Wednesday, October 25 – A young functional patient for Kelly and the second visit with Daniel Tewa

A very nice running trail for Kelly

The photos today are predominantly those taken by Kelly on one of her early morning runs. I’m not sure that I can give an actual count of how many times she was accompanied on her runs (though I do know that it was absolutely zero times by me), but I can saw that she was the most dedicated to some form of exercise during her time here out of all the residents. She was up before dawn every day and out the door in time for sunrise. Today, though, her photos were particularly informative of the sights surrounding FAME, and of the Black Rhino Academy.

I’ve mentioned the Black Rhino International Academy many times in the blog, and it has become no less impressive since its conception several years ago. It had been the long-time dream of Caroline Epe to open a school in Tanzania ever since she had arrived on the continent well over a decade ago and, after being a work in progress for several years, it has now become one of the pre-eminent learning institutions in Northern Tanzania with levels (grades) covering all primary school and the recent addition of early childhood learning. Caroline has been a fixture at FAME since just after it opened in 2008 and was actually the volunteer coordinator when I first arrived in 2010, though has moved well beyond that position, now being the primary development person on the Tanzanian side, though on a part-time basis given her involvement with the Black Rhino. One of the other unique features of the Black Rhino, though, is its sports facility and its incredible football pitch (field) which is one of the finest in all of Tanzania that even hosts training sessions for the national football team.

Even though no one had been out extraordinarily late at the Sparrow last night, I’m sure the extra half hour of sleep with no educational lecture this morning was much appreciated by all those who had not chosen to run this morning. Our days at FAME for this session were winding down as we had only one more full clinic day after this and a half day on Friday as we had plans for an early dinner at the African Galleria for our last night in town. We would all be departing on Saturday evening, with everyone, including me, taking the same flight to Doha, though I would be heading on to Barcelona to meet Jill for a week or vacation, and the others would be heading to Washington, D.C, as Qatar Airways was no longer flying directly into Philadelphia.

The football pitch at the Black Rhino

Having flown the first several years out of Newark or JFK on KLM (which had been the only airline with flights from outside the African continent to fly to Kilimanjaro), it had been a blessing when Qatar first announced that they would be flying direct from Philly to Doha given both the huge benefit of not having to drive up to or near NYC, and the fact that Qatar is hands down one of the best airlines operating at the present time. How things will play out going forward remains to be seen and we will have to reassess the situation based on cost and convenience.

Kelly and Dr. Anne

We were planning to visit Daniel’s home for the second time this visit as the current group had not yet had the pleasure of a visit with that remarkable man. With plans for a visit, though, it meant that we did have an early target time to leave, hopefully well before sunset, as it’s best to see his home in the daylight, and though it can be done after dark, the effect is just not the same. Of the patients that stood out for the day, there were two.

The first was a young patient who had come in with their family and, as I was sitting right next door to them, I could hear all the conversation after they arrived, which made it very clear to me early on what type of matter we were going to be dealing with. Kelly’s interest not only in epilepsy, but also functional disorders (those without a physical cause) would clearly play a role in the management of this child. The unfortunate part, though, was that the patient had been taken by the family to be seen all over, including Muhimbili University in Dar es Salaam, as well as India. The symptom complex was really all over the place and within several minutes of listening to their discussion, I had simply asked Kelly if this was someone in her area of expertise, to which she had given me a simple “yes.”

Greeting Daniel and Elizabeth as well as their cute little puppy

In addition to an extensive GI workup that had already been done with lots of testing and records that were contained in several shopping bags and all of which had been stone cold normal, they had also been having episodes of unresponsiveness or loss of consciousness for which they had undergone an EEG. This was, of course, also normal, though it is important to point out that a normal EEG does not, in and of itself, come close to ruling out epilepsy in the right clinical setting. The neurologists in Dar had noted that in the EEG read in their clinical notes (which is standard), though had decided to place the patient on sodium valproate to see if that would, in some way, affect the frequency and nature of the episodes. There was some suggestion by the father that the medication had, in fact, helped a “little,” but the episodes were still occurring and, given the fact that they sounded definitely very functional to us, we were not at all convinced that it had helped.

Ready to explore Daniel’s tembe

In the end, the family was very accepting that the diagnosis was most likely functional neurologic disorder, and it was then a matter of figuring out how to find some type of therapist who could help with the situation considering we were literally in the middle of a therapy desert. Amazingly, though, I had been contacted by someone at Kilimanjaro Christian Medical Center while we were in the Serengeti last weekend who is a neuropsychologist and was also interested in collaborating with patients. We put them in touch with each other and, hopefully, they will be able to begin some type of therapy soon.

