Traveling Through the Countryside

By Volunteer Neurologist, Dr. Michael Rubenstein

One of the unique aspects of our bi-annual Neurology Clinic is the team’s mobile clinic outreach that they provide for villages surrounding Karatu. Below are reflections on their experiences for their four outreach clinics last month:

 
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RIFT VALLEY CHILDREN’S VILLAGE: Our outreach began in the village of Oldeani at Rift Valley Children’s Village (RVCV). India Howell (Mama India) founded the children’s village in 2004, and over the years, they have continued to grow such that she now has nearly 100 children that call this their home and call her Mama. She has partnered with the community to improve their schools by helping to fund certain programs and she has offered healthcare to the residents of the surrounding community, as they knew that a healthy community would only improve the chance of success for their children. It was on the backdrop of India creating her children’s village in Oldeani that Frank and Susan ultimately decided to locate FAME here in Karatu, allowing them to be in close proximity to India and her children.

After morning report, we all loaded up and began our drive towards the village of Oldeani along a lovely route through cultivated fields and eventually arriving at the coffee plantations surrounding the children’s village. Driving into the parking circle in front of the administrative offices, there is a huge gathering of patients sitting on benches and waiting to be seen. Our first thought is how we are possibly going to see all these patients in one day, but we were relieved to find that the attendees are not all neurology patients as RVCV’s nurse Gretchen was seeing patients today in their regular clinic. Still, there are quite a few patients for us to see so we make sure with our social worker, Kitashu, that the patients are going to be properly screened. Triage, though, it really tough. At FAME, it’s easy for us to send them over to the outpatient department. Here, they would have to see Gretchen and she was definitely going to be a bit overwhelmed today.

Many of the patients here we’ve seen before, some for as long as I’ve been coming. We see some of the children from RVCV with epilepsy or ADHD, but there are more patients from the community that are seen. We usually see a larger percentage of epilepsy patients here than at other clinics, but otherwise, there is the typical smattering of diagnoses. Several of the patients are new to the clinic and we’ve diagnosed them with chronic illnesses, such as epilepsy, and they will require continued medications going forward from the clinic at RVCV. We had planned to finish early, but somehow the time got away from us and clinic stretched to after five.

KAMBI YA SIMBA: Kambi ya Simba is a small village in the Mbulumbulu ward of the Karatu District and about 45 minutes from FAME. It is a totally self-contained clinic, meaning that we bring all of the medications we will prescribe to our neurology patients and all of the tools that we would need to provide our care.

The drive to Kambi ya Simba took us through extremely fertile farmlands past the Rhotia valley and on to the Mbulumbulu ward. Despite the dry season, there is quite a bit of green as we meander through the hills in this area that sits at the top of the escarpment of the Great Rift Valley and continues until the mountains of the Ngorongoro Highlands meet the drop off and the road ends.

As we arrived at Kambi ya Simba, it was evident that the new dispensary has continued to grow even in the last six months since I was here last. In addition to the large number of buildings that are here now, they have rebuilt the original dispensary that we had begun to work in and now there is a covered arcade connecting everything. There is even an area to drop patients off who are arriving by car or motorcycle. Amazingly, a large number of patients arrive at the clinic on the backs of the motorcycle taxis called piki-pikis. Watching a nearly paraplegic patient load onto one of these as one of two passengers, in addition to the driver, can be a bit nerve-wracking to the say the least.

At the clinic today we have a smattering of return and new patients who all have to be screened for neurological disorders. Our purpose here is not to supplant the government medical staff here providing care, but rather to work with them and provide specialty care that would not otherwise be available in most of Northern Tanzania. These clinics allowing us to practice in their community is not something that is merely a given, but rather a sign of trust that we respect.

Before lunch we had seen our general mix of patients, with headaches and epilepsy, along with a few arthralgias, and still had several patients to get to after lunch who had showed up through the morning. The last patient we saw, though, was perhaps the most complicated. He was a gentleman in his thirties who came to see us in a wheelchair because he was unable to walk due to lower extremity “pain.” It turns out that this gentleman has lost most of the use of his legs, with no effects in his upper extremities, about ten years prior and hadn’t been evaluated medically for this condition.

His examination was myelopathic (meaning that he had a problem somewhere in his cord) as we surmised even before Lindsay, one of the U Penn residents, had first tapped on one of his reflexes. The process, though, had occurred gradually over several years and was purely motor-related as the predominance of his sensory examination was fully intact. Without a sensory level, though, we were unable to tell exactly what level in the spinal cord we were dealing with, but it was clearly thoracic in nature. Having purely motor-related findings is more the exception than the rule. There was little else we could come up with for this gentleman and, perhaps more importantly, nothing that we could do to make him better at this late date. Though we tried to explain to him what our thought processes were, in the end, the answer was the same, that very little could be done other than to make him more comfortable by using a medication such as baclofen for his spasticity which we prescribed.

