Monday, September 23, 2019 – It’s back to work at FAME…

Standard

Everyone had a wonderful time over the weekend in the Serengeti, and how could they not have. We slept in tents for two nights under the beautiful stars and though our camping was as far from roughing it as one can get, it was still in the traditional style of game drives of the past with the sounds of wildlife throughout the night (much to Andrea and Marissa’s dismay). It is the only way to really experience the Serengeti short of camping on your own, but I’ll leave that to the tremendously more adventurous of which I can think of only one who has come with me so far, and that would be John Best. John had decided to climb Kilimanjaro after his time here at FAME and, if I’m not mistaken, chose to carry his own gear rather than the typical fashion of having more porters than clients which is how I did it back in 2015. Spending two nights in the Serengeti gave everyone a very good taste of what a magical place this is, where the animals are really secondary to the scenery itself, and where the term “endless plain” is an understatement. There is no other place like it on Earth.

The doors to our clinic

Meanwhile, everyone was exhausted from the weekend trip and dragging getting out of bed Monday morning for clinic. There were no major neurologic issues that had occurred over the weekend so that we had no patients that were in the wards needing a neurological evaluation on our return. At morning report, though, we did discuss two burn patients that were in the wards, one a young boy with very serious burns on over 60% of his body and requiring skin grafting that was actually going very well, but taking a long time due the fact that they were having to wait for the donor sites to heal before harvesting again. The child has been here since we had arrived weeks ago and will probably be hear much longer. There is also a woman on the ward service with severe burns who has been here for over a month, though I am not entirely certain of how she got them.

A typical Tanzanian cooking scene

Burn injuries are a tremendous issue here for many reasons, though the primary one has to do with the manner of cooking in the typical Tanzanian household, which is over an open flame utilizing either charcoal stoves or propane burners that sit in the middle of the kitchen. These are all very easy for small children to fall into while playing, for older adults with an unsteady gait to navigate around or for patients with epilepsy to fall into while having a seizure. We have seen so many of our epilepsy patients over the years that have been injured in this manner and many patients who come to see us for the first time with uncontrolled seizures have been horribly disfigured and disabled by these injuries in the past. We have seen children who have fallen into boiling pots of porridge or women who have spilled the contents of their cooking upon themselves. The burn injuries don’t necessarily have to involve epilepsy, though, as neither of the two patients in the ward have seizures. There were merely injuries caused by cooking over open flames in tight quarters where accidents are bound to happen.

Cooking over an open flame

Last week, while we were off in Mang’ola, Dr. Ray had seen a patient before heading home that raised concern for a spinal cord injury – the patient presented with three weeks of difficulty walking and urinary retention and had an examination that clearly localized to the cord below the cervical spine, but was unclear whether it was thoracic or lumbar as he was not overtly myelopathic. He was admitted and underwent a CT scan that demonstrated what were preliminarily read as degenerative changes at the T6-T7 level. We had been away at Mang’ola on both days having left early in the morning so the patient had been discharged home as there was little to do immediately, but the final read came back with concern for an epidural process at that level and compression of the cord. This is not something that is easily seen on a CT scan and is where the MRI really shines, though it was still extremely concerning for an abscess or possibly TB given his presentation. We had him come back today to discuss what needed to be done and that was to send him to Arusha to the neurosurgeon. I contacted the surgeon and the cost of the surgery and hardware necessary would be 4.8 million shillings, or something a bit over $2000 USD. The family went home with that information and the hope that it might be able to be raised by them so he could be treated.

One of Denis’s paintings

Marissa’s paintings

Another interesting patient that was seen by Andrea today was a patient with progressively frequent attacks of vertigo who also had tinnitus and possibly some sensorineural hearing loss. They had seen the ENT docs in Arusha and had been recommended to have a CT scan of the temporal bones, but hadn’t done so yet. His exam was normal other than the hearing loss and we were concerned about the possibility of either Meniere’s disease or a mass in the cerebellopontine angle on the ipsilateral side. The other thought, and why the ENTs had wanted a CT scan of the temporal bone had to do with the possibility of dehiscence of the semicircular canal causing his vertigo, so we asked that the temporal bones also be imaged with the CT of the head. The study was negative for both the mass and the dehiscence, so we were left only with the possibility of Meniere’s disease and recommended that he go back to see the ENT docs in Arusha with his CT scan disc that they could now look at for any abnormalities.

Dinner Monday night

Dinner, take 2

We finished out the day of patients and went back home to rest, still exhausted from the weekend travels. The movie of the night was the original Lion King which made tremendous more sense now that they had all been to the Serengeti and to Pride Rock. There were lots of references that were now made clear as well as many of the names and Swahili words and phrases used in the movie. It was an early evening for everyone and there was an early educational lecture in the morning that Kyra was going to give on how to evaluate patients for cognitive impairment.

Sunset

The Lion King

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