Throughout the early morning hours, a very fierce thunderstorm raged with constant lightning and thunder that felt as though it was centered right on top of us. The sound of heavy rain on the tin roof and the bright flashes followed by the loud booms kept us intermittently awake, though it was also somehow settling to be sleeping comfortably in our little home that we have here. I have always slept with my screened windows open, as do most others in the house, as the nights are usually brisk, but not cold, and the overhang of the roof is more than enough to prevent most any downpour from coming in the house. I have even been here in the monsoon season and have yet to see anything close to reaching the inside of these structures.

The morning was slow as we didn’t have to be to clinic until 8:30 am as it was not only Saturday, but also still Easter weekend and we suspected a low patient volume given that. I decided to eat my granola outside as the rain had stopped and the views with the low clouds were wonderful. Looking out over the overgrown landscape, I suddenly spotted a reedbuck, which is a small to medium sized antelope that are usually alone or in very small groups in the marshes (hence their name) or brush around small bodies of water. It’s color is a reddish brown, close to auburn, and they are very shy. How this animal got into the FAME compound wasn’t clear, though I suppose it might have squeezed through the fence somewhere. It sat there perhaps 25 yards away from me and wasn’t aware that I was watching. I was able to wave to the others inside to come out and see it and everyone made it out in time before it disappeared into the brush. It was very cool to see such a beautiful creature just outside our back door and was a real treat.

We had a slow but steady stream of patients come in which was fine as we had planned to go to the African Galleria for dinner tonight and hoped to leave early enough to do a little shopping there as well. As is usually the case, though, a more complex patient seems to come in at the end of the day requiring our attention and throwing us off schedule. The child that Marissa had seen initially several weeks ago in focal status and has been seen back on several occasions with adjustments in their antiseizure medication returned once again even though they were not supposed to come back for at least another week to allow our plan to work.

When we had originally seen the child, we had recommended that they have a CT scan given the focality of the seizures and the fact that they had started only a month ago in this 7-month-old child, but unfortunately, the family was not in the position to obtain one. Given the difficulty we were having in controlling the child’s seizures, though, we felt that it was very important to have an imaging study as it would very likely affect the recommendations that we were making. It was a holiday Saturday and late in the day, so Angel gave us permission to obtain the scan and the particulars would be worked out later with the family as far as payment was concerned. Without a clear history telling us what was going on, we would also need to contrast the scan and that would require a creatinine, further delaying the scan.

When the scan was eventually done, we all went to radiology to look at it and when the scan was brought up on the monitor, it was quite clear, even from across the room, why the child was continuing to seize despite our best efforts at treating them. There were no normal areas in either hemisphere of the brain with both cortical and subcortical destruction that, given the lack of history, was most suggestive of some devastating encephalitis, probably viral. The brainstem and cerebellum were perfectly intact.

Maya and Michael went back to speak with the family regarding the incredibly poor prognosis and the fact that it would be unlikely that we would be able to completely control their seizures going forward. The rest of us went back to the house to get ready to head down to the African Galleria. When the two returned, Maya frustratingly told us that after further discussion with the family, the child had not been developing normally and, furthermore, their birth history was entirely consistent with hypoxic ischemic encephalopathy, or HIE. How this had eluded everyone who had seen this patient previously was puzzling, though as I have pointed out repeatedly, getting an accurate history here can be like pulling teeth at times.

With this history, it was clear that there was very little we could do for this child from a functional standpoint, though we could certainly continue to adjust their antiseizure medications with the hope of lessening their seizures, but that was certainly not a given. Had we had the history of HIE from the very beginning, it may have changed our recommendation for the CT scan, though possibly not. It was just another example of the difficulties there are in when seeing patients in other cultures and trying to obtain the necessary information to provide the appropriate care.

Thankfully, Maya and Michael returned in time for us to depart for the Galleria with the possibility of shopping and we were off. Ke had been at the house since 3 pm as I had told him that was the departure time, though things usually don’t go perfectly as planned, especially here. We arrived around 4:30 pm with the shop closing at 5 as it was slow season. Everyone seemed to have a sufficient amount of time to shop, and we sat down for dinner shortly after 5 pm. Dinner was delicious, as expected, and there was no trouble for Holly to find enough vegan-safe things to eat there. Though one of the things they are known for is their barbecue, they had a wide variety of vegetarian options that were cooked without animal products. Nish ordered a vegetarian curry with rice and vegetarian samosas specifically for Holly, both of which were scrumptious per her report. We couldn’t finish everything and brought some of the meat home with us.

We had needed supplies for our game drive to the Crater tomorrow and, luckily, all the shops were open when we got back to town on our way home. We hoped out of the vehicle, and all went on our separate missions with Jill and me going to the vegetable market where we found not only things for the crater, but also for dinner tomorrow night. We had gotten a big pot of rice from the kitchen on Friday that in the fridge and we were planning to make fried rice, both vegan and regular.