It was our last day of “unadvertised” clinic as we would be starting our full on FAME neurology clinic next week, one that is announced to the entire Karatu District with personal visits that are made by FAME to churches, local villages within the district, and the local markets. Fliers are also posted around the community announcing the neurology specialty clinic and attempting to communicate what type of disorders we will evaluate, but despite these attempts to triage patients in advance, we still see very many musculoskeletal pain patients that slip through our screening process. Theoretically, this wouldn’t be an issue if we had the capacity to see the patients, which we often do, but it is a problem financially as we are subsidizing the cost of these neurology visits that are for neurology patients and not for the general pubic as that would not be sustainable for us. It is already tenuous just trying to fund the neurology patient visits without adding in all the non-neurology MSK (musculoskeletal) patients who would overwhelm us in very short order.
The clinic today was surprisingly slow at the start and, though it picked up later in the morning, we were still able to finish a bit early, which was good as we had plans for dinner at Gibb’s Farm tonight and that entails arriving there early to take advantage of their fantastic grounds and amazing views prior to sunset. There were several interesting patients today and one of the more interesting ones was a young woman who had a history very suggestive of schizophrenia, but also epilepsy, and the two disorders seemed to have very little to do with each other, but were both very convincing from her history to the degree that we weren’t comfortable even considering discontinuing her anticonvulsant treatment. She wasn’t on anything currently for her behavior so we provided a prescription for olanzapine, a very reasonable atypical antipsychotic medication that would work very well for her and is one that is reasonably priced here.
Susan and Susanna evaluated a young 19-month-old girl whose mother had accompanied a friend to clinic and hadn’t actually planned to see us, but thought she would since she was there and we were all very glad that she had. The little child did not have any neurological disorder, but she did have an incredibly severe case of malnourishment, weighing only 5kg with a normal head circumference. The mother reported that she had been eating normally and had a good appetite, but given that she was well under three standard deviations below on the weight-to-height charts, it was quite clear that she had a very serious problem.
We had asked Dr. Jackie to come help with a decision of what we would be doing for the young child and both she and Susan were in agreement that should be admitted to determine why she was so malnourished and also to begin consideration of a refeeding program once she had undergone some testing. It was clear that her mother was caring for her, but not how she had become so malnourished. When Jackie and Susan spoke to the mother and informed her of their desire to admit the child, she indicated that it would not be possible, as she had come from a long distance with others and had to return home to take care of her other children. The gravity of the situation and the degree of malnutrition was made clear to along with the potential risks to the child of not coming into the hospital, but mom was adamant that it would not be possible to bring the child in, so we ended up doing all the lab work planned as an outpatient and had them wait for the results of those tests before they would leave for home.
I did have some vague recollection of the refeeding syndrome, but Susan reminded me of the seriousness of this condition that occurs when giving protein-rich feedings that can cause numerous electrolyte abnormalities, cardiac arrhythmias and other potentially life threatening complications. It was important, therefore, that we didn’t just send the child home with these feedings and find out later that she had succumbed to one of these complications. The child’s labs returned essentially normal, but this didn’t give us much of an answer as to why she was having the problem with her ability to grow. To give you some idea as to the degree of malnutrition and growth retardation, the little 2-month-old boy on the ward we are treating for meningitis weights some 10 kg, or double the weight of this 19-month-old patient.
As I mentioned, patients were filtering in rather slowly over the day and so when Angel and someone else pointed out a wonderful chameleon climbing in the tree outside of clinic, I quickly grabbed a ladder and climbed up high to catch the beautiful creature before it could escape. For those of you who are not familiar with these old world chameleons as opposed to the new world anoles that live in Florida, Mexico and further south, there is really no comparison at all. The true chameleons are just the sweetest lizards that wouldn’t hurt a flea, though love to hunt bigger insects such as crickets and beetles. Their feet are like clamps with tiny little nails that they use for their climbing in trees and their eyes move independently of each other so they can be looking in two directions at any one time. They are simply an amazing feat of nature. When I was young and we owned a pet shop, we used to have chameleons as pets and actually successful bred some of them much to the dismay of my father who never quite understood our fascination with reptiles. I had later instilled that love in my children, and especially my daughter, Anna, who had a series of bearded dragons growing up.
This had to be the healthiest chameleon I had ever seen and when I grabbed him out of the tree, he hissed and opened his mouth in a threatening manner as if he were going to bite me when that is never their intention. It is merely a bluff. Mindy fell in love with it immediately and couldn’t hold him (or her) enough, having it climb all over her while trying her best to keep it on her arms in front of her rather than her shoulders and head. Johannes held him as well and they were both quite adamant that we bring him back to the Raynes House and release it the general vicinity in one of our trees. I got a cardboard box and was big enough for him, but couldn’t climb out, and Mindy brought him back to the house. Later, when I arrived home after the others, I found them all out on the veranda holding Doug, as he was now called, and letting him climb on them. As we had planned to head up to Gibb’s Farm for the evening, they would have to let him go shortly in the bushes near the house where he would hopefully do just fine, catching as many flies and bugs as his little heart desires as that will limit the number of those creatures that wish to share the house with us as this is a continual battle.
I had forgotten to mention that the night before, on our way to the Kudu lodge, as Mindy stepped out the door to put her shoes on that were just sitting outside, she let out the cry as there was a considerably large spider sitting at the toe of her sandal that turned out to be a rather small tarantula, but a tarantula just the same. Her reaction was already perhaps one of the highlights of my trip here.
Tonight, though, we were heading to Gibb’s Farm for dinner and, as I mentioned, it’s always important to get there with plenty of time to enjoy the scenery before sunset. We drove my standard back route which is a series of small trails that eventually intersects the Gibb’s Farm road and winds its way up through the center of Tloma, which the small village nearby Gibb’s that is one of the Iraqw cultural centers and from where a number of our patients come that we see at FAME. Once at Gibb’s, I had the residents explore the vegetable gardens that occupy a large plot of land that slopes sharply down from the parking area and reception where they grow most of the food that is served in the restaurant and is just such a pleasant place to visit. At the bottom of the very large garden is a massive and majestic tree where they have talks in the evening around a fire pit for the guests. While the residents were in the garden, I went and found a nice place on the veranda to sit as it has one of the most spectacular views of any lodge in Africa, looking east towards Lake Eyasi. Tonight it was particularly cloudy such that the sunset wasn’t the best, but no matter, the view was still awesome and, more importantly, the drinks were delicious and were a great prelude to the dinner to come. I had ordered my Moscow Mule and sipped on it while waiting for residents as many of the waiters who know me from past visits came by to say hello. As everyone else arrived, they ordered their drinks and we took some photos to remind us of this magical place that has to be one of the most truly serene locations on this planet. The positive energy that exudes from there can be felt and it is no wonder that it has special healing powers for there is a sense of wellness that permeates through the premises. One cannot help but look forward to visits here.