Build it and they will come. Not only does this describe the history of FAME, but equally so our neurology clinic. In a country with so few neurologists, or for that matter, specialists in general, having an incredibly efficient team of outreach coordinators who scour the local villages to make announcements of our arrival means that you will never want for patients. No matter how I make the schedule for our first day of clinic, hoping to limit the number of patients as we are all still jet lagged and the residents need to be given an orientation on the EMR (electronic medical record), it never seems to make a difference. With the schedule clearly stating that we would be seeing patients beginning at noon today, there were patients lined up waiting to be seen almost before we arrive.

The neurology clinic here tends to be a microcosm of what’s happening out front at the general OPD, and today was no different. Tying to limit the number of patients in a manner that would actually allow us to get everything finished that was necessary is very often akin to a salmon swimming upstream – not only exhausting, but often feeling as though it will end in death. Mondays are always the busiest day of the week, and the reception/waiting area of FAME will look as though there’s a run on the bank or it’s the best blue light special ever offered. As FAME typically sees around 30,000 patients a year with the average number in a day nearing 100, it’s not difficult to realize that on Mondays, the OPD can be seeing far in excess of that number. And on top of that, we’re adding in the neurology patients when we’re here visiting. Needless to say, the reception area can become a very crowded area with little notice.

Though our plan had been to start working at noon, we started earlier than that as the patients were already here waiting for us, and the volume was only building. Seeing neurology patients typically takes far more time than seeing most of the other outpatients here as it requires obtaining a very detailed history, not the easiest when exclusively using a translator, or sometimes two when the patient only speaks their tribal language, and there is a detailed neurologic examination. This is not unique to practicing neurology here in Tanzania, for the same situation exists back at home when seeing patients, absent the translator most of the time, of course, but not the detailed history and examination. Not wishing to sound condescending, practicing neurology is often far different than most other specialties as it requires far more detective work and is often what one would refer to as very “touchy feely” and very intuitive.

We had a full complement of translators, who, for the most part, are all clinical officers, which is the equivalent of nurse practitioner back home. Most of medicine in Africa is practiced independently by clinical officers, or COs, as they staff nearly all of the government health dispensaries throughout the countryside and see patients routinely on their own. Some of the clinical officers work here at FAME, and others will volunteer here, hoping to gain valuable experience to possibly be hired by FAME, but if not, obtain a good letter of recommendation to be hired elsewhere. For the most part, they are all amazing and motivated.

Dr. Anne, who is an assistant medical office, or AMO, a position no longer offered in Tanzania, but had required her to go to school for an additional two years after becoming a CO, will be with us for half days as she is still on partial leave after having a baby. Anne has worked with me for over ten years and is our neurologist on the ground here. Elibariki is a CO who I have worked with in the past and is a FAME employee who has been a delight to work with and train. Hussein is a CO who is volunteering with us and hoping to gain more experience, though is very, very good at this point in his career and will have no trouble adapting to any position. Emanuel is a clinical officer who I have not worked with before, but has already shown that he can fit in without an issue. Nuru is a pharmacy tech who has worked with us for several years and, even though she is not a clinician, is incredibly helpful and energetic, and has always been a pleasure to have working with us.

This is the contingent that will be working with us over the next six weeks and who we will be spending every day with, and even some evenings. Kitashu and Angel are our absolutely amazing social workers who organize and run our clinics for us in addition to doing all of the outreach work in the communities, notifying patients of clinic and making certain that we’re seeing appropriate neurology patients. If it were not for the two of them, none of this work, though there is also plenty of behind the scenes planning that goes into making all of this work smoothly.

