We were now back on schedule since we had definitely planned to be at FAME today from the very beginning and though our patient volume wasn’t immense, it kept everyone busy. Kelly delivered an excellent morning lecture to the staff on treatment pathways for both seizures, including status epilepticus, and headaches, including migraines. Treatment pathways are important tools in treating patients with these issues as it helps to standardize care as well streamline processes when it is necessary to develop protocols. With the new emergency room about to open in the next month, this will become a more significant issue as patient volume will only increase as will patient acuity lending itself to more chaos unless these treatment pathways become more the standard than the exception. To develop these pathways, she spoke to several FAME doctors, to make sure they made sense as we were no longer in Philadelphia, and spoke with Dr. Amanda, our visiting emergency room physician from Australia as she will be working on similar pathways for other emergency scenarios.
The vast majority of the experience here for the residents is not about learning how to treat new conditions they have never seen before, but rather it is about treating common conditions they see often at home in a low resource setting. The algorithms that are learned and used on a routine basis at home are only as good as the medications and services that are readily available and affordable, and that chasm of medical equity is unfortunately quite vast when traveling to the majority of this continent. Though that situation is certainly improving over time with the efforts of many who have come to help, that change is incredibly slow and most often stymied by factors that are far beyond the control of those who are providing care for anyone in need. The oft quoted, “The economy, stupid” from James Carville during Bill Clinton’s 1992 presidential campaign could easily sum up the situation in most African countries, though it had been used in an entirely different context than what is found here.
Medications and therapies are available in most cases, though they are very often completely unaffordable by the population we are treating here at FAME, necessitating tremendous thoughtfulness and long discussions regarding the actual ability of families here to continue the care that is most appropriate. The first question that families ask regarding their admitted family member will be, “when can we take them home,” and although this may seem to be driven primarily by a sense of responsibility to care for one’s own, and this is certainly part of it, the cost of the hospitalization is more often the driving factor in those decisions. For families that cannot afford to provide care for their loved ones, they will often go home to their community to raise the necessary funds. In a country that has no safety nets, no welfare, and a national health insurance that very few participate in, healthcare is often a secondary concern and survival is primary. To add insult to injury, patients seeking treatment here very often have advanced stages of common treatable conditions whose care has now become more complex and compromised because of this delay.
It is within this environment that FAME has chosen to build a hospital and healthcare facility to provide patient centered care to a region of Northern Tanzania where the population is worse off than the national average in this country that ranks in the bottom 10% internationally. Making a difference has been challenging, but the work that Frank and Susan began nearly 20 years ago has continued and has been successful because of the Tanzanian FAME community they have built since opening in 2008. Those of us who have been privileged enough to have shared in their vision by volunteering at FAME (some of us who have not found a way to leave) have seen what can be done through the generosity of others and the sheer determination of those who care enough about others in the world to have made that difference that counts every single minute of every single day.
Today we saw an adolescent girl complaining of severe headaches that sounded migrainous, but who brought and MRI of her brain that had been done previously and was reportedly abnormal. When we loaded the disc that the family had thankfully brought with them, there was a small region of focal encephalomalacia (loss of brain tissue) in the left posterior parietal region, and though was unlikely to be related to her headaches, was still something that had to be explained. When questioned further, it turned out that she had a head injury when she was only 3 months old and corresponded to the abnormality that we saw on the current study. Crisis averted. She was treated for migraine and will follow up in several months.
Meanwhile, Kelly evaluated a patient that had come from a very long distance to see us for a multitude of unexplained neurologic symptoms. The middle-aged patient had been to numerous specialists including other countries, but no one had figured out the nature of their symptoms. After reviewing all the outside records (and there were many) as well as the outside imaging studies, it seemed clear that the primary problem with the patient was underlying anxiety and, in the end, it was determined that the patient had a functional neurologic disorder (FND). This is a category of diseases that are psychologically based as opposed to physically, though they can often be triggered by some physical symptom. The underlying personality trait for these patients is most often one of underlying and untreated anxiety and, at times, depression though perhaps secondarily.
The treatment for this is therapy, therapy, and more therapy. Medications certainly have a role, but more so at the beginning and the hope is that therapy will then take over as the most effective treatment and medications can be stopped. Thankfully, Kelly has a huge interest in functional neurologic disorders and took charge of this patient’s treatment plan. The family members who had accompanied them were totally on board with the treatment plan and the patient also seemed to have some insight into the situation, a very positive sign for a successful recovery. The family was very pleased for they had been to numerous doctors for treatment and finally had some answers.
Dennis evaluated a 13-year-old Maasai boy who had been having episodes of loss of consciousness for most his life, typically occurring about twice a month and, given the epigastric rising sensation that occurred with them, were most likely focal temporal lobe seizures. The boy had been seen at a health dispensary three years ago but had been placed on phenobarbital (phenobarbitone) which had not helped for his seizures, and they continued at the same frequency. Given the focal nature of the episodes, the seizures should be very responsive to carbamazepine, a medication specifically tailored for focal onset seizures, and one that is very inexpensive and available here in most duka la dawas (medicine store, or pharmacy). Though phenobarbital is the preferred anti-seizure medication by the WHO because of its availability and its incredibly low cost. Unfortunately, it also has a number of significant side effects including impaired cognitive and slowing development. We use it only in children under the age of 2 and, even then, try to get patients over to another medication as soon as possible.
As the day finally wound down, it was decided that we would run to Teddy’s house to pick up the clothes the residents had ordered from her. Of course, she had done another fantastic job, and everyone had to show off their new threads, though having ordered nothing from her, I sat in chair on my computer which is what I usually do during a visit to her shop. Over the years, I have tried having her make a few things for me, but I’m pretty finicky about the fit and feel of my clothing (an idiosyncrasy since childhood) and have never felt comfortable in them, unlike all the residents who have absolutely loved the clothes she makes. I did have her make a few gifts for me to bring home, though, but they obviously didn’t have to be tried on and modeled.
Just prior to our departure for Teddy’s shop, I had answered the phone at the house (never a good sign) and had been informed that we had a consult in the surgical ward. A patient had come in over the night with a head injury and a very abnormal CT scan that demonstrated a fracture, a traumatic subarachnoid hematoma, and some swelling. As the patient had no surgical indication at the moment, I informed the ward that we would see the patient as soon as we returned from our errand. On our return, Kelly volunteered to run up to see the patient, who unfortunately was poorly responsive and had a right hemiplegia, though again, after reviewing his CT scan, there was no intervention that could be taken other than giving him steroids for the edema that was seen. The hemorrhage would eventually resolve, but unfortunately, it would just take time for him to improve, which would be gradual, and he would need rehab once awake.
We have been seeing an increase in the number of traumatic head injuries, almost all from MTAs, or motor traffic accidents, often on motorcycles (boda bodas or piki pikis) without a helmet, or from pedestrians struck and knocked down by vehicles. Dr. Manjira, our chief of surgery has provided burr holes to a number of patients with subdural hematomas, a life saving procedure, though in patients such as the one above, the injury was not amenable to surgery.
Tomorrow morning, we would be leaving for two nights in the Serengeti and a stay at Dancing Duma, the camp we had used previously. Everyone was incredibly excited, including me, as visiting this remarkable park has never gotten old for me, even after fourteen years of visiting and probably over 50 days in the park.