Wednesday, September 25, 2019 – A very busy afternoon…and then the Sparrow….

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Dr. Anne and Marissa evaluating a patient

Our morning report was very interesting today in that one of the patients who presented yesterday emergently to FAME was a young gentleman who had been attacked by a Cape buffalo. These events remind us that we’re definitely not in downtown Philadelphia as there is very little violent crime here other than the attacks by wild animals. Baboon or monkey bites have been relative common in the past given the total lack of fear these animals have at the Ngorongoro entrance gate and the picnic areas in Tarangire. At the gate, the baboons will very quickly enter any open window in a vehicle, target the lunch boxes or any food and be back out in a quick flash unless someone tries to stop them which they don’t appreciate and will quickly. provide a very nasty and dirty bite. Last year, a very unfortunate Maasai man from the NCA was brought in after being essentially eviscerated by an aggravated elephant and did not survive the night from his injuries. A Maasai women came in a few years ago with nasty hand wounds after tangling with a hyena who had successfully taken her infant from her hut and had to be referred to KCMC for more specific orthopedic repairs. Her infant was never found.

Another Denis creation

So, the gentleman who ran afoul of the Cape buffalo was actually a bit lucky in that what he had was a bit hemopneumothorax that needed to be drained, and though there was concern that he would need ICU level care (not available at FAME), a chest tube overnight seemed to stabilize him. There was concern for his mental status in the morning and we were asked to evaluate him from a neuro perspective. Mike went to see him in the ward and he was totally intact to the degree that I joked that he followed commands better than 90% of the patients that we were seeing in clinic. He was a lucky individual as Cape buffalos can be very, very dangerous in situations where they feel threatened and they unlike many animals as they will defend themselves. If you’ve ever seen the video of the Cape buffalo completely upending an adult lion, throwing it at least ten feet in the air in a tumbling fashion, and using its razor sharp horns, you can certainly understand the need to avoid them at all costs. There had been talk of transferring him, but he looked so good I the morning the decision was to keep him at FAME and to continue treating his injuries.

Someone assisting me with my blog

We had a patient come today who was following up from our clinic in Mang’ola last week and he had looked mostly cerebellar on examination. He was now encephalopathic and tremendously worse such that we were fairly confident his diagnosis was Wernicke encephalopathy, which often occurs in the setting of alcohol abuse and is the result of dietary deficiencies usually related to thiamine deficiency. If it is severe and irreversible and more associated with confabulation, we call it Korsikoff syndrome. In the US, patients with a history of alcohol abuse are immediately given what is called a “banana bag” intravenously that contains thiamine, magnesium and folate primarily  which effectively prevents the acute exacerbation of Wernicke that can occur when patients are given dextrose intravenously prior to correcting their vitamin deficiencies. We have no banana bag here nor IV thiamine for that matter, but we did have thiamine tables to send with the only proviso that we are unable to know for certain whether it’s being fully absorbed or not. Regardless, it was the only thing that we had and so it was five tablets every eight hours for several days to totally supplement and correct a presumed thiamine deficiency. Kyra had seen the patient in Mang’ola, so also evaluated the patient here and we all agreed that he should be admitted to make sure that he got his thiamine. With Dr. Anne’s assistance, this was taken care of and Kyra wrote the orders for him to receive thiamine as well as some other vitamins, none of which were quite as important as the former supplement, though.

Mike evaluating the ED patient in the ward

Mike evaluating the ED patient in the ward with the help of Dr. Jacob

In the midst of everything going on, a young patient with an IV was wheeled into our clinic space on a gurney by one of the nurses saying that he had been sent to us directly from the OPD to be evaluated for episodes of unresponsiveness. There was really nowhere to place him with all the patients sitting waiting to be seen, so he was wheeled into one of the unused rooms in the ward, but I insisted that there be a nurse with him as we had no one to spare that could monitor him. Though this hadn’t happened yet this visit, it is not all too uncommon for patients to brought to us in this fashion having come in unresponsive, many times after having “swooned” at school or work. I recall one time that a patient was delivered to us in this manner and after briefly examining the patient and getting the history, it was clear to me that it was not anything serious and that they would wake up eventually. We left the patient on the gurney nearby, monitoring them occasionally until, sure enough, they awakened and were back to their normal self-following what we refer to as PNEE, or a psychogenic non-epileptic episode. These are a form conversion disorder and are most commonly a response to underlaying stresses, though it takes a good deal of time and therapy to determine exactly what they are and how to best deal with them.

Mike evaluating the ED patient in the ward

For our patient, though, it was much simpler as after having taken an accurate history and examining him, it was quite clear that this was just a matter of several episodes of syncope in a patient who had been dehydrated. These are patients that we are often asked to evaluate at home to determine that they don’t have a neurological cause for their loss of consciousness, such as seizure, so it not at all that unreasonable to have us evaluate patients such as these, though typically it will be done in the ER if it is acute and they are not wheeled into our offices.

CT of patient with large right sphenoid meningioma

At the same time as the syncopal patient arrived in clinic, we had been called over to see a patient in the ER who had arrived unresponsive after having developed a severe headache, vomited and become less responsive the night before. Mike went over to see him right away (which is why we had no immediate person to evaluate the syncopal patient) and the patient was moving all extremities, but not following any commands and was very poorly responsive. We were most concerned about a subarachnoid hemorrhage and without any focality on his examination, this would have been suggestive of an aneurysmal bleed without significant parenchymal injury. We had another patient already in the scanner at the moment which had to be completed first, but he would be getting his study very soon and he was moved to the ward while he waited as it was clear he needed to be admitted.

