It was the first day having the full crew on the second shift, though Fien would be leaving at the end of the week. FAME has initiated a more formal morning report that occurs on Monday, Wednesday, and Friday, and cases are presented by the overnight nurse on the ward as opposed to the doctors. The entire medical, nursing, and support staff show up for these rounds making it quite crowded in the conference room, but the rounds are very informative and there is a forum to discuss the patients, if necessary. In the past, when presented by the doctors, it was often, “they’re doing OK,” and that was the entirety of the assessment. The nurses are much more detail oriented and their presentations much more informative.
Being Tuesday, though, it was our education day and today’s lecture was being given by Dr. Leslie, our family medicine NP, who was going to talk about management of diabetes mellitus and other health management issues in these patients. It was a very helpful review for me since I haven’t really considered these things in many years and guidelines have certainly changed with the advent of new medications and our knowledge of co-morbid disorders such as the need to control blood pressure and lipids to reduce risk of heart attack and stroke.
Chronic disease states have always been an issue here from a cultural standpoint and health literacy is very poor as one would imagine. Taking a course of antibiotics for malaria or any other infection is well understood, and patients are certainly capable of taking medications for a short period of time in a curative fashion, that is, you take a medication for a specified time until the problem is gone and then you stop the medication. In our world of neurology, it is extremely common for patients with epilepsy to come in to see us for the first time and tell us that they were seen elsewhere, took the medication that was prescribed, which stopped the seizures, but then discontinued them when their prescription ran out and the seizures started back up again.
The two chronic medical conditions that come to mind first are high blood pressure (hypertension) and diabetes mellitus. These are conditions that are treated with chronic medications and lifestyle management and, even though patients can occasionally improve, and even go off medications with aggressive lifestyle changes, it is much more likely that they will need to be on chronic medications to control their condition and to reduce the likelihood of complications such as stroke and heart attack. Over the years, FAME has instituted chronic condition clinics for things like diabetes and hypertension that have been quite successful for the patients who have attended, but again, there is a constant battle with reinforcing the need to remain on medications and to continue following up in clinic. Looking at our data for one clinic here back in 2019, we did find in a small number of patients that were seen by us had a higher adherence rate to the anti-seizure medication than those started on medications elsewhere.
I introduced all the new doctors who were here to the medical staff at the end of morning report and Fien covered the rounds in the ward so that the others could start in clinic for the morning. The young boy who had a stroke at 4-years of age and whose sickle cell screen was positive returned to clinic this morning so that we could send off a blood sample to Arusha for electrophoresis, which is a more confirmatory test. Unfortunately, the test would cost 50,000 TSh (or $20), and that was not something they could afford as they barely had the bus fare to reach us today. Given the limited resources, I wanted to make sure first that they were treating sickle cell disease here at FAME as the likelihood that they could afford to go elsewhere was very small.
After discussing the issue with Elissa, our pediatric ID specialist who has worked at FAME for the last year and will be working here for another, she and Dr. Ken have been seeing these children and providing what was available medication-wise as well as counseling families. Given that there would be a purpose in spending the money for the test, we arranged to cover the cost of the test. Dennis also obtained a history that the patient had had a blood transfusion in the past, which clearly suggested that the boy would turn out to have Sickle Cell Disease rather than just the trait (i.e., heterozygous), and would be at risk in the future of having further complications of this condition. For those non-medical readers with an interest, Google sickle cell disease and malaria for an excellent discussion of why this condition (sickle cell) remains prevalent today among people of African descent.
Caroline’s first patient of the day was a rather doozy of a patient as it was an older gentleman who presented in a wheelchair due to what sounded like Pott’s disease (tuberculosis of the spine and myelopathy) many years ago who subsequently had what sounded like a stroke and also had progressive blindness. His differential was incredibly broad and included, among others, CNS TB, a cerebral vasculopathy, dissection, or one of another dozen or so conditions. As his Pott’s was very remote and his probable stroke had occurred several years ago, there was little reason to go looking for the underlying process as it would be very unlikely to affect his care going forward. Additionally, he did not appear sick, nor did he have any pulmonary symptoms to suggest that he had active TB (he had completed a course of TB therapy after his Pott’s disease presentation). We checked a bunch of lab work to see if he had anything else active that we could consider treating, but they were all normal giving us little in the way of clues and certainly nothing to treat actively. We did discuss whether to place him on aspirin (I don’t recall the outcome) but had little else to recommend.
At the end of the day, we had decided to go into town for everyone to purchase fabric, and then on to Teddy’s so that everyone could decide on what clothes to make, and she could take measurements. Shopping in town can be a bit of an experience as a group of Mzungu (strangers) walking through town are immediately noticed and prices seem to rise and are no longer as negotiable as they would have been, but having a Tanzanian with you who knows what things should sell for will typically prevent this from happening. In the past, Dr. Anne has always come with us, but with her new baby, we went without her several weeks ago and had found out later that they overpaid for much of the fabrics they had purchased.
Not wishing to make the same mistake twice, Dorcas was enlisted for her services, and Amos and Hussein also came for good measure. Not wishing to be involved in the shopping for fabrics, I sat in Myrtle making phone calls to friends and family, though I found myself playing Wordle and the NYT mini crossword puzzle while trying to occupy myself while they shopped. No matter, though, as I’m always very happy to also just sit and people watch, especially near the shops in Karatu, where I’m often spotted by residents who I have come to know over the years.
Once they had their fabric in hand, it was time to drive to Teddy’s for their fittings and selection of clothes to be made. It is always wonderful to visit her shop as she is always so very cheerful and it is wonderful to see Allan, her baby who is soon to be one-year old. Additionally, we were able to see Dorthea, who is someone I have cared for since 2011 for seizures secondary to a neonatal stroke and has a hemiparesis (Dorthea has given me permission to use her information and has been part of a video that was done for FAME to promote our neurology clinic). Dorthea has been apprenticing with Teddy now for the last six months and has come a long way in being able to work with the fabrics and sewing machines.
While everyone worked with Teddy deciding on what fabrics would be used for which pieces of clothing and getting measured, I sat in a chair on her porch out front of her home and worked on my computer. This is my normal position during a visit to Teddy’s as I have long given up on finding something that I would wear and not just sit in one of my drawers. It’s not that her creations aren’t amazing, but I’m just very particular about my clothing, not in any fashion sense as I am the furthest from being a clothes snob and typically where the same things over and over (I’m very conservative and don’t like change when it comes to clothes). My dress code here is the same pair of shoes every day to work, the same pants I’ve worn here for the last 10 years, and a selection of decade old Polo collared, knit shirts with horizontal strips and are short sleeved.
By the time everyone had finished, it was now quite dark (remember, night near the equator falls very quickly) and time to go home. We loaded up in Myrtle (Turtle is still in Arusha getting repaired), but when I turned the ignition key, it just clicked as if there were something wrong with the battery or starter. We would have push start the vehicle and thankfully we were situated in such a way that it would be possible to get the car rolling one we got it turned in the direction we needed to travel. Everyone exited the vehicle other than me (I needed to steer and pop the clutch) and pitched in with pushing me around first and then in a straight line. In quick order, we had Myrtle purring and ready to drive home. As we were approaching our house and were just in front of Frank and Susan’s, the headlights illuminated two tiny, though full-grown, dik diks who were foraging alongside the fence line and on the FAME property. We sat watching them for what seemed like forever, though we eventually had to move forward to make it home. They scrambled into the shrubbery along the fence line and quickly vanished.