Thursday, October 1 – A few very sick patients….


A mother and our patient

In the absence of our normal neurology lectures that are given by the residents when they are here with me, our synchronous virtual lecture series continued with today’s session being a case conference format that would be given by my Tanzanian neurology team on the ground here. I had asked Dr. Adam, Abdulhamid, and Revo to each select a case that they had seen in the last weeks and present them to everyone here plus Mike Baer and Kelley Humbert, both veterans of the FAME Tanzania rotation, who had graciously agreed to sacrifice their sleep as the talk would be from 12:30-1:30 am East Coast time! It was a great exercise for my three awesome colleagues here as the format would require that they present the history, examination and differential with a discussion between each as a way of explaining their thought processes of each case. Mike, Kelley and I each weighed along the way asking questions as did the other docs here. It was a great inaugural case presentation session to our new neurology virtual lecture series and we forward to more of these in the future. For those of you with an interest in what was presented, Abdulhamid presented our patient with ALS, Adam presented a case of Parkinson’s disease, and Revo presented a case of absence epilepsy.

One of our younger patients

Our cases for the day were our typical grouping of epilepsy, headaches and numbness, but we did have one case in the ward and another that came in later in the day that garnered a bit of extra attention from us. We did hear at morning report that there was a woman on the ward service who had come in awake, but was now unresponsive and was clearly in need of our expertise to determine what was going on with her. I had asked Abdulhamid and Revo to head to the inpatient ward to evaluate her while Adam and I would get started on seeing outpatients that had already arrived that morning. When they came back a bit later, the story was not very good at all. She had apparently undergone a total abdominal hysterectomy several weeks prior and was recovering at home, but had come in the day prior with a headache and overnight had declined to where she was no longer responsive and her neurological examination was not very promising. She did not localize or respond to painful stimuli and her pupils were large and poorly responsive. We asked them to send her immediately for a CT scan of the head and, what we found, was not necessarily what we had expected, but fully explained her poor examination.

A higher cut of our patient with the bilateral subdurals and midline shift

She had bilateral acute on subacute subdural hematomas with significant midline shift of the brain, or simply put, she had bleeding over the brain that was putting significant pressure more on one side then the other which was why she was no longer responsive. We were initially unable to obtain any history of a fall, though apparently later the family may have told the staff that she had indeed fallen. Regardless of whether she had or not, we now had the answer to why she was doing so poorly and I met with Dr. Lisso, the doctor on for the day covering the inpatients, to tell him that I felt it was really unlikely that sending her to the neurosurgeon in Arusha would change the eventual outcome as I didn’t think she would survive either way. I verified that he was quite comfortable with the information I had given him and was also comfortable conveying that to the patient’s family. I went back to evaluating our outpatients when, sometime later, our FAME ambulance pulled up to the loading area just outside the night office where we were seeing patients and my presumption that it was for this patient with the subdural was correct. Apparently, the family had decided that they wished to do everything possible despite the fact that it would almost certainly be futile to do so. I heard later, that the patient did have surgery and her hematoma evacuated, but that she had not survived the ordeal after all. Though it had been clear to me that it was unlikely she would survive based on her exam and CT scan, the family had apparently wanted to make an attempt as unlikely it was that she would survive. That is the prerogative of the family in this situation and certainly not something that we can decide for them as long as they have a clear understanding of the likelihood of success.

Who said neurologists don’t use stethoscopes

The other case we saw was equally interesting and had a far better outcome than the previous one. In the afternoon and, in fact, in the middle of dealing with our ward patient, we saw a young man in his mid-thirties with a seven year history of diabetes that was most likely adult onset and not juvenile. He had been blind for a few years secondary to diabetic retinopathy and had not been walking for nearly a year with symptoms of neuropathy in his legs, though his weakness didn’t seem to be from a severe length depended neuropathy and very likely from another diabetic related process such as a diabetic amyotrophy, which is a more proximal process with muscle wasting, though he did not have the classic pain I’d expect from this disorder. He was in a wheelchair when he came into the room and had his head down and was very quiet overall. He had been seen at FAME about a month ago for his diabetes and at the time had a Hgb1c that was simply listed as “>14.5,” which is dramatically high (it should be under 6 in a normal person and perhaps around 7 in a well-controlled diabetic) and clearly indicated that he was in dire need of better glucose control. He was put on insulin at that time and had been using it since.

Abdulhamid examining a patient

Abdulhamid examining a patient

As the visit progressed and we were able to get him up onto the table to examine him, he seemed to be less and less engaged with the questions that were being asked of him and had difficulty even following directions during the examination. As I was typing my notes for the visit while the others were questioning him and examining him, I think it dawned on all of us at the same to time that he was getting more and more hypoglycemic before our eyes. As Adam ran to get a glucometer, we were told that his blood sugar had been 72 that morning and that he had taken his morning insulin rather than adjusting the dose. When we checked his blood sugar it was 50, which is exceedingly low for a diabetic and we were worried that he was still dropping. We threw him back into his wheelchair and around the corner into the ER where we put an IV catheter into him and immediately started a glucose drip. He was admitted to the ward as we weren’t about to send him home given this experience and he clearly needed some serious education regarding insulin and his blood sugars. No necessarily a neurological problem, but we were able to intervene and very likely saved him from any more serious injury from becoming even more hypoglycemic than he turned out to be in the end. Unfortunately, he later went home from the ward without us actually having a chance to fully examine him regarding his weakness, but given the story, I was fairly certain this was going to be a diabetic related issue and that the treatment would be control of his blood sugar in the end.

Neurologists in action along with Siana

With all of our excitement, the day went long and I had been invited to Abdulhamid’s aunt’s home for a visit after work. This was where I should have used my instincts and knowledge of their hospitality here when I asked Abdulhamid whether this was for dinner or not and he had told that it wasn’t. I had a nice dinner of spaghetti and vegetables that Samwell had prepared for dinner and then picked up Abdulhamid at the tarmac junction to drive him to his aunts as no one at her home spoke English. As I have mentioned before, Asha, his aunt, has been head of housekeeping at FAME for many years and it was really through her that he and I had been introduced in the first place. I recall when we were making the plans for his trip to Philadelphia how appreciative she had been and I despite the language barrier, I just know how she felt. Not only was she incredibly proud of her nephew, but she was incredibly grateful for the opportunity that had presented itself through FAME.

Abdulhamid’s well-behaved little cousins

So, as you might have guessed, he and I sat in the living room of her wonderfully remodeled house, while she worked in the kitchen for what I knew was soon to come. It was quite clear to me that I was now going to be expected to eat my second dinner that evening and it was not long at all before this premonition came to fruition. Asha’s son was also home to join us at her dinner table, which is unusual in most small Tanzanian homes were dinner is usually served on the low table that serves alternatively as a coffee table in front of the couch. I will have to admit, though, that I did not have trouble with my second dinner as Asha is a wonderful cook and her roasted chicken was absolutely delicious, so much so that I know I had a second, and quite possibly a third, helping of the chicken along with ugali and watermelon. It was a great way to end the evening with a dinner from a very gracious and thankful host who has been a part of the FAME family for many years. I know that she is very well respected in her position there and, as I have mentioned before, though it may have been an honor for her to have me here for dinner, the real honor was truly mine as I have been taken in here as family and am forever grateful for these opportunities I’ve been given.

A gorgeous sunset from the back porch

A gorgeous sunset from the back porch

A gorgeous sunset from the back porch

A gorgeous sunset from the back porch

A gorgeous sunset from the back porch

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