As Pete was giving the morning lecture on neonatal sepsis, I wanted to go as did the pediatrics contingent of our group – Marissa, Gina, and Megan. I had mentioned before that Pete and Amanda have been spending the year here, along with their two children, Oliver, and Astrid, as volunteers in pediatrics and emergency medicine, respectively. They are being funded by an Australian non-profit, though their choice of location wasn’t something that occurred entirely by chance. Pete’s sister is the founder of Plaster House, now known as Kafika House, with is an NGO that had originally been set up to provide treatment for children with surgically correctable orthopedic disabilities but has grown over the last twenty years to include neurosurgical and plastics procedures as well. They have sites in Arusha and Moshi, and now Karatu, partnering with FAME as the facility in which to provide these surgeries.
Pete’s talk was, of course, great, not only for its content, but also for his wonderful humor which is undoubtedly enhanced by his Aussie accent. Though the need for Amanda’s expertise given the new emergency department opened late last year was clear, Pete has provided invaluable assistance in all things pediatric and then some. Having him here to help teach, along with Elissa, has provided a solid team of educators as the two of them really understand the nuances of providing care in resource limited settings, an area that Pete has worked in much of his career and Elissa, having been essentially raised with FAME in her genes. It is always essential to realize, though, that any volunteer here at FAME, whether short term, long term or intermediate, are transient, and that the true strength of FAME and its mission, resides in the Tanzanian staff who are here, day in and day out, to provide the best of care to the residents of Northern Tanzania.
After the talk, I drove Jill to the Black Rhino International Academy, where she has been volunteering during her time here (https://blackrhinoacademy.org/) as she did last year when she visited. Jill’s background as an early education specialist and kindergarten teacher for many years has made her an incredible resource for the school which started with the early grades, or levels, as they are referred to in the British system, but has continued to add years as their children have grown. The Black Rhino is an amazing facility that is the creation of Caroline Epe, a longtime member of FAME’s administration, and Nickson Mariki, a FAME Tanzanian Board member and much, much more for the town of Karatu. Nickson, who I have known since first coming to Karatu when he was managing the Happy Day pub, now also owns and operates numerous Lilac enterprises throughout Karatu that include the Lilac Café here at FAME which, in addition to providing food for all the inpatients here, serves as a place for everyone to get snacks when needed, and also as a home base for our medical student, Megan, to have a cappuccino or a latte in the morning which doing here data entry.
The drive to the Black Rhino, which is really just a stone’s throw from FAME, can vary from mundane to exciting depending on the route you’d like to take. The shortest way to get there is through the fields behind FAME where everyone walks, but the trail is overgrown and very narrow, and there are some major ditches just waiting to knock your vehicle out of alignment. I did that once with Jill a week or so ago and learned my lesson. The intermediate route, which is less exciting, but still carries a modicum of the unknown, is a drive that takes you up behind the High View Lodge. Though the road is heavily rutted, it’s easily passable and much shorter, unless, of course, there is some other vehicle that is stuck, making the route impassable. That has happened to me twice now, one of which required that I reverse up nearly three-quarters of a very steep and muddy path. Thankfully, the Land Rovers are virtually unstoppable in low range, even in reverse, and it took me faithfully up the hill without a whimper.
Much to everyone’s dismay, our internet has been incredibly problematic over the last several days. Apparently, Vodacom (the carrier we use for our router) has had an outage over this last weekend due to undersea cables having been disrupted with major impact on West and Center Africa and some impact here in Tanzania. This is one of the other corollaries of the TIA principle – nearly all internet here is by cell tower, not fiberoptic cables or satellite as those are incredibly expensive – and Mr. Musk has not seen fit to provide StarLink to the country as of yet. When the system is down, it can be incredibly isolating and unsettling as you lose your connection with home and the outside world. Posting a blog becomes impossible given the need to upload photos, in addition to my blog, and spending hours constantly fighting with the internet isn’t very much fun, let alone productive.
