We were pretty certain that today would be busier given the fact that Kitashu had gone to the market yesterday to announce our clinic once again to the town. Though our recurring neurology clinic has now become very well established over the last 13 years that I have been returning, we have realized that it is still very important for us to inform the general public of our clinics as the population here is in constant flux. Karatu has grown tremendously during the short time that I have been coming and I am constantly amazed each time that I arrive with the amount of vertical building that has gone on and the number of new hotels and lodges where there were none when I had first come. Also, what used to be a total frontier town where the only paved road was the main drag through town en route to the Crater gate. Now, many of the backstreets off from the main road have been graveled, if not paved, and are nearly civilized. In the past, rains would completely take out a road with nary a thought of doing so. I guess this is the price of progress and little can be done to hold it back, unfortunately.

Kitashu is our main outreach coordinator and spends a good amount of time during the month or so prior to our arrival visiting the villages where will hold our mobile clinics as well as letting everyone now the dates that we will be at FAME. In addition to being our outreach coordinator, Kitashu, along with Angel, are also the two social workers here at FAME who assist with any of our issues that involve patient’s difficulty with payment for services or medications as well as communicating with patients and families to explain why they may require treatment or admission to the hospital and especially when they choose to decline it as can often happen and, when it does, can be very disheartening.

As very few patients have the national health insurance and, even if they do, FAME does not participate with it due to the difficulties with what it covers and the difficulty in payments. It is most often the concern about how patients and their families will pay for treatment and services that is the roadblock to providing what is needed and what is necessary. If an elderly patient comes in the hospital with a stroke, the first question by the family is often about when they can take their loved one home, rather than which rehab center or nursing home will their family member go to. On the infrequent recommendation to family for admission to the hospital as the patient’s problem either needs inpatient therapy or further evaluation to tell exactly what is going on.

During today’s clinic, a young girl named Pendo was brought to us from home for she had been having intermittent fevers and difficulty urinating. I had first met Pendo during my last visit here in the fall when we had been asked to visit her in her home which was about 30 minutes outside of Barazani and the crazy adventure had been well described in my fall blog. Pendo had unfortunately become paraplegic in the last year or so, presumedly from Tb of the spine (Pott’s disease), though we have no records of prior evaluations, nor do we have any imaging studies as it was felt that this would not change her management. Through the help of individuals at CHOP, funds were raised to not only send Pendo to a good school in Moshi, but also to obtain some health insurance for her, though neither of these at the moment were very helpful as she had been sent home from school due to GI issues (she is chronically constipated due to her spinal cord issue and has no bladder function).

She had been brought to us today as she had been having recurring fevers, difficulty urinating and had foul smelling urine, all pretty convincing signs that she, at the very least, had a urinary tract infection that needed to be dealt with and, could even be something requiring more than just oral antibiotics. She was sent off for labs and, despite the fact that she actually did not look that bad, was found to have a WBC today of 63 thousand, extremely high and far higher than any of us had anticipated, and raised concerns that she might indeed have urosepsis, which would require inpatient treatment for at least several days of IV antibiotic. Her mother, as it turns out, was very much against considering any type of admission and merely wanted to bring her daughter home. No matter how much we tried to convince her otherwise, she resisted our every argument, but eventually relented and at least allowed us to admit her overnight. She had other children to consider, and, in her eyes, Pendo was no more deserving than her other children who would have to go without if she had to pay even the smallest of additional medical expenses for Pendo’s care. With some last-minute negotiations, we were finally able to convince her mom to at least allow us to admit her overnight and, thankfully, she received the necessary treatment for now.

Of the other patients we saw today, Mark had a patient who was extremely hypertensive and didn’t seem to want to drop to something reasonable and seemed to be a bit confused raising our concern for a hypertensive encephalopathy and further risk of stroke. Rechecking the BP even after treatment with medication didn’t seem to matter, though at the last minute, the BP seemed to begin drifting downward, avoiding the need to be admitted to the hospital for BP control. That was good, because earlier in the day, we had been summoned to the ED to see a patient with continuous seizures, or status epilepticus (a potentially life-threatening condition), who needed our assistance. Wells went to see the patient, who was indeed having very frequent generalized seizures and a suppressed mental status with an otherwise non-focal neurologic examination. She also had a history of having developed a paraplegia the prior year, again raising concern for Tb of the spine, or Pott disease, but these details were unclear from her family.

Status epilepticus is normally treated with IV medications to stop the seizures as soon as possible, though unfortunately, the only IV seizure medication we have here is phenobarbital and, due to its respiratory suppression at the necessary dosing to stop seizures, it is something that we don’t rely on in adults given that we have no way of ventilating patients her FAME (outside of our OR, that is), it is not particular comfortable loading patients on this medication. She had already received phenobarbital and valium and we needed to come up with something that would last longer without causing her to stop breathing. Levetiracetam, or Keppra, is a medication that can be loaded quickly, either IV or through an NG tube, and we have used this quite successfully in the past. The trouble is that levetiracetam, though available and registered in Tanzania, is quite expensive. We can use it in these necessary and limited settings, though it is unfortunately difficult to place patients on long-term given its cost.

Her CT scan later that night was normal, and it was very unclear what was producing her seizures, though we were worried about a meningoencephalitis and possibly Tb despite her lack of B symptoms or other constitutional symptoms by history. The plan was to do a spinal tap given the normal CT scan and to go from there once we had some results. Meanwhile, her seizures had slowed down on the levetiracetam, but had not completely stopped, so we added valproate to her drug regimen with some further success. We would have to keep a close eye on her and see how she was in the morning.

It was going to be a quieter time at home this evening as there were no social events that had been planned and it was a gorgeous evening outside. Having loads of work to, I had opted out of any activities, though everyone else, being up for a walk after it was suggested to them, decided to take advantage of the weather and lovely evening. On my very first trip here, in 2010, I had decided to take a long walk at sunset to get some nice photos, but after trekking for nearly an hour up onto a high ridge for the best vantage point of sunset, quickly realized that I had forgotten to bring a flashlight. Darkness falls nearly instantaneously here and there was absolutely no moon that night and, furthermore, this was before we were using iPhones here in Africa. I started my long walk home, in the darkness of night, with only my camera to protect me, thinking that I could perhaps throw it at an attacking animal giving myself an extra moment to escape. I made it back to the volunteer house in one piece, though my two housemates at the time, Carolyn, and Joyce, were not at all amused with my little escapade and proceeded to sternly berate me for scaring the crap out of them.

So, as I sent my team of residents along with Jill out to walk into an unfamiliar rural African countryside with what I thought were some reasonable directions of where to head and what to avoid, I had full confidence that they would all make it back safely. I also told them that with the setting sun, they would find darkness upon them very quickly and to try to be back in an hour so as not to duplicate the wonderful experience I had so long ago. You can imagine my surprise then when Anya arrived back to the house nearly an hour later along with the report that she and Wells had actually broke off from the group to do some running and she had returned on her own while Wells had continued his run. This meant that Jill, Mark, and Usha were off walking on their own and it had now been an hour which is when I had been planning for the entire group to return. Wells did come back after his run, but it was some time for the others to return and quite close to sunset and looming darkness. Needless to say, I was not overly impressed with their attention to detail, nor for their common sense, but they were all back safely and that’s all that counted. Having a chance encounter with a Cape buffalo, an elephant, or a leopard in the waning sunlight is not a particularly comfortable situation and, thankfully, it wasn’t something that had to be dealt this time.