Both Kelley and Laurita had agreed to do two more lectures for the medical staff. The first was to finish the talk on evaluating an unresponsive patient that had been started on Tuesday, but they had run out of time. Dr. Msuya also wanted them to do the talk on headache that they had originally planned for last Tuesday, but had been preempted by the unresponsive patient talk which has been in response to the patient last week who had not survived his code. Since the nurses were using the conference room for their regular morning education lecture, we decided to use the education room in the admin building that doesn’t have the big screen TV like the conference room, but does have a small LCD projector for PowerPoint presentations that can be shown on the whiteboard that works quite well. Laurita finished the lecture in about 30 minutes which meant that we were on schedule for morning report.
Laurita finishing her talk on evaluating the comatose patient
We hadn’t planned on seeing any patients today, but as we’ve come to expect, there is almost no way that we can be here and not have patients to see as it seems that patients show up looking for us no matter what. We were working in the volunteer office, me composing my blogs and Kelley and Laurita working on data entry, when Sokoine came looking for me to tell that there were a few patients to be seen. As usual, it is often those who most need to be seen that are the ones who straggle in at the end of our visit here. It would be unthinkable for us not to see them given the difficulty to find any specialty care here and the fact that we won’t be back until March of next year.
Laurita getting the history on our young boy with weakness
I watched them wheel the first patient in for Laurita and it was a young boy in a wheelchair. I decided to follow him in since I had some suspicion about his diagnosis and wanted to be there since it is not something seen by our residents often and certainly not as a new diagnosis as I didn’t recognize him as having seen us before. He was an 8-year-old Maasai boy who had been brought in by his uncle who he was living with as his mother could no longer care for him. His main complaint was that he was having pain in his legs and was unable to walk any longer. His symptoms had been present for several, but he hadn’t walked in four months. Weakness was only his secondary complaint, but I knew from being here so long that this was a bit misleading.
Our young patient with Duchenne’s muscular dystrophy
One of the tough parts about taking a history here is that patients often create complaints to explain their deficits which requires a bit of practice to tease out the real problem. A young boy who can no longer walk doesn’t necessarily complain of weakness, but rather will explain that it “hurts” for him to walk, meaning merely that he can’t do it. When Laurita began to ask questions about his pain, I subtly told her not to worry about it and to ask more questions about why he couldn’t walk. What came out was that he actually had weakness in the legs and arms that had been getting progressively worse over the last several years to the point that he couldn’t walk. His complaint of leg pain was what we call a “red herring” and wasn’t his primary problem. When still walking earlier in the year, he had been seen at FAME and diagnosed with a polyarthralgia for which he was given ibuprofen. His history was further bolstered when the uncle said that he had an older brother with the same problem. His examination was quite classic with proximal greater than distal weakness in his upper and lower extremities, pseudohypertropy of his calves and a very classic Gower sign when he tried to get up from sitting on the floor. Laurita originally wanted to spare him from having to do this, but I felt it was important enough for her to see this finding in person as that is the real way we remember things.
We had a discussion with the uncle, initially through Selina and then through Sokoine, who speaks Maa since he’s Maasai, as we wanted to make certain that the uncle fully understood the prognosis for his nephew. It is often very hard to tell situations as the Maasai like many tribes here are very stoic and often don’t volunteer their emotions quite the same as we do in the west. We did institute steroid therapy as that is one thing that has been shown to help maintain ambulation, but it is not in any way disease altering and certainly does not extend life expectancy. Since the boy had stopped walking in the recent past, I thought it was worth a shot to see if perhaps he could regain some function, though it would only be on a limited basis. He will need to watched closely on the steroids to make sure he doesn’t have any side effects and there is a small increase in his risk of infection which is always a concern here in rural Tanzania. We also asked that he come back once Dr. Reed is here next month as he will need to have a cardiac evaluation with an echocardiogram as these children have cardiac complications as part of their muscle disease. As unfortunate as this diagnosis is, it is always rewarding to be able to diagnose a condition with certainty so that a family will hopefully not have to go on searching which is quite often the case here as families typically don’t get answers and then travel from facility to facility looking for them. At least we can give them the answers they seek and spare them from the unknown, or at least that is our intention and we do the best we can at it.
Kelley evaluating the patient with a spinal cord infarct
Kelley’s first patient of the day was a gentleman in his 40s who had been seen by Dr. Frank in the past and was from Arusha. Frank had shown me a CT scan on Wednesday and had asked what I thought about the story so I told him if there was any way possible for the patient to come on our last day it would certainly be helpful to examine him which was the interesting of the case. The patient had been previously well until earlier this year when he was walking with his wife and suddenly collapsed to the ground without any loss of consciousness, but was quadriplegic. I had told Frank that from the sounds of it he had a vascular event in the spinal cord and if his arms were involved that it localized to the cervical spine, but the CT scan had been done of the thoracic cord only. He did indeed have an asymmetric quadraparesis that had improved somewhat from the onset of the event and a sensory exam that demonstrated a level at the low cervical region. He also had crossed motor and sensory findings confirming the location was in the spinal cord. There was very little else that could have done this and even though we suspected a low cervical cord process, we found very little reason to obtain a CT scan as it would not change his management at this time. We did offer him some medications for neuropathic pain and for his spasticity which might help make him more comfortable overall. He may continue to regain some function, but unfortunately he will never be independent or be able to lead a normal life and at a very young age.
