March 6, 2020 – And an even busier day in Neuro clinic….

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A view from our back porch. The trees have gotten big

As I have mentioned in the past, the March trip has traditionally been the less hectic and less attended of the two for reasons of weather and planting. That has not been the case based on the first two days of our clinic, one announced and the other not so, as the numbers have been on par with the fall trips so far and that will put is on target for a record spring volume. The other thing weighing greatly on our minds here is the Coronavirus-19 outbreak going on globally at the present time that has continued to spread and, from the very good sources I have communicated with in the last days, will continue to do so regardless of what travel restrictions will be implemented throughout the world. Things here are safe, though the Tanzanian Health Ministry did meet with FAME officials several days ago regarding protocols to care for patients who may show up here (don’t forget that we also care for many tourists on safari in the region) with symptoms and may require isolation and protective gear for those treating them. We would not be seeing anyone with those symptoms (I keep reminding everyone here that we’re neurologists), but having a patient here would certainly increase everyone’s risk. I think that likelihood is very low for the immediate future.

The neuro team in the morning before patients

Our patients waiting for us first thing in the morning

Waking up this morning reminded me of just how beautiful if is here as the sun was shining with few clouds in the sky and you could already feel the radiant warmth in the early hours after sunrise. The number of birds songs to be heard here is absolutely immense and I wish I could identify them all other than the morning dove whose song is so very distinctive. Walking to morning report in the bright sunshine never gets old and, even though walking to clinic in the light rains of the morning is still being in paradise, there is something about the crispness of those clear mornings that reminds you of everything good in the world and provides a reassurance that is so difficult to describe. I had a feeling, though, that this morning was likely to be an anomaly as I still believe the weather has changed and we’re in for the rains. In any event, I’d rather think that way and be pleasantly surprised rather than the reverse and be poorly disappointed.

A bright clear day at FAME (though a monstrous downpour later)

Angela playing “who’s got the reflex hammer” with a young patient

Now Amisha playing “who’s got the reflex hammer” with a young patient with Angela looking on

In morning report, we didn’t have any neurology patients to focus on, though there was a young man from Rift Valley Children’s Village who had presented with recurrent abdominal pain and they were worried he might have inflammatory bowel syndrome, needing to be referred to Arusha to specialists who could do a colonoscopy on him. Since both Amisha and Angela are pediatricians, we were asked to have them see him and weigh in with their thoughts. Mama India, the long-time director of RVCV, would be by after lunch and Susan wanted to have an update for her so our peds contingent stole away from clinic momentarily to take a look, and, thankfully so, as they felt the young man suffered only from gastritis after taking tons of ibuprofen. They recommended treating that and seeing how he did rather than jumping to a scope at the moment. India was quite happy to hear that it may not be anything more serious than overusing the non-steroidals and would likely get better on its own without more aggressive testing or treatment.

Alice and Anne evaluating a patient with Carrie looking on

Molly and Africanus evaluating a patient

We did hear about a young man who had come in the night before with fever and confusion and who they had possibly wanted our input in if it hadn’t been for the fact that he had a tremendous number of malaria parasites running around his bloodstream and most likely had cerebral malaria. Malaria isn’t a common condition that we see here at FAME given our altitude (a mile high) and weather that is much more moderate than Arusha. There is malaria in many of the areas that we travel through, though, so that everyone traveling her for a short time (meaning everyone on our trips) will prophylax with typically Malarone, or, for those allergic to it, doxycycline. Malarone tends to cause vivid dreams, though not nearly so significant as mefloquine, an older drug used to treat and prophylax for malaria, but still enough of an effect to be noticeable and distinct. There is little question in my mind that I have had very vivid dreams here in Tanzania over the years while taking Malarone, clearly more than I have back at home, and I would be the first to say that they are not disturbing, only vivid as billed. Meanwhile, the young man with cerebral malaria was doing much better the following day with treatment of his underlying condition and there was little need for our involvement given that.

Carrie doing her crossword puzzle by headlamp

Dan examining a patient

Walking into our clinic area, the old ward 2, it was clear that the trend over the last two days would continue over the coming weeks as there was already quite a queue waiting for us. Angel and Kitashu were working hard to get everyone registered as we needed to have their charts whether they were new or follow up. There is no electronic medical record at FAME, and even though they are working on one as I am writing this, it will take several years to get that in place. They do have all of the demographics online for every patient, though, as well as an accounting of all of their visits, laboratory testing, radiology testing, etc. that makes life much very much simpler for reception and the doctors caring for the patients.

One of Amisha’s pediatric patients

Amisha and Marin

We had been told that there was a group of patients coming today from the Tarangire region, a fair distance away, and would be arriving sometime around 11 am, but when they did finally get to us, and around the appointed time which was not at all expected, the group was far exceeding the 11 patient slots that we had reserved. We had decided in advance to keep our numbers around 30 patients for today, given the long day yesterday, but by lunchtime we had already exceeded that number in our log book as the group of Maasai from Tarangire ended up being more like 15 patients, all told. On the good side, the majority of those patients ended up being children, much to the delight of Amisha, Angela and Marin, who are all obviously in their zone seeing children and there is little else required to keep them happy. It was also quite interesting that there was a large contingent of trisomy-21, or Down syndrome, patients in the group that were of varying levels of function. In this group of patients, who, by the way, I manage many of at Penn who are adults, we typically do annual thyroid testing, given the high percentage of hypothyroidism, and cervical spine studies as they are also prone to cervical subluxation. We have little difficulty getting a TSH here at FAME, but even if a patient had cervical subluxation and myelopathy, there would be little that we could do them as that surgery is not something that could be undertaken here by any means.

