On the last Friday of the month, FAME clinicians present an M&M conference in which a case is chosen to review, and to discuss what went right and what went wrong. M&M conferences are considered peer review, and anything contained in the presentation, discussion, or the ultimate recommendations that arise as a result of the case are protected and, at least in the United States, are not discoverable from a legal perspective meaning that what is discussed in an M&M conference is not admissible in court. The reason for this, and for peer reviews in general, is to allow a forum in which everyone is free to express their opinions, and not necessarily to point fingers, but rather to move forward and to improve the delivery of health care. There are no sanctions or punishments that arise from these conferences as it is meant as a learning experience for all involved.
As such, it would be improper for me to discuss any of the details of the M&M conference, though, on the other hand, I can certainly comment on the general topic as I think it would be helpful. When I discuss with others at home what we have here at FAME, I am always asked the question, “Do you have an ICU?” My response has always been consistent and straight forward. “Well, we don’t have an ICU per se, but we do have many critically ill patients who we are caring for at FAME.” That may sound very strange to those who are used to practicing in hospitals where there are very strict criteria for which patients are on the floor, which patients are in the ICU, and which patients are in the step-down unit in between the previous two. These criteria consider a patient’s vital signs, level of acuity (or acuity score), acute organ dysfunction, physiological instability, and the need for advanced interventions such as mechanical ventilation or pressure support with medications. In addition, a patient’s prognosis is considered as well as goals of care to determine whether the patient would benefit from the level of support offered by an ICU.
At FAME, we do not have an ICU and are unable to provide prolonged ventilatory support (as I have mentioned previously) as the only ventilators we have here are for the operating theater of which there are two. That is the case in many hospitals here in Africa – it is not a thing to have patients on ventilators for prolonged periods of time and there are very few ICU beds that exist in Northern Tanzania for any circumstances unless the patient is suffering from a very clearly and quickly reversible process. What we are able to do, though, is to identify those patients who require a higher level of care in regard to more frequent vital signs and nursing checks, and to use one of the rooms in our medical ward that will serve as a step-down unit where these patients with a higher level of acuity can be placed and cared for more closely. M&M conferences are a learning experience that provides a forum for new ideas and overall improvement in our healthcare delivery.
As it was Jack and Joe’s last day in clinic, I made sure to make that announcement once morning report was completed. It also gave the two a chance to thank everyone at FAME for their hospitality and acceptance. I can’t recall if I’ve mentioned it before, but it requires a special attitude for people to volunteer at FAME, and to work side by side with such qualified Tanzanian clinicians as we have here, without managing to offend someone along the way. Thankfully, every resident, fellow, and colleague who I’ve brought to FAME have understood that nuance, which is critical for anyone working anywhere in the global health field, and any others who have volunteer at FAME are of the ilk to understand this with very rare exceptions.
We had been asked to see a patient in the ward who had lower extremity weakness as well as extensive lymphadenopathy of the neck, the latter having been biopsied in the past with no clear diagnosis. When the team went to see the patient, it turned out that her lower extremity weakness had actually began well over a year ago when she noted that she had bent over and developed acute weakness of both of her legs, and that they had remained weak since that time with no real progression, though her weakness was so severe that it would have been difficult for it to have progressed very much. On examination, she was found to have a spastic paraparesis with severe contractures and had a T4 sensory level suggesting a spinal process either two levels above or below the T4 level.
Unfortunately, with her condition having started over one year ago, there was very little we could offer as far as investigations that would have led to some treatment of her condition, though we could certainly offer some symptomatic treatment for her spasticity. We obviously had lots of curiosity as to what had caused her underlying spinal process but as it would not help to reverse anything of her weakness or improve her function, there was little reason to spend anyone else’s money. Of course, the differential for the problem was a bit broad, but the rather acute nature suggested perhaps a spinal infarct or sudden cord compression from a thoracic disc or Pott’s disease (tuberculosis of the spine and collapse of the vertebrae with compression). How to connect the lymphadenopathy of the neck with cord process wasn’t clear. Sending the patient for an MRI would certainly have been interesting for us as it would have shown whatever the underlying process was but wouldn’t have led to treatment or changed her overall outcome or function.
This is often the dilemma we face here when resources are so scarce, and patients are paying for the majority of their investigations and treatment. Though we do subsidize the neurology clinic somewhat (visit, medications for a month or more, and laboratory studies all for about $2 USD), we are unable to sustainably cover the cost of a CT scan (approximately $90-100). Things here are never done out of academic interest, nor for curiosity, ever. The patients we see often have difficulty affording the even the visit fee, in which case we will have them speak with our social workers and often figure a way for us to cover their cost without it appearing to be a gift, which is also a big no-no here and is a quick way to completely alienate all those Tanzanian clinicians who are otherwise unable to provide the same financial gifts that we can. This is true in aspect to what we do here and is a rule that is strictly adhered to at all times – we never reach in our pockets to help a patient in need without first going through our social workers who will first assess the patient’s need and then, with the greatest of sensitivity so as to be certain it does not appear as a gift, make whatever services available to the patient under the guise of an unnamed benevolent fund rather than from the visiting mzungu (non-Tanzania) doctor. Although this entire process may sound quite frivolous, I can assure you from having to undo completely innocent actions in the past, it is totally necessary.
At the very end of the day, the team saw a 50-year-old patient in the ED who had come in after a seizure and was encephalopathic. Though her history wasn’t entirely helpful and the report was that she had only recently (days) developed any problems, she did have some focality on her examination, so it was felt that a CT scan of the head was an appropriate study for her. Though we didn’t get the CT results until the following day, it wasn’t a very good picture her problem appears to be a high-grade multi-centric glioma involving the deep left hemisphere and left temporal lobe and, perhaps more importantly, would not be resectable given its location. I sent the images to the neurosurgeon in Moshi at Kilimanjaro Christian Medical Center, and she agreed with the assessment, though suggested that perhaps she might be a candidate for temozolomide and radiation. We will discuss a possible referral with the family, and whether this is something they would be willing to consider, though ultimately, we will have to convey that her prognosis is very poor.
As it was Jack and Joe’s last day in clinic as well as their last night in Karatu, everyone decided that we would go out to celebrate at the Lilac Oasis with the entire neuro team. Our translators have been wonderful, and it would be a way to show our appreciation as going out like this would not be something they would normally do. The Lilac Oasis has been open for a few years and is still a work in progress, though what has been completed so far is really gorgeous – a lovely bar/club with live music and karaoke, a beautiful restaurant, and an outdoor venue for music with a “Dunga,” or a converted safari supply truck serving drinks and food. The landscaping for the entire facility, complete with ponds and running streams, is really spectacular. We sat in the bar having drinks and ordered food which, as is typical of almost every restaurant in Africa, took well over an hour to prepare and serve. They moved us to the restaurant in the end so we’d be more comfortable, which was fine, as it was getting late and we would be leaving after eating. Everyone seemed to enjoy a nice night out together.
