Friday, March 24 – Mark and Anya depart and a few interesting patients…

Saidi giving Anya her thank you gifts upon leaving

Our first three weeks were nearly complete and though we were having clinic today, two of our team would be departing mid-day as they both had flights to Dar es Salaam this evening for the first leg of their trip to Gombe where they would be spending time with the chimps. I had done this back in 2019 with one my residents, Mike Baer, and our medical student, Leah Zuroff, who had accompanied us on that trip to FAME. It was one of the most incredible trips I have taken, not only because of the time we spent in the wild with the chimps, many of whom were members of the original group that Jane Goodall had been studied, but almost more so for me because of the history of Gombe and what it meant to science. For anyone who has watched her biographical movie, “Jane,” the significance of her achievements is obvious. For those of you who haven’t seen it, you must.

Our final tea together

Morning report was the last time for everyone to say goodbye to FAME for Wells and Usha would be traveling with us to Arusha for their outbound flights tomorrow and there was no clinic. I think it was a sad departure for all the residents who had very much enjoyed working here at FAME and getting to know everyone. The FAME team is always so appreciative of the time we spend here and the work that gets done, not only patient care, but the educational lectures and the teamwork in general. For the residents, they’ve also had a chance to experience working in an amazing environment half-way around the world in a low resource setting that is as different from being at home as one can imagine. There are no “million-dollar work ups” here in Tanzania such as we see at home, but rather incredibly thoughtful evaluations with the resources we have at hand and developing a treatment plan that fits within the constraints we have here in Tanzania.

Pre-op reconstructed CT of our patient hit with a hammer in the forehead

Though the weather remained cool and rainy with flooding nearby in Arusha, there were still patients coming to clinic. Mark and Anya were leaving around 1 pm for their evening flight, so we were not counting on them to be in clinic today. Thankfully, there wasn’t a rush of patients at the end of the week and given we’d be back working on Monday with the next group of residents, it was a generally quiet end of the week day. An 11-year-old Maasai girl came in from the Endulen region in the Ngorongoro Conservation Area who had been having daily seizures for the last month after running out of their medication (carbamazepine) with four seizures the day prior and who was very encephalopathic. Given her history and seizure frequency, it was not at all surprising that she was confused and sleepy and after evaluating her, it became clear that she was just post-ictal and only required restarting her medication. Unfortunately, we are unable to load carbamazepine, so she was placed back on a starting dose of medication with an up titration over the next week and her family was also counselled not to run out of her medication again.

Post op reconstructed CT scan

Usha’s final patient of the day, and for that matter, of her rotation, was a small child who she said helped restore her faith in medicine. I find it hard to believe that Usha had actually lost her faith in medicine given the amazing doctor that she is, so I took her comment more to mean that even those who love the profession they’ve chosen can still use those subtle reminders that what they are doing has made a difference. This was a 3-year-old girl who had seen Dr. Anne in February with seizures and had been started on sodium valproate which had immediately controlled the episodes and she was doing well with no side effects. We checked her labs to make sure that she was having no metabolic issues with the medication, which she was not, and continued her on medication with instructions to follow up with us in six months when we return.

Sagital contrasted scan

Finally, a twenty-something Maasai man walked into clinic with an incredibly interesting story and what turned out to be a significant problem. He had been working as an askari (guard) in Kenya where he was apparently attacked by thieves and hit in the forehead with a hammer in January. He had originally been taken to a hospital there where he was stitched up, given antibiotics, and then sent home. Once home, he had a seizure and was subsequently brought back to the hospital where he was found to have significant skull fractures, bone fragments in his frontal lobes, and pneumocephaly on a CT scan. He subsequently underwent extensive surgery with duraplasty and had returned home to Tanzania.

He was now presenting with a constellation of symptoms that was very worrisome – nausea and vomiting, fever, confusion, and a headache, all of which pointed to an intracranial process until proven otherwise. He absolutely needed a CT scan to rule out some underlying process as his symptoms also were concerning for an underlying infection given the fact that he had been manipulated (his surgery). I’ve attached some samples of this CT scan along with the preoperative study just for reference. We were considering doing a lumbar punction as there were no contraindications, though in the end, it was felt to be unnecessary as the new CT scan demonstrated an underlying abscess formation and probable cerebritis (an infection of the brain itself) requiring an additional procedure to wash out the infected area. We had started him on antiseizure medication as given the size of his injury and infection, there was little doubt that he had a significant seizure risk outside of the acute setting.

The fashionable side of Mark

He was admitted to the ward to be placed on IV antibiotics and we began the process of referring him to Kilimanjaro Christian Medical School in Moshi where there is a neurosurgeon and ENT who could deal with taking care of his complex situation. Sadly, the following morning, the patient and family decided to take him home to a traditional healer despite our protests. We sent him home on an oral antibiotic course that we knew would be insufficient to cover the process that he had going on and hoped for the best. This is often the case here, that patients and/or families decide to go home rather than to follow our recommendations. Sometimes it is to go to a local healer for cultural beliefs, but often it is secondary to money. Even with Kitashu, who is Maasai and our social worker, it is very often impossible to dissuade families from leaving the hospital in these situations. As frustrating as this can be, one always must remember that we are guests here and working with vastly different cultural and economic paradigms than our own.

Mark’s photo of the house key left with airport security

Mark and Anya had left for the airport around 1 pm, being driven by Dr. Adam, who just happened to be on his holiday and offered to shuttle them instead of having to hire someone they didn’t know. Considering that he was driving a nice BMW, they probably scored considering the long drive to get there. Upon walking home after clinic, though, I realized that I had forgotten to ask Mark to leave his key to the house which are an unusual type here that cannot be reproduced or copied. We tried calling Adam (though Mark had a new SIM card on his phone, they hadn’t turned it on, unfortunately), but he had just left the airport after dropping off. Finally, Mark contacted us and had actually realized he still had the key, but after Adam had left. I told Mark to ask around the airport to see if there was anyone, he could leave it with and, thankfully, the security office was willing to hold the key with my name and number as I would be at the airport the following evening to drop off Wells and Usha. I had a pretty good sense that this would work as there were no other alternatives to getting the key back to FAME in a reasonable timeframe.

The night was spent for packing for Wells and Usha and for Jill and me to bring whatever we needed for a night in Arusha. The plan was to leave sometime around noon for a leisurely drive to Arusha and a stop at the Shanga Shop, a very nice little shop that sells the wares made by disabled artisans using recycled glass for glass blowing, looms for textiles and beadwork for jewelry. It was a quiet evening at home.

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