Friday, March 15 – A very sad case of a stroke….

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Having had just a wonderful night with Daniel Tewa and his family, we were now ready for the end of the week. Our Saturday would be a half day of patients with a “Wellness Day” for the afternoon and then on Sunday, we had plans for a day game drive to Ngorongoro Crater, one of the premier game viewing sites in all of Africa. Since it will be March 17 the day we’re in the Crater and Phoebe, who is Irish, is coming with us, we will be bringing some beer along with us to celebrate at lunchtime. I will do my best to post the Ngorongoro Crater blog on Sunday night depending on how exhausted I am after driving and guiding all day. I was recently asked what my favorite thing to do here was, and I would have to say very honestly that it is taking people on safari and driving myself. I can easily remember how I felt when I first came here seeing the remarkable sights and visiting with these amazing people here. My greatest love is to introduce others to this wonderful country.

The neuro team enjoying the Lilac Cafe

At morning report, we ran through all of the patients in the ward, several of who were our pre-eclampsia/eclampsia women who, thankfully, were all doing well though needed some stricter blood pressure control as we were afraid that their PRES could easily return and they had been doing so well. Sheena’s patient who had been billed as a post-partum psychosis, but had no psychiatric history and seemed to respond well to blood pressure management and levetiracetam. She improved by the following morning, having gone from being completely uncooperative and constantly singing to being fully alert and cooperative. There seems to be a very significant incidence here of pre-eclampsia/eclampsia and it is not entirely clear why that is other than perhaps the much higher incidence of hypertension, even in young women.

Marin taking a photo of Jon discussing an outside CT with Dan

At the end of morning report, we were also able to pull up the X-ray of the young baby who had died last weekend so that Dan could review it in light of the initial concerns of some congenital heart issue. He felt that the X-ray was very abnormal and definitely suggestive of this. The baby had been initially fine, but then cried out several times, each time associated with desaturation of oxygen and turning a bit cyanotic. On the third cry, the baby died and they were unable to resuscitate it. The CXR had been done prior to all of that occurring and had a very large heart and wide mediastinum. Dan concurred that the baby most likely suffered from one of the congenital development cardiac issues such as transposition of the great vessels and that is not something that can dealt with here by any means.

Jon reviewing an outside CT scan with Dan

A baby had come in the day before and was presented today at report with severe anemia and thrombocytopenia who had been seen here last October with similar problems and had responded to steroids with the platelet count increasing from 5K to 85K the following day. It was unclear how much of a workup had been done at that time, but the baby hadn’t been seen in the interim so it was presumed that they were doing at least reasonably well. They now had a hemoglobin of 5 and platelets of 5K on admission. Given the fact that he hadn’t returned in the six months, that would make leukemia very, very unlikely, but an autoimmune thrombocytopenia was a possibility, but wouldn’t explain the anemia, so that would have to be from another process. After much discussion, the child was placed on IV steroids to see it he would respond again and will be monitored going forward.

Dr. Caren, Dr. Julius, Dan and Frank discussing stroke case with patient’s husband

Just before noontime, we were urgently requested to come to the OPD to see a patient who had been brought in with an apparent stroke. Daniel accompanied Dr. Julius back to the OPD to see the patient and returned a few minutes later to report that she was a younger woman (51-years-old) who was not moving her right side, was not responsive and had systolic blood pressures over 200 mmHg.  She was being moved over the emergency bay so that we could care for her more appropriate. When she arrived here, she was already posturing her right side, her pupils were sluggishly reactive, and, most concerning, she was dropping her heart rate in the setting of severe hypertension with systolic pressures still well over 200, which is known as a Cushing’s response and occurs in the setting of high intracranial pressure and impending herniation of the brain.

Unfortunately, her symptoms had begun the day prior when she was shopping and developed right-sided weakness and aphasia. At some point, the family had taken her to a dispensary and she had been referred to come to FAME for a CT scan. Our CT scan has been down since last October due to the various problems, but was ready for operation once it was approved by the Tanzanian Atomic Energy Commission, which we were waiting for and had not yet happened. What ensued at that point was a very practical discussion of what should be done. Given her presentation, we were reasonably confident that we were dealing with a hemorrhage large enough to have caused her to begin to herniate. If we were to send her off to Arusha for a CT scan that would cost $200, it was very unlikely that there would be any intervention that could be performed. Even if some intervention could be performed, it could only be expected to possibly save her life, but to what purpose we were very confident that she would never be able to move her right side or speak and would be totally dependent on others for the rest of her life quite possibly with complete lack of awareness.

Frank discussing a case with Marin, Caren and Jon

We did discuss the situation with her family at length to explain to them the dire nature that she was in and that regardless of what we did, it was most likely that she was going to die and that the very best we could hope for in this situation was to save her life, but that she would be dependent on others for the rest of her life. We were limited in what to treat her with here as our IV antihypertensives are minimal and we were hoping that the family would agree with our plans to initiate palliative care. Anything that we did now would only prolong the inevitable. The family insisted in contacting her parents even though her husband and other family were here and, thankfully, after everyone was contacted, there was a very reasonable understanding on their part so that she was moved to the ward and placed on comfort care only. She was given a small amount of morphine to decrease any agitation she might have as a result of her oxygen hunger and she was made comfortable, waiting for the end to come.

Frank, Dan and Daniel discussing care for the stroke patient

Considering the circumstances, it was clearly the right thing to do, but regardless, it was tough for everyone considering her age and the fact that this very likely something that was preventable had she only been compliant on antihypertensive medications. Hemorrhagic stroke is much more prevalent here in Africa than it is elsewhere solely because of the higher incidence of hypertension in general, and untreated hypertension specifically.

We spent the evening at home, relaxing, and thinking of what we were going to have for dinner. We received our “bacon, no lettuce, and tomato” sandwiches on homemade bread, but I had been dreaming of making a bacon and tomato egg scramble with the ingredients after deconstructing the sandwiches. Jon was all in for the scramble as well so I whipped up some eggs and Adys joined us as well. We had borrowed a small, compact LCD projector that Phoebe had and watched the Lion King on the wall. I listened to most of it while cooking and typing, but it hasn’t changed. It’s a classic and everyone’s now exited to go find Pride Rock while we’re on safari. After Lion King we watched a very good climbing movie that Marin had on her computer called Free Solo about free climber Alex Honnold. For those of you who love extreme outdoor movies, it is an amazing documentary about an incredibly select group of climbers who do not use ropes and place their life at risk every moment on the mountain. It is also an excellent documentary from the perspective of what kind of person it takes to succeed in such an endeavor and the psychopathology (I’m using that word in a purely clinical perspective and not at all judgmental) that is necessary.

 

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