We had some short, but heavy rains last night and the temperatures were very comfortable over night into the morning hours. The grass glistened with it’s fresh coating of moisture as we walked to clinic along the two cinder tire tracks of a road we walk every morning. The sky was gorgeous and clear with nary a cloud. There was an education meeting at 7:30am today dealing with tuberculosis treatment in children and though quite a stretch for us as neurologists, it was still quite helpful to hear and well worth our time. Morning report followed and we learned of three new patients in the ward for us to see and hopefully provide some valuable input.
There were two adults that I had Jamie start with in the morning and once she was finished, then Nan could see the child in the ward that needed our services. One case was presented on rounds as a young pregnant women who presented with severe headache, vomiting and vision loss. All of our neurologic ears immediately perked up with this introduction as this could have been a number of conditions well within our purview and all of interest to each of us. They had considered as a migraine, mostly as her vision loss was transient, but it would take far more convincing than that for us to agree with that assessment. The full history, though, was that she had vomiting through much of her pregnancy, was dehydrated and had developed the severe headache associated with vision loss that resolved after a short while and with no residual deficits. She had had a few headaches in the past, but it was unclear if she had had migraines so we couldn’t relay on that as a definite diagnosis. She had not been febrile and her examination was totally normal. We were left with offering her symptomatic treatment and watching her one more night to make sure things didn’t get worse during which we could continue to hydrate her as this may have been a precipitating cause.
The other patient was an elderly gentleman who hadn’t really needed hospital admission, but they had decided to admit him so he could see us first thing in the morning. He had a several year history of severe shaking (tremor) that involved his upper extremities and head and neck primarily. It was primarily at rest and was quite obvious walking into his room, so much so that his diagnosis was rather clear to both Jamie and I when we each first saw him. His examination demonstrated little in the way of rigidity, though, and he told us that he had been placed on a medication in the past to treat his condition that he had taken three times a day, but hadn’t been on it in a few years. In the end, we decided to treat him with carbidopa-levodopa at a reasonable dose to start to see if he had a dopa responsive tremor and then come back to see us in a week. If his tremor is unchanged then we’ll have to make a decision whether to increase his carbidopa-levodopa or to try another agent like trihexyphenidyl which is not a standard medication here, but I had brought some in the past for another patient who hadn’t used it all.
Nan’s pediatric case in the ward was far more troubling and necessitated emailing one of her “fundis” (specialists) at CHOP to discuss further. It was one-year-old child with lethargy and was very thrombocytopenic (low platelets) and had an elevated white blood cell count, but no fever. She was a bit of a diagnostic dilemma and the differential diagnosis included idiopathic thrombocytopenic purpura which is a very scary diagnosis and one that would be very difficult to treat here for certain. Thankfully, it was felt at the end of the day that the child was improving somewhat, so at least there is some time for everything to get sorted out. We have certainly seen patients come, often overnight, and worsen suddenly. The young gentleman last October who came in overnight with lethargy and confusion who they asked us to see and then abruptly stopped breathing when Kelley went in to see him. What was to be a simple consult turned into a full code that was quite lengthy and unsuccessful and left us all quite shaken that day, especially Kelley. FAME is an amazing medical facility, but in the end, we are in rural Africa where despite the extraordinary efforts of everyone here, we are not in the practice of performing miracles. With all of our amazing successes there will always be failures, those we cannot treat and we must always recognize this. It will not lessen our resolve, though.
Our clinic day was again a number of childhood epilepsy cases, some of which were quite difficult. A number of children from the Shalom orphanage that is just down the hill from us were brought up today for us to see. Several of them continued to be well controlled on medications, while a few were not and needed medication adjustments. One young and very complex child came who was not from the orphanage, but was from a local school had been having worsening seizures over the last several months. She was sixteen and had developed seizures a few years ago that were well controlled on a medication that we no longer have available here and had to be switched to another very good medication, lamotrigine. After the switch, though, she has become very lethargic and encephalopathic and has been having what are described as tonic seizures in which she falls and injures herself. It’s a very odd reaction to this medication, but seemed to occur immediately after switching. Unfortunately, there is also a very significant amount of trauma in this child’s life which always raises the concern for non-epileptic or psychogenic seizures. In the end, we decided to put her on the only other good medication we have here now which is valproic acid as it should help control things if they are seizures, but it’s not a medication she can remain on long-term as it has serious issues with pregnancy and birth defects. That’s the furthest thing from our mind right now, though, so we will place her on it and hope for the best since we are here now and can make adjustments or switches as necessary before we leave. I sure wish that we had our EEG machine in working order as that would have solved a great deal for us. Maybe in the future.
