We awakened to our second absolutely gorgeous morning of clear skies and sunshine. Since arriving nearly two weeks ago, we have had simply amazing weather, though the mornings have been typically overcast with the clouds burning off by late morning. Not a soul has complained given that it has been otherwise the perfect temperature wherever we have gone and quite conducive to our activities. Next week, we’ll be traveling for our mobile clinics and the hope is that any precipitation will hold off so the roads remain passable. Slippery mud here can deter travel even for the most robust of vehicles such as our Land Rover and getting stuck on the way to a mobile clinic can be a very depressing experience. We are in the dry season here so the likelihood of a torrential downpour is exceedingly small, thankfully.
Our morning began a bit quietly again, though we had a steady influx of patients throughout the day so that our final number was still respectable in the grand scheme of things. The flow of patients throughout our stay for the month can be very irregular and frustrating as it is not always steady or predictable and typically suffers from whatever factors may be affecting the populace here – weather, planting or harvest season, and elections. They have all affected our patient census in the past at various times.
One of our earlier patients for the day was a gentleman in his 40s who reported a three-year history of right eye visual loss and a two-year history of headaches that had worsened over the last year such that he was waking up night with headaches and associated with vomiting at times. His exam was very abnormal with no vision in his right eye, a right afferent pupillary defect, a right sixth nerve palsy, and an incredibly pale optic disc on the right. It was very clear from his history and examination that he was presenting with a right frontal mass lesion that had caused significant mass effect on the retro-orbital region. We sent him for a CT scan with and without contrast to help define what was present and what we were going to have to deal with for this gentleman. Of course, Ray had already declared where and what we would find on his scan (sort of like calling the pocket for the eight ball when playing pool). The patient went for his CT scan and, of course, the lesion was exactly where he had said it would be – a sphenoid wing meningioma the size of a large apple that was producing significant mass effect on the left hemisphere and causing a great deal of vasogenic edema. It was an ugly scan and hard to believe that he had actually walked into clinic to see us. He was placed on some steroids with the hope that they would help his headaches and the plan was to refer him to the neurosurgeon as soon as would be possible as long as he would be able to afford having something done in the end.
Marissa also had a great case for a pediatric neurologist that she pretty much diagnosed in the waiting room. Years ago, as a neurology resident, I had been taught the term “augenblick diagnosis” which means “in an eye-blink” and is a reference to how our brain processes certain information almost reflexively. This was an augenblick diagnosis for her and she quickly recognized the child as having Rett syndrome, a rare genetic disorder that affects 1 in 10,000 to 15,000 births and is very rarely inherited. This 9-year-old girl had started to have developmental regression at 18 months of age and then began having seizures at three years of age following that. She had briefly been placed on phenobarbital, but it was ineffective for her seizures and the family had stopped the medicine long ago. She was now having about three seizures daily and was severely impaired cognitively, not being able to do anything for herself whatsoever.
She was a very classic case of this syndrome, complete with her handwringing and, though we had very little to offer for the bulk of her symptoms, we were more than willing to tackle her seizures which were clearly a very disabling issue for her. We decided to place her on valproic acid as it would offer the best coverage all around for her events. By the way, the other diagnoses that we consider to be augenblick diagnoses are Parkinson’s disease and some of the other similar movement disorders that we encounter.
In the afternoon, Mike had an interesting encounter with a very elderly Maasai patient and his son who had come to clinic with numerous constitutional symptoms including joint pains and headache and insisted that they wanted to get a CT scan of the head. He had a very hard time getting any detailed history from the patient or the son and the patient’s examination was completely normal, though again, he didn’t seem overly interested in participating in the examination. Overall, he was an extremely frustrating patient for Mike to evaluate, but he clearly did not have any red flag symptoms in his history of findings on his examination. Mike informed the patient and his son that he did not feel that the CT scan was necessary, but the pair remained quite insistent that they had come here for a scan and were not willing to leave without having it done.
We ended up having both Angel and Sangale (who is Maasai) become involved in the situation and we making no progress. At one point, the patient or his son had told them that they came here because FAME has “the mirror that looks at the brain,” referring to the CT scanner. I found this to be an incredibly insightful and profound comment serving to remind us of vast differences in understanding of Western Medicine here. We’ve had similar encounters here in the past, of patients coming and wanting testing that wasn’t indicated or appropriate presuming that it must be the best because it is a new technology unfamiliar to them. This, of course, happens at home in a similar fashion and it is not always the patient who makes this faulty assumption in these cases, but can at times be the physician. I remember when the first MRI came to Arusha a few years ago and was quickly followed by banners strung across several streets around town announcing that “the most advanced radiation therapy” had now arrived in Northern Tanzania. Technologies are only as good as the doctors who are applying them to the care of their patients.
