March 15, 2017 – A full day in clinic…

Standard

Wednesdays are special days here for it is mandazi day. These are little fritters or doughnuts that are deep fried and delicious. Tea time here occurs every day from 10-11 am, but on Wednesday, the tea is always accompanied by mandazi that are prepared the night before and everyone here is sure to make it for this treat. On the other days of the week, plain bread and butter are served with the tea and is obviously much less tasty. The tea we drink at teatime, by the way, is African tea, or Chai Masalla, which is a sweet and spicy hot tea that is just to die for. Nothing tastes like the chai we drink here.

Chris examining his patient with headaches

Chris examining with the help of Cliff

It was another bright and beautiful morning walk to the clinic and morning report. After morning report, we already had patients coming to see us and Chris’ first patient was a headache patient that sounded more like muscle tension headaches that we decided to treat with a non-steroidal rather than our normal remedy of amitriptyline (an older tricyclic antidepressant that we use at very low doses to treat chronic pain both here and in the US). I believe it was Jess Weinstein last March who developed the algorithm, somewhat tongue in cheek, which stated that if it was an adult, then give amitriptyline with no other choices. This was after I think she had seen 15 straight chronic headache patients one day during which she had basically validated her own algorithm. So Chris broke tradition since this patient was having daily headaches and gave him the non-steroidal.

Popi finding a cozy place to sleep in the planter

“Popi dog”

Popi has been at FAME as long as I have and has survived several close calls with death. She is a cancer survivor having received chemotherapy and also survived a strychnine poisoning incident early in her life. She is clearly getting up in years, but is still a fixture here at FAME and everyone looks out for her. Charlie, who is the newest fixture here, came about a year and a half ago and is tolerated by Popi, but not adored. I remember when Popi used to wander the area outside of FAME, but she no longer leaves the grounds nor does she need to.

Measuring the head circumference of the little Maasai girl with CP and anemia

Nan entertaining her patient

Nan examining her patient

Nan had her morning cut out for her dealing with the small babies in Ward 2 as well as a new consult for 10 year-old Maasai girl with cerebral palsy who had been admitted with vomiting and diarrhea. The girl was extremely malnourished and severely anemic and had previously received transfusions for her anemia and on the ward she really didn’t have much in the way of vomiting, or diarrhea for that matter. But her anemia was quite severe with a Hgb of just over three or about one quarter of normal. She had received one unit of blood here with an appropriate response and when her blood smear was sent to several specialists, it was agreed that she most likely had just an iron deficiency anemia due to her malnourishment. This is so often the case with disabled children who may not be feed a proper diet and end up being severely malnourished.

Nan charting

The little full-term baby now three weeks old and only 3 lbs.

The tiny Maasai baby

The other interesting case that Nan had been seeing in Ward 2 is a three-week old Maasai child whose mother had been febrile during her pregnancy and died three days post delivery. This baby, who is now three weeks old weighs just slightly over 1.5 kg, or about 3 pounds, and looks so much like a premie, but was a full-term IUGR (intrauterine growth retardation) baby and is the smallest little thing. She’s eating and doing what she’s supposed to be doing, but the worry is that sending her home with her family will likely not end well for her. Formula is very expensive here and it is likely that the baby would receive only cow’s milk leading to severe malnutrition. Nan convinced the family to consider using formula and offered to pay for the formula for the first several months of her life so she would have a chance of surviving. Later that afternoon, Nan and I drove to town where she purchased three tins of Nestle Lactogen Starter Infant Formula for them and would deliver it tomorrow. We become attached to our patients here and it is often through small acts like this that we can make a difference.

Getting the history from our headache patient on the ward

A fundiscopic examination

Meanwhile, Jamie was busy seeing a young headache patient on Ward 1 who had been admitted that morning after reportedly suffering a severe headache of sudden onset with vertigo and dizziness. With a more thorough history, though, Jamie learned that she had a long history of headaches dating back several years and had had similar headaches in the past. She was very lightheaded and probably dehydrated which was clearly contributing so we treated her with IV fluids and some IV headache medications, but she continued to complain of headaches intermittently throughout the day, eventually leaving the following morning with somewhat less of a headache, albeit not cured.

Jamie examining her young CP patient with seizures. Sokoine assisting

Sokoine demonstrating the Jendrasik maneuver

A portrait of our patient’s mother

At the end of the day, we had a patient that was clearly in Nan’s wheelhouse. She was a one-year old child whose mother had brought her in because she was not walking. The child, in fact, was not doing quite a few things, but this wasn’t due to the typical cerebral palsy that we commonly see her as the child clearly had syndromic features indicating that she most likely suffered from a genetic disorder which was causing her delay in development. The physical features that we noted were hypertelorism (wide spread eyes), down slanting eyes, epicanthal folds, broad bridge of the nose, flattened midface, low set ears and a high-arched palate. In the US, we’d be all over this to determine the exact nature of the genetic disorder, but those tests are unavailable here, and even if they were it would not change management in any way other than to counsel the parents. Nan’s recommendation was to have the father come to be examined along with the mother to see if we could gather any further clues to her diagnosis. That, and sending photos home to CHOP to get help from the experts there. Again, nothing that will likely change management in any way, but we at least hope to be able to give some answers.

Our little child with a genetic disorder and his mother

Much of medicine here is, unfortunately, like that. Though we have so much technology at our disposal back home, it very often does not aid in caring for the patient or changing their outcome and may only provide answers. That’s not to say that does not serve a purpose, but in a resource limited country such as this, there is no room for doing tests or procedures that do not provide a greater benefit for the patient other than just answers. Thankfully, we are able to provide some of those answers many times without utilizing valuable resources other than our clinical skills and time and can provide many of these answers that can be so often elusive. Here, before we order a test that may cost the major portion of a family’s annual income, we ask ourselves first whether what we might find is treatable here, and if it is, whether that treatment is even within the means of the patient and their family. If either of these answers are no, and there are no other options for outside resources, then we cannot move forward and we must realize that it is not within our power to do so. That is not so say that it is easy, but it is reality. And anyone wishing to work here must at some point accept that. We have our success stories for certain, and for those we are grateful. But success can be measured in many ways, and it is often in one’s ability to comfort that we find our true calling.

2 thoughts on “March 15, 2017 – A full day in clinic…

  1. Robert weisman

    Dr r please give the family that needs the formula $200 and I will settle up with you when you decide to come to this very mixed up country
    Thanks
    Robert Weisman

    Like

    • Robert – Thank you for the gracious offer. We informed the family this morning and they were incredibly grateful and very, very touched by your generosity! Asante sana sana! Mike

      Like

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