I have celebrated my birthday in Tanzania nearly every year since 2011 save one. On most occasions, I have done my best to keep on the down low as I was never one much to be at the center of attention. For my thirteenth birthday, I had traveled to Disneyland on a school trip with friends and even though my mom had told me to be at a restaurant on main street with my friends for lunch to meet her, I decided that we were having fun on the other side of the park and that it wasn’t a big deal. She sat with my brother, a few other friends, and my birthday cake wondering where I was. Since then, others have also tried to surprise me for my birthday but being the totally nosy person (or perhaps it’s always wanting to be in control) that I am, I have always managed to mess it up somehow. I didn’t think there was a chance in hell that was going to happen this visit with Jill here. I was pretty certain that she would want to have some type of party and, to be totally honest, I was looking forward to it. I decided not to keep it a secret which turned out to be a good thing as Susan and Frank wished me a happy birthday before I even had a chance to tell anyone or spill the beans.
Mostly what I think about on my birthdays, though, is my parents and having been raised in an incredibly loving family with tons of support for my brother and me despite my parents having divorced when we were both in early adolescence. I won’t bore you with the story that some of you may already know, but there was never anger or hate in our home and, despite the inability to live together, my parents remained closely in touch and friends until their eventual passing a decade ago. Having had this foundation and upbringing has made all the difference in my life and I am forever grateful for the values they helped instill in both my brother and me. It was into this life and that family that I was born some sixty-seven years ago, and I will remember it every March 9th.
The education session today was being held by Diane Berthal, who had been consulting for FAME on a regular basis over the last several years, spending three months a year here in Karatu. Last year, she helped the FAME staff and administration create our new Five-Year Strategic Plan which lays out our biggest goals over the next five years and what we will base all decisions on as we go into the future. This morning’s session was on resource management as it applies to the physicians and clinical officers here at FAME. As I also mentioned during the session, we are all ambassadors of FAME and the part the community of Karatu will see when they first enter the system here. This was a session that the residents did not need to attend, and all were grateful for the extra 30 minutes of sleep in the morning.
Since it was now public knowledge that it was my birthday, this meant that I now had to endure lots of birthday wishes throughout the day which included having happy birthday sung to me at lunchtime, afterwork and later at our dinner at the African Galleria. Thursday’s lunch of pilau with meat was somehow extra tasty as the meat seemed more tender than normal, though perhaps this was mostly to do with the day and the fact that I was very much looking forward to heading down to Nish’s and the African Galleria for a birthday dinner tonight. I had told Nish that we would leave as early as possible from work and our afternoon schedule seemed to be cooperating, at least until the last patient of the day who turned out to be tremendously more complicated than any of us had expected, but more about that later.
Several of the patients who came in to see us today were well-known to me such as the young man with cerebral palsy who had come in to see us in the last couple of years complaining of new movements. Without having seen him previously, it was tough to tell what was new, but we were persistent, and the family was adamant that he had been perfectly stable for many years (his long-standing CP then at age 17) and that over the month prior to initially seeing us he had developed new movements that were quite different for him. The case was presented to me, and it was tough for me to tell what was going on, but the minute I saw him, the movements were quite familiar as I had diagnosed two other patients here and it was a disorder that we rarely get to see in the US.
He had Sydenham’s chorea, a movement disorder that occurs in the setting of subacute bacterial endocarditis and is due to a Strep infection resulting in the onset of choreaform movements occurring in adolescent females predominantly but can also occur in males. He has now been receiving prophylaxis with monthly penicillin over the last few years but will need to continue this for at least ten years after his diagnosis to prevent heart valve damage. He is doing very well and has had no complications at this point, but it is extremely important for him to continue the penicillin for the necessary amount of time. His movements have resolved, and his family’s question was whether he still needed to follow with us every six months. As much as I want to continue following him to ensure that he remains on his prophylaxis, there really isn’t a need for him to see us otherwise, so with some reluctance, mostly on the part of my wanted to watch him continue to do well, we agreed that he would only see us if he developed a recurrence of the movements which would be quite unlikely at this point.
One of the other patients who came today was a gentleman I’ve been treating since the first year that I arrived. He is a truly lovely patient who came to see me with predominantly psychiatric issues, but as I came learn back then, there are no psychiatrists here and, therefore, we’re the closest thing to a psychiatrist that they have in this region. After spending some time with him, it was clear to me that he had bipolar disorder, or manic-depressive disorder, and that his life was falling apart around him. Thankfully, several of the medications we have here and which we use commonly as both are also anti-seizure medications could also be used effectively for bipolar disorder. Between valproic acid and lamotrigine, I decided to use the latter for its better side effect profile and when he returned six months later to see me, he had a complete turnaround in his symptoms and was rebuilding his life. He has continued to follow with us ever since and other than a few little tweaks here and there, has remained incredibly stable and functional.
