Monday, September 5 – And it’s another season of neuro patients…

Standard

Everyone had been in bed early last night given the amount of traveling that had taken place, both by distance and time, over the preceding three days, but despite this, the residents were up early for a run towards town. I had just a bit of trepidation since they really hadn’t seen anything of FAME yet in the daylight, but they were determined and I was pretty confident that they couldn’t get lost running in that direction. Our first morning was gorgeous, its bright and clear skies as welcoming as one could possibly hope for. It is the dry season here now and any rain will be sparse at best. The temperature was very cool, though not unseasonably so, but enough for you to take note that despite being in Africa, the weather can surprise you at times. We are at the same altitude as Denver, the mile-high city, after all, so it really does make sense in the grand scheme of things.

Cara excitedly awaiting her first patient!

FAME is located in the Ngorongoro Highlands of Northern Tanzania, one of the greatest coffee growing regions in the world perhaps, with plantations that cover immense swaths of land here. As with most products here, though, they are not shipped to the west routinely and most end up in China. We are also at the edge of the giant Ngorongoro Conservation Area, a dual use facility that occupies all of the land between us and the Serengeti and is home to over 100,000 Maasai and their cattle while also being home at certain times of the year to the massive herds of wildebeest and zebra as they make their giant circuit yet once again, completing the greatest land migration known and a true miracle of nature. The migration itself is rather far from FAME, though we do see occasional wildlife nearby, perhaps a stray elephant or Cape buffalo or even a hyena late at night, as they come down from the hillside looking for a snack, or in the case of the elephants, some local mischief is always a possibility.

Morning report, which begins at 8 am each morning and is attended by all the doctors and some of the nurses, is a time for everyone to hear about the nights activities – how everyone in the general and maternity wards did overnight and whether there were any new issues that had surfaced or new patients admitted. Though we are not typically involved in the general medicine patients (though we can sometimes help on these), there will often be patients admitted to the ward with neurologic problems such as stroke, encephalopathy or head trauma that will require our evaluation and assistance in their management. Though morning report, and medicine in general here, is practiced in English, it’s often very difficult for us to hear the presentations for the fact that most Tanzanians are generally soft spoken from a cultural standpoint and considering my hearing disability (I have deaf in my left ear since a bout of viral labyrinthitis six years ago), it is often a real challenge for me to pick up more than half of what is said. Therefore, I rely greatly on the residents to listen in closely for anything that sounds remotely neurologic.

Our patient with the unfortunate cervical fracture and cord injury

This morning, a very unfortunate patient was presented who was 24-years-old and had apparently been attacked by some unknown assailants, presenting with severe weakness in their arms and legs. A CT scan of the cervical spine performed last night had demonstrated fractures of several of the mid cervical vertebrae so it was clear as to where the problem was and what needed to be done, but unfortunately, to transfer a patient here, they must have the necessary funds up front to get them in the door to pretty much any hospital. And, with the anticipation that the patient needed surgery without question to stabilize their spine, that would be a significant amount. This had been explained to the family at several different levels by several of the FAME staff, but they were still debating on what it was they wished to do. Meanwhile, I had Alex and Husain, the Tanzanian clinical officer working with him, go to see the patient in the ward just to document a good neurologic examination as this would be helpful to have. Alex’s report back to me was pretty discouraging as the patient had a complete C7 level with intact biceps, but everything else below, including his hand function was completely out. Bowel and bladder function were completely out as well. The patient had been given steroids the day prior and I made sure that he was still receiving a hefty dose today, but at the same time I sent off an email to Sean Grady to get his advice about continuing them. His note was equally discouraging about any recovery of function at this stage regardless of having surgery, but he did need to be stabilized to prevent further damage from occurring. Late at night, of course, his family requested to just take him home, but were thankfully talked out of that and we were still discussing the potential of transferring him to the neurosurgeon at KCMC.

After morning report, I turned over the group to Prosper for their formal orientation with Prosper, the volunteer coordinator. I pretty much stay away during this so that everyone gets the proper training and hears the same thing about FAME with my editorializing, which is so often easy to do. I spent some time with Susan and William (Susan is co-founder of FAME and executive director of FAME Tanzania and William is our super-star Tanzanian assistant director) just discussing some logistics for our stay here and the mobile clinics we’ll be doing now that there are going to be two rotations each visit. When the group had finished their orientation, it was almost time to start our clinic which we had decided would begin at 11:00 am this morning to allow for everyone to get their EMR (electronic medical record) training as FAME is now fully integrated with an EMR, and though it’s not as robust as Epic by a longshot, it’s still something quite different than just writing on paper charts which is what we were doing until only two years ago.

Me enjoying my gin and tonic with mango juice in our veranda garden as the sun is setting

We decided to start with only three stations and teams as the patients were initially few, though later we opened a fourth station as more patients than we expected showed up. Angel later told me that they had only called five patients about coming in for clinic today, but in the end, we had 20 show up so it must have gotten out that we were here. It all worked out in the end, though, and we actually finished on time a little before 5 pm. Our patients were a good mix of diagnoses and ages so that we had plenty of epilepsy and headache, adult and pediatric. Oh yes, and a few psychiatric patients mixed in with rest just to keep us completely honest. Despite my continual protests to Frank that we are not psychiatrists, his response has always been that we’re the closest thing to a psychiatrist that they have here in Tanzania – I guess that’s not entirely untrue.

Monday’s dinner of roasted chicken, potatoes, and green beans

We had plenty of time to drive into town in the afternoon as we needed a few things from the market, most importantly some tonic water to make some gin and tonics later around sunset. Having never been one for mixed drinks, or drinking at all for that matter, I will be the first to admit that there is something about a gin and tonic that just somehow tastes better here in Africa and not just because of the medicinal history of this drink and its effect on malaria. Our veranda is perfectly situated to watch the sunsets over the mountains here and the colors can be spectacular depending on the clouds. It’s also a perfect spot to watch the lightning storms in the distant Ngorongoro Conservation Area that often come in the late afternoon and evening. Either way, though, there is just something about the G&T that fits. Better yet, or at least in my mind and those that have tasted it have also agreed, is my variation of the drink that includes a touch of mango juice, somehow making even that much more tropical. Everyone partook in our pre-dinner libation and it was a perfect end to our first day in clinic.

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