Friday, September 30 – A very challenging clinical day…

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A crowded morning report with Mary Ann teaching about child development

Today, we were very busy on numerous fronts and it all seem too start with morning report. But first, Mary Ann had wanted to cover a topic that was very dear to her heart, and ours as well – child development – in about 10 minutes at the beginning of report. She had some very tables and graphs that were simple and easy to remember and would help to identify whether a child was meeting their developmental milestones or not. There is certainly a wide range on when a baby reaches of these milestones, but at least this gives one a ballpark for reassuring parents. Not every child is spot on with their dates, and reassuring families is often the most important thing. The charts Mary Ann presented to help with these determinations were very simple to understand and would also be very easy to put in one’s iPhone for future use, especially by those adult neurologists of us seeing these children when we don’t have a pediatrician or pediatric neurology around. It was also Ankita’s birthday today, so everyone sang Happy Birthday to her at Morning report, but then we had another surprise for her that she would receive at lunchtime along with Taha, whose birthday was coming on Sunday.

Our patient with the brainstem hemorrhage

There were two patients in the ward that were both concerning from a neurologic standpoint and would each need our attention sooner or later. The first, was a gentleman in his 50s who came to FAME after drinking and then developed nausea, unsteadiness, right sided weakness and diplopia. We were clearly worried that he had a brainstem event and, since Ankita is planning to go into stroke, she was more than happy to go see this patient and to check out the situation. The patient looked much better than anticipated given the story we had heard, though he continued to have excessively high blood pressures, probably a manifestation his chronic hypertension which had unfortunately not been adequately controlled previously. The patient went for a CT scan of the brain at some point that morning that demonstrated a very significant brainstem hemorrhage that should have caused far greater deficits than he had, which was certainly good for him considering that there was very little we had to offer him other than restricting him from any antiplatelet agents and managing his hypertension going forward.

Hypertension and stroke occur with a much greater incidence in Sub-Saharan than what we see at home and much has been written about in the countless journals on the subject and numerous studies concerning this matter have also confirmed this additional burden of disease here. Hemorrhagic stroke also occurs at a higher incidence in Sub-Saharan Africa and this is very felt to be due to the excessive amount of undiagnosed and untreated hypertension here where it is always an issue trying to treat chronic disease in culture that still hasn’t fully recognized this entity or the need for chronic medications. Treating an infection with an antibiotic or a case of worms with albendazole requires only a short course of treatment and you’re done. Taking medications for any length of time is something that requires an entire readjustment of the thinking here.

The other case that we had to see in the ward was a 13-year-old Maasai boy who had come in last night and was reported to be confused and was also complaining of pain in his legs. Dr. Jacob, also a Maasai, had conversed with the boy and noted that he wasn’t entirely confused and had mostly been complaining about his leg. Taha had offered to go the ward to see the boy before our clinic, but the true extent of his condition and all its ramifications would not unfold until much later in the day.

Ankita, Dr. Anne, Amos, Taha and Sara conducting a teaching session during a lull in clinic

When it came time for maternity rounds at morning report, there was very vigorous discuss regarding a woman who was 25-weeks pregnant and had been having significant issues with severe hypertension for several weeks so there was concern over impending pre-eclampsia that would not only risk the life of her child, but hers as well. The problem was that her baby wouldn’t survive being delivered at 25 weeks here in Tanzania and that the closest full neonatal intensive care unit that could deal with a neonate that small was in Arusha at Arusha Lutheran Medical Center, or ALMC.

An amazing birthday cake in Tanzania

Initially, there seemed to be the decision that the woman should be advised to deliver her baby, who would not survive here at FAME or, if they did, they would undoubtedly have a tremendous burden of neurologic deficits. If the woman did not wish to proceed in this fashion, then that bridge would be crossed at that time. At this point, Mary Ann weighed in heavily with the recommendation that we should strongly consider transfer to ALMC immediately as was a very difficult situation and, that in her experience, it was much safer transporting the mother and infant still intact before delivery than it would transporting a 25-week premature infant on their own after delivery. In the end, after discussion with ALMC, the director of the hospital agree not only to take the woman and her unborn child, but also committed to covering the cost of their care if the patient and family were unable to do so. Miracles to happen every so often.