Amisha with one our Down syndrome patients

A hearty downpour at FAME

One of the children that we saw very late in the afternoon was really quite interesting, though also quite sad given his problem. He was with the group from Tarangire, or really Babati to be more accurate, and had come a long distance to see us. He was seven-year-old boy who had not moved his lower extremities since birth for the most part and his father told us that he had a “rash” on his bottom that occurred recently. When Marin had the father pull down his son’s pants, what was really present was an incredibly large ulcer over the sacral region that appeared to have stool in it making her initially concerned for the presence of an enteral-cutaneous fistula, but it was really difficult to make the connection between his lack of walking since birth and this wound. Eventually, it was discovered that the wound had begun very recently and had first shown up as an abscess that had been drained at one of the local health centers. Once the wound was cleaned fully, it was determined not to be a fistula, and the wound, or now wounds, appeared to be just very large sacral decubitus ulcers that actually had fairly clean borders, though it wouldn’t be long before this entire mess became horribly infected and the young boy would become septic in no time. He looked as though he may have hydrocephalus, or at least had significant frontal bossing and was scaphocephalic (elongated front to back) making us quite suspicious for this condition. His chest was also poorly developed and, in the end, Dan was pretty certain that he had sacral agenesis , a congenital disorder in which the sacrum and other midline structures of the lower spine are not fully formed.

One of Amisha’s children

Even though the reason for the child’s visit was the fact that he wasn’t moving his legs, a problem that we had very little to offer for, we felt compelled to help with the now likely decubitus ulcers (bed sores) and after the father had cleaned them out to reveal no clear evidence of a fistula, rather just the two large ulcers, we asked if the nurses here could help clean them up a bit further. As the child didn’t need to be admitted to the hospital, we had very little else to offer immediately, but suggested that he be taken to Haydom Hospital, a regional facility much closer to the family, that could fully evaluate him treat his ulcers further. After his treatment by the nurses, he sat on his father’s lap waiting for everyone from their group to be ready to leave and was clearly a very attentive and cognitively intact child who needed no further evaluation or care from us.

Angela and one their pediatric patients

One of Amisha’s patients

The other child from the Babati group with an interesting problem, albeit non-neurological, was an incredibly cute 3-year-old young girl who was presenting with a very large vascular malformation of her lower lip and a large protrusion of her abdomen (which later turned out to be just a simple ventral hernia). There was little question that neither of these issues were neurological in nature, but given Dan’s vascular background, there was no way that he was going to allow anyone else to see this child. Once it was determined that her AVM was limited only to her lower lip, meaning that she did not have more extensive involvement, it was merely a matter of documenting the extent of the lesion and then determining if there was anything we could do about it, which meant contacting specialists back home for recommendations. The lesion was very limiting for her causing issues with her speech and ability to eat properly, not to mention the risk of ulceration or infection as time goes on. The fact that it was limited just to her lower lip meant that it would not be incredibly difficult to deal with, but would require specialized services not likely available here in Tanzania.

Our cute young child with the AVM of the lip

We ended up seeing 36 patients today which, combined with the 35 from yesterday and the 20 patients from the day prior, meant that we had seen 91 patients in our first three days here. And that did not include the inpatient consults that we had seen along the way which would have brought our total to nearly 100 patients in only three days of work, only two of which had been announced to the community. There had also been an incredibly heavy downpour during the midafternoon, an event that usually brings most everything to a halt here, but since most of patients had already arrived, we had a steady stream during that time, of both patients and rain. The downpour was so heavy and lasted for so long, that during this time you could hardly hear yourself think, let alone communicate with others which is quite necessary when the residents present patients. One special patient who came this after was a Maasai woman and her husband who I have treated now for many years and who comes back to see me every visit and he thanks me every time for having taken care of his wife. A few years ago, we had visited his boma and his four wives who live on the far side of Lake Manyara, where they had honored us with a goat roast that was amazingly tasty, though it seemed that I was the only one in our group who was partaking in this delicacy as the others were either vegetarian or just not enthusiastic about eating fresh goat roasted over the open flame on wooden skewers.

My friend whose wife I have treated for many years

Regardless, it was the tastiest barbecue that you could ever imagine and, since that time, I have been to several other goat roasts that have been equally incredible on every occasion, not only for the taste of the meat, but also for the significance of the event as it is very meaningful in the Maasai culture and carries a tradition of true honor and friendship when it is presented in this manner. Each time that our group has participated at the boma in this affair, everyone has left with a sense that they have been part of something very special. I have felt this every time I have visited this country with its very special and resilient people; a sense of unity and oneness in the world with the knowledge that love and tolerance can overcome any differences that may exist and, most importantly, hope for the future.

Molly playing the “skittle game” with Amisha (and losing – sorry, Molly)

 

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