Friday, March 13, 2020 – A knock at the door….

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Life here at FAME is indeed very comfortable for us in the Raynes House as it has been in other houses I’ve stayed. I will have to say that it hasn’t always been that way as it probably took several years before the hot water situation was ever sorted out which mean cold showers during that time. Now, hot water is supplied by Kuni boilers, which are essentially hot water heaters that must be fired once or twice a day to provide us with the hot water necessary for everyone, or almost everyone to shower. That means that the boilers must be filled with wood or some other combustible material in order to be lit and that can certainly be a choir. The boilers are each shared by two houses, and how much hot water you have in the morning depends on how many people are sharing the house and wanting to take a hot shower at any particular time. Everyone taking a shower at the same time here means the hot water will run out very quickly and chances are there will very likely be many unhappy people that morning.

Marin, Amisha, Frances and Angela

Breakfast for us is usually whatever we want it to be since it’s the only meal that we are responsible for ourselves. It will vary from something fancy, like scrambled eggs (ala Carrie), or less complicated like a bowl of corn flakes and banana (ala Dr. Mike). I can even be simpler, such as a granola bar which many of us will do if we’re running late in the morning. I can often be found sitting at my desk in the wee hours of the morning, typing on my blog, so my mornings are most often the cup of tea and a granola bar later at clinic. On rare occasions, someone will run to the Lilac to pick up coffee for several of us. Though I have offered to Carrie that she can work on entering the patient data in the morning at the Lilac and have breakfast, she has opted to do them in the afternoon/evening and spend the days with us observing in clinic.

Africanus, Carrie and Alice evaluating their patient

So, this morning, as I was sitting at my desk pecking away on my blog, I was a bit surprised when, at 7 am, my thoughts were disrupted by hearing that there was someone at our door insisting that two doctors were needed at the hospital to help manage a patient. There are certainly neurological emergencies here at FAME that require our immediate assistance, though it is very rare for us to be summoned in this manner, and, there are no stroke alerts here as there are at home where we have TPA and mechanical thrombectomy to offer, neither of which are available here. Meanwhile, Molly felt that it was a nice throwback to medicine as it once was, receiving a knock on the door to politely request our presence and not some beeper or alarm. There was something about it that made her think of house calls and the days of all small town doctor, I believe. Whether or not that was the case, though, both Molly and Carrie volunteered to come up to the hospital with me, where we found Dr. Julius, who had been on overnight, in our emergency room (which also doubles for the endoscopy suite) with an acutely psychotic and very combative patient who was wresting with one of his family members.

Amisha and Anne evaluating their patient

We were told that our patient, a 31-year-old gentleman, had a similar episode a year ago and had been seen at an outside hospital and given Valium for a week and, after that, he had apparently returned to normal (for him). Unfortunately, though, he had not been placed on any long term medications nor sought psychiatric evaluation anywhere. From our perspective, we were most concerned that he would hurt himself or someone else, and we needed to get some control of the situation, which meant giving him a strong intramuscular sedative, in which case he probably wouldn’t be awake for some time. We were unable to access the haloperidol that I had brought in the past as it was locked away, but we were able to located some chlorpromazine (Thorazine), a powerful antipsychotic, which we proceeded to give the patient along with some lorazepam (an anxiolytic) to get things working more quickly. He continued to fight with us for several minutes, but it was only a matter of time before he fell rather suddenly fast asleep with all of standing there and very happy that the wrestling match was over. During the height of his psychosis this morning, he was having very clear visual hallucinations, but it was impossible for us to gather any history from him so it was unclear if he was having any auditory hallucinations in addition. He was transferred to the medical ward and later in the morning, the team went to gather more history, but it was very difficult as his wife was a rather reluctant historian and, other than the episode from one year ago, was not willing to admit much more, meaning that we wouldn’t have much more to go on from a standpoint of making a diagnosis. Our suspicion was that we were dealing with schizophrenia and were just not getting the straight story from his wife, but either way, he would be put on a chronic antipsychotic for now (olanzapine), and would have to be re-evaluated in the future to determine how long he would remain on the medication.

Presenting to Dan

Having finished for the moment with our psychiatric patient, it was almost time for morning report so the three of decided to run down to the Lilac Café and order coffees to go. We received our French presses of wonderful Ngorongoro Highlands coffee just in time to head to report and hear about a patient in the maternity ward who was a few days over 36 weeks and had very significant pyelonephritis that had been causing her to be febrile. A very brisk debate ensued among all the FAME doctors, the nurse midwife in charge, and the volunteer ob/gyn regarding whether the child should be delivered early or not. I will not burden you with the details of the discussion since I had very little understanding of what was actually being said given that my last journey into this realm, other than my own children, was over 30 years ago and it was not something that I had planned to pursue at the time. I’m not certain as to what the final decision was on the matter, but either way, it didn’t involve us.

Carrie, Amisha, Marin, Dan and Angela discussing things

Our patient who had been admitted yesterday with the question of Paget’s vs. osteopetrosis was now on IV antibiotics and was going home as he had family in the area that could continue to provide him his IV medications at home over the next week before being placed on oral medications for a month or more. This seemed like a very good plan as he had plenty of support from family, a number of who were actually in the medical field so could manage his treatment in the future as well. We believe that we had mostly come up with a solution for his chronic osteomyelitis, but there had still been no resolution regarding his underlying condition that was causing the continued deformity of his skill along with his difficulty opening his mouth. Treatment for Paget’s would have been one of the bisphosphonates which they do not have here and treatment for osteopetrosis, a hereditary disorder would be stem cell transplant which is certainly something that is not available here.

