Thursday, October 4, 2018 – Day 2 of our neuro clinic….

Standard

Steve giving his lecture on meningitis to the clinicians

One of the responsibilities for volunteers who travel to FAME is that they contribute to the education of the clinicians here at FAME and these lectures are given on Tuesdays and some Thursdays. At morning report yesterday, they announced that they apparently did not have anything scheduled for today, so Steve volunteered to a lecture on meningitis at the last minute. The lecture was well attended considering that it was 7:30 am and Steve did a great job which really isn’t surprising considering that he has been a master educator for his entire career and there are countless physicians who he has trained over the years and who are now master educators themselves. Though there is only a thirty-minute timeslot for each lecture, I have become quite familiar with their tolerance for speaking overtime, so when Steve was still speaking at 8:15 and hadn’t been yanked off stage, it was clear that he had caught their attention. There were a number of very good questions asked that were followed by the Tanzanian manner of congratulations with three claps accompanied by a hearty “pasha, pasha, pasha,” or at least something that sounds like that.

John and Shaban evaluating a patient with Peter scribing

Lindsay examining a patient with Amisha and Anne

Following morning report, Steve joined the ward team for rounds while the entire neuro team prepared for another day of outpatient clinic. I was again an unannounced day so was relatively quiet and manageable at the start with a slow accumulation of patients throughout the day. Our patients once again ran the gamut of neurological disorders, but as is par for the course, also included a few non-neurological patients who manage to slip through our triage process. As we are offering to see patients for the flat fee of 5000 Tanzanian Shillings (TSh) (less than $2.50) which includes the visit, medications for a month and any labs that need to be drawn, it is not surprising that we typically have many patients coming who hope to be seen whether they have a neurological illness or not. I have spent countless hours working on our triage process over the last several years, but it is very difficult for anyone who doesn’t really have a good grasp of neurology to truly be effective in this role.

Dr. Anne, Lindsay and Amisha in between patients

We had several patients with essential tremor and others with epilepsy. One of our patients with epilepsy was a gentleman who was accompanied by his son and had been on phenobarbital for many years and had a very dull affect. Phenobarbital is still the first line anticonvulsant that is recommended by the World Health Organization, but it has such significant side effects that we use it only in children under two years of age. After that, we are using medications such as carbamazepine, phenytoin and valproic acid as they have excellent tolerability with good response rates. We also have a few newer medications such as lamotrigine and levetiracetam, but unfortunately, these medications are very expensive compared to the cost of the three listed above and orders of magnitude more expensive than phenobarbital. The patient had what sounded very much like localization-related epilepsy based on the semiology of their seizures, though, so we placed him on one of the other agents that he would tolerate much better and we hoped that he would perk up some once off of his phenobarbital. The taper of his phenobarb would take six months or more given the length of time that he has been on the medication so as to prevent any withdrawal seizures or the possibility of status epilepticus.

Amisha evaluating one of her young patients

Amisha continued seeing kids which made her very happy, though one of them who we had seen on our last visit had continued to deteriorate. He was a ten-year-old boy who we had first seen about a year ago and diagnosed with muscular dystrophy. We had placed him on steroids which is the recommended treatment for Duchenne’s muscular dystrophy and recommended that he come back to see us in March when we were here, but unfortunately had not come. He was from the Loliondo District which is about a seven-hour bus ride north of us near the Kenya border and a region that is quite large with little in the way of medical facilities. I had visited a hospital in Wasso several years ago that was staffed by physicians from a religious organization and partnered with the government, but at the time I was there, they were understaffed with only a few junior physicians and far too many patients which is all too often the situation here. It was an incredibly overwhelming experience for me and they had asked if I could look at a few patients for them, one of who was a young woman with a severe anoxic injury that had occurred while undergoing a C-section and was quite tragic as she had regained no function was mostly in a persistent vegetative state as far as I could tell based on my one examination.

Amisha with one of her patients along with Anne, Shaban and the patients caretaker

This young boy was living in an orphanage and had been brought to clinic by one of the women who care for him. She noted that he had improved some with the steroids, but it was unclear just how long he had been on them and he was clearly no longer taking them. His pseudohypertrophied calf muscles were quite impressive and could easily be seen through his pants. He was still able to ambulate, but with the expected hips forward and exaggerated back to compensate for his hip girdle weakness. We brought the other residents in while examining him so they could see the Gower sign, an extremely classic maneuver done on patients with muscular dystrophy, but not specific to MD necessarily and more a sign of proximal lower extremity weakness. We had him lay on his back on the floor and then try to stand without holding on to anything and, as expected, he rolled over, got onto his knees and then pushed himself up walking his hands up his thighs to stand.