It was again a rather quite day and though a few more patients than yesterday were seen, we still finished rather early and had time to catch up on things. We had plans to visit Daniel Tewa and his family which is always a highlight for the trip as Daniel provides a fantastic cultural history to Tanzania, it’s history through independence in 1961 and the current political situation here. He also has one of the only Iraqw-style houses in the area that he built in 1993 and has maintained since then. After independence, all of the different tribes were ordered to move to villages rather than live separately as it was impossible to develop an infrastructure in the country with the 126 different tribes here all living separately. All of the Iraqw houses were demolished at that time and they had to move to the villages and live in Bantu-style houses as there were 100 tribes of Bantu origin and they were by far the most numerous. Daniel built his Iraqw house not to live in, but rather for historical purposes and it is now used by many as a fine example of this construction for college students from here and abroad as well as tourists who come to visit him. His wife, Elizabeth, who only speaks Iraqw, also makes traditional Iraqw wedding skirts made of goat skin and beautiful pictorial beading that all tells a story.
I met Daniel in 2009 while on safari and we have been friends (family as Daniel will tell you) ever since. I was the first white person to have returned to visit with his family and share meals and he has been gracious enough to have allowed me to return every time I’m here and to bring my residents so they can also experience the local culture with such an amazing person. It is really an incredible experience to sit outside under the eucalyptus trees at his farm having drinks or coffee well into the dark and just talking about Tanzania and America. At some point, we always meander over to his Iraqw house so he can share his stories of growing up in such a house and fending off the Maasai with clubs and spears. An entire family slept in the house along with all their animals so they wouldn’t be stollen at night. They slept, men on one side and women and children on the other (how a husband and wife got together to make a family is top secret as Daniel will tell you), with the kitchen, which really consisted of a large pot in which to make ugali, sat underneath the sleeping area that was suspended several feet off the ground.
The Maasai and the Iraqw were at odds until a treaty was finally signed in 1986 and their battling ended. It was all over livestock, and primarily cattle, that the Maasai believed they owned as God had intended all cattle be theirs and they were merely being returned to their rightful owners. The Maasai and Iraqw no longer share this difference and live together in harmony, though if you mention it to either of them you will find out that it remains part of their history and culture.
Well after sunset and perhaps prompted a bit by the swarming mosquitos who had now found us, we decided to walk to Isabella’s house where dinner would be served. The moon wasn’t full, but was more than bright enough to light our way along the Gibb’s Farm road to her house that was a short distance away. Isabella is Daniel’s oldest of twelve children and her daughter, Renata, who has been a fixture at these dinners for seven years now, was there. Renata has worked with us on several occasions in the past and has an interest in becoming a doctor. She is more than smart enough for this and is just a matter of whether she can remain the course over time.
Our dinner was an amazing spread of rice, Chagga stew (bananas, potatoes and meat), chicken, beef and a spinach like vegetable that was great. Daniel can be very persuasive when it comes to filling our plates for seconds and thirds and by the time we were all finished I think each of us felt as though we were going to burst. Thankfully we didn’t as there was still desert to come which consisted of fresh fruit – bananas, watermelon, avacado, mango and pineapple and was just as delicious as the rest. Finally, we were nearing the end of this eating marathon when Daniel mentioned that we still had coffee to serve. I thought Nan was really going to explode at that moment and her expression was priceless, but she finally relented and had a cup of wonderful African coffee (coffee boiled with milk in which we add a teaspoon of brown sugar) with the rest of us and it was truly delicious.
It was finally time to leave and Daniel and I walked back to his house hand in hand as is the usual custom here with close friends and family. It was another special evening with the Tewa family, but it was now time for us to make the journey home and back to the comfortable Raynes House. We’d be up for another clinic in the morning and have plans for a safari on Sunday, the day after tomorrow, to Lake Manyara.