Saturday, September 10 – Quiet, but an interesting day none the less…

Standard

Saturdays at FAME can be hit or miss, but overall, they have rather sleepy over the last several years. Imagine having Saturday office hours back at home – I’d rather think they would be filled to the brim with patients not wishing to take time off of work or children out of school. It’s a much different pace here considering most individuals are self-employed on their farms or in their own shops, so that is not an issue for them. There is no morning report on Saturday which means that we do have an extra 30 minutes in the morning to gather ourselves or sleep and the pace of the morning is just very different.

Moira working on lunch for the Crater

Also, thankfully, the kitchen is still open on the weekends for tea time and for lunch, so we do not have to fend for ourselves. The tea we drink each day is a delisddghtful tea masala that is a mixture of tea and spices and sweetened with what I suspect is honey. They make a huge pot of it and are continually refilling the tall plastic vacuum thermoses using a pitcher that is dipped into the pot. Considering the number of staff having tea (though somewhat less on the weekend), the thermoses are in constantly running low. Given the cool temperatures of the last week, the bees that normally swarm around the mouth of the thermoses containing the tea were far less than is normal, but in the warm months, you have to shoo them away and for those afraid of bees, it’s not an easy thing. Just to clarify, there are also thermoses of hot water for those die hard caffeine addicts who must have their cup of joe in the morning. You can easily differentiate the two thermoses by those swarming with bees and those without.

The pool at Manor Lodge

In years past, we had a massive bee hive in the rock wall adjacent to the cantina. Thankfully, the bees were not aggressive in the least and never had an interest in us given all the sweets inside with the containers of tea, but still, it was a bit of a detractor for some having quite so many of these little flying missiles swarming all around the area. I would often have to fill cups for those residents who were a bit more on the squeamish side. At some point, the hive was moved somewhere else so there are fewer of the bees outside by the tables to bother people, though they’re still inside with a strong interest in the honey and on warm days, still manage to home in on those thermoses with the tea.

Everyone at the pool with Alex the only adventuresome of the bunch – though didn’t go in after all

I should also mention that the coffee they drink here in the morning at tea time is an instant coffee called “Africafe,” which is very different than any of the instant coffees used back home for the simple reason that it tastes very good. It does seem odd that sitting in one of the greatest coffee growing regions of the world, anyone would be drinking instant coffee, but when you think about it, though, it does make sense that this is exactly where you’d expect to find a great substitute for a fresh brewed pot of coffee when it isn’t practical to make or press it. Not that anyone would choose the Africafe over a brewed pot, but there seems to be little hesitation in considering that option in the morning when you’re running late, or at tea time when it’s being served. Amisha in past had me bring her home a large can of the Africafe as she liked it so much and wanted to have it at home. It isn’t available in the US, but it should be. We’ve gotten in the habit of all getting fresh pressed cups of coffee in the morning at the Lilac Café as clinic starts, but that is always dependent on how caffeine addicted each group of residents is and this one seems to be pretty hooked. Personally, I have mostly given up coffee for tea over the last several years, but I’m also always up for a nice cup of fresh brew in the morning if someone happens to be serving one.

Approaching the Monor Home at the Manor Lodge

As we were getting set up for clinic this morning, Dr. Julius, one of our long time clinical officers here at FAME, came up to me to ask if we could see a patient in the ward who had come in overnight and was having frequent seizures this morning. At times, there does seem to be a bit of disconnect, for this is exactly the reason that we’re here – not only to help take care of these patients, but to help the doctors here to take of these patients and future patients in similar situations. Alana and Cara went to see the patient, who it turns out, had a long history of seizures, either never on medications or at least not recently, who the family had said had stopped moving their right arm the day before and had then started having frequent seizure which was quite unlike his past history. His CT scan that had been done overnight did look like it might have an early right middle cerebral artery territory infarction, or stroke, and though his examination was also pointing in the same direction, it wasn’t entirely clear that his repeated seizures weren’t producing the deficits seen on his examination. Unfortunately, it also looked like he had aspirated along the way and his O2 sats weren’t very good.

Anne and Cara goofing off at the Manor Lodge

The first thing was to stop his seizures, both from a standpoint of the harm they were causing, but also so we could get a good examination on his at some point to determine whether he had indeed had a stroke. We are significantly limited here in the IV medications that we have available to load patients on for this purpose, but we do have levetiracetam (Keppra) tablets that could be crushed and put down his NG tube and would be rapidly absorbed. The levetiracetam, though, is very expensive and not be something that we would want to continue him on so, at the same time, we started him on valproic acid (Depakote), a much more affordable and equally effective medication, but would take a bit longer to take effect. As expected, his seizures stopped shortly after having been loaded through the NG tube with the levetiracetam, and we would have to wait so time to re-examine him to determine whether he had indeed had a stroke, but it was sounding pretty much like that was going to be the case.

Back grounds at the Manor Lodge

Deciding which antiseizure medication to use for a patient here not only has to do with which medication would be most effective, but also with the cost. Making a wonderful diagnosis and placing patients on an effective medication will only help if the patient can remain on the medication which means they will have to afford the medication at some point. Though our neurology clinic is subsidized for the patient’s first visit which covers the visit, any labs and typically a month’s worth of medication, we are unable provide a continued supply of their medication given the costs involved. Someday, inshallah, I would like to have funding enough to provide continued medications for our epileptic patients as this is a specifically vulnerable population of patients. If anyone is aware of any incredibly well-funded foundation specifically interested in funding this type of project, please send them my way. The positive effect that we’ve had on so many patients with epilepsy over our years at FAME has been tremendous, but there are so many heart-breaking stories of patients who were well controlled and had to stop their medication due to a lack of funds. For such an incredibly treatable condition, having this story repeat itself time and again has been very frustrating.

