Thursday, March 7 – They’re old hats now….

Standard

Having survived the first day of clinic, albeit a bit slower since it was unannounced, was certainly a positive sign and the residents should absolutely have felt a keen sense of accomplishment over that fact. Being thrown into a completely different process as back home, without the necessary hoops that we have to jump through in regard to our documentation gives one a sense of freedom, but it is also new for each of them who have not had to write notes in some time now that the electronic medical record has virtually taken over the medical world. All that those of us used to hold sacred, most of all, our patient interactions have changed now that the computer keyboard has entered the picture and sits in between the doctor and their patient. It is a sad reality in the end.

Another gorgeous morning in paradise

Medicine here is as it should be. It is without the clutter of the electronic medical records, insurance verifications or HMO referrals. We don’t have the millions of dollars’ worth of tests to order, and even if we did, there wouldn’t be anywhere to send the patients for treatment. What we have here is our clinical acumen, some basic laboratory tests and the patients. They come to see us as there are no other accessible neurologists in Northern Tanzania that come on a regular basis and certainly no others in the Karatu district or for hours in any direction. Last visit, we saw over 400 neurology patients in the short time that we were here and the numbers have steadily grown over the years as have the numbers of patients seen annually here at FAME. Dr. Anne, who we are working with for much of this trip and who has worked with me for several years now, has such a tremendously better understanding of neurology than do nearly all other clinicians in the region and, if all goes well, I am hopeful that we will continue with her education so that in addition to seeing the other patients she sees, she will also care for our neurology patients in between our visits along with those new patients that come in to be seen. This will create a more sustainable neurology presence here in Tanzania and begin to build on the work that we’ve completed so far.

Our garden at the Raynes House

FAME has a very significant focus on education here for both the nurses and the doctors. It is one of the major foundations of their mission here in Northern Tanzania. Not only to do they sponsor nurses, clinical officers, assistant medical officers and doctors for continuing education, but they also have two weekly educational sessions that are provided either by the FAME doctors or by the visiting volunteers. Over the years, we have provided countless lectures on various aspects of neurology that have been given by every resident who has accompanied me. I did these in the beginning, but have felt that it should really be the residents providing these talks as part of their educational process once they began to come with me on a regular basis. It has worked out incredibly well and we have typically asked the FAME staff to tell us what they would like to hear about. Wednesday evening, Dr. Gabriel had asked if it would be possible for us to provide a talk the following morning which was a bit of concern considering that we were heading over to Happy Day in the late evening and I wasn’t sure if the residents had any canned talks to give to the doctors here in such short order. Jon volunteered and I actually suggested that we discuss the pre-eclamptic woman from yesterday in somewhat of a “professor rounds” format that I felt would be useful for the other doctors to see how we approached these types of cases. Jon did an excellent job presenting the case with the help of the others commenting along the way and though it was a bit tough at times to get the others to participate, I think that everyone got the picture of what we do with these cases in regard to a differential diagnosis, evaluations, and management. Again, she was a very complex case that provided an excellent opportunity for lively discussion.

Professor Jon running JAR report

Our clinic today was about the same size as yesterday and considering that it was still unannounced, I was happy to see that we had a fair number of patients coming. Of the interesting cases of the day, Jon saw a young boy who had had what sounded like a psychotic break as an adolescent, where he suddenly began hallucinating (thinking his classmates were a pack of hyenas) and then began running away from home and biting people that tried to stop him. Over a few years, he had become non-verbal, was no longer ambulating and then several months ago began having episodes of extremity shaking that were arrhythmic so didn’t sound like seizures necessarily, but would also have eye fluttering. When Jon saw him, none of the episodes of arrhythmic activity were seen, but he did seem to have some eye fluttering. His case was very difficult to sort out and the boy was completely non-functional in his current state. We all went down the various list of disorders that we felt were likely, less likely and completely unlikely.

