Monday, September 26 – Our first day of the second session of neuro clinic….

Standard

I’m sure that it had been an exhausting day yesterday for everyone – the residents having just traveled half-way around the world to reach Tanzania and my having driven to and from Arusha over the weekend and twice to the airport. Just to familiarize everyone with the enormity of the African continent, it is further from West Africa to East Africa than it is from east coast of the US to West Africa, a fact I learned traveling here during the Ebola outbreak in West Africa and peoples fear of traveling to FAME at that time. We were further from Ebola here at FAME than those who were on the east coast of United States during that time. Though the Ebola outbreak was a very scary time here in Africa, particularly, it was managed to be contained through the efforts of an international force and specifically those lead by Partners in Health and Paul Farmer. Interestingly, the Ebola outbreak ended up being only a minor dress rehearsal for the COVID-19 pandemic that has ravaged the planet over the last two plus years and continues to create problems despite the fact that life has returned to some sense of normalcy in many areas.

Bringing a new team to morning report is always an exciting time for not only are they introduced in some fashion to what they will be doing over the next several weeks, but it is also the time that they are introduced to the FAME staff who they will be working with going forward. Though morning report is primarily directed at the inpatient and maternity wards, giving report on each in-patient that also includes the many neonates, some of who may be quite premature, we can also discuss interesting outpatients who were seen overnight or the day before. One patient, who had come in over the weekend while I was away, was incredibly sick and very interesting.

It was a young Maasai girl who had come in with severe lymphadnopathy on one side of her neck, but by the next morning, her entire neck was terribly swollen and there was concern for her airway. She was still breathing fine and her O2 sats were perfect, but the decision was made to send her to Arusha Lutheran Medical Center (ALMC) where they would be able to intubate her if necessary and ventilate her as well. The concern here was for diphtheria, as many children here are not vaccinated, and it was felt that she may have had a pseudo membrane visible, a defining feature of that disorder. There was also a concern for anthrax as the history came out that she had eaten a dead animal about a week prior, a behavior that is high risk for acquiring this disorder here – I have seen two prior cases of cutaneous anthrax while working here at FAME and it is not very pretty. Both had come from eating dead carcasses that had been laying on the ground where the anthrax spores remain dormant for many years and are fairly ubiquitous in the environment. Unfortunately, we received word later in the day that the young girl had died even though she had been intubated. There was also no clear diagnosis that had been obtained meaning that those caretakers who had significant exposure to the young girl would need to receive the appropriate prophylaxis for the suspected diagnoses.

A Maasai missing his two bottom front teeth

Also ubiquitous in the soil here are tetanus spores, and though they are perhaps less infectious than anthrax requiring an inoculation or entrance wound to gain access to the victim (cutaneous anthrax requires only a scrape or a mucosal surface, if I’m not mistaken) it is still a relatively common diagnosis here where it is almost never seen in the US for reasons of vaccination. In fact, it is so common among the Maasai, and especially those living in the Ngorongoro Conservation Area, that they very commonly remove their two center bottom teeth so that they can be feed liquids in the event they contract tetanus. I specifically recall one young boy who came in with tetanus that he had developed after having had soil placed in traditional cuts over his abdomen that had been made by a local healer when he was being treated for abdominal pain. The boy came in with horrible spasms throughout his body and in tremendous pain. We didn’t have the tetanus immunoglobulin here at the time, so the treatment was solely benzodiazepines and keeping him in a dark room with absolutely no stimulation. Having never seen a patient with tetanus before, it was quite impressive and once you see it, it is not something that you will soon forget.

Having been fully introduced to the staff at FAME and morning report now complete, it was now time for the residents to get their formal orientation to FAME and to learn how to use the new EMR here. Having an Electronic Medical Record, or EMR, had been a goal for FAME for a number of years and it finally came to fruition in September 2020 after months and months of incremental implementation. It was the height of the pandemic and I had traveled here on my own despite the fact that there was a complete travel ban being imposed by the University of Pennsylvania. I appealed the travel ban on the grounds that I had been visiting FAME every six months for ten years and that there were patients expecting to be seen in follow up. After having gained the trust of FAME and the community by returning every six months, pandemic or not, I was not about to let them down and not show up. The reception I received from everyone here was heartwarming and absolutely worth any risk that I had taken, though I didn’t perceive there to be one, and the reassurance that was given by my presence was considerable.

The young Maasai boy with tetanus

Having originally hoped that I would be long retired by the time EMRs became the norm, and realizing that battle had been lost long ago, I eventually accepted the fact that this was an inevitability and made peace with the EMRs I have come to know. The EMR at FAME is very basic and serves the basic purposes that are necessary here. I did learn the basics of FAME’s EMR and, more importantly, the residents, incredibly quick to pick up these new technologies, as opposed to an old fart like me, took no time at all to learn the ins and outs of the system here. It is actually a pretty clunky EMR, but gets the job done and this morning, both Dr. Anne and our IT person, Valence, had set aside time to go over the specifics so they could all get comfortable seeing patients for the second half of the day and documenting them appropriately. The other thing the EMR does help with is our database of neurology patients that we have been accumulating now since 2015, and has made their information now incredibly more accessible for everyone, and though we still have full access to the EMR while on FAME’s campus, accessing it from back home is another matter and a bit more complicated requiring a VPN and lots of prayer.

Once having taken the complete tour of the entire FAME campus, which is tremendously larger than it was back in 2010 when I had originally come to volunteer, there only existing the single OPD, or outpatient department, at that time, the residents were now ready start seeing patients. We had several patients who had come early, but as there are no appointments here and most patients who come are willing to spend most of the day to be seen, it wasn’t an issue to have them wait. There were only three residents this session, so they set up shop in three of the cubicles, again outside, which is a tremendous advantage for us given the open air and sunshine that exists here in the dry season, though it also works out quite well in the wet season of the spring. We had plenty of translators to go around as there were several clinical officers (similar to our nurse practitioners or physician assistants) volunteering at FAME who would be helping us and Nuruanna, a pharmacy student from Rift Valley Children’s Village, who has been working with us over the last several years.

Both MDs and COs (clinical officers) will often have a difficult time finding jobs in Tanzania once they have graduated from school and will volunteer at facilities both with the hope of obtaining employment, as well as also hoping to gain some valuable experience along the way that would serve to make them more valuable when they move on to a new position. Both MDs and COs are also often employed by the government, the latter commonly being placed in very remote regions of Tanzania in health dispensaries such as the one we visited several weeks ago at Kambi ya Simba. In these settings, a CO will take care of all medical issues in an unsupervised setting, but considering the environment and remoteness, this is most often quite satisfactory.

Thankfully, there were a steady number of neurology patients needing to be evaluated throughout the late morning and afternoon, though none of them were particularly remarkable to be honest. Lunch may have been the highlight of the day for the residents since it was their first introduction to more traditional Tanzanian cuisine and my favorite lunch here, rice and beans with some mchicha (African spinach) on the side and lots of the pili pili that I’ve spoken about so often. We finished seeing patients around 4 pm which is pretty typical for us, and made our way back to the house for a nice quite evening of relaxation and finally our dinner.

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