Even though we had been scheduled to be on mobile clinic today which had been cancelled at the last minute, it was nice to be back home at FAME. After two days of long drives to the Mang’ola region and Lake Eyasi, we could begin the day with a short walk to morning report and then clinic. With the new format of two three-week rotations for the residents, I’ve tried to have the experience relatively equivalent between the two groups within reason though they could never be exactly the same. The busiest of our mobile clinics are, without a doubt, the Rift Valley Children’s Village/Oldeani clinics and those in the Mang’ola region. Kambi ya Simba, where we had gone three weeks ago and is in the Mbulumbulu region, can be hit or miss and depends on the time of year, whether there’s a market day nearby, and to be honest, the phase of the moon. It’s just impossible to predict. The Children’s Village is always busy as we are not only seeing patients from the village, but also the entire community of Oldeani.
The clinic that had been scheduled for today was to be held at a school/orphanage in a nearby town, but in the end did not work out for a number of reasons, all of which were completely out of our control. Having started the mobile clinics well over ten years ago, we have always targeted communities where we could provide neurological services, but ultimately patients would need to come to FAME for their medications and any follow up laboratory testing, if necessary. Traveling to villages that are otherwise inaccessible or where patients can’t get to FAME for follow up would not serve to benefit the patients and, in the end, would fail in improving their health. For this reason, not only is the location of the clinic important, but an understanding with the patient population that they must come back to FAME for their refills of medication.
The two long drives to Mang’ola had taken their toll on the vehicles and they were both in need of some minor repairs after the incredibly bumpy and dusty roads we had taken over the last two days en route and returning from our clinics in the bush. I had driven the stretch Land Rover (Turtle) both days to and from the clinics, and we were having an issue with the temperature gauge not registering properly. Driving long distances in East Africa, it’s not only imperative to have enough water in the engine, but it’s also incredibly important to know what the engine temperature is and to prevent it from overheating. We had this very same problem last March on our drive from Arusha to Karatu, in which the engine overheated and we lost all our water but had no warning as the temperature gauge had also been malfunctioning at that time. We were able to find water at a nearby house, which worked to get us home, but unfortunately, the episode had left us with a warped cylinder head that had to be replaced. So, it was necessary to see if we could fix this problem prior to heading into the Serengeti this weekend with the vehicle.
The short Land Rover (Myrtle) was being driven by Erasmus, a long time FAME driver who doesn’t speak English very well but was trying to tell me that something on it needed to be fixed, but I just wasn’t sure what it was. It had to be simple as he was going to have it fixed today, so I told him OK and to let me know the cost of taking care of the issue. The drivers here at FAME, as well as most the safari guides, are excellent at fixing simple things on the vehicles, and especially the Land Rovers as they need constant upkeep and tweaking, but are also incredibly inexpensive to do so, making them the perfect vehicle for here when costs are an issue. I gave Erasmus both sets of keys to the vehicles and told him he had all day to work on them for me.
Meanwhile, it turned out to be a bit of a slow day considering that we hadn’t been scheduled to be here today. Our clinic schedule is typically made well in advance and the dates that we will be on mobile clinic as well as those that we will be here at FAME are distribute throughout the communities that we serve with announcements in the community centers, churches, and similar settings to get us the best possible visibility and attendance.
There was a very interesting patient in the wards, though, who was an 18-year-old Maasai women who had come in with mental status changes but did not look medically ill at all. The initial concern was that this was most likely an underlying psychiatric illness and very probably a psychosis with catatonia, though we had little in the way to rule other things out. Though we’ve been chatting with someone about getting the capability of doing EEGs here at FAME, we don’t have anything at the moment, and it would have been very reassuring to know that she was not in status epilepticus.
The other concern, though one that would have been very difficult to diagnose here as well as to treat, was an autoimmune encephalitis. This is a category of illnesses that were described less than 20 years but are very scary and difficult to treat in the best of circumstances. The most common of these, known as anti-NMDA-receptor encephalitis, was the first to be described, and has a very interesting presentation. Though it can occur in anyone, it is most commonly seen in young women with a presentation of subacute or acute psychosis that is often followed by mutism and catatonia. This is then followed by a host of other complications that include either focal or generalized seizures, or both, that are difficult to treat, autonomic dysfunction with huge swings in heartrate and blood pressure, and abnormal movements.
There are a number of tests that are supportive of this diagnosis, none of which we can really do here, though one of the common features in the young women presenting with this condition, is the presence of a very specific benign tumor called an ovarian teratoma, that can easily be detected on an abdominal ultrasound. We sent the young women for an ultrasound, that was negative, and though ruling the teratoma out, it did not answer the question of whether this could be anti-NMDAR encephalitis. Other than the catatonia that she presented with though, she had none of the other features and her examination over the rest of the day and evening pointed much more to this being a primary psychiatric diagnosis than anything else and we continued treatment for this. Over the next days, I can say that she slowly improved and what we were eventually able to discharge her home to her family.
Tomorrow would be a scheduled clinic day at FAME with the likelihood of more patients and Friday morning we’d be leaving for the Serengeti for two nights.