Chana with little patient on discharge day, after a very long healing process

by Chana Schaffer

It had just rained.  My morning walk was weighted with layers of thick red mud stuck like glue to the bottoms of my sneakers.  I had been at FAME for just over a month and I could feel my inner pace of life slowing with every sunrise and walking meditation each morning. The heaviness of my life in the U.S. seemed to lift with each layer of mud shed.  It would build, one, two, three inches thick on my heels, and I would excitedly wait for the step when it would all fall off and I would feel 10 pounds lighter.  What a relief.

Every day at FAME was different than the last.  The anticipation and unknown was similar to that which I experienced working in the Coronary Care Unit (CCU) at home.  Added cultural and language differences made it even more interesting and challenging.  I had already learned so much in such a short period of time; yet I had only scratched a miniscule area of the surface.

It was my last day and I was working in the ward with Safi, one of the many amazing nurses employed at FAME.  We admitted a young woman who was very lethargic with a blood pressure that is considered “incompatible with life”.  Dr. Luigi informed me that she had a large pericardial effusion- fluid accumulates in the sac surrounding the heart, putting pressure on the muscle and making it difficult for the heart to beat properly.  Dr. Luigi asked me if I knew how to do a pericardiocentesis- a needle is used to puncture the sac surrounding the heart and a catheter is thread over the needle so that the fluid can drain into a bag.  This procedure relieves the pressure and is often lifesaving.  In addition to the dangerously low blood pressure, the woman’s heart started to show signs that it was giving up.  Her heart rate would “brady down” (become very slow) and then speed up again.  Her heart was threatening to stop.  I knew that if we didn’t do something heroic and fast, the woman would die. 

Dr. Luigi and I found Dr. Frank and told him that we had a patient that needed a pericardiocentesis.  Dr. Frank heard the urgency in our voices, took one look at the worry on our faces, and came immediately to our aid. I have watched and assisted with this procedure many times in the CCU, so I thought setting up would be easy.  The nurses and I brought the crash cart into the room, gathered the sterile supplies and the ultrasound machine…but where was the pericardiocentesis tray?  It was time to get creative.  FAME has a lot of medical supplies available and at hand, but some specialty items are not readily available.  Everyone mobilized.  When something unfamiliar is happening at FAME, everyone (both nurses and doctors) is ready to step up to the challenge, learn quickly, and contribute any skills and expertise he or she has to offer.  The teamwork and sense of community never ceased to amaze me.  I felt so blessed to work side by side with such intelligent, resourceful, and caring individuals.  I always felt like I was learning far more than I was contributing.

With many hands at the bedside to help, Dr. Frank successfully performed a pericardiocentesis and drained almost 1200 ml of fluid that was compressing our patient’s heart.  The patient’s heart rate was still intermittently dropping, and the blood pressure remained dangerously low.  We began administering life saving medications, and I taught the nurses how to mix and titrate them to support the patient’s blood pressure and heart function.  It was a long night.

The nurses rose to the occasion and provided a high level of ICU care that was new to them.  Everyone worked together and supported each other to keep this woman alive, and we succeeded.  I was in partial disbelief when I walked into her room 3 days later (I came back to visit with my dad during our safari travels) and she was sitting up at the side of the bed talking to her husband.  The cardiac supportive medications had been weaned off, and the drain was removed.  The joy that I experienced after witnessing her recovery was unparalleled.  I knew that my knowledge and skillset, paired with unending support from my FAME colleagues, helped to save her life that first night. 

My time at FAME was profound.  The environment demanded self-reflection and growth in a beautiful way.  I was outside my comfort zone of fancy cardiac ICU monitoring and toys, immersed in a new culture, and trying to understand an unfamiliar language.  I was helping to care for patient populations very unfamiliar to me (i.e. burn victims, children, pregnant woman etc.).  I could feel the layers of self-doubt and hesitation shed with each passing day.  I realized that everyone was doing his or her best to provide excellent healthcare to an amazingly resilient community in need. 