We had decided to go out to Happy Days tonight since it was Angela’s last day with us and she would be leaving in the morning. We had forgotten to have everyone say goodbye to her at morning report meaning that we would have her show up tomorrow to do so before leaving FAME. I can’t recall whether I had explained Angela’s connection in the past or not, but she had first come as a global health scholar to Penn last summer where she spent a month taking some short epidemiology courses and also was able to spend time with me in clinic both at HUP and CHOP. She is a board certified pediatrician in Ghana who has a keen interest in the various development disorders in children and, as such, pediatric neurology. When I discovered this, I had her meet a number of the peds neuro residents as well as the adult neuro residents. In the end, she would very much like to do further training in pediatric neurology and is looking into the various options to pursue this in the future. She had heard lots about my work here in Tanzania during her time in Philadelphia and had asked at one point if it would be possible for her to come observe us here. She had some vacation time at the beginning of the month and the stars seemed to align, enabling her to travel her to spend the two weeks with us. I believe it was a fantastic experience for her to have spent the time with us and was equally valuable for us to have spent time with her.

The young Maasai boy with TB meningitis improving every day

Happy Days (or Happy Day which it was originally known as) is a pub that is frequented expats here in Karatu and which has been around since I first came in 2010. It also has cottages that pretty minimalist, but adequate, and over the years have housed a number of volunteers throughout Karatu as well as some FAME volunteers. Peter Schwab stayed at Happy Days in September 2018, and was very happy there. It came under new management about two years ago and received a significant makeover in regard to both its ambience and its food. Where there used to be large picnic benches on the covered porch, there are now low tables with sofas and chairs loaded with pillows that are incredibly comfortable for lounging and eating. On Wednesday nights, which is the traditional expat gathering night there, they now have wood fired pizzas while on other nights their menu has more traditional pub food that includes a wonderful mac and cheese along with lots of other dishes and even a few burgers. I’ve never sat inside, which has also now received a similar makeover, since it is so pleasant outside, even in a rainstorm as the roof is covered.

Carrie, Molly, Frances, Marin, Dan, Amisha, Angela, Alice and me

Since it was Angela’s last night in Karatu, we all decided to take her out to Happy Days for a celebration dinner. The one thing that hasn’t changed about Happy Days, is the time to receive you meal once it has been ordered. It will usually take over an hour to get your food once you have placed your order and that’s just the amount of time you have to wait. No questions, no apologies. Thankfully, the food is very good and, in most circumstances, well worth the wait. And besides, it is like paradise living here in East Africa, so having a few beers with your fellow expats on occasion is well worth the wait. And besides, living here in East Africa, which is essentially like living in paradise every day, isn’t a bad place to relax and have a few drinks together with your friends. The evening was rainy, but under the covered porch we were dry and the air was cool. It took nearly forever to get our food, but no one cared for we were all among friends and, as they say, life is good!

Relaxing with a wonderful kitty on my lap at Happy Days

Despite the fact that life has been normal here, though, much of our focus did remain on the ensuing Covid-19 pandemic throughout the world and the fact that life was not normal over much of the globe and would very likely soon be affecting us as well. Angela was flying through Nairobi tomorrow and Kenya had announced their first confirmed Covid-19 case today. She had a layover there of 16 hours before her flight to Ghana and had anticipated going to a hotel, but was not thinking otherwise about leaving the airport and somehow not being able to get back in. We also knew that it was only a matter of time before we would be affected also and this inevitability did loom very large over us.

Thursday, March 12, 2020 – A slow start to a busy day….

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It was another slow morning that was very likely the result of the rains overnight, but it once again made me worry about the volume that we were seeing. I did have some concern that the local population may be worried about seeing a bunch of mzungu doctors at FAME when they were certainly becoming more aware of what was going on in the rest of the world with the coronavirus. Africa has been relatively spared to date, but the tightening travel restrictions have been in the headlines of recent and it would not be unreasonable for them to worry about us having brought something other than enthusiasm along with us. The news of our country’s new travel restrictions, not accepting anyone from Europe other than the UK, was something of a shock to the rest of the world and certainly to the European countries it affected and probably on further heightened the extreme anxiety over the situation without actually having made anyone safer. The fact that the decision was also a surprise to many of those in the administration and had been made unilaterally by our president was anything but a shock to me. It is questionable to me just how US citizens will be able to get home from Europe once the airlines begin cancelling flights since the majority of the passengers booked will not be allowed to enter the final destination being the US. That remains a mystery to me.

