Thursday, September 26, 2019 – Our last day of neuro clinic….

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Surfing the hallway with one of Marissa’s little patients

It had now been nearly a month that we’d been away from home and three full weeks of seeing patient here at FAME. At had no indication by anyone’s mood or actions that they were homesick or tired of this place, but rather that it was becoming a second home as it has with me over the years. Today was our last day of neuro clinic, albeit unannounced, but we knew from the past that patients would come regardless and, besides, we had told several to come back today to see us in follow up or to have studies done. It was 18th clinic day, all told, and we were nearing 400 patient visits which is what our fall trips have been consistently running as opposed to the spring trips which are usually around 300 patients. I believe that had it not been for the extended coffee picking this month, we would have seen many more as that is the major employment in this area and, as I’ve mentioned before, the season is only around 40 days so that to miss the opportunity of making the equivalent of $2 USD for a day of picking can be extremely costly for most residents here. Whenever we’re driving down the road to town in the morning, coffee pickers are walking up the road towards the fields with their 5 gallon buckets in hand, ready for their work that will bring some shillings to their family and food on the table.

Group photo after our last patient for fall 2019

It was also everyone’s last morning report as the residents and Leah had already let me know that they would be sleeping in tomorrow rather than coming to report since we had no clinic. I had absolutely no issue as they had all earned that luxury given the days of hard work they had put in and the fact that we’d be getting up early on Saturday to leave for Arusha. Andrea had volunteered today to give the educational lecture on the different types of tremor and how to evaluate and treat them. Since she will be going into movement disorders, this is obviously her passion and it showed in her lecture which was complete, well-organized and well-received by the FAME clinicians. Also, as it was our last morning for the team to be at report, there were words of thanks by all the doctors, but especially by Dr. Anne, who had spent the month with us as she will be the FAME neurologist going forward, and Dr. Gabriel, FAME’s head doctor and someone who I have known now for many years. After the words of thanks came the mandatory claps, which are usually three, but this morning were six, the extra three as a sincere sign of appreciation. “Pasha, pasha, pasha, choma…” and then the six claps by everyone around the table.

The neuro team relaxing at the Lilac after our last clinic for sodas

Before this, though, Jacob, the overnight doctor, presented the ward and maternity cases to the group for any overnight changes. Our gentleman that Kyra had admitted with Wernicke encephalopathy had improved and was much less ataxic and less encephalopathic this morning after his supratherapeutic doses of thiamine which was great to see as we were worried about the oral thiamine replacement we had given him. As we had walked to report, we had noticed the FAME ambulance backed up the walkway near the ward which was a good sign as it meant that they were readying the patient with the meningioma for transport this morning to Arusha. Unfortunately, what we discovered from Jacob was that the patient had markedly improved overnight in regard to his encephalopathy (theoretically, a good thing) and that he was now refusing to be transferred to Arusha (a bad thing) after he found out the expense of surgery, despite the fact that his family was agreeable to him going and had already raised the money necessary to have him treated. Jacob had already. spent a great deal of time with him before rounds and the patient was adamant about not going and his family was now beginning to waffle.

An impromtu vote of confidence for Leah’s success as a neurologist (note – Leah’s eyes are shut)

The steroids would not continue to hold him for very long and his edema would eventually begin to reaccumulate and worsen and, if nothing were done for him, it was very likely that he would die due to complete obstruction of his ventricles and hydrocephalus. Mike went back after rounds to reassure me that the patient had capacity to make this decision as well as to make sure that his family was also well aware of the consequences. He was and they were, though they later indicated that they would likely drive themselves to Arusha rather than in the ambulance and were planning to see the neurosurgeon.  We made sure to make Dr. Rabiel, the neurosurgeon in Arusha, aware of the change in circumstances as Dr. Gabriel had called her yesterday afternoon and that we were hopeful that he would see her sooner rather than later as there was little question that he would be worsening in short order if nothing were done. If we had been at home, we would have made him sign something discharging him against medical advice, or AMA, but that would have been solely out of concern for medical legal reasons and of that we had little concern here.

