Our day began early as it was Tuesday which is education day. Today, Nan was speaking about neonatal sepsis as it has been a topic of discussion since her arrival and was an area that certainly needed further clarification. The real issue here was when to proceed to an LP and how that would change management as our resources are far more limited than they are at home. We have no cultures here, either blood or CSF, though they are coming in September, and are critical when managing these patients. In the US, any baby less than 28 days presenting with fever has an LP done as part of their work up. That has not been the practice here and the issue really becomes how long of an antibiotic course these children receive and what are the doses, either sepsis or meningitis coverage.
Somehow, Nan managed to find studies from various Tanzanian institutions that covered this topic perfectly and they were tremendously relevant considering where they were from. It had already been decided that it was not only impractical and resource consuming to do spinal taps on every neonate with a fever, but without cultures, there was also a significant question as to the information they would yield in this particular situation. She delivered an impressive lecture that provided an immense amount of relevant information with which to develop a protocol for FAME to use that would be appropriate for care in a resource limited country, though with a progressive attitude to continue improving the care here at FAME which is always the purpose of these exercises. There are always many questions that follow our lectures and this morning was no exception. Hopefully, the outcome will be that Nan will help to develop a practical and realistic protocol for neonatal sepsis and meningitis.
After her lecture (we did morning report beforehand due to a brief windows vs. Mac snafu) everyone began rounding in the ward while I went off to find Sokoine so we could get started on seeing patients that were already arriving for us. Chris rounded on his stroke patient with the team (the 90 year-old gentleman with a large left MCA territory infarction by clinical signs who was now nearly a week out) as he was still on the ward and hadn’t been eating well so had a feeding tube placed. After that, I was able to get Jamie and Chris started with patients and then went over to Ward 2 (maternity) looking for Nan as we had a third translator this morning to run three rooms seeing neurology patients.
Before I could reach Nan, though, Siana, the head nurse here, walked up to me with her phone to show me a photo that was of an anencephalic baby. When I asked her when the picture was taken she told me that she had just taken it in the labor room as the baby had just been born and was alive and crying. An anencephalic baby is one whose cranium and other parts of it’s skull and face have not formed properly nor has their cerebral hemispheres, but they do typically have an intact brainstem so are able to breath. I asked Siana to grab Nan from rounds and the two of us made a bee line for the labor room where we found one of the nurses attending to the mother and another nurse attending to the baby in the incubator.
The baby was severely malformed and didn’t have a complete face nor cranium so that the majority of it’s brain was not enclosed. Worse yet, the baby was struggling to breath and would intermittently cry. It had a very rapid pulse and was clearly very cyanosis, though we had difficulty getting an accurate oxygen level as we had to measure it from the limbs which were not reliable. Nan took immediate charge of the situation, attempting to make the baby comfortable knowing that it didn’t have very long to live. She got an oxygen line even though there was no where to hook it up to on the baby, so we just allowed it to blow in her face in an attempt to help her breathing and make it less labored. Dr. Brad was in as well and assessing whether the mother wished to hold her dying baby or after it had passed as we would have to wrap the baby in something to make her more presentable to her mother. There was some confusion by the nursing staff as to whether the mother wanted to see her, but it was unclear if they had actually discussed it with the mother or whether they had made the decision for her.
After a bit, we were concerned regarding the babies labored breathing and didn’t want it to suffer any more than it already had, so we were all in agreement that we give it a small amount of morphine to ease her breathing and pain. The baby remained alive for perhaps an hour after that, slowly fading, but with a clear drive to remain alive as that is a very strong desire regardless of one’s situation. The baby finally passed quietly and the family was comforted. It was nothing the mother did to cause this to happen and it would be unlikely for it to happen again to them. It was a tragic end to her pregnancy and she had no warning prior to going into early labor and delivering the baby prematurely. But with the tragedy, we were hopefully able to offer a bit of comfort to the portents and the baby, however short its life was.
We had excellent patients today including several epilepsy patients and a four year-old child that Chris evaluated with clear developmental delay and who had seizures previously, but was no longer having them. We brought Nan in to help with the child, but there didn’t appear to be any regression of milestones so it was very likely another story of perinatal injury or anoxia. It was decided not to treat the child with antiepileptics as she wasn’t losing milestones nor having clinical episodes.