Molly’s tremor talk in the education room of the admin building

Since it was Thursday, it was a day for our educational lecture. Dan and Marin were going to present, though Marin had to take an examination online for her PhD program and given that she was a bit preoccupied with that, Molly traded the day with them and was going to present on tremor. Again, they had asked that our presentations be more case based now, which was perfectly fine with everyone here as that gives a much better platform along with greater relevance when you think about these things in relation to a specific patient and trying to come up with a differential diagnosis, etc. The nurses were having their education meeting in the large conference room, so we were relegated to the smaller room in the education building which always happens to be locked up at 7:30 am while no one has the key to the front door. Luckily, someone had the side door key and upon entering the building with Molly a few minutes early so she could set up, a bat came swooping down the hallway directly for her, then thankfully made a hard about face and decided to hang onto an unlit light bulb on the ceiling for security. Bats are incredibly numerous here, which is a good thing, as they gobble mosquitos and other insects by the thousands to make our life better. On the other hand, they are not something that is good to come in contact with as are also known to be a reservoir for rabies. Thankfully, we don’t have to choose between malaria or dengue and rabies, but if we did, it would definitely be the former.

Registering our patient and getting vital signs

Molly’s lecture was well received and an excellent review of tremor that that doctors here could use going forward as we see a number of patients with movement disorders including both Parkinson’s disease and essential tremor. They will now have an excellent strategy for when they encounter these patients enabling them to differentiate their underlying movements and treat them with the appropriate medications as the treatments are very different, but both very effective. FAME had actually participated as the only non-neurologic center in a global project of the Movement Disorder Society for providing online consultations, and had submitted several, but in the end, the cases that were sent were those that we could deal with on our own and it became easier for them to send me videos of the cases with their questions. The online consultation service was an excellent option for a neurological center with complicated cases in which a neurologist has already evaluated the case and was in need of further assistance.

As we all made our way over to clinic, it was again apparent that there was no mob scene outside and it would be another slow morning. By late morning, though, things started to pick up and we ended up with numerous interesting cases. One of the cases was a young women in her thirties who was brought in by her cousin with symptoms of psychosis and was incredibly catatonic throughout her interview and examination. There was little question that she was floridly psychotic and with her catatonia, Alice wanted to give her a benzodiazepine challenge which in a catatonic patient will cause them to paradoxically awaken. Sure enough, she received 2 mg of lorazepam and, in a very short time, was back to her normal self and asking what had happened. She was sent home on a short lorazepam course along with olanzapine in the hope that it would best control her symptoms going forward and to come back in two weeks when we’ll still be here to see how she’s doing before we leave.

Young Maasai with the skull deformities and recurrent infections

Probably one of the more interesting patients we have seen here was a young Maasai who was otherwise normal developmentally and began to have abnormal growth of his skull about twelve years ago that has continued and several years ago, he began to develop either abscesses or boils that would drain regularly and appeared to be infected. The abnormal bony growth was so significant that it has affected the alignment of his eyes and he is now seeing double. In addition, he was now having difficulty fully opening his mouth and this was also becoming a concern. He had apparently seen doctors in Dar es Salaam before who had told him that it was not cancer, but they had suggested no other treatment. He had undergone a CT scan of the head back in 2018 here at FAME, which we had reviewed earlier and which demonstrated very abnormal bone thickness of the skull among other things.

He came in to see us today, having come from the Loliondo district which is about a seven hour drive away and close to the Kenyan border to the north. I have there in the past and it is a very remote region that is populated by the Maasai and is just south of the Maasai Mara in Kenya, an extension of the Serengeti that is north of the border. We had sent his CT scan images to CHOP to get more information from them, but had initially felt that this may have represented very early Paget’s disease. The other possibility after speaking with the CHOP folks, though, was that this may represent late onset Osteopetrosis. Either way, it was not something that was malignant and both conditions can often be complicated by osteomyelitis which is what we thought the recurrent infections were likely related to. We checked an erythrocyte sedimentation rate that returned at >140, an extremely high number that is most often seen in cancers or inflammatory conditions and was quite consistent with osteomyelitis of the skull which we had already thought was present. In the end, we decided to admit him to the ward for IV antibiotics, but prior to that, someone would aspirate what felt like loculated lesions on the scalp to gram stain them to get some additional information. Unfortunately, we really didn’t get any additional information from the gram stain. So, he was admitted overnight  and placed on the appropriate IV antibiotics for a week or so and then will have to be on a long term antibiotic course for his chronic osteomyelitis. None of this will help his abnormal bone growth, but it will hopefully help the chronic infection that he has with the osteomyelitis.

Our little girl with swollen knees

Another patient that was seen today was a young girl with swollen knees bilaterally that had been going on for some time. She had been brought to us for knee pain, which certainly isn’t neurological, but between the number of pediatrics we had here, it was decided that we would evaluate her and try come up with a plan. We spend a great deal of time communicating to the staff here and to the population exactly what are the diagnoses and symptoms that we evaluate and treat, but we still have to triage many patients who come to see us for several reasons. First, patients who have not been helped elsewhere, or those who feel that we somehow be able to evaluate them “better”  because we are specialists, will come to see us in the hope that we can make them better. The second reason, which is more unfortunate, is that we have chosen to subsidize the neurology clinic, making a single cost for our care, medications for a month and lab tests. This is obviously a situation that is very attractive to anyone as it is often far less than would be paid for any regular visit, and so patients will often come in hopes of being seen in our clinic when, in fact, they have no neurological complaints. Our rationale for subsidizing those with neurological disease is often so important to get them here to diagnose them, especially for the epilepsy patients, that we’ve chosen to continue this practice in an attempt to capture as many of these patients as possible.

