It’s simply amazing just how much an extra half an hour of sleep can make you feel, but I’ll have to admit that one does look forward to those days without an educational meeting. I think it’s more a mental thing, though, as I have become accustomed to getting up extra early in the mornings to finish my blogs and get them posted. I have set a goal on this trip to not fall behind with my writing, as has happened so often in the past, leaving the last days unfinished. I will do my very best to stick with this plan and see if it lasts.
This would be our first full day of clinic and we were already a bit handicapped in that I knew that Kitashu would be heading back into the NCA to complete their search for the rabies exposed children and to continue their work of contact tracing. We would not be without a clinic director, though, as Angel would be working with us today and, as social workers go, she is a gem both from the aspect of keeping the clinic running smoothly as well as helping with the patients when access issue would arise. Having them both with us is always the best, but Kitashu does have the benefit of having been raised in the NCA and still has his family there, hence the need to have him leading the rabies contact tracing expedition, and that clout is often very welcome in our clinic when it comes to these patients. FAME’s catchment area in Northern Tanzania throws an incredibly wide net over approximately 2.9 million people living in these regions, many of whom are Maasai from the NCA, and it is frequently necessary to have someone who not only speaks their language, but also understands the complexity of their lives. Kitashu brings all of this to the table and more.
Having an outdoor clinic certainly has its advantages and, in addition to all of the fresh air and openness, one also quickly realizes how busy the clinic is as the “waiting room” sits adjacent to us so that it is readily visible just how many patients are waiting. And, in addition to seeing the volume of patients that need to be seen, we now have the EMR that also displays the patients waiting to be seen by us in neuro clinic. When patients come to FAME for our clinic, they are registered and segregated for us in a separate area and today we discovered a small issue with the standard process of triaging and taking vitals in one area. When we’re here seeing patients, these are in addition to the normal volume of the clinic and with seeing nearly 100 patients per day, adding nearly a third more to that can be very disruptive to the patient flow. Starting tomorrow, we’ll make sure that the normal clinic patients are triaged first to get them moving as seeing a neurologist tends to be a lengthier and more thorough process so that our patients can be triaged much more slowly given our pace. Thankfully, everyone here working is here for the same purpose and there are never issues in working these situations out.
So, it became readily apparent once we started clinic that it was going to be a very busy day for us as the patients were quickly piling up after we opened for business. There are no appointments here for the most part, and most patients will show up at around 8:30 am (2:30 Swahili time) to be seen with the knowledge that they will most likely be spending the entire day here. The EMR has made it much easier to keep track of the patients as seeing someone out of order can create an issue and when we see those who come in with special situations, it must be done quite discretely. It is always a bit of an educational process for the residents when they get started here as their normal workflow from home may not work depending on the patient and the volume of patients that we have in clinic for the day. We had planned to have three examination stations originally, each staffed by at least one resident and doctor or translator, but it became very clear quite quickly that we would need to have four stations given the volume of patients that were showing up to be seen. We can’t control the number of patients who come to be seen on a given day, but we can control how many patients we can see in a day with the overflow having to come back the following morning to be seen at the head of the line.
Natalie, our pediatric neurologist, had more than enough kids to keep her busy through the day, including one young child with hydrocephalus who I saw along with her. The child did have a shunt that had been placed shortly after birth but had a very large head despite this and though mom reassured us that her head had not grown in size over the last year, her prior CT scan had been done elsewhere and we therefore had nothing to which to compare it. Furthermore, she had a very broad opening in the back of her head where her sutures had not fused and, though this did not pose any immediate concern, this was something that would normally have been addressed with a cranioplasty. The child was also on very low dose phenobarb for a history of seizures and it was recommended that she continue on that given the high risk of recurrence based on her abnormal examination and the focality seen. It was unclear as to whether or not she was cortically blind based on our routine examination, but Natalie recalled that Meredith had brought along an optokinetic strip (OKN), a tool that is used less commonly these days, but certainly something that could help us determine whether she had vision as drawing this striped band in front of her eyes would produce movements, or optokinetic nystagmus. And sure enough, she had some vision, which was very reassuring to us. We had discussed obtaining a CT scan now, but in the end, the decision was to hold off, both for financial and clinical reasons, and we would see her back in three months.
