Friday, March 16, 2018 – An interesting stroke syndrome and a slippery walk…

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Our patient arriving by vehicle

We were on the home stretch for our weeklong neurology clinic at FAME and, to date, it had been a rather slower than usual clinic. It’s always hard to predict what the volume of this clinic will be beforehand as it can be affected by so many variables. I know that Alex and Angel had gotten the word out to the Karatu community at large as well as to all of the mobile clinic sites, but even with the excellent outreach team we have working in advance of our visit, the other factors involved are well out of our control, such as the weather, harvest time and, at other times, politics. In October 2015, we were unable to do our mobile clinic due to the national elections and many patients were fearful to travel to clinic out of concern for their safety. Most recently, though, we are having more rains than we’ve had in the past during this month which is the main reason for the lighter than normal clinic volume. The orange-colored clay of Karatu turns to pure muck during the rains and makes travel often very difficult, if not impossible. During the heavy rains yesterday, I was very surprised to see the patients that came, but was very happy they did.

…and being loaded onto a stretcher

At the start of clinic today, the stroke patient we had seen previously had come back to have her INR (a measure of how thin her blood was from the warfarin she was taking) checked and was booked into our clinic again even though we hadn’t planned to necessarily see her back. It was good that we did, though, as she had been put on a medication to treat her stiffness and it was working rather well so that we could adjust the dose upwards and she would get yet greater benefit. This is often such a problem here as many medications are meant to be titrated to effect or they have to be started slowly so a patient can adjust to any potential side effects. Trying to do this in the absence of a neurologist here isn’t ideal and is something that I am hopeful to address in the near future by possibly training practitioners who can care for our patients in our absence and following through with our recommendations. So often, we see patients back after six months and nothing had been done in the interim. Hopefully we can help to change this going forward.

Johannes, Susan and Baraka evaluating a patient

Johannes’ favorite patient of the day was a gentleman who came in after a stroke, but it was a very unique syndrome that Dr. Price, Penn’s residency director, loves to focus on because of it’s importance when trying to localize lesions. The gentleman had severe right facial weakness of sudden onset that was quite atypical for a Bell’s palsy, or facial nerve palsy, that is so commonly seen. The other unique feature of his examination was that he had abnormal eye movements, and, specifically, a sixth nerve palsy on the same side. This is caused by a brainstem stroke that hits the sixth nerve nucleus and the facial nerve fibers and they travel around the sixth nucleus. The gentleman had actually had an MRI done and there was a lesion in just the right location, but it hadn’t been read as such, and, so for us, it was a great case. It had actually occurred only a month or so ago, so we were able to institute so secondary prevention therapy that might help him in the long run. He was a very nice man and it was a pleasure to not only have helped to treat him, but also to be able to explain to him definitely what had happened and what his prognosis was. Of course, even though he spoke good English, it was still challenging and took much longer even with that. Thankfully, we weren’t tremendously pressed for time today.

Baraka with his two language students

Mindy and Susanna continued on their quest to not only master the neurologic examination in Swahili, but also in Iraqw, as they are neck and neck with the Maasai in regard to the patients we see here. We really don’t have a full-time Maasai translator to teach them Maa, so they will have to be satisfied with those two languages for now. Given that, though, they have become extremely proficient in Swahili and Iraqw and they continue to amaze me. Susan and Johannes have also picked more than is usual for the residents on this trip, but the other two have excelled.

Mindy teaching Dr. Julius how to do occipital nerve blocks

The rest of the day was filled with our normal smattering of developmental delay, headache, epilepsy, and back pain, and Mindy was even able to do occipital nerve blocks on a patient with occipital neuralgia and show Dr. Julius how they are done. This is a technique that we use often at home to manage our headache patients who have a significant posterior component to their headache or more classic occipital neuralgia and it is often very helpful in relieving their symptoms. We have had the supplies here to do these and over the last four years have found them equally helpful here as they are at home.

Mindy seeing a patient with Dr. Julius’ help and Susan scribing

Susanna evaluating a patient

With the light patient volume, we were able to get home at a decent time and though I was still behind in my blogs, I offered to show Susanna and Mindy where we normally do our walks from the house here. There is a gate at the bottom of the slope behind our house that lets you out onto the road traveling around FAME and takes you further from town and finally out to the fields behind our compound. It was quite muddy and there was no way we were possibly going to take the normal circuit, but there is a part of it that would be possible even with the mud. So we began walking and eventually climbed the hill to where Caroline, the development coordinator and someone who’s been here as long as I have, lives. From her property, you can also see the new private school she has built, and so we continued our walk in the direction of the school. It was a gorgeous evening to be out walking despite the muddy roads, or at least I thought so until I took a misstep and slipped, almost catching myself, but alas, didn’t, coating my hands and pants in the sticky goo that is the Karatu clay. Thankfully, no injuries other than my pride, and we continued the walk back home with one of us a bit more distressed in the furniture or fabric sense of the word.