The other patient was a young Maasai boy from the Loliondo area (seven hours away by way of the Lake Natron Road) who was seen by Dennis and was clearly not acting himself. The history that was given to us was that he had fallen off the back of a boda boda (motorcycle) within the week and several days before coming to see us, had what was very well described to us as a focal seizure. They had also reported that the boy had been febrile. The boy was encephalopathic and unsteady on his feet which, given the history of the fall and seizure, made us very concerned about a subdural hematoma following a traumatic brain injury meaning that it was imperative that the boy have a CT scan as soon as possible, though this would not explain his fever.

We were able to arrange the CT scan perhaps quicker than most and, when it was completed, it turned out to be normal (it was also done with contrast as I had some concerns about the history not being as simple as billed which is often the case here), meaning that there was no intracranial bleed or other abnormality that we could see to explain the presentation. Being that histories here are quite often not always as simple as they seem, the concern now was that the boy could have a meningoencephalitis, such as herpes simplex, given its common presentation with encephalopathy and focatl seizure. He was admitted to the hospital and placed on antibiotics, as well as an antiviral agent, with plans to do a lumbar puncture for more information, though given that we are not able to do cultures at FAME, we would be limited to cell counts, gram stain, glucose, and protein.

Daniel tying a wedding skirt on Kelly

Lumbar punctures, though quite simple to perform, do have significant cultural bias here in Africa for several reasons, with a big one being the history on this continent of HIV and patients coming to the hospital on death’s doorstep, having a lumbar puncture done as part of their evaluation, and then dying, with the perception by the public that their death was in some way contributed to by the procedure. Thankfully, having Kitashu here to help explain the need for the test and, in fact, that it is not at all dangerous, helps immensely in these situations. The family consented and we were able to do the LP with no trouble. The boy would be kept on his antibiotics and antiviral agents at least until we had the results of the spinal fluid either later that night or the following morning.

Dennis demonstrating his warrior skills

Having to deal with the young boy, though not complicated, did set us just a bit behind schedule having to make all the arrangements for the spinal tap and the admission, but it was finally all taken care of allowing us to depart at a reasonable time for Daniel’s house. We loaded in Myrtle and made our way towards to the Gibb’s Farm Road where Daniel lives, near the Ganako Secondary School and the village of Ayalabe, where I had first met him in 2009 while volunteering at the primary school there with my children. As an elder of the village, Daniel was there to help us with the painting we were doing and to act as a liaison for the community. He later invited us to come to his home, meet his wife, Elizabeth, and share with us the history of the Iraqw tribe. Now, fourteen years later, Daniel continues to host my teams for similar stories of the Iraqw tribe and culture and considers me part of his family. I have worked with several of his younger children (he and Elizabeth have twelve, eleven of their own and one adopted whose mother was a neighbor and died in childbirth).

Dennis demonstrating his drone to Daniel

We sat on the stoop of the new house his children are building so they have a place to stay when visiting, as Daniel still lives in the small three-room Bantu house that he built in 1973 when he first settled on this property. We shared his wonderful African coffee, boiled with fresh milk from his cows, and enjoyed fresh (and amazingly delicious) cakes that he had purchased in town just for the occasion. After giving everyone U.S. geography lessons on their home states (when they joined the union, capitols, square miles, important facts) that none of them knew, we finally walked over to visit his unique underground Iraqw house that he built in 1993 to prove to his children that he his stories of his childhood were true and that he wasn’t crazy. The houses were built underground to protect their cows from the Maasai who believed that all cows were theirs and they were only stealing what was rightfully theirs. Daniel grew up in a house like this for the first twenty years of his life, defending their livestock and listening for intruders who would walk on top of their houses at night. The Iraqw and the Maasai continued to fight until a treaty was finally signed, but not until 1986.

A photo of our group taken from the incoming drone

What stood out the most to me tonight, though, was just how vast the differences were in our cultures and in the technology that we all took for granted. Dennis had brought his drone with him and, though he was keen to fly it and take some nice aerial photographs, I was also excited to share it with Daniel. Yes, we all had our smartphones and computers, but here was also something very physical and real, a drone that took off at our feet, flew miles away, and then returned, taking video the whole while, with the final images of our little group, including Daniel. A man who grew up in an underground house, using spears and clubs to defend himself, goatskin wraps to dress with, and, all the while, teaching us facts about the United States that he learned in school (he only went to the 8th grade) and that none of us had known ourselves. The significance of the moment was just beyond comprehension.

3 thoughts on “Wednesday, October 25 – A young functional patient for Kelly and the second visit with Daniel Tewa

  1. Klenisson Brenner

    What a great story. It’s truly amazing the work that you do in Africa. I am an international medical graduate and will be applying for Neurology next year. Hopefully I’ll match at UPenn and join you in one of your journeys. God bless. Klenisson

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