It had been an incredibly long day yesterday and took some time to unwind from the trip – I’m sure it would be easy to imagine just how filthy everything was after three days on the trail, especially with the addition of the mud and rain. Amazingly, the camp had cleaned our car pretty thoroughly every day, though I’m not quite sure anyone would have noticed given how covered in mud Turtle was each and every day after getting to camp. The same was obviously true for our return to FAME – Turtle was completely and unequivocally covered with mud from the roof to its mudflaps along with much of our belongings. Three days of clothes immediately went into the laundry and each of us headed for the shower. For dinner, we had planned to make a batch of fried rice with the vegetables we had ordered and stale rice we had put in the refrigerator on Friday. Everyone wanted to pitch in, so I worked on unpacking all the camera equipment and storing it for our next adventure in several weeks.
Since it was a Monday, we had a good number of patients for the day, many with epilepsy having varying degrees of control, several psychiatric patients, a few headaches and one back pain – eighteen patients in all and the day flowed perfectly for us as we had plans to go out for dinner in the evening. In addition, we did have a vascular patient who presented to the hospital and saw them as an in-patient consult. He was a 64-year-old gentleman with untreated hypertension who had a witnessed fall and brief loss of consciousness after which he was noted to have a right-sided weakness. When he arrived at the district hospital two days prior, his blood pressure was greatly elevated and required multiple medications to control. His CT scan here demonstrated a left lenticulostriate hemorrhage with bilateral ventricular extension, left greater than right. Other than blood pressure control, there was little to offer the patient initially, though with the amount of blood in his ventricles, he would be at high risk to develop hydrocephalus, so would have to be watched for several days.
Hypertension is one of the chronic illnesses (in addition to diabetes mellitus) that are treated in FAME’s chronic illness clinic, though, unfortunately, far too few patients attend, and the complications of chronic disease remain a major concern here for the long-term management and patient-centered care that FAME strives to provide for the community. Hypertension is particularly problematic given the significant complications that are directly related such as stroke, heart disease, and kidney disease and the fact that patient’s pressures can typically be well-controlled with medications and life-style modifications, greatly reducing the risk of complications.
Chronic illnesses have always been a difficult concept here as patients do not routinely see a primary care physician, nor do they commonly chronic medications – the vast majority of medical care occurs on an incident basis and medications are usually taken for a specified course only and for a particular problem, discontinuing the medication as soon as the problem has been treated successfully. Infections are treated with an antibiotic for a set period of time, children are dewormed every year, malaria is treated with a specific course of antimalarial medication.
This has been a significant issue for us when treating epilepsy as patients require treatment for an extended period of time at a minimum, and often for life. This is part of the education process for both patients and clinicians here that we have been working on for many years. Patients may come to see us with a history of epilepsy and tell us that they went to a dispensary or hospital and were given an anti-seizure medication. When we ask how it worked, we’re often told that the patient did well for a month but then started having seizures again when the medication ran out. The fact that the patient was to have remained on the medication for a longer period of time or indefinitely was never explained to them and the concept was foreign. By having a continuity neurology clinic every six months and emphasizing that the patients must remain on their medication, over time, we have been far more successful in managing these patients in the long-term.
Similarly, patients with hypertension must remain on their medications and continue to follow in clinic to ensure their pressures are well controlled so their complication rate will continue to be reduced. In addition to the high incidence of hypertension in Sub-Saharan Africa, so is the incidence of stroke and hypertensive hemorrhage increased here over other populations. Our gentleman with the lenticulostriate hemorrhage, an area of the brain that is particularly affected by chronic hypertension and risk of bleeding, was a set up for this complication, unfortunately.
Though clinic was busy, we were able to finish at a decent time which was good as we had plans for sundowners and dinner at the Manor at Ngorongoro. Previously known as The Manor Lodge, it sits on top of the ridge behind FAME, and above the Shangri La coffee plantation, one of the larger such plantations in the Karatu area. Driving to the Manor, you drive through much of the coffee plantation with its rows and rows of mature plants, until you finally reach a spot where you can drive into the conservation area along an easement for several hundred meters and come to the gates of the Manor. While in the short stretch of road in the conservation area, if you’re lucky, you can run across Cape buffalo or elephants – on our way home tonight, we ran across what were either two huge bush pigs or giant forest hogs, which were the size of a very large domestic pig , and were definitely not something I’d be interested in having a tussle with. One had just crossed the road in front of us and the other came up to the roadside about to cross, then ran back into the underbrush. With the darkness, I couldn’t quite make out which of these creatures they were. This is clearly not a road one would want to walk, even in an emergency.
The Manor at Ngorongoro was built nearly twenty years ago and is designed in the manner of the wine regions of South Africa – Cape Dutch Architecture with Stellenbosch seeming to resemble it the closest. There is a large manor house with nine cottages, each with two suites, surrounding it in a semicircular arrangement. The grounds are impeccably landscaped and the views are wonderful. Most importantly for us, the veranda is wonderful for drinks as the sun sets in full view to the west, and their service for dinner is as good as anywhere. Their menu was delightful and consisted of many smaller tasting courses that were perfect. We never fail to have a wonderful time there and I would highly recommend their dining to anyone.