We left Kambi ya Simba in the mid-afternoon to make our way slowly back to Karatu, once again traveling through the gorgeous countryside that we had traversed earlier in the day.

 
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QARU: The drive to Qaru is less than 45 minutes and is on a main thoroughfare, albeit gravel, as there are very few paved roads other than the main highway traveling from Arusha to Karatu, as well as the road that travels east from Makuyuni towards Tarangire.

It is important to understand that the purpose of our neurology mobile clinics is perhaps less to provide care for patients who cannot reach FAME, but rather to bring the concept to them that neurological diseases can be treated effectively. The villages are not so remote that their residents are unable to get to a medical facility capable of providing treatment; rather their illnesses are often just accepted as part of their life. This can often be most impressive for patients with epilepsy where it is merely a matter of placing them on the right medication and they can be seizure free or at least nearly so. Epilepsy carries with it a huge social stigma, which results in severely limited access to adequate medical care in countries like Tanzania. The percentage of these patients who are treated is appallingly low – in the range of 10%. It can be so rewarding to see one of these patients who has never known a life without seizures become seizure free with a simple medication. Thankfully, many of the patients we see are young children with epilepsy and we are able to place them on the appropriate medications at a much earlier age.

At Qaru, the number of patients waiting for us was rather small – a common occurrence at the mobile clinics. We do advertise the clinics much the same way as we do for those we hold at FAME (where we are always packed), but since we’re at each village only one day, if that happens to be a day of planting or harvest or your cow has run away, then you may not be able to make it. There were several new patients with epilepsy and a few follow-ups, as well as our normal smattering of patients with complaints that we couldn’t necessarily attribute to an underlying neurological process.

UPPER KITETE: It was off to Upper Kitete for the day, a trip of less than two hours, but out to the far reaches of the Mbulumbulu area and the top of the escarpment where one can travel only a few kilometers further before running out of land. We took the same road we use to get to Kambi ya Simba and then continue beyond for an equal distance making it almost twice as far as the closer village.

We arrived at the Upper Kitete dispensary only to find a huge gathering of patients that were thankfully not all for us as it was also their well-baby visit day. After some negotiation with the clinical officer here, we eventually ended up using the two offices that we normally use (the nurse’s office, otherwise referred to as the bat cave for the distinct smell of guano coming from the opening in the ceiling, and the labor and delivery room that was not currently being used), along with the outside area that we normally use as our pharmacy, but would now serve as our third examination room. The pharmacy was bumped to the end of the outdoor walkway and we just moved all of our patients to the other side of the building to wait for us so as to maintain some sense of privacy.

We got through our patients, though, and had our lunch around midday with still a few stragglers to see afterwards. One of our later patients was a gentleman who was brought to us sitting in a chair (not a wheelchair). We were told that he had been unable to walk for well over 10 years. His examination was myelopathic, suggesting some sort of cord problem, and we felt he most likely had a cervical myelopathy as it had been gradual in onset. We discussed the possibility of an evaluation, but were realistic with him: We noted that it was very unlikely that we would find anything that would be treatable at this late stage and, therefore, it would not benefit him functionally. The family understood and we did treat him with some baclofen for his spasticity, which was the least that we could do for him. As with our patient at Kambi ya Simba who was also paraplegic, he was eventually helped onto the back of a motorcycle by his sons and began his trip home. Not long after, we also loaded up and headed home, finished with our mobile clinic outreach for this season.

 
Kathrine Kuhlmann
This is Why I'm Here

By Volunteer Nurse Barb Dehn

 
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I was standing by the side of an old metal gurney covered in a thin blue pad, holding a small child’s hand. This little boy lived so far from any town or village that he had not had any health care or treatment for a common skin condition that had started four years earlier. His father had carefully explained how the rash started out on the top of his head and was only the size of a small coin, but over time had spread to cover his entire scalp, neck and the side of his face.

What began as small and yet common fungal infection, tinea, was now infected with another infection, oozing and painful, that had completely changed his appearance. The other children in the village made fun of him, so he only went out wearing a borrowed hat, which had never been washed and caused the condition to worsen. 

When we first met, his head was covered in a blood-soaked bandage and he was using an old green cracked mirror to try to see how he looked. I wondered how I might help and later returned to visit him with a few gifts. For some reason, I had slipped a few small handheld folding mirrors in with all the medical supplies I brought to FAME, figuring some of the people in our community might find them useful.

