Having come home from the Serengeti last night, we were all still on a bit of a high from the adventure that we’d all experienced. Having spent well over fifty nights in that remarkable place since I’ve been coming to Tanzania, I can honestly say that I have never tired of it. Not even of that long and dusty road, though I will admit that I much prefer the Endulen road given its scenery. I attended morning report with one of the residents as we hadn’t been here for three days, and I didn’t want them to get swamped if there had been a number of neurology patients over the weekend. Thankfully, there had not been and the patient who had suffered the head injury the day before we left was doing better as far as his mental status, though unfortunately, he was still not moving his right side.
Since shortly after we arrived at FAME, one of the neurology residents has rounded with the ward team to help not only with continuity of care for the neurology patients, but also to help the residents understand just what the doctors here must do as far as their schedule and the various types of patients that each of them must see. It is quite often that the doctor covering the ward may also be first call for maternity and tied up doing a C-section. Not quite what we do back home in our super specialized medical society that we have. There are so few generalists left these days, which is really a shame and a loss to patient care.
As you may have gathered from the photos that picture either me or Vitalis driving, is that it is the British system here, driving on the left, or wrong, side of the road as most Americans think of it. This is from Tanzania having been a British colony, or actually protectorate, in past prior to its independence in 1961 when it became Tanganyika, and subsequently joined Zanzibar in 1964 to become Tanzania. But one of the interesting features that follows this phenomenon (of driving on the left) and which I had never really recognized in the past, is that pedestrians also “drive” on the left here. Walking anywhere around FAME, I am constantly surprised about just how apparent this distinction is for I am always running into people on the “wrong” side when walking through the halls and corridors here for the first few weeks until it finally sinks into my brain that I need to make a conscious effort to walk on the other side. I know that it sounds like a small thing, but it is very reproducible and recurring. Thankfully, this has never been a problem for me on the road as I have never had a problem switching back and forth between driving here and at home.
We had a steady number of patients for the day that included two with idiopathic Parkinson’s disease (PD) currently on carbidopa-levodopa and doing reasonably well on their medications. Unfortunately, we do not have some of the other adjunctive medications that are used in this condition and that can make patients much more functional as the disease progresses. Treating this condition is always a bit tricky regarding how to explain it to patients as there are no therapies that improve the underlying condition itself, only the symptoms and functional status. Off medications, the patients return to whatever their baseline was or perhaps worse if they progressed some. Also, the carbidopa-levodopa comes in a number of different ratios between the two ingredients and the one that is most often available here is not the normal starting formulation (25/100), but rather the stronger (25/250) that is typically used for more advanced patients. I have brought large bottles of the 25/100 dosing in the past, especially when Whitley Aamodt and Meredith Spindler were here, as we were hoping to see all our PD patients in follow up that visit.
There were a good number of epilepsy patients that were coming both for follow up and as new patients including a few who had been started on medications with the last group a month ago and were now checking in with us. Unfortunately, without a patient portal (a means for a patient to communicate with their doctor online in the EMR), the only way to adjust these medications here is to have patients come back to see us and to decide whether their therapy needs to be changed.
One of the biggest issues we have here in caring for our epilepsy patients, as well as many of our other neurology patients, has to do with communicating instructions. In a culture where chronic medications are not the norm, the health literacy in that regard is not very good causing patients to either stop their medication when it runs out or to not understand titration schedules even if they are written in Swahili and explained to them in detail. Anti-seizure medications often need to be cross titrated, meaning titrating a new medication until it’s therapeutic at which point you then begin to taper the older medication you’re planning to discontinue. This is not an easy concept to explain to patients with some experience in this process let alone ones who have no experience whatsoever with daily medications.
Once we had finished with our patients for the afternoon, Kelly came to me asking about walking to visit my artist friend, Athumani, from whom many residents have purchased artwork in the past. He used to be an artist in residence at Gibb’s Farm, where I had first met him, though is now showing his artwork just down the road from Gibb’s, next to the woodcarver and Phillipo’s home where we visit to buy coffee. It’s about a 30-minute walk down through the brick quarry and up the Tloma Village Road and, in very short order, she had enlisted the remainder of our group, plus Leslie, to go with her on the journey. I reached out to Athumani to let him know they were coming and, off they went. I stayed home as I had other work to do and had been there to visit him with the last group of residents when several of them had purchased artwork from him. In the end, Dennis purchased a piece from him, but Kelly did not.
The group made it home sooner than I had thought they would, and the remainder of the evening was quite restful with our roasted chicken and potato dinner that comes every Monday. Except, of course, Kelly, who is a vegetarian.