October 12 – Day four of our FAME Neurology Clinic…

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An older Iraqw woman complaining of memory loss

At morning report today, we discussed the little newborn who we had tried to do the LP on but were unsuccessful and who was receiving antibiotics for presumed meningitis. The baby had improved substantially following the institution of antibiotics and we still had a significant concern that we were indeed treating a CNS infection that would necessitate the baby receiving a full course or 21 days of antibiotics, but the family wanted to take the baby home now due to how we’ll the little baby was doing. We felt that would be the wrong choice and that we had to convince the family to stay in the hospital until the course was finished which would cost them additional money for the continued stay and treatment. They were finally successful in making a case a full treatment course with the family, thankfully, so they will be here with us for a few more weeks.

Patients on Thursday morning

Patients on Thursday morning

Patients on Thursday morning

Arriving to our neurology space after morning report, we were again encountered by a mob of patients waiting to be registered for our clinic. Once again, the numbers were not going down at all and we had a large group of patients waiting to see us today. I have limited each day to somewhere between 30-35 patients, otherwise the days become quite unwieldy for us. Chai time is from 10-11am and all the Tanzanian workers, including our interpreters and doctors working with us expect to go up for Chai that essentially shuts us down during that time. Lunch is at 1:30-2pm usually and everyone goes up to eat with us going typically on the later side. The patients today were all great neurology cases today except for a two, I believe. The first had a painful rash and the second had something else that was non-neurological. These patients were sent back over to the regular OPD (Outpatient Department) to be seen by the general FAME doctors.

Sara getting a history on the muscular dystrophy patient

Sara examining the young boy with muscular dystrophy

The case of the day was a young boy that Sara was seeing for weakness. The child was quite thin, though many Maasai are, but he was now having difficulty walking. He was here with his sister, but it turned out he was adopted from another family, as is often the case here, so we didn’t have a good family history for him. They had come to see us from Loliondo, a region far north by the Kenyan border and a seven-hour bus ride from here. I have been up this region to visit before and it is very, very remote, primarily Maasai, and has a small hospital in Wasso that is run by some priest/doctors, but is quite overcrowded, understaffed and undersupplied. I was totally overwhelmed as I toured the hospital with the only Tanzanian doctor there for around one hundred patients and had been asked to look at a young woman who had had an episode of asphyxia during childbirth and was now unresponsive, but still breathing. It was a very depressing case with little to be done either diagnostically or therapeutically other than to wait and see what she recovered, if anything. It is also a very poor region, further complicating providing medical care there.

Facial features of our muscular dystrophy patient

Pseudohypertrophy of the calves

This young Maasai boy of approximately 9 years of age had come with his adopted sister due to weakness and difficulty walking that he had had over the last year or slightly longer. The problem was progressive and we were both immediately thinking of a muscular dystrophy, probably Duchenne’s, which would be the most likely to see. He had a very hatchet-shaped face with what looked like some facial atrophy and also some atrophy around his temples quite possibly. His shoulder and humeral muscle bulk was quite atrophic and there was also some possible scapular winging. The most impressive finding, though, was his large and rubbery-feeling calves clearly suggesting pseudohypertrophy. He had definite weakness primarily of his shoulder and hip girdle and was strong distally in the upper and lower extremities.

Whitley teaching the neurological examination to Dr. Anne

Given our lack of ability to further evaluate with lab studies such as a CPK or to do an EMG, we were really limited to our clinical history and examination in this case, but our thoughts really were that though he most likely had Duchenne’s muscular dystrophy, we could rule out other forms with the present data and that we would want to see him again in six months. We put him on a low dose of prednisone which can help muscular dystrophy patients remain ambulatory for a longer period of time but would not likely change his overall prognosis. When we pressed the older sister for any additional family history, there didn’t appear to be any other family members who had similar problems.

Whitley and Dr. Anne discussing a patient

Whitley had an interesting patient in the morning today as well. This was a gentleman who I had seen 5 years ago and had given a history of a gradual onset of weakness in the lower extremities and difficulty urinating. I had requested lumbar spine films to rule out a mass lesion or similar, but he had apparently not gone to get the X-ray and was now back to see if there was anything that we had to offer. On exam, he definitely had a spastic paraplegia and a T10 sensory level that was consistent with my examination back in 2012. He also had urinary problems, having to usually manually compress his bladder in order for him to urinate. We sent him for the lumbar X-ray that I had originally ordered in the past and it was normal other than some osteophytes that were not what we had been looking for. Whitley got a much better history of the onset of his weakness that seemed to have been more sudden in onset or at least over a period of days suggesting that it was much more likely vascular in etiology than anything else and was certainly not compressive from any type of bony problem having now looked at his plain films. He was given some baclofen for his spasticity, but told that we unfortunately had very little else to offer him.

Aziza learning the neurological examination

Aziza learning the neurological examination

During our visit with the young dystrophy patient, while grabbing my camera off the table to take a photo of his calves, the camera strap somehow caught on the table causing it to pull out of my hand and promptly crash to the floor with the sound of broken glass. Luckily, it appeared that I had only shattered the lens filter and not the lens itself or the camera, but it was definitely out of commission for the time being. The filter that has a metal bezel and threads was heavily dented from the impact and completely unable to be screwed off no matter how hard we tried. I was later able to remove all of the glass from the filter, but with the bezel remaining on the lens, I could not attach another filter to protect the lens so would have to go sans filter, which I have never done before for fear of damaging irreparably the outer element of an expensive lens though this is what most professional photographers do. Not earning a living from my lenses, though, I have never been able to justify ruining a lens and buying another should that happen.

Dr. Anne and Whitley evaluating a patient

Sara examining a patient

We finished up the day with some time to spare as tonight we were heading to dinner at the Manor Lodge that sits high up on the ridge overlooking FAME and borders the Ngorongoro Conservation Area. Shangri La coffee plantation, one of the largest in this area occupies the slopes and ridge top of the Ngorongoro Highlands so that you drive through the coffee plantation to get to the lodge, also driving through a bit of the conservation area along an easement where you can see some animals occasionally. The main building at the Manor Lodge was an old German home that has been built up to be one of the premier high end safari lodges in the area with cottages that are quite spectacular and expensive. We have come though just for dinner that we get at a reduced rate due to our work at FAME, as most lodges in the area do for us.

My poor lens and cracked filter – the lens survived, the filter did not

The Manor Lodge has been designed to replicate the wine region of South Africa with its ornate English-style buildings that are quite beautiful. The views are great and they also have horses to ride here along with a pool, so many volunteers will come here to relax from time to time. As we sat out on the veranda watching the beautiful sunset with our special drinks (I’ve become accustomed to a Moscow Mule given my love of ginger and have embarked on a survey of Moscow Mules at all the lodges here) while we were also served some appetizers to whet our appetites.

Panorama of the grounds at Manor Lodge

We were called to dinner and sat at a table containing more silverware than I’m used to even at the fanciest of restaurants stateside while we were all served a five-course meal accompanied by first a white and then a red wine from South Africa. The food was, of course, delicious and we had a wonderful, relaxing and enjoyable dinner after a tough day of patients.

We eventually all piled into the Land Cruiser to drive back through the easement (no animals seen), through Shangri La Coffee Plantation and eventually back to Karatu and FAME, where we all settled into the Raynes House for the rest of the evening before climbing under our mosquito nets to enjoy the cool night air of the Ngorongoro Highlands while we slept. Tomorrow we were working in the morning, but would be free in the afternoon having scheduled our very first resident “wellness day” for that afternoon. We were still coming up with plans of what to do.

The four of us enjoying Manor Lodge

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