It had been an interesting day and evening yesterday as they had been so very different for us – the tremendous diversity of the clinical problems we had seen, some neurologic and some not, that had really run the full gamut of emotions, though unfortunately more that were incredibly trying rather than hopeful unless you count the gentleman with the brainstem hemorrhage who could have looked much worse than he did. The little baby who everyone had worked so hard to keep alive and even beat the odds, eventually did not, but more from cultural issues than medical. The young boy with what we believed to be rabies and, if so, the only thing to offer would be comfort care. Of the bunch, our real hope for a good outcome would have to rely on the mother who was 25 weeks pregnant and was transferred to ALMC – there was still a reasonable chance that either her pregnancy could be extended or, if she delivered, that the baby would survive against all odds as they often do here given the resilience of the patients and people living here in this often harsh environment.
Meanwhile, I had spent the night at Rift Valley Children’s Village in some luxury given the lovely dinner and lodging we had there as guests and board members of FAME. I had a tiny bit of angst over having left the residents on their own for the night, but in the end, they had enjoyed themselves at the Highview Lodge and despite several messages that I sent this morning, they went unanswered as the entire group had slept in quite late and hadn’t seen them. I wasn’t really worried, though, as I knew if anything seriously wrong had occurred, I’m certain that I would have heard about it.
It was another group affair at India’s for breakfast with the large group of older kids home from school sitting at her very long dining table having cereal and friend and Kahawa, or coffee. I broke down and had a bowl of granola, corn flakes, blue berries and yoghurt, even though I’ve been amazingly firm about sticking to my intermittent fasting that I started several months ago. I don’t eat until noon and finish by 8 pm and I’ve felt great with this regimen that fits perfectly with my schedule both here and at home. We left RVCV by around 11 am and were home before noon, back to FAME and a quiet schedule for a rare day off for us. The clinic had slowed up during the week and Anne, who is a Seventh Day Adventist and whose sabbath falls on Saturday meaning that she will typically take these days off when we’re not around, but will graciously work them during the time that we’re here. Given that we expected very low numbers of patients for the day, both for us and the OPD, and the fact that Anne has been working most Saturdays, we decided not to schedule clinic for the day, but to remain available should there be any inpatients for us to see or should a straggler happen to wonder into clinic needing to be seen by us.
We had also planned to have dinner at Gibb’s Farm tonight which we would have done for no good reason, though we could also celebrate both Ankita and Taha’s birthdays at the same time. With the plans for dinner and an early arrival at Gibb’s, we could try to finish up any business at the clinic early and be on our way at a reasonable time. Depending on the weather, we would also plan for a possible swim in their pool.
The young boy with presumed rabies was still in the ward and, even though there was really nothing to offer in regard to treatment of his underlying condition, we were providing him with comfort care measures, meaning any sedation or muscle relaxation that would make him more comfortable. Taha and I made our way over to the ward to discover that he had been moved to the isolation ward that had been created with the pandemic, and now was to be turned into a surgical ward for post op patients as FAME was working on beefing up their surgical program as part of our new five-year strategic plan.
The boy had been on standard isolation precautions previously, meaning only gloves, masks and eye protection, though the main issue was really to avoid any secretions, but primarily his saliva. I had mentioned previously that there has never been a case of human to human transmission of the virus, other than through organ or cataract donation, but given the consequences of contracting the virus and becoming symptomatic, meaning certain death, doing everything possible to prevent its transmission seems pretty reasonable. The boys older brother remained at his bedside and the boy was certainly quieter than he had been the previous day, likely the effect of the standing haloperidol and as needed lorazepam that he was now receiving. We had his brother conversing with him while we stood mostly in the doorway so as not to risk exposure and it was clear that the boy remained severely encephalopathic and, by the way he was handling his secretions, it was also obvious that he was unable to swallow. He was refusing to drink any water per his brother and, very shortly upon our watching him, began to launch streams of his saliva across the room in a spitting action that was very impressive and very dangerous for those of us in his vicinity. He wasn’t screaming any longer, but was babbling on and on about which I had no idea, nor do I believe did his brother. It was very, very sad to see this young man in his current condition, but there was absolutely nothing to do for him other than provide compassion.
We walked over to the OPD to find the doctor who was covering the ward for the day just to discuss this case as well as the gentleman with the brainstem hemorrhage. The timing was good as they were just about to order rabies immunoglobulin for the boy, but this had been discussed the night before with folks from a Tanzanian NGO team as well as an ID consultant back home and it was very clear that once a patient is symptomatic, neither the immunoglobulin nor the vaccine will provide any benefit. It would be a waste of a very precious resources and, thankfully, our timing was perfect as we were able to intervene and prevent the immunoglobulin from being administered. At the same time, we were also able to pass on the news that they could discharge the man with the brainstem hemorrhage as he continued to do well and was surprisingly ambulatory.
With our work at the clinic complete and any cloud cover having broken up, it was time to consider heading to Gibb’s Farm. The others had decided that they would like to check out the pool, though neither Mary Ann nor I were up for that. We made it there by late afternoon and the weather was spectacular with bright equatorial sun and plenty of necessary shade throughout provided by their magnificent trees and landscaping. Sally, their general manager, just happened to meet us at the front entrance of the property and invited us to join them at the poolside at 5:30 pm for the local Tloma Village Choir which I had seen several weeks ago, but ended up equally entertaining as they had been the first time. She also invited the residents to enjoy the pool as much as they wished which was a real treat for them.
It was a lovely late afternoon and evening with the residents swimming and Mary Ann and I sitting in the shade and just enjoying the peace and quiet that is Gibb’s. At around 5:45, the choir came marching in and gave a very nice performance of song and dance and then it was time for dinner. They did have drinks at the poolside during the choir performance that I believe we all took advantage of, and then it was time for dinner, which, of course, was amazing as usual. I had told them of Taha and Ankita’s birthdays, so, come dessert time, the waiters and kitchen staff came out with two plates, each containing a personal chocolate cake, candle and decoration with their names. They all same “Jambo Bwana” first followed by “Happy Birthday” twice, once for Ankita and another for Taha. It was tremendous fun.
We drove home at a reasonable time given the fact that we were leaving for Ngorongoro Crater quite early the following morning and still had to prepare our lunches, which the residents were going to do, and I would gather up all the additional supplies necessary for the trip that included most camera equipment and binoculars. I have two cameras, one for me and one for the residents to use, both with longer telephoto lenses and perfect for shooting photos of the animals. They were all incredibly excited to be going tomorrow.