Johannes conferring with one of his patients one last time before they leave

Mindy examining a patient with Dr. Julius’ help while Susan scribes

Everyone was happy to remain home this night, though Susanna and I made a quick run into town to the exchange bureau where we get TShillings for dollars, only to find our normal exchange closed and were directed to another down the block that I hadn’t know about before. I had had to replace the battery on the Land Cruiser and needed to pay the mechanic in the morning when he brought the car back to us.

Johannes evaluating a patient with Baraka’s help

 

Thursday, March 15, 2018 – Dinner with Daniel Tewa and his family…

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It had begun to rain in the early morning hours well before 5am as basically everyone had heard it in his or her slumber. It remained heavy and relentless well through the morning hours so the walk to clinic was a wet and muddy one that required full rain gear and mud boots and, despite this, kept only half of the water and dirt out it seems. When it rains like this, it is difficult for most patients to make it to clinic as the roads become very treacherous and walking, the main mode of transportation for patients we see here isn’t feasible. Thursday mornings are now reserved for the Tanzanian doctors to give a lecture on a specific topic and this morning, Dr. Badyana was speaking about the surgical treatment of appendicitis. We had all been out late and some of us later than others, but Susanna, Susan and Mindy were determined to make his lecture on time, which they did, and Johannes and I were much slower to move so straggled in a bit later. Having to make a lecture at 7:30am requires a very dedicated and concerted effort, neither of which Johannes nor I had that morning.

Susan and Baraka taking a history

I knew that we had at least one patient who a friend had referred from Loliondo, a district that is accessible primarily by the Lake Natron road and is north of here near the Kenyan border. It is a very remote area with few resources and I have visited there once before a few years ago. It is very dusty and dry, but absolutely gorgeous in that very rugged sense and totally worth visiting if you were ever to have a chance. The Lake Natron road travels through some valleys and by the foot of Ol Doinyo Lengai, or the Mountain of God, and is a sacred mountain to the Maasai. It also erupted in the not too distant past, so still has Lava flows that drape over the top of the mountain and radiate downward from the cone traveling to the base of the mountain. There are places on the road where you are driving over crazy rock formations, often with very little shoulder to them so there is little room for error. It is not exactly rock hopping, but it comes very close and is certainly not for the faint hearted.

Susanna examining a patient with Emmauel

We had some very interesting and diverse patients this day, most of which were quite determined considering the long rains of the morning and the difficulty in getting here. Susanna and Johannes evaluated a young woman who was having episodes of loss of consciousness that had previously been diagnosed as seizures, but clearly were not. The episodes also raised concern for PNEE, or paroxysmal non-epileptic events, that used to be referred to as pseudoseizures and a type of conversion disorder and usually not malingering as was often thought to be the case in the past. These events are obviously not treated with anti-epileptic drugs, but there is one caveat; a significant percentage of patients with PNEE also have underlying epilepsy that complicates the issue of diagnosis. At home, we’re often admitting these patients to the epilepsy monitoring unit, or EMU, which is an inpatient unit where the patients remain on continuous EEG monitoring with the hope of capturing an event. It goes without saying that there is nothing similar to an EMU here or probably anywhere in East Africa. Having had the EEG machine here back in 2015 was such an amazing resource, but, alas, it is no longer operational and has yet to be replaced. In the end, though, this young woman’s events were also concerning for syncope, or loss of consciousness that is related to perfusion of the brain due to a drop in blood flow, so we decided to get both an EKG and echocardiogram on her to rule out this possibility, both of which were normal.

Everyone getting into the action

A young child that Susan say this morning had a very interesting combination of developmental delay and epilepsy that fit the phenotype of GEFS+, or generalized epilepsy with febrile seizures plus, that is a genetic disorder and requires specific medications to be avoided, that are unfortunately nearly every medication we have available here and are the medications that are the least expensive. Perhaps the most common medication we are using in the US currently, levetiracetam, is the most expensive anti-epileptic here and is nearly impossible to use due to that fact. The reason it is used some commonly at home is because of its versatility in the seizure types it can treat along with the low likelihood for interactions and side effects. The least expensive medications here are the older AEDs that are being used less and less in the US. Phenobarbital, which is still the first line AED listed by the WHO, has many, many side effects, especially for developing children and is really something we try to get most patients off of when we see them. It is also known to make patients with generalized epilepsy worse rather than better so that is another significant issue. In the short time that we were doing EEGs here, we found a great number of patients with primary generalized epilepsy in whom you would not want to start phenobarbital.