I also had with me a large bag filled with hundreds of colorful Coban self-adhering stretch gauze bandages. I had every color in the rainbow and every size with me when I went back to see him.

He liked the green bandages best and so, through a translator, we decided that I should come with him when his bandages were changed. Because it would be a painful procedure, he would be receiving intravenous anesthesia and pain medication from one of FAME’s nurse anesthetists, Teddie.

I was smiling as I watched the small group of Tanzanian nurses gather the anti-fungal cream, the special yellow gauze and the other supplies. Dr. Badyana and Dr. Jackie, both Tanzanian physicians from FAME, discussed how they would carefully remove the infected skin so that new healthy skin would regrow. 

I was smiling because my job was not to do the procedure or to advise or to interfere. My job was to hold a little boy’s hand and my privilege was to observe what a sustainable hospital and clinic really is. FAME’s highly capable staff of local doctors and nurses were doing what they do every day, day in and day out, 24 hours each day, 7 days each week, providing excellent health care in a remote and rural part of Tanzania. As I watched the dressing change, it occurred to me that this was why I’m here. This is why I am so passionate about raising money and bringing supplies, working on projects and recruiting people who can mentor and share knowledge with the providers at FAME. 

The oxygen tubing he needed to breathe through and the special yellow gauze came out of my suitcases just two days before, not to mention the bright green bandages. It was all necessary to support FAME’s mission – providing patient-centered care to the community. 

If you’re inspired by the care FAME provides in rural Tanzania, near the Serengeti, I hope you’ll consider making a donation directly: FameAfrica.org

 
Kathrine Kuhlmann
Continuity of Care

By Volunteer Tracy Hoffstetter

 
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My opportunity to engage at FAME came at the invitation of my aunt, Dr. Kim Hall FNP, DNP and the generous approval of Dr. Frank Artress and the volunteer coordination team at FAME.

I have been a registered nurse for 30 years with a specialization in neonatal intensive care for the last 21 years, but have never had the opportunity to serve anywhere abroad. This prospect was so exciting for me and I began my experience on July 30, 2019.  I really had no idea what to expect and was a bit worried that I would not bring anything of value to the table.

What I discovered very quickly was that FAME is an institution of inpatient and outpatient care that covers the entire age and wellness continuum and is staffed by highly trained and experienced staff.  Everyone was so warm and welcoming on my first day of reporting for work. That first morning, I participated in the medical inpatient rounds even though my area of interest is newborn medicine. All the mother/baby action happens when we reach ward 2, the Maternity Ward! This ward staff can do it all!!! They labor mothers, deliver babies, resuscitate and assess newborns and provide post partum care for the maternal/infant couplet after delivery.  Additionally, they are so kind and welcome the collaboration of the ever-changing rotation of volunteers.

On my first afternoon, I was invited to attend the last stage of labor and the delivery of a mother’s first baby. After an uncomplicated labor her full-term baby girl was delivered. The newborn assessment was perfect and the baby was placed with her mom to do all of the normal baby things!  When I saw that mother the next morning during rounds, I smiled at her, greeted her, and told her that her baby was pretty and doing well in my “best” Swahili. She rewarded me with the warmest smile of recognition! As her delivery and post partum course were uncomplicated, she and her baby were discharged after the second day. I treasured the brief connection that we had made.

The next week of duty flew by and I continued to be impressed by the level of care demonstrated by the staff of ward 2. On August 6th was the weekly “Well Baby Day” clinic and I was able to attend this under-five clinic where the new babies receive a check up and their vaccinations. I walked in to find a room full of mothers and babies of various ages waiting to be seen. In that crowd of faces was that same warm smile of recognition that I had seen in the ward the previous week! She was in the clinic to be seen for her one-week post partum check, baby assessment and breastfeeding support.  

What I discovered was that FAME serves the greater Karatu community with a comprehensive prenatal/post partum follow up clinic which provides breastfeeding support, family planning services and five years of well child care in one inclusive package. This continuity of care lays a tremendously strong foundation for a healthy community. Strong, healthy families equal strong healthy communities! FAME is making that happen and the word is getting out.

It is difficult for me to articulate the nuances of all the things I have seen and done. I arrived at FAME with a desire to make the most of this ONCE in a lifetime experience. But if my heart has its way, this will just be my FIRST in a lifetime experience. My deepest heartfelt thanks goes out to all of the wonderful staff and other volunteers at FAME whom I have had the privilege of meeting. Asante sana!

 
Kathrine Kuhlmann
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