Kelley evaluating a young seizure patient
Laurita and Kelley checking out the little premie
Mama and baby
So we had actually planned not to see patients today, but ended up working until around 2pm or so and still needed to hand out blankets to mothers with newborns. A patient of mine at home, Mildred Staten, and a group of her friends crochet (I’m hope I’m correct on the process) blankets for newborn babies that they distribute in hospitals back home in Philadelphia and a year or so ago she had asked whether I thought they would like them at FAME. We brought them last October and it was a huge hit on the maternity ward, so we had brought them again and hadn’t yet had a chance to hand them out as we had been so busy seeing patients every day. We went to Ward 2, the maternity ward, with Sokoine as our interpreter and photographer, and each had a small stack of baby blankets for the mothers to choose from. It is so enjoyable to see the mother’s faces light up as we offer them a blanket and each mother eyes the blankets to find the one she likes the best for her baby. There are several premises in the ward right now, one of whom is in an incubator and ways a mere 0.76 Kg, or 1.67 lbs. The baby is just so very tiny, but has been holding their own since we’ve been here and seems to be thriving despite everything. It is a miracle to see these babies fight so hard to stay alive and it is this resilience that exists among all those we meet here. It is clearly something born in each and every Tanzanian and part of why we are so privileged to work and live with them. The blankets from Mildred and her group of women were very much appreciated by every mother we presented them to and I am sure by each little newborn, big or small.
A young mother choosing her baby’s blanket
Another little premie, though a bit larger
It has been a tradition it seems for Frank and Susan to have a get together for our team the last night or two of our departure. This trip was no exception and we were all meeting this evening at their lovely home that sits just above the volunteer houses as if to keep an eye on everyone though from an appropriate distance. Alex, our new volunteer coordinator as of two months ago with Pauline’s departure, had taken it upon himself to personally prepare the menu for tonight. The party of typically catered with pizza or similar, but tonight we were having a feast of Mexican food with homemade tortillas, corn salad, homemade salsa fresca, lettuce and rice. Most of the vegetables were from FAME’s garden. Oh, and I forgot to mention that Alex was unable to find good group beef in Karatu so went instead with some unreal sliced filet that was out of this world. Frank had forgotten that he had a talk to give on animal borne pathogens in Africa to some visiting doctors that he does annually so was running a bit late. We all gathered at their house just after sunset – there were about ten of us without Frank – and just sat and relaxed before dinner with popcorn, beers, soft drinks and wine while Alex and Laurita worked in the kitchen. Kelley was told there were too many cooks in the kitchen, but she and I were fairly certain that it was excuse for Laurita to sample the cuisine as it was well after her dinner time. She swears she didn’t, but neither of us really believed her. As we sat on the veranda with their three dogs – Molly, Nickie, and Oscar (their new mostly Rhodesian ridgeback puppy) – and Charlie, FAME’s mascot (Popie, who is now very aged, no longer partakes in parties) roaming around getting lots of love from everyone. Elvis, their fairly rare Kenyan or Ethiopian cat (I can’t recall which and what the name of the breed is), also showed his face from time to time.
Mama and baby
A Maasai grandmother checking out their blanket
Frank arrived finally after his talk just in time for dinner and couldn’t believe that were than just scraps left, so he was very excited to join in the food line as it really was amazing. Somehow, though, Frank never left the food line as I didn’t see him on the veranda again and noticed that he stayed in the kitchen munching until it was after his usual bedtime of 8pm. I’ve been at these enough to know that Frank usually just slips off to his bedroom without saying goodnight and those that aren’t familiar with this ritual will look around and wonder where he went. Given his work schedule, he needn’t make any excuses and I know that he’d agree with that.
Posting a note from Mildred in the maternity ward
The party continued for a while longer as we just relaxed and told lots of great stories of FAME, past and present, of how it’s changed over the years, and where it’s going. Stories of travel and aspirations which is always amazing when you consider the diversity of the group sitting around the table. A Swiss pediatrician who has worked in Africa for a number of years, a cardiology physician assistant who has been here for long stints in the past and worked with me before, a Swiss emergency room nurse here for her first time, a retired professor of laboratory sciences who built the lab here and spends nines of the year here, two neurology residents working in Africa for the first time and trying to decide where their careers will take them, our volunteer coordinator who just finished with several years working at a primate rescue in Ecuador, and then me and Susan. Susan has committed her life to FAME along with Frank and they have successfully built a health care facility out of nothing that now rivals any institution in Northern Tanzania and employs well over 100 Tanzanians. They have truly changed the lives of countless patients as well as the residents of Karatu whose families benefit from their employment by FAME. And then me.
Global health had never been on my radar screen until very late in my career, but it was the education aspect that had always been the most important part of my work and that led me to FAME on that fateful trip in 2009. Still, it was not a given that I would return and there was something that drove me to do so and it is so hard to explain. We all look for purpose in our lives and providing the care for my patients and teaching residents had obviously been totally fulfilling for me through many years. There must have been some unknown void, though, that lead me here, to return again and again, and to bring those individuals who I knew would equally appreciate the significance of what we are achieving here. And in doing so, I hoped to impart in them the same enthusiasm I have not only in practicing neurology and teaching, but also to see the World as a smaller place without borders where we all speak the same language of love and deep down, we all have the very same values. The residents that have accompanied me here have all found this very same message on their own, and even more so, have managed to teach me more than I could have ever hoped for. This is my legacy.