Creighton Telemedicine & Elephant Evisceration
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Each week, Creighton’s surgical team convenes to discuss cases and gain insight from one another. Often, depending on the case, the team will also invite relevant specialists to comment on the case and offer their expertise. This week, the FAME team was invited to join the weekly meeting via teleconference. Dr. Kelly, our Global Surgery Fellow from Creighton University, facilitated the call with her colleagues. She had sent the FAME team a presentation featuring several cases we had seen during her time in Tanzania, including tropical pyomyositis, reactivated latent TB, and a dramatic trauma case of a young man who had been gored by an elephant.

The Creighton team presented the cases and asked for input from Dr. Kelly and a few surgery and tropical medicine specialists. On the FAME side, we had nine of our doctors present and one of our radiologists. It was very rewarding to be able to swap ideas and discuss these difficult cases in real time with doctors on the other side of the map. Additionally, it was exciting to be able to see our Creighton colleagues and conduct  question and answer sessions as if we were all seated together around the table in our small conference room in Karatu.

Both teams greatly benefitted from the experience.  We were able to learn new treatment methods and hear diverse opinions, while also being able to teach our Creighton colleagues what it’s like to work in rural Tanzania.  On several occasions, our doctors had a good snicker when we were told to use a type of advanced equipment as an interventional tool when that tool does not yet exist in Tanzania’s medical setting. Dr. Kelly was very open about what resources we have here and how practicing medicine isn’t as simple as it is in the US. We were grateful for the opportunity to share the reality in which our doctors and nurses must work each day. 

The surgeons were nearly speechless when it came to discussing the last case – a patient eviscerated by an elephant tusk. The director of the Global Surgery program, Dr. Philipi, ended the conference saying the experience was “illuminating to many people in this room how limited your resources are.” He praised the FAME team for caring for patients at the level we do even without all the newfangled equipment they have access to in their hospitals.

 
Kathrine Kuhlmann
A Day at FAME Medical, Karatu, Tanzania

By Volunteer, Dr. Todd Sack

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8/2/2019 Fri: FAME Day 20:  Ulcers:  At Morning Report, we learned that the Maasai baby with pneumonia also has hepatitis (Aspartate Aminotransferase 830) likely due to village herbal treatments. I went back to her room in the inpatient ward later with Kitashu, our Kimaasai translator, to caution her not to give herbs to her family. We discussed an 81-year-old diabetic woman with diarrhea and mild sepsis; a woman with ascites whose abdominal CT by Barbara, my wife and radiology volunteer, seems to reveal TB peritonitis; and a man who traveled 10 hours to us for care of a dental abscess and is doing well after a FAME doctor drained a cup of pus from under his right jaw this week.

During an endoscopy, I found benign duodenal ulcers in a 21-year-old man with five years of epigastric pain. These likely are caused by Helicobacter pylori, themost common bacterial infection in humans. A man in whom I found a large stomach ulcer last week came back and was admitted because he is still vomiting. We hope that he’ll improve if we administer his medicine intravenously, but we also fear that his failure to improve may be because he has stomach cancer rather than a simple ulcer. Unfortunately, we cannot routinely do pathology testing of endoscopic biopsies due to the cost.

Every patient in clinic today seemed to come in with one problem but more emerged. A minor stomach upset was also accompanied by a urinary retention from prostate disease and a massive forearm lipoma. A bad cough was accompanied by low back problems and charcoal stove-induced chronic lung disease (the #1 cause of lung disease in African women). I spoke with a woman with cough, fever, upper abdominal pain and mildly abnormal liver blood tests.  After blood tests and a normal ultrasound by Barbara (it’s fun working together), I prescribed doxycycline for possible Leptospirosis.

A 41-year-old man came to the ER very weak with a blood pressure of 75 systolic and distended abdomen.  Within minutes and before any of his blood test results were back, Barbara had done an ultrasound (necrotic liver masses), I’d done a paracentesis (blood-tinged ascites), and antibiotics were given for liver abscesses.  These cases were a small part of a very busy, fascinating day.

There were lots of good-bye hugs from nurses, doctors and technicians, as our three weeks end tomorrow.  Barbara and I had a nice vegetable curry at our house, with a South African Pinotage. We stepped outside into the cool night for a spectacular sky of stars. We look forward to returning to Karatu and FAME Medical next year.

 
Kathrine Kuhlmann
Versatility and Collaboration at FAME

By Volunteer Saja Erens

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One of the first things that struck me at FAME was how versatile the Tanzanian medical staff is. At one moment, you will find them doing a complicated surgery, the next moment they are assisting a delivery, managing a premature baby, dealing with a psychotic patient, or treating a child with a severe viral or bacterial infection. In the relatively short period I stayed as a volunteer, I saw quite a lot of interesting, sometimes “exotic”, medical cases and I learned a lot about conditions I had no previous experience with.

