This morning, Natalie gave a wonderful talk to the FAME clinical staff on Intracranial Hemorrhage that included both treatment recommendations as well as cases with CT scans. Trauma cases have increased exponentially since the opening of FAME’s new emergency room, and the number of head injuries from high speed boda boda and car accidents are being brought in every night. Thankfully, the FAME staff are now perfectly comfortable routinely performing burr holes for subdural hematomas that has become lifesaving as these patients were previously sent to Arusha or KCMC, several hours away each, often decompensating or dying in transport or on arrival. After several years of trying to make it happen, in the fall of 2021, Sean Grady, chairman of neurosurgery at Penn at the time and a long-time colleague, finally made it to FAME specifically to teach the surgeons how to do burr holes. Sean was also accompanied by Kerry Vaughn, also a neurosurgeon who had been at Penn for training and had subsequently done a pediatric neurosurgery fellowship, to help out with the training. We had brought two manual burr hole drills, or braces, with their bits, and Sean had set up the trays and instructed the OR nurses on their use. It was a slow startup, to be honest, but once Dr. Manjira had come to lead the surgical program here, everything took off, and these lifesaving procedures are now performed on a regular basis.
Anything more complicated from an intracranial or neurosurgical standpoint that arrives here at FAME must be transferred to KCMC to see Dr. Happiness Rabiel, a neurosurgically trained clinician who is currently the only acting neurosurgeon in Northern Tanzania, though Kerry Vaughn had worked there at KCMC with Happiness for an additional year as a global neurosurgical fellow following her time at FAME. The ability to perform more intricate neurosurgical procedures that require specialized operating room setups must be done in Dar es Salaam if they can be done in Tanzania at all. These highly specialized procedures are either completely unavailable to patients, or they must travel out of the country to places like Nairobi, South Africa, or even India if they’re to receive this care and can afford both the travel and the hospital fees that would be required.
Independent of whether or not a trauma patient requires a burr hole for a subdural or a referral to KCMC for something not treatable here, the presence of a fully equipped and fully staffed emergency room has been a game changer for the Karatu community and for FAME. Coupled with the opening of our emergency room, FAME and the Karatu community greatly benefited from the good fortune of having Dr. Amanda, our Australian emergency room doctor extraordinaire, who spent two years here at FAME training the ED staff and developing virtually every ER protocol one could imagine to care for our patient population. Her departure this last July to return home with her pediatrician husband, Peter, and her two children, was bittersweet, though lessened by the incredible work she had accomplished during her time here and the fact that she was leaving our ED in such great shape for the coming years.
To put things into perspective for everyone at home as to how emergency services are provided here, you have to first understand that there is no “911” service or emergency medical squads to show up at the scene of an accident. Victims of an MVA (motor vehicle accident) are almost 100% reliant on good Samaritans to assist them at the scene and to then transport them to a medical facility for assessment and treatment. This is not to say that there are no ambulances here, but rather that ambulances are not for bringing patients to the hospital, but rather they are for transporting patients between hospitals once they’ve been assessed at the ED and are then being referred to another institution for further treatment. Ambulances are privately owned here (FAME has one newer ambulance as well as a few older ones) and payment is typically arranged in advance for these services.
In the ward, there was a 4-year-old boy who had presented several days prior with concern for meningitis who wasn’t improving, and a CT scan of the brain was obtained as we had wanted him to have an LP. The scan was interested as it showed hydrocephalus as well as a well circumscribed cyst that to my looked very benign and I felt most likely represented an incidental (unrelated) choroid fissure cyst. Despite his hydrocephalus, though, his fourth ventricle and basal cisterns were wide open so it would not present an issue for him to undergo an LP, though he had been on antibiotics for several days which would certainly affect the CSF results. Hopefully, we’ll be able to add something to his management as he wasn’t doing very well neurologically.
We finished in clinic at a reasonable time and had decided we would take a drive into town to pick up some groceries for the house as we had forgotten to order more corn flakes (a staple for Leah and me) and needed some additional eggs just in case Natalie got the energy to make stovetop banana bread as some of our bananas were getting long in the tooth. Just before we were to leave, Susan stopped in the house to let us know that there had been another accident in the conservation area and the victims were being brought to FAME, but it would be some time prior to their arrival. That worked fine for us as we wouldn’t be in town long, though on our way to town, we passed an ambulance with its lights on that was likely carrying someone heading to our ED. Since it would take some time for them to make their initial assessments and given that neurologists aren’t great as the initial evaluator in trauma cases, we continued to town.
It was evening time, and the sun was just setting, but the central part of Karatu was completely a buzz with activity as it seemed everyone in town was out shopping and taking care of business. We first went to the “supermarket” that I have used for the last 15 years – Deus Market – as they always seem to have everything, and if they don’t have it on the shelf, they’ll send someone to find it for you and bring it back. We picked up our corn flakes, our eggs, a bottle of delicious looking habanero hot sauce, and a large bar of Cadbury chocolate. The next stop was the vegetable market – this is a very large, now with a roof though only over the last several years, building the size of a Karatu square block, that has probably 100 stalls or more of produce with each stalls displaying virtually the same items for sale. Every type of vegetable and fruit that one can image as well as grains, fish, some kitchen wares, and much more. I had wanted to get several kilos of dry beans to use for a second bean bag that I had brought for our safaris – they are used to stabilize the camera and long lens acting as a tripod on the side of the vehicle. I bought the beans for 3000 shillings per kilo (a little over $1 per kilo), though was concerned I had paid too much (Mzungu price), but was relieved after calling Saidi to ask the price which turned out to be spot on, so I felt better. Leah was buying bananas for the house, but the first stall she checked, they wanted much more than the 200 shillings per banana that Saidi had suggested, so she passed and quickly found the right price at the very next stall.
Completely set with our groceries and my beans, we decided to take a leisurely walk around the shopping district before heading home as we hadn’t yet heard from the ED about the possible patient for us to see. That call came while on the FAME road driving home, so we stopped at the house to get our tools and headed up to the ED. It turned out to be a single patient who had been in a safari vehicle that hit a large hole in the road during poor visibility from the excessive dust, launching the entire vehicle and the couple into the air, and losing the entire rear axle upon their landing. Surprisingly, no one had suffered a head injury or been thrown from the vehicle, but our patient did have severe back pain and weakness of one of their legs. We did a CT scan that demonstrated an incomplete burst fracture of the L1 vertebrae, thankfully without any projection into the spinal canal, and very likely not the cause of the leg weakness as that was from a different level completely. We recommended bed rest overnight as the fracture was stable and would not require surgery, though they would have to travel back to Arusha in the morning and then home after several days as they could not possibly continue on their safari. Having the ability to rapidly assess patients for more serious injuries in these situations is certainly and essential service that FAME offers and there are many that are quite thankful for that.