When it came to our lunch that day, I had asked Prosper to have a cake made for both Ankita and Taha that could be presented during lunch and all the staff could sing, “happy birthday.” The cake hadn’t quite shown up in time, though I was able to drag my feet long enough for everything to get set, which meant having the cake brought to the kitchen and placed on the counter where our lunch is traditionally served so they would see it immediately upon entering the cantina. Sure enough, they were both entirely shocked, as was I , and I think they were both quite surprised to see such a gorgeous cake here in the middle of Africa and I was equally so. There had been lots of kidding about what they both could expect and Anne had them convinced that they were going to have cold dirty water poured over their heads when they least expected it, though, of course, this was all a rouse and there was no such thing, or at least not that I’ve ever seen. Typically, though, the birthday cake is to be cut in many bite sized pieces and then everyone lines up to have the one whose birthday it is feed them a piece of cake with a toothpick. I had to do this for my 60th birthday at the Highview Lodge, but for today, it was just a matter of singing “happy birthday” to the two of them while the cake was doled out to everything along with their rice and beans.

Sometime during the afternoon, Mary Ann had brought some sad news to me regarding one of our recent patients, a young 28-week premmie born at FAME earlier in the spring who had actually been discharged home but had been admitted several times in the recent past with complications of her bronchopulmonary dysplasia. She had come back in well over month ago and had been slowly gaining weight and improving, but still required the smallest amount of oxygen otherwise she would desaturate. While the last group was here, Cara had seen this child daily and, on some days, multiple times checking in on her. Apparently, her bebe (grandmother) came in insisting that she be discharged so they could take her to KCMC, though, in the end, that was not their intention. Given her even tiny oxygen requirement, it was not surprising that the child died without it shortly after having been discharged from the hospital. She was a beautiful child who had battled back from incredible odds only to suffer the consequences of a complete lack of understanding despite our best efforts otherwise.

So, now back to our young boy who had been brought in last night with complaints of confusion and leg pain. His vitals were fine and there were no signs of infection or meningitis that we could find, yet he was seeming to worsen with increased confusion and all of his lab work was unremarkable . At some point in the midafternoon, though, it was reported that he was having difficulty swallowing and, upon learning this, Taha because concerned about an infamous disease that is rare at home but not in other parts of the world like Africa and Asia. He quickly asked the boy and his older brother who was also there whether he had been bitten by an animal prior to the current symptoms having started.

Sure enough, the boy related the story that he had been bitten in the heel by a dog that was aggressive and that he and his younger brother had subsequently killed. He also reported that his younger brother had also been bitten by the dog. The boy was encephalopathic and had very rapidly developed severe dysphagia and, shortly thereafter, was documented as having a fear of drinking water, or hydrophobia, when he was offered it. The boy had the hallmark features of rabies and, sadly, now that he was symptomatic, the disease would be 100% fatal with no adequate treatment existing anywhere in the world.

When I arrived later in the evening, the boy was severely agitated and screaming in his bed, confusion and was unable to swallow his own saliva. I will never in my life forget that image of his massively wide eyes and the look of fear or madness in them along with his continued screaming in Maa, the language of the Maasai. At that point, as we had little doubt to the diagnosis, we began treating him with comfort measures to reduce his suffering and first gave him some haloperidol, a strong tranquilizer to calm him down and provide some sedation. I also immediately put into action the network of contacts that had been developed six months ago when another child had presented to FAME and immediately died.

The issue wasn’t in regard to treating a patient currently symptomatic, but rather doing contact tracing for any exposed to the boy who would benefit from receiving rabies vaccination, the current recommendation from the CDC and WHO for the prevention of human to human transmission, though a case of human to human transmission of rabies has never been confirmed outside of organ or corneal transplantation. The matter, though, is one of absolute, 100% safety as there is no room for mistakes when a disease is uniformly fatal and can potentially be prevented by receiving a simple vaccination. Any healthcare worker or family member who had been exposed to the patient’s secretions, a scratch or any other means of possible transmission should receive a vaccination. Taha, who had made the amazing diagnosis to begin with, would be one of those at FAME to receive his vaccinations.

In the midst of all this, a number of us had been invited up to Rift Valley Children’s Village for dinner and to stay the night, Mary Ann and I were to be staying in the Kili House, their accommodations for their own board members when visiting, but given the partnership between Tanzanian Children’s Fund and FAME, the two of us apparently qualified as board members. Frank and Susan stayed at India’s home and Dr. Elissa, a previous volunteer at the RVCV many years ago, found lodging with some of India’s older children. It was a lovely night that followed an incredibly hectic day and it was so good to relax for a moment.

An ad for the Rabies-free Tanzania campaign in the past

Meanwhile, the residents had decided to visit the Highview Hotel which is next door to FAME as they had a spa with massages, manicures, facials and pedicures, all of which they took advantage of prior to having dinner there as well. The hotel even provided them with a ride home that night which was actually very good considering several days later, there had been a killer bee attack nearby and a local woman died as a result. This was obviously a specific situation in which they were near the bees or working with them and not something remotely likely to happen otherwise. Still, I was quite happy to know that the residents had made it home safe and sound after their night out.

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