As morning report on Monday, Wednesday, and Friday, here has become a much more involved affair with the entire clinical staff of FAME showing up and there not being enough room for everyone in the large conference room, we have been sending only one or two residents for each session to avoid all of us standing outside and being unable to hear. Tanzanians are often very soft spoken when speaking English, which is what is spoken at morning report, and it’s hard enough to hear them if you’re inside the room, let alone standing outside with your ear to the open window. The nurses are now presenting the cases which has served its purpose well, which is to involve them more in the treatment plans, while the doctors still contribute during the discussion if there are more technical issues to discuss.
Our role at morning report, in addition to gaining some insight into how treatment decisions are made by the staff on patients in general, is to also listen for anything that sounds halfway neurologic, meaning that we could potentially contribute to a case. If that occurs, we will either have one of the residents round with the team and see the patient at that time, or they will come back to clinic and then return to the ward later with one of our translators to provide a full consult on the patient.
As we learned last fall, though, the fact that a patient doesn’t sound neurologic in morning report doesn’t mean that they are not. LJ had been rounding with the team when a patient was presented and there was just something that made her worry that the patient may have had a stroke as the reason for his symptoms, which was not the direction the presentation was going in. She briefly examined the patient during rounds but came back later and was more convinced of her hunch and obtained a CT scan confirming her suspicions. The changed the entire plan for the patient and greatly affected his treatment.
This issue, though, is not necessarily the fault of the clinician. As I’ve mentioned before, information in East Africa is on a need-to-know basis and this is equally the case when patients come in to be treated. They, or their families, will not always share with the doctor all of their symptoms, or they may share something that they think may be related or is not. It is absolutely necessary to obtain a complete review of systems and to perform a complete examination on a patient as you will very often find out of the way clues to whatever disease process is affecting the patient. This can often be very frustrating as no matter how hard one tries, it is not at all uncommon for very significant features to slip by and have major implications in the care of a patient.
I recall one patient that Danielle Becker and I were seeing a number of years ago who appeared to have a simple mononeuropathy with a specific differential, but when I asked Dr. Ken what his thoughts were, he told us there was something that just didn’t add up when he was speaking with the patient. They also had a rash on their chest, and, when further questioning the patient regarding their social history, it turned out that he was married, but was living with one of his children. When Ken asked him why that was, it eventually came out that the patient’s wife had kicked him out of the house. Not that it would have made the top three on our differential, but when we checked the patient’s RPR for syphilis, it was positive, and it turned out that the patient both neurologic and dermatologic complications of syphilis that needed to be further treated. Things are not always what they seem to be and there are cultural nuances that may take years, if ever, to appreciate here.
The optic neuritis suspect patient, who we had seen yesterday and had recommended that she have an MRI of the brain, returned today reporting that she was completely unable to do so, which was not surprising given the cost of such a study (about $200) which is nearly the annual income for many families. Our concern, once again, was whether the patient could potentially have MS, which would greatly affect our recommendations for treatment going forward. We were also unable to get any further vision testing as Sehewa, our awesome nurse anesthetist who also doubles as our eye doctor, was out of town until Friday and the patient was unable to travel to KCMC which would be the closest ophthalmologist with the expertise in picking up any abnormalities.
So, the dilemma before us was how suspicious we were with the clinical features of the patient and whether we felt the patient should be treated for optic neuritis, which, at home, would be a course of IV steroids. There is also good evidence that oral steroids are as effective as the intravenous ones, but it was the dose of steroids that was the problem as she would require 1000 mg of either methylprednisolone intravenously, or its equivalent, or 1000 mg of prednisolone orally. The only problem that we had was that our prednisolone was in 5 mg tablets meaning that we would have to give the patient 200 (!) tablets, and the only IV steroid we had was dexamethasone that came in 8 mg vials, and we would need a total of 187.5 mg, or nearly 24 vials, which would be very expensive.
We presented the dilemma to Eric, one of FAME’s two pharmacists and who has been most involved with the day-to-day operations now that our long time pharmacist, Egbert, has taken on the role of a project manager. After pondering the issue for a few minutes, Eric remembered that I had brought several boxes of Depo-Medrol injectable, that we use for nerve blocks for our headache patients, with me last fall that were good through May of this year.