Hannah evaluating a patient with Emanuel

He was a wonderfully cheerful child who brightened everyone’s day despite what we all knew about his future. He still had several years of life left and we wanted to make them as functional as possible, so we restarted his steroids and gave him a pneumococcal vaccine (typically given to children under 5 which took some persistence on my part to convince the nurses in the RCH clinic to give to him) as he would be somewhat more prone to infection on the steroids. Hopefully he will be back in six months to see us, but it is always difficult to tell here as these things aren’t in our control and decisions such as these are often made with many variables in play.

Amisha and Shaban evaluating a patient

One of John’s cases was a patient with cognitive changes who had been admitted on several occasions for her psychosis and had also had some confusing results for her syphilis tests with both positive and negative results that required some additional thought to interpret. The patient’s history was pretty much consistent with a primary psychiatric disorder, but with the positive syphilis testing in the past it became a bit more complicated. Thankfully, we had our very own infectious disease consultant here and brought Steve into the mix to help us decide on a treatment plan. He, of course, gave us a dissertation on the how the RPR could be falsely negative in active disease where the antibodies are so prevalent that they overwhelm the test and cause what is referred to as a “prozone” effect, which of course none of us had heard of before. In the end, we decided to treat her for syphilis given the benign nature of the treatment (which consists of three weekly IM injections of penicillin) and the significance of not treating it if, in fact, that was what she was suffering from.

Hannah, John and Amisha during a break

My new hammock

Charlie, FAME’s lovable “guard” dog

We finished clinic at a reasonable time today as it was again an unadvertised clinic day (tomorrow we were anticipating getting slammed) and only those patients who had been called by Angel were coming to see us. We were back to the house early and everyone wanted to run to town for some groceries as well as to see what was there since they had been here for two days and still hadn’t had a chance to explore the environs of Karatu. It was still quite light out when we left for town, driving “Turtle,” the current name of my Land Rover, down the dusty 2.7 km road on our way to central Karatu.

Cruising the streets of Karatu

Lindsay next to the vegetable market

As I mentioned before, Karatu reminds me of a frontier town from the Old West or the Yukon Territory with it’s one paved road and all of the activity that takes place on either side of the main thoroughfare. There are the piki pikis (motorcycle taxis) that run up and down the main drag and the side streets along with all of the bijajis (three wheeled covered carts that are basically a motorcycle with a body that shuttle passengers to their destinations) and there are many of them. Finally, there are the dala dala, which are the little mini vans that travel along a route within town and from town to town. Each of these is marked with a different color strip to tell where each of them is going to. I have always avoided riding the dala dala for several reasons. First, they manage to pack every last inch of space with either passengers, goats or chickens and there are probably twenty seats in a vehicle that is slightly smaller than our minivans. Secondly, I have been entirely unable to figure out just where each of them is planning to travel and ending up someplace I hadn’t planned doesn’t seem like it would be very much fun. I stay off of the piki pikis and bijajis basically out of principle.

Three children in the vegetable market

Some of the many beans and grains here

We parked Turtle just around the corner from the vegetable market and the shops where we usually buy our supplies. We walked through the vegetable market which is covered and dark with a dirt floor and is made up of small kiosks, each having essentially the same items with only a small variation from shop to shop. You can buy pretty much anything that grows here whether it be fruits, vegetables or grain. Lindsay was planning to make some guacamole on Friday night so she was in heaven with all the fresh vegetables and roamed the market with her new baskets she had purchased picking out hot peppers, tomatoes, onions and anything else she could throw into the mix. The vegetable market is an incredibly colorful place and it has been a favorite of mine since I first arrived here many years ago. Wandering up and down the aisles is just such a pleasure and I could easily spend the entire day there.

Hannah, Amisha and Lindsay

Twins?? Note Lindsay’s baskets and her guacamole ingredients

We spent some time leisurely walking around the market area and purchased some much need supplies (potato chips, plantain chips, bar soap and such) as we also went on a search for the new “Coke Zero Sugar” (not to confused with Coke Zero as per Hannah who has researched this issue in depth for some reason that I am not sure I understand). It was getting darker with the coming of dusk and beyond, but the streets seemed to come alive with more and more of the local population and it was clear that this was the time for socializing and taking care of the whatever business propositions were necessary. The weather was quite seasonable and refreshing and as we all piled into the Land Rover for our short drive home, we looked forward to our dinners waiting for us in the Raynes House. After dinner, we all went out back with the lights off and enjoyed stargazing for some time. Most of the planets were quite visible and the milky way shown with all its brilliance. Unbeknownst to us, this was something on Amisha’s bucket list and could now be checked off. The nights here are cool and refreshing and the sounds of nature after sunset are so relaxing that it seems as though the world we left is a million miles away and from another time. There are no sounds of man or industry here, just those that ancient man had heard hundreds of thousands of years before us and the ones we hear today, lulling us into sense of serenity that is much needed after our day’s work here. We are all very grateful for it.

A busy street in Karatu at dusk

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