By Women's Health Nurse Practitioner Kelley Brennan

I'm not talking about the near blinding lights and deafening cheers that signal Friday night high school football in the USA but rather the spot-lights in the Operating Room at FAME. Lights that bring just as much adrenaline and excitement, along with possibly even greater significance and life changing results. You see, we've spent three of the past four Friday nights performing life-saving cesarean deliveries. FAME opened its doors for Reproductive and Child Health, including a Labor and Delivery ward on the first of October. Since then we have saved six lives with the ability to perform emergency cesarean sections; something far too many women do not have access to in rural Tanzania.

On Friday, October 10, a woman arrived to see me in clinic, 15 days overdue with her first baby. At first, she simply said she wanted an ultrasound to see when her baby was due. But as I have learned while providing medical care in Tanzania for the past two months, you rarely get the full story upfront. The patients are strong and resilient and they don't want to worry or burden their doctors. It often takes quite a bit of questioning to get down to the real problem. In this case, the baby initially appeared active and full term on ultrasound, but there was virtually no fluid surrounding him. This young mother-to-be also had high blood pressure and protein in her urine, indicating pre-eclampsia, a potentially dangerous condition for mom and baby that can only be cured by delivering the infant and removing the placenta.

The patient was admitted and soon the baby was showing signs of distress. FAME's head doctor/surgeon, Dr. Mshana, and I made the decision to go for a cesarean section. This would be the first cesarean section ever performed at FAME. The patient was frightened, and rightfully so as surgery can be risky business in Tanzania. As Mama Mshana, one of FAME's extremely talented nurse midwives, consoled her, the patient revealed the full story as to why she had travelled several hours from her home in Ngorogoro to be seen at FAME. Shortly after sunrise that morning, she was walking near her home and was charged by a Cape Buffalo. These massive animals can be quite dangerous and aggressive. As this terrified young woman ran for her life and the life of her baby, she fell twice, landing on her swollen pregnant belly. This trauma provided even more of a reason for an overdue baby, lacking enough amniotic fluid, to be in distress.

At this point, the patient was rushed into FAME's operating room, which is remarkably well equipped. You'd almost believe that outside of those OR doors you'd find a large, well funded, stocked and supplied hospital in California or New York or Boston, and not a small, rural hospital in Tanzania. Dr. Mshana, an amazing doctor and surgeon with decades of experience, performed the operation with my assistance and the assistance of his wife, Mama Mshana, who acted as our scrub nurse. We were tremendously fortunate to have both FAME anesthesiologists, Sehewa and Doctor Frank, at our disposal along with Siana, the head nurse, Chana, a nurse volunteer from Washington DC, and Dr. Doug, a volunteer pediatrician from Philadelphia. Under the glowing OR lights, on a beautiful Friday evening, this young woman had the very first cesarean section at FAME. Dr. Mshana and Mama Mshana worked as a well oiled machine; you'd never know it had been a few years since they'd last performed a cesarean section.

This patient was complicated. She'd suffered a trauma on top of being pre-eclamptic; her baby was 15 days overdue and surrounded by almost no fluid, covered in meconium and clearly in distress. After delivering the infant, a baby boy, we noted that the placenta had abrupted, starting to separate from the wall of the uterus and soon the patient was hemorrhaging. Due to the talented and dedicated staff at FAME, along with the availability of necessary supplies and equipment, this young mother and her baby boy survived. FAME is an amazingly special place, that provides tremendous care to all of its patients and saves lives on a daily basis. I can't think of a place I'd rather spend my Friday nights than under the OR lights in the operating room at FAME. It was such an amazing experience to take part in that I've decided to repeat it twice more on the past two Friday nights. I think if I keep this up, attracting the high risk Obstetric patients for cesarean sections every Friday night the staff here just might kick me out.

Three beautiful babies brought into the world so far at FAME Medical. The second and third were emergency C-sections. Two have been discharged and one is recovering well in the ward right now. Lots of joy around here.

“I could not get my fill of looking.There should be a song for women to sing at this moment or a prayer to recite. But perhaps there is none because there are no words strong enough to name that moment.” ― Anita Diamant, The Red Tent

By Pediatric Neurologist Volunteer,

Doug Smith

Remember the days when you didn’t need an alarm to wake up?  When you woke with the sun rise, and your body was so anxious to rid itself of sleep that it was insufferable to stay in bed?  The song in your head is not one you heard on the radio and can’t shed, rather it’s the background music of your life.  You knew that the day ahead was one to remember.  One where you will experience the payoff of weeks, months, or perhaps even years of planning and anticipation.  Possibly one in which you will meet challenges or opportunities you have never had before, ones you feel prepared to overcome, with meaningful experiences as your reward.