Sometimes we had puzzling cases and had to put everyone’s knowledge and efforts together to find the right approach. For example, we had a case with a pregnant lady who presented herself with severe joint pain and diabetes. We tried different medications that were available, but to no avail. One of the volunteering internists suggested Sulfasalazine, which became accessible at FAME with the help of the pharmacy staff. It finally relieved the patient’s pain and we could see her smiling again.

Another great example of the collaboration at FAME was when we received a pregnant woman who had been rushed to FAME due to complications. The doctors in charge were very fast with diagnosing her with an erupted ectopic pregnancy and even faster with rushing her to the operating theatre and saving her life. Other available staff members responded quickly in finding blood donors and stabilizing the patient after the operation. I was very proud of the staff involved and how they handled this emergency, from the first call to the hospital to the aftercare by the nurses, and the way everybody tried to help the husband cope with this rather traumatic experience. With the entire team working together, I encountered a passion for making both the patient and their families feel better.

 
Kathrine Kuhlmann
A Hectic Day in Neurology Clinic

By Volunteer Dr. Mike Rubenstein

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Over the last several years, we have come up with a pretty good system for just how to schedule our neurology clinics during each of the months that I am here with the residents. We knew that to build the program we would have to come on a recurring basis (hence the visit every six months) to develop a trusting relationship with the clinicians here and the patients and families who come to see us and appreciate our care. Back in 2011, we had also developed the Neurology Mobile Clinics to serve some of the more remote areas of the Karatu District. This model seemed to work very well: The clinics were very well attended, and patients, who wouldn’t normally come to FAME for medical care, could continue seeing us in the villages, while also having access to FAME if necessary. What began in 2010 with my teaching the FAME clinicians how to do a neurological examination for patients, has now evolved into a well-organized, month-long clinic attracting nearly 300 patients each time we visit.

Our visits are now comprised of an approximately week-long, clinic that we do here at FAME, a week of mobile clinics that entail travel to more remote villages in the district, and then several days of clinic back at FAME, where we see follow-up patients or patients who missed us the first time around. News of the clinics, including the mobile clinics in the villages, is well disseminated to the community by FAME staff. They travel throughout the district announcing our arrival a month in advance and inform potential patients of the types of disorders we treat. In addition, FAME’s social worker, Angel, has a list of patients who had visited FAME in the time between our visits with neurological disorders and would need to return to see us.

 

The first few days after our arrival are reserved for those patients Angel will call. This structure allows the new residents to get a good feel of how things run here. Every patient is seen with an interpreter (who might also be a clinician) or possibly two interpreters if the patient doesn’t speak Swahili, which is not uncommon among some of the local Iraqw and Maasai populations. The medications we use are limited and some are different than those we have in the US. The doses are different than what we are used to and the options for testing are considerably different. Additionally, the types of therapies we have at our disposal are much more limited than those in the US. However, in the end, it is still mostly the same disorders we are treating here, though the differentials may vary quite a bit. The principles of medicine are still the same, and it is all a matter of taking a good history, performing a good examination, and developing your differential. It is actually medicine the way medicine was meant to be practiced – an all too uncommon event in today’s world.

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Today was our first announced day and what we encountered outside the emergency ward (having been taken over this month to be our neurology clinic) was a bit of a mob scene, with patients everywhere waiting for Angel to get them registered. They would then proceed to have their vitals taken so we could begin to see them. Our first patient at morning report was a young gentleman, who had arrived during the night with new onset left hemiplegia following left neck pain. He was also found to be HIV positive – a new diagnosis. He would need to be seen in consultation by one of the residents.

We had three exam “rooms” for patient visits, and I told Angel that we could start by registering thirty patients for the day, as I knew we would inevitably see more than that. Later in the morning, the residents suggested setting up a fourth station to see patients waiting in the hallway adjacent to one of the other stations. So, it was with this arrangement that we began to plod away seeing patients for our first “announced” clinic day of the season. The number of patients we would see would quickly increase well beyond the thirty we had originally registered.

Ståle, a gentleman who runs a home in Mto wa Mbu and whom I have known for several years, came this morning with his car full of neurologically impaired children. Somehow, he has been tasked with caring for a number of young men with muscular dystrophy, most of whom we diagnosed and have treated for several years. He brings all of them on the same day packed into his Land Rover with their wheelchairs tied to the top.

Every resident who has met Ståle and the children he cares for has been changed for the better after seeing the dedication he has to these kids and the wonderful outlook these children have, despite knowing the condition they have and what the future holds for them. With this in mind, we saw all the kids, most of them with Duchenne’s muscular dystrophy, and continued on with our incredibly busy day.

