Monday, September 25 – A new addition to our neuro clinic and the Maasai group from Tarangire…


Perhaps the most significant thing for today is that it is Fien’s first day with us, and I am happy to say that she required virtually no orientation. She was off and running from the get-go. As I had mentioned, she arrived from Belgium yesterday and will be joining us for three weeks. Fien (whose name is pronounced like the end of “Josephine”) had contacted me almost a year ago inquiring as to whether it might be possible for her to join us sometime on one of our rotations. She is a fourth-year neurology resident in Belgium (the program there is five years compared to our four) who had been listening to BrainWaves, an amazing neurology podcast, that had been created by Jim Siegler, a former Penn resident and fellow, and covered a variety of neurologic topics with each episode featuring a guest who would be interviewed by Jim and would elaborate on whatever topic was being discussed. I have participated in probably half a dozen of these podcasts (which I believe numbered in the 180s when it was finally discontinued only recently) over the years, but very early on, he asked us to do one on our work in Tanzania and global health. An-Thu Vu, one of my former residents who had come to FAME in 2015 and who is now a movement disorder attending at Jefferson in Philadelphia, was interviewed by Jim, as was I.

Wajiha and Fien evaluating a patient with Elibariki

After listening to the podcast, Fien realized that coming to FAME with us was something that she would love to do. Having volunteered previously in several global health circumstances – Lebanon, Cameroon, Tanzania, Ghana, Croatia, and Albania – she knew exactly what she wanted to do. She searched for me on the internet and, in addition to finding my contact information, also found this blog, which she spent time reviewing, only further confirming her interest in working with us. She contacted me by email and shortly thereafter, we connected on Zoom. It was immediately clear to me that she would fit in with my residents and our program and, furthermore, this would be an experience that she could draw on going forward in her career. Additionally, and somewhat selfishly, I felt that my residents could only benefit from working with someone with a completely different academic and training background such as Fien. There were really no logistical issues on my end, so the only matter that had to be dealt with first was with her training program and to make sure they were OK with her joining us for three weeks. That didn’t seem to be an issue, so the next step was just deciding when she would come, and this time frame worked perfectly for both her and us.

Wajiha examining a patient with Hussein, Elibariki, and Fien looking on

The residents spent some time with Fien last night as far as orientation on the EMR (electronic medical record) and Wajiha brought her to morning report where she was able to introduce her to the FAME staff as a new addition to the neuro team. Our clinic began at 8:30 am as usual and Fien fit right in such that she was seeing patients on her own (with an interpreter, of course) and presenting them in exactly the same fashion as if she had been training with us all along. If there had been any concerns whatsoever from my standpoint, they had been immediately quelled.

LJ and Dorcas evaluating a patient

Given the problem we were having with Turtle (having the rear door swing open constantly on a bumpy road was just not a tolerable situation, especially as we needed to use the vehicle for our mobile clinics over the next three days, and then to the Serengeti on Friday morning), I was having two mechanics come from Arusha to work on it today. I had hoped that they would arrive early, but having waited all day for them to arrive, it was not until about 3 pm that they eventually landed at FAME (causing much angst on my part given that if we could not get Turtle repaired today, I would need to rent a stretch vehicle from Kudu Lodge to make it through the mobile clinics this week, something I would hate to do given the cost), meaning that the any repairs would likely go well into the night and I wouldn’t have an update until very late.

Fien evaluating a patient with the help of Elibariki and Hussein

Perhaps the most interesting patient of the day was a gentleman in his 50s who had a lesion on his skull, but it was not just any lesion. Dr. Manjiro, FAME’s surgeon, had brough the patient to me asking if we could possibly see him and, despite that fact that his primary problem wasn’t very likely going to be neurologic in nature, he still needed to have a good neurologic assessment based on a CT scan of his head that he underwent earlier in the day. His history was such that he had been seen in Arusha earlier in the year and had the mass at least biopsied, and quite possibly resected, though it had grown back and was now much larger. They had been told that it was a lipoma, which is a benign fatty tumor, though the appearance on the new CT scan done today was anything but benign.