Susanna checking a patient’s postural stability

There was a family who came from a great distance to be seen today by Frank in the general clinic and he had asked us to evaluate an older woman among them who he noticed a tremor in. The woman clearly had a significant resting tremor that was not disabling and Susanna also found some subtle abnormalities of tone suggestive of possible Parkinson’s disease. The findings were subtle, though, and we didn’t feel that she required carbidopa/levodopa as this medication provides only symptomatic relief and primarily related to rigidity or increased tone, which she really didn’t have. The woman also had an abnormal gait that turned out to be from a monoparesis, which was the result of childhood poliomyelitis affecting only leg. None of the residents had actually ever seen a patient with a dramatic monoparesis and wasting of a limb as the result of polio.

Johannes and Baraka evaluating a patient

One of the families seen today had a young boy with severe autism and developmental delay, but also with episodes that bore some concern for epileptic events. They really hadn’t found any good support systems for their child as they do not live close to other relatives and schools for this type of problem were far too costly and would be prohibitive. Later, we were given the name and number of a women living in Moshi, near Mt. Kilimanjaro, and who could possibly help them significantly or at least know someplace that they could go to for that type of rehab that might be closer to home for them.

Mindy and Susanna evaluating a patient with Baraka’s help

With the long rains of the morning, the patient volume was only moderate and we were able to finish up clinic a bit early, which was good as we had plans to visit Daniel Tewa and his family tonight for dinner. I’ve written about Daniel so many times on this blog that I don’t want to bore those of you who have read about him before, but our visits with him are so significant that I can’t help but expound on it for those who are new to the blog. I fist met Daniel Tewa when I was here in 2009 with my children and we had asked to do a bit of volunteering as a part of our safari. We spent that time in Karatu (which is when I was introduced to FAME and Dr. Frank, and, as they say, the rest is history) working at the Ayalabe Primary School helping to repaint the school buildings. Daniel, being an elder in the village, had been asked by Thomson Safari to be a liaison for us, so we spent three days with him working on the school. There was an immediate friendship created and when I came back the following year to work at FAME, I had contacted Daniel to reconnect and it was almost as if I had never been gone.

Daniel helping Susanna model an Iraqw wedding skirt

He invited me for dinner that trip, and I have gone to his home to have dinner with his family ever since, and now bring my residents to meet them. It is a wonderful friendship that we have and Daniel has been so gracious to open his home to us as this is an amazing experience for the residents who accompany me making this not only a medical mission, but also a cultural experience so we get to know more about the people we’re seeing every day to who we are providing treatment. That is such a very important part of global health as you much have some understanding of the people here and their lives to be able to provide them care. Though the basic principles of medicine may be the same wherever you are, your ability to apply them and to provide patients with the information they require to make those important necessary decisions relies heavily on that understanding.

Dinner at Isabella’s

We sat out in front of Daniel’s house as I had nine years ago when we first met and drank the wonderful African coffee they serve here, in which the coffee is boiled with fresh whole milk. It is mostly milk, but it is rich and tasty for even those not used to drinking coffee. We also had avocados from their garden that we sliced in half and ate with a spoon as they do here. All of this while discussing everything from politics, both US and Tanzanian, to the intricacies of the Iraqw culture and their history. It was dark, but we managed to spend time in Daniel’s authentic Iraqw house that he built on his property back in the 1990s as a reminder of the type of home in which he grew up. It is underground, which was for protection against the Maasai whom they were always battling with, and provided shelter to an entire family along with all of their animals so they would not be stolen in the night. The Maasai and the Iraqw signed a treaty finally in 1986 ending their conflicts that were quite real prior to that.

Susan and Baraka evaluating a young patient

When it was time for dinner, we all walked down the road to his daughter, Isabella’s home where we would eat as the group has become larger than can be served in the small living room of Daniel’s Bantu home. It was a wonderful dinner that was served to us by Isabella and two of Daniel’s neighbors who had come to meet us. Daniel has always reminded us of what a true honor it is for his family to serve us in this way, and I have always reminded him of how grateful we are to his family for providing us this friendship. Everyone there, whether American or Tanzanian, was truly moved by the experience and I knew there would be a lasting impression on everyone. We drove home through Karatu, which is always a challenge at night without streetlights and with every headlamp misaligned and seemingly pointing right into your eyes, as the faint shapes of people, and sometimes animals, are dodging in front of you to cross the street. Up the bumpy and muddy road to FAME and we are home, everyone happy to have had the wonderful experience of dinner with Daniel Tewa and his family.

