Wednesday, October 10, 2018 – An interesting drive to Plantation Lodge…

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Happiness!

I think everyone was still reeling a bit from the wonderful dinner the night before, both from a standpoint of being quite full, as well as the feeling that we had all experience something very special with Daniel Tewa’s family. Morning report was at its regular time and there was no educational talk so we all walked to the hospital at 8 am to hear about the inpatients and any new admissions that had come in overnight.

John enjoying a free moment

Steve in between sessions

As we were heading out last night, we were asked to come see a patient who had just been admitted with a new stroke, but when Lindsay and John went to see the patient, it turned out that he had actually had the stroke, a complete right middle cerebral syndrome, three weeks prior and had been admitted at Haydom Hospital, a teaching hospital several hours to the south of us. As they did not have a CT scanner and the patient was not improving, the family brought him here with the anticipation of getting a CT scan and possibly having something that we could do for the patient. Unfortunately, he had a completed stroke and had they brought him anywhere in Tanzania, there would not have been therapy for him. Haydom had been providing him with all of the appropriate therapy including physiotherapy, but his stroke was something that was very dense and he had profound weakness with no improvement since the onset. We spoke with the family at length to let them know that he did not need a CT scan now nor would it have impacted his care had he gotten one when he initially presented to Haydom. It would have been a waste of their money and what he really needed was the physical therapy and aspirin, but he also had dense neglect on the left side that would impair his functional recovery most likely.

Lindsay loving her job

John and Lindsay fighting over a patient

Despite the fact that this had been reiterated to the family on morning rounds, they still had questions that required John to go back later in the morning to reiterate to the family that the CT scan wouldn’t help or change anything and that there was no reason to get one. The third time the message seemed to get across and the family was satisfied with our explanation and accepting of the fact that he could go home.

Not sure what to make of this mzungu

The Maasai woman with the venous sinus thrombosis was continuing to improve and was now awake and talkative. She had no apparent neurological deficits on examination and it was quite likely that the small right frontal stroke was clinically silent as it seemed to be in front of the motor strip. She had a very stoic attitude which is so often common among the Maasai and it was unclear that this had anything to do with the stroke she had suffered. She was doing amazingly well, all things considered and our plan now was to switch her to oral anticoagulation from the enoxaparin (which is subcutaneous) and to continue her on the phenytoin considering that she presented in status. The medications do interfere with each other’s metabolism, though as long as the phenytoin dose remains stable, they should be able to get her on the correct dose of warfarin. One of the main issues that we needed to settle for her was whether or not she had any plans for pregnancy in the near future as this would affect our plans for anticoagulation as well as what we would do with her anticonvulsant medications.

These discussions are very personal for many reasons that not only include the obvious, but they are even more so with the Maasai. The person who makes these decisions is ultimately the husband and the Maasai value children almost more than anything else. Therefore, Kitashu, who is Maasai, was enlisted to help with this discussion. Once the necessary information had been conveyed to the husband so that he could make a decision as to whether or not they would be having children in the near future, he gave a very wonderful reply. His reply was simply, “I love children, but I love my wife more.” When I heard what his reply was, I was incredibly impressed and touched on so many levels. Considering the risks of her becoming pregnant again with her probable underlying antiphospholipid antibody syndrome and the fact that she had already suffered a venous sinus thrombosis, it made absolute sense to delay having another child.

Is this part of the peds neuro exam?

As for our other ward patient, the child in who we suspected meningitis but had a negative spinal fluid, they were more awake and crying, but still appeared very sick. We were still unsure of a diagnosis given the spinal fluid and began to suspect a more systemic infectious process, though we had very little to go on. The decision was to continue the antibiotic we had them on and continue to watch for now. We had no other testing to suggest at the present.

Clinic was busier than yesterday, but not totally crazy as it was on other days. Lindsay ended up seeing a young woman that had been referred to us, though her complaints were not neurological in origin and Lindsay remained quite persistent in trying to ferret out exactly what was going on with her. Thankfully, she recognized her symptoms as being those of rheumatic heart disease and the patient’s examination findings further confirmed that she had severe valvular disease and would need rather immediate attention. We enlisted the assistance of Steve since this was really a pure medicine case and he was certain that the patient in the US would have been referred for immediate valve replacements and admitted directly to the hospital. Unfortunately, we do not have access to that type of care here so it was decided that they would try some diuretics and have her come back in the morning to see if it made her feel any better.

Our patient having a seizure on the bench

At the very end of the day, as Hannah and I were walking back towards clinic after staffing a patient, we suddenly became aware that one of our patients waiting to see us was having a seizure on one of the benches, As we walked up, he was leaning over and in the midst of a generalized convulsion so that we needed to make sure he didn’t hurt himself. The seizure lasted perhaps 45 seconds and then he was just postictal and fairly out of it. This lasted for several minutes after which he became very agitated, insisting to get up and walk around when he was clearly unaware of where he was or who we were, We tried to keep him from standing up as we were worried that he would fall and injure himself, but he was quite strong and I quickly realized that someone was going to get injured and I was worried that it was wasn’t likely going to be him. Hannah lasted longer in the ring than I did, but eventually a number of the FAME staff came to our rescue. He remained a handful for some time and we actually had to give him two IM injections of a benzodiazepam to slow him down. Unfortunately, his family had left him there alone and so we had to wait for them to come back to get any history on how he’d been doing since last seeing us six months ago. He was finally quite and Hannah was able to finish getting his history from one of his family members.