The surgical scar on her right knee

The young girl had developed a swollen knee on only one side and had a surgical procedure in the past in which they opened her knee to make a diagnosis, but we had none of this records and when she came to see us she was on no medications or therapy. What she did have was an incredibly large and disfiguring scar over her one knee. Subsequently, her other knee became as swollen as the first and, without treatment, she had developed contractures of the knees and was unable to walk due to the joint abnormalities. We did X-rays of her knees and sent them back to the fundis (experts) at CHOP and she was given a diagnosis of juvenile rheumatoid arthritis and treatment was initiated. Whether she will regain function of her knees at this point is not entirely clear, but perhaps with aggressive physical therapy, which Frances gave to her and her family, she will one day walk again, even if it is with a noticeable limp.

Her swollen left knee

The last patient to mention for this day was a young Maasai boy who had come in with fever and mental status changes. When Dan and Marin had gone to see him yesterday, he had clear meningismus (a stiffness of the neck primarily to flexion indicating inflammation of the meninges) and so they did a lumbar puncture to determine what was going on. The findings were very profound in that he had a very high protein of 300 and a very low glucose of 20. A more typical bacterial meningitis with that low of a glucose would not be seen in a patient that was still responsive, but is much more indicative of TB meningitis, a relatively common disorder here given the high incidence of TB and, even more so, as a complication seen in HIV positive patients . This young boy of 12 was not HIV positive after we tested him, so had TB meningitis as a complication of his TB infection elsewhere and needed to be treated quickly as there is an extremely high mortality for TB meningitis even in treated cases. Another complication that we would have to deal with is that his CT scan demonstrated not only jugular vein thrombosis, but all cavernous sinus thrombosis, a serious complication of a basilar meningitis such as TB, and he would have to be place on anticoagulation in addition to his TB medications. There is a significant interaction between two of them that would require a higher dose of warfarin and he would need to be monitored extremely closely, otherwise his blood could become too thin and he could have serious bleeding. This would be a very difficult situation to manage for someone going back to the boma once he was finished with the IV portion of his treatment and his blood was appropriately thinned here.

Our Thursday evening was spent at home with our macaroni and cheese with massive amounts of garlic, thankfully made that much more cheese by Chef Amisha. Tomorrow would be Angela’s last day in clinic and we would all be sad to see her leave as she has been a very integral part of our team and a great addition with her knowledge of pediatrics. Teamed with Amisha, Dan and Marin, we have had a pediatric neurology dream team here and probably the best anywhere in Africa.

Marin and one of her patients

 

 

 

Wednesday, March 11, 2020 – A very slow day, indeed…

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Our volume here has just been very unpredictable so far, and it has not been totally clear to me why that has been. I have been reassured by the FAME staff that is merely a result of the rather early rains and that when they occur, there are many things that need to be done around the house requiring everyone’s participation, making it difficult for them to come to FAME. Regardless of the reason, though, it has left us with more time on our hands than we’d like so that all of us were going a bit stir crazy.

A fair share of our attention, of course, has been on the Covid-19 pandemic that has now caught the world’s attention in a big way with a great deal of craziness and misinformation that has been spread in addition to the real science that is being carried on around the world by many agencies. For better or worse, we had left just advance of the real scare, as had we left a week later, it is unlikely that we would have been allowed to travel, and a question of whether we would have wanted to. We have been monitoring the situation on a constant basis and I have been checking in with those knowledgeable back at Penn to be sure that we are not only making smart decisions here, but also those that will remain in line with what the university has been recommending.

The one thing that has remained quite clear to us all along has been that we are safer here than we would be in the US given the current spread of the disease both globally and in the US. FAME has had meetings with the government here regarding our preparedness in the event someone with symptoms of Covid-19 were to be treated here and we also have a designated isolation room now, but is very unlikely this will be utilized anytime soon and, if it is, it will likely be a due to a tourist coming here with it. We’ve now been here long enough to be pretty certain that none of us are infected and, though that is certainly reassuring, we still have to travel home at some point, which means going through the international hub of Doha, where we’ll spend six hours overnight, and then have to get packed into a large body jet carrying 200+ passengers from around the globe to their final destination during a 12 flight, all breathing the same air. Doesn’t sound like the best of situations when trying not spread a new disease, but I guess there is no other way to take care of things as we have to get home one way or another.

One of the many banana slugs that come out in the rainy season

Amisha had planned to be traveling to Israel after her time here and discovered that they had just announced a mandatory 14 day quarantine for anyone entering the country which meant that she wouldn’t be able to do the things she had wanted to do. Unfortunately, there are so many people in a similar situation trying to the reach the airline and the hotel, that she has been trying to get through to them all day. When she contacted the online agency, who had booked the flight she was asked for a call back number (she gave them mine) and it was going to be 12+ hour wait. I kept joking all night that they had called and I told them she was unavailable. The real joke was, that after all that waiting, they never even called and I guess that wasn’t overly surprising given the circumstances.

Though Covid-19 is, and will continue to be, a major event that seems to be worsening by the day, life here in rural Northern Tanzania seems to be going on as usual and I certainly hope that will continue to the be the case, though I know that it will eventually reach this region in some fashion in the very near future. I know that we’re discussing the shortage of ventilators in the US and number of people that will need them, but imagine living in a place where there are no ventilators to begin with, so that the discussion of their rationing becomes moot. We deal with this on a daily basis here, knowing that a patient, of any age, including neonates, would not have access to this therapy regardless of their need or prognosis. That is life in a limited resource region that includes most of Africa as it is only in a few regions of this continent in which anything else exists. We have been practicing here for a number of years and have learned to care for patients with these barriers to treatment, recognizing that it is not our place to necessarily change their system, but rather to learn to work within it and, hopefully over time, the system will change on its own for the better.

