As the first group of residents would be leaving FAME tomorrow for their continued adventures, this was their last day in clinic, and we had scheduled it for a half day to see any final patients that needed our attention. As you might imagine, though, making plans and sticking to them are two completely different things and there’s Africa. It was LJ’s day to make rounds after morning report and it turned out to be a very interesting day for her on the ward. It was also an interesting day in clinic with a wide selection of patients.
I had mentioned that Whitney had initially seen a young 4-year-old boy at the Children’s Village who had suffered a stroke earlier in the year and we had asked them to bring him to FAME to have labs done. He had reportedly been evaluated and worked up at KCMC, though without having the specific records, we decided to send whatever we could think of and what would be available at FAME for, though we have an extensive array of labs, many are missing as we are either unable to do them here or they would be done so infrequently that it would be too expensive to keep the reagents on hand. Regardless, we had sent one test that was very important, but did not come back until this morning and was positive – a sickle cell screen! We were surprised that it had not been done at KCMC, and, though we’re not entirely sure that it wasn’t, having a positive screen was very suspicious and would need to be followed up with electrophoresis to confirm that the child did indeed have sickle cell disease. If that turned out to be the case, he would need specialized care that is only partially available at FAME.
While on rounds with the ward team, LJ had heard a case presented of a gentleman who had come in the day prior with nausea and vomiting and had been diagnosed with gastritis for which he was currently receiving care. There was something about the case, though, that bothered LJ and watching the patient, she thought he looked somewhat ataxic. Not wanting to rock the boat, she mentioned that perhaps she could see the patient in consultation, and though she initially received a bit of push back, she received approval and once rounds were completed, she returned to evaluate the patient fully.
What she found was that in addition to his nausea and vomiting, the patient complained of headache with no prior history of such, and on his examination, she found that he was indeed ataxic and had nystagmus. She was adamant that the patient needed a CT scan as she was concerned about a cerebellar process. His CT scan was obtained shortly thereafter and revealed a moderate right-sided cerebellar hemorrhage with mass effect. Posterior fossa processes like hemorrhage or infarct, or any space occupying lesion for that matter, can look good one moment and trying the die the next because there is very little room there and a very small increase in the size of a lesion can cause a huge increase in pressure. It was decided that the patient would be transferred to KCMC for neurosurgical management if he were to worsen and required an emergent decompression which could not be done at FAME. Had it not been for intuition on rounds, it is very likely that the patient would have worsened and quite possibly have died. These are the subtleties of neurology that are the most difficult to teach.
While managing her patient with the cerebellar hemorrhage, LJ became involved in another patient who presented unresponsive and was hemiplegic. I believe the story was that he had been found down at home and the initial concern was for a stroke, though on examination there was concern that he was having continuous seizure activity and was in status epilepticus. After receiving a benzodiazepine to break his seizure, she also asked that he be given a levetiracetam loading dose and, though we only have this at tablets, we have used it successfully many times in the past by putting it down an NG tube and it is absorbed rather quickly. Meanwhile, she was assisting with getting him a CT scan in the midst of everything else going on, and it was unremarkable. This doesn’t necessarily rule out an acute infarct, but it does rule out a hemorrhage or other mass lesion that may have been causing his hemiparesis. [Follow up: I had lost track of this patient, but reached out to LJ to see if she knew anything and she sent a message to Dr. Omary, who replied, “Actually I discharged him a day before yesterday (Sunday), he is improving very well. No more seizures reported since admission, blood pressure normalized without medications, paralysis improved as well. Will see him after 14 days. You have done a very good job, LJ.” I’m not certain there is higher praise than that.]
Meanwhile, in the clinic there was a patient who presented with complaints of a mild tremor that turned out to be primarily resting, and she had some other features on her examination that suggested she had very early Parkinson’s disease. Since the medications we use for PD are only symptomatic in nature, and her tremor was dysfunctional for her in any way, we decided not to initiate any medications and have her follow up with us in six months. If her tremor became worse for any reason, she was advised to come back earlier at which point Dr. Anne could see her and we could start medications, if appropriate.
Another gentleman came back to clinic to see us who had been admitted to the hospital six months ago while we were here and had presented then with seizures and an abnormal CT scan of the brain that looked like a possible cerebritis. Looking back at the old CT scan, it was a really difficult call to make back them, but he had been doing well since his hospitalization and had recovered completely. We had kept him on his anti-seizure medication over the six months, but he had no recurrent seizures in the interim since having seen us last visit. As one of the main questions was whether he needed to remain on his medication or not, we decided to do a repeat CT scan of the brain as if there were no remaining structural injury, we would discontinue the medication. His repeat CT scan was completely normal meaning that we could safely take him off the medication and it would be unlikely that he would seize again, though certainly not 100% I’ll have to admit that seeing complete resolution of the abnormalities on his prior CT was a bit surprising, though not shocking, and was very reassuring as to the prior prognosis that we had given him.
With the very busy morning we were having, I wasn’t sure there was going to be time to go to the African Galleria for the afternoon as we were really pushing our window of opportunity. Thankfully, though, things quieted down quickly by around 2pm and those of us interested in having a light lunch at the canteen could do so, while others ran home to have a snack before we headed off down the road. We were planning on an early dinner at the Galleria so that we could then come back up and go to Green Park, where a number of people from FAME were meeting as it was Judith’s last day of work here. We don’t have much in the way of snacks here at the house, though there is Nutella, and I think that sufficed just fine, especially for LJ, who seemed to have an addiction to the stuff. I gathered up the troops, loaded them into Myrtle, and we were off down the road in the direction of Rhotia and Manyara.
The African Galleria, which is owned by my friends, Nish and Punit, brothers who grew up in Mombasa and then moved to Tanzania over a decade ago. The African Galleria wasn’t here when I first came through Karatu in 2009, but within a few years it became the largest shop for souvenirs and art in the region, as well as amazing gemstones of the best quality including lots of Tanzanite. The Ol Mesara restaurant at the Galleria was opened in March 2019, with the unfortunate timing of being just in time for the pandemic as the tourist industry pretty much collapsed for almost two years. Thankfully, though, they weathered the storm, and the restaurant has become one of my go-to spots with the residents as the food is just out of this world and the setting in a large open-air, covered space is just delightful. The dishes are traditional East Africa but done in a gourmet manner and everything is served family style. Though every single dish is scrumptious, my particular favorites are the pumpkin soup, cheese samosas (to die for), and the grilled paneer and beet skewers. Everything served there is just incredible.
The residents did some shopping first, and then we all met for a light dinner and drinks. My favorite, the Dawa, a traditional Kenyan drink that is made at Ol Mesara with local gin, honey, sectioned lime, tonic, and a wooden stick to muddle the ingredients. By the way, “Dawa” in Swahili means medicine and the drink certainly cures whatever might ail you.
After dinner, we hit the road again and it was back to Karatu and Green Park, an outdoor club that serves nyama choma (barbecue), chips, and chips mayai, the latter being essentially a frittata made with French fries and eggs (mayai). Of course, they also serve drinks, and the local beers seem to be the favorites. All our translators were there, so it was a nice going away party for us, as well as for several other volunteers who had been working here. Pete and Amanda were there with their children, Ollie and Astrid, who, of course, were the hit of the party it seemed. Ollie crashed early, though, and many were happy to cradle him in their lap while sleeping including Whitney, for what else would you expect from a pediatric neurologist.