I think we were all recovering from our three days in the Serengeti and needed a break from all the excitement. It had been a wonderful trip on all accounts, and even considering the fact that we had one breakdown, another need for a repair, and Turtle was on its last leg as we pulled up to the house in Karatu, we had seen everything that we wanted, there were no catastrophes, and we spent two nights in the luxurious Dancing Duma tented camp which was quite unexpected. I hadn’t mentioned in yesterday’s post that Turtle’s engine sounded horrible as we were ascending to the crater rim and Kitashu’s boma. I knew that it would get us home, but it clearly needed repairs and was a bit disconcerting as we had just put a “new” rebuilt engine in it prior to my return. One of the cylinders was losing compression, though knowing what the problem was did not help the situation as we had nothing to fix it here. Thankfully, we had Myrtle, the other Land Rover sitting at FAME and, with no outings or game drives this week, it was perfect timing to get it back to Arusha for repairs. Vitalis had taken the bus from Arusha to get to us on Thursday, so it was a simple matter of having him bring it back with him.

There were several patients over the weekend who had been admitted to the hospital and needed our input, so I went to morning report to hear about any updates that we could assist with. As I walked back to the OPD (outpatient department) and to our outdoor neurology clinic, I noticed that there were a good number of young children walking around with abnormal gaits (something a neurologist always notices) and wondered if they were for us, though quickly realized that it was the week that the Plaster House Kids were coming to be seen by the orthopedist and have surgeries.

The Plaster House (www.theplasterhouse.org) is a wonderful organization that was founded in 2006 to provide surgical care and rehabilitation to children with disabilities throughout Northern Tanzania. Their model was to create an incredible outreach program to identify children with primarily orthopedic disabilities who could potentially be treated surgically, bring them in for a full evaluation and, if appropriate, provide them with surgery, post-operative care and then a complete course of rehabilitation so that all their medical care will be taken care of prior to their return home. They have been located primarily in Arusha but have recently decided to open a house in Karatu for children to receive their care and have identified FAME as their surgical partner where the children could undergo the surgery that was necessary. This partnership was obviously incredibly exciting, though did require that FAME could accommodate the additional surgeries which has not been an issue for us.

The orthopedic surgeon is now on staff at FAME to provide surgery to these children and all of that will usually occur in a given week, typically once a month. Children stay here at FAME for their first pre-op night but will then go to the Plaster House in Karatu for their continued care and rehabilitation. I’ll hopefully take a tour of their house in Karatu in the next few weeks as Pete, who is now volunteering here at FAME, is quite connected given that his sister, Sara, founded Plaster House nearly 20 years ago. Pete, a pediatrician, and his wife, Amanda, an ER doctor, are both volunteering at FAME for the year with support through an Australian foundation (yes, they are both Australian). Pete and Amanda, along with their two children, Oliver, and Astrid, joined us in the Crater in their own vehicle a week or so ago.

With the Plaster House now doing much more than just orthopedic cases and providing plastic surgery for children in need, the name has been changed to Kafika House to represent just more fully what it is that they do. Though I have not been directly involved with their work in the past, I have known about them since I’ve been coming here. They are another amazing organization who have changed so many lives here similar to FAME.

There were not a tremendous number of interesting cases for the day, though one that took up a considerable amount of time for us was a 20-year-old psychotic man who we had seen in the past and had placed on olanzapine (the primary antipsychotic medication we use here) a year or so ago, which had helped, but he unfortunately had stopped it and though had been doing OK in the interim, was now coming in acutely psychotic and difficult for us to manage in our neurology space. It was very likely that he had a primary psychiatric diagnosis and most likely schizophrenia, though there was also a question as to whether there was some contribution, at least in part, of drugs and alcohol. Regardless, we could not manage him, and it wasn’t long before we brought him over to the emergency room (the old one with only two beds as the new one is not open yet) to received more appropriate IM medications that would work more quickly.

I had learned some time ago from Frank that the best combination we have here is 10 mg of haloperidol mixed with 4 mg of lorazepam (simply known as 10-4) given intramuscularly so that it’s rapid action. I have used this combination here on a number of occasions and it has worked very well. You might be asking what a neurologist is doing treating primary psychiatric disease, and it would be perfectly reasonable for you to ask such a question. The simple answer is that there equally few psychiatrists here as there are neurologists. Frank puts it another way when he says, “you’re the closest thing we have here to a psychiatrist.” I have heard this so many times that I’m almost starting to believe it, though I’m very cautious about doing anything that I’m not entirely comfortable with and I counsel my residents to think the same way. There’s never an issue with trying to help, but you should never leave your comfort zone, nor should anyone ever expect you to do so.

Given the patient’s agitation, it was imperative that he receive his medication parentally, i.e., by injection, rather than by mouth as we really wanted him calmed down rather quickly. There was some discussion in the ED as to whether we had injectable haloperidol or not, though I know that we’ve had it in the past because I had brought a supply at some point and, regardless, we should never be without it given its effectiveness in just such a situation. He was given some IV midazolam, which is a very short acting benzodiazepine, to calm him down until we figured out the haloperidol situation, but the midazolam, though short acting, is pretty potent and the last thing wanted was for it to suppress his respiration in which case someone would be bagging him for a bit as we do not have ventilators to use in such situations.

Thankfully, after asking around (mainly a quick phone call to our pharmacist), the haloperidol injectable was located, ordered, and drawn up into a syringe for the patient. After it was given, the patient quickly calmed down and was more manageable, finally allowing us to have him admitted so we could keep a close watch on after his injection and while getting his oral medications back on board. The following morning, he was much calmer, though not so easily redirectable and tended to want to wander around the hospital. He was back on his outpatient antipsychotic, olanzapine, and we felt that he was OK to discharge at that point.

With the excitement, and the exhaustion, of the weekend, it was decided to spend the evening in. The residents all took the opportunity to watch the original Lion King with my LCD projector and make some popcorn. Not at all surprisingly, none of them had previously realized just how realistic the setting for the Lion King actually was and how much Swahili was used in the dialog and song lyrics. If you’d never been to the Serengeti before, how would they have known? Next up is Out of Africa, but that will have to wait for our return to the US and a post rotation gathering.