Today is our final day here at FAME.  I've been waiting to be part of a delivery and I finally got my wish :).  Unfortunately, all deliveries that present to FAME are usually high-risk given their late presentation.  If the delivery was easy, it would be done unassisted at home.

Mom presented after 48 hours of laboring.  The baby was difficult to extract and didn't cry immediately.  After some help though, the baby is doing fine.  Mom is also doing well thankfully.  Practicing medicine in Africa while training in the US is really interesting.  In residency, you train by repeated exposure.  You've seen so many deliveries by the time you're done that it's ingrained in your memory.  Prolonged rupture of membrane --> needs rule out sepsis workup --> draw cultures and CBC --> start empiric antibiotics.  Those were the string thoughts running through my head after the baby was stabilized.

Then I stopped.  Everyone who presents to FAME has prolonged rupture of membranes, because only the most difficult cases come here after driving or even walking for many many miles.  We do not have the facilities to perform cultures here so how will we rule out sepsis?  CBC and CRP seem like good screening labs, but how do we interpret them in a newborn who's undergone the stress of prolonged labor?  All of these questions required much deliberation and together our team came up with a reasonable plan for this newborn.

FAME has been such a challenging and rewarding experience.  Practicing medicine without the same supplies you have at home requires creativity and utilizing all the resources you have available.  I am grateful for the small corridor in our clinic where we have internet access.  It has allowed me to keep in touch with the intelligent individuals I know back home.  Many thanks to their help with taking care of the patients here.

This will probably be my last post here in Tanzania as we leave for Arusha tomorrow and then fly home shortly thereafter.  Thanks for your interested in my blog.  Hope you had as much fun reading it as I had living it...

Remember those mornings when you would hop out of bed excited to see what the day would bring.  Usually they were while you were on vacation, but every once in a while you find yourself in a situation where it's impossible to stay asleep.  Since I've been in Africa, I don't think I've woken up to my alarm once.  Maybe once for our pre-dawn safari ride, but other than that my body rises well before the alarm rings, usually at the crack of dawn.  A wise resident once told me that if you find yourself jumping out of bed and racing to work, you've found you're true calling.  Everyday here is an adventure.  In fact, even after the work day ends, there's always more to come.

Many of the volunteers here say they work harder here than back at home.  Maybe it's cause the need is so great or that the work is so enjoyable.  Whatever it is, it seems to be contagious - you're never the only one up and ready to see what the day will bring.  In fact, sleeping in would probably be an anomaly.

Today was one of the best clinic days I've had by far.  I got to meet Stale, a Norwegian man, who found himself in Tanzania many years ago and decided to call it home.  The Maasai culture (see prior post) is a fierce one, and often times families find themselves fighting over a small quantity of food.  You can imagine that if you were a handicapped child, it would be near impossible to survive.  Stale found that when he would visit the bomas (Maasai villages - usually a circle of huts surrounded by fences), he would find children in the corner who hadn't been fed, clothed or seen the light of day since they were born.  He's adopted many of these kids and they come to see us on a biyearly basis.  He only adopts as many children as he can pay attention to - looking after their quality of life rather than looking for quantity.  Not only has he given these kids a fighting chance, it's obvious that they are well cared for cause you can see the joy on their faces.  You would think that seeing such devastation would leave these kids disheartened, but watching them today reminds you of the resiliency of the human spirit, especially in the young.  I wish I could share the feeling of a hug or listening to them break out into song randomly in the waiting room.  Unfortunately, all I can leave you with is this picture...and maybe the desire to do this yourself one day :)

Meet Grace.  I'm usually not a fan of singling out patients especially because so many of them have a heartwarming story.  There's no way to pick one, but an urgent situation has made me reconsider...

Grace Joel has been a permanent fixture at FAME.  She was diagnosed with acute lymphocytic leukemia at the age of 3 and has been receiving chemotherapy for the last 2 years.  She finished her induction therapy in the national capitol - Dar es Salaam and has been receiving her oral maintenance therapy here at FAME.  Like many children, she has a way of sneaking into your heart without you realizing how. She would hang out in people's offices and follow the staff home, smiling and giggling the whole time.  Grace has quickly became our 5 year old bundle of joy and many folks here consider her family.

