Friday, March 16, 2018 – An interesting stroke syndrome and a slippery walk…


Our patient arriving by vehicle

We were on the home stretch for our weeklong neurology clinic at FAME and, to date, it had been a rather slower than usual clinic. It’s always hard to predict what the volume of this clinic will be beforehand as it can be affected by so many variables. I know that Alex and Angel had gotten the word out to the Karatu community at large as well as to all of the mobile clinic sites, but even with the excellent outreach team we have working in advance of our visit, the other factors involved are well out of our control, such as the weather, harvest time and, at other times, politics. In October 2015, we were unable to do our mobile clinic due to the national elections and many patients were fearful to travel to clinic out of concern for their safety. Most recently, though, we are having more rains than we’ve had in the past during this month which is the main reason for the lighter than normal clinic volume. The orange-colored clay of Karatu turns to pure muck during the rains and makes travel often very difficult, if not impossible. During the heavy rains yesterday, I was very surprised to see the patients that came, but was very happy they did.

…and being loaded onto a stretcher

At the start of clinic today, the stroke patient we had seen previously had come back to have her INR (a measure of how thin her blood was from the warfarin she was taking) checked and was booked into our clinic again even though we hadn’t planned to necessarily see her back. It was good that we did, though, as she had been put on a medication to treat her stiffness and it was working rather well so that we could adjust the dose upwards and she would get yet greater benefit. This is often such a problem here as many medications are meant to be titrated to effect or they have to be started slowly so a patient can adjust to any potential side effects. Trying to do this in the absence of a neurologist here isn’t ideal and is something that I am hopeful to address in the near future by possibly training practitioners who can care for our patients in our absence and following through with our recommendations. So often, we see patients back after six months and nothing had been done in the interim. Hopefully we can help to change this going forward.

Johannes, Susan and Baraka evaluating a patient

Johannes’ favorite patient of the day was a gentleman who came in after a stroke, but it was a very unique syndrome that Dr. Price, Penn’s residency director, loves to focus on because of it’s importance when trying to localize lesions. The gentleman had severe right facial weakness of sudden onset that was quite atypical for a Bell’s palsy, or facial nerve palsy, that is so commonly seen. The other unique feature of his examination was that he had abnormal eye movements, and, specifically, a sixth nerve palsy on the same side. This is caused by a brainstem stroke that hits the sixth nerve nucleus and the facial nerve fibers and they travel around the sixth nucleus. The gentleman had actually had an MRI done and there was a lesion in just the right location, but it hadn’t been read as such, and, so for us, it was a great case. It had actually occurred only a month or so ago, so we were able to institute so secondary prevention therapy that might help him in the long run. He was a very nice man and it was a pleasure to not only have helped to treat him, but also to be able to explain to him definitely what had happened and what his prognosis was. Of course, even though he spoke good English, it was still challenging and took much longer even with that. Thankfully, we weren’t tremendously pressed for time today.

Baraka with his two language students

Mindy and Susanna continued on their quest to not only master the neurologic examination in Swahili, but also in Iraqw, as they are neck and neck with the Maasai in regard to the patients we see here. We really don’t have a full-time Maasai translator to teach them Maa, so they will have to be satisfied with those two languages for now. Given that, though, they have become extremely proficient in Swahili and Iraqw and they continue to amaze me. Susan and Johannes have also picked more than is usual for the residents on this trip, but the other two have excelled.

Mindy teaching Dr. Julius how to do occipital nerve blocks

The rest of the day was filled with our normal smattering of developmental delay, headache, epilepsy, and back pain, and Mindy was even able to do occipital nerve blocks on a patient with occipital neuralgia and show Dr. Julius how they are done. This is a technique that we use often at home to manage our headache patients who have a significant posterior component to their headache or more classic occipital neuralgia and it is often very helpful in relieving their symptoms. We have had the supplies here to do these and over the last four years have found them equally helpful here as they are at home.

Mindy seeing a patient with Dr. Julius’ help and Susan scribing

Susanna evaluating a patient

With the light patient volume, we were able to get home at a decent time and though I was still behind in my blogs, I offered to show Susanna and Mindy where we normally do our walks from the house here. There is a gate at the bottom of the slope behind our house that lets you out onto the road traveling around FAME and takes you further from town and finally out to the fields behind our compound. It was quite muddy and there was no way we were possibly going to take the normal circuit, but there is a part of it that would be possible even with the mud. So we began walking and eventually climbed the hill to where Caroline, the development coordinator and someone who’s been here as long as I have, lives. From her property, you can also see the new private school she has built, and so we continued our walk in the direction of the school. It was a gorgeous evening to be out walking despite the muddy roads, or at least I thought so until I took a misstep and slipped, almost catching myself, but alas, didn’t, coating my hands and pants in the sticky goo that is the Karatu clay. Thankfully, no injuries other than my pride, and we continued the walk back home with one of us a bit more distressed in the furniture or fabric sense of the word.

Johannes conferring with one of his patients one last time before they leave

Mindy examining a patient with Dr. Julius’ help while Susan scribes

Everyone was happy to remain home this night, though Susanna and I made a quick run into town to the exchange bureau where we get TShillings for dollars, only to find our normal exchange closed and were directed to another down the block that I hadn’t know about before. I had had to replace the battery on the Land Cruiser and needed to pay the mechanic in the morning when he brought the car back to us.

Johannes evaluating a patient with Baraka’s help


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