The last day of clinic for the current group of residents would start a little early as we had the M&M report that I had mentioned yesterday to attend at 7:30 am. The M&M is run very tightly with specific time constraints and a discussion that follows each case to be presented noting things that were done correctly and things that can be improved. The entire process took close to an hour so that our morning report was running late and the presentations of the patients on the various ward services were abbreviated to allow everyone to begin work only a few minutes late.
We had planned to have a half day of clinic to allow everyone time to pack tonight for their departure tomorrow. Marissa would be leaving this afternoon to head up to Gibbs’ Farm to meet her boyfriend there who was arriving today at Kilimanjaro. Unfortunately, he had missed his original flight out of NYC that would have had him to Kilimanjaro early this morning, and, instead, had to fly a circuitous route to Washington, D.C., then to Addis Ababa, and finally into Kilimanjaro, arriving not until 1 pm. The most important part, though, was that he was on the final leg of his flights and would soon be on the same continent.
With Kevin’s arrival today, Marissa would be departing FAME, and I would once again be on my own as the only faculty here to supervise the residents. Having another faculty member here with me, which has happened on only limited occasions over the years, has always been a real treat as it allows for some downtime during the day in which I can get other things done, like this blog. Over the last several years, having all four residents constantly seeing patients throughout the day, normally keeps me completely occupied in that capacity, and can be very exhausting by the end of a big day seeing more than thirty patients. With Joe having been here for the first two weeks, and then Marissa for the second and third weeks, I’ve had some breathing room. Well, that would all end today.
The little six-month old child who had presented several days ago with focal status back hadn’t returned to clinic yet, so we asked Kitashu to give them a call and get them back in before we finished the day. Thankfully, they made it in, and it appeared that the carbamazepine we had started was helping, though it was still a bit early to make that determination as we were still up titrating the dose (carbamazepine cannot be loaded) and it would be another several weeks before they were on a full therapeutic dose. The family was also describing some abnormal movements that sounded like myoclonus, or possibly spasms, and, if this continued, we would consider switching them to topiramate when they return.
We also saw a 9-year-old boy who had a long standing non-specific static encephalopathy, though the child was dysmorphic appearing and very likely had an underlying syndrome, as well as many years of untreated epilepsy. As with many of the patients we see here, he may have had a history of a brief and unsuccessful trial of phenobarbital when he was young but hadn’t see anyone in many years for his seizures. He was placed on one of “broad spectrum” antiseizure medications, such as valproic acid or levetiracetam, though I cannot recall which it was. Equally important, though, he had never been referred in the past for any rehabilitation which, in the long run, would be helpful with the possibility of improving his functional status.
Monduli is a rehab center that is just this side of Arusha, that is government run and free to patients with disabilities that could benefit from inpatient physical, occupational, and speech therapy. We will often send our patients with cerebral palsy or similar syndromes when they around three years of age as the benefit is less significant if they are younger than that. The good news is that services for the patient are covered, but to go there, the family must accompany the patient, essentially live there for several weeks’ minimum, and those expenses, which are often much more than families can handle, are not covered, making the situation very difficult at times. The philosophy of having the family accompany the patient in rehab and learn the techniques that are used by the therapists is a totally valid one, but unfortunately, with very limited healthcare funding, the advantage of this wonderful opportunity is often lost.
The clinic was coming to an end for this group of residents, all of whom had an excellent experience (at least that’s what they’ve told, though I do believe them), and, over the three weeks they have been here, they have had the opportunity to develop close relationships with the translators and other staff they’ve been working with on a daily basis. Traveling to a clinic such as FAME, and in a country such as Tanzania, leaves little to the imagination of what you are doing or what the purpose of being here really is. We always have a lunch at the Lilac Café here on campus with everyone involved with the clinic our last day, or when each group leaves. That means all the interpreters along Kitashu and Angel. As food usually takes about an hour, we had sent some up to order the food early, though in the end, we all ended up at the Lilac waiting for our food but were not disappointed when it arrived.
While at Manor Lodge on Wednesday evening, Jenn had spoken to me about the possible collaboration between Wharton (Penn’s business school) and FAME not only for fundraising, but also for help with global health systems management from a business and infrastructure standpoint. I had wanted to have Susan hear it directly from Jenn, so had set up a meeting time for us to meet with her and hopefully with our onsite director hear, William. Well, nothing necessarily goes according to plan here as you’ve probably noticed. Our late morning meeting soon became a noontime meeting and then slowly morphed into an early afternoon meeting that we had at the end our lunch. It was an interesting discussion that will certainly be worth exploring in the future.
We were home quite early and after a bit of rest, we all decided to take a walk. Though the fields behind FAME are absolutely gorgeous and the best for a power walk in the morning or evening, my favorite walk from FAME is still down into the brick quarry that sits next door at the bottom of a ravine. Bricks here are made in quarries, which are essentially places were the dark red clay is easily mined and then formed into bricks. From there, the bricks are stacked into large blocks nearly ten feet high that usually have two, though sometimes one, firebox in the bottom in which piles of wood are placed for firing the bricks. The huge stack of bricks is then completely covered in mud and the bricks are ready for firing. This will make the bricks essentially impervious to water, so a house build from them doesn’t just melt with the first rain.
There are quarries all over Karatu, but the one nearby is one of the bigger around. Walking down the steep hillside into the quarry, you follow a cow path to the bottom passing a few smaller digging sites. At the bottom of the ravine is a creek that is normally easy to cross, though unfortunately, it was not crossable today without all of us having to take off our shoes which we didn’t think was smart. Had we crossed and gone up the other side through the larger part of the quarry, we would have ended up on the Tloma village road and ended up at the junction with the Gibbs’ Farm road where the woodcarver shop and Phillipo’s home sit.
In the end, we walked back up the hill and took the road in the direction of the fields. It was a beautiful evening and perfect timing for a walk. We eventually walked down to the fields and then back up to FAME where we all settled in for the night. Leah, Jenn, Evan, and Gina would be heading to Gibbs’ Farm in the morning, and I would be driving them. Though they originally wanted to leave here at the crack of dawn, I convinced them that leaving at 8:00 am was far more reasonable.
