With the new group having arrived, it is always tradition to have everyone introduced at morning report on Monday as the entire FAME clinical staff – doctors, nurses, laboratory personnel, radiology techs, and anyone else dealing with patients – would be in attendance. We would be shy one less resident for the second tour, though thankfully we had a pediatric neurologist, Harry McAdams, for the three weeks given that a full third of our neurology patients are pediatric, and that includes a great many neonates with a great number of those having suffered hypoxic-ischemic encephalopathy (HIE). I’m perfectly happy dealing with childhood epilepsy or headache, but having to evaluate neonates was not something I did during my many years of practice.
Joining Harry would be Geena Ianni and Maria Melendez, both adult neurology residents and, coincidentally, both pursuing fellowships in neurocritical care. Though that isn’t specifically an area where we have a lot going on here at FAME, at least as far as an actual neuro intensive care unit (NICU), or even a medical ICU, we do have more than enough critically ill patients in each of our wards to keep anyone interested in critical work busy for as long as they would want to be. The key limiting factor here is that we don’t have ventilators on which to place patients for any extended period. At home most of the NICU patients are intubated and ventilated, and when there’s no longer a need for that level of care, they are transferred to a stepdown unit or to the floor. We have ventilators to use in our two operating rooms, but if we used them for anyone else, it would bring our busy surgical program to an immediate standstill.
Until this week, if a critically ill patient who was intubated required transport to Arusha or Moshi, two and three hours away, respectively, it would require that someone bag the patient for the entire trip. Amazingly, we were just loaned a portable transport ventilator for this specific purpose by the Meserani Snake Park and Clinic (more below), a nearby facility with reptiles on display that also works tirelessly to treat venomous snake bites by distributed multivariate antivenom to health facilities as patients would usually not survive if they were required to arrive at a tertiary center for initial treatment.
Monday was once again time for the residents to get their orientation to FAME and how our neurology clinic would work. Since there were only three residents, I would have my own desk to work at where I could watch the patients pass by on their way to seeing one of the resident teams and I could form an early impression just by observing them. Much of neurology is observational and our neurological examination is used to prove or disprove the hypothesis that we’ve generated following the history that we take. I would now get a sneak preview by observing the patient walk by me – noting a spastic or parkinsonian gait is something that we’re trained to recognized and the exam is used to confirm our initial thoughts or direct us back to the drawing board.
After a quick tour of the FAME Hospital compound, it was time for EMR instruction before the residents would start seeing patients in the afternoon. Prior to September 2020, all patient records at FAME were on paper and each patient had their own physical chart – there was a database, of course, but it was only for patient demographics and information as opposed to containing a running account of the patient’s clinical record. After institution of a true EMR here, all patient records could be reviewed without having to pull their physical chart, though unfortunately, the old records weren’t able to be scanned into the EMR as that was far too labor-intensive to have been undertaken.
The purpose of the EMR was not only as a repository for patient records, but it also served to provide the necessary reports and data necessary to provide for grant opportunities and for potential or current funders of FAME. Last March, as the original EMR proved insufficient in providing the necessary reports and information, a new EMR was introduced and required additional training for everyone at FAME. Thankfully, the residents are incredibly quick learners as I have purposely avoided knowing too much about the inner workings of the EMR and can honestly claim ignorance to nearly all the questions asked of me. Dr. Annie and our wonderful translators do most of the education, though we also have several IT FAME staff members who help answer questions the residents may have.
The first few days of clinic for the new group were surprisingly slow, and it worried everyone that perhaps the first group had completely stamped out neurological disease in the Karatu District (a very unlikely proposition). I reassured everyone that there were many factors that affected the number of patients coming to clinic – such as weather, planting, harvest, market days, just to name a few – and that it was often impossible to predict the clinic volume. On Tuesday morning, the Meresani Snake Park staff came to FAME not only to present us with the transport ventilator previously mentioned, but also to provide important updates to the snake bite algorithms used at FAME and elsewhere across Northern Tanzania.
The World Health Organization (WHO) has recognized snakebite as a Neglected Tropical Disease and the number of snake bite deaths is vastly underreported in regions such as Sub-Saharan Africa given the rural nature of the regions where most of these incidents occur. The WHO currently estimates that between 20,000 and 32,000 people die from snakebites in Sub-Saharan Africa alone, with a far great number of limb amputations and lifelong disabilities. The number of highly venomous species in East Africa is staggering, with snakes such as the black mamba, the black spitting cobra, and the puff adder being among the most feared and most deadly. Though the need to be certain about which snake was responsible for the envenomation of the patient remains extremely important for the purpose of treatment, the availability of polyvalent antivenoms (effective against many types of toxins) has greatly reduced that concern. The clinical features of each of the toxins – neurotoxin, hemotoxin, and cytotoxin – are all unique to each, and the talk this morning discussed those various aspects. Having a particular interest in reptiles since childhood – my brother and I used to catch and release all sorts of lizards and snakes, some venomous, when we were young. This later carried over to our family owning a pet shop for a few years when I was a teenager and is probably in part responsible for my daughter, Anna, becoming a veterinarian.
Having finished patients a bit early on Friday, I offered to take everyone on a hike down to the brick quarry below FAME, and then all the way up to Tloma Village. Given the nature of the soil here – a dense red clay – which seems to be perfect for making bricks, there are numerous quarries of various sizes throughout the communities here, where standard bricks for building houses are produced and sold. The quarry below FAME happens to be one of the larger ones around. The clay is first carved out from the sides of the quarry and then formed into bricks that are spread out on the ground to dry in the sun. Once dried, they are stacked leaving small spaces between them forming large square structures that may be over ten feet high and equal in both length and width with some even larger. There are one or more openings in the bottom of the stack that are used as fire boxes and are filled with wood logs. The entire structure is then plastered with a mixture of mud and cow manure that once dry will keep all the heat from the fire boxes contained within to fire the bricks into the final product.
As we hiked through the quarry and up the other side, we greeted the workers toiling on various stages of the brick making process and eventually climbed up the other side where we attracted plenty of local residents and numerous children curious as to what we were doing since walking for exercise or pleasure wasn’t something often practiced here. The local residents may walk to work and walk home, but no one walks for the sake of walking. We were on a bit of a mission, though, as I hadn’t realized what a coffee fiend Geena was until now, and the fact that the house was completely out of ground coffee was just not something that was acceptable. At the far end of our planned walk, though, was Phillipo’s house and an endless supply of the very best coffee as long as we could make it there before dark.
It was getting later than I had anticipated given the number of town’s folk who wanted to say hi or have their picture taken with us, and none of us had brought flashlights other than our cell phones. As we turned the corner in Tloma Village, heading in the direction of the coffee farm, the sun had almost set, but there was Phillipo, walking down the road in our direction. He was only too happy to turn around and escort us back to his place so that we could purchase several bags of ground coffee for the house and avoid a disaster. Walking back home, though, was another matter. By the time we reached the quarry, it was already very, very dark which meant we had to climb the rest of the way home being incredibly careful not to trip along the way. Everyone made it safely, and best of all, Geena had her coffee for the morning.
