Dinner at Carnivore and Psych Day at FAME…
Our Wednesday was a somewhat nondescript day which really means it is hard for me to recall specifics about the many cases we saw. There are some days that you just plow through the neurologic cases and though they are all so interesting in their own right, they are often also similar. We’ve had two general neurology teams working while Danielle and Lindsay have been working with Cara and the nurses to teach them EEG in such a short time. If there is an obvious epilepsy case then we try to have Danielle and Lindsay see that patient, but we have to be cognizant of the fact that FAME is running their regular clinic at the same time so we don’t have unlimited clinical officers or translators to work with. So far, though, we managed to run through the patients like a well-oiled machine with few interruptions sorting out those that should be seen by the epilepsy group and those to be seen by general neurology.
Later in the day, the nurses were working on firming up their proficiency of performing EEGs checking themselves with measurements for the electrodes and running the EEG machine. They have been remarkable in picking up the necessary skills which gives us confidence that this is something that will be helpful going forward in treating our epilepsy patients in between our visits here. It has already proved invaluable in caring for many of the patients we’ve seen and will continue to be so.
We finished early enough in the afternoon to head to town before dinner to pick up some things at the fabric store that had been ordered by Thu and Fima. Thu had a wonderful skirt made out of lovely fabric and Fima had a pair of pants made that are actually very cool and perfect for working at FAME. The exciting thing, though, is that we had planned to have dinner at Carnivore. Now this might sound a bit intimidating to many of you, but they specialize in serving grilled chicken and chips (french fries) and they are a bit of a local legend. We had all planned to meet there for dinner (twelve of us) and so we had called earlier in the day to order the chickens and chips – It’s like most local Tanzanian restaurants, which have dirt or gravel floors, plastic tables and chairs, music and dim lighting, Carnivore does not disappoint. Add to the wonderful decor a smoky grill in the middle of the restaurant where the cook is grilling your whole chickens before they are pulled off the grilled and very skillfully cut up into pieces using a butcher’s cleaver. Whack, whack, whack and you have a plate of the most wonderfully tasting grilled chicken anywhere. Now, I will warn you that these are not the plump juicy chickens found in most US grocery stores or restaurants, but rather a bit less meaty of a fowl that has had a much harder life than it’s American cousins. Still, we all had enough to eat with the chicken and chips and beer to go around. It was quite a nice evening out for all of the FAME volunteers.
The following morning began with a lecture by Ali using a case presentation from last week on the gentleman who had suffered an intracranial hemorrhage and was transferred to KCMC. She ran through why we had immediately thought that he had suffered a bleed rather than a stroke and some of the treatment decisions that were made with that in mind. It was an excellent presentation that really gave the doctors here not only the criteria we use to decide clinically whether we think someone has had a stroke versus hemorrhage, but also what to do when initially evaluating along with initial treatment options.
We jumped right into our first patient of the day who was a young 22-year-old Maasai man who was brought by his father and brother because of strange behavior. He had already accosted several of the volunteers (Cara and Pauline) who were shaken up by the affair and it was quite clear that this was going to be one of those cases where I hear “but you’re the closest thing we have to a psychiatrist here in Northern Tanzania” which is the truth unfortunately. We brought the three into the exam room with me standing between the patient and Danielle, Lindsay and Ali and Zawadi, our translator, standing near the door. Lindsay did a great job interviewing the patient and the family so we could have some semblance of what the history had been for this young man. It was quite clear that he was acutely psychotic and also quite agitated and nearly manic. I made the offer to examine the patient which was happily accepted by Lindsay as the patient remained quite physical throughout our interview process and was even perhaps a bit more so with the discussions we were having.
He had gone off to Dar with his brother when he was 18 and the two were working as security guards there. At some point, they were on a beach watching some wazungu (white people) swimming and his brother jumped in to join them. Not knowing how to swim, though, he promptly drowned. The father and brother confirmed this story, but what happened after that wasn’t entirely clear. He eventually made it home to his family and over the last year had acted strangely as he was acting today. He had gone into the forest on his own for part of the time and was continually speaking of things they didn’t understand and roaming around.
