Monday, March 11 – A full week of neuro clinic begins….

Standard

I think just about everyone had a hard time getting up this morning after the exhausting day on safari yesterday so it seemed like a longer walk to morning report than normal. We arrived to the conference room for report to find now one there so left to find out what was going on for the morning. Bumping into Dr. Julius, we discovered that everyone was either attending the code going on currently in Ward 1 or was with the pre-eclamptic patient who presented with seizures in Ward 2. To say the least, it was going to be a very hectic day. We quickly discussed the other ward patients in morning report and then left to see what was in store for the day at the neuro clinic. Once again, there were far fewer patients there than I had expected and compared to what we have seen during past visits. Given that we have the same outreach team that brought in over 400 patients last October, it must be the time of the year and the fact that it is currently planting season here. Patients must decide whether they can neglect their fields to deal with their health and most often, their health will come in second place. It is essentially a matter of survival and without their crops, they have very little else.

Cappaccino at the Lilac

So, back to the busy start of the day. The ongoing code in Ward 1 turned out to be a young woman who had a history of about five days of gradually progressive confusion and lethargy, had presented to an outside dispensary where she had been treated and sent home. She had lost consciousness and was rushed to FAME the evening before. In the morning, unfortunately, she had had an arrest requiring her to be resuscitated and eventually intubated. She was now on one of the surgical ventilators in the PACU and without brainstem reflexes. Given the question of brain death, which is something that neurologists do routinely, it was just a matter of time before we were asked to see her. Daniel offered to do the evaluation and went over to the PACU to see her, and, as expected, found the patient to have no brainstem reflexes whatsoever.

Daneil working on a chart in the moring

Unfortunately, there were several factors that also played a role in the decision making. Patients here are usually not intubated even during a code as there are no long-term ventilators for use in most institutions. As you recall, the baby last week had been physically bagged all night as there was no pediatric ventilator available and the same situation existed for this patient in that there was no long-term ventilator available for her regardless of what anyone would have wanted. This is a basic problem all over Africa in that there are no facilities that can manage these patients requiring this care. I’d fight long and hard if we had a patient with Guillain-Barré syndrome come in needing ventilation given the knowledge that would be expected to recover fully. On the other hand, this patient, now without brainstem reflexes, meaning that she was unable to breath on her own, had an extremely poor prognosis even in the best of circumstances. Dr. Gabriel had spent a significant amount of time with the family to explain the gravity of the situation and prepare them for the fact that their family member was not going to survive. Her ventilator was eventually removed with the family understanding that would pass and that it was clear that she was brain dead, meaning that we had determined death by neurologic criteria rather than the more common cardiopulmonary criteria. Things don’t always go this smoothly with the decision making, of course. Her presentation, Daniel felt, may well have been that of meningitis given her encephalopathy for several days, and given that it hadn’t been fully treated until she arrived to FAME, her prognosis from the get go was incredibly poor.

Mid day at FAME

After dealing with this patient, we were peripherally involved with two patients who had also presented with pre-eclampsia, but were doing well as they had both delivered. In addition to this, there was also a woman who presented with abdominal pain and was eventually found to have a rupture ectopic pregnancy with a very large hemorrhage requiring her to take a trip to the operating theater to stabilize her. It was a very hectic morning for the FAME staff and since things were rather slow for us once again given the vagaries of the planting season here, we were happy out with some of the patients as best we could while staying in our comfort zone. No worries, though, I did not send any of my residents into the OR to assist. The closest thing we have to that here is Jon, soon to be a neuro critical care fellow, who is always more than happy to volunteer for any potential procedures and so far, has been incredibly helpful with the ultrasound machine here looking at hearts and optic nerves (for increased ICP). We haven’t provided him with any central lines yet, much to his dismay, but you never know.

Adys relaxing at the Raynes house

We had a number of children to evaluate this morning, which was fine as they were all relatively straight forward, but it was a bit frustrating as Dan and Marin, our pediatric neurology team, would be arriving around noontime today. One of the children we did see was a little baby with a question of developmental delay as the mother was concerned he wasn’t walking at 12 months since her other children had walked at 9 months. The walking issue was of no concern to us since they were still well within the range, but there were other much subtler signs that were present that did raise some level of concern. It still wasn’t 100%, though, and neither myself nor Adys felt that we say one way or the other. Hence the need to have a full pediatric person with us here as it has always been my contention that I am comfortable evaluating children, but admittedly feel less confident when it comes to floppy babies or early development.

A frisbee game in paradise

Thankfully, Dan and Marin arrived around noontime as expected and were both prepared to see patients that afternoon, though we only had a few. They had been traveling for several days to get here, making a small detour in Dar es Salaam, but eventually arriving safe and sound into Kilimanjaro International Airport. After having spent the night at the KIA lodge, they were awake and on the road early to join us here for two weeks and the bulk of our clinic. Dan is a pediatric neurologist from Children’s Hospital of Philadelphia, who graciously offered to accompany us for this visit as we didn’t have a pediatric neurology resident along to help with the children. Marin is primarily a pediatric inpatient neurology nurse practitioner, who I am told pretty much runs the ICU service at CHOP, and has been incredibly enthusiastic about the possibility of accompanying us here and has finally made it happen.

Fabric shopping in town

Given the rather slow nature of the day, we took the opportunity to run to town for some fabrics as everyone was interested in having some clothes made by one of the shops in town. The fabrics here are incredibly colorful and beautiful and there are many, many shops downtown that offer a wonderful selection of patterns and then it is merely a matter of trying to describe to one of the tailors what it is that you would like to have made. That can often be an issue, though, since most of the women at the shops do not speak English and it’s always just a bit nerve wracking hoping that they understood everything you were trying to convey. Today was only a fabric buying trip and that would not be difficult. Phoebe accompanied us all downtown and in very short order, there was agreement on which fabrics were being purchased. Going to the dressmaker or tailor would wait for another day. I had told Kitashu to call me if any patients came in for us to see while we were away and he called at just after 4 pm to let me know that someone had arrived.

A view during a walk…

Adys agreed to see the patient with Dr. Carin and it turned out to be a woman with what appeared to be some cognitive impairment when they took the history and she was initially thinking about a neurodegenerative process. The more that Adys got into the history, though, it seemed that the confusion was episodic which wouldn’t necessarily be consistent with a diagnosis such as this. After further questions and the recognition that the patient had underlying diabetes mellitis, it was decided to check a blood sugar. Thank goodness they did as her random blood glucose was 18 (!) meaning that she was severely hypoglycemic and at great risk of suffering injury if it weren’t corrected immediately. We whisked her to the emergency bay to get an IV started and gave her fluids and D50 and within moments she began to perk up. Though she had improved with the D50, I believe it was decided that she would come in the hospital overnight to make sure that she was stable. It was disaster averted and just reinforces the fact that you have to look at the basics first before you begin to consider other things. Had that patient had to wait much longer for us it could have been a very serious problem. The old adage, “if you hear hoofbeats, don’t think of zebras,” doesn’t necessary translate in this part of the world given the number of zebra we see here every day, but it still conveys the necessary concerns of thinking of the basics first.

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