The topics for our morning education lectures that we deliver are always selected by the FAME clinical staff which is a very important point and a basic premise for anyone involved in global or community health programs. The people who know best in regard to what is needed, whether it be educational lectures, supplies, training, or volunteers, for that matter, are those on the ground and who are familiar with the lay of the land. Barging in with the attitude that “we know what’s best for you and what is needed” will inevitably end in failure of the program and a relationship that is irreparable. Hence, the topics for our lectures are always decided upon by the clinical staff and communicated to us by the education officer for FAME (who currently happens to be Dr. Jacob). Often there may be recent cases or events unbeknownst to us that effect what topics they wish to hear from us. This morning’s topic, mood disorders and psychosis including their effect on health care workers, to be delivered by Dr. Joe, was a particularly timely subject that had been requested and would be followed up in the future by additional talks.
Though we are not psychiatrists, by any means, neurology residents, and neurologists in general, do receive extra training in psychiatry and we do share the same board in the United States, though they are completely different certifications. As there are so very few neurologists here in Tanzania, there are equally few psychiatrists, and, as Dr. Frank continually reminds me, we are the closest thing to a psychiatrist here in Tanzania meaning that the burden of evaluating and treating many of these patients falls to the neuro team. Several years ago, we did have a graduated medical student, Phillip Bradshaw, with us who was planning to apply for psychiatry residency (and is now finishing us his residency at Penn), who was a great help in evaluating these often difficult patients, and even Noor ul Sahar Khan, who had been with us in the spring as a visiting guest after finishing medical school in Pakistan and was interested in pursuing psychiatry, were incredibly helpful as they were both willing to spend that extra time that is often necessary with these patients.
Dr. Joe’s talk contained a great deal of material concerning this very important topic and, amazingly, he was able to get everything in that he had planned to do and was still under the 45-minute mark which is what the educational talks are allotted. He even left a little time for questions, though there were so many that followed, we went way overtime. As morning report was to follow the talk, as is usually the case, it kept getting delayed with all the important questions that were being asked, though it was clear no one was going to pull the plug given the critical nature of the material. Amazingly, I think we may have ended up going over by thirty minutes, but it was perfectly fine, and everyone understood. Joe also developed a number of treatment pathways that he presented and will be useful for the staff going forward when dealing with these patients in our absence as it often falls to the primary care doctors to deal with these issues.
Once we made it to clinic, there was a huge Lilac Café order placed for everyone in the neuro clinic, including a number of chapati mayai and plain chapati – I stuck with my standard two beef samosas that I often enjoy in the morning. The staff from the Lilac bring our order to the clinic and it usually gets set on my desk where there are no patients being seen.
A young Maasai child came into clinic for follow up with a history of febrile convulsions, though they were slightly atypical as being a bit prolonged. Normally, we would not necessarily place this patient on anti-seizure medication, or at least we would think long and hard about it, though this family lived in the Loliondo district which is near the Kenya border and a seven-hour bus ride over rough roads from Karatu. Given the distance they would have to travel to receive care or any follow up, it was decided to start the child on levetiracetam until they outgrew the risk for febrile convulsions at which point we would then consider tapering off the medication as long as they hadn’t had any further seizures. Sometimes, you must consider all the different variables when recommending treatment options and, in this case, the family felt most comfortable with this plan.
Another interesting patient that was seen today was an 18-year-old young man who had come to FAME 10 days ago after a large tree branch fell from a tree and struck him on the head causing loss of consciousness. He was admitted to the medical ward after obtaining a CT scan that demonstrated a very wicked right temporal fracture as well as small epidural and parenchymal hematomas. He spent two days in the hospital with the complaint of a headache and then discharged home with paracetamol. We didn’t see him, unfortunately, though he wasn’t described as having any focal neurologic signs.
He was returning today for routine follow up and, amazingly, wasn’t complaining of a headache. He did note that he had some subtle numbness of his left hand, but his neuro exam was otherwise non-focal. He is one incredibly lucky patient as his injuries and the outcome could have been significantly different had his epidural been much larger – epidural hematomas are almost always associated with traumatic skull fractures and are the result of a lacerated artery leading to a high-pressure lenticular shaped hemorrhage that often requires at least a burr hole and often a craniotomy to ligate the bleeding vessel. They are typically the most emergent types of intracranial hemorrhage as far as surgical treatment is concerned, though given the small size of his epidural and the lack of further expansion, he was able to tolerate it without requiring a surgical procedure. The small parenchymal hemorrhage seen in the right parietal region clearly explained his left hand numbness and will most likely resolve over time. His skull fracture will heal over time as well, though we told him to make sure he stayed away from falling branches for a while as having another head injury in the near future could be very serious and compounded by his existing fracture before it heals. If one had been able to find a bicycle or hockey helmet in Karatu, I would have told him to wear one for several months, but they’re nowhere to found here.
The afternoon was fairly quiet with only a smattering of our typical patients, and we were home at a decent time when I received a message from Susan informing me that there had been a serious car accident nearby and several injured tourists were being brought to our emergency room. She wanted to make sure we were available to come in for any possible head injuries among the victims, which we were, of course, though it soon became apparent that there was at least one patient with multiple traumatic injuries that were life-threatening, and she thought it best that we didn’t crowd the ED until we were needed. It wasn’t until several hours later that William called to ask us to come to the ED to evaluate one of the patients with only a minor head injury who had wanted to be discharged, so several of the group headed up to take care of that. Thankfully, they had suffered no severe injuries and were fine to go home. The following morning, we were called into the ward to see one of the other patients who had also been in the accident and had suffered a minor head injury, but they too were neurologically intact and required no additional care from our standpoint.
Since its inception in 2008, FAME has served to provide urgent and emergent care not only to the residents of the Karatu District, but also to those tourists who come to Tanzania to enjoy their truly remarkable and unique parks. The Northern Safari Circuit, which includes Lake Manyara NP, Tarangire NP, Ngorongoro Conservation Area and Ngorongoro Crater, and Serengeti NP essentially encircle FAME, making it the most accessible medical facility, and I would argue the finest, to receive these patients for their initial emergency care and triage. As part of FAME’s commitment to providing this world class medical care, we opened a fully equipped eight bed emergency room, something unheard of in this region, and have developed emergency and trauma protocols with the assistance of several emergency and trauma care volunteers, but which continues to run and further enhanced by our amazing all-Tanzanian staff that has taken on this challenge and never looked back.