The patient was also complaining of right-sided weakness that had started more recently, but on examination, this seemed to be related to a mass in his right upper arm or axilla rather than being of a central origin. Given that the largest mass on the right side of his head, it would not have made sense for him to have right sided weakness that was related. Unfortunately, there was another large intracranial mass that had eroded much of the left sphenoid wing and was also beginning to invade the left orbit. All in all, this was a very bad situation and not something that could really be handled at FAME given the extent of the disease. We could have potentially biopsied something superficial, which may have given us some answer, but it would not have helped from a treatment standpoint. I contacted the neurosurgeon at KCMC, asking her to see the patient, which she could do in the next several days, but after hearing back later that morning from our neuroradiologist that he felt the scan was most consistent with a plasmacytoma secondary to multiple myeloma, it was clear that the patient would absolutely require an oncologist for treatment. Seeing a patient with advanced disease to this extent was something we would rarely run across in the US.

Our patients from Tarangire eventually arrived in the late morning, but we were sad to see that there were on about 12 patients as opposed to our normal 18-20 patients from this region outside of the Karatu District.  I can’t recall exactly how this relationship with the Tarangire folks began, though it has been a very rewarding one over the last several years. I believe that their “chief” had heard of our clinic and, on his own initiative, brought some patients to FAME for us to evaluate. After identifying several epilepsy patients and treating them with appropriate medicines and having them improve, he has continued to bring us more and more patients to be seen. All the patients have been more than appropriate for us to see and other than helping with the cost of their transportation to and from FAME, which is quite inexpensive, we have tried not to provide any additional services that are not available to other FAME patients. The chief has done a great job in making sure that the patients who need to see us are brought, though we have had some issues with patients running out of medications and will continue to work on that aspect of their care in conjunction with Kitashu as they are all Maasai, which allows him to have a greater appreciation for their cultural needs.

At some point in the morning, a young man was brought to FAME with an altered sensorium and a history of having another similar episode several days prior. The episodes had been precipitated by stress or anxiety, including the episode today, and his examination was most consistent with a functional disorder, meaning that it was not organic (i.e., physical). It was reported that he had improved when he was given IV fluids with the earlier episode, though there was absolutely no indication for that with this presenting episode. There were no tests to be ordered nor treatment to be given other than to reassure the patient and the family that he was well and that he would improve and be back to normal. There are very few counselors here in Tanzania, so trying to find someone for him to see going forward was going to be very difficult. Sure enough, shortly thereafter, he woke up and his examination was perfectly fine.

We were home early enough for Jenna and Whitney to take a run down the road. Whitney decided to play football with some of the children along the road – who would have imagined.

We had decided to have a quite evening at home and LJ must have had a ton of energy as she decided to cook up some eggs and hash browns for dinner that were delicious. The dinners that had been sent to the house that night, for those of us who eat meat, consisted of fried chicken and boiled potatoes, which we would typically devour had it not been for LJ’s burst of energy, which was a very nice diversion from our usual menu. I’ll have the admit that the hash browns were especially good having cooked them in some sesame oil and margarine with onions and peppers. Throughout the evening, I was waiting to see what was going to happen with my Land Rover. The mechanics had told me to give them the car for a few hours, but it wasn’t until 10 pm that they finally drove back to the house to deliver it. I let Kitashu know that we wouldn’t have to rent another vehicle after all, though the mechanics would have to come back next week to finish fixing some additional things that needed to be done. Thankfully, though Land Rovers are incredibly finicky, they are also relatively inexpensive to fix. We would take Turtle out on tomorrow’s mobile clinic for a test run and hopefully she would hold together.

While sitting in my room working and waiting for Turtle to return, I could hear lots of music and laughter coming from the main room and it made me very happy to know that the residents were having such a good time, including Fien, who has fit in so well with the others. At one point, I wandered out of my room to find the entire group dancing together to songs I didn’t recognize, totally comfortable with the generational gap (several?) that existed between us. Sharing this experience with others, though, is all that matters, and there is absolutely nothing generational about that.

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