Monday, March 28 – Back to neurology clinic and a welcome break from those terrible tsetses…

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Just how much has FAME grown since 2008?? This is how much…

Though it had been a really wonderful weekend diversion from our normal schedule here at FAME and the lovely relaxation at the pool had been a real treat, it was now time to re-engage with our primary mission here. Having come to Karatu on my own for several years prior to bringing residents, the first in 2013, I had developed so many relationships not only with the staff at FAME, but also with locals and lodges throughout the community. The primary goal of bringing residents here was to have them partner with the clinicians, not only acting as educators, but also as students, for it was clearly a two-way street and what everyone would learn in the process could not have been accomplished had it been otherwise. The true value, though, was not merely in the two-way communication of the medical knowledge that was occurring, but rather, and perhaps more importantly, in the cross-cultural education that everyone was receiving passively. That is something that is not taught or learned, but can only be experienced and, without traveling here in person for the month, would be otherwise impossible to absorb. These relationships that are built will only occur when both parties are in the proper frame of mind and are both equals.

Developing these relationships with the staff at FAME is, of course, quite simple, for everyone is working towards the same goal, but spending time with Tanzanians whose only connection to FAME is that they live in the same city or region, is another matter. In the past, our entire group would spend the night with the Temba family in Arusha, but since the pandemic, the flight schedules have changed such that we now arrive in the morning rather than the afternoon, and are able to make it to FAME on the same day during the daylight hours. Spending that night in Arusha with the family was always something that the residents valued tremendously, and though we’re no longer spending the night, we still have the opportunity to visit and have breakfast with the family. Leonard and Pendo have been invaluable to the development of this program, having helped immensely with all of our logistics here, from housing everyone in the past, to arranging transportation and, perhaps most importantly, maintaining Turtle during my absence.

Dr. Anne and Savannah evaluating a patient
Abdulhamid, Peter and Nuruana evaluating a patient

When the team arrives to FAME and Karatu, there are many members of both communities who are ready and willing to make everyone feel right at home, whether it be for helping with a dinner out at one of the lodges or visiting someone’s home as in the case of Daniel Tewa. Teddy, our ready and waiting seamstress has always made everyone feel right at home, greeting us with a smile and her tray of pipi (candy) that she offers to us as we pull up to her shop in Turtle. She is now in an area of Karatu known as G-Arusha that is on the other side of town, exposing everyone to a new area here. Gibb’s Farm has been a staple from the very beginning of these trips, strongly supporting the volunteers at FAME by offering dinner and lunch at greatly reduced prices as well as the opportunity to spend time at their brand new pool. The attraction, though, isn’t only the food and view, but also its place in the history of this region and all of the employees who I have come to know over the many years. There are those I know only through my visits to Gibb’s and then there are those who have either been our patients or their children have seen us in clinic. Our team is always greeted not as guests, but as family because being a volunteer at FAME, even if only for a month, means that you are now part of this resilient and wonderful community and our goals are the same.

Savannah and Anne evaluating a Maasai woman
Natalie evaluating a young child

At morning report, we learned of a patient who had come in with very significant hyponatremia and was otherwise neurologically intact. Though one might not consider hyponatremia to be a neurologic problem, and you would be correct, it can very quickly become one if the sodium level is corrected too quickly, causing something that used to be called Central Pontine Myelinolysis, and is now referred to Osmotic Demyelination Syndrome as it affects other parts of the brain other than just the pons, a potentially devastating and irreversible process that can be easily avoided with proper monitoring. Not wishing this to occur and wanting to be diligent, I spoke up to inquire as to the patient’s location in the ward and making it known that we would simply look in on the patient to assist in their care.

Eliza and Alex evaluating a young school student
Peter looking a bit suspicious while Abdulhamid questions a young school student

There was also another patient that had come in over the weekend who had been involved in a boda boda (motorcycle) accident and had suffered a severe facial fracture with involvement of the maxillary region and orbit on the right side. Not being an expert whatsoever in the treatment of facial fractures, I listened intently in the discussion of which La Fort fracture this represented as there is a grading scale depending on how much of the midface is involved and, essentially, how significantly the midface is separated from the rest of the skull. Ke had already taken a look at the CT scan and was far more qualified to be discussing this than any of us were, but there had also been a finding of a small subarachnoid hemorrhage noted in the right basal cistern around the brainstem. Now this was just a bit closer to our neck of the woods and, so, there was another consult now for us to see in the ward and our Monday morning clinic had not yet even begun.