That’s what this morning was like.  That’s what nearly every morning has been like during my time in Africa.  At night, the darkness is absolute, an almost palpable heaviness to the air.  The lack of sensory input gently and slowly turns the brain off.  It is disarmingly relaxing, and I find myself in bed and asleep well before I had intended to rest.  Come morning, the energy of the world changes with the sun rise.  The light calls to action dozens of songbirds and crowing roosters.  You can nearly feel the world waking up, and the call is hard to deny.  Then you remember what you’re here to do, and it really is impossible to stay asleep.

This is my view while I eat breakfast. I can literally see where my morning coffee was grown.

The medical experience thus far dwarfs my time in Botswana.  Morning starts with 8:30AM rounds.  FAME Medical has just 6 general inpatient medical rooms, each with 2 beds.  Despite the low numbers, the acuity and complexity of patients is impressive.  Currently, over half of the admitted patients are children.  We spend a particularly long amount of time with one child who became neurologically devastated over the past three months; I come up with some answers, but without significant testing abilities, I’ll never know if I’m actually right.  The father, a proud warrior whose stretched earlobes and traditional garb could just as easily grace the cover of National Geographic, tears up at my explanation.  He will not be the last person to receive bad news today.

5 kids from a nearby orphanage, awaiting their turnto see me.

The rest of the medical load, while significant, is African-casual paced.  Today, two orphanages delivered half their children to our doors, having heard that for the first time ever, a pediatrician has come to town.  I see five of them today.  The experience is exactly what I have come for.  

For two of the boys, I can make a diagnosis: muscular dystrophy.  They will never walk again. It is not all bad news, though.  A large percentage of families here do get the answers they've been seeking for a long time.  Down syndrome, Ohtahara syndrome; in these cases, I can offer a somewhat clear picture of the future, even if it is not the one they had hoped.  For others, they get confirmation of what they had suspected: that their severely weak, "disabled" child in fact has a full mind, capable of learning.

This is no small reward.  You see, schools here are very limited in their resources.  Any child with any somewhat significant problem is refused entry to school.  As an example, one 10 year-old boy was refused entrance to school his whole life because of a very subtle tremor, and they came to meet me to get a note saying he was medically cleared for school.  After TEN years!  In a more heartbreaking example, a boy with severely dystonic cerebral palsy, where he has basically lost control over all of his muscles (including his mouth and face), has a very full cognition, as far as I can tell.  When I asked his caretaker what I can help with, the boy replied, "I am a cripple."

Where schools have failed, the generosity of others have succeeded.  He was taken in by a Norwegian man, whose name I can't pronounce, let alone spell (it sounds like Skroli, but I'm sure there's an umlaut or two in there).  He has spent every cent he owns and has raised money from Norway to build an orphanage of sorts for children like him, children with significant physical handicaps but a lesser extent of cognitive impairment.  He takes them in and teaches them, not just basic schooling but also life skills, with the hopes of one day reintroducing them to their families.  So far, I have seen 7 of his sickest, and have given him half the money in my wallet to continue doing what he's doing.

Were it not for the FAME clinic here in Karatu and for Dr. Mike Rubenstein, the Penn neurologist who introduced me to the facility and is here with me now, none of these neurologically impaired children would have ever found the care they need.  Thanks to their charity, they are on appropriate medications now, and being cared for by people with the right mentality towards disability.

Skroli will have many more children for me in the coming days.  I hope I have the emotional wherewithal to handle them, and that I brought enough money to leave with a clear conscience.

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Waiting to see the doctor at FAME

Remember little Elibariki? Well, he is definitely on the mend. Dr. Duane is very pleased with the post-op progress. I think Elibariki is pretty happy too:) Our other burn patient is also doing well after her skin graft. She still has a long way to go but is looking better every day. 

The ward is almost full just now. We had two evening emergencies. The first was a tourist who had a bicycle accident and required some major suturing on the chin. The other a 26 year old man with Typhoid we had to admit. Already sick for 2 weeks, he was in very rough shape upon reaching us. Now on the appropriate medicine, we hope he turns the corner soon. He was doing better this morning.