Reaching and Teaching

by Volunteer Nurse Practitioner and Diabetes Educator, Kim Hall

 Dr. Jackie and PA Volunteer, Joyce, meeting with a patient during Diabetes clinic

Dr. Jackie and PA Volunteer, Joyce, meeting with a patient during Diabetes clinic

Diabetes (mostly type 2) is on the rise in Africa with an estimated 15 million plus cases in 2017 (up from 14 million in 2015), and there are approximately one million documented cases in Tanzania according to the World Diabetes Federation.  Experts predict that only about 1/3 of cases have been identified, implying that as many as 3 million cases of type 2 diabetes exist in Tanzania.   The costs of the severe complications that can arise when type 2 diabetes goes untreated far outweigh the cost of treatment and efforts for prevention.

 Kim and members of "TEAM SISI"

Kim and members of "TEAM SISI"

Given these alarming statistics, I am happy to report that the FAME Diabetes/Chronic Disease Clinic continues to build steam! My favorite time at FAME is spent working with the fabulous staff, especially of “TEAM SISI,” the self-proclaimed name of the diabetes team formed during my March FAME visit.  SISI means “us” in Kiswahili and is a clear indicator of the spirit of teamwork, which continues to prevail in this dedicated multidisciplinary team.   The diabetes/chronic care clinic was launched by the TEAM with the help of Dr. Michael Zimmerman in April, 2018, with enthusiastic patient participation from the start.  The SISI team continues to assist patients with self-management of diabetes and hypertension at FAME.

 

Anecdotally there are several success stories and informal reports of high patient satisfaction and reported positive behavior changes.  A favorite is of a honey farmer who heavily used his own product, reporting marked thirst associated with his high blood sugars, which he quenched with a case of coke weekly.  Changing these two behaviors, and resuming medications which he had run out of, brought his sugars down from over 500 to under 100 in one week! FAME also intends to begin gathering more formal data by documenting improved outcomes and instituting patient exit surveys to continue to reach and teach this population.

I left a piece of my heart at FAME when I first visited it in 2015. When I came back to reclaim it in 2018, I left more of it there instead.  Thanks to all the great FAME staff for taking good care of it, until I return next time!

Advancing Patient Monitoring

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In late 2017, we received an amazingly generous donation from a longtime FAME volunteer!  During her stay with us she noted FAME’s need for more robust monitoring equipment. With a growing number of emergencies finding their way to our ER, increasing numbers of high acuity patients in our general ward, and a rapidly expanding surgery program inspired her to do what she could to help us help our patients. Her gift enabled us to purchase additional and much needed state-of-the-art monitoring equipment. We received 4 bedside monitors to help with continuous monitoring of patients -- finally arriving this past July! The monitors are now up and running and strategically located in our Recovery Room, Small Procedure Room, Emergency Room, and Inpatient Ward.  These invaluable pieces of equipment are helping our doctors and nurses provide a superior level of health management for our patients who need close observation and continuous monitoring. When the equipment arrived on campus, a trainer arrived along with it, orienting our staff on how to properly use the machines for patient care. As soon as they were installed, our doctors and nurses were putting them to good use! We want to express our sincerest thanks to our volunteers for their continuous support and for embracing our mission to advance patient-centered care in rural Tanzania!

It Takes A Team

By Volunteer Dr. Apple

 Dr. Apple and Dr. Badyana with their patient

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.

A Second Source of Water

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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.

Welcome, Dr. Kelly!

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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.

Why I Will Keep Coming

by Volunteer Cardiologist, Dr. Reed Shnider

 Dr. Reed during heart checkups at a primary school

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.

A Sense of Shared Mission

by Dr. Thu Vu

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

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.

