Thursday, September 8 – More cold weather and a paucity of patients…

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Morning lecture with Nurse Barb

Our string of unseasonably cool days continued this morning meaning that our patients, whose intolerance of cold is undeniable in this region of the world, are remiss to leave their homes to see us. Having thought that it was mainly due to the fact that yesterday was market day, was clearly an over simplification, or at least it was only a partial answer. Walking out the front door of the Raynes House this morning, a few minutes before 7:30 so as to make the morning lecture on menopause, we were in the clouds, literally. There was the unmistakable misting that was the result of the clouds coming down off of the crater rim, a sight I remember so well having flown over the crater from the Serengeti all those years ago. On Sunday, we will be visiting the crater and I suspect, if this weather holds, that we’ll be in the pea soup fog that exists on the rim on mornings such as these. This is the dry season and the weather should be much warmer than it has been all week as the cold spells typically occur in June, not in September. Where things stand currently with the Great Migration is unclear, though I suspect the wildebeest have already made it across the Mara River and are north into Kenya by now.

Nurse Barb

As I mentioned, our educational session this morning was being given by Barb Dehn, or Nurse Barb, who is a fellow board member and long-time volunteer here at FAME. Barb is a nurse practitioner specializing in women’s health issues not only in the care of her patients, but also in the education of the public through her many books and publications as well as radio and television appearances. Having Barb on the board of FAME ,given her energy and enthusiasm, has surely been a God-send, but having her come to FAME on a regular basis to work with the nurses and doctors here given FAME’s mission to improve women’s health through our reproductive and child health programs has been worth more than anyone could possibly imagine.

Pilau and cabbage salad
Meow at lunchtime

Her lecture this morning on menopause was certainly more than just that. It was a discussion of women’s health issues related to hormones and hormone replacement, birth control, and, in general, improving women’s health and happiness by better understanding the changes unique to women that occur through a lifetime. Though not something I would have signed up for at a conference, it should have been as even an old neurologist could take away many of the teaching points Barb focused on during her presentation and I’m glad I was there.

Making friends with Gary the cat

The neurology patients seemed to trickle in steadily throughout the day and, to be honest, there were no exceptionally challenging patients except for a young 5-month-old child who had been having focal seizures for some time with poor control on phenobarbital at a pretty high dose with significant sedation it seemed. Despite the numerous seizures and poor seizure control, the patient seemed to be doing reasonably well with appropriate, though delayed, development all secondary to their seizures. The child’s examination also looked very good without any clear focality or concerns and no reasons to image them. Given that the child was still seizing on a high dose of the phenobarb and our concern that the phenobarb was causing sedation, we decide to switch her to another AED and would do that over probably several weeks to a month. We would try to see the child back after several weeks to make sure they were doing well with transition.

There was also another young patient of about 8 or 9 years of age who had come to us for evaluation of episodes of behavioral arrest that were occurring quite frequently and were concerning for possible seizures. There were many features of the episodes that suggested they were not seizures and were more consistent with behavioral events, or even what are referred to as PNEE (psychogenic non-epileptic events), but without the benefit of a routine EEG or, better yet, an ambulatory EEG during which we could capture one of the events, we would have little in the way of being able to document anything. I did have Cara try hyperventilating the child, a technique that is often used to bring on an absence seizure in primary generalized epilepsy, something we have done successfully here on a number of occasions in lieu of having an EEG handy, and during the hyperventilation, the child did have an episode, though it was not entirely convincing as she was easily distracted, something that should not occur if it were indeed an actual seizure.

Though empiric treatment is always fraught with the difficulty of not knowing whether it was the medication that helped the problem or whether it was a placebo effect as there is nothing objective to measure success by, we chose to place the patient on valproic acid, a broad spectrum antiseizure medication that treats generalized epilepsy, such as we were considering, quite well. Rather than commit her to medication long term, we asked her to come back in several weeks to see how she was doing and would make a further assessment at that time. We’ll keep our fingers crossed and see what happens. If it turned out that we did feel she had seizures, we would have to eventually transition her to a different medication, such as lamotrigine, as valproic acid cannot be used in women of child bearing age due to its risk for severe birth defects.