Leah had an interesting patient today who was an older gentleman who had been having focal seizures for about eight years that had never been evaluated by us before. He was from the Conservation Area and, though he had spoken Swahili previously, his son felt that he had lost much of this ability as well as some trouble with his ability to speak his native language, Maa (or KiMaa). There was also come complaints of mild right sided weakness that, though on his examination, the only focal findings were an upgoing toe on the right and some difficulty following directions, but it was unclear if that was mainly an issue with the translation (English to Swahili and then Swahili to Maa) or with language. Puzzlingly, though, there was no history of an event that had occurred, such as a stroke, that would have explained his seizures or his examination.
The history was so difficult, we couldn’t tell if there was progression of any of the features or not, which would have raised concern for a mass lesion that was growing, but regardless, there are lots of things here that can cause focal seizures that include brain abscesses, subdural hematoma, stroke, neurocysticercosis (though unlikely in a Maasai as they don’t raise pigs), toxoplasmosis (if he were HIV positive), or lymphoma (again if he were HIV positive, though unlikely for eight years). In the end, we recommended that he have a CT scan to sort things out, but they were unable to do it today as they would need money from home, so it was determined that he would return for the study. Meanwhile, he was placed on an antiseizure medication, which was the easy part of the treatment plan, and we would get his scan done when he returned in several days.
Having patients return to complete their evaluation is always a mixed bag as there are certainly times where they don’t come back, though that is the patient’s prerogative, and, as long as you’ve been completely clear as to the reason for the return, i.e. they are fully informed, then that is patient autonomy. Though we would always love to know what the issue is as soon as possible, it doesn’t always change your immediate management, and can therefore wait until the patient is ready, or, at times, we will manage just the same without the additional information.
One of our last patients to be seen for the day, and a more complex patient as is usually the case, was a young woman coming in with several days of painful eye movements and vision changes that to any neurologist raises the immediate concern for optic neuritis. Her examination was entirely normal other than the findings on her eye exam, that still made us worried about the possibility of optic neuritis. Though optic neuritis can occur in isolation, it is very often the presenting clinical feature of multiple sclerosis, and, in the US, there is little question that a patient presenting with these symptoms would get an MRI of her entire neuroaxis (brain, C-spine, and T-spine) to see if there are any other lesions to make the diagnosis of MS.
We recommended that she have at least an MRI of her brain, partially due to the question of a field cut on her exam, but also as a screen for MS as I’ve mentioned, but, for that, she would need to travel to Arusha to NSK and it would be twice as expensive as an MRI. She wasn’t sure if she would be able to afford getting the study done, so said that she would speak with her husband and come back tomorrow to let us know what her decision was. As I’ve mentioned earlier, though MS is felt to be much less common on the equator for a number of reasons, the incidence isn’t zero and is probably much higher than has been suspected in the past due to lack of testing and lack of neurologists.
We finished our day and all headed home to relax for a few minutes before heading out to town for supplies as well as to pick up everyone’s orders from Teddy as she had sent notice that everything was complete. With Turtle back, it would mean that everyone had a seat since Myrtle’s rear seats left a bit to be desired. We drove down to the change bureau as the residents needed shillings, and then to the liquor store as they also needed wine and other spirits. Once completely stocked up, we made the short drive to Teddy’s shop where was once again waiting for us with her huge smile and a plate full of candy. Allen was awake and it was great to see him again, though initially, he was a bit afraid of me. He eventually warmed up to me and it was so nice to spend some time there. I’m usually sitting out in front of her shop with my computer, but I didn’t bring it this time so was able to enjoy the surroundings a bit more. In addition to the residents picking up their things, for once I ordered some things for me – a runner for my new dining room table along with some matching cloth napkins. I can’t wait to get them home and to try them.
It was back home for dinner, after which I worked in our room while Jill read, and the residents all watched “Devil Wears Prada.” We would be going out for dinner tomorrow night to the Manor Lodge.