While sitting in clinic this morning and leaning back in my chair against the wall behind me, Hussein suddenly warned me to be careful of the insect that was not very far from me. It was a very harmless looking insect that was perhaps ½ an inch long and red and black in color, but unfortunately, it packs a punch, not by it’s bite or sting, but rather from a compound that it releases and causes severe burns. It’s known as a Nairobi fly, but, in actuality, is a small beetle of the genus paederus which is found throughout East Africa. Any contact or disturbing it in any way will cause it to release a very nasty chemical called pederin that will cause a significant burn that is both very painful and also causes a severe inflammatory reaction. Needless to say, it’s not something very pleasant and best to avoid at all costs. Unfortunately, they often show up in unexpected places and before you realize what you’re brushing off your arm or face, it’s too late.

Shortly before lunch, the skies began to darken and the rain began to fall. At first, it was a light steady rain, but then began to come down a bit heavier, though not the deluge that can often happen here, when there are virtually rivers in the streets and the rain coming off the roof becomes as thick as curtains that are difficult to see through. Loud booms of thunder became more frequent and we could even see a few flashes of lightening from underneath the overhanging roof of our outdoor clinic. It was still raining as we went to lunch, making the seating a bit tight for everyone, but we all squeezed in. The lunch menu had changed for the first time in years and the rice, beans and mchicha that has always been my favorite lunch was no longer being served on Mondays. Today, it was to be ugali (a stiff corn meal dish) and a stew made from the tiny sardine-like fish that are harvested from the local lakes in the region. It was also served with mchicha, a dark green vegetable similar to spinach. I opted to have beans with my ugali rather than the fish stew, but Gina and Megan said they both enjoyed the stew.

There were two patients in the ward to be seen in consultation, so both Joe and Leah went together with Hussein to see the patients. One was a young boy with neurofibromatosis who had a chest wall resection of a probably neurofibroma, but after surgery, had been noted to be complaining of painful weakness in his legs and difficulty walking. After obtaining a more thorough history, though, it seems that he had some of these symptoms before surgery and was also significantly malnourished, raising the concern for some nutritional causes of what appeared to be a painful neuropathy.

There was also another case for them in the ward which they were able to see, though they were both soon back to neurology clinic to help with the outpatient load. The patients just kept showing up and even after reaching our maximum, we were still being asked to add more patients. An elderly gentleman who was being seen by surgery for urinary incontinence and a prostate problem but had also been noted to have problems with ambulation. He was referred our way and was sitting out in our waiting room in a wheelchair, but it took only a quick glance from me to know what his diagnosis was. He had the classic masked facies, decreased blink rate, bradykinesia, and drooling of parkinsonism and, most likely, Parkinson’s disease.

His history was such that he had been having ambulatory dysfunction for about two years and progressive cognitive dysfunction for the last year. The reason for his urinary incontinence was, in addition to his prostate, the fact that he could not communicate to others that he needed to use the bathroom and was immobilized so that he could not get there on his own. He was our last patient of the day and it was appropriate to place him on a carbidopa-levodopa trial, though the only formulation that we had in the pharmacy was a 25-250 strength and far too much for him to start on. Thankfully, I had brought a supply of the lower strength of this medication that much more appropriate for the initiation of therapy in a new patient. Patients with idiopathic Parkinson’s disease are so responsive to carbidopa-levodopa (otherwise known as Sinemet) that we often use it as a test which is diagnostic. Not responding to therapy is usually a sign that the patient is not suffering from Parkinson’s disease.

We had ended up with more patients than we had anticipated for the day and clinic had now run long past our normal stopping time. As much as all of us would love to keep seeing patients, we have to keep in mind that the staff we’re working with have families at home and other limitations such that they do not have the same freedom that we have here. We ended up seeing patients until well after 6 pm which was a significant issue for the translators as they all depended on taking the staff bus home at the end of the day and that had departed long ago. Walking was an option, but it was still raining intermittently and having a downpour on the way home would have been very unfortunate. They ended up catching a ride from Dr. Anne, who had stuck around just for that purpose.

Everyone was more than exhausted after such a long day, but not only had we seen many patients, we had seen those in whom we could make a difference and, for that, I think everyone felt that they had accomplished something.