Which is why when Grace began complaining of an increasing headache yesterday, we were all very concerned.  We assessed her and also spoke with the pediatric cancer specialist at Muhimbili this morning to discuss Grace’s treatment. She needs an urgent CT scan to rule out an acute intracranial process such as sinovenous thrombosis or an abscess possible followed by a lumbar puncture.  Unfortuately, we can’t do those things here at FAME, and even if we sent her to Arusha for the CT scan, they would not be able to perform the lumbar puncture to help differentiate whether her problem is due to worsening leukemia or an opportunistic infection. Either way, she has some intracranial process that needs urgent attention. She has previously been doing very well and has responded to her chemo, so this is a major setback.  

We can’t send her to Dar by public bus as she is neutropenic from her chemo and trying to fly her commercially will take at least two days to arrange. We contacted flying doctors, a medical flight service here who picked her up and took her to Dar where she will be taken by ambulance to Muhimbili, the government hospital and only place to receive oncologic care in the country. The cost for this trip will be 1.2 million Tanzanian shillings which converts to $1275 USD. FAME doesn’t have this kind of cash lying around in their budget and we’ve raised some of it here from volunteers, but I am also hoping that a few of my readers may also be able to help out with this. Flying doctors has graciously taken many of our patients without the fee upfront and we are grateful for their help. 

Any donations can be made directly through the FAME website at http://www.fameafrica.com and just make a note or send an email to them that it for Grace Joel. If you’d like to email me you can as well and I will keep you updated on Grace's care - payal1128@gmail.com. Life is so difficult here, but to have an illness like this would be difficult anywhere.

Thank you for your generosity!

The baby, the baby, the baby...

That was the cry heard from our safari vehicle as we watched a lion take down a baby zebra.  An exciting but gruesome end to our three day safari in the Serengeti.  We were really lucky to witness a successful lion kill - apparently one of the safari guides whose been doing this for 20 years has seen 100 hunts and only 10 kills.  I have everything on video to share when I get back!

We spent three days and two nights camping in Ndutu (southeast Serengeti).  Animals were so use to vehicles they would walk right up and sleep in our shade, including lions! We saw baby cheetahs, wildbeast, lions, zebras, giraffes, elephants and so much more.  And in the evening we would sit by a camp fire (we called it bush TV) and watch the stars.  You could see the entire Milky Way galaxy.  It was magnificent.

At night, you hear the lions roaring in the distance (I hope - I could never really tell how far away they were).  Luckily the camp had Maasai guards standing watch so I doubt anything would seek up on us.  A few weeks ago, a lion ate a goat that a 5 yo little Maasai girl was herding and she tried to beat it off with a stick! So fearless.  More stories on our adventures when I get back home, promise :)

Another record breaking day at FAME - 34 patients all seen via a language interpreter.  A few of the patients I saw today were followups from prior visits.  These patients always bring me the most joy because they often have had a good experience with the past visiting neurologist and are starting to see the benefits of their treatment.  In fact, most of the follow-up epilepsy patients have seen at least some improvement in their seizure frequency since our last visit.  A testament to the amazing work Mike Rubenstein is doing here.

It is very interesting to practice medicine in a culture so different from your own.  In fact, there are many different cultures and subcultures here in Northern Tanzania given the fact that Tanzania use to be a conglomeration of 280 separate tribes.  By far the most well-known group is the Maasai population.  The Maasai are a Nilotic group. They inhabit the African Great Lakes region and speak their own distinct language. The Maasai are famous for their fearsome reputations as warriors and cattle-rustlers.  They believe that God gave them rights to all the cattle in the world and in the past have used this divine right as a means to steal cows from other tribes.  Maasai's weapon of choice is a long spear, and they are known for their fierce determination to fight their opponents to their deaths.  Many companies have hired Maasai as bodyguards in safari areas as guns and ammunition are prohibited.  

