Tuesday morning’s educational lecture was given this morning by Alicia Wiley on electronic fetal monitoring, something that I had not really contemplated for nearly 40 years since graduating medical school, that is, except for those of my own two children 33 and 30 years ago, respectively. We all attended, though, as we always do to be respectful to every volunteer that comes here to provide this necessary education in such an amazing atmosphere. It also helps, to be honest, given that we listen every morning to the report from the maternity ward along with the medical ward and this gives us some additional perspective on what is being discussed.
After lecture, during report, we gave the updates on our little seizing baby, who was just now receiving their first dose of levetiracetam through their NG tube and was on his way to improving significantly over the next days. As we were just preparing for another day in clinic, I was summoned to reception for a call from radiology, which is never a good sign here, and then asked to come down to the radiology building for a patient there. Entering the front door of the suite, I was met by Jafar, one of our radiology techs, and Dr. Josephat, who had apparently been working overnight and evaluated a patient who had reportedly fallen several days ago and had not regained consciousness after the fall. The patient was on the CT scan gurney and had just had their scan completed and they had the scan all teed up on the computer for me to view.
What was on the screen after my several clicks of the page up button was not a subtle finding and several things were immediately clear. The patient’s problem had not come from their fall, but rather had caused their fall, and it was highly likely that the patient was not going to survive their injury. There was a very large area of hemorrhage in the right basal ganglia with blood in the ventricles, very significant midline shift and compression that was causing hydrocephalus. These findings were consistent with a hypertensive hemorrhage in a patient who most likely had a past history of hypertension and, unfortunately, she was in the process of dying. There was little for me to do at the moment and she did not require any immediate management other than getting her to a bed in the ward where we could make her comfortable so I asked to get to the wfard and I would have one of the residents come down to fully evaluate her.
Walking back to our clinic space where everyone was just getting started seeing patients, the choice of resident was clear since Moira would be starting a stroke fellowship in July and she was clearly excited to head off to see this patient even though it was quite likely there was very little to do. After a little while, she came back to present the patient to me and to give her recommendations on what should be done. Hypertension is a very significant problem here in Sub-Saharan Africa and the percentage of hemorrhagic versus ischemic strokes is much higher as a result of this. Though it most accurate to determine whether a patient has suffered a hemorrhagic stroke rather than an ischemic one by using a CT scan, there are often clinical symptoms that will help as CT scans are not only unavailable throughout most of East Africa except in the larger cities where medical centers exist, but they are very costly if the patient were to have to pay for it themselves, which is often the case. In the end, since thrombolytic medications (clot busters) are not available here for a number of reasons (cost, necessity of using them with hours), the vast majority of stroke patients can be managed safely without a CT scan. When your clinical examination is very limited, though, as in our patient who is unresponsive, it can be helpful to have an imaging study available for management.
Our patient, who by the way was around 80 years old, had a very large hemorrhage that was causing significant mass effect and hydrocephalus. Had we been at home in the US and this patient had come into the emergency room, it is very likely that the most that would have been done for her would have been to insert an extra-ventricular drain, or EVD, that would have relieved that pressure intracranially resulting from the hydrocephalus, but not that from the hemorrhage itself which was causing the midline shift and resulting in the majority of her impaired consciousness. She was not a candidate for any other therapy such as evacuation of her hemorrhage as it would not have improved her functional outcome at this point. We also did not have the capability of placing an EVD here at FAME nor placing her in a neuro-ICU which would have also been necessary to manage a patient with an EVD.
So, Moira proceeded to have the very same discussion with the family that she would have had back home at Penn or anywhere else for that matter. Though there were procedures that could possibly be life-saving, they would not improve her functional outcome nor would she ever awaken to have any sense of a quality of life to interact with her family or others. These decisions, as tough as there are, are always those that must be tackled at the front end of any clinical relationship as it is entirely necessary that the correct expectations be set on both sides very early to avoid any misunderstandings.
Moira’s initial assessment that she sent to me on WhatsApp was very telling in regard to this patient’s prognosis. “GCS 3, patient has fixed dilated pupils, negative VOR, negative corneal. Does have some respiratory function but satting 77.” Shortly after, she came back to clinic and we all discussed the situation, the patient’s prognosis, what should be done and what we were going to communicate to the family. The patient was going to die regardless of what anyone tried at this point and, other than giving her some hypertonic saline or mannitol, neither of which would really make a difference, but might make her more comfortable, we would tell the family that she was going to pass away and we recommended only comfort measures. We heard shortly after that the family had discussed among themselves possibly transferring her to KCMC, though the FAME staff were able to convince them that this would not change anything and it was very likely that the patient would not survive the transport, regardless.
