“If it’s Tuesday, this my lecture day.” I’ve made reference to this corny, class B 1960s movie numerous times in the past, but for those of us from a certain generation, “If It’s Tuesday, This Must Be Belgium,” became a saying oft used, though I’m sure only a small portion of those reading this blog will have any idea that this movie existed nor the actors who were in it. Suzanne Pleshette was probably who most remember, or at least me, and the saying has stuck in my brain since my teenage years, which is some time ago.
The residents chose to provide a case based lecture on outpatient management of epilepsy today to compliment the lecture given by the previous group on in hospital management of status epilepticus. Given that epilepsy is the second most common diagnosis that we see here and the incidence of this condition being so high in Sub-Saharan African, and all low to middle income countries, for that matter, it was very appropriate. It is always a huge dilemma of how to treat this illness as it is very often a life-long condition and with medications being required for that long, the expense of this therapy becomes completely prohibitive in the majority, if not all, of the cases we see here.
The WHO has considered phenobarbital as the first line antiseizure medication (ASM) for the planet due to its cost and availability, but it is also a medication that has many, many issues with its long-term use such as cognitive side effects and bone health as well as interactions with other medications. We rarely use it in the US or the Western Countries, but it is often the only thing available in most low to middle income countries where the majority of epilepsy exists in the world. The newer medications that exist elsewhere are not necessarily tremendously more effective, but they have far fewer side effects and medications such as levetiracetam, which is a broad spectrum ASM, are tremendously easier to use as they are more forgiving and cause a fraction of the side effects of not only phenobarbital, but also the older medications such as carbamazepine, phenytoin and valproic acid.
Unfortunately, phenobarbital, which is available for free from the government in many locations, or cost literally pennies, is a fraction of the cost of levetiracetam, or even the other three older medications available here. An average month’s cost of carbamazepine is 18,000 TSh, or approximately $7.80, which is as much or more than many families make in an entire month here. Though we may encounter these issues at home on occasion, it is the norm here and greatly impacts our decision-making and the long-term benefits of the care that we provide here. Too give the impression that our mere presence will fix things would be entirely misleading and much still needs to be done to correct the inequities that exist in this world.
I had left out one interesting patient that Ankita had seen yesterday and wanted to include them in today’s blog. A middle-aged gentleman came to see us for a second opinion regarding an episode he had two weeks prior. He had a sudden loss of consciousness and awakened with a severe headache and vomiting and had gone immediately to a local hospital where he was then taken to NSK in Arusha to obtain an emergent CT scan. Based on those findings, which demonstrated a very significant subarachnoid hemorrhage in the left sylvian fissure and essentially throughout subarachnoid space over the left hemisphere, this was most likely an aneurysmal bleed that needed to be further evaluated and treated. He was seen by the neurosurgeon in Moshi at Kilimanjaro Christian Medical Center and recommended to go to Dar es Salaam to have this done. This didn’t happen and he came to see us to ask if we agreed with these recommendations and brought along a single sheet of X-ray film from his CT scan which I photographed and have presented here. Amazingly, considering the extensive nature of his subarachnoid that had only been two weeks prior, he was completely neurologically intact and without any further symptoms from his hemorrhage, which was part of the problem as he felt that it was no longer an issue for him since he felt so well. Though Ankita knew exactly what to tell him, I gave her a bit more ammunition to use with him. I told her to tell him that he was the luckiest man alive at the present time and if he wished to remain so, he should get himself right to Dar es Salaam to be evaluated and treated as soon as possible. And, oh yes, we also made certain that his blood pressure was under good control.
Another very fascinating patient that actually came in today, was a young man who had come to see us about a month ago with a very interesting story and examination. He was complaining of headache that had been present for some months as well as a strange phenomenon in which he would, for long periods of time, develop a bulging on his forehead that would protrude more when he would Valsalva (bear down). Sure enough, he could make this region of his forehead bulge out and then flatten at will. Concerned that this was some type of vascular malformation that could also involve intracranial structures, we obtained a CT scan of the brain with and without contrast that did demonstrate a vascular appearing structure on the exterior of his skull without anything intracranial and a very normal appearing brain.