Of the other interesting patients that we had for the day was the 91-year-old Maasai gentleman with the primarily proximal lower extremity weakness who we thought was mostly myelopathic, but without apparent sensory changes and normal ESR and ALT/AST (proxies for a CPK which we do not have here). He underwent his CT scan of the cervical and thoracic spine that were unremarkable as far as any destructive lesions anywhere, though I will admit that my abilities to look at CT scans of the spine in regard to the cord or other soft tissues aspects is a bit lacking since we rarely do them for obvious reasons as the MRI has become the gold standard for evaluating the spine. We remained at a loss for his diagnosis considering other possibilities such as spinal AVM or an inflammatory myelitis, both of which would be very difficult to diagnose with access only to a CT scanner. Unfortunately, we sent him home without a diagnosis, but will still be thinking about him with the idea of coming up with something.

Possible cysticercosis of the muscle

On a completely different note, though, we had a rather frustrating woman who came in with complaints that seemed mostly non-neurologic, but we decided to evaluate her none the less. She did have a swollen left lower leg that we really couldn’t ignore and sent her for an ultrasound, that was negative for a DVT, but Dr. Gabriel did note that she had some tenderness and pain to palpation and suggested that we get a plain film to rule out a fracture or other pathology despite her lack of trauma. We went ahead and ordered the plain X-ray of the foot, not something we normally do, only to notice that there some hyperdensities posteriorly that were in the soft tissue above the ankle. We had no idea what these were, but were surprised when Dr. Alex, our radiologist, read them as calcifications that could be suggestive of cysticercosis of the muscle.

A sagital view of our gentleman with progressive cerebellar ataxia

Now, this was a twist as we are totally aware that neurocysticercosis (pork tape worm cysts in the brain which are one of the most common causes of epilepsy worldwide) is present in this area (though it’s unclear if we’ve actually seen any to date), but in researching the possibility of cysticercosis of the muscle, it turns out that it is very rare and that if it is seen, patients should be screened for asymptomatic neurocysticercosis as this entity is so much more common than involvement of any other organ system. The following day, Dr. Gabriel did call the family explaining to them our concern and recommending a CT scan of the brain, but they elected not to do it and it was unclear if this was due to the cost or whether due to a local belief that X-rays take away years from someone’s life. Either way, it wasn’t going to be done which was unfortunate from an academic standpoint as it would have been very interesting to have answered that question.

Our favorite dinner spot

So, we had lots of commotion for the afternoon with all of these complex patients, but we did have something very much to look forward to as we had made dinner reservations at Gibb’s Farm for the six of us this night and it was a much anticipated event. We had actually finished everything up a bit earlier than anticipated, but most importantly, we had exceeded the previous number for patients for a trip by one, having had 405 patient visits for the month and still wondered what the number would have been were it not for the extended coffee picking season. We did have to run back to Teddy’s, now the all-time favorite FAME seamstress as there had been a few other things she was making for people that needed to be picked up. We decided to do this on our way to Gibb’s and, as expected, there can never be a short visit to Teddy when bringing along a female majority. I do apologize if there is something a bit sexist about that statement, but having visited her shop multiple times now on three separate trips, I believe I have the clear data to validate my observations if anyone wishes to challenge me.

Chicken dish at Gibb’s

Winning dessert at Gibb’s

We finished up at Teddy’s and then made our way up to Gibb’s for our dinner. None of the others had dinner there before, so I knew it was going to be a real treat for all of them tonight. We had arrived after sunset with plans to have some drinks before dinner, but they had a table all ready for us and since everyone was more than ready to eat, we decided instead to be seated and get drinks with our dinner. Visiting Gibb’s for me is always such a pleasure, not only for its wonderful setting and the scenery, but also for the fact that all of the waiters there, most of who have been there for years, know me and greet me with hearty handshake and hug. I have cared for a number of them or their families over the last ten years and they all know the work I have done at FAME and are appreciative of it. Visiting Gibb’s Farm is clearly one of the highlights of the residents’ visit to FAME and I always make sure that we make it here at least once for dinner and once for lunch during our month long stay. I am sure that one can find other lodges that may have some better attribute here or there, but when it comes down to the entire package, there is really no other that comes close to Gibb’s Farm.

Suave and debonair

We finished dinner early enough for everyone to spend time in the gift shop with both Mike and Kyra finding wonderful bathrobes to purchase. Everyone had worn their new Tanzanian attire except for me and Mike, who had decided not to wear his infamous jumper to dinner, so he wore the bathrobe that he had purchased and I wore Kyra’s bathrobe for a group photo in front of the Gibb’s fireplace. It was a great ending to a wonderful evening.

Our group after dinner at Gibb’s

Night scene at Gibb’s

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