Fodr our patient who presented with near continuous seizures, or a condition known as status epilepticus, the long-term morbidity and mortality is extremely high if the condition were to recur and, therefore, one must put the patient on a medication that will be effective most rapidly, hence the decision to use valproic acid. Had the patient had a single seizure in the setting of a stroke or other focal neurologic problem and time was not of the essence, then another medication like carbamazepine would have been a less expensive and reasonable choice. Phenobarbital, the antiseizure medication felt by the WHO to be a first line treatment of epilepsy, would not be good in this setting, or, to be honest, most settings as it is a very sedating medication with lots of cognitive side effects, especially in children, and something that is not used widely at all in the US or developed countries. Though the debate is always one of sustainability, which is a very valid point given costs, using what we feel is a significantly suboptimal medication in so many ways, is often very difficult for us to swallow. That being said, we have used it in select situations, but always feel somewhat remiss in doing so.

One of the guest houses at the Manor Lodge

We had plans tonight to go to the Manor Lodge for dinner and to possibly also use their pool, so were all set to make an early exit from clinic. So much so, that I sent everyone back to the house to ready themselves for the evening and wasn’t prepared when saying goodbye for the evening to Jacob in reception. He told me that he had just put a patient in the computer who had just shown up at clinic and would be heading off to boarding school the following day. The Manor Lodge and the pool would have to wait just a bit and Cara graciously agreed to see the patient since he was an adolescent, and Dr. Anne, who was also coming to dinner with us, would see the patient with her.  Of course, the patient turned out to be one of the more complicated ones that we had seen all week, though mostly from a standpoint of their medications. He had a history of seizures and had never seen us before, but had been seen at KCMC (Kilimanjaro Christian Medical Center) in Moshi and by the history from the patient and mother, he had been placed on both valproic acid and carbamazepine, but what he was taking currently were both significantly subtherapeutic doses and only once daily when these medications were to be given two or three times daily due to their pharmacokinetics.

Utilizing the internet on the veranda

The more significant issue, though, was that he was also HIV positive and on antiretroviral therapy, medications that could, and do, have serious interactions with many medications and especially the antiseizure medications that we use here. The older antiseizure medications tend to fall into one of two classes – they are either enzyme inhibitors or enzyme inducers, which means in English that they will either block the metabolism of other drugs or speed up the metabolism of other drugs. The newer medications, which also happen to be dramatically more expensive for us to us here if they are even available, have far fewer drug interactions she as this which is why everyone likes to use them so much. That and the fact that we rarely check levels of these medication as they are not as helpful in monitoring. When asked about his CD4 count, a test that monitors just how suppressed the immune is by the HIV infection, his turned out to have been seriously low when recently tested meaning that his HIV therapy was not doing what it was supposed to be doing. Our concern became directed to which one of the antiseizure medications was causing the problem and this seemed to most likely be related to the carbamazepine, for it is an enzyme inducer and will make his medications less effective.

Given this situation, bumping his valproic acid up to a fully therapeutic dosing and tapering his carbamazepine would most likely maximize both his seizure control and his HIV treatment, neither of which were currently being allowed to provide their maximum benefit to the young man. The same issue would occur with phenobarbital  as it is also an enzyme inducer and would make the antiretroviral agents far less effective than anticipated and lead to the exact same problem we were dealing with now at least as far as the HIV status was concerned.

So, after finally sorting this patient out with some fairly complex instructions of titrating his valproic acid and tapering his carbamazepine and then following up with the government dispensary as we do not do CD4 counts at FAME per health ministry protocols, Cara, Anne and I made our way back to the house where we discovered that the others had been diligently working on preparing our lunches for the following day as we would be heading to Ngorongoro Crater for a game drive. That way, we wouldn’t have to deal with it upon returning from dinner given the early hour we’d be leaving for the crater.

The Manor Lodge sits high atop the hill above FAME, but the road to get there is quite circuitous as you must drive into town and onto the tarmac, then take the turn for the Shangri-La coffee plantation and Black Rhino Academy. There are large while columns that frame the turn off the tarmac and then each consecutive turn along the way.  We drive high up onto the ridge about Karatu and through the coffee fields until we come upon an electric fence line that signifies the border with the Ngorongoro Conservation Area as we must pass through a short distance along an easement until we arrive at the dominating gate for the lodge. Owned by The Elewana Collection, a company that provides unique lodging experiences in East Africa, the Manor Lodge is fashioned after the architecture of the South African wine region (I believe), and their setting is magnificent. A large Manor House is the centerpiece the resort with a small number of bungalows surrounding on the large grounds that provide complete privacy. They have a pool, horses and world class dining.

Our dinner group at the Manor Lodge

Though it ended up a bit cold for the pool, we all enjoyed the relaxing environment of the Lodge and the weather was amazing for this. We all sat out on the veranda having drinks and enjoying each other’s company, that is, all except for Alex, who chose to be just a tad antisocial and enjoyed his book alone in the garden until he eventually began to miss us. Either that, or it was significant guilt and peer pressure we all placed upon him at the time. We sat for dinner just a little before 7 pm at an incredibly fine table with more silverware on it than I have seen in some time and a menu for a five-course meal that was impeccable. Given that we’re here providing services to the community, we are well taken care of by the lodges in town as their workers are also members of the same community we working to keep healthier through FAME’s infrastructure and name. We were home by 9 pm and with everything prepared for our day in the Crater tomorrow, it was early to bed for everyone. I had my camera equipment to prepare, but that wouldn’t take long. The gate opens a t 6 am, so our plan was to leave a few minutes prior to that.

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