As his headaches were vascular sounding, we placed him on verapamil for them, and when he returned, he reported that his headaches were actually improved, but he was still concerned about the bulge in his forehead and very much wanted to know exactly what it was. Without doing a more formal angiogram, which we do not have here at FAME, it was impossible for us to tell the exact nature of the lesion, but I did send off the images and a brief video to Dr. Carrie Kovarik at Penn, who has provided consultations for us before and is a dermatopathologist with a tremendous amount of global experience. Sure enough, with the help of colleagues at the Children’s Hospital of Philadelphia, they turned up a case report that was identical to this patient and suggested that this was a venous varix, or essentially an enlargement of the veins in this region. Whether there is anything further that is necessary to done or not, or whether it could even be done here, remains unclear, but at least we have some answer to give the patient and to start a discussion.
Just before lunchtime today, I was called emergently to the CT scanner for a 2+-year-old child who was still in the scanner and had been involved in a motorcycle accident having suffered significant head trauma. The child was awake and crying, but tolerated having the CT scan done which demonstrated a very severe facial fracture (a Le Fort 3 per Dan Licht) that also included his frontal sinus with a small amount of intracranial blood and some pneumocephaly (air intracranially). The child was actually intact neurologically from what I could tell in the scanner room and his brain looked otherwise OK, but it was urgent that he be transferred to a center who could deal surgically with his facial fractures and he would absolutely need an ICU. I had immediately sent images to our peds neurology and neurosurgery colleagues in the US and, thankfully, heard back from them rather quickly as this was not something that I wanted to be dealing with alone.
It was ugali and nyama (beef) day once again which is always a happy day for Charlie and Meow as they get to have the reject chunks of meat, mostly from the mzungu volunteers who aren’t as adept with the chewing and pulling that is often required to eat them. This doesn’t seem to both either of the FAME pets in the very least. I’ll have to admit, though, that I took a particular liking to today’s ugali, which had a bit of a grainier texture to it and more “palenta-like” than usual which was quite tasty. Or perhaps it’s just that I’m becoming more African? I did eat it with a spoon, though, as opposed to the proper way which is with the hand. Taha, on the other hand (no pun intended), was being traditional and forewent using his spoon so at least there was some representation by our team.
I had on our agenda of cultural immersion for the evening a visit with Daniel Tewa. We had also invited one of the other FAME volunteers, Leslie, a family medicine nurse practitioner from Washington, D.C., to come along with us, so there were a total of five visitors to the Tewa residence that day. I had forgotten that drinking African coffee is one of the activities as Taha does do any hot drinks and I hadn’t realized that Leslie avoids caffeine, so the three remaining of us were obligated to drink the entire batch of coffee that they had prepared for us. The coffee is rich and amazing as it is boiled with fresh milk from their cows and tastes fantastic with just a touch of brown sugar in it. As soon as Daniel sees that your cup is empty, he immediately refills it so by the time we left that evening, I was pretty well wired with all the caffeine as I had three cups of his coffee and was wondering if I would sleep that night.
After sitting around having our coffee, Daniel took everyone for a tour of his authentic Iraqw home that is underground and which he built in 1992 as an example of what he spent the first twenty years of his life living in and to prove to his children that his stories of childhood were not crazy. The house now serves as a resource that is studied by many students here in Tanzania as well as other historians of the culture. Their houses were underground mostly for protection for their cattle, who also slept in the houses, from the Maasai who would steal the livestock at night as they believed that all cattle were rightfully theirs and, as Daniel would say, they felt they were not stealing but only taking back what was rightfully theirs. The Iraqw and the Maasai were at odds over this issue until an agreement was finally signed in 1986 officially ending this dispute.
After our tour of the underground house, Daniel took us back to his home where he had the women try on the traditional wedding skirts that his wife, Elizabeth, makes out of goatskin and colorful beads in many meaningful designs to signify marriage and life. The skirts are beautiful and are still used for their wedding ceremonies today with each bride’s mother making her a special skirt. We didn’t get home until after 8 pm and there had been plans to go to the Golden Sparrow tonight at 9 pm, so we ate dinner quickly and I dropped Taha and Ankita off at the Sparrow while Sara and I decided to stay home and relax. They caught a taxi home later as I was not about to drive back and pick them up given the time it would be. They arrived safely at home well after my bedtime.