Another patient who had presented today was a young man who was originally seen last month with new onset focal seizures and was found to have a rather large left parietal enhancing mass on CT scan. His seizures involved his right arm and on examination now, he was found to have mild right sided weakness. In reviewing his CT scan, the mass was quite evident and quite large with some surrounding edema and was somewhat cystic. It had been read officially as a meningioma, which is a reasonably benign tumor from a pathological standpoint, but when very large can produce problems based on its mass. Based on the fact that it was producing a mild hemiparesis, it was producing enough mass effect that it would most likely be amenable to at the very least resection, though depending on its ultimate pathology, we may also have other options such as radiation. Regardless of this, we adjusted his carbamazepine to achieve a more therapeutic level for him.
Our other incredibly interesting patient of the day was another gentleman who had been having focal seizures for about five years and was on carbamazepine with incomplete control. He had come to FAME about a week ago and had been sent for a CT scan here that was felt to be diagnostic for neurocysticercosis. He was started on albendazole, an anthelmintic used to treat tapeworms which is the parasitic agent that causes cysticercosis, and had returned to see us a week later. His seizures were still under poor control on his carbamazepine dose, which obviously needed to be adjusted further, but there also issues with him taking the albendazole as patients with a high lesion burden can have severe reactions with brain swelling and hydrocephalus.
Neurocysticercosis is actually the number one cause of epilepsy in the world and very prevalent in South America where there are many pigs, and therefore pig tapeworm. Small cysts develop in the brain that cause irritation (through immune reaction) and lead to patients developing focal seizures. In addition to the numerous cysts in the brain, patients can develop hydrocephalus that complicates the treatment as the patient will require that a shunt be placed prior to any parasitic treatment for the reason that I mentioned regarding reaction that can occur with the death of the organisms and a massive inflammatory response. For this reason, patients are also given high dose steroids when ready to initiate treatment to prevent this reaction and will most often have placement of the VP shunt prior to treatment if there is any concern for hydrocephalus developing with treatment, or they have already had it placed for hydrocephalus that has developed before treatment has been started. In addition to a great many cystic lesions (i.e. high lesion burden), this patient already appeared to have some hydrocephalus. Given the significant possibility for a severe reaction with treatment, he was place on steroids, his carbamazepine was titrated higher for better efficacy, and his albendazole was discontinued until he could be fully evaluated at a tertiary center where a neurosurgeon could weigh in regarding whether he would benefit from a VP shunt. As you can see, he was also a very challenging patient regarding his management.
Clinic was fairly busy as I mentioned and, in the end, the residents had seen approximately 29 patients throughout the day, all of whom were very interesting, whether it be from a medical, social, or cultural standpoint. Managing patients in such a resource limited setting can be incredibly challenging, though also quite rewarding given the lack of neurological care in the entire country.
As we travel here every March and I have done so for the last 12 years but one, I have also had the pleasure of celebrating my birthdays here with the residents and FAME staff. As my family will tell you, I am not one to naturally accept such attention, and I have done my best to typically avoid drawing any attention to the fact that another year has passed for me. I’ve come to the realization, though, that birthdays are more of an excuse for those who care about you to show it than they are for the one who’s gained a year and, with this in mind, I have slowly accepted this philosophy. As tonight was my birthday, it was another time for celebration and arrangements had been made for us to go to the Golden Sparrow, a local Karatu club that just happens to serve the most amazing roast chicken. It also has an indoor dance club that is a throwback to the discos of the 70’s (at least in my limited view of the dance scene today), though without the Donna Summer disco music.
We all enjoyed drinks and some food, but the highlight was Dr. Anne’s birthday cake that she brought for me and was amazingly delicious. It had red frosting (my favorite color), a big blue frosting flower on top (my second favorite color), both of which made it look just a bit like something out of a Dr. Seuss skit. After having cake, we all made our way inside into the dance hall and enjoyed non-stop dancing for about 1 ½ hours, fueled of course by some Konyagi, which is the local gin and half decent when mixed with some tonic water or ginger ale. Whitley seemed to have good handle on making sure that the DJ was playing just the right songs for us and I was happy to have at least recognized one or two of them. As we all had to make the 7:30 am educational lecture in the morning, I was fairly intent on making 11 pm the witching hour and, in the end, had little resistance from any of the neuro team and they all went quietly. Once home, it was quickly to bed and ready ourselves for another wonderful adventure in clinic.