The last of the long-term follow up patients who came back today is a young woman who had also initially seen back in 2011. She came to see us with a seizure disorder that was secondary to a neonatal stroke that had resulted in a hemiparesis and, because her seizures were not well controlled, she was unable to attend school, which is so often the case here. Though clearly if a child is having daily frequent seizures, it may be difficult for them to remain in the classroom, but having an occasional seizure is another matter. More importantly, though, is the fact that the majority of these children have not been maximized on their anti-seizure therapies as they have often not had the opportunity to see a doctor, let alone a neurologist. This patient responded very quickly to adjusting her medications and has been seizure-free for many years. More importantly, she was able to go back to school and has now completed her secondary education. It is so rewarding to see what the effects that your care can have not only regarding the underlying neurologic disorder that you’re treating, but also in the functional status of the patient as well as their life in general. This is such an important part of what we do here.
Meanwhile, as I had mentioned earlier, it was our intention to finish as early as possible so that we could all travel down to the African Galleria for my birthday dinner and to possibly do some shopping as well. Things were looking quite well for us until a 15-year-old patient was seen in clinic who looked absolutely terrible and was complaining of new onset headache, weight-loss, and lethargy and who I had seen vomit while he was waiting to be seen. His examination also demonstrated a left hyperreflexia. Most of the symptoms had been present for the last 1-2 months and there was absolutely no question that this patient was in dire need of a CT scan as we were very concerned about the presence of a mass lesion. It was not until late in the afternoon, though, that he was actually able to get into the CT scanner as he need to have his creatinine checked for the contrast he would need to receive.
The non-contrast scan was incredibly ominous and even though it didn’t give us the entire picture, it demonstrated what appeared to be at least several mass lesions and a significant amount of vasogenic edema and mass effect. The contrasted images told the rest of the story in that there was a large right frontal ring enhancing lesion along with another large midline ring enhancing lesion that was obstructing CSF flow near the front of the third ventricle. The vasogenic edema was also massive and there was some subfalcine herniation with midline shift. We immediately called the only neurosurgeon in Arusha as the child would need an EVD, or extraventricular drain, immediately to relieve intracranial pressure and impending hydrocephalus, a procedure that we did not do here at FAME.
While we were making these arrangements to possibly transfer him to Arusha, the situation was being explained to his uncle, along with sharing the scans with him, who was communicating the story to the patient’s family who live in the Ngorongoro Conservation Area. What came of all this communication, though, was not encouraging to us as the family did not wish the boy to be transferred to Arusha even though we explained to them that his risk of dying from the intracranial pressure was very great and that there was absolutely nothing we could do for him at FAME other than to give him medications that would hopefully reduce the pressure, but that this may only be temporizing.
We braced for a rough night and placed the boy on IV steroids and hypertonic saline to do whatever we could at reducing his intracranial pressure, but we had nothing else to offer him other than supportive measures such as keeping the head of his bed elevated. Doing a lumbar puncture for diagnosis was not an option given his increased intracranial pressure and we were relying on the radiologic appearance and the likelihood of other diseases here which put tuberculosis at the top of our list as these very likely represented meningoencephalitis and multiple tuberculomas.
After getting him admitted to the ward and all his medications ordered, the team was finally ready to depart for dinner as everything was pretty much on autopilot and there was nothing else for us to try if things went south overnight. Mark was unable to accompany us as he had a fellowship interview schedule tonight but was able to partake in the birthday cake and ceremony that was held for me prior to heading down to the Galleria. The cake was beautiful, and everyone sang happy birthday – Prosper, Rose, and Annie were all here to share in the festivities, though somewhat brief as we needed to get on the road for dinner as soon as was humanly possible. The cake was delicious and, even though it was a bit odd having dessert before dinner, Jill reassured me that there was absolutely no rule about this in life.
At the Galleria, dinner was relaxing and as amazing as it always is. Nish ordered our food – the cheese samosas are to die for, the grilled halloumi skewers were just incredible, and the pumpkin ginger soup (my favorite) was scrumptious. And, as always, the drinks felt as they were well deserved given the day we’d had in clinic. The Dawa, which has been the standard, is a modification of a Kenyan drink, Nish’s home country, and is gin, tonic water, honey, and lime with a muddler to mix and crush the chunks of lime and mint that are also added. They are very effective. At the end of dinner, of course, they brought out a birthday cake for me – Babu Mike – that actually had olive and grape tomato halves for decoration. All the restaurant help came out singing the traditional “Jambo Bwana” and carrying my birthday cake with them. I also received a lovely gift from Nish and the Galleria that is a lovely Songye power figure statue from the Democratic Repulic of the Congo.
On returning home, Mark was still on his Zoom interview. He later shared with us that the internet had gone out three or four times during his interviews and that he had to wait for the router to recycle each time and reconnect. My only comment to him was, “TIA,” this is Africa.
