Thursday, October 6 – Dinner at the African Galleria and a late night consult…

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Having spent on average two months out of every year here in Tanzania for the last twelve years does amount to a considerable amount of time out of the country and away from family and friends, but the months I have spent away also account for both my own birthday as well as a considerable number of my daughter, Anna’s, birthdays. Over the last two years, as the pandemic has caused so many the inability to travel and visit family, Zoom has probably saved our sanity on this account and I am sure that many families have resorted to the regular family Zooms as we have. Well, today, or at least I thought, was to have been one of those days that we were all going to get together for Anna’s birthday and, given the time differences between California, where she is currently attending veterinary school at my alma matter, UC Davis, and East Africa, it meant that I would be jumping on the call at 6 am my time, which would be at 8 pm Pacific time the previous day for her. Daniel and his fiancée, Chloe, who live in Denver would be on at 9 pm the prior day and Kim, their mother and my ex, would be on at 11 pm east coast time.

Ankita, Taha and Sara presenting on stroke management

Somehow, it never occurred to me that at 6 am on October 6 East Africa Time (Anna’s birthday is on October 6), would actually be October 5 for everyone else and not her birthday. I had woken up around 5:45 am to be ready for the call and when no one had yet signed in, I reached out to everyone on WhatsApp, only to discover the mistake I had made and that the actual call had been scheduled for tomorrow at 6 am my time, which would be, quite appropriately, still her birthday in the US. Somehow, I had missed that important fact on the message that had been sent to me, though even if the date hadn’t been included in the message, it should have occurred to me that it wasn’t yet her birthday. I would just have to do it all over again tomorrow.

A fuller view of a packed room for lecture

This morning was again an early day for educational lecture and the residents were to give a talk on stroke using a few cases as examples from which to begin their discussion. Dr. Ken has asked that we use cases from which to teach as it seems to work best for them and also allows the talks to be a bit more interactive, though sometimes it’s a bit like pulling teeth to get the team to offer answers and we have to call on them to do so. A stroke talk here is very much different here than it is at home for a number of reasons that mostly have to do with the therapies that are available for the acute treatment of stroke as well as the testing that can done. All of the efforts in the United States and in the west have been to deal with having the public recognize warning signs of stroke so that patients are brought into the emergency room as quickly as possible where, if appropriate, they can receive the miracle drugs such as tPA, or the newer TNK, which are clot busters (thrombolytics) that will break down the offending blood clot to hopefully restore blood flow to parts of the brain. The big limitation with this therapy, though, is that one, it requires a CT scan prior to administering, and two, is required to be administered within hours after the onset of the stroke for reasons of safety. If given “outside the window,” the risk for a hemorrhage outweighs the benefits of the medication.

Barbecued chicken on the skewer and nyama choma (barbecued short rib)

The availability of CT scanners, and particularly ones that are working as they are frequently down at many sites that have them given the cost to keep one operational, is very poor and it is incredibly unlikely that a patient will be brought to a center with a CT scanner in the short time necessary to do any acute therapy safely. There is also the cost of the CT scan that is involved, and, even if this was possible, the cost of the therapies are very expensive and pretty much unavailable anywhere in the country for stroke. Even if these two technologies (CT and thrombolytics) were readily available and affordable, which they are not, the other matter is the time. Given the difficulty with transportation in the country and the amount of time it takes to get anywhere due to both roads and vehicles (there are no public ambulances or rescue squads here), it would be nearly impossible that anyone would get to a center capable of administering these agents within the several hours from the onset of the stroke necessary to give them safely. And this is not just for places like FAME, but also for centers such as their national hospital in Dar es Salaam. The fact is that patients coming in with stroke, typically arrive to the hospital days after the onset of their symptoms and the stroke has already been completed.

Chicken curry, curried mutton and fried ugali sticks

At home, a huge effort is made in the emergency room to determine what is referred to as “LKN,” or last known normal, which is considered the time of onset of the stroke, unless, of course, their LKN was just prior to bedtime in which case the time is onset would technically be unknown. During their talk, the residents mentioned this term several times and I was tempted to say something as it is really not something that is used here for these reasons, but decided not to interrupt their talk as it was otherwise going very well. This is just to say that working here is very, very different than at home where the focus of our efforts is often directed towards providing therapies that are not even conceivable here without first having Herculean changes in their infrastructure both for their healthcare system and for their economy. And my discussion of acute care of stroke didn’t even touch the newer therapy of mechanical thrombectomy, where a catheter is placed in the artery to retrieve the clot and restore blood flow which can be done much later than the thrombolytics, but requires not only the technology of catheter labs, but also those highly trained individuals who provide the therapy, none of which exist in this country outside of heart institute.

