Thursday, March 8, 2018 – Our first day of neuro clinic…

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There is always an air of excitement and anticipation for everyone after waking up on the first day of clinic here, both for me, as well as the residents. Despite this being my sixteenth trip to FAME (and seventeenth to Tanzania), each visit brings such new and varied experiences that there is always that feeling in my chest as we walk along the short trail by the other volunteer houses and approach the hospital and the outpatient ward. Just remembering everyone’s name given the six-month absence would be enough by itself to instill a bit of anxiety in anyone (There are over 100 employees here at FAME and I know the names of at least half of them which is pretty darn good for me). There is always a short delay, of course, as I approach someone for their name to pop into my head. For each of the residents, I can only imagine what feelings they must have as they are first walking to clinic. They have all been briefed by me and their fellow residents who have come before, but there is still no way that one can fully anticipate what their first impressions and emotions will be. Walking down the corridor between the hospital and the surgery suites brings you to the courtyard (that used to be the parking lot) with its lovely landscaping and total openness that suddenly reminds you (if you haven’t figured it out already) that you are in rural East Africa. The weaver birds in the trees, with their constant songs trying desperately to attract their mate, and the gorgeous flowers make you acutely aware that you are not at home.

Susanna and Baraka evaluating a patient

As we have done for the last several years, our clinic will be held in the emergency room area and specifically in the doctor’s night office, the emergency room itself, and the hallway in between where there’s a small alcove that is large enough for a desk, exam table and several chairs. This has worked well as it provides us with a separate outside waiting area from the main clinic so that our patients are lost in the mass of humanity waiting to be seen by the FAME doctors on a daily basis. They are currently seeing over 100 general patients per day and during the height of our neurology clinic we will usually see around 30 patients per day, so the waiting areas can become pretty crowded during the day. Most patients come first thing in the morning and, depending on how busy we are, may have to wait most of the day to be seen by us. Angel, who is now our coordinator for the clinic, has even arranged for our patients to have their vital signs done here in our section so there is less of a chance of someone sitting in the wrong place as that usually doesn’t get discovered until the end of the day since no one speaks up here and they are used to waiting for services. This is very much different than back home.

Baraka and Johannes evaluating a patient

The emergency room was being used for a procedure this morning so we could only use the two other “rooms” to see patients, but we also had a few ward patients to be seen, both of whom were children, so Susan broke away to take care of that while the others go started working on the growing stack of patient charts. Baraka and Emmanuel were interpreting for us this visit, which they’ve done in the past, and we would eventually have a doctor to work with us after the procedure was finished. Doctors here practice general medicine for the most part, meaning medicine, ob/gyn, surgery, pediatrics, etc., so it happened that the doctor working with us for the day was performing the endoscopy procedure that was also occupying the emergency room. That worked out fine, since we had the two other interpreters, but there is always a sense of loss opportunity when we’re working without one of the doctors as we lose that chance to educate.

Susan hyperventilating a child

Susan went off to see the young Maasai boy in the makeshift ICU as we were quite concerned about him. He was perhaps subtly improved, but only in regard to perhaps some minimal withdrawal to pain in his lower extremities, still with no heart rate variation with pain. Susan decided to opt for a trial of weaning from the vent and after a short period of time, the young boy had proven that he still had at least some respiratory drive meaning that at least some of his brainstem was still functioning. Unfortunately, this only mean that he wasn’t “brain dead,” a term we use to indicate that someone has suffered a permanent and irreversible injury of their brain with complete loss of all functions of the brain and brainstem and can be declare dead by neurological criteria. The presence of withdrawal of his lower extremities, which is sometimes tough to differentiate from “triple flexion,” which is a spinal reflex and not inconsistent with brain death, would have also meant that he was not brain dead, but was less definitive for us than the breathing was, of course, so now we had to make some decisions. Without going into all of the details, that would undoubtedly bore anyone without a strong interest in critical care medicine, we decided to obtain another CT scan after lunch to see what changes had occurred and may help us with the decisions that were necessary to make.

The CT scan ultimately demonstrated significant worsening of what appeared to be a progressive suppurative meningitis, meaning that his brain was covered with pus, despite being on numerous antibiotics along with acyclovir. His brain was also more swollen such that performing a lumbar puncture now could be very dangerous. We discussed his case at length with everyone involved and decided to continue watching him overnight and make decisions tomorrow of whether to withdraw care or not depending on his examination.