Professor Jon running through our thought process on the woman with PRES

We were initially discussing entities such as non-convulsive status epilepticus, an epileptic encephalopathy or possibly something psychiatric in nature, but considering we were from Penn, we couldn’t leave out the possibility of an autoimmune encephalitis. Just to clarify this, a the autoimmune encephalidites, of which a fairly famous one, namely NMDA receptor encephalitis, are a group of disorders that can present in very many flavors and much of the early work in this was done at Penn, where we continue to see patients transferred to our institution on a regular basis to be evaluated for these disorders. Often enough, though, patients who come in will be found to have some either specific or more generalized autoantibodies that may full well be the problem at hand and in need of treatment. Other than steroids, though, we have little else that we could try here to treat anyone with this disorder.

Considering diagnoses that we could possibly treat here, it was decided to give the child a benzodiazepine challenge to see if he was possibly in non-convulsive status or ictal stupor. This is a diagnostic procedure where we give a valium-like medication to a patient who is encephalopathic, which would in normal patient or someone not seizing, cause them to become sleepier, but in a patient,  who is actually having ongoing seizures, it will cause them to paradoxically wake up. In the correct clinical setting, this is an incredibly impressive maneuver and one that will usually cause medical students to immediately consider neurology as their career. A patient who is otherwise unresponsive will suddenly awaken in a very “Lazarus-like” moment that will certainly produce lots of oohs and ahhs from those observing. We gave the young boy a 2 mg IM injection of lorazepam (we didn’t have IV access in the child) and set him aside in the emergency room, under observation of course, and otherwise went about our work seeing other patients. Jon went back to assess the child on several occasions and he did appear more alert and the eye fluttering that he had observed earlier did appear to have resolved. Not quite a Lazarus moment, but it was enough for us to consider the option of placing the child on valproic acid (Depakote) and having him come back to see us in a week. We loaded him orally on the medication and asked them to return at the end of next week to reassess the child. It’s a long-shot, but that’s often the very best we can do here. Had we had access to an EEG machine, things would have been entirely different as we could have immediately known whether the child was in status or not. We would have to work with the next best thing, though, by loading the child on a very good anti-convulsant medication and see him back in short order.

We had not made it to the ward all day, though we knew from rounds that the woman we believed to have PRES had been doing better overnight as we had been told that by the morning she was awake and appropriate and moving all of her extremities. We went back to evaluate her late in the day and, indeed as billed, she was quite alert and fully oriented. Her vision was fine as well, but she still had asymmetric weakness with a left upper extremity drift and some facial asymmetry. Her blood pressures had been just in the range that we had requested and she had continued to receive magnesium overnight so her reflexes remained suppressed. With everything we say, we were still leaning much more towards PRES, but with her continued deficits it was very likely that she had suffered some ischemic injuries along the way. Our CT scan was still down and we debated whether there was still a need to image her or not as she had improved, and given the very low likelihood of venous sinus thrombosis, which would have required anticoagulation, we didn’t feel that it was necessary at the moment. If she continued to improve, we were quite comfortable with our diagnosis and would continue to treat her at PRES.

Daniel and Adys evaluating a patient with Dr. Anne

Unfortunately, the young infant who had suffered the hypoxic brain injury did not fare as well which had been entirely expected. When Jon had had the goals of care discussion previously, and into the evening, the family had indicated that they were still interested in pursuing treatment, possibly being transferred to another hospital, but thankfully our message had gotten through and it had been decided to withdraw care from the child who was extremely unlikely to have survived, let alone had any semblance of a life with any quality. The child died peacefully during the day with medications to make her more comfortable and everyone felt that the right thing had been done. Making a difference isn’t just about saving lives, but it is about preventing suffering and helping patients and families through that process.

We all went back to the house with a sense of accomplishment from the day, in the patients that we helped and those others that we had worked with here at FAME. It was a quite evening that ended with an amazing display of celestial brilliance as we all wondered outside to gaze at the heavens. It was a completely clear night that offered a glimpse of what we rarely can see in North America except in a few places and even more unique that we’re in the southern hemisphere. As our eyes became even more adjusted, it was readily apparent that there almost more stars than there was darkness here. As you looked at any particular constellation, you would immediately begin to see that there are stars beyond that until you realized the huge immensity of our universe. And, at the same it becomes readily apparent that we are just a small dot in someone else’s night sky and you quickly realize how tiny our significance is in the grand scheme of things and that we are not at the center of the universe.

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