CT of patient with large right sphenoid meningioma

He eventually had his study and it was not at all what any of us had expected. He had a very large, right sphenoid wing mass that was homogeneously enhancing and causing significant mass effect on his right lateral ventricle with right to left shift of the midline. There appeared to be some involvement of the cavernous sinus as well. The mass was most likely a meningioma and it was almost identical to the mass we had found in a gentleman two weeks prior, though that patient had a more gradual history over several years including complete loss of vision on the right secondary to optic nerve involvement. We were really unable to get any relevant history in our current patient given his severe encephalopathy. We spoke with his family at length regarding the fact that he had a potentially very treatable problem, but would need to be referred to the neurosurgeon in Arusha and transferred there the first thing in the morning as nighttime transfers are dangerous, risking the life of not on the patient, but also the lives of the support staff involved in the transfer. The family was agreeable so I proceeded to contact the neurosurgeon, as I had done several times already during this visit, to find out what the expectation would be for the amount of money they would need up front. We placed the patient on intravenous dexamethasone at the end of the day to help with some of his swelling and went back to finishing our work in the neuro clinic. We arranged for his transfer first thing in the morning by the FAME ambulance.

CT of our patient with progressive cerebellar ataxia

There are several important events that occur here in Karatu on Wednesdays. First, it’s meatloaf night for our dinner and Samwell cooks a very mean and moist meatloaf with some tanginess from a barbecue sauce that he uses and is probably homemade. It comes with a large side of mashed potatoes as well as green beans to add some color. I don’t know about the rest, but the meatloaf was clearly Mike’s and my favorite of the various dinners that we’re provided by the FAME kitchen five nights a week as part of room and board while volunteering here. In addition to these dinners (we have to fend for ourselves on the weekends), we’re also provided lunch every day which is perhaps my favorite food of all – five days a week it’s rice and beans with a local spinach made even more tasty by Samwell’s homemade pili pili, or hot sauce, that is made from the local hot peppers here which are very, very hot. This combination of food, the beans, rice, spinach and pili pili, may be my all-time favorite meal that I would choose if I were ever stranded on a deserted island. Tuesdays we have ugali, the East African staple that is a stiff porridge made from maize, and meat, while on Thursdays we have perhaps everyone else’s favorite, pilau, which is brown rice (cooked in meat stock) mixed with beef and then a coleslaw-like salad to go with it. Both of these, of course are made that much tastier by the addition of Samwell’s pili pili.

Yes, we even enjoyed a bit of Konyagi, The Spirit of the Nation

The second event that occurs on Wednesdays is our Happy Day night. Happy Day is a long-standing local pub that also has small bungalows where many of the long term volunteers at FAME have lived in the past, including Peter Schwab, the medical student who worked with us last October and is now a neurology resident at Penn. Happy Day (note the “Day” and not “Days” so as not to be confused with that popular sitcom) has been an institution here in Karatu since my very first trip, but has changed its ambience since taken over by new management. What used to be uncomfortable picnic benches on the outside deck are now very comfortable outdoor sofas and pillows, lots of them. It has been a tradition for years that all the ex-pats working in Karatu and surrounding areas come to Happy Day on Wednesday night to socialize and share stories. Frequent attendees include much of the staff from the School for Field Studies in Rhotia, which is quite close and is field school where college students come for study abroad programs. The mix of individuals depends on who is in town and who is around and is different every Wednesday night.

Andrea and Marissa enjoying themselves

The third event on Wednesdays is much less of a sure thing and really depends on how much energy everyone has and what we have planned for the following day. If everyone is up to it, and that is not always the case, we will all make our way over to the other local hotspot which is the Golden Sparrow. “The Sparrow” hasn’t been around forever, but was the creation of the owner of the previous dance club which was called “Carnivore,” and was a little hole in the wall place that served the most scrumptious, though also the scrawniest, barbecued chicken and chips along with drinks. Seating for dinner was mostly outside on a dirt floor where they cooked the chicken whole on a huge grill and then literally whacked it into pieces with a huge cleaver before bringing it to your table to eat while dancing occurred inside on a tiny little dance floor that was nestled amidst the bar tables and stools.

The gang at the Sparrow

Carnivore is no more and the owner, Martha, created a true dance club that would rival anything in a larger town and includes a DJ, disco lights and televisions around the dance floor. I will have to admit that in the past, there has been dancing on the tables though I will not mention any names (Mindy, Susan, Susannah, Whitley and Neena, I believe), but the tables have been changed and it’s no longer possible to do so. There is a very large outside seating area for dinners where they still serve their delicious chicken, but the most fun occurs inside on the dance floor. This night, we all loaded into Turtle and drove over to the Sparrow to let off some steam as we had working very hard for the month and were looking forward to our final day of clinic the next day, though no one really wanted to leave. Yes, there was dancing tonight, but none on the tables and we left before midnight to make sure that we’d all be in OK shape for the following day. It wa an incredibly enjoyable time, but not something that can happen every Wednesday night, that’s for sure.

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