Maasai are incredibly paternalistic.  They are a polygamous group with the head male independently making all family decisions.  In fact, in the presence of male Maasai members, females are not allowed to speak.  You can imagine that this makes getting the history on a female Maasai patient very difficult.  In fact, for one of our patients, our history required two different translators each one interpreting her events through her husband's eyes - so of course we got the wrong history.  Finally, after attempting to navigate this situation for a half hour, we were able to encourage the husband to allow his very young wife to speak to our female Maasai receptionist.  That simplified things tremendously and empowered our patient to take ownership of her own health - not to mention saved me from treating the wrong diagnosis!  It is incredibly complex and yet rewarding to work in such a unique environment.  You feel blessed to be able to interact with people in such an intimate way and witness the intricacies of their culture.

Just the fact that Maasai are willing to come to FAME is huge as the Maasai are very very traditional.   Infant mortality is so high amongst the Maasai that they don't give their children names until they are 3 months old.  FAME has done a tremendous amount of outreach and maintained cultural sensitivity in their clinics, which has resulted in good patient experiences. So, as they have recently opened a new labor and delivery unit, hopefully FAME's reputation as a respectful and trustworthy place will  do wonders for everyone in this community.  I'm excited to see how FAME will grow over the following years and am happy to be a part of the journey.  

It's been a busy 2 days here at FAME.  Our opening day neurology clinic was a big hit - we saw 34 patients total between the three of us!  Seventeen of them were pediatric cases.  I've been able to see health care in a variety of different settings around the world, and this is one of the few times that I've felt confident that we are making a difference.  In fact, I was blessed to see all of the good work my predecessor, Doug Smith, has done.  About half the patients with epilepsy that I saw in clinic yesterday were well-controlled on their medications!  It's a huge deal given the high risk of traumatic and burn injuries patients with epilepsy face in this setting as well as the significant financial and logistical barriers to care.

For more info on our work here (as well as an update on our patient from before) take a look at my attending's blog: Michael in Tanzania  He is far more diligent than myself about posting everyday.  Enjoy!

Here's an interesting case…

All my medically savvy friends let me know what you would do.  Feel free to post responses in the comments section.

Friday was our first clinical experience.  We started the the Rift Valley Children's Village and saw many kids with a variety of neurologic disease.  By far the most prevalent was epilepsy secondary to an acute event such as birth trauma or history of CNS infection.

In the afternoon, we were called to the bedside of a 16 mon old F (We'll call her J) who has had a history of a single simple febrile seizure a few months prior.  This afternoon she was in her usual state of health when she developed left sided face, arm and leg twitching in the setting of a fever to 104.  This episode lasted 20 min and resolved with rectal diazepam.  Following this, J was post-ictal with moderate left sided hemiparesis but was slowly improving - both from a mental status standpoint as well as her possible Todd's paralysis.  In fact, her left hemiparesis had almost resolved by the time I left her side 20 min later.  Our plan was to admit her to FAME clinic about 30 min away.  Approximately 15 min later, I was called back to assess a rash.  When I saw J, she had developed complete L hemiparesis and now had a new L visual field deficit.  She grimaces to pain on her left but does not withdraw.  She had not made any sounds since the event.  She was purposefully moving her right side and tracking objects to her right.  Her reflexes are 2+ throughout and toes are down going bilaterally.  There was no witnessed seizure activity prior to this change in her neurologic status - parents and RN were in the room the whole time.

We hopped in a van and headed to FAME.  Here is what we had available:
Most antibiotics in IV and PO form, most antiparasitics
Depakote IV and oral, Phenytoin IV and oral, Keppra oral, Phenobarbital oral and Trileptal oral
Diazepam IV

We can perform a STAT glucose, hemoglobin and malaria screen.  Basic labs (such as a CBC, BMP or LFTs) are also available but take 1-2 hours to come back.

The nearest hospital to obtain any imaging is 3 hours away.  Even if the technology is available, there is no guarantee you can get the scan given the logistical challenges you'll face when you get to the hospital.

So what do you do?  Which interventions would you recommend at FAME?  Would you drive to attempt to get imaging? (I did and it's a crazy story I'll post later)  On the drive over, what type of equipment would you carry with you?

I'll let you know how J did in a later blog post.  I'm interested to hear your thoughts.

Lala salaam (good night)