Monday, September 18 – A much busier first day of clinic than expected…


Though I have described the wonderful sense of family here at FAME on so many occasions, it never really seems to be enough, and I have always been reminded on my many visits what an amazing place FAME is…

Their first day of “school” at FAME
Our grocery list for the beginning of the week

It’s much like the first day of school when I walk out of our house with the new group of residents. Such was the case this morning as we departed in plenty of time to get to morning report, only to discover that only one of us was to have come given the large number of staff and the current size of our conference room. Last visit, it was quite clear that we had outgrown the size of this facility and were in need of expanding it, though it is not nearly as sexy as fundraising for direct patient care which means it may be some time before this is accomplished. I had the residents stay in the conference while I went outside and listened through the open window, not a particularly good situation given my lack of hearing when there are surrounding noises. Thankfully, I was able to hear most of the conference so that when it was concluding I could interject and introduce the new neurology group to everyone in attendance.

A happy crew

We had scheduled an orientation for the new residents which was being handled by Saidi, who is the volunteer coordinator here at FAME. When I first came in 2010, the volunteer coordinator was a 1–2-year position, funded with a small stipend, and was typically filled with individuals from the US or Europe who were looking for a short-term position in Africa either as their first experience on the continent or to gain more experience if they were planning to stay here working. Having now been coming to FAME for over 13 years, I have worked with everyone who has held this position. Beginning about three years ago, though, the decision was made that the coordinator should be held by a Tanzanian and, rightly so as it is important that FAME is a Tanzanian facility that is fully staffed by Tanzanians. Prosper Mbelwa became the first such Tanzanian volunteer coordinator and he was stellar at his job, so much so that when his term had finished, he was promoted to a program manager here and is now an integral part of FAME dealing with multiple projects.

Saidi Swedi, who fully took over as the volunteer coordinator about six months ago, is a very remarkable individual and someone who has literally grown up with FAME as he and his brother were two of the very first patients seen here back in 2008. In fact, Saidi, having grown up at the Rift Valley Children’s Village and one of Mama India’s children with more than 100 brothers and sisters, has been a part of FAME since its very inception. He excelled in school and, after finishing college, is now ready to take on the world. I very much look forward to continuing to work with him here at FAME and am certain that he will continue to do amazing things with his life. We are lucky to have him for this time.

Saidi giving his world renowned FAME tour
Jenna, Wajiha, and Whitney

Having had their tour of FAME, it was now time for the residents to have their orientation on the EMR, or electronic medical record, that is used here at FAME. The fact that we even have an EMR here is really somewhat of a miracle and the days of writing on cardboard charts and handwriting scripts has passed, though I must admit that having practiced most of my career in the days of written records, or the stone age as my residents remind me of quite often, I had somewhat hoped that I would have been long retired before they became ubiquitous in the medical world. That being said, I have made peace with the fact that my life now completely revolves around the EMR which is used at Penn, and I am actually quite happy with the way things have gone in that realm. EMRs, though, come in lots of different flavors, and the one here at FAME is not even close to being as robust as Epic, which we use at Penn and is widely used at large centers throughout the US. Though the training on our EMR here is pretty basic, the person who usually does that is Dr. Anne and she would not be starting today until noontime as she is currently coming back from maternity leave.

Whitney and LJ on their tour

It had been planned to be a quiet day for our first session of clinic, but as they say, “best laid plans of mice and men….” Clinic was to start at 11 am and though it is always my intention for the residents to be given plenty of time to work into our schedule, they were thrown into the chaos that can often be Monday mornings here. I also later found out that due to many changes in the region that have affected the healthcare services available, they have been seeing a much greater volume of patients. The start of clinic was a bit of a whirlwind with a seizing neonate, a child with a head injury and vomiting who needed a CT to rule out an acute process, and then the normal smattering of epilepsy follow up patients. Having Whitney here for the seizing neonate was a godsend as that is not something that I feel comfortable with, though can do so in a pinch.

Ready to work? My office in Tanzania

The child with the head injury and vomiting, who obviously needed a CT scan, turned out to be a bit complicated in that the scan raised some initial concern for a very small bleed and, in trying to get some assistance, needed to send her images to a US pediatric neurosurgeon (who was here at FAME for a few weeks in 2021) working for the year at Kilimanjaro Christian Medical Center, or KCMC, which is about three hours away. Trying to send the movies of the scan sequences was no small feat considering their size and the lack of bandwidth on the internet during the daytime hours. After multiple failed attempts on WhatsApp and Dropbox, we finally received word (once it was morning in the US) from our consulting neuroradiologist that the scan was normal. The patient had already been admitted for observation, but it was a relief to hear that they didn’t have a bleed and we were left with a young child who probably had a stomach issue as the cause of vomiting. Thank goodness.

A love affair

The day was rather long and were still seeing patients in clinic well past the normal 4:30 pm cut-off here. The problem is not so much that we are wishing to leave early, but our support staff in clinic, Kitashu, our interpreters, and others, have the expectation of going home at a reasonable time and it’s unfair for us to expect them to remain late with us. Despite this, we have a child arrive at the very end of clinic who was a 1-year-old who had reportedly fallen (not again?) and had seemed to be very unsteady on her feet following the incident. Her exam was abnormal as she had unilateral nystagmus and was, indeed, unsteady on her feet, both findings raising concern that she had a cerebellar process. Trying to obtain a CT scan on a non-sedated 1-year-old can be a lesson in frustration (which it was) such that we had to reach out to anesthesia to sedate the child which was not going to occur until 10 pm as she had eaten.

We all went home to eat dinner with plans to return later after the CT scan had been completed, which it was shortly after the arranged time and was thankfully normal, both to our eye as well as to that of the neuroradiologist back in the US reading the study. With that in mind, it now seemed to be entirely possible that she was not unsteady because of the fall, but rather she had fallen because she was unsteady. Children can develop an acute cerebellar syndrome that is a self-limiting and benign process, though they can also develop more significant cerebellar conditions that can progress and be quite harmful. A CT scan is generally quite poor for evaluating posterior fossa processes due to the amount of artifact caused by the boney skull, and, as such, the MRI scan is the imaging modality of choice in these situations, though very unrealistic given the closest facility is several hours away.

Down to business

After checking on the young girl who had fallen days ago and whose CT scan was subsequently determined to be negative, but had initially raised concern, we made sure our young ataxic patient was admitted to the ward for observation, both for her primary issue as well as because of the sedation that we had given her. We would check on both in the morning when they would hopefully be improved and, if not, we would have to decide on further investigations that may be required. We walked home in the cool air of the evening with a dark sea filled with stars above our heads and solid band of the milky way arcing above our heads. It had surely been a full day and then some, but it seemed everyone felt the satisfaction of having accomplished something special in our own little part of the world. Tomorrow would be another day.

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