 

Wednesday, March 14, 2018 – A day of wellness and so much more…

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I had designated today as a wellness day for the residents. Now you might just ask yourself, “isn’t everyday in Tanzania a wellness day?” and you would be entirely correct in your assumption, lending yourself to the expected follow up question that would be, “why would anyone need a wellness day in Tanzania?” In fact, these were exactly my responses to Ray Price when he asked me to schedule these days for the residents here on rotation, but it actually turns out that the GME (graduate medical education) office had asked all residency programs to schedule these days into the resident’s schedules and who am I to buck the establishment when it means accompanying the residents on their half day off.

Johannes and Mindy outside clinic

But first, we had plans for clinic in the morning and would finish by lunchtime so that we could make it to Gibb’s Farm for their fabulous buffet lunch. Now mind you, I had absolutely nothing to do with the fact that the residents chose to spend their wellness day at Gibb’s Farm having a wonderful lunch, but anyone who knows me has already realized that if I did have any say in the matter, this would have been it. OK, back to clinic….

Angel, our fearless leader

Mindy’s favorite patient of the morning was gentleman who had eight different complaints and was not very happy when she tried to narrow them down to those that were the most important and were neurologic, which of course is what we are supposed to be doing here. We certainly encounter this issue in the US when we’re seeing patients and it can be very similar here at times. Our job is to try to get the patient to focus on the issues that are most bothersome to them or the ones that we feel are the most likely to do them harm. Fortunately, Mindy’s patient had no life-threatening issues, but unfortunately, he did have quite a few that were bothering him. We ended up treating him for neuropathy as he was a diabetic with poorly controlled blood sugar along with headaches, so amitriptyline, our most commonly prescribed medication here, would work well for him as it would treat several of his problems quite well.

Johannes and Mindy chatting with Dr. Julius

Drs. Ivan and Asanga chatting with Jacob

We were able to wrap up the morning clinic with little time to spare to begin our trek up to Gibb’s, when I discovered that there was a patient who had traveled from Arusha and who would need to see us for an assessment. Since it was getting just a bit late and I didn’t want the resident to miss out, I told them to go ahead with one of the FAME drivers and I would meet them there. It ended up though that the patient had nothing acute neurologically and had actually suffered trauma several years ago so there was very little I had to offer. I gave my recommendations to Frank, who was also planning to see the patient and I arrived back at the house just as the FAME driver was pulling up. It was a pretty comical scene, but I asked him to wait to make sure our car started, but he understand me and drove off just as I was trying to start the Land Cruiser, which, of course, didn’t start. We were eventually able to get someone over to jump the car and as we were finally getting under way, very much later than I had planned, it began to rain on us.

Susan on the ward discussing her patient with Drs. Badyana and Mbogo

I typically take a very nice short cut to get to Gibb’s and, since we were running late, decided to do so today as well. As soon as I got up on top of the slight ridge it rides upon, the road suddenly became mush so that it was a pure slip and slide trying to stay on the road and required that I drive mostly in second gear and, at times, first gear just to keep from having to hit the brakes which would mean a definite off road excursion in the pure muck. It probably took us twice as long to get to Gibb’s as I had to take some different routes to keep from getting stuck and drive so much slower than normal. The drive seemed like an eternity and when we finally reached Gibb’s I took a very deep breath and let out a huge sigh of relief.

Johannes and Dr. Julius examining a patient

Once there, the blue skies opened up and it was once again gorgeous, so much so that we were able to eat out on the veranda looking out over the valley and once of my favorite places on earth. The lunch buffet at Gibb’s is a wonderful feast of mostly local dishes and all grown on their farm there. There were cheeses, breads, a ginger carrot soup, quiches, many salads, samosas, grilled chicken and so much more. And then there was desert. We all just relaxed in the shade of the umbrella over our table and enjoyed the good food, good company and unbelievable scenery.

Susan and Susanna evaluating a patient with Baraka’s help

We had plenty of time after lunch for another adventure, so it was decided that I would drive everyone down to a friend’s gallery in the town of Manyara where everyone could buy gifts for family and friends. There are so many amazing crafts here from the local tribes with beautiful jewelry and carvings that are probably the nicest. We were in no rush so everyone had plenty of time to spend shopping to his or her heart’s desire, although the shop was closing up around 5pm, so there was a bit of a deadline, I guess.

Johannes evaluating a patient with Dr. Julius’ help

Once finished with the shopping (of which there was plenty), we headed home in time for dinner as we had plans later that night to meet all the other volunteers in town at Happy Day, the local pub where everyone meets on here on Wednesday nights. Everyone enjoyed the night out as we later moved on to the Golden Sparrow, which is the new club in town that was opened by the owners of Carnivore. Carnivore, a place of lots past memories, was a fine joint that served only grilled chicken, chips (French fries) and fried plantains. The Golden Sparrow has all the same food, but also a separate dance club, which was our destination that evening. It was quite crowded for a Wednesday night, but everyone seemed to be watching a soccer match and had less concern with dancing, though we well made up for any lack of enthusiasm by the locals. We all made it home safely that night and with a 7:30am lecture on management of acute appendicitis, it wasn’t going to be a long night of sleep.