Riziki's Story

by Co-Founder, Susan Gustafson

 Nurses taking Riziki to the OR, photo by Moon Lai

Nurses taking Riziki to the OR, photo by Moon Lai

Full term, Riziki began feeling labor pains and prepared to give birth at home. She labored for two full days, and was given local herbs believed to help her with contractions. Riziki’s contractions continued but her baby was not descending. Alarmed and worried, her family took her to a dispensary near her remote village where her labor was monitored for another four hours. With no progress of labor, the healthcare provider knew there was something terribly wrong and referred her to FAME Medical for help. When she arrived, she was having very strong contractions. Dr. Gabriel examined her and performed an ultrasound. What at first glance looked like an enormous cyst, was upon closer examination, the infant’s head showing massive hydrocephalus. Riziki had been pushing for so long her uterus was showing signs of a possible rupture. The team knew they needed to get her into the OR fast and called for blood product from the lab to prepare for the worst. Upon opening the stomach, Dr. Gabriel could see that the uterus was buldging and there were signs of a lower segment hemmorhage. They worked quickly, delivering a baby boy. Despite the hydrocephalus, his Apgar score was strong and he was active. While a nurse cared for the baby, Riziki started bleeding badly. Treating her with the first line of treatment for post-partum hemmorhage, she was slow to respond. As they moved to the second line of treatment, she went into shock. Sehewa, our anesthetist, immediately intubated her and inserted an NG tube. The team began rescusitation and giving her IV fluids while transfusing intra-operatively what would be two units of blood. Her pressure began coming up and when she was able to breathe on her own again, she was extubated and returned to the ward where she stabilized and soon recovered. She still faces some serious challenges, specifically that of taking a medically compromised baby back to the boma. But thankfully, we were able to refer the child to a pediatric surgeon 2.5 hours away who inserted a shunt. Riziki has already returned for her post C-section follow-up visit, reporting that her baby is recovering well. We rejoice in knowing that another precious mother was saved by the FAME team.

It was very, very good

By Volunteer, Dr. Carolyn Apple

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The phone rings in the volunteer house.  I glance at the clock – almost 10pm.  This is not good.  The voice states a patient has been brought by family to FAME after having a motor bike accident and appears to have a head injury.  Can I come?  This is not good.  A few minutes later, I am standing by Dr. Gabriel and Dr. Kiduge looking down at a young man with abrasions to his face, scalp and shoulders.  The patient occasionally calls out nonsense and only arouses to pain. This is not good. The FAME team has already placed a cervical collar and started the initial assessment and stabilization of the patient and Dr. Gabriel performs a focused abdominal ultrasound for trauma exam – no evidence of blood in the abdomen/pelvis. This is good.  We proceed through the remaining primary and secondary assessments taught in trauma care. The patient becomes agitated, requiring cautiously administered sedation.This is not good. Within minutes, a FAME nurse anesthetist is at our side, helping with sedation and airway management.  This is good.  Laboratory study results return and blood typing has taken place.  This is good.  We are notified the radiology technician has arrived and X-rays and CTs are performed quickly.  This is good.  The CT reveals a subdural hematoma.  This is not good.  CT of the cervical spine and x-rays of the chest and pelvis are negative.  This is good.  Dr. Loie Sauer, a volunteer surgeon, joins the team.  This is good.  The team confers and quickly agrees the patient needs a referral for neurosurgical care.  The family agrees to a transfer.  This is good.  The local ambulance is called as the patient receives continued monitoring, medical and nursing care from the team.  This is good.  The ambulance arrives and the FAME nurses equip the vehicle with the necessary equipment and supplies for transport. This is good. The patient is loaded up, along with the FAME nurse anesthetist who will monitor the patient’s vital signs, airway, need for additional sedation and general condition enroute.  This is good.  I return to the volunteer house three and a half hours after having left my bed.  What the FAME Medical team was able to do tonight was very, very good.

 

Justine's Story

by Director of Development, Roanne Edwards

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It was perfect timing for Justine. She was at church the day FAME’s social worker, Angel, began visiting churches, mosques, open markets and water collection points to announce the free-of-charge Cervical Cancer Screening clinic at FAME Medical. Justine had been experiencing lower abdominal pain and had heard about cervical cancer on social media. At FAME, the following week for the screening procedure, she learned that there was an abnormality in her cervix. She felt frightened and apprehensive but was ready to undergo the recommended treatment for pre-cancerous dysplasia. Six months later, the FAME team screened her again and returned with wonderful news – the treatment had cured her abnormality. Justine went home to share the news with her family and to encourage all the women in her life to undergo this simple procedure that could literally save their lives.

 

Cervical Cancer is the leading cause of cancer-related death in women in Tanzania.
—  ICO HPV Information Center 2017 Report