Anne and Savannah evaluating another of the school children

I had also failed to mention that we were now down one of team members, for poor Savannah, after surviving the weekend like a real champ, was now completely reeling from her battle with the tsetse flies, having been unable to sleep last night due the multiple bites she had suffered on her ankles and the amount of edema and inflammation that was causing. She was pretty incapacitated by the pain and it was clear that coming to morning report and clinic with the rest of us was not in the cards for her today. I suggested a good bolt of steroids for her inflammation and pain as I had them with me in my bedroom cabinet, never traveling anywhere without them as they are not only good for anything that ails you (I am only half facetiously saying that), but for anything inflammatory, they are what’s indicated, whether it be something like Savannah’s bites, a prolonged migraine, or any host of acute inflammatory musculoskeletal injuries. And, as you’ve seen in some of our neurology cases, they do wonders for brain vasogenic brain edema with tumors or infections.

Natalie and Nuruana evaluating a patient

Savannah must have been really hurting for she did not put up a fight when instructed to stay home and take care of herself for the morning and to take as much time as she needed until her feet felt better. In the end, she showed up at the clinic earlier than I had anticipated, but knowing her, it was probably later than she had wanted to be there. Alex was off seeing the patient with the facial fractures and small subarachnoid hemorrhage and Peter was dealing with the hyponatremic patient, so it fell on Natalie to begin clinic that morning with everyone else having been occupied. Thankfully, it was not quite as busy as some other Monday mornings had been so far this trip, but there were definitely patients slowly showing up to be seen and it wasn’t long before we had a steady stream of patient arriving for hour services. And it also wasn’t very long before Natalie began getting her baby consults in the maternity ward with the first one being a twofer, requiring her to see both mother and baby, and I being thankful that she’s equally comfortable with adults and children given her plans to most likely do an adult stroke fellowship it the future.

In between patients

We had finished with clinic relatively early for a Monday, but received a late consult from the ward for a child that had brought into the ward by their family and concerns that the child was having continuous seizures. What we found instead was a story that was completely tragic and gut wrenching as the child, who was a 15-month-old little girl, was not having seizures, but was rather having continuous posturing of her extremities, a sign of extremely severe cortical dysfunction and something that is referred to as “decerebrate posturing,” meaning that the cerebrum, the part of the brain excluding the brainstem, is not functioning for one reason or another, and it is most often due to a devastating and quite likely irreversible process.

Working on documentation

The story had been that her Maasai family had taken her a month ago to a hospital in Arusha due to fever and seizures, and that she had been admitted to the hospital where she remained an inpatient until the family finally took her out of the facility after a month as they were concerned she wasn’t getting better. They then took her to another hospital briefly as an outpatient, finally making their way to FAME. I don’t recall whether they knew that we were here or not, I don’t recall, but as soon as she arrived, she was admitted to the ward and we were called. There was some mention that a CT scan had been suggested sometime over the last month, but it had never taken place either due to cost or some other reason. Regardless, her family was now intently aware of the grave circumstances and wanted our opinion.

Subarachnoid blood in our trauma patient

On examination, the child looked horrible – she was not awake and had constant decerebrate posturing of her extremities that did not represent seizures. She was breathing on her own and did seem to have some bulbar responses, but really had nothing else. And, to add to the situation, she had very marked hydrocephalus with all of her cranial sutures separated and splayed wide. It was immediately clear to us that there was nothing we had to offer this child in regard to helping her get better, but we were still at a loss as to what had happened to her and given that, it would be very difficult for us to have a meaningful conversation with her family not being able to give them this information. At home, we would never have been in this position for a multitude of reasons, the first of which would be that we would already have had tremendously more information as she would have been scanned a gazillion times so we would not be sitting here without information for the family other than her clinical picture.

We sat and wrestled with the decision as to whether or not to get a CT scan on the child. It would absolutely not change her outcome, which we knew was dismal, and the only thing that it would help would be to give us information that we could convey to the family and, hopefully, some insight into what had happened to cause this. We would have to make it clear to them that getting the CT scan would only help us answer questions for them. Even with the small chance that this was merely hydrocephalus, the likelihood of there being any intervention after a full month in the hospital was essentially nil. Thankfully, the family agreed to obtaining the CT scan, knowing full well that it was not going to save their little girl, but would at least give them some answers that they had been searching for over the last month.

Near complete loss of the cerebral hemispheres and hydrocephalus in a 15-month old

The images were frankly shocking to all of us as they demonstrated the near complete destruction of both of her cerebral hemispheres with the additional features of what appeared to be trapped ventricles, while there was some preservation of the cerebellum and the brainstem. What could have caused this degree of devastation while not having proved fatal was something that was mere speculation to all of us and even those back home who we shared the images with in an attempt to gain further clarity. I equated it to trying to explain all the events of a high speed traffic accident by piecing together information from the skid marks and mangled cars. In the end, it was felt to have most likely been due to an infection that had caused the massive damage and had never been treated. Herpes simplex and tuberculosis were two leading contenders, though there were other possibilities as well. Regardless, it would matter little to her family one way or the other as they were losing their child and no treatment existed anywhere in the world to save her now.

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