Having gotten a half-way decent night of sleep, the new residents seemed bright-eyed and bushy-tailed, ready to begin their three-week rotation here at FAME. It was time for their orientation that always begins at morning report when they’re introduced. Thankfully, they had all gotten seats inside the conference room as that’s not always the case on Mondays when the entire clinical staff – doctors, nurses, lab technicians, radiology – come so that everyone is included in the clinical discussions. We are definitely in need of a larger conference room just in case anyone is looking to have a plaque with their name on it here at FAME.
I had asked the residents to all go to morning report so they could be introduced to the staff and, as I had driven Jill to the Black Rhino again and would not be back until 8:30, I had asked Megan to do the honors of introducing them since I would not be there. As it turned out, though, I arrived by the end of report, in time to hear about the deaths that had occurred over the weekend and was then able to introduce the residents so everyone would know who these new faces were. With our neurology clinic and the program with have, we are always the largest contingent of wazungu (white people or strangers) during our time at FAME.
There are usually a number of volunteers working here with the Tanzanian clinical staff, so it is not unusual to see other white faces, but the mission of FAME is to have volunteers here that leave something behind, not just to see patients. Over the years, I have met a great many volunteers, virtually all who return, if not on a regular basis, every one or two years. I have been the most frequently returning volunteer based on the fact that I have come every six months faithfully since 2010, establishing the sustainability of our neurology clinic. Another long-term volunteer has been Joyce Cuff, who single handedly developed the laboratory here at FAME and has brought it to a state-of-the-art level from early on. Over the years, Joyce has spent lengthy periods of time at FAME, sometimes spending 9 months of the year, though since the pandemic, her time here has decreased somewhat.
After their introduction at morning report, it was time for the residents to go on a tour of the FAME campus that would be given by Saidi, our volunteer coordinator. When I first came here in 2009, all that existed was the OPD, or outpatient department, building , and the intervening years, the campus has grown exponentially, now containing countless buildings that include apartments and two houses for the staff, four volunteer homes, a duplex for long term volunteers, a laboratory building, two hospital wards, two operating theaters, radiology, a 25-bed maternity wing that also houses a neonatal step-down unit, a reproductive and child health building, an administration building, and a brand new 10-bed, fully functional emergency room that is certainly unique in Northern Tanzania. Needless to say, FAME has grown from an outpatient dispensary to a large hospital complex for which it has obtained the designation of hospital in Tanzania, a big accomplishment.
After Saidi’s orientation session for the residents, it was now time for them to learn to use the electronic medical record, or EMR, utilized here at FAME. The EMR is a local intranet capable system, so is not accessible elsewhere and you must be logged into one of the local FAME networks. The EMR, which is web based, was developed in Tanzania, and is supported by a local company. It is very different than the incredibly robust EMR, Epic, that is used at home and by most institutions in the United States. My relationship with EMRs, in general, has been a love hate relationship. Though I had originally wished that I would be long retired from medicine by the time EMRs became a thing, I have now made my peace with them and have learned to live in harmony, having to use them nearly every day. That’s not to say, though, that I use the EMR here at FAME, for it is the residents seeing he patients who need to be most familiar with it. I had learned it in September 2020, when it was first introduced, and I was here by myself, but have not had to use it since, other than to run reports for our data collection.
Once the EMR training was complete, which was conducted by Valence, our IT specialist, and the translators who have worked at FAME before, it was time for us to meet with Susan and Elissa, our long-term pediatric ID specialist, who is now in her second year at FAME. I have spoken numerous times about the transition that one must make when practicing medicine here, not that it is practiced in any way different than it is at home as medicine is the same, but rather it is the environment in which you are practicing that is different. The cultural differences are immense, and even though we often encounter similar cultural differences at home, it is once again the different environment in which you are working and what the accepted norms of treatment are.
Having the perspective from Elissa, a westerner, who has now worked here for several years was essential for the residents to hear and though I have often discussed these differences in conferences at home that I am sure they have all heard, it is not until you are here in person, with the patient sitting in front of you, that you must grapple with these issues. Though taking a history here is far different than at home, not only for the language barrier, but also for the fact that East Africans do not readily divulge the complete story to you on the first go around and what may seem at home to be quite obvious, is not so obvious here. With all that being said, the medicine we practice here is how medicine was meant to be practiced. Simple expectations and limited resources very often require greater skill in eliciting the outcomes that one wishes to achieve.
