Tuesdays and Thursdays are educational days for the staff here, with lectures typically given by the visiting volunteers on the subjects that best reflect their strengths. Given that today’s lecture was on peripartum hemorrhage, I’m sure you can guess that it was not one of the neurology team that was giving it. Alicia Willey is a visiting OB/Gyn global health fellow who has come from Phoenix to spend two months here at FAME, working with the doctors and nurses on all things women’s health and was asked to do this lecture this morning for the FAME staff. I’ve always enjoyed hearing what other experts have to say about all subjects medical and this morning lecture was no exception – it keep my attention for the entire time. At morning report following lecture, we learned that the patient with the fracture cervical spine had agreed along with his family to be transferred to a government hospital outside Arusha where he could then be further assessed for consideration of surgery. Whether this would eventually happen or not was a question, but at least it was a possibility that did not exist while he sat here at FAME. Unfortunately, our ambulance was out of commission with an engine rebuilt in the works at present, though we were able to hire one for a cost that would transport him and, in the end, FAME decided to waive his hospital and ambulance fees given the likelihood there would be more costs upcoming and this might help in the end.
Anytime fees are waived such as this or care or service are given, this must be done in the most sensitive manner as FAME is not set up to provide medical services for free and our existence would be very short lived if we tried to do so as the entire population of Northern Tanzania, if not the country, would suddenly flock to receive their care here. Instead, FAME provides medical services to the population for very fair and reduced rates that in no way completely cover the costs of the services or of running FAME (hence the need for our ongoing fundraising throughout the year, hint hint – www.fameafrica.org then click the DONATE banner). When fees are waived, the patient must understand that this has been done out of compassion and that it is not the normal course of business to do so, hence it is a one-off and should not be expected to occur again. It is always done on a case by case basis. And, the last thing that we would ever want to happen would be for a patient to perceive that their fee was paid for by a volunteer or that in some way having seen a volunteer meant that they were more likely to have had their fee waived as this would not only alienate the entire Tanzanian staff, but would also undermine their sense of purpose and their ability to practice. When we speak of “unintended consequences,” this is often one of the biggest problems that volunteers have in coming to a LMIC (low or middle income country) or low-resourced setting. It is often a very fine line that we walk.
Meanwhile, it was now time for clinic to start and patients were beginning to accumulate in our waiting area. It was an incredibly cool morning and this will often affect the number of patients who come to clinic first thing in the morning, though that wasn’t necessarily the case today. Regardless, it meant that all of us needed to grab something extra to stay warm given the nip in air and the slight breeze. The residents all decided to walk home to grab their sweaters along with something for me, but of course returned having completely forgotten about their fearless leader necessitating my leaving clinic for a short time to return to the house.
At some point during clinic, I received a WhatsApp text from Alana, who was apparently in the CT scanner, asking me to look at a scan of someone’s brain. Looking at the pictures on my iPhone, I wasn’t quite sure exactly what I was looking at, or who I was looking at for that matter, so left my post at clinic to run over to the scanner where I could view things on the computer screen much more easily.
The patient was apparently a young woman who had been drinking and had apparently stumbled, striking her head on a large rock with an initial period of prolonged unconsciousness for which she had been seen at an outside dispensary and then sent home. She was now presenting with a right sided headache, but hadn’t come to neuro clinic and was instead seen by Dr. Josephat, who had appropriately ordered a CT scan. The scan, which was quite abnormal, demonstrated a skull fracture through the right ear canal and a small, but concerning epidural hematoma. Though the patient was awake and intact neurologically, our concern was to keep her that way as epidural hematomas, unlike their cousin, the subdural hematoma, can take a sudden, and often life-threatening, turn for the worse. Watching her here at FAME was not the problem, but rather what we were going to do should she suddenly become worse and require a burr hole to evacuate the hematoma. Though we now the capability to perform burr holes here at FAME, this has not yet happened, and given we had the benefit of time on our side, we chose to send her to KCMC where there is a neurosurgeon and something could be quickly should it become necessary.
There was once again the standard smattering of headache, epilepsy and psychiatric disease that occupied the day and kept everyone pretty busy and on their toes. Though I had said that we’d be able to see 40 patients between the four teams of residents today, we ended up seeing only a few more than 30 patients during our day. The impact that we can have here seeing patients with neurologic disease is always significant whether it be headaches that are non-life-threatening or neuropathies that are less than disabling, but the greatest impact we can make is with the patients suffering from epilepsy. It is not at all uncommon for us to see patients who have had seizures since childhood and have never seen a physician or have never been on medications for treatment. Children with seizure disorders that are not completely controlled are unable to attend public school which is obviously a horrible situation and it does not take long at all for those children to fall drastically behind their classmates and unable to catch up. For many of these children, they have never been placed on the correct medications or appropriately therapeutic doses of the medications necessary to control their seizures and it often requires very little effort to make these changes that will have a very significant effect on their lives.
Since 2015, we have kept a database of all the neurology patients seen at FAME for the purpose of knowing what diseases we were treating, where patients were coming from and what medications we were using to treat everyone. In addition, we included outcome data for patients with epilepsy and realized that we were obtaining excellent results as these patients were returning to see us at much higher rates than other diagnoses and much better adherence to their medications if we had started their therapy than at other medical facilities. All in all, it was just incredibly encouraging that not only was FAME making a huge difference in the lives of Tanzanians in the Karatu district, but that we were also greatly improving the lives of patients with neurologic disorders and specifically epilepsy.
Our clinic days are broken up with the traditional colonial tea time in the morning around 10 am and then lunch usually sometime after 1 pm. All the staff at FAME eat together during the day and lunches here are delicious – rice and beans plus mchicha (a dark green spinach-like vegetable) is served five days a week while on Tuesdays we have ugali (a very traditional stiff porridge made from maize), meat and mchicha and on Thursdays will have rice pilau with meat and cabbage salad. All of this is served with pili pili, a delicious salsa that is made fresh daily with very spicy peppers and will vary from day to day as far as spiciness is concerned so it’s always a bit of a surprise. All the water on FAME’s campus is safe to drink, though in the early days we used to filter it in each of the houses until testing determined that there was no need for that. Outside of FAME, though, only bottled water can be consumed.
Our dinners are supplied to us Monday through Friday and are typically pretty basic which, to be perfectly honest, is just fine as it gives us something to look forward to on the weekends. Getting out to the local lodges is always such a treat and we have always been treated well by them given that we are here volunteering. Gibb’s Farm has seemed to be everyone’s favorite over the years, but the Manor Lodge and the Plantation Lodge are also very good alternatives. These lodges, all pretty much out of our price range as far any thought of spending the night there, have wonderful restaurants and great chefs with all locally grown foods that are served in impeccable settings. Taking a moment out of schedules for one of the finer things in life has never been more appreciated than this.
Our clinic today finished at a reasonable enough time to allow us all a trip to town to look for fabrics as all of the residents, as well as Dr. Alisha, were interested in having clothing made which has become a tradition while here on this rotation. Dr. Anne has always accompanied us to the fabric store to help with the purchases as well as to determine just how much cloth everyone would need for the clothing designs they had chosen from those she had sent to everyone. We descended upon the fabric store like a ruthless mob in search of loot and the group quickly moved behind the counter to search through the rainbow of fabrics stacked along the wall. For those of you who have traveled through the mid-section of Africa, whether it be West, Central or East Africa will be very familiar with the incredibly colorful dress of these regions and it from shelves such as these that it comes from. Once everyone had found what they were looking for and had made all their purchases, we loaded back up in to Turtle and made our way back up the hill to FAME for dinner and a relaxing rest of the evening.