A view along my ride

Lunch today was pilau with meat and a cabbage salad on the side. This may be everyone’s favorite lunch, though is served only one day a week and I am still partial to the rice and beans we receive on a daily basis other than Tuesday, when we receive the Ugali and meat, and these Thursdays. Lunches are a special time of the day, not only for the fact that we’re taking a break and enjoying our meal, but also because the entire FAME staff eats together – doctors, nurses, housekeeping, security, grounds keepers, drivers and administration. For many of the staff, this is their main meal of the day and, for others, it may be their only meal of the day depending on their financial and home circumstances. Be that as it may, the simple gathering of everyone at the same location and the same time only further solidifies the intense sense of mission that exists at FAME. This is not simply a job for those who work here. FAME is a family that has now continued to serve the community for nearly fifteen years and, with the continued support of our donors, will do so for many years to come.

It remained quite cold through much of the day, though the sun did finally break out just before our clinic was finished meaning that we would have some very good down time at the house. The residents put the time to good use by breaking out my hammocks and hanging them up on the foundation poles at the back of the house. There are six poles making it perfect for four hammocks with a space in the middle directly in front of the porch and back door for access. It seemed like the minute they were up and secured, all four hammocks were immediately occupied by the four residents which was great to see not only for the fact that they were getting good use, but also that everyone was having a chance to relax.

Dinner at Kudu

I, on the other hand, decided to go out for a ride as I had picked up my bike from Frank and Susan’s house and was able to get it into good running order. For those who don’t know, riding has become a bit of a passion of mine over the last years, though that includes riding exclusively long distances on pavement with a very nice road bike and doing no off road cycling what so ever. Here, riding only on pavement would be next to impossible which is why, in September 2020, when I had come by myself to FAME as the residents weren’t yet allowed to travel, I sought out something to occupy my spare afternoons and evening. Through a company that imports used bikes from Europe that is in Moshi and Arusha, I was able to find a very nice 29’er mountain bike made in Germany (by Cube) with front suspension, hydraulic disc brakes, and top end Shimano components. It’s actually more bike than I would ever need, but the price was reasonable and I thought it would fun to do some trail riding here. Though I’ve found that I’m much more comfortable riding 20 mph on the pavement with my road bike than I will ever be riding off road, it’s still fun to ride some of the unpaved roads and larger trails here while still being safe. At my age, taking a tumble in the bush of Africa would not likely be a very pretty thing. I was able to get in a bit over six miles this evening which isn’t bad considering that we’re also a mile high here at FAME.

We had made arrangements tonight to have pizza at the Kudu Lodge in town with a large contingent of Karatu’s ex-pat population. Kudu does make a pretty awesome personal wood oven pizza, one of the better in Northern Tanzania, though there were probably 25 guests for dinner meaning that as quickly as they brought out the pizzas, they were eaten as we were sharing each of the pizzas among everyone. They had a margarita pizza (tomato and cheese), a vegetarian medley, and a 4-season pizza (ham, mushroom and onion) that everyone had a choice of ordering in advance and that would then be shared among the guests. Before dinner, we all mingled with drinks on the outside deck in front of a beautiful hearth and fire as there was still a bit of a nip in the air.

Me with one our little friends at Kudu

The pizzas were delicious, though dinner did take quite a long time to complete given all the pizzas that had to brought out and shared. We had planned that we would be heading over to the Golden Sparrow after dinner to listen to some music and perhaps do a bit of dancing. For those of you who remember, the Golden Sparrow is the newer version of Carnivore, which was the tiny established that served grilled chicken, chips, fried plantains and lots of drinks. The owner closed Carnivore a few years ago and opened a much more sophisticated drinking and dining establishment that still has some of the same character as the old place, but now has a dedicated indoor dance floor with all of restaurant facilities outside under roof. As we had already eaten dinner, we went directly into the dance hall and proceeded to order a bottle of Konyagi (“The Spirit of the Nation”) and bottles of tonic water to make our gin and tonics. The music was blaring and the base was intense so it didn’t take very long for all of us to leave our chairs and begin to boogie. Cara and Alicia were clearly the most animated of the group and the rest of us followed along.  As promised in advance, the witching hour was 11 pm since we all had to work the following morning, though I was pretty certain there would be no one up early to exercise and, in fact, that was definitely the case.

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