Eventually, they agreed to remain here , though later that night, opted to take her home to die peacefully with her family. In the US, we may well have contacted hospice services to assist the family in bringing her home and provide some support in doing so, but the fact of the matter is that this would probably not have occurred. Here, there are no hospice services, nor any social or home services, though families are comfortable bringing their loved ones home in these situations. Having the ability to participate in a patient’s care in this setting, though perhaps not life-saving, remains life-reaffirming and fulfilling for us as providing comfort to patients and families in these times of need are essential.
We finished out clinic for the day and had plans to visit my good friend, Daniel Tewa, for coffee that evening. Daniel is a wonderful person who I first met in 2009 during our first visit to Karatu when my children and I were spending several days volunteering at the Ayalabe School where Daniel was one the village elders. We spent several days together, painting at the school, and quickly became good friends during that time, but it was a year later when I returned that our true bonding occurred. I reached out to Daniel a full year after having visited with him on that first trip, and his first question to me was “how are Anna and Daniel?” Not only had he remembered me, but he also remembered my kids and their names!
When I visited with him that very next trip, he insisted that I stay for dinner as he told me that it was impolite here to ever have a guest leave without having eaten. I sat in the family room of his small house to eat a traditional Tanzanian meal of ugali, chicken and vegetables. His granddaughter, Renata, who was only 6 or 7 at the time, helped with some of the serving, but I was distinctly taken and incredibly impressed by the fact that she sat quietly throughout our dinner and did not speak or attract any attention until Daniel and I were both finished with our dinners. At that point, she was quietly given her grandfather’s plate and his leftovers and I was told that this was an honor for her to be given this. I could not imagine a similar situation such as this ever occurring in the United States.
That simple meeting began a long standing relationship with Daniel and I have never failed during a single visit here to spend time with him at his house, initially with just me during my first visits, then with one or two residents during my subsequent visits, and finally with our entire team of residents, medical students and accompanying faculty on more recent visits. He would always insist on having us for an entire dinner, eventually moving to his daughter, Isabella’s, home for the benefit of greater space, and it was typically one of the highlights of everyone’s visit here to Karatu. Unfortunately, for safety’s sake, we have limited our meetings with Daniel to being outdoors and enjoying his delicious African coffee – boiled coffee and milk – that is simply amazing.
Daniel is a local Iraqw villager and cultural historian whose knowledge of everything Tanzania is impeccable and his knowledge of most everything else is equally impressive. He loves to quote everyone’s home state’s capital, square miles, when they joined the union and much more. His grasp of world politics is far better than any of us would hope to have. And this is from a man who only finished the equivalent of middle school for when he was a child, there was a single secondary school (high school) in all of Northern Tanzania. Daniel and his wife, Elizabeth, have 11 of their own children, all of who had attended university, and a 12th child, Stanley, they adopted when his mother died during childbirth. Several years ago, Danielle Becker and I probably saved Stanley’s leg when we stopped at their home to say goodbye only to find him with a horrible knee infection and probable osteomyelitis that had been treated at the local hospital less than optimally. We got him right to FAME for IV antibiotics and he is walking normally today.
As part of his love of history and to help his kids understand the Iraqw culture better, he built a replica of the type of traditional Iraqw house which he grew up in, but were outlawed in the 1970’s when it was required that all Tanzanians move into villages together (there are total of 128 distinctly separate ethnic tribes in Tanzania) so an infrastructure for the country could be developed. The traditional Iraqw house was built mostly underground with a large dome over the top that was covered with dirt and grass. Having their homes underground were to provide protection from the Maasai, who were their principle enemies in a long-standing dispute as the Maasai in those days felt that all cows were their gift from God meaning that they could recover their property. The Iraqw would store their livestock in their homes at night, which is when the Maasai would come to get them and this continued until a truce was finally signed between the two tribes in 1986. Daniel’s traditional Iraqw home is one of the only ones in existence and scholars from all over come to see it and study it.
When I had first visited Daniel in 2009, he had no electricity to his home and all of the lighting and cooking was done with methane gas obtained through an ingenious system in which urine and feces from three cows was drained into a large underground domed tank, fermented and then the gas collected and run to his home. The exhausted excrements were then forced out of the tank by the pressure of the gas and flowed into his fields as fertilizer, helping to grown more crops and enable to feed the corn shucks to the cows, thus perpetuating the process. It was only several years ago that he had power run to his home, but has continued to use the methane for cooking, and also now has a solar panel on his roof with solar bulbs outside and inside for additional lighting.
We had a wonderful evening with Daniel and everyone enjoyed seeing his home and listening to his stories. We bad him farewell, though I’m sure I’ll see him again shortly with the new group next week as well as with my future groups of residents.