Blood smear from our thrombocytopenia boy we had seen last year that came back to see Dan and Marin

That has been the mission of FAME since its inception over ten years ago; To enhance the quality of medical care in East Africa and to create educational opportunities for individuals who express an interest in contributing back to their communities. FAME is essentially “for Tanzanians and by Tanzanians,” and we are only guests here to assist in providing those educational opportunities that will allow them to improve the quality of medical here in the Karatu district. We have continually kept detailed records of the neurology patients that we have seen here since 2015 along with the assistance of the FAME doctors, and have shown that we have changed the lives of many Tanzanians who we have had the privilege of caring for during that time.

This has been most evident among patients with epilepsy, many of who have never seen a doctor or have never been on an anti-epileptic medication, or if they were, it wasn’t the correct medication. I have mentioned numerous times in the past of how epilepsy patients are stigmatized here in very severe ways and children with seizures are typically restricted from going to school because of them. We see many young adults who were not allowed to attend school from an early age because of their seizures when, in fact, they had a very treatable condition that merely required a medication to completely control their epilepsy. These patients respond incredibly well to placing them on simple medications that they have here and our data shows that there are very adherent to their medication schedule and also have a very high rate of either being completely controlled or marked better in regard to frequency.

Blood smear from our thrombocytopenia boy we had seen last year that came back to see Dan and Marin

In monitoring the cost of our program in regard to the total cost of medications that we supply for a month, along with the future cost of medications over the year, it would require only a small amount of resources to completely control this population of patients.  Providing continued care would truly make a difference in their lives and that of the community where they would return as productive members as opposed to a burden to the community and their families.

As you might expect, there are plenty of insects here in Tanzania, as there are everywhere, but given how exotic it here, they can sometimes be a bit more intimidating with the consequences of an encounter more significant than it is back home. The same goes for snakes here where there are no rattlesnakes, which like to warn you ahead of time, but rather tremendously more deadly reptiles such as the many pit vipers, the boomslang, cobras, and the black and green mambas. Despite my incredible love for reptiles, which comes from my childhood growing up in the pet industry and having many, many reptiles at home over the years, which has led me to search for them here in Africa, I have actually seen very few during my adventures into the bush. I have seen one large king cobra in Manyara and numerous Nile monitors, but overall, snakes have eluded me much to my disappointment.

Insects on the other hand, have been quite numerous and I have mentioned the tsetse fly on many occasions as a real issue here in some of the parks, and, in particular, Tarangire National Park, where they can be terribly numerous and bothersome. I have seen residents with the most incredibly strong demeanor, who could stand strong regardless of what was thrown at them, melt when threatened with a swarm of these flies, only slightly larger than our house flies. Tsetse flies are blood sucking and have a bite that is difficult to feel initially, but then develops into such a significant pain that it is difficult to ignore and will eventually become a large itchy welt that last for days. It is far more severe than a mosquito bite, which is no different than those at home other than the fact that they can carry malaria here which is why all of us are taking our Malarone. If you’d like to see something truly disgusting, watch a video of a tsetse fly engorging itself and enlarging to twice it’s normal size with blood. They also have a nasty habit of flying up your pants leg when sitting in the vehicle on a game drive, especially mine as I’m driving, and I will suddenly notice the sensation of something crawling up my leg, reach down and crush it inside my pants. On several occasions, this has left me with blood oozing down my leg and on the inside of my pants, that hasn’t been my own as I hadn’t been bitten by anyone and I could only assume that it was that of a nearby Cape buffalo or wildebeest.

A Nairobi fly on the wall outside of clinic

Another bug that has been here in the past, but in limited numbers, has been the Nairobi fly and it seems to be much more prevalent on this trip. This small insect (1 cm in length) is actually not a fly, but rather a beetle and, more specifically, a paederus eximius beetle whose hemolymph contains the toxin pederin which is a very potent toxin and can cause a severe burn of the skin by just touching it, or worse, if it is crushed against the skin. The burn may not declare itself for 12-24 hours so it not always obvious where it came from and even more problematic, is rubbing your eye if you’ve happened to touch one of these little creatures as you will develop “Nairobi eye,” a severe irritative conjunctivitis caused by the toxin.

I have seen these before, but never as many as I have this time, and there are many of these on the walls of the main corridor where we staff our patients. I typically lean against the wall when residents are presenting to me, so this has become an occupational hazard for me if I happen to forget to inspect the wall in advance. Several nights ago, when readying my bed for sleep, I pulled back the covers, only to discover a single Nairobi fly smack in the middle of my sheets where I was just about to lay down. Dan informed us this morning that while using the bathroom last night, he looked up at the roll of toilet paper to see one of these nasty insects on the top sheet. Had the light not been on or had he not looked first, he could have been in for at least several days of some very uncomfortable sitting. To date, none of us have been impacted by the Nairobi fly, but given the number of these little devils that we’ve seen, it would not be surprising for one of us to encounter them while we’re here.

