Tuesday morning was once again time for our educational talks and there was a special request for Kelley and Laurita to cover the causes and evaluation of patients with altered mental status, a very broad topic that was quite a challenge for them to prepare. Like the pros they are, though, they tackled it with enthusiasm and came up with an excellent presentation that fully covered the topic. Once again, they had the full attention of the entire medical staff and when it was clear that they weren’t going to be able to finish the presentation in the time allotted (Dr. Lisso again did not cut them off which is always an excellent sign that they’re doing a good job) they were asked to finish the lecture on Thursday morning which is not a typical morning for educational lectures. Not only that, but the lecture that had gotten bumped for the altered mental status evaluation, headaches, was now being move to Friday morning, the morning we’re leaving for Arusha, but both Kelly and Laurita were more than willing to give the lecture before we leave that day. So, all in all, there will three educational lectures this week when there is normally only one.

Morning lecture

At morning rounds, we discovered that our young boy with meningoencephalitis was actually somewhat improved as he responded slightly. The night before, on our way home, Kelley had brought up the thought of covering him for listeria, which causes a brainstem encephalitis, as he did have some of these features on presentation. We stopped by the ward and wrote orders for ampicillin to cover him for Listeria. He continued to have fevers and had also had a few more seizures so we were keeping him on his anticonvulsant medication, but were considering adding another if he continued.

Patients in our neurology “waiting room”

Our young woman with Sydenham’s chorea was actually doing better after receiving the steroids, antibiotics and more diazepam to help her sleep the night. She was still having some confusion, though, and we knew it would take some time for everything to clear. Frank and I had a long discussion with her mother who was now also staying at FAME and tried to explain the nature of this disease to her. They are rural Maasai so it is very difficult to explain the nature of an infectious and Neuro-immunological disorder that isn’t contagious and wasn’t caused by anything her daughter or she did wrong, but just happens to some people when they develop a strep infection. She would be going home at some point and would probably still have some of her movements and confusion and we wanted to make certain that her family wouldn’t take her to a traditional healer or shaman where they might try to exorcise her. We frequently see patients here at FAME after they’ve been to a healer and they have lots of marks and burns on their bodies from attempted treatments or they’ve ingested local herbs that have unknown toxicities or effects. We also explained to her mother that this wouldn’t get better immediately, but would take at least several weeks to notice any possible benefits and that she would have to come back to be followed.

Laurita examing her patient with complaints of neuropathy and massive tophi

Laurita had a very interesting patient with the largest gouty tophi any of us had ever seen. Gabriel told us that this wasn’t as uncommon here as both of us thought as many patients are unfortunately non-compliant with their medications and many can have tophi such as this patient had. The reason he was seeing us, though, was because of his symptoms of neuropathy which were undoubtedly related to his gout. His examination confirmed his neuropathy and he was treatment with medication for symptomatic relief and hopefully he will be compliant with it.

Gouty tophi of the hand

A very large gouty tophus

No other patients stood out for the afternoon, but we were able to finish in a reasonable time today. I had driven downtown to pick up some things from one of the fabric stores after lunch, but they hadn’t given me everything for some reason, most likely because I was by myself and I’m not sure how clearly I had gotten the message across to them. So Kelley and I decided to run back down there before they closed for the evening and brought Selina along with us to help with any interpretation. It turned out that they had really failed to give me several things and it was unclear if they just weren’t sure if I was supposed to be picking up stuff for everyone or what. We had all ordered a number of things from them and given them quite a bit of business they wouldn’t have otherwise gotten so it seemed reasonable to us that they would want our business. We were never entirely sure, though, and that is something that is often the result of the cultural spread.

Kelley examining her patient

We returned home before sunset and once again sat on he veranda overlooking the beautiful hills that opened up in front of us. Dr. Liz, another volunteer from the US who has been here several times with me, arrived yesterday afternoon and joined us on the veranda to reminisce as well as to catch up on each other’s lives and the events of the day. We had the last of our prepared dinners as we’d be going out for the next two nights before we leave. What seemed like such a long time for us to be here now seems like it has slipped away so quickly and we are all becoming very sad at the thought of leaving soon.

A very pleasant patient