Having to restrain our patient with a seizure

I hadn’t mentioned previously, but our Land Rover (now officially named “Turtle”) had had a few minor problems while on our game drive at Lake Manyara last Sunday. The stick shift (which by the way is on my left-hand side since this is a right-hand drive vehicle) didn’t seem to want to fully engage into first or third gear at various times as it seemed to be physically limited by the console in front of it. This became an issue when trying to make a rather steep ascent, which is essentially what these vehicles are known for, though if I just shifted into four-wheel low I was able to use the second gear in low to compensate. I did this for much of our drive at Manyara whenever I was unable to shift into first gear which worked reasonably well, but when driving home from there up the steep rift, I only had second and fourth gear which took a bit more ingenuity and planning. We really didn’t need the use the vehicle much, but driving up to Gibb’s Farm was a bit of an issue and so, we had a fundi (expert) come from Arusha to look at the vehicle and see if he could fix it for me. He was supposed to have been here in the morning, but ended up arriving at around 4 pm. He didn’t speak English, so I used Anton from the lab to help translate for me and I explained to him what the problem with the vehicle was. He took it for a test drive and promptly announced that it needed something called a pilot bearing which he would have to buy in Arusha and would then come back in the morning to fix it which would take around five or six hours.

A congenital cataract

Having been driving the vehicle as it was in Manyara and up to Gibb’s Farm, I thought there should be no problem for us to take it to the Plantation Lodge where we had been invited to have dinner tonight. We all loaded into Turtle and were on our way around 5:45 pm, hoping to make it there by sunset and enjoy some drinks and appetizers before dinner. The turnoff to the lodge is very difficult to see, but we made it (having to turn around only once) and were quickly on our way along a small dirt road that is typically for the lodges that are out of town. About half-way there we stopped at a fork in the road to ask a couple if we were heading in the right direction, which I was pretty certain we were, and they directed us to continue on in the same direction.

Drinks at the Plantation Lodge

Then, as I went to shift the vehicle into first gear, the entire gear shift column came off in my hand! I was a bit stunned for a moment until I realized what had happened and then realized that we were in neutral so that we had little chance of getting it back into some gear to at least be able to drive. Realizing that our dinner was waiting for us at the lodge and knowing that this called for extreme measures (i.e. there was nothing that was going to keep us from making this dinner), I quickly called Alex and asked if he could call a Noah (the local vans for hire) to come pick us up and take us the rest of the way. That would mean, though, that we’d have to leave Turtle there and I’d have to deal with the nightmare of getting it back to FAME on the following day. Peter was sitting up front with me and after speaking with Alex, we put our heads together to see if we could come up with some other solution than the Noah. I pulled up the boot to see where the shifter had broken off and we still had some remnants of the plate attached to the transmission. We realized that we could possibly push the plate forward to hopefully engage third gear and, sure enough, Peter was able to force it into gear as we had hoped. That meant that I was in third gear as the only driving gear, but I could shift into four-wheel drive low which effectively gave me another gear to use.

Drinks at the Plantation Lodge

I got the vehicle moving forward in the direction of the lodge (and, of course, our dinner) and, as long as I kept up some good momentum, I was able to get us to the lodge safely. Pulling into the parking area I almost forgot we had no reverse, but was reminded by Steve and pulled us around so we were pointing forward without obstruction when it was time to leave. Our dinner was delicious and we spent several hours on the veranda enjoying everyone’s company. When it was time to leave, we all headed to the car and prepared ourselves for the interesting ride home with only two gears. There was a bit of a steep part of the driveway, though, as we were leaving and I was unable to get Turtle up it even in third-gear low, possibly because he the engine wasn’t warm. Backing down was a bit of treat considering I had no reverse lights (since I had no reverse gear) and I needed to have someone get out and direct me as the driveway was quite curvy at the spot where we were.

Somehow hoping the stick shift would just miraculously go back in

I tried two runs up the hill, but was unable to make it each time and so finally, everyone got out of the vehicle to help push it over the hump. We tried again once, but were unable to make it up in which case, I backed down the steep grade again for a final go. This time, I really revved the engine and made a mad dash up the hill noticing some wheel spin as I did and surely hoping that no one was hit with any of the stones that I heard striking our underside. I kept my foot on the gas until we arrived at the top of the small hill and then waited for everyone to load back into the vehicle. Steve was one of the last and I found out that he had been hit by some of the stones, but said that he was mostly uninjured which I was pretty thankful for. Once moving, I drove most of the way using only third gear, but if needed I could easily shift into low and then have a whole ton of traction to get us moving on the incline if needed. We dropped Peter off near Happy Day and then drove up the FAME road and to our house, the entire time trying not to really stop for anything if we could help it.

A stick shift in the hand isn’t worth two in the bush

The fundi would be coming in the morning to fix Turtle and I now had a new problem to tell him about and that he could hopefully weld back the shift lever for us. It was a lovely night out even with the vehicle dilemma and it made for more interesting stories in the future. Once again, we all just kept saying, “TIA,” and this time really meant it.

 

 

 

 

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