In addition to there being data for using oral prednisone tablets (1000 mg daily x three days), there is also data for using the intravenous formulation of methylprednisolone mixed in a smoothie or fruit juice and taken orally. This was popularized by Elliot Frohman, an MS specialist who was at the University of Texas for many years and is now at Stanford. In any event, as our Depo-Medrol was a formulation of methylprednisolone that was meant to be injected into tissue, and we had plenty of it, we decided to mix enough of this into bottles of a multivitamin formulation that the patient would drink daily for three days. Each tiny bottle contained only 40 mg of the Depo-Medrol, meaning that we would have to aspirate the contents of a great number of bottles to make enough to mix in with the multivitamin. That being said, it was a plan that would not only work to get the necessary medication into the patient, but we had excess of this medication that would be expiring in several months and was the perfect excuse to utilize it. The cost would all be covered by the patients visit to neurology.
Dr. Anne and Evan sat at a table methodically aspirating enough bottles to mix in with the multivitamin and, once finished, we had three small bottles of liquid continuing the appropriate amount of medication that she would take daily for three days. We would have her come back in several weeks to reassess her, but for now we had a plan that would work.
We had plans tonight to have dinner at the Manor Lodge, and lovely resort that is high up on top of a ridge that is just shy of the NCA, but does border it and, in fact, requires that you drive through a short easement to get to the main gate. It always seems, though, that when we have these plans with the hope of leaving at a decent time, we have one of the more complex patients of the day show up at the very end. The patient that came today, with tons of records both from within Tanzania, as well as several visits to a neurologic facility in India, was a young man with a very complex seizure history and was accompanied by his stepmother.
At home, the residents affectionately refer to these patients as “OSH-bombs,” with the anacronym “OSH” referring to “outside hospital.” These are patients who have been admitted to an outside hospital for days, or even weeks, and are then accepted for transfer to one of the University of Pennsylvania hospitals, often arriving with stacks of records (hopefully) concerning their recent care that must then be reviewed, summarized, and ultimately presented to the attending physician. These patients will often arrive after hours as that is when beds become available in the hospital from earlier discharges. These patients can very often be much more ill than was conveyed in the initial transfer communication.
This patient, who came from several hours away, had stacks of records and films that needed to be reviewed and then discussed in order to come up with our recommendation for treatment. Thankfully, he had not previously tried too many medications, so we were able to recommend a reasonable trial of an anti-seizure medication that was new for him along with a plan B if that did not help. He too, would follow up with FAME in the future to see how he was doing on the new medication regimen that was suggested to them.
We were finally able to head home and get ourselves ready for a nice evening at a very lovely lodge. I hadn’t been up to the Manor Lodge in over a year, to be honest, but had heard through the grapevine that their food was still top notch and, knowing that the grounds of this lodge are some of the most beautiful around, it was the perfect opportunity for all of us to spend an evening together relaxing. Marissa had offered to take everyone to dinner here as it would be much easier than trying to get everyone’s schedule together at home.
The drive up to the Manor Lodge, as I mentioned, is a journey that travels through a small part of the NCA, but, in addition, travels up through the Shangri-La coffee plantation, one of the largest in the area. Coffee is surely king here and is second only to the tourist industry with the game parks. The rich volcanic soil, the altitude, and the amount of rainfall here make the Ngorongoro Highlands the perfect environment for growing the rich Arabica coffee bean that is most popular for this region. Until recently, Tanzanian coffee was unavailable in the United States, though I have seen it slowly enter the specialty market at home over the last several years.
The Manor Lodge is owned by the South African company, Elewana, and is designed after the wine region of their home country. The manor house is a large and very formal building that is absolutely gorgeous inside, but in a completely different style and setting as that of Gibb’s Farm which is elegant and casual. This place is simply elegant. The dining area is very formal, and the settings have more silverware than I’ve seen anywhere in Africa, or even at home, for that matter. Thankfully, the dress is not formal as that would never go over here, at least in this century. The bar is pretty much from a scene in Out of Africa and would not have shocked me had I seen Ernest Hemmingway resting in one of the lounge chairs having just returned from a rhino hunt. How they ever transported the baby grand piano up that hill is beyond me.
Simply put, the Manor Lodge is one of the loveliest properties in all of Northern Tanzania, and I suspect, all of East Africa. I have never stayed there, which isn’t saying much as I have never stayed anywhere here other than the Ngorongoro Crater Lodge for two nights, but the rooms, which I’ve toured, are equally elegant and comfortable. The dinner we had was also amazing and was far beyond all of our expectations. It was a five-course meal, and each course was in itself a work of art. Needless to say, everyone was incredibly thrilled with the meal, and we were all thankful that Marissa had suggested having dinner there as a special treat.