Enjoy the sights and sounds of our precious weavers here at FAME

 

Tuesday, March 13, 2018 – And a few more neurology patients….

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Tuesday mornings at 7:30am have traditionally been reserved for volunteers at FAME to give a lecture on a topic that would be useful for the doctors here to help with their practice. We have obviously repeated many of the topics, as there are only so many general neurology topics for us to cover for the practitioners here. Remember, most doctors here have never worked with a neurologist, often even in medical school. In all of Northern Tanzania, there is one neurologist currently at Kilimanjaro Christian Medical Center in Moshi, and up until several years ago, the neurologist there was not fulltime. Never having worked with a neurologist, or ever having seen a neurologist perform a neurological examination would be a huge disadvantage in caring for these patients as our specialty is so driven by the history and physical examination rather than testing. I so enjoy teaching the neurological examination to medical students and residents and can still remember all of my mentors as I was training. I cannot imagine not having received that wonderful and empowering knowledge of the physical examination from these superlative teachers and then having tried to go on and do what I do today. Having had to learn it form a textbook or even from a non-neurologist would not have been the same and I’m not sure I would have chosen neurology as a career had it not been for that long line of mentors that began in medical school and continue even into the present.

Absolutely an Academy Award best actor nomination worthy performance

Susanna and Susan chose to speak about epilepsy this morning, and though we have given lectures on this topic several times before, it is always presented in a slightly different manner and always contains new information for the doctors here. They can never learn enough about this topic that is so prevalent here in Sub-Saharan Africa, likely due to the frequency of childhood illnesses and trauma that are also so prevalent and increase the risk of developing epilepsy over ones lifetime. That being said, when Daniel Becker brought her EEG machine here in 2015, we found many patients with primary generalized epilepsy that is more commonly genetic in nature rather than symptomatic. Their lecture this morning was organized around taking a seizure history and what information is important to ask when evaluating a seizure patient. To do this, Susanna gave an academy award worthy performance of a patient having a focal seizure progressing into a secondarily generalized seizure and then the two of them launched into a discussion of what the doctors had observed and what questions they would ask of a family member who had possibly observed the event. It was really a very helpful discussion and, though it usually hard to get the full participation of the often doctors here (it is also quite early as these talks commence at 7:30am), I thought they did a wonderful job of garnering their attention so there were many great observations and questions. Or perhaps it was just the shock of having seen Susanna have a full-blown seizure right in front of them that early in the morning. Regardless, the lecture was well received which is usually determined by how long Dr. Msuya allows the questions to go on after the lecture which has usually gone over the allotted time cutting into our morning discussions of the ward patients (sit down rounds).

Susan and Susanna giving their epilepsy lecture

Patients this morning this morning were quite varied and one of Susan’s first was a young three-year-old child with developmental delay, macrocephaly and seizures. The child clearly had frontal bossing (meaning their forehead was quite pronounced and bulging forward that is seen in children with hydrocephalus and increased intracranial pressure) and, perhaps even more significantly, had what appeared to be bilateral sixth nerve palsies, meaning that his eyes both inward leaning due to the loss of the lateral rectus muscles supplied by the sixth nerve. The significance of the sixth nerve palsy is that it is the nerve that has the longest intracranial path and is frequently stretched or injured in patients with increased intracranial pressure. The baby looked very good, but we definitely had concerns that they might still have active hydrocephalus that might benefit from a shunt. This is the one neurosurgical procedure that is easily available here and so, if present, we would definitely want to know about it as we could intervene.

Susanna and Susan giving their epilepsy lecture

Radiology (and other procedures) are not covered in our “all-inclusive” price for the neurology evaluation (5000 TSh or less than $2.50) which includes blood tests and medications for a month, so having a discussion about obtaining a CT scan that costs just shy of $100 USD can be very difficult. FAME does not turn away patients who cannot pay, but they do charge for services as to open an entirely free clinic here would be unsustainable as you would soon be taking care of the entire population of Northern Tanzania, and perhaps further away, as everyone would flock from every corner of the country to come. There is a very delicate balancing act here between maintaining some status of fee for service, although that is not even sustainable without significant outside support, and making sure we provide treatment for those in need. Thankfully, we have Angel here, who can help sort things out in these situations. We presented the options to the family and our recommendation that the child undergo a CT scan of the head to look for hydrocephalus. There were very open to the idea and understood our concerns, so we proceeded to get the baby ready for the CT scan, which is not a small undertaking in a toddler. They are no quieter than an infant and are less manageable as they are much stronger. We sedated the child after an IV was finally place and put them on the CT table, but as they went to inject the contrast after the plain scan was done, the IV was found to not be working and we were only able to complete the non-con study.