While Chris was seeing his patients today, Dr. Jackie slipped into the room to inform him that his patient who had suffered a stroke last week had died. Even though the patient was 90, it was still a bit of a shock as we had seen him that morning and there were no clinical changes. Chris finished with his outpatient and went over to the ward to find out what had happened and learned that family had been in the room with the patient and had just thought he was sleeping. By the time anyone realized anything, the patient had fixed and dilated pupils and there was no point in trying to resuscitate him here. Chris was rather surprised that there had been no code status on the patient, though I explained to him that coding patients here can be very tricky as we don’t have an ICU or a mechanism to support patients for any length of time on a ventilator. Performing CPR for a witnessed arrest is one thing as they have a reasonable chance of recovering quickly, but trying this on someone who has been down for sometime with the likelihood of having suffered significant neurologic injury and would require long term recover is another matter altogether. Regardless of what this patient’s outcome was going to be, it’s never easy to have someone you’ve been caring for pass away so suddenly.
We had planned to visit a long-term patient of mine and her husband at the boma after work today and were able to finish a bit early to get on our way. Elias is a Maasai who met over four years ago when he brought his wife to me for seizures and she had never been treated before. We eventually transitioned her to lamotrigine (not an easy trick with someone living far away in a boma) and she has not only been seizure-free now for several years, but has also had several children without incident. The last two visits, he had expressed an interest in having me come to his boma for a goat roast to show his gratitude to us, but we have always run out of time to do this. I had told Sokoine last visit that I wanted to made sure this happened during our time here this month.
So today was the day for our goat feast and we loaded everyone up in the Land Cruiser to visit their boma. We picked up a few gifts to bring as Sokoine says that you never visit a boma without something to give so we brought a bag of rice, a case of water and a case of soft drinks. The boma was on the other side of Mto wa Mbu and Lake Manyara which was about a 45 minute drive for us to reach the turn off. Alais met us there along with one of his neighbors who led us to the boma driving a motorcycle in front of us while Alais jumped in our vehicle. The drive was longer than I had anticipated and traveled along a thin trail the majority of the time and at times was more a cross country jaunt. We eventually reached his boma, an enclosed or six or so mud and dung huts. We drove our vehicle through the opening in the brush fence that enclosed the boma and when we arrived, all the children and wives came out to great us.
They brought small stools and five-gallon buckets out for each of us to sit on. In addition to Chris, Jamie and Nan, we had also brought Sokoine and Angel along with Abbey so we had a large group of us. We sat around in the boma and presented them with their gifts before eventually taking a short walk to where they were roasting the goat for our dinner. Thankfully, they had already butchered the goat which was just fine with Jamie as she is a vegetarian and even though she hadn’t planned to eat, it was still nice not having to watch the poor goat before being cooked. It was being cooked on small stakes leaning over a fire and as we waited for the meat to finish, they were piling all of the organs in a bowl of water to boil as they waste nothing that is potentially edible. Even the head is roasted and eventually striped of all it’s meat.
Once ready, they would take one of the various cuts and place it on a taller stake that allowed them slice chunks of meat off as we ate them. The first pieces were all a bit chewy and it was hard to tell what was meat and what was gristle, but it was tasty just the same. As time went on, though, the slices of meat became leaner and leaner and were pretty much irresistible, at least to my palate. The others were not quite as enthusiastic as I was and, because of this, they seemed to continue handing me the chunks of meat to eat, which was perfectly fine with me. It became a bit of a joke after a while as I kept saying “last piece” and they kept handing me more which I didn’t want to turn down so as not to offend anyone. Eventually, though, I had to step aside or I would have burst.
The scenery was amazing with nearby Lake Manyara shimmering in the setting sun and the lush vegetation of this area after the recent rains. As we walked back to the boma with the long shadows of the dimming light, it was never more apparent to me both the differences and the similarities of our cultures. Beauty and joy seem to transcend all as we give our thanks for the courtesy they have shown us here tonight in their home, in their land and in their world.