Monday, March 12, 2018 – Our FAME Neurology Clinic week begins….

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Susanna and Dr. Julius with a patient and family

We had had such a wonderful safari the day before that I think everyone was still reliving thoughts of elephants and Cape buffalo, some of whom were chasing us. Most had gone to bed early, exhausted from the busy day of travel, and now we were ready for the week ahead that would bring us the bulk of the neurology patients for us to see as these were the days announced to the community and the far lying reaches of Karatu district. Alex had worked on most of the announcements and had traveled as far as Lostete, the village that sits far along the rift in the Mbulumbulu region at the very end of the road. We have plans to visit there in October, but now the road is not suitable so the patients from that village will travel to Upper Kitete, the village where we have held neurology clinic now for the last six years. Mobile clinic will begin next week, though, and for now, we are focused on the patients that have traveled here to FAME. Last week, we had seen patients who traveled from as far as Dar es Salaam to see us, a twelve-hour bus ride. I’m sure we’ll see many more that have come from similar distances or who have made more difficult journeys.

Susan and Baraka evaluating a patient

Mindy and a follow up patient

It had rained some overnight, so the volume of patients at the clinic at the start of the morning were much less than you typically see on a Monday morning, but from past experience, I knew that we’d see more patients come as the day went on. I had been introduced to someone in Arusha last week who had already called me this morning that he was on his way with two of his family members for us to see so I anticipated their arrival mid morning. There were no new consults in the ward from over the weekend, but we did have the little baby with meningitis to tend to as well as the young man who had come with severe back and neck pain who lumbar puncture had been benign, but had been on antibiotics for several days which clouded the picture. The baby was still quite sleepy which Susan felt could easily be from the phenobarbital so she had planned to lower the dose and, if he began to have more seizures, we would load him with either levetiracetam or phenytoin, both orally, of course, as there are no IV preparations here. The older boy with back pain was markedly better, but given that we could not rule out partially treated meningitis, it was decided to leave him on his antibiotics and continue to follow him.

Mindy and Emmanuel examining a patient

One of Susanna’s early patients was a gentleman who had severe hoarseness and difficulty swallowing along with weight loss and we could find no neurological deficits otherwise, so were mostly concerned that he could have an occult malignancy causing his problem. We sent him back to Frank to discuss our findings and that we were recommending a scope of his throat and vocal cords, which was quickly set up to occur the very same morning. Things can happen a bit faster here as there is no bureaucracy to manage in any way and it is merely a matter of setting up the procedure room, finding a time that Dr. Gabriel is available and then it happens. By lunchtime, we had been told that his scope was normal, though we still had significant concerns for a malignancy so his evaluation would continue.

Susan examining one her pediatric cases

Johannes and Dr. Julius evaluating a patient

The friend from Arusha had soon arrived with his two family members and we began to evaluate them. One had had a stroke recently affecting his right side, but had recovered quite well albeit with continued deficits of mild weakness and dysarthria rather than any language dysfunction, making a subcortical infarct the likely scenario here. He was hypertensive, which was the likely mechanism of his stroke and we counseled him on getting his blood pressure well controlled along with his lipids. We sent him home with atorvastatin and aspirin, blood pressure and lipid parameters and made sure that he knew that he needed to find a primary doctor in Arusha to manage these things to prevent another stroke.

Johannes, Susanna and Julius evaluating a patient

The other family member was someone who could be diagnosed just looking at him for a second, something known as an “augenblick diagnosis,” or “in the blink of an eye.” This is an expression that I learned many years ago while training and I try to pass on these historic pearls to the residents as often as possible as they are often very meaningful. To lose the history of our profession would be a tragic loss for it is this knowledge of how we got to where we are that helps us know why we are here. I have universally used the “augenblick diagnosis” expression in reference to patients with movement disorders, as the initial observation of the patient sitting in the waiting room can often be one of the most informative parts of your examination. Seeing a Parkinson’s disease patient sitting there with his masked facies and resting tremor tells you the diagnosis and your history and examination are often merely confirmatory. Seeing a progressive supranuclear palsy patient sitting in a chair with their neck extension as opposed to neck flexion of the Parkinson’s patient is also a differentiating observation that helps you even before the patient is brought to the exam room. These are pearls that the late Fred, or Fritz, Dreifuss, a giant in epilepsy, had instilled in me some thirty years ago at UVa while training and which I will never forget.