Johannes and Baraka evaluating a patient

The child didn’t have overwhelming hydrocephalus, but the scan was also not normal. There was asymmetry of the ventricles that were larger than they should be and this seemed to be more consistent with arrested hydrocephalus, though, the sixth nerve palsies still worried us. Susan sent images from the CT scan to the US for one of the neurosurgeons at CHOP to review and would hopefully get back to us with some guidance shortly.

Caught in the act… as Baraka and Emmanuel look on

Sometime after lunch, Frank came over to tell me about a patient who had come with her family from ten hours away and who had been seen yesterday with complaints of left arm pain. He had injected her, but her pain continued and she had come back to take care of some other medical issues. He brought her over and asked in typical Frank fashion if he could consult with me on a “neuro-orthopedic” case. After I heard the story, I took my normal course of action, which is to deny any and all accountability, for his patient or the “non-neurological” problem she would very likely be suffering from. As she walked over in my direction, I immediately noticed that she had a very distinct and unquestionable drooping of her left eyelid. For a neurologist, this is a very, very bad combination of symptoms, perhaps second only to the patient coming in complaining of twitching in all of their muscles and who happens to be a “really nice person,” as they will usually have amyotrophic lateral sclerosis (ALS) or Lou Gehrig’s Disease, a terminal condition from which patients usually die within several years. This patient, though, had a combination of findings that makes us immediately concerned for a tumor, usually lung cancer, in the apex of the lung that erodes into the brachial plexus, or network of nerves supplying the arm, and the sympathetic nerve supply going to the eye and causing a Horner’s syndrome.

Johannes and Baraka evaluating a patient

As soon as I walked in the room with Susanna and Mindy and said they were going to see patient with arm pain and a drooping eyelid, they both immediately knew what to be concerned about. The woman had had the symptoms for about a year or slightly less and both the arm pain and the drooping eyelid had begun at approximately the same time, making us even more concerned than we had been before. She had no weakness or other physical findings other than some swelling of the left arm and she had apparently had some surgery in the left axilla about five or so years ago, which was a bit of a confounding piece of information, but didn’t lessen our overall concern very much. The way to diagnosis this problem is, of course, a CT scan of the chest, which will reveal a mass in the apex of the left lung and typically bony erosion into the chest wall as well. When we discussed our concern with the patient and her family member also present, they had very little hesitation whatsoever in what was necessary to do, so we prepared to do the CT scan in very short order. I looked at the scan myself and couldn’t really see much of anything, but I will be the first to admit that CT scans of the chest are absolutely not my forte and not even close, for that matter. We would have to wait for the radiologist back home and who is reading FAME’s CT scans to look at the films and get back to us and this would be some time due to the time difference.

Mindy and Emmanuel examining a patient

We eventually received word that the there was no mass in the left lung apex, but he did see some questionable inflammation in the left axilla and this, unfortunately, could merely have been residual from her prior surgery. I’m really not certain we were able to get an answer on this one, which was very frustrating to all of us, and especially Dr. Frank, who keep asking me “well, what’s next?” I didn’t really have a very good answer for him and, as usual, he was less than thrilled with this fact and, somewhat jokingly, probably wonders what good we are at times. All joking aside, though, we are often limited in our ability to explain everything, and that includes being in the US, where we can do a multi million-dollar workup and still not have the answer. Here, it is much more common as we do not do things just to find an answer, but rather to benefit the patient, meaning, that if doing a test won’t change your management or the management necessary is not available in this country or not accessible to the patient, then we elect not to waste valuable resources for either ourselves or the patient.

Susan and Baraka evaluating a patient

We finished a bit earlier today and elected to head home to get work down in our wonderful home with it’s veranda looking over the beautiful hillsides in the far distance. Everything is green and plush right now with the changing over to the wet season soon to come in April and May. Tomorrow is a resident wellness day meaning we will work just in the morning and have plans for lunch at Gibb’s farm mid afternoon. That is something that can definitely be dreamed about as I’m sure each of us did that night, heightened to some degree by the effect of the Mallarone each of us is taking that gives you very lucid dreams.

 

 

Monday, March 12, 2018 – Our FAME Neurology Clinic week begins….