 

 

 

 

Tuesday, March 10, 2020 – If it’s Tuesday, it much be education day….

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Alice presenting on kizunguzungu

It was to be our first day to present a lecture and the doctors here had asked us to do some case based education rather than didactic sessions as we had most often done in the past. I will admit, though, that a case based presentation has allows allowed for more participation by the audience and, therefore, has had a better reception than the more typical lectures that are given where everyone sits silently unless called upon. Alice decided to speak about kizunguzungu, or dizziness, and what are the key points of the presentation and evaluation that will help to determine the differential for the patient’s signs and symptoms. She did point out to everyone that dizziness is disliked by almost all neurologists (except perhaps Ray Price) and one of the emergency room consultations that is most frowned upon by the residents who are doing them. Upon that background, she dove into several cases that each were an example of patients presenting with a complaint of dizziness, but each patient’s symptoms were very different as were their exams and their differential. The last patient she presented was a case of labyrinthitis and it took me a few seconds before I realized that the case she was referencing was actually mine! Perhaps it was because she aged me a few years that I didn’t pick up on it sooner, but either way, it allowed them the opportunity to hear about my experience with this condition and I was able to describe things for them in detail as I still remember the day quite well despite the fact that it was nearly four years ago. The episode itself had been incredibly disabling, but the kizunguzungu finally resolved after a bit more than a week, though, unfortunately, I never regained the hearing in my left ear which has become more than just a nuisance to me.

Alice’s presentation

Alice’s presentation

A baby with jaundice had been presented at morning report following Alice’s talk, though when Dan and Marin went to see the baby, it appeared to have the much more serious condition of kernicterus that would require the baby to receive an emergency exchange transfusion. The baby had been at an outside facility for four days where they had been monitoring it and then they were finally transferred her to further care. The bilirubin was apparently quite high and the baby’s jaundice was quite apparent when looking at it. Based on the high bilirubin and the length of time that it been present, the baby needed to be transferred to Arusha “sasa hivi,” which means “immediately,” or “right now” in Kiswahili. There the baby could receive their transfusion.

One of Amisha’s and Angela’s patients

Angela and their patient

It was our second slow day in a row, with perhaps 15 patients, and becoming more concerning to me as the day wore on. We clearly had some banner days last week and had hoped that it would continue in that fashion, but for whatever reason, the patients were not coming to clinic over the last several days. The general OPD was equally slow so it certainly nothing that was related to neurology in particular, probably just the weather and the roads. We were heading tonight to Daniel Tewa’s home so this would at least mean that we would be getting a decent start to head over there in the daylight to visit outside with him.

Marin, her patient and mom

Working on our computers. Yes, I may closed my eyes for a split second

I have written about Daniel Tewa numerous time before as I have been visiting him ever since my first trip to Tanzania in 2009 when I was here with my children and we volunteered in the Ayalabee School to help paint the facility and Daniel was an elder there. He is a remarkable individual who is from the Iraqw tribe and is somewhat of a local historian and ambassador for his tribe, having done cultural presentations for many years for visiting safari guests. When I first returned to FAME in 2010, I had contacted Daniel and he remembered both of my children’s names even though it had been a year and countless other guests who had been there since our visit. I went to visit him in the late afternoon and as it became dark, he insisted that I stay for dinner as it would unheard of here for a guest to leave his home without having been fed.

Alice and Molly deciding who will throw the spear better

Frances readying to throw the spear

This would be the first of many, many meals that I, and now my residents, would share with Daniel and his family. As the groups became larger, the meals have moved over to his older daughter, Isabella’s home and they have become somewhat fancier, but have the same meaning to Daniel and his family. I now bring up to six people with me for each visit and we sit out in front of Daniel’s home, a small structure that he build himself many years ago, and we drink real African coffee meaning that it is boiled with fresh milk from his cows. It is different coffee than I have ever drank anywhere else in the world and is truly delicious and very easy to keep drinking long into the evening.

Molly taking aim

Daniel enjoying spear throwing lessons

One of the remarkable things that Daniel has done, among many, is that he has built a replica Iraqw house similar that in which he was raised and no longer exist as they were all destroyed when Tanzania became independent and Julius Nyerere, their first president, made the decision that all tribes needed to move into villages together and live in Bantu style houses so that the country could develop its much needed infrastructure. Daniel spent three years building his traditional Iraqw house, finishing it in 1992, so that it would stand as a reminder of his heritage and be used by historians as an example of how the Iraqw used to live. The houses were underground as protection from the Maasai, who the Iraqw were at odds with unit a treaty was signed between the two tribes in 1986. Prior to that time, the Iraqw believed that housing their cattle underground at night in their houses would prevent the Maasai from stealing them. An entire family would live in this house, along with all of their livestock, cows, sheep and goats, safe for the night without risk of being stolen.

Molly receiving spear throwing instruction from Daniel with a rainbow in the background

Each group that has come with me to Daniel’s home to visit with his family has uniformly found the experience to be one of the most rewarding of their time here in Tanzania. We arrived with plenty of light and enough time to inspect Daniel’s original Iraqw home and his lessons on Iraqw culture and history that included courtship and marriage. Afterwards, the residents received lessons from Daniel on throwing spears as a wonderful rainbow reached high above to the south. As we later sat outside under the darkening sky and eucalyptus trees, everyone shared their place of origin with Daniel so that he could share with us everything he knew about each location, most often more than each of us knew about our own home state or country. We discussed the current US Democratic race and where things stood at the present time between the candidates.