Susan and Baraka evaluating a patient

MIndy evaluating a patient

Mindy examining a patient with Emmanuel looking on

Sure enough, Susanna, being the resident that she is, had already noticed him sitting in our waiting area so was typed off to what she was looking for long before she even asked a question or laid a hand on him for the examination. This is something that we are trained to do as neurologists for it is often these initial observations as the patient is sitting in the waiting area or walking to the examination room that are the most telling. Unfortunately, back at home, we have often lost this opportunity to observe the patients as they are brought back to the examination room by a medical assistant. It is not a perfect world and not all progress is to the benefit of our patient care at times, which is sad. The gentleman had been gone to see the doctor in Arusha with complaints of feeling tired and they had done an MRI, telling him subsequently that he had had a stroke. Given that his blood pressure was over 200 systolic when we saw him, it would not be at all surprising that he had significant small vessel disease on his scan, but his presentation was certainly not that of a stroke. We told him that he definitely needed to get his blood pressure controlled, but we also prescribed him carbidopa/levodopa, or Sinemet, which is the single most effective medication for the symptoms of Parkinson’s disease, and that this would very likely make him feel much better. They were both quite thankful for our care and we sent them back on their way to Arusha, hopefully much for the better and certainly much more informed.

Johannes teaching Dr. Julius the finer points of the neurological examination

One of the more interesting patients that we have seen this trip was evaluated by Johannes, and was very apropos, and clearly had some trouble with his ambulation, swaying in all directions as he walked into our makeshift examination room in the hallway between the night doctor’s office and the emergency room. He was 35-years-old and his problems had begun in his twenties, but the most significant part of his history was that many of his family members had had the same problem and had died from it. This didn’t come out early in the history, though, as the notion that a disease can run in families is not something that comes to one’s mind here and the concept of genetics is a foreign topic that is quite difficult to explain. Indeed, he had multiple family members on his father’s side that had developed the disorder and had lived into their 60s by the sounds of it, many dying of traumatic injuries suffered by their unsteadiness.

Mindy examining a patients

His speech was severely affected and was quite cerebellar in nature and that explained his difficulty with his ambulation. In fact, he was mostly all cerebellar on his examination with little else that could be brought out. Given his family history and the findings on examination, we were fairly certain that he had one of the spinocerebellar ataxias, a group of genetic disorders that are affectionately know as the “SCAs” to us are a seemingly ever expanding group with new discoveries being made on a regular basis. The apropos nature of Johannes’ caring for this patient is the fact that his father is someone who has spent his career studying these disorders (his mother, by the by, is also someone who has studied similar genetic disorders) and someone who has actually described at least one of them in connection with a large family in Cuba that was discovered. Finding a family here with one of these disorders was an exciting event, though unfortunately, we do not have access to any genetic testing or other methods of being more specific about which one he might have, not that we would have any treatment either here or in the US for it even if we could gather that information. It was still very exciting for Johannes to be able to email his father and then talk to him later on the phone about this patient. We don’t have the mechanism to get a specimen home currently, so we are unable to do any of the necessary genetic testing at the moment. I am hopeful that in the future we will eventually have the opportunity to more thoroughly evaluate these patients with some form of collaboration as providing genetic testing here will never likely be possible due the cost and lack of treatment, but would possibly further our knowledge of these disorders and be worth the investment in resources from that standpoint.

Mindy examining a patient with Emmanuel looking on

Mindy also saw a Parkinson’s disease patient today who had seen us previously and had been put on carbidopa/levodopa with excellent results, but had unfortunately run out of his medication for the last month and was unable to get here to refill it. He had very profound resting tremors and was quite bradykinetic, but both he and his family were adamant that the medication had benefited him significantly. This is such a common problem here regarding medications and the fact that we can really only give one or two months at a time for several reasons. First, we’re subsidizing the cost of the medications as our visits are 5000 TSh (Tanzanian shillings which currently are 2200 TSh per dollar so they are paying less than $2.50) and that covers the cost of seeing the doctor, any labs and their medications, typically for a month. On occasion, more than a month is given out, but not on a regular basis and we do this very judiciously. CT scans or x-rays are not covered under the 5000 TSh cost of the visit. When patients return they have to buy the medications so it is important to be certain that they can afford them for making an awesome diagnosis and starting medications only to have them stopped in month due to cost serves not purpose for anyone. If a patient is unable to afford the medications, we will involve our social worker, Angel, to speak with them and to decide what they might be able to afford and work something out with them.

Mindy demonstrating tandem gait to a patient

Because of the slow start due to the overnight rains with patients coming later in the morning, our patient flow was shifted a bit into the afternoon. We ended up working a bit later into the evening than normal so didn’t finish up until probably 5:30pm this evening. By the way, most of the patients we see use Swahili time, which is a real thing and is based on 6am being considered zero time. So 7am is actually 1:00 and so on. 5:30pm would be 11:30 in the evening, or jioni. Signage here on stores and on our clinic indicate the time in both the western format as well as Swahili time. Thus we’re open from 2:00 until 10:30 Swahili time on normal days.

Susanna examining a patient

We walked back to the Raynes House after a full day of clinic looking forward to our dinners that would be there for us. It was a relaxing evening with catching up on some charts from Saturday and with today and my trying to catch up with this blog, at times an all-consuming vocation. We all slept very well this night.

Johannes examining a patient with Dr. Julius

 

 

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