The elections and the potential for protests and possible violence continue to keep the patient volume low here at FAME. Patient volume, at least for us, has been rather low and perhaps only half of a typical day over the past several years. We had seen a steady growth in the neurology volume with each successive visit, but the election has definitely put a damper on that trend. I am certain that things will pick back up for our next visit in March, though, and we will be right back on track. The new from Zanzibar was not encouraging today as they had received more ballots than registered voters and the government has announced that they are nullifiying the results and will have a special election. News is trickling in at this point and the opposition has called for a nullification of the entire election at this point. The official release of the results was to be on Friday, October 30, but that is now in question. We are hopeful that things will remain calm for our departure Friday night.
Regardless of the low volume at the clinic, we still have neurology patients come for us which was a good sign.
Our first patient of the day was a 90-year-old bibi (“grandmother” in Kiswahili) who had been brought in by her family over night. She appeared to have had a stroke in the past with very significant left sided weakness on her examination, and was having intermittent and frequent rhythmic movements of her left side. As we watched, her left leg began to twitch lasting about 30 seconds and happened repeatedly during our visit.
She had been receiving care in Arusha at one of the major hospitals there and the family was certain she had had a CT scan, but didn’t have the film or records. Luckily we found an old chart for her here at FAME that confirmed she had had the CT scan in the past and that it had demonstrated multiple strokes and not anything like a tumor. She had a pseudobulbar affect due to her bilateral strokes so she often cried and laughed at the same time.
She remained awake during her episodes and given what we had observed, it was clear that she was having recurrent simple partial seizures consistent with epilepsia partialis continua, or EPC. Since she had been having some mild agitation we decided not to place her on levetiracetam and rather started her on valproic acid which should be absorbed rapidly and she could be loaded orally as we don’t have IV anticonvulsants here at the present time.
We began our outpatient work with three patients who had seen us over the last two weeks and were asked to return. There was a gentleman with a radial nerve palsy who was gradually improving and another gentleman with Parkinson’s disease and tremor who we had placed on carbidopa/levadopa and was doing much better than we had originally seen him.
We also saw the 18-year-old young woman who we had seen two weeks ago with seizures that were worse on carbamazepine and was our very first EEG patient here at FAME, with the study demonstrating generalized spike/wave discharges consistent with a primary generalized epilepsy – one that would potentially worsen on carbamazepine – and she was switched to levetiracetam, a much more appropriate medication for her condition. Her mother reported to us that she had had no further episodes of seizure or the confusional episodes she had been having since starting the new medications. She was also now more able to help around the house and was acting normal again as she hadn’t been for some time. Had we not had the capabilities to do that study, we would have been guessing in treating her as her initial story had sounded much differently than it had turned out. This 18-year-old woman will now hopefully be able to lead a productive life, perhaps marry and have children of her own, and without the continued stigma of uncontrolled epilepsy.
I had seen a wonderful Maasai gentleman one year ago who suffered from a fairly significant essential tremor and had placed him on propranolol to help control it. He returned today with his young son who spoke excellent English, Swahili and, of course, Maa, and complained of the same tremor. He hadn’t returned in the interim for refills which is so often the case as the people here are not used to taking a chronic medication and it is always so difficult to get that message across to them. Thu was happy to see the patient as she will be doing a movement disorder fellowship next year and she took the opportunity to videotape his examination. It was difficult to tell whether or not he had had any benefit from the medication I had placed him on last year, so we made sure that both he and his son understood the expectations for the medication and elected to retry and to titrate to a higher dose this time. They live two hours aways so it’s not the easiest for them to return often, but I strongly encouraged them to return in March when we are back.
Later in the morning we evaluated an elderly Iraqw woman who was related to Jacob from reception and spoke only Iraqw, so Jacob helped translate for her. She didn’t have much wrong with her neurologically other than some neuropathic pain for which we prescribed our favorite drug here, amitriptyline, and told her also to exercise her right shoulder which had significant arthritis and was beginning to freeze.
Fima returned this evening after traveling to Dar es Salaam to help Flying Doctors transport the patient who had suffered a heart attack and needed to be transported to Muhimbili University yesterday. It was an exciting trip for him as he was able to visit with a friend who is a resident at Muhimbili along with a nice sight seeing flight to Dar. Today’s trip only took him to Arusha, though, and he had to catch a van back to Karatu which was another two hours on top of the flight from Dar.
Tomorrow is our last full day here at FAME and it is always sad to think that I will not be back until March. But at least I know I will be back and each time with a new set of residents who will experience this amazing place for the first time. And each time I will share in their experience and recall the first time I came to FAME so many visits ago and somehow knew that I was meant to return.