By Volunteer Dr. Apple

Dr. Apple and Dr. Badyana with their patient

Afternoon clinic was winding down on the quiet Saturday afternoon, when a young woman was wheeled into Dr. Badyana’s office.  “Oh, this is not good,” was my immediate thought.  The patient before us had extreme swelling of her face, neck and upper chest and was not able to swallow anything, including her own saliva.  The patient’s mother quickly provided a history of her daughter starting with dental pain and some swelling three weeks prior.  She had received antibiotics from two other hospitals, but her condition progressively worsened.  The patient had a history of diabetes, controlled by her diet, but there had been no recent testing. 

Our examination and a bedside ultrasound performed by Dr. Badyana confirmed a diagnosis of an extensive oral infection spread to the tissues of the face, neck and upper chest, a rather rare condition called Ludwig’s Angina.  A very serious and potentially lethal condition, the patient needed immediate surgical drainage of the infected area, monitoring for swelling closing the airway producing inability to breath, intravenous antibiotics and treatment of her diabetes, which was found to be uncontrolled.  The young woman was seriously ill.

Our patient was immediately taken to the procedure area where a surgery to open the infected area was performed.  That afternoon began our FAME team’s long journey with this patient, with the team working tirelessly to treat her infection and manage several life-threatening complications that arose during her treatment. 

And yes, it took a team to bring this patient safely through her illness.  From the FAME staff doctors caring for the patient around the clock, to the volunteer doctors with expertise in diabetes care, infection treatment, surgical wound management and skin grafting, to Dr. Frank working with the anesthetists to find the best procedural sedation for this complicated patient, to our nurse/architect Nancy who suggested and acquired a high protein tube feeding supplement made from ground legumes used to improve wound healing, to the nurses who monitored and cared for the patient 24/7, to all the FAME support staffs, etc., etc.  

Five weeks after her arrival at FAME the young woman returned home, having survived an illness to which she likely would have succumbed had she not arrived at FAME on that Saturday afternoon and had the FAME team not been there with the facilities, equipment and expertise to save another life.

The drilling team flushing out the new pipe for our second borehole

In early May, we were able to complete the drilling of a second borehole on the FAME campus. The manual work was not easy after Tanzania experienced an uncharacteristically heavy rainy season this year. The muddy aftermath of the rains meant that the drilling team was working in difficult and challenging conditions. It took nearly two full days of drilling to hit a strong and reliable source of fresh water at 170 meters deep. According to the technicians and experts on site, the borehole should produce between 30,000 liters to 40,000 liters per hour. With both boreholes operational, we will be able to pump the water between the two sources. This solution will decrease the daily demand on the current borehole water and will provide a back-up solution in case of an emergency such as a failed pump or a drained aquifer. Overall, the drilling of this new borehole adds a vital layer of security to the FAME water supply for the entire hospital and all of our patients, and we are grateful to the very special supporters who saw the need and made this possible.

This June, we welcomed Dr. Kelly Shine to the FAME team as a part of a new partnership with Creighton University and their Global Surgery Fellowship Program.  Dr. Kelly comes to us after having practiced general surgery on the East Coast for 15 years. She graduated from the Yale University School of Medicine and completed her residency at the University of New Mexico Health Sciences Center. She has experience in general surgery, vascular surgery, and acute care surgery. 

When asked about her fellowship, she responded that the program is about "more than me." Creighton's goal with the Global Surgery Fellowship is to build relationships with hospitals abroad that may need resources that Creighton can provide. There is a particular emphasis on bidirectional learning through the fellowship. The idea is that both sides of the partnership will be able to enhance their knowledge and skills. Kelly mentioned that practicing here at FAME has already helped her revisit certain skill sets she doesn't use as often in the states. She also mentioned that she's seeing many cases that she wouldn't see in the US in her specialty, such as rabies or shoulder dislocations, as doctors who do surgery in rural Africa typically function as generalists as well. Through this program of partnership, Creighton has a vision of building ongoing relationships and, ideally, creating a foundation for the fellows to pursue a career in global surgery. 

A new program at Creighton, Kelly is the first fellow to participate in the Global Surgery Fellowship. She'll be spending a full year at FAME as a general surgeon, partnering with our doctors to teach them crucial components of general surgery and learning how to practice medicine in developing countries. She mentioned that when she's in the operating room, she’s not necessarily the one always doing the surgery. She said, "it's not for me to just do, it's for me to teach." In line with FAMEs mission of building local capacity, Kelly’s goal is to leave a substantially strengthened surgical team behind when she moves on.

