Qaru is a very small town that is south of Karatu and on the road towards Haydom, where there is a larger teaching hospital, but is about three hours away. We had chosen Qaru to visit several years ago when looking for an additional site to hold our neurology mobile clinics and where there was also a nice dispensary that would serve well for us to work in while there. Qaru fit the bill perfectly for its health center had been recently built by an organization wishing to provide this resource to the community. There is a nearby school and in the past, we have been able to interact with the children during their recess time. I had also been fortunate enough to have shared in church choir rehearsal not long ago which was really a treat.
The drive to Qaru is less than 45 minutes and is on a main thoroughfare, albeit gravel, as there are very few paved roads other than the main highway traveling from Arusha to Karatu, as well as the road that travels east from Makuyuni towards Tarangire. Trying to describe what these vehicles take here from the standpoint of abuse would be very difficult. All of the roads have severe washboards, which is the natural effect of vehicles driving over loose surfaces such as sand and gravel. This makes for an incredibly bumpy ride which the vehicles here take day in and day out, giving their suspensions an incredible work out and eventually leading to necessary repairs and breakdowns. More about that later.
Again, it is important to understand that the purpose of our neurology mobile clinics is perhaps less to provide care for patients who cannot reach FAME, but rather to bring the concept to them that neurological diseases can be treated effectively. The villages are not so remote that they are unable to get to a medical facility capable of treating them, but more that their illnesses are just accepted as part of their life without having explored an alternative. This can often be most impressive for patients with epilepsy where it is merely a matter of placing them on the right medication and they can be seizure free or at least nearly so. Epilepsy carries with it a huge social stigma and because of this and the incredibly limited access to adequate medical care in general in third world areas, the percentage of these patients who are treated is appallingly low and in the range of 10%. It can be so rewarding to see one of these patients who are young adults and have never known a life without seizures become seizure free with a simple medication. Thankfully, many of the patients we see are young children with epilepsy and so we are able to place them on the appropriate medications at a much earlier age.
At Qaru, the number of patients waiting for us was rather small that can be for many reasons and is a common occurrence at the mobile clinics. We do advertise the clinics much the same way as we do for those we hold at FAME (where we are always packed), but since we’re at each village only one day, if that happens to be a day of planting or harvest or your cow has run away, then you may not be able to make it. There were several new patients with epilepsy and a few follow ups, as well as our normal smattering of patients with complaints that we couldn’t necessarily attribute to an underlying neurological process. Many of these are musculoskeletal in etiology, but some we’re just unable to attribute to anything. We have many patients, almost exclusively young adults, who complain of hemibody numbness and the only features of their examination will be the finding of sensory abnormalities, often quite patchy and without a good anatomic localization. Of course, we see these patients in the US, but much less frequent than we do here and at home we will evaluate these patients extensively and rarely find a cause for their complaints. Often, you will find some underlying psychological event that may have precipitated the complaints, such as the death of a family member, but other times you won’t and it leaves you very unsatisfied in not being able to have some unifying diagnosis.
During our visit to Qaru, Frank called me to let me know about a patient, a tourist, who had come in with the worst headache of their life associated with vomiting and vertigo. This was obviously very concerning for a subarachnoid hemorrhage and our CT scanner here was unfortunately down so we were unable to get an imaging study. Her examination was non-focal so I recommended performing a lumbar puncture to rule out a hemorrhage. By the time we returned from Qaru, they were just in the process of getting the LP done, so Hannah evaluated the patient instead and then proceeded with obtaining the cerebrospinal fluid. We do not have the LP kits here that we are so used to using at home, and so Hannah went about positioning and prepping the patient with the nurse’s assistance while provided some coaching and moral support.
Managing to keep one’s self sterile in the setting where you have no drape to cover the back (those who perform these procedures will understand the reference) that allows you to constantly check your position with your fingers is not a simple proposition. Kudos to Hannah, though, for only having to change her gloves once during the whole affair as it was quite the challenge. Overall, it proved to be a very difficult procedure and, in the end, it was non-diagnostic as we had entered a venous plexus (this happens on occasion and is not something that can be avoided) and though we did find the CSF space, the fluid would not clear and we were unable to interpret the results. Our concern was high enough for the patient to have had a sub-arachnoid hemorrhage, though, and so we recommended that they be transferred by medivac to Nairobi in the morning as we did not recommend that they fly home to the US without having this fully evaluated.
After Hannah and I had returned home from evaluating this patient, we all decided to head to town for some ice cream (instigated by Steve, I might add). We jumped into Turtle for the short ride to the market area and all picked out an ice cream bar of our choice, then happily enjoyed the treat standing out on the street watching all the locals making their last transactions of the evening and carrying out their final choirs. Tomorrow we would be off for our last mobile clinic to Upper Kitete, which is the furthest away that we travel, so much so that it is also a dead zone for all cellular service which puts us entirely out of reach to the rest of the world and to FAME for the entire day.