr. Sean instructing Dr. Ivan

By the time we were finished with orientation for everyone, it was already tea time, and this is not something that is taken lightly here. The wonderful African tea, or tea masala, is served as well as coffee and bread. I’ve never totally understood the tradition of eating slices of white bread with margarine, but it seems to be well accepted by everyone here with employees walking from the cantina holding several slices in their hands. In a continent where caloric intake is poor at best, I guess it’s certainly a means of improving that issue, even if it isn’t terribly appetizing to me.

Dr. Sean working one of the FAME doctors

Our clinic began at around 11:00 AM when everyone was finished with their tea since, as I’ve mentioned before, this is not something that we would ever interfere with here. The patients who came today were mostly return patients who had been called by Kitashu or Angel, our clinic coordinators, to come see us for their follow up visits. There were a number of well controlled epilepsy patients on medications that were working well and merely needed to be renewed or a few may have needed lab work to make sure they were having no issues on their medications. There were also a few consults for us. One was a patient with a long history of quadriparesis from what sounded like Pott’s disease (Tb of the spine), though the history was a bit inconsistent and would require a bit more interrogation to make sure we had an accurate story. The other was an unfortunate baby who had a very problematic birth with likely HIE or hypoxic ischemic encephalopathy and then began promptly having seizures. Akash went to evaluate the child who was now very sleepy and on phenobarbital which was very likely contributing to the sedation and they hadn’t seized in some time. We elected to hold the phenobarbital and observe the child to get a better exam on them as far as a prognosis.

Our patient with carpopedal spasm

Just before we were finished for the day, Dr. Anne and Cat ran to the ER to see a very interesting patient for a neurology consult. It was a 28-year-old gentleman who had no past medical history and had been driving their family member to the hospital when he developed a bizarre posturing of his hands and feet that looked dystonic in nature. They brought him to FAME fairly quickly where he continued to have the same posturing that indeed appeared to be a dystonic posturing of the hands with flexion and abduction of the fingers and, to a lesser degree, the feet. He was given some diazepam with eventual resolution of the abnormal posturing. When Cat and Dr. Anne got there, he was back to totally normal with a totally normal examination. Thankfully, they had taken a video of the patient when he had first arrived and they brought this back to show me. The patient was clearly hyperventilating and I took one look at the video and was pretty certain what the diagnosis was. The patient was having carpopedal spasm in the setting of a panic attack! What a great case for the residents.

Meow and Charlie

We gathered for dinner once again on Joyce’s veranda and enjoyed a meal of curried vegetables and chapati. Matilda was once again pestering everyone in constant search of some morsel of food despite the fact that she is fed daily by housekeeping. The sky was quite clear tonight and Akash took some amazing photos of the stars. I was working late only to realize that I had an important Zoom conference scheduled from 11 PM to 12 AM that I had forgotten about. It was with the Center for Global Health at Penn meeting with the director and assistant director as well as others at Penn who are currently doing work in Tanzania. It was great to be on the call considering I was the only one actually in Tanzania at the time, but it was also very late and we had clinic the following morning. Thankfully, we didn’t have a 7:30 AM educational meeting so that I could at least get a few minutes more of sleep.

The heavens above (photo courtesy of Akash)

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