March 23, 2017 – Day two of our clinic at Qaru…

Standard

The team rounding on a patient with severe burns – Dr. Elle managing

 

I completely forgot to mention that the night before, we had a ward consultation regarding a gentleman who had presented after the sudden onset of right-sided weakness and inability to speak or comprehend. Chris had gone to see him after we had returned from clinic and was happy to report that they had assessed him correctly after his lecture Tuesday morning which was very reassuring. He appeared to have a complete left MCA territory infarction on examination with a global aphasia, right visual field cut and right arm and face weakness with some sparing of his leg. He was also in atrial fibrillation which we had discussed at length at the lecture in regard to the fact that you should wait about two weeks before anticoagulating a patient due to the risk of hemorrhage. It was great for Chris to use as a teaching case, though not so great for the patient. He was a bit agitated when he was admitted, likely due to his global aphasia. So on morning report, we discussed his case and what his continued management would be going forward.

Chris examining his stroke patient with the team. Dr. Gabriel, Dr. Msuya and Siana looking on

Chris examining his stroke patient

Rounding on a pediatric patient with Nan discussing the case with Dr. Gabriel, Dr. Msuya, Siana and Dr. Brad

Nan, of course, was busy with her pediatric cases before and during rounds which she has been doing a great job with. This morning, the very tiny Maasai baby, whose name is Frank, had decent labs so he will go home today with his family. They live quite far and it will still be touch and go with him. The family agreed to come back next week to see us before we leave and we hope to reinforce the education that was given before he left when they return. He’s so small and without his mother, it will be touch and go. His family, though, was very motivated and seemed to want to provide excellent care for him.

Chris and Angel evaluating a patient

We picked up Sokoine in town as he was buying our food for lunch so we could get an earlier start. Stopping at the grocery store with everyone getting out of the vehicle and choosing what they would like to eat can be a bit cumbersome and time consuming to say the least. We’re often delayed in town for 45 minutes picking everyone up and shopping for each days lunch. I had tried lunch boxes (which are what is used when you’re traveling on game drives so are quite commonly sold here) before, but it didn’t go over well with the Tanzanians as it wasn’t what they were used to eating. Since then, we’ve typically bought the various pastries that are all full of carbohydrates and typically fried so they are the furthest from a healthy diet that you can imagine. Everyone seems happy with these, though, so that has been our practice for the last several years. At least having Sokoine buy everything in advance will save us time, if not calories, carbs and saturated fats.

Jamie evaluating her patient with epilepsy

Jamie examining her patient with epilepsy along with Dr. Mary. Moments later, the patient had a seizure

Discussing treatment options after the patient was back to his baseline

Clinic today was a bit interesting, considering Jamie’s first patient, which I had decided to sit in on today, wanted to demonstrate for us what his seizures looked like. This was a 21 year-old gentleman who was accompanied by his mother and spoke mainly Iraqw which is quite unusually for a young man. His mother described episodes that were fairly classic for seizures and, specifically, frontal lobe seizures that were reasonably frequent. As Jamie was examining him, he suddenly leaned forward and spit on the ground, then stood up with a very blank stare and was clearly having a seizure. We eased him onto the bed where she was examining him and his eyes were fixed to the right and he was not responding. This lasted only briefly and then he began trying to get up and was still quite confused. We put his coat under his head and he curled up for several minutes before he was finally able to speak and comprehend. He didn’t generalize, though his mother clearly described generalized convulsions in the past and this seizure was clearly a partial complex seizure without generalization and was quite consistent with a left frontal focus for his seizure. He had been put on phenobarbital sometime in the past, but the dose wasn’t clear and it hadn’t helped him at all. His mother had eventually stopped the medication due to it’s ineffectiveness and he just continued having seizures on a regular basis. How amazing it will be to possibly finally control his seizures after all these years. His mother was so appreciative and grateful that we were at least giving her son some hope that she was close to tears and couldn’t thank us enough even though we hadn’t even done anything yet.

Nan examining an adult

Nan happily keeping busy seeing patients.

Patricia in our “pharmacy”

Patricia talking with a patient in the “pharmacy”

Nan’s final patients of the day were also quite interesting. It was a mother and daughter who both suffered with epilepsy, though it wasn’t quite clear that it was genetic. Mom’s seizures hadn’t begun until her 30’s and her daughter’s seizure began at age 4 and she was now 7. The description of mom’s seizures by her husband, which very much embarrassed her, looked primarily generalized, but the description of the daughter’s seizures were less clear. While Nan was taking their histories, I gave the daughter my cellphone to play with for a bit and when I left with it after a while, she apparently burst out in tears so I had to give it her again. She was quite cute and thankfully seemed to be cognitively normal despite having had untreated seizures for several years which is so often not the case here. It was a struggle for us to decide what medication to use for each of them as we don’t have the full complement of medications to use that we have at home and some of the medications we have here are often in short supply and sometimes too expensive for the patients. We eventually came up with a plan that seemed reasonable, but it will require that they be followed up at FAME to make certain that they’re each doing well.

Lunchtime in the shade at the car

We were finished with patients and decided to have our lunch under the same tree, but try as I may, I couldn’t track down another chameleon and was very disappointed over that. After lunch, we discovered that we had more patients who had showed up in our brief absence, and since it was our last day at Qaru, it was only appropriate that we see them despite the fact that it was getting late.

Nan evluating a mother and daughter epilepsy case

Playing games on my cellphone

Happy with my cellphone

We traveled back to Karatu, arriving back to FAME sometime after 5pm and decided to relax for the evening. We were planning to go on Safari for the weekend and needed to do some shopping, but that would wait until tomorrow after work. So, for tonight, it was dinner and work and then to bed. Tomorrow we would be heading off to Rift Valley Children’s Village for our last day of mobile clinic and then next week we will be back at FAME for neuro clinic again.

Abbey’s new boot

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