Having been literally slammed with patients on our first day three weeks ago (I believe that we may have seen thirty patients), today was the total opposite. Though FAME was still overwhelmed with the typical Monday onslaught of patients, we had far fewer coming to the neurology clinic. This has happened before and, in an attempt to compensate for this, we have our mobile clinics structured so that the mobile clinic week for this group will hopefully have a greater number of patients. We will be going to Mang’ola which is next to Lake Eyasi and typically have no issue attracting patients in those areas. Kitashu will travel there this week to make announcements to ensure that we see as many patients as possible.
One child we saw today was a tiny premature baby whose parents noticed that their head had been enlarging. The baby was so very tiny, that when I glanced at them wrapped in their mother’s lap, the first thing I thought was just how microcephalic the baby was, but I hadn’t had the benefit of seeing their body. It is truly a miracle just how many premature babies we have here and how well they will often do which is a testament to the care that they are receiving, both from their family as well as from FAME. We were able to do an ultrasound of the baby’s head and the ventricles did not appear to be overly enlarged so, for the time being, we continue to observe the child and monitor their head circumference.
I have mentioned the issue of treating hydrocephalus here before in regard to having to perform VP shunts that require monitoring and can, at times, have catastrophic failures with the inability to intervene in most of Africa, often leading to death. Though the process of performing an endoscopic third ventriculostomy (ETV) had been introduced by a number of neurosurgeons during the 20th century, it was not until the procedure was coupled with a choroid plexus cauterization (CPC) to reduce the production of CSF that a true benefit over a VP shunt and its inherent risks was shown. Dr. Benjamin Warf, now of Boston Children’s, performed and studied this combined procedure in East Africa in the early 2000’s, and validated the benefit of the procedure, especially in low resource regions.
After clinic, everyone was excited about going into town to buy fabric at one of the shops to use later at Teddy’s, and it was also market day, so they wanted to see the Maasai Market. We stopped briefly at the change bureau for everyone to get shillings and then headed to the center of town where most of the fabric shops are. Thankfully, we had Annie with us who could help negotiate prices for having six wazungu walk into any shop in town is a recipe for disaster is one is hoping to even pay the regular price, let alone a discounted price. Sure enough, the initial prices given to the residents were way too high, though with some assistance from Annie, they immediately became more reasonable. I never have an issue paying the regular price for something, just not an inflated mzungu price.
Once the fabrics had been purchased, it was off to the Maasai Market, and Annie was excited to come with us as she wanted to look for clothes for young Denzel. I have not walked into a Maasai Market in several years, but, since Annie was there, I felt a bit more adventurous, and we followed her to an area where there were plenty of clothes. Vendors put out large tarps on the ground, perhaps 8 feet square, on which they place clothes for sale, some very orderly, and others completely disorderly. The vast majority of these clothes have come from the US and are shipped in huge bales that are tightly bound and are eventually purchased by a vendor at the docks and then transported to the market. Some are new, others not, and they are in every condition one could imagine. T-shirts from every university in the US and those from the losing super bowl team can be found here.
We left Annie at one of the clothes vendors while we went off as a group to an area of the market that had more kitchen ware. We ran into Isabella, Daniel Tewa’s eldest daughter, who was selling wares from her shop in town here and, having wanted to buy some coffee mugs for the house, we used her to help us with a price, as I didn’t want to offend anyone by making an insultingly low offer. Isabella told us that the six very nice new coffee mugs we had selected would be 20,000 shillings, or just over a dollar a mug. I thought that was very fair.
I not only have a habit of being too trustworthy, but also of carrying my cellphone in an unsecured back pocket all the time. In Barcelona, the pickpocket capital of the world, Jill had repeatedly reminded me to keep my phone in my front pocket, but each and every time I took it out to photograph something, I reflexively placed it back in my back pocket. The market was an ideal place to lose your phone, so I had placed it in a front zippered pocket in my pants, only to discover that moments later, the zipper was wide open, and my phone was gone! I had an immediate sense of panic at the thought of having lost my phone in the midst of this mass of humanity where it would be gone forever. It was what seemed like an eternity before I realized that I had done the same thing as I had in Barcelona – my phone was sitting in my unprotected back pocket, right where I had put it after having taken a photo earlier.
We walked back to the vehicle having left Annie at the clothes vendor and I immediately texted her to tell her we were back in the vehicle. When I went to text her again, Megan, who had stayed back to watch the car, reminded us that Annie had left her phone so it wouldn’t be stolen. Smart thinking.
