As we were planning to work a shorter day tomorrow, this would be our last full day of clinic for Fien and of the week. We had anticipated a morning lecture at 7:30 am, though as we left the house to walk to campus, Leslie, who was outside exercising (yes, some of the volunteers do exercise on a regular basis), informed us that there was no lecture. We all reversed direction, quite thankful that we all now had an extra 30 minutes of down time, which I, of course, used for a quick cup of tea prior to starting our morning clinic. When we arrived at the education room in the admin building, where the education lecture and morning report take place on Thursdays, all the doctors were present and were having a session in Swahili that, regardless of the language, was clearly somewhat of a “gripe” session in which Dr. Gabriel was soliciting things that were being done right and those that weren’t. The session continued for another 10-15 minutes after we arrived and given that a small amount of it was in English, we got the gist of the conversation.
Things got busy even before our clinic started as there was a middle-aged patient who had come into the ED earlier with severe hyperglycemia in the setting of diabetes, but more concerning for us is that he was in status epilepticus, though had a history of seizures and who had not been taking his home medications, unfortunately. In reviewing his records, he had been seen before with similar issues and had actually had a CT scan, which had been commented on in the chart as showing some focal hypodensity, though the official read was unfortunately missing, and it would take some time to bring up his old study. In the ED, Fien was mostly working on the patient, who continued to have mostly focal status, though was not waking up between events. Dr. Amanda, along with an ER resident from Scotland who just happened to spending the day at FAME, worked to keep his respiratory status stable without intubating him as we have no ventilators to use on patients outside of surgical theater.
Compounding the issue, the only IV antiseizure medication we have is phenobarbital, which can only be used at real loading doses if you’re ready to intubate and ventilate the patient and that was not something we were intending to do. The patient received significant amounts of midazolam, a short-acting benzodiazepine, that, again, is an issue when it comes to breathing. Stuck between a rock and a hard place, with Dr. Amanda and Dr. Anna (our Scottish ED resident) maintaining constant jaw retraction to keep his airway open while we asked for an NG tube to be placed that would enable us to get some longer acting anti-seizure meds on board. With the NG tube now placed, we first gave him a levetiracetam load of 3 grams, which, if we had been in the US would have been immediately effective, but not so when giving it via the NG tube. To be honest, status epilepticus is a condition that is treated as an emergency, so I am very doubtful that there are guidelines anywhere referring to the use of an NG tube, though, as I have said often before, this is Africa.
By about this time, the CT scan done the prior year was finally made available for our review and was completely normal, which made me feel better as I was a concerned that the hypodensity someone had described last year could have been something more concerning, but at least that was not case. Waiting a full 30 minutes for the levetiracetam to work, which it hadn’t (he was continuing to have very brief focal seizures, but was not waking up in between), we then decided to give him a loading dose of sodium valproate through his NG tube. He eventually stopped seizing (thankfully), but given the amount of time he had been, he was not waking up. He was admitted to the ward with decent oxygenation, and, over the course of the day, seemed to become a bit less obtunded for us. Fien had an excellent lesson on how to manage status without IV antiseizure medications, something I’m not sure she had imagined doing previously.
At the same time as we were dealing with the seizing patient in the ED, Dennis was asked to see a young child in the ward with a bulging fontanelle and some developmental delay. Though he was pretty certain the child was going to have hydrocephalus, when they did an ultrasound of the head (possible with the open fontanelle), the ventricles looked normal, and it didn’t give us an explanation at all for the delay and the finding on exam. He also checked the baby’s thyroid as that was also on the differential (a simple blood test that is available at FAME) and it was essentially normal. With no good answer and an adequate ultrasound, he didn’t want to expose the baby to radiation from a CT if it wasn’t necessary so we recommended that they come back to see us in a few weeks when we would still be around.
Later in the day, we were asked to see a young Maasai boy who had been brought to FAME from the conservation area after having fallen over a cliff and had a serious head injury. The story was that two days earlier, the boy had been herding the family’s livestock when he slipped while standing on a rock at the edge of an overlook and fell approximately 50 feet, striking his face and head when he landed. The child had remained with his family for two days, but wasn’t getting better, so he was brought out of the conservation district by bus to FAME. In looking at the boy’s CT scan, he had very serious fractures of the right very much greater than the left orbits, right frontal skull fracture, and severe contusion of the right frontofrontal brain with some subarachnoid blood. He had no subdural or epidural hematoma, something that would have required immediate surgery, but his orbital fractures were something that would require an ENT specialist. He was not alert and his eyes were pretty much swollen shut. We recommended transfer to KCMC where he could be seen emergently and, thankfully, he was transferred before it got too late as ambulance transfers are very risky in the dark.
It was a very busy morning which was great as it went quite quickly for us, and before we knew it, lunch had rolled around. Thursdays are pilau day, typically one of the favorites for everyone, that is except for the vegetarians in the group. The pilau, being rice cooked with meat and seasonings and accompanied most often by a cabbage slaw, is definitely delicious, though I am still totally partial to the lunch that is served for five out of seven lunches and that is the rice and beans with mchicha on the side and lots of pili pili. As I have mentioned numerous times in this blog, I think of this lunch often when I am home and miss it dearly the moment, I leave FAME.
Our evening activity tonight, which was rather impromptu, was an invitation for us all to attend Teddy’s son’s first birthday party. Teddy, the tailor who has taken such wonderful care of the residents over the last several years and has also now taken Dorthea in as an apprentice, had her first baby last year at this time. Not only was Allan born while we were here a year ago, but we have watched him grow and have enjoyed seeing him on each of our visits to her shop. Birthday celebrations, and especially the first, are huge events here in Tanzania, and a time for family and friends alike to gather and show respect. Being invited to such a celebration was an honor for us and something not to be missed. There were plenty of kids from the neighborhood in attendance, but more significantly, there were lots of adult. Allan, of course, will remember very little of the party, but his mother will, and it was a chance for us to congratulate her on such a handsome young man and to give a gift for his future.
Another tradition here, which I happen to love, is that birthday cake is cut into bite sized squares and then fed by birthday person with a toothpick to each of the attendees. Allen could not do this, of course, so it was left up to Teddy and everyone filed by to receive their piece of cake delivered directly into their mouth. I did this for my 60th birthday at the Highview and remember everyone dance in line to file by for me to place a piece of my cake in their mouth with a toothpick, just like a mother bird feeding her chick in the nest. After our little piece of cake, we were all invited to partake in a lovely dinner that she had prepared for everyone. It was buffet style and Babu (meaning grandfather), or I, was invited to come up and get the very first plate of food for which I was obviously touched and incredibly honored. It was a lovely evening, and I am sure that it was something the residents will not soon forget.