Me, Daniel and Carrie

Daniel, Carrie and Frances

We all walked to Isabella’s home, only a short way from Daniel’s to have our dinner that his family had prepared for us. His son-in-law, who lives in Dar es Salaam and who had been in Moshi for the day, had also come to eat with us as that was how significant our visit was to his family, and how equally significant it was to us. They had spent the evening preparing this meal for us and were clearly honored to be serving it to us. The fact of the matter, though, is that we were equally honored, or perhaps even more so to be sitting in Isabella’s home with her father, Daniel, and the rest of her family sharing it with them. It was a wonderful dinner and as we walked home to Daniel’s house in the light of the moon, and our flashlights, we were all quite full and ready for sleep.

Sitting in Daniel’s living room

We had one short adventure remaining, of course, and that was the drive home. It hadn’t rained for most of the afternoon nor the entire evening while at Daniel’s, so I thought it would be fine to take the normal shortcut I have between FAME and his house that bypasses having to go through town on the tarmac. There are no lights on the main road and at night, it is nearly impossible to see people crossing until you are directly upon them, and all of this is occurring while motorcycles and cutting across in front of you or traveling the wrong direction on the shoulder. It can be a bit intimidating to say the least. The short road across from Daniel’s that takes us across a large ball field and is where I pick up another small road to head towards fame. The initial short road was quite treacherous with large ruts and crevasses that cut across and made for a very rough ride for everyone in the back. As we came to large ball field area, though, we discovered that the cross road had turned into a river that may have been reasonable to attempt crossing during the daylight, but certainly not late at night where becoming stuck would have been a major fiasco. I turned around, which is not an easy thing to do in a stretch Land Rover that has the turning radius of the Exxon Valdez, nor in the dark of night, but it was eventually successful and we were on our way home to the comfort of the Raynes House.

Our group in Isabella’s house after dinner

Monday, March 9, 2020 – a difficult day for our peds folks….

Standard

The first two springs trips to Tanzania for me were in April rather than March, and, on the second one in 2012, I discovered why they call them monsoons in other parts of the world. That month, there were torrential rains such that the roads were just terrible and I ended up get my Land Rover completely stuck in the mud axle deep, a rare event for these tank-like vehicles, at which point I changed my future spring trips to every March. Though it seems that the reasoning behind that decision may have been slightly faulty given the amount of rain we’ve had so far on this trip, every March trip prior has been absolutely gorgeous with limited amounts of rain as this month typically falls between the short rains of January/February and the heavy rains of April/May so I guess having one bad month in eight isn’t terrible odds.

Morning report

The reason I am telling you this, though, has nothing to do with the weather, but rather with the fact that I have now spent my last eight birthdays here in Tanzania with second family at FAME. I have never been much for birthday celebrations (my mother would have been the first to tell you that having missed my surprise birthday party in Disneyland when I was 13 as I was having fun with my school friends and thought it was only a lunch I was meeting her for – she never let me forget that event), but the residents have now managed to remind each subsequent year of the fact that my birthday occurs here and I have become a bit more tolerant of celebrating it. Today, my birthday as you might have guessed, Amisha made certain that this tradition was not overlooked, alerting Dr. Gabriel to the fact such that the entire FAME medical staff and volunteers had the opportunity to sing me happy birthday at morning report. Even for me, this was a special event and I very much appreciated everyone’s thoughtfulness, and especially Amisha’s, as this is her second trip to FAME with plans to have more along with a career that includes global health, confirmation that giving residents this opportunity will have some impact in the future.

It was the start of our full week here at FAME seeing neurology patients and, typically, our busiest. With the rains we’ve had, though, there were not a tremendous number of patients waiting for us when clinic began that was clearly a suggestion that the weather was impacting their ability, or at least willingness, to fight the muddy roads and floods in certain areas to get here to see us. We had been extremely busy last week for the days that we had announced, matching some of the highest numbers of patients that we’ve seen in a single day (remember, we are neurologists and we do a bit more thorough histories and physicals, hence we are much slower than other specialties), so we were very excited that this was going to be a banner spring clinic. Often, when the weather of bad overnight or there is rain in the morning, patients come a bit later in the morning, though we didn’t see the volume today that we had hoped for, ending up with only about half of what we had seen on Thursday and Friday of last week. The cases that we saw, though, were a bit more complicated, at least for two of the pediatric cases.

Our standard lunch here – rice, beans and mchicha

Amisha and Angela evaluated a 6-year-old boy who had a history of probable birth asphyxia and subsequent seizures with severe developmental delay, as well as a probable aspiration that had occurred with one of his more prolonged seizures. During their evaluation, they had noted that he seemed to have a number of bony deformities that were unusual, so did X-rays of his extremities (thankfully, our plain radiology plate had just been fixed allowing them to do so) and discovered that he had severe demineralization of his bones along with multiple fractures that raised the concern mainly for some underlying bony disease such as one of the osteogenesis imperfecta variants or something similar. Unfortunately, there would be no way here for us to do any testing on the child in regard to his fractures or diagnosis causing them and they were only able to continue his seizure treatment. Having an underlying diagnosis of bone demineralization and risk of fractures as well as seizures is not a great combination as there is always a greater risk for epilepsy patients to suffer trauma as a result of their seizures from falling (this child was not ambulatory, though) or just from the convulsion itself.

