October 6, 2017 – Day two of our “unannounced” neurology clinic….

Standard

Having planned to finish yesterday’s blog this morning, I somehow managed to oversleep. There are some who may not be too surprised by that (I am a champion at hitting the snooze button on my alarm), but I had accidentally turned my alarm off this time so to be completely accurate, it was not a world record at hitting the snooze button. Just the same, I awakened to another gorgeous day outside my windows with a cool morning breeze gently sweeping through my room and against the mosquito netting. The only problem was that I had to be at the clinic in just half an hour and there was a shower to placed somewhere. Thankfully, I am also a champion when it comes to jumping out of bed, showering, getting dressed, drinking a cup of coffee, having two sweet bananas, grabbing my gear and hitting the road. Well, actually it’s just a short walk to the conference room where we hold morning report, so along with the residents (who were up much earlier than me this morning), there was not issue making it in time.

Sara taking a quick break to chart the old fashioned way

There was already a rather animated discussion going on among the staff that was in Swahili and had to do with their maternity program (RCH). After some time, Gabriel apologized noting that they were having a brief staff meeting and felt more comfortable speaking Swahili. It was fine with us as long as we knew if didn’t involve neurology or something we had done wrong, which it hadn’t. Once underway, Dr. Julius, the clinical officer on overnight, went over all of the inpatients from overnight. Again, they had two patients that needed to be seen by us. One, a young adolescent with headaches and syncope and the other, a baby born several days ago at Karatu Lutheran Hospital having seizures the first day of life, the family requested discharge home and then came to FAME when both the baby and mom weren’t doing well. The mom had an infected abdominal wound from her C-section and the baby was now febrile and was looking worse.

Neena, Angel and Baraka evaluating a patient with seizures

Neena examining her patient

It was a slow start to the morning, but things picked up rather quickly and we had a nice stack of charts waiting to be seen. With the little baby in the ward, it worked well to have Sara start there and the other consult was an adolescent so she was going to see both of the consults. Whitley and Neena started on our group of outpatients now accumulating. I had thought perhaps we might actually make tea time at 11am this morning, but that never happened and before we knew it the morning had long passed and it was time for lunch at 2pm. We had been seeing patients straight through for 5 hours without a break. The work is so engrossing though, you don’t even realize the time passing and it’s a general feeling here.

Whitley evaluating Dorthea who has a hemiparesis and seizures and who we’ve seen since 2013

The patients were a bit more typical today – vague numbness, back pain, headache – but they were still quite interesting. Neena saw young woman with a spastic paraparesis that occurred at the age of four who had been completely evaluated at either KCMC or Muhimbili Hospital in the past, but the scans and all the records had been lost when their home burned so we had none of them. It ws very difficult to resist putting her in the scanner here just so we would have our questions answered, but it wouldn’t change her care one bit and we were left with only speculation as to whether she had had an ischemic event, bleed from an AVM or anything else that might have produced her deficits. She had been stable for 15+ years so it certainly wasn’t something that was progressive. She had seizures that we were treating and we would work on that for now.

Neena evaluating a post-ictal seizure patient

Neena also had the opportunity to evaluate a young woman brought in on a stretcher and who was totally unresponsive. This is quite a common event here, to have either someone brought from school or from the fields after having fallen down and were now unresponsive. They are usually woman, though occasionally we’ve had boys come in with this, but I’ve never seen an adult male with it. This young woman was accompanied by her teacher and she had had a similar episode in March when Jamie Podell had seen her, but she had done well since then until we arrived back in town.

Neena’s patient with conversion

Neena went through her exam, which was, of course, normal though her eyes remained closed throughout her time with us and she had absolutely no movements. She blinked to clap, didn’t allow her hand to fall on her face and in general had all the signs we see in a patient who has “fallen out” or “swooned.” She was having another conversion episode. We had treated her with amitriptyline previously as she had also had some headaches and so now we decided to move her up to fluoxetine, a bit more potent of an antidepressant as it was clear she was having some issues with stress being away at boarding school. Neena reassured her teacher along with the patient, who remained “asleep,” but was clearly listening, that she would wake up very soon and be back to normal. I last saw her being loaded into their truck from the stretcher, still unresponsive, but more importantly not being admitted to the hospital as she had been in the past.

Patient with conversion leaving the clinic

Meanwhile, the young adolescent female that Sara went to see in the ward had a very similar story, though also had migraines and what sounded like some orthostatic hypotension contributing to her episodes. She also had a boatload of unresolved issues including previous suicidality that Sara very patiently listened to for some time and which the patient didn’t want her parents to know about making the situation that much more difficult. She also had complained that a teacher had broken her thumb at school so we involved our social worker, Angel, to look into that allegation, but it turned out not to be true and was something that had already been resolved in the past. She also had numbness on the left side of her body that was clearly functional and her examination was otherwise normal. Given the background of stress and unhappiness she was having being away at school (similar to our other young woman) it was not surprising that she could have a large component of conversion to her presenting symptoms, but given her migraines we decided to treat these as well and put her on amitriptyline for the headaches hoping that she would improve.

Sara’s other pediatric consult was the little baby who was about 7 days old and had been seizing since day one, was now febrile and didn’t look very well at all. She had a bit of a bulging fontanelle and a poor suck making Sara very concerned that she might have meningitis. She had not been on antibiotics to cover meningitis, so those were changed and we felt the need to do a lumbar puncture. Beforehand, we had Dr. Gabriel do an ultrasound of the baby’s head to make sure there were no contraindications to doing the spinal tap and there were none. Sehawa, our anesthetist, was going to do the LP, but called later in the evening to tell us that he had been unable to successfully get any spinal fluid so we decided that we’d try again in the morning as the baby was now on the correct antibiotics and it was really to determine the length of antibiotic treatment.

Sara evaluating a prior FAME premie returning for a follow up visit

We finished clinic in time for everyone to return to the Raynes House and relax for a bit with the sun still high and sunset more than an hour away. Everyone was again exhausted and looking forward to some real downtime tonight. In fact, a movie night with popcorn had been planned and the movie was “Lion,” certainly not chosen for the fact that we were residing currently in a region highly populated with this animal, but rather for the wonderful real life story told by this movie. If you haven’t seen yet, it’s highly worthy of your time. Tomorrow would be another day in clinic with more interesting patients, but for tonight we were on idle in our comfortable home where we’d be staying for the month. Sunday will be a day safari to Lake Manyara National Park where hopefully we’ll spot some real lions.

Working on charts in the Raynes House looking towards the back door

Looking towards the front door and veranda

My room in the Raynes House

One of the three other bedrooms

Our view from the veranda

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