Towards the end of our day, we were called to the emergency room to help with a patient that had fallen from the back of motorcycle and was now confused and lethargic. We went there to find a 50ish-year-old Maasai gentleman on a gurney who was arousable, but not answering questions and was not oriented. He was also not moving his right side as well. His family said that he had fallen from the back of a motorcycle two days ago and that yesterday he had apparently become worse and not as responsive. Of course, he was not wearing a helmet on the motorcycle. Our other patient with the frontal mass was already in radiology having his IV placed, so there was a short delay in getting this patient to CT scan, but he eventually got there. We had been concerned about a subdural hematoma, but his brain was normal and, so, we scanned his cervical spine to make sure that he did not have a fracture that was resulting in his hemiparesis. All that was found was an osteophyte that could have caused a cord contusion perhaps, but nothing else was seen to explain his condition. It was felt that he had a significant concussion and possibly a reversible spine injury, but nothing was unstable and other than observation for the moment, we had no other specific therapy to offer. He was admitted to the inpatient ward and we’d see him again in the morning to check on him.
Our plans for the evening were to visit Daniel Tewa and his family for coffee and dinner. I’ve spoken about Daniel so many times on this blog, so for those of you who are already quite familiar with my story of Daniel, feel free to skip the following paragraph(s). I first met Daniel Tewa in 2009, when, here on safari along with my two children, he had been asked to work with us on our short volunteer stint that we had requested as part of our safari package. We would be painting at the Ayalabee school outside of Karatu and Daniel was to be our host for the three days. We had immediately bonded and he then asked us over to his home to give us a presentation of Iraqw history and culture which is something that he provides for numerous safari guests of various companies throughout the year. When I returned the following year for my first visit to volunteer at FAME, I contacted Daniel and it was if we had just seen each other the day before. He remembered my children’s names and many other details from our prior visit the year before.
On that trip, I visited Daniel and had dinner at his home and with his family. Despite having met hundreds of guests who had come for his demonstrations over the previous years, I had been the first one to contact him and return and was now the first to have ever come to his home for dinner. It was an amazing honor for me and I remember that dinner today like it was yesterday. That was nineteen visits, and nineteen dinners, ago, as he has insisted on every one of my subsequent visits that we come for dinner no matter how large our group is. What used to be just me has gradually grown larger every succeeding year and the dinner has now moved from the small living room of their Bantu house to his daughter, Isabella’s, home which is just a short walk from Daniel’s home and had a larger dining room. Megan Richie was the first to go there with me, and given that she was a vegetarian, not something encountered often here, Daniel’s brother-in-law, who is a chef, had made dinner for us and had more than enough vegetarian dishes to make Megan quite happy. Since that time, we have visited his home on numerous occasions, having dinner at least once each trip, as well as at other times to stop by for coffee. He has adopted me into his family, and I have met nearly all of his twelve children along the way. Whenever I have tried to discuss the fact that our group has increased in size and that perhaps it is becoming a burden for him to have us, he will hear none of it, continuing to insist that we honor his family with each of our visits. It is with this past history between us that I bring each group of residents to his home to share one of my African families with them and to meet this amazing individual.
Daniel’s home is an amalgamation of the old and new Tanzania in some ways. Out back, he has one of the only, if not the only, original style Iraqw houses like that in which he had grown up, but were later outlawed by President Nyerere when he recognized that to build his country after independence in 1961, they needed everyone to live together in larger communities in order to develop an infrastructure that could support the country. College students and others come from far away to study his house and hear his talks. The house is mostly underground, open on only one side, and covered by layers of brush, then grass and then dirt in order to detect anyone walking on top of it at night such as the Maasai who would come to steal their cattle. The Maasai, it turns out, believe that all cattle were God’s gift to them and that they are not stealing cattle, but rather taking what was rightfully theirs. A treaty between the Iraqw and Maasai was not signed until 1986. Daniel shared his spear throwing talents with us (very impressive), while Mike impressed us all by applying his javelin throwing knowledge to the Iraqw spear and succeeding quite handily.
We sat outside with Daniel in the setting sun and eventual strong moonlight having his wonderful African coffee – fresh cow’s milk boiled with the coffee – and everyone, other than those who are not coffee drinkers or are lactose intolerant, loved it. We eventually walked the short distance to his eldest daughter’s home, Isabella, where we would be eating our dinner. One of his other daughter’s was also there to help and we proceeded to have an amazing meal that everyone loved. It was very special and I know that everyone was very taken with Daniel’s comments about what it meant to him and everyone in Karatu that we were coming to FAME to help. It has been a very, very special relationship that we have had over the years and one that we both greatly cherish.