He had both hallucinations and delusions as well as paranoid ideations so we suspected he was schizophrenic or at least schizoaffecctive, though there was still a small possibility that this was bipolar disorder, but the issue at hand was that he needed to be slowed down rather quickly as he was a risk to himself and others. He emphatically denied any alcohol or drug use while in Dar or back at home which his family confirmed. We checked all the appropriate labwork to rule out things, thyroid, HIV, syphilis, etc., etc. Luckily, Frank had requested that I bring injectable haloperidol with me this trip just for this occasion so we gave him a 5 mg dose IM and watched him for about 30 minutes. It didn’t slow him down one bit. The rule is that you double the dose each time so I gave him another 10 mg along with 4 mg of lorazepam (another tranquilizer) and he continued at the same pace for perhaps 20 minutes and then began to look slightly drowsy. I asked Sokoine (now also enlisted into the security detail) to ask the patient if he felt sleepy and he told us he can never sleep, and then in less than a minute his head was promptly on his shoulder and he was out like a light. Success!
His labwork was all unremarkable and our diagnosis was acute psychosis, most likely schizophrenia or schizoaffective disorder, but with the small possibility this could be a presentation of bipolar disorder. We treated him with olanzapine, which is an oral antipsychotic, with the hope that this would at least help with this issue, but made sure his family understood that he would likely need another medication such a valproic acid. Frank, of course, didn’t want him to return until I was back in March, but we told the family to return if the medication wasn’t completely helping with the thought that this would likely be the case. We let him sleep for some time and then the family was finally on their way back home to their boma in the Ngorongoro Crater area.
Several patients later we had another psychotic patient, but luckily not nearly as threatening as the earlier one. He was an elderly patient who presented a letter from the district office notifying anyone evaluating him to be aware that he was a longtime psych patient and to take this into account in discussing his complaints. Sure enough, he was off his medications and had been doing tremendously better before when he was on his medications. A new prescription for olanzapine and he was on his way and happy.
At the same time, the epilepsy team was seeing another patient who had been treated for some time and seen by us last visit at which time they had been doing well with no seizures. They were on carbamazepine and were referred back to consider withdrawing medications. They decided to hook them up to the EEG machine and low and behold, they had very frequent generalized discharges meaning that they would likely have seizures off medication, but more importantly, that the carbamazepine was not the right medication for them as it could exacerbate other seizure types. The patient’s medication was promptly converted over to levetiracetam, a much more appropriate medication for this type of epilepsy. Another example of how the EEG machine will clearly change the management of epilepsy here and change patient’s lives going forward.
We had finished all of our neurology patients for the day and I was sitting by the lab checking emails when Danielle came out of the ER ward (where we’re doing our EEGs) and called to me that she needed my help “right away.” Danielle does not overreact, so I promptly dropped everything and ran down the steps to find out that their patient in the EEG lab was having a non-epileptic event during her EEG and was thrashing about on the table requiring restraint. The problem was that she was HIV+ and was putting everyone at risk so we needed to sedate her post haste. I ran to the clinic to grab some injectable medication and ran back to find that she had luckily slowed down in the meantime and didn’t require the medication. Then the long process began of working with the patient to help with her non-epileptic events which is tremendously more complex than treating if she had epilepsy and requires predominantly therapy and some insight by the patient. Lindsay did a fantastic job of talking with the patient using translators, not the easiest considering the topics that were being discussed. She also had a very significant stage II foot ulcer that needed debridement so she was admitted for that and also to keep an eye on her given the new diagnosis of non-epileptic events. Despite the fact that the episode was clearly not a seizure clinically, she probably would not have had it if she weren’t hooked up to the EEG machine, so the technology once again served to greatly impact our care of the patient and will ultimately benefit her greatly. Most importantly, it will keep her off anticonvulsants that would have interfered with her HIV medications so likely saved her on that account as well.
We ended the day at Frank and Susan’s house for a wonderful get together of all the volunteers for the traditional going away as Danielle, Cara and Lindsay will be leaving tomorrow and we will be leaving in a week. Dr. Marcus and his wife, Susanna had also arrived recently and will be leaving in several weeks. Pizza, samosas, cheese and crackers and wine and beer. A feast here that was much appreciated. Pauline acknowledged everyone’s work with FAME hats and lovely Tanzania scrub shirts as gifts and most notably, Frank stayed up well beyond his normal bedtime of 8 to 8:30! It was a wonderful last day for the epilepsy and EEG team and a visit tremendously more successful than any of us had imagined.