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Susanna and Dr. Julius with a patient and family

We had had such a wonderful safari the day before that I think everyone was still reliving thoughts of elephants and Cape buffalo, some of whom were chasing us. Most had gone to bed early, exhausted from the busy day of travel, and now we were ready for the week ahead that would bring us the bulk of the neurology patients for us to see as these were the days announced to the community and the far lying reaches of Karatu district. Alex had worked on most of the announcements and had traveled as far as Lostete, the village that sits far along the rift in the Mbulumbulu region at the very end of the road. We have plans to visit there in October, but now the road is not suitable so the patients from that village will travel to Upper Kitete, the village where we have held neurology clinic now for the last six years. Mobile clinic will begin next week, though, and for now, we are focused on the patients that have traveled here to FAME. Last week, we had seen patients who traveled from as far as Dar es Salaam to see us, a twelve-hour bus ride. I’m sure we’ll see many more that have come from similar distances or who have made more difficult journeys.

Susan and Baraka evaluating a patient

Mindy and a follow up patient

It had rained some overnight, so the volume of patients at the clinic at the start of the morning were much less than you typically see on a Monday morning, but from past experience, I knew that we’d see more patients come as the day went on. I had been introduced to someone in Arusha last week who had already called me this morning that he was on his way with two of his family members for us to see so I anticipated their arrival mid morning. There were no new consults in the ward from over the weekend, but we did have the little baby with meningitis to tend to as well as the young man who had come with severe back and neck pain who lumbar puncture had been benign, but had been on antibiotics for several days which clouded the picture. The baby was still quite sleepy which Susan felt could easily be from the phenobarbital so she had planned to lower the dose and, if he began to have more seizures, we would load him with either levetiracetam or phenytoin, both orally, of course, as there are no IV preparations here. The older boy with back pain was markedly better, but given that we could not rule out partially treated meningitis, it was decided to leave him on his antibiotics and continue to follow him.

Mindy and Emmanuel examining a patient

One of Susanna’s early patients was a gentleman who had severe hoarseness and difficulty swallowing along with weight loss and we could find no neurological deficits otherwise, so were mostly concerned that he could have an occult malignancy causing his problem. We sent him back to Frank to discuss our findings and that we were recommending a scope of his throat and vocal cords, which was quickly set up to occur the very same morning. Things can happen a bit faster here as there is no bureaucracy to manage in any way and it is merely a matter of setting up the procedure room, finding a time that Dr. Gabriel is available and then it happens. By lunchtime, we had been told that his scope was normal, though we still had significant concerns for a malignancy so his evaluation would continue.

Susan examining one her pediatric cases

Johannes and Dr. Julius evaluating a patient

The friend from Arusha had soon arrived with his two family members and we began to evaluate them. One had had a stroke recently affecting his right side, but had recovered quite well albeit with continued deficits of mild weakness and dysarthria rather than any language dysfunction, making a subcortical infarct the likely scenario here. He was hypertensive, which was the likely mechanism of his stroke and we counseled him on getting his blood pressure well controlled along with his lipids. We sent him home with atorvastatin and aspirin, blood pressure and lipid parameters and made sure that he knew that he needed to find a primary doctor in Arusha to manage these things to prevent another stroke.

Johannes, Susanna and Julius evaluating a patient

The other family member was someone who could be diagnosed just looking at him for a second, something known as an “augenblick diagnosis,” or “in the blink of an eye.” This is an expression that I learned many years ago while training and I try to pass on these historic pearls to the residents as often as possible as they are often very meaningful. To lose the history of our profession would be a tragic loss for it is this knowledge of how we got to where we are that helps us know why we are here. I have universally used the “augenblick diagnosis” expression in reference to patients with movement disorders, as the initial observation of the patient sitting in the waiting room can often be one of the most informative parts of your examination. Seeing a Parkinson’s disease patient sitting there with his masked facies and resting tremor tells you the diagnosis and your history and examination are often merely confirmatory. Seeing a progressive supranuclear palsy patient sitting in a chair with their neck extension as opposed to neck flexion of the Parkinson’s patient is also a differentiating observation that helps you even before the patient is brought to the exam room. These are pearls that the late Fred, or Fritz, Dreifuss, a giant in epilepsy, had instilled in me some thirty years ago at UVa while training and which I will never forget.

Susan and Baraka evaluating a patient

MIndy evaluating a patient

Mindy examining a patient with Emmanuel looking on

Sure enough, Susanna, being the resident that she is, had already noticed him sitting in our waiting area so was typed off to what she was looking for long before she even asked a question or laid a hand on him for the examination. This is something that we are trained to do as neurologists for it is often these initial observations as the patient is sitting in the waiting area or walking to the examination room that are the most telling. Unfortunately, back at home, we have often lost this opportunity to observe the patients as they are brought back to the examination room by a medical assistant. It is not a perfect world and not all progress is to the benefit of our patient care at times, which is sad. The gentleman had been gone to see the doctor in Arusha with complaints of feeling tired and they had done an MRI, telling him subsequently that he had had a stroke. Given that his blood pressure was over 200 systolic when we saw him, it would not be at all surprising that he had significant small vessel disease on his scan, but his presentation was certainly not that of a stroke. We told him that he definitely needed to get his blood pressure controlled, but we also prescribed him carbidopa/levodopa, or Sinemet, which is the single most effective medication for the symptoms of Parkinson’s disease, and that this would very likely make him feel much better. They were both quite thankful for our care and we sent them back on their way to Arusha, hopefully much for the better and certainly much more informed.