One of his young boys, who had recently moved to Ståle’s home and had been assumed to have Duchenne’s muscular dystrophy, was clearly different from the other children. I saw him with Amisha, a neurology resident from Children’s Hospital of Philadelphia, and, unfortunately, we really had no history as the boy couldn’t give us any and Ståle had no family members to contact. The boy was unable to walk, but had no pseudohypertrophy of his calves and the majority of his atrophy was in his shoulders and arms. He also had some mild wasting of his temporalis muscles. Given this constellation of findings, it became clear to us that he had either fascio-scapulo-humeral or limb-girdle dystrophy, both of which have a tremendously better overall prognosis than Duchenne’s as they have a normal life span, albeit with significant disability. Still, it was a bit of good news we were able to relay.

Finally, in the midst of our incredibly busy clinic, I found that a patient had been brought in to see us on a stretcher and was promptly placed in the emergency room. Dr. Gabriel had mentioned to me previously that there was a patient he wanted us to see (and appropriately so), who had been in the hospital here in July with presumed encephalitis and wasn’t recovering. Unfortunately, after bringing the patient in, he promptly began with focal seizures that appeared to be epilepsia partialis continua – something that can often be difficult to treat. According to his family, the seizures had begun about a week prior and were essentially occurring on a regular basis. His original presentation was such that he was found unresponsive by his family at home and then had been brought into a local hospital where he remained unresponsive for about another 48 hours before being transferred to FAME. Here, it was clear that he had an encephalitis and underwent an LP and was placed on antibiotics and acyclovir. He eventually had a CT scan showing numerous large early hypodensities in the brain and more specifically, the bilateral temporal lobes, the most common location for injuries that occur in herpes encephalitis.

He had been treated with a 21-day course of oral acyclovir, but had never really woken up. He had also been placed on carbamazepine for his seizures, but at a relatively low dose considering the injuries to his brain and his propensity to have seizures for the rest of his life. As he lay on the emergency room gurney, unresponsive with continuous jerking of his left face, arm and leg, his family stood by patiently awaiting our input and whether we had anything at all to offer their 28-year-old family member. There was no issue with handling the seizure part of the equation, but having our very own infectious disease specialist here was certainly a blessing. We have no confirmatory tests here such as a PCR on the spinal fluid, so the diagnosis would be based on the clinical features that were quite suspicious for HSV encephalitis with treatment that had been delayed by at least several days. Herpes simplex encephalitis is something that must be treated immediately upon consideration of the diagnosis, as the virus rapidly multiplies and the damage it causes becomes more extensive. It is also irreversible once it occurs. The mortality rate for HSV encephalitis can be very high even when treated and the morbidity is great with chronic seizures and very common severe cognitive deficits.

We had to tell the family that he would not recover any of his function and would almost unquestionably remain unresponsive if he did not succumb to some complication. Yet, we could possibly improve his seizures by increasing his carbamazepine and, if that did not work, we could add phenobarbital later.

Our other patients were the typical mix of epilepsy, Parkinson’s disease, headaches, and back pain, to name but a few. Thankfully, we had no plans for the night as we had seen a total of 42 patients – the largest number we had seen in a single day.

 
Kathrine Kuhlmann
Back to School: Hosiana Update!
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When I walked past the wards after our daily morning patient report meeting, there was an unusual amount of commotion and excitement. As I poked my head in, I saw a sweet, familiar face I hadn’t seen in some time. Our nurse Hosiana was back, visiting us from Huruma School of Nursing in Moshi, and everyone was excited to hear all about her experience. She had a short break between semesters and had decided to return to FAME to briefly volunteer before visiting her family and then heading back to school. “I missed FAME, that’s why I wanted to come before going back, even if just for three days,” she told us.

With support from one of our funders, the Brethren Community Foundation, Hosiana enrolled in a year-long  program in 2018 to upgrade from Enrolled Nurse to Registered Nurse. She is really looking forward to second semester because she will be studying midwifery, which she’s really passionate about.  

Hosiana has been performing incredibly well in school. She received all As this semester and hasn’t had any challenges. “It wasn’t easy,” she said, “but having the support from FAME makes me study hard. I don’t have to worry [about fees], so I feel encouraged to study my best.” She’s excited for this coming semester and knows she’ll continue to make FAME proud.  

Hosiana feels very comfortable at school and has enjoyed being exposed to different environments outside of FAME. However, she still misses being with us in Karatu. As she noted during her visit to FAME, “I’m a good ambassador. I keep saying, ‘we provide the best care ever.’ We are super good.” We are all looking forward to having her back on the team in six months!

 
Kathrine Kuhlmann