The CT scan of our 7-year-old with the pontine glioma

The second difficult child they saw today was a much tougher situation. She was a developmentally normal 7-year-old girl presenting with several months of neurological symptoms that consisted of double vision (she had a very obvious esotropia of the left eye), redness of the eye from decreased blink, right-sided weakness and ataxia. Her examination confirmed that she had involvement of at least cranial nerves VI and VII on the left, her cerebellum and/or its pathways and the left corticospinal tract above the decussation. There was no way for us to place this anywhere but her brainstem and we all knew that was not going to be a good thing regardless of how we looked at it. To make matters a bit worse, we had quite a bit going on patient-wise at that moment with the young boy with multiple fractures, this girl and a patient that was in the ward at the time and things were pretty hectic.

The CT scan of our 7-year-old with the pontine glioma

The family did not have the money to pay for a CT scan, but thankfully, they were able to pay something towards it that would allow it to be done. An MRI scan would have been much better to obtain given the location of the problem, but they would have to go to Arusha for that and it would be much costlier than just the CT scan. As I’ve mentioned before, FAME does not have the resources nor is their intention to provide free medical care to everyone, but rather to make quality medical care accessible to the residents of the Karatu district for a very reduced price. Secondly, though, we have to be very careful not to reach into our pockets to pay for the medical care of our patients as this has no sustainability going forward and creates a situation in which patients would begin to rely on help from the Mzungu (white person, or stranger) doctors and would alienate the Tanzanian doctors as they would not have the same ability to pay for things and, furthermore, they would already be aware of the problems this would create.

We were able to obtain the CT scan which demonstrated a very large mass occupying the entire mid brain, though without compression of the fourth ventricle or other CSF structures so, thankfully, there was no hydrocephalus that would have ultimately required a more urgent procedure to prevent her from herniating. The mass was most consistent with a Diffuse Intramedulary Pontine Glioma (DIPG) that was very extensive and is not something that responds in any meaningful fashion to treatment. Radiation, which would typically be offered in the US, would be done only for palliative measures and would perhaps help her to live a few months longer, but nothing more than that. It was really a horribly unfortunate diagnosis to have to provide to her parents, the fact that she was not going to survive much longer, and, in the end, even though they accepted our prognosis, asked us for a referral to Dar es Salaam to be seen at the pediatric cancer hospital which would be expensive for them to travel there as a family and they would be told nothing different than what we had told them today.

During the midday, there was an incredibly heavy cloudburst that made it nearly impossible to hear a thing either in our clinic or in the passage way outside given that they both had metal roofs on top. The noise that these downpours make is very impressive and, thankfully, they only last a short time before they are gone and most everything dries up without a trace as if nothing had ever happened. The rains can wreak havoc on the roads, though, and at one moment it can be perfectly beautiful, and the next, a slip and slid as I’ve discussed before. Given the weather and the likelihood of bad roads, combined with my past experiences as I’ve mentioned earlier, it seems the smart thing to do to have one of the FAME drivers, who are very experienced in these conditions, drive my Land Rover to the villages. Additionally, with the size of our group, we will require an additional vehicle, as we have on our most recent trips, and for various reasons, FAME will not be able to supply us with one for this visit, necessitating an alternative plan so that we will have enough room for everyone. There are many safari vehicles for hire here in Karatu and, given the fact that there have been many cancellations as a result of the current Covid-19 situation, I was fairly certain that we would be able to find something not only available, but also for a reasonable cost. We contacted Kudu Lodge here in town and they were able to supply us with a stretch Land Cruiser for a decent price that we could live with. Having the vehicle situation for next week clarified meant that there was one less thing for me to worry about over the weekend.

Shopping at Teddy’s

Since the day had relative slow, or at least steady, we decided to try to make it to Teddy’s shop, the seamstress that we have used over the last year and who we had been introduced to by Kat, our previous social media director here at FAME. Teddy has been a godsend for those interested in having clothes made, as she not only does a wonderful job and a for a fair price, but she is also great to work with and speaks some English. Of course, as soon as we decided to visit her and I had sent her a message, some later patients began to trickle in to clinic threatening our chance to get out at a reasonable time. Luckily, she was still willing to wait for us, even though we were later than we had thought we’d be, and everyone, other than me, of course, decided to have her make something for them. We were at Teddy’s for a surprisingly shorter time than I’ve spent with others in the past, which I was quite thankful for, and afterwards, we went into town to look for additional fabric designs. Everyone was apologetic that I was spending my birthday shuttling people around, but I reassured them that I couldn’t imagine anything that I’d rather be doing than driving my Land Rover in a frontier town in East Africa, something that I had never imagined that I would be able to do, and sharing my new home with others, all of who I knew appreciated that very much. Standing in the street outside the fabric stores, while the others did their shopping, watching the hustle, bustle of nearly all of Karatu’s residents doing their evening business only solidified in my mind just how lucky I am to be here and to be doing the work we do at FAME as it has truly changed so many lives – mine, those who accompany me here, FAME, my Tanzanian friends, and all of the patients who we have had the privilege to care for over these last 10 years that I have spent in this remarkable country.