Johannes teaching Dr. Julius the finer points of the neurological examination

One of the more interesting patients that we have seen this trip was evaluated by Johannes, and was very apropos, and clearly had some trouble with his ambulation, swaying in all directions as he walked into our makeshift examination room in the hallway between the night doctor’s office and the emergency room. He was 35-years-old and his problems had begun in his twenties, but the most significant part of his history was that many of his family members had had the same problem and had died from it. This didn’t come out early in the history, though, as the notion that a disease can run in families is not something that comes to one’s mind here and the concept of genetics is a foreign topic that is quite difficult to explain. Indeed, he had multiple family members on his father’s side that had developed the disorder and had lived into their 60s by the sounds of it, many dying of traumatic injuries suffered by their unsteadiness.

Mindy examining a patients

His speech was severely affected and was quite cerebellar in nature and that explained his difficulty with his ambulation. In fact, he was mostly all cerebellar on his examination with little else that could be brought out. Given his family history and the findings on examination, we were fairly certain that he had one of the spinocerebellar ataxias, a group of genetic disorders that are affectionately know as the “SCAs” to us are a seemingly ever expanding group with new discoveries being made on a regular basis. The apropos nature of Johannes’ caring for this patient is the fact that his father is someone who has spent his career studying these disorders (his mother, by the by, is also someone who has studied similar genetic disorders) and someone who has actually described at least one of them in connection with a large family in Cuba that was discovered. Finding a family here with one of these disorders was an exciting event, though unfortunately, we do not have access to any genetic testing or other methods of being more specific about which one he might have, not that we would have any treatment either here or in the US for it even if we could gather that information. It was still very exciting for Johannes to be able to email his father and then talk to him later on the phone about this patient. We don’t have the mechanism to get a specimen home currently, so we are unable to do any of the necessary genetic testing at the moment. I am hopeful that in the future we will eventually have the opportunity to more thoroughly evaluate these patients with some form of collaboration as providing genetic testing here will never likely be possible due the cost and lack of treatment, but would possibly further our knowledge of these disorders and be worth the investment in resources from that standpoint.

Mindy examining a patient with Emmanuel looking on

Mindy also saw a Parkinson’s disease patient today who had seen us previously and had been put on carbidopa/levodopa with excellent results, but had unfortunately run out of his medication for the last month and was unable to get here to refill it. He had very profound resting tremors and was quite bradykinetic, but both he and his family were adamant that the medication had benefited him significantly. This is such a common problem here regarding medications and the fact that we can really only give one or two months at a time for several reasons. First, we’re subsidizing the cost of the medications as our visits are 5000 TSh (Tanzanian shillings which currently are 2200 TSh per dollar so they are paying less than $2.50) and that covers the cost of seeing the doctor, any labs and their medications, typically for a month. On occasion, more than a month is given out, but not on a regular basis and we do this very judiciously. CT scans or x-rays are not covered under the 5000 TSh cost of the visit. When patients return they have to buy the medications so it is important to be certain that they can afford them for making an awesome diagnosis and starting medications only to have them stopped in month due to cost serves not purpose for anyone. If a patient is unable to afford the medications, we will involve our social worker, Angel, to speak with them and to decide what they might be able to afford and work something out with them.

Mindy demonstrating tandem gait to a patient

Because of the slow start due to the overnight rains with patients coming later in the morning, our patient flow was shifted a bit into the afternoon. We ended up working a bit later into the evening than normal so didn’t finish up until probably 5:30pm this evening. By the way, most of the patients we see use Swahili time, which is a real thing and is based on 6am being considered zero time. So 7am is actually 1:00 and so on. 5:30pm would be 11:30 in the evening, or jioni. Signage here on stores and on our clinic indicate the time in both the western format as well as Swahili time. Thus we’re open from 2:00 until 10:30 Swahili time on normal days.

Susanna examining a patient

We walked back to the Raynes House after a full day of clinic looking forward to our dinners that would be there for us. It was a relaxing evening with catching up on some charts from Saturday and with today and my trying to catch up with this blog, at times an all-consuming vocation. We all slept very well this night.

Johannes examining a patient with Dr. Julius