Well, the time had finally come for our last day of neurology clinic for our fall season (though, mind you, there is only wet and dry seasons here) of this year. As I have mentioned before, we have now had two groups of residents here rather than one, so for each group, the trip has actually been shorter than it was in the past by week. I have done my best to make each of their experiences equal both to each other’s as well as to what the previous groups have had and, hopefully, it’s been a successful transition, though I guess you would have to query each of the residents on that issue. Interestingly, though it had often seemed much slower for me during the six weeks, we had actually ended up seeing about the same number of patients, and possibly even a few more, during this trip as we have seen on prior visits, so it was just the same number of patients spread out on my days with fewer each day. Though I can’t imagine there are a finite number of neurology patients here in the Karatu district as our limiting factor, so it probably had more to do with the law of averages. I’m looking forward to seeing if this pans out with future trips being a third larger than the current.
For me, it has been the longest time I’ve been in Tanzania in one stretch, though by only a week or ten days. For my patients, I have been covering my in box at Penn if not daily, at least several times a week to field messages from those who have questions, or recent test results perhaps, though most importantly, medication refills. In this day and age of the electronic medical record, including at FAME, the ability to stay on top of things has become seamless, though some might argue that it’s become too invasive and being away for this time I should be focusing on what I’m doing here. The fact of the matter is that I so dislike covering colleagues in boxes that it’s just easier for me to cover my own in box and be done with it. So, there you have my logic and I’m certain not everyone agrees with it, but that’s OK.
With the last day of clinic, though, it is clear that the end of this time in Tanzania is growing nearer and I will soon be traveling home, nearer to close friends and family. I will have to admit that one of the silver linings of the pandemic has been that it forced many of us who hadn’t been overly comfortable in the past with video chats to learn this relatively new technology. In the past, I would do my very best not to answer any FaceTime calls I would randomly receive from family and then call them back at some point to chat on the phone, something that I was equally ill at ease with, though with the pandemic, it has now become an essential part of our lives both personally and professionally. Had it not been for the ultra-quick adoption of “telemedicine” visits right at the beginning of the pandemic and as soon as I returned home early from our March 2020 trip, when the you know what hit the fan, urgent medical care not requiring the emergency room and routine visits would have ground to a halt and there would have likely been more suffering than was already occurring directly related to COVID-19.
Leave it to say that I adopted not only the new telemedicine technology for those patients where it was appropriate, but I also quickly realized that not using the Zoom or similar technologies meant that I would be incredibly isolated from co-workers, those who wished to meet with me, and, perhaps most importantly, family. Had it not been for our weekly family Zooms, I know that I would have gone stir crazy and I’m grateful to my ex-wife, Kim, for having stressed the importance of these sessions as they brought at least some normalcy to what was hopefully the most significant event in our lifetimes. This is all to say that I have now fully embraced this technology and, though it does not in any way replace or even come close to having direct human contact, it does suffice as a substitute for remaining close to those you really care about even though you are literally half a world away. Whether it be Zoom, or WhatsApp video, the technology worked nearly seamlessly and it was something that I looked forward to the entire time I was away, and I say that not having missed even a single day of my time away. Though now it was time to begin the process of looking forward to that personal contact as I was now in the single digits and it didn’t seem so far away.
Thursday mornings are education days and yesterday, Dr. Ken, who is in charge of the education lectures, approached me asking if the residents could do another lecture for the Tanzanian doctors, which of course they agreed to do, and it was decided that the talk would be on dementia. Though the talk would primarily cover the different types of dementia and how to tell them apart, mostly with the patient’s presentation and symptoms rather than testing, which is good here since testing is so limited here, and expensive comparatively. And furthermore, testing here, similar to at home, would rarely, if ever change the treatment that we have for patients in the long run as the symptomatic treatments are based solely on the clinical issues and do not rely on any testing results. This does, of course, exclude the rapidly progressive dementias, that group of disorders we sometimes see in which the clinical presentation has been less than six months and we become concerned for Jakob-Creutzfeldt disease, an insidious disorder caused by a prion, or a precursor to viruses that is uniformly fatal. This is an important group as there are also mimics of this condition that that are treatable and, therefore, must be ruled out.
