We now have phone in each of the volunteer houses which is a double-edged sword. In the old days, if you were needed at night or after hours, someone would come to the house to find you and knock on the door or the window to wake you up. Over the last few years, though, the ward has become increasingly busy and the patients sicker such that the on-call doctor overnight may need assistance in dealing with those patients that are sicker than usual. I had forgotten to tell everyone, and when someone called from the ward about a new stroke patient, they weren’t able to get their point across, and so, the call didn’t register properly and wasn’t passed along.
It wasn’t until a bit later that evening, when I had already gotten into bed, that a friend of this patient’s family texted to let me know they were at FAME and asking if I could go to the ward and evaluate the patient myself. Although, I know that we teach everyone that “time is brain,” the stroke had occurred days ago and there was very little we were going to offer overnight unless he was worsening. I texted back saying that we would hear from the ward if there were any major issues, but that we would see the patient in the morning after morning report.
Tuesdays and Thursdays are educational days here at FAME and the medical staff meets at 7:30 am (or 1:30 Swahili Time) for a lecture that can be given by either one of the volunteers here or by one of the Tanzania staff. We try to do as many of these lectures as possible as it’s a great way to reach all the FAME staff, including those who do not work with us directly during our clinics. We’ve covered many, many topics in neurology over the years and as there are often newer doctors when we arrive, and it certainly never hurts to repeat as much of this information as possible along the way.
The staff had wanted another lecture on the neurological examination, and it was decided that Wells and Anya would deliver the first lecture of the trip. They were able to get through most of the lecture in the allotted 45 minutes (Dr. Ken watches the time like a hawk and will be sure let us know when we’re over the time limit) and it was decided that they would finish when Usha and Mark would be doing the pediatric neurologic examination. As have pointed out in the past, the fact there are so few neurologists in this country means that patients will rarely have the opportunity to see one, but it also means that almost none of the doctors we work with have ever seen a neurologist do an exam and have been taught only by non-neurologists. To us, the examination is essentially sacred, and it is difficult to express to anyone, other than another neurologist, just how very much we rely on it and the history for our diagnosis and treatment. Testing is most often secondary to us and is used primarily to support our hypotheses.
After Morning report, Mark, who is planning to go into stroke, went to evaluate the patient who had come in last night. He was a 90-year-old gentleman who, on examination, had a complete left middle cerebral artery syndrome meaning that he was globally aphasic (he couldn’t speak, nor could he understand) and couldn’t move his right side at all. He hadn’t yet had his CT scan of the brain, but when he was brought over for this study, it turned out that he actually had a medium sized hemorrhage without significant mass effect. With the bleed, it meant that we had less to do for him than we had thought we had with the original diagnosis of a bland infarct that would have required aspirin and a statin. Though there was some hope that he might improve given his hemorrhage, this was not to be the case, and over the next several days, he remained global aphasic with the dense hemiplegia and was eventually discharged home to his family. He was unable to swallow safely and, in the end, will probably suffer complications of an aspiration pneumonia.
I received news that our shida (trouble) with Turtle persisted and what had seemed like an easy fix was now involving replacing the cylinder head gasket, at the very least, and would quite possibly require replacement of the cylinder head itself which is not a small feat to say the least. They removed the head and brought it back to Arusha, but eventually needed to bring the entire vehicle back to Arusha to work on it, finally getting it to us on Saturday morning with everything fixed, or at least we hope so. In the meantime, Myrtle was more than sufficient for me to drive everyone around Karatu.
Along the way, Usha did see a young child with an examination concerning for hydrocephalus. This condition, which is most often congenital, and certainly so in the absence of some other process such as a mass lesion, would eventually require a ventricular shunt to prevent further accumulation of fluid and increased pressure intracranially. Unfortunately, we do not do these procedures here at FAME, but they do them in Arusha, at one of the hospitals there, or at Kilimanjaro Christian Medical Center in Moshi, where there is a neurosurgeon, though these procedures are also done by the general surgeons in Arusha. So, the baby was referred to Arusha for placement of a VP (ventriculoperitoneal shunt) that will drain fluid from the ventricles of the brain into the abdomen and will be left for life.
Having Myrtle here to drive around was pretty much essential for me as, having grown up in Southern California, I have always had a vehicle of my own and have always been mobile. Life without a car for me is unthinkable and even when I travel to remote places, I will usually rent a car just to be mobile. We have not yet put the back seats into Myrtle, and with the two-bench configuration that are facing each other in the back, a drive into town was a bigger production than expected. Mark and Wells were being subjected to sitting in the back (boot) of the vehicle on cushions that we had borrowed from the couch on our back veranda. The pillows certainly softened the blow on their backsides, but it was more the fact that I missed seeing one of the many well-hidden speed bumps on the way to pick up Dr. Anne that really stuck in their minds, mostly because I think they both struck their heads on the ceiling of the car when they bounced out of their seats. Thankfully, there were no serious head injuries (some might say that I knocked some sense into both) as the neurosurgeons here are few and far between, and both were willing to accept my sincere apologies for having introduced them to the “African massage” in such an unanticipated manner.
After picking up Dr. Anne at her home with plans to head downtown, I had forgotten that it was market day in Karatu. I have described the phenomenon of the Maasai Market on several occasions in the past, though the take home message should be that is shear mayhem on a rather logarithmic scale and not for the faint of heart. My recommendation to anyone considering a real visit (meaning spending at least an hour shopping) would be to have one of the stiffest drinks you can imagine immediately prior to arriving or taking a strong dose of Valium (sorry, diazepam here) to soften your senses enough to tolerate the constant barrage of those peddlers and hawkers doing everything in their power to get you to purchase something from them. I drove them to edge of the market where several chose to get out of the vehicle long enough to confirm what I had told them which was about five minutes maximum.
After stopping by a change bureau (of which there are very few after the government crackdown a few years back finding that the change bureaus were all laundering money) for we had not a shilling to spare among us, it was off to buy fabric as the group would visiting Teddy, our seamstress, later in the week to have clothes made before their return. Mind you, I do not have any clothing made and, so, sat in the vehicle waiting for the group to finish their search for the perfect pattern. I was very surprised to see everyone returning after what seemed like an incredibly short time, but it seems they were all very focused on the task at hand and had all chosen the fabrics they desired, several of them choosing to share fabrics as well. We drove home well before sunset and had the benefit that today was also one of our grocery days, so the cupboards were no longer bare as they had been on arrival. It was a late morning for us tomorrow (by a whole 30 minutes) so we would have a bit more sleep, though considering most everyone was in bed well before 10 pm, having enough sleep was of little concern to anyone in the group.