In addition to building surgical capacity within our team, Kelly has already helped to put systems in place that have enabled us to shift where surgery patients are recovered. With new monitors now in place and nurse anesthetists and ward nurses working more closely together, Dr. Kelly looks forward to using our hospital’s Recovery Room more efficiently and consistently for post-op patients. We are so excited to see all that Dr. Kelly and our team accomplish together in the year ahead! To learn more about the Creighton Global Surgery Fellowship Program, visit Creighton's website.

by Volunteer Cardiologist, Dr. Reed Shnider

Dr. Reed during heart checkups at a primary school

The 3 year old Maasai was likely deathly ill from the time that his family set out for FAME on a trip that was likely many hours. By the time they arrived he was in severe respiratory distress, minimally responsive, limp with a barely palpable pulse. His father, sensing his son’s grave condition passed him wordlessly to the nurses and doctors and sat silently at the end of the bed. We were called to help. Initial measures included IV fluids and oxygen, which were provided quickly as the history of his illness was obtained and comfort provided to his worried parents. It appeared likely that our little patient was suffering from a severe systemic infection . IV steroids, antibiotics, fluids and epinephrine were infused without delay. With no Pediatrician on site, contact was made with an overseas consultant, Dr. Rachel, who, being a veteran of several visits to FAME, was able to provide insight and additional recommendations, validating our impression and treatments. Shortly following her call, despite our best efforts, our new arrival suffered a respiratory arrest. CPR and respiratory support were initiated immediately. Medications given without delay.  As if in anticipation of this course of events, we had completed a review of Advanced Life Support just the day before, and the team had learned admirably as evidenced by their efforts. Although it became clear that recovery was unlikely, no one was ready to give up. Even so, there came a time when it was clear that it was time to stop and I called the code as over. As I did, I realized that the father had been sitting at the foot of the bed the whole time quietly observing. Nurse Safi, the Ward Supervisor,  and I  led him to a quiet corner. We explained how sorry we were that we couldn’t save his son. The illness had weakened him too much, that sometimes even our strongest dawa (medication) and greatest efforts were not enough. As parents and grandparents we felt his loss and pain. I think Safi and I were both tearful at that point, waiting to hear what he had to say. He was quiet for a moment then spoke, “I brought him here because we knew that he was very sick, and we knew that you would do everything possible to make him well. I watched and saw that this was true. You have nothing to be sorry for. Thank you for working so hard to save him.”

I like writing about successes. Cases that make us happy. Cases that highlight how far we’ve come. But I realize that the essence of what makes FAME so special is also highlighted by stories like this one. How much the doctors and nurses wanted to save that 3 year old as if he were each one’s child. How painful the loss. How that feeling of caring was communicated wordlessly to the father who came so far to have his child cared for by very special people. How it made an immeasurably painful loss a little more bearable. That’s what I feel a part of when I come to FAME, that’s why I will keep coming.

by Dr. Thu Vu

Dr. Thu (left) with Dr. Michael Rubenstein and Dr. Ali at FAME Medical

Of the experiences I had in residency and the stories I tell over and over again, my time in Karatu is the one I reference the most. I cannot even truly enumerate all of the things that I learned there, which ranged from clinical skills and reasoning, to the business of medicine and public health. The rotation I spent there was truly formative in my style of practice, making me a better neurologist, teaching me the importance of healthcare quality and safety, and allowing me to contribute to social good through teaching and clinical care.

Learning to practice in a resource-limited environment was a test of clinical skills including physical exam, localization of lesion, triaging of problems and prioritization of testing. We could not simply rely on other experts or advanced diagnostic testing. For the patient with hand weakness that came in, with large burn scars covering his right arm, we were forced to think carefully and ascertain the localization of his lesion based on examination alone, without the assistance of imaging or EMG. In the realms of treatment, we had to consider the whole patient carefully, including the social context in which they lived, and tailor treatment accordingly — what is the distance this patient would need to travel to obtain their medications? Do they understand that they need to take this medication every day? Every patient came with a piece of critical thinking, rather than rote protocols to follow and panels to order.

The frustrations of local healthcare delivery were educational as well. In an environment like this, it can be very easy to slip into a learned helplessness, an apathy of "well, we did what we could." I have been in other resource-limited areas of the world in which this is true, but not at FAME. FAME embodies the true spirit of quality improvement and patient safety initiatives, which is quite simply asking the question repeatedly, "What can we do better?" I felt that at FAME, I learned more about the best ways to approach healthcare quality and safety improvement from the ground up, and doing so in a cost-effective fashion. I think that these larger systemic initiatives in trying to deliver quality care to patients may have the most impact on the region, perhaps even more so than just seeing individual patients -- it sets a standard for the area which other local hospitals will try to emulate in order to compete.

Seeing patients in this way, carefully considering each case one-by-one, and maximizing resources to do the most good for each patient, enabled us to feel like we were truly doing the best we could for each patient. Often times in residency, one can lose a sense of personal accomplishment -- there is always another consult to see, another call night, another rotation. However, at FAME, the mission of education and patient care, put into perspective by our medical leaders Dr. Rubenstein and Dr. Artress, made all of us who went feel like we had truly done good in the world, that we had made a difference in the lives of the people living in and around Karatu, and made a difference in the lives of the staff working there. That sense of shared mission is clearly evident in everyone there, and it renewed my sense of hope and ambition in my chosen profession. If there is a solution to residency burnout, this feels like one of them.

Global health opportunities were one of the reasons I chose to train at Penn, and my time at FAME with Dr. Rubenstein and Dr. Becker went above and beyond my expectations. What FAME has been able to accomplish in its community has been nothing less than remarkable, and the visiting resident rotation is a program that I feel strongly should be nurtured and expanded as we continue to serve that community and build up a standard for neurologic care in such areas.