Ol’ Mesara’s amazing cheese samosas

So, as you can see, the problem is quite complex. This does not mean, though, that all is lost as we can still do much in regard to not only providing care that can lessen the functional impact of a stroke in the hours or days after it has occurred, but also there is much to be done in the prevention of stroke, or what we call risk reduction. Recognizing the medical conditions that increase the risk of stroke, such as hypertension, diabetes, smoking, lipid management and cardiac arrhythmias, are incredibly important in populations where these conditions often go unrecognized and untreated. Things as simple as taking an aspirin a day can lessen the risk of stroke in the appropriate patient or even given in the aftermath of a stoke can lessen the severity of a stroke. Improving the understanding of the clinicians here at FAME for the general pathophysiology of strokes and their treatment can go a long way and will allow them to be more effective in both treating their patients who have suffered a stroke and those who are at risk to suffer one due to comorbid medical conditions.

Grilled paneer and roasted beet on a skewer

As we were leaving for the Serengeti tomorrow morning, Turtle was in need of some necessary repairs, as the locking mechanisms in two of the doors were again acting up and there were only two that worked (which thankfully included the driver’s door) so Vitalis was going to come to Karatu early in the day, or so I thought, to get them fixed while we were working. In the end, he didn’t get in town until 2 pm, which did pose a bit of a problem as we had plans to visit Nish’s place, the African Galleria, for dinner tonight which would require transportation. We had also wanted to get there on the earlier side as the others wanted to do some shopping for gifts. Our clinic was going along smoothly and though this didn’t end up keeping us late as the car and Vitalis hadn’t yet arrived, we were delayed by a last minute tourist who had somehow lost their medications and one of them, which was not available in this country, could be replaced by a similar medication we did have, but would require some dosage conversion. Since the medication was one that we do use, we were enlisted to figure this out which did take a bit of time looking things up on the internet and making some assumptions. I the end, we had come up with what I felt was a good solution and we were able to head back to the house.

Intracranial hematoma in a patient involved in a motor vehicle accident with skull fracture

Vitalis finally arrived, though a bit later than we had hoped, and we all drove down to the Galleria for shopping and dinner. Thankfully, it was crowded at the shop so they stayed open later than normal giving everyone plenty of time to shop. Dinner at the Ol’ Mesara restaurant was again fantastic and Nish ordered plenty of food for everyone. We had brought Vitalis with us, who had never eaten there, and Amos also came along. We did enjoy some of their fancy cocktails before dinner, as well as during and after dinner, and the night was rather long, or at least it seemed so, but in the end, it was only around 8:30 pm when we finally left. I think we tried all of the meat dishes they had, but to be honest, the pumpkin ginger soup and at cheese samosas remain my favorite. The grilled paneer that I had tried for the first time a few weeks ago is also now one of my new favorites. The food seemed to keep coming and never stopped and, for the first time there, we weren’t able to finish everything.

A good demonstration of his skull fracture on bone window

Just before we left, I received a call from Onaely, our radiology tech, that there was a young patient there with a small bleed who had been in a motor vehicle accident earlier in the day and that the ward was requesting a consult from us. Not that any of us was looking forward to seeing a patient that night for obvious reasons, though Sara, who really hadn’t had much too drink, became the one that would do the consult along with Amos who was also feeling fine. We returned home and all went straight to radiology to look at the scans first. Even though the patient had skull fracture with some pneumocephaly (air in the head), the bleed, which looked somewhere between an epidural and subdural hematoma, was quite small and required no immediate treatment which we confirmed with Dr. Grady back at Penn just for reassurance, and the patient was fully intact neurologically when Sara went to evaluate him. In fact, the patient didn’t want to remain in the hospital and it took some convincing by Amos to keep him in the hospital overnight. The eventual recommendations were to repeat a scan in 24 hours and, if there was no change, he would not require any intervention. We were all quite relieved that the patient’s situation didn’t require anything more complex in nature such as an overnight transfer, though I believe that Dr. Thomas would have been willing to provide a burr hole if it had been necessary.

I would be getting up ultra-early tomorrow morning for my redo on the Zoom birthday call with my family for Anna’s “real” birthday and then, we would depart for a weekend in the Serengeti. Everyone was filled with excitement, including me, as it is always a thrill for me to bring the residents there for their very first visit to this truly magical place. No matter how many times I’ve been, and it is many, I always manage to see and experience new things.

Another view of his skull fracture

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