It’s the end of our first week here and the patient volume has been a bit down, likely due to the weather, which has been very cool and overcast in the mornings. The weather has been incredibly delightful for us, though this temperature is considered “freezing” for the Tanzanians who come completely bundled up with multiple layers of clothing, while I’m walking to the clinic in a short-sleeved polo shirt. At the Maasai market, ski jackets are a hot commodity, and anyone riding a motorcycle (known as a boda boda or piki piki here) will be wearing a big puffy jacket to fight off the cold. When the weather is cold like this, people tend to remain indoors and don’t come to clinic early in the morning, choosing rather to wait until later in the day when the sun is shining and its warm rays can be felt.
Morning report on Monday, Wednesday, and Friday are attended by the entire clinical staff at FAME – doctors, nurses, lab personnel, radiology – and our conference room where it’s held is far too small to accommodate everyone, meaning that if you show up late, you’re relegated to listening from outside at the window. There were several patients of interest to us this morning – one young man who had a head injury and another older woman with an initial scan concerning for a tumor. These were both inpatients, and we would see them once we arrived in clinic and determined what our volume of patients would be for the morning. We were told of a third patient who had weakness, though we had no other information. In the end, the patient was described as having “GBM” and wouldn’t need to see us. That might seem a bit odd to those neurologically minded readers as “GBM” in our parlance refers only to the very ominous diagnosis of glioblastoma multiforme, the most aggressive of brain tumors one can have and which is essentially not survivable. When I first came to FAME fifteen years, I couldn’t understand what was in the water that was causing so many patients to develop “GBM,” until I was finally told that it wasn’t referring to the devastating glioblastoma, but rather meant “generalized body malaise,” a far less problematic diagnosis.
There were few patients waiting to see us at the start of clinic, probably as a result of those cold temperatures I had mentioned, so Julian stayed behind to hold down the fort while Joe and Jack went off to the inpatient wards with Dr. Annie and two of our translators. We have three new translators working with us this session who I had forgotten to introduce – Novati and Zuhura, who are both clinical officers (kind of a cross between a nurse practitioner and a physicians assistant), and Zainabu, or Zai, who is a fourth year medical student at Kilimanjaro Christian Medical Center in Moshi, and is one of the main referral hospitals in Northern Tanzania. There is actually an oversupply of both doctors and clinical officers here in Tanzania, so there are many that are looking for work and are willing to volunteer here at FAME with the hope that they will not only get additional experience, but also a letter of recommendation that will help them secure a job in the future. We have certainly hired a number of those who have volunteered her with us in past, though the jobs at FAME are quite desirable and scarce, and there are often very few openings. There are several volunteers who have worked with neurology in the past, though, and have now become clinicians here – Elibariki, Dorcus, Africanus (who now runs the clinic at Rift Valley Children’s Village), and others.
One of Jack’s patients who had been seen yesterday or the day before and had new onset aphasia that was concerning for a stroke but required an imaging study to be certain it was not related to a mass lesion. The patient had her scan, and thankfully it was totally consistent with a subacute cerebral infarction in the left insular region (much better than a mass lesion for sure).
The patient with the head injury had been in a motor vehicle accident and suffered significant head trauma resulting in fractures and a traumatic subarachnoid hemorrhage. We needed to see him to assess his mental status and to make sure he didn’t have any significant neurologic deficits. Thankfully, he was neurologically intact for the most part, though we couldn’t assess his right eye movements due to the amount of swelling he had and the inability to even open that eye. The main concern we had was whether he had any entrapment of his eye muscles on that side as a result of the fractures. We would have to see him again later to be certain whether he had any double vision or not. His mental status was fine, and the traumatic subarachnoid hemorrhage didn’t require any intervention as it would simply resorb on its own.
As for the patient who had been billed as a possible mass lesion, her history was that of sudden onset of left sided weakness which was more consistent with a vascular event, or stroke, than it was with a tumor, but we still wanted to obtain a contrasted CT scan to be certain as to which one we were dealing since their treatment would be completely different. The contrasted scan was indeed more consistent with an infarct, or stroke, and her workup would therefore be very different. She did appear to have some left atrial enlargement on her chest X-ray and CT scan of her chest (which had been obtained due to a history a chronic cough), raising the question of a cardioembolic source for her stroke meaning that we would probably obtain an echocardiogram at some point.
We arrived home from clinic in plenty of time for some evening activity and Cat was in definite need of a hike, her favorite pastime. She, Joe, Jack, and Patrick had decided to walk out behind the house and there was plenty of time before sunset before such an adventure as I had no intention of letting them head out on their own had it been later. I had just told them of one of my first hikes here which I had done solo to take photos of the sunset from a distant ridge looking west, only to realize when I got there, that I hadn’t brought a flashlight and this was in the day before iPhones had the flashlight feature. I took my sunset photos, which really weren’t that great, threw my camera back into my daypack and started on my way back to the volunteer house at FAME. One of the great benefits of being in rural Africa is the fact that there is very little atmospheric light after sunset and, unless the moon has risen, it gets very, very dark very, very quickly.
Walking across the many fields and through several orchards in the dark, the very same ones that I had traversed to get to my original destination of the ridge, I only knew the direction in which I should be walking along with a rough estimate of the time it had taken me on the way up in the daylight. I imagined that every bush and stump was an animal waiting to pounce on me, and was quite happy when none of them did, but I had to suppress my fears the entire walk home which I’m sure seemed my longer than it really was. When I finally reached the house, my two roommates were none too pleased with me for making such a drastic error in judgement as they were certain something had happened to me long ago. This was at a time where we didn’t have cellphones that worked here, so I had no opportunity to call them or send word that I was safe, though I was certainly scared silly during the entirety of that walk.
I now have several sets of walkie talkies here that I’ve used in the past when we’ve taken two vehicles out on game drives so we could communicate with each other, so I gave one to Cat and her group so that we could at least stay in touch during their trek. Julian has stayed behind to work on one of the lectures for next week, and I had wanted to get some other work done, so each of us remained at the house. Unbeknownst to me, Cat had decided to take the group down to the brick quarry and up the other side of the ravine towards Tloma Village when I had actually thought they were heading the exact opposite direction. They had a great walk, and thankfully there were no issues as the walkie talkie didn’t work that great in that direction and I wasn’t sure they had a phone with them to call if they needed any assistance. As the sun was dipping lower towards the horizon, I had memories of my trek in the darkness fifteen years ago, so I was quite happy when I heard them all arrive home well before the black of night appeared.