This is all to say, that unfortunately there is little to do here just as there is very little to do at home for these patients, though, there is plenty of research and trials going on. At the moment, though, Alzheimer’s disease (the most common of the dementias) or the mixed dementias, as very often there are several contributors to the patient’s underlying cognitive decline. The biggest thing that we can do in these situations, both here and back home, is to reassure the family that there is nothing else going on to them begin to educate them on what will happen in the future and to set expectations. There are no nursing homes here in Tanzania, or at least none that I am aware and certainly none that would be available to the primary population of patients that we care for in the Karatu district where family incomes may be $250 per year or less, so it is even more imperative that families understand what to expect. One of the most significant things that we can do for patients and families with dementia is to offer medications for significant agitation that may occur in the setting of moderate dementias, more so than in mild or advanced dementias. We do see quite a few patients presenting with chronic dementia, so this will absolutely be something that the doctors here at FAME will see in our absence, so it was very helpful to have gone through all of this with them and the residents covered it brilliantly.
At the end of lecture, since there would be no morning report tomorrow with the holiday and this was our last day, they asked each of the residents to say something about their experience at FAME, as well as myself, though they have gotten to hear from for the last twelve years so it is very much more important to hear from the residents. We received the customary three claps from the group and I’m sure that it was a special moment for each of the residents given the fact that there are so few similar situations to being at FAME, where you begin to become a part of the community, both as a caregiver and someone who also deeply cares about the well-being of all those who reside here.
It was our last day for Pilau with meat and, as usual, Charlie and Meow enjoyed it as much as we did, though, thankfully, we don’t have to share any of the pili pili with them as we have become very possessive of that condiment and maintain very close tabs on its supply and whether there becomes any need to ration it going forward for the thought of eating here without it is hard to imagine.
Right after lunch, everyone was called quickly to the emergency room where there a young man who had fallen into some type of a large hole in the ground, striking his head and neck. He had reportedly had loss of consciousness at the time of the fall and, in the emergency room, remained mostly unresponsive to voice and painful stimuli and didn’t seem to be moving one side of his body well. There had been no seizures reported and the presentation was certainly concerning for type of head injury, so, after placement of a cervical collar to protect his cervical spine in case there had been any type trauma to that region given the lack of exam, he was heading off the CT scan to look at his brain and spine to decide if he needed any treatment which would very likely require that he be transferred.
His returned from the CT scanner in very short order and it was reported not to demonstrate any concerning signs of trauma, either an intracranial hemorrhage or spinal abnormality, and sometime later that afternoon, he began to slowly wake up and move. He was admitted to the ward for the night just given how profound his presentation had been, though the following morning, he was asking to be discharged from the hospital, and, with nothing else for us to do clinically for him in the setting of a normal examination, he was released home and told not to fall in any more holes.
Given it was one of our last nights at FAME, everyone wanted to head out to the Golden Sparrow later this evening to spend time together and let off some steam. This has been a tradition here in Karatu, even in its older configuration, which was called Carnivore, as it’s allows fun to do some dancing out with the local population despite the fact this is something I do on a very limited basis back home, usually only on the occasion of the resident graduation after after party (there were two “afters” there intentionally as you might imagine). Carnivore was a tiny pub that served only roasted chicken, chipsi (French fries), and drinks, but had a tiny dance floor that we could use that had mostly an earthen floor, or at least it seemed so, and could accommodate only perhaps six dancing comfortably, though there were always many multiples of that dancing on good nights. The owner of the Carnivore then opened Golden Sparrow, a much fancier and larger place with a formal dance hall and closed the former. The Sparrow, as it is affectionately known in Karatu, has just completely upgraded their dance hall, doubling in size, and to something that now approximates a legitimate dance club. We all had a wonderful time with many of the local Tanzanians who had worked with us for the neuro clinic having joined us for the evening, though any of the details will have to go undocumented for “what happens at the Sparrow, stays at the Sparrow.”