Thursday, March 23 – A difficult post-partum psychosis patient and a visit to the Golden Sparrow…


With more follow up on the Marburg virus situation in the Northwest of the country, it seemed there have been no new cases since those initially reported. With the WHO involved there is a sense that the outbreak has been contained to a very small location and after speaking with those here at FAME, the sense is that the risk of travel to Gombe will be incredibly low, and Mark and Anya will be fine with their current plans to leave tomorrow for their trip. Flights to Kigoma, the town on Lake Tanganyika from which they will depart by boat for the last leg to Gombe, are not available on Sunday, so they will be departing from FAME a day earlier than originally planned and will be spending tomorrow night in Dar prior to flying to Kigoma. It is a true adventure, flying all the way across the country to its western most border on Lake Tanganyika, the second oldest, second largest by volume, and second deepest freshwater lake in the world, while also being the longest freshwater lake in the world, that sits between Tanzania and the Democratic Republic of the Congo, or the DRC.

King Leopold II of Belgium

Mere mention of the DRC can bring shudders to anyone remotely familiar with its past, but the greatest atrocity occurred more than 100 years ago when King Leopold II of Belgium decided that he deserved a colony as much as any other European nation. Under the guise that he was colonizing the Congo for its own benefit and to improve its standard of living, he proceeded to found the Congo Free State for himself in 1885 and, over the next 20 years continued to rule the Congolese population by force using a mercenary army to enforce his rule through violence and atrocities. He first began exporting ivory in massive amounts and, when the price of natural rubber made its harvest profitable, turned to having his mercenaries force the population to harvest it for export.

A Punch cartoon from the turn of the century

During this time, he had the backing of the US Government as he completely duped them into believing that he was doing good. While the exact number of Congolese killed during his reign is estimated to be between 1 and 15 million, a consensus seems to center on 10 million killed, making it one of, if not the, largest mass killing or genocide (some debate the definition of genocide) in the history of mankind. Despite this incredibly dark history, the atrocities that occurred in the Congo Free State were where not widely known until the publication of “King Leopold’s Ghost” in 1998 (a great read that I would recommend to anyone).

Congo Free State

I recall my visit to Gombe as an amazing experience and often sat on the beach near sunset, with the mountains of the DRC looming from across the lake some 25 miles away, but clearly visible to us in the waning daylight as darkness quickly fell upon everything around us. It was haunting not for what I knew of its past, but more so for what I didn’t know about its present and the fact that it occupied essentially a black hole that sat just across the lake from me.

Dressed for the Sparrow – Jill, Wells, Usha, Mark, and Anya

We had a young woman present today that was very similar to a case we had seen several years ago here at FAME. Back then, it was a young Maasai woman who was post-partum and presented with severe headache and focal deficits on her neurologic examination. Lindsay Raab was here at the time and had seen her in consultation and was worried about a cerebral venous sinus thrombosis (CVST), or clot that had occurred in the large venous sinuses of the brain that drain blood into the jugular veins. Indeed, her CT scan was consistent with this diagnosis – not only did she appear to have CVST, but she also had evidence of a venous infarct that was causing her weakness. The treatment that was indicated, though, was something completely counterintuitive to most as it involved anticoagulating the patient with heparin to help the clot resolve and effectively reduce the back pressure that had developed causing the infarct. With very little technology to go on (we had no CT angiogram capability at the time that we have now), we placed her on intravenous heparin and hoped for the best. Had she developed a hemorrhage on the heparin, one of the possible complications, we had no means of operating as the closest neurosurgery was more than two hours away.

A night at the Sparrow

I will have to admit that I relied tremendously on Lindsay’s and the other resident’s input regarding this case as they were all much more up to date with the neurovascular data that existed for this situation and, even though I was comfortable with the concept, it was their dedication and commitment, especially Lindsay’s, that allowed for the comfort level I had with the plan. In the end, the patient did amazingly well and returned to a normal neurologic exam. It was quite a triumph, and I was very proud of the team. The patient also had a history of prior miscarriages, as did her mother, which made us suspect some clotting abnormality such as anticardiolipin antibodies, but without the necessary testing available here, we were unable to say for certain what her future risks were. We felt quite strongly, though, that a future pregnancy would be an extremely high risk for her and counseled her against becoming pregnant again, which also had to involve her husband. A Maasai man’s wealth is his children and his cattle and telling them she could not get pregnant in the future could have been a problem. Low and behold, her husband told us that he loved his wife more than having more children, which was music to our ears.

Our patient today underwent CT scans with and without contrast demonstrating that she did not have CVST, or a clot, and we treated her headache conservatively. Thankfully, I did not have to make the same decision that we had in the past as I’m not so sure I had it in me to approve anticoagulation again.

The weather was continuing to change, and we were getting more rain and cool temperatures. We hoped that it wasn’t the change of the season with the monsoons coming as that is a particularly unpleasant experience that I was hoping to avoid.

We had a Maasai patient present to the clinic who was five weeks postpartum and was now severely psychotic with pressured speech and marked paranoia. She was impossible to reorient or redirect. She had no history of psychiatric disease, and this was her third pregnancy. She was so out of control that it required quite an effort to get her to the emergency room where she was eventually administered two doses of haloperidol mixed with diazepam that, unfortunately, had little effect on her. She was eventually admitted to the maternity ward due the fact that she was postpartum, and later given olanzapine which is the medication we were planning on using at least short term for her. The following morning, she was calmer, but remained psychotic and agitated requiring that she remain in the hospital.

Our last piece of business for the day was to visit the Golden Sparrow with the entire neuro team for a night of dancing as Mark and Anya would be leaving the following day. We were joined by the entire group of interpreters who had been working with us for three weeks as well as Dr. Anne even though she was well into her pregnancy. Konyagi, whose claim is that it is “The Spirit of the Nation,” is the local drink of choice here, and, mixed with tonic water, makes a perfect gin and tonic. Better yet, it’s very inexpensive and perfect for the club. Though the club was entirely empty when we arrived, and remained so for about two more hours, it did fill up with other patrons later in the evening so that we were not the only one’s dancing. Everyone enjoyed themselves immensely and even though I have included a few videos, it is still “what happens at the sparrow, stays at the sparrow.”

Leave a Reply