Susan and Baraka evaluating a patient

Susan also saw a little 2-month-old baby who had come in with presumed meningitis and was having focal seizures. The baby had ben given diazepam (Valium) at the time of its last seizure so the examination was not entirely informative as Susan was worried that the baby could have been lethargic and unarousable due to the medication and not the meningitis itself. Given the focal seizures, I was also concerned about herpes encephalitis and the baby wasn’t on acyclovir. We discussed further with Dr. Jackie and it was decided to do a lumbar puncture on the child to see if we could further characterize the meningitis any better. She had been on several days of antibiotics, though, so it was uncertain how helpful the LP would be in the end. We had little else to offer treatment-wise, though, so we went ahead and performed the procedure that showed few cells, but was not hemorrhagic. We started the baby on acyclovir (for herpes) regardless, along with continuing her other antibiotics and asked not to treat the seizures with any benzos in the future so we could get a good exam on the child. Hopefully, she will come around over the next several days.

Mindy and Susanna evaluating a patient with the help of Emmanuel

Despite the clinic being “unadvertised,” for the next several days, meaning that it wasn’t broadcast to the community here, we had plenty of interesting patients that came, some new and any follow up patients. One of the more interesting of the day was a seven-year-old girl with a myelomenigocele, or a failure of development of the bony spine typically at the bottom of the lumbar region that often involves various structures of the nervous system, meaning either the cord, the cauda equina (spinal nerves after the cord ends) or a combination of both. Most often, these children undergo surgery within days of their birth, but this child had never been operated on and still had the large and soft myelomeningocele sack at the bottom of her spine, obviously not open otherwise she would have developed a fatal infection shortly after birth. The problem here was, that though she had preserved function in her lower extremities, often completely lost in this syndrome, she was now developing bowel and bladder symptoms that were clearly due to the fact that her spinal cord was tethered, or essentially being stretched as she grew taller and the cord moved upward with growth. This was going to cause a progressive problem for her and she would need surgery to prevent this from getting worse over time. Also associated with myelomenigocele is a condition called Arnold-Chiari Type II, far different from the more common, and often asymptomatic, Arnold-Chiari Type I. Patients with Chiari Type II develop hydrocephalus due to a brainstem deformity and aquaductal stenosis so are most often shunted early in life. This child clearly had frontal bossing consistent with some history of hydrocephalus, but it had apparently arrested, as she no longer had any clinical signs of such. We ended up referring the family to Haydom Hospital, which is a medical center several hours away and apparently has a visiting team of neurosurgeons there on occasion. There was certainly very little that we could do from our standpoint.

Our patient with hyperhidrosis

Another interesting patient for the day was a young woman with hyperhidrosis that primarily involved her hands and was very impressive. She had sweat dripping from both hands and moments after it off, it returned. She had been seen her previously by Frank and he had referred her to us to see if there was anything that could be done from our standpoint, perhaps. This is often treated with Botox back home that is injected into the wrists, but that’s very out of the question here. We wracked our heads to think of something else to try and eventually came up with using trihexyphenydil, an older anticholinergic medication that might work by helping dry her up and decrease sweating. We gave her a prescription for it and we will see her back in several weeks before we leave to see if it’s effective.

Johannes and Baraka evaluating a patient

Our last interesting patient today was a young woman with narcolepsy and cataplexy that had very classic symptoms of both and was disabling for her such that it was going to worth treating her for the condition. The classic medication used for the narcolepsy component (the inability to control sleep onset such that they fall asleep frequently throughout the day) are the stimulant drugs like Ritalin, though there are newer medications out such as modafinil, which works much like the stimulants, but without some of the same concerns or side effects.

Susan evaluating a child with Johannes and Baraka looking on

Otherwise, we saw our normal smattering of epilepsy and headache patients, many as follow ups and some new patients, all coming to get their medications and to have us determine what labs they may need based on the specific medication they were taking. Angel had called about 20 patients to come see us today and we ended up having 15 show, or at least we saw 15 patients from the pool she had called in addition to others that just happened to pick the right day to have come to FAME.

Susan evaluating a child with Baraka

We all walked home after a successful first day of clinic, all the residents finding the day to have been quite satisfactory and exciting to them. Seeing patients here is much different than at home and not only because of the allure of being in a remote part of Africa and the fact that we’re using translators. I believe that it has to do with the lack of technology available and the fact that we are making decisions without having scans or other sophisticated testing available so that it is just the patients and ourselves. That’s not to say that there shouldn’t be more equity as far as technology and resources are concerned, but more so that practicing here requires you to think a bit more, perhaps, about what you want to do with a patient and how you’re going to do it.

Susanna and Baraka evaluating a patient

We drove to town to get some airtime to reload the phone the residents were going to use as an Internet hotspot and a case of Coke Zeros. There are still some things that we just can’t live without, but that’s fine. We’re here and that’s what really counts.

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