Life's little curve ball

So there I was minding my own business after having appointments with specialists in infectious disease and neurology Monday of last week, lots of lab drawn, an EEG and MR scan on Wednesday of this week and then “the phone call” came on Thursday. My neurologist (weird how that sounds to me) had seen the new MR scan, comparing it with the old one, and found a “new finding” this time in the L temporal lobe. Those that follow this remember that I have a “hole in my head”, actually an area of unexplained encephalomalacia about 3mm wide in my R temporal lobe. That finding is unchanged and stable, whatever the hell that means. No new holes this time around but there is “a subtle area of inflammation on the cortical surface of the L temporal lobe", the significance of which is cause a fare amount of debate in several departments at Penn.

The end result of all this is that I/we were asked to delay our return to Bots for another week to sort this out with a PET scan and an evaluation by a neuro-oncologist. The differential is tumor vs. infection vs. who-the-hell-knows.  All are treatable and the anti-seizure meds are really making a noticeable difference. Both of those evals are on Monday of next week, then who knows…

This feels a little like what I often referred to with my patients as “specialist hell”. The risk of visiting a high powered place like Penn is that, while I have received nothing but very kind and solicitous care, I may get tested to a fare-thee-well only to find out what it ain’t or, worse, “could be” without any definitive sense of what this is or where it's headed. While I’m prepared for that I honestly never thought I’d find myself in this fix. I know, who does, right?

So I’m amused that I seem to be experiencing the classic and well defined grief reaction: denial, anger, bargaining, depression, and acceptance. And I’m slamming around between poles of these stages with a rapidity that is as annoying as it is fatiguing. The truth is that these episodes had been a relatively minor but persistent pain in the ass and had reached a place in my life where some answers were in order. But while the symptom complex is annoying, it’s largely unchanged from when it began just several weeks after leaving Sudan in '06. In any case, I’m assured by my neurologist (that term again) that whatever it is, it’s treatable.

I’d like to be less annoyed by it all and have truly been moved by the response of my kids and family. Time, I need some time to gain perspective. And I need to get back into the things I was doing and love, teaching medicine in a developing nation.

It has been other-worldly being introduced around Penn as a “faculty member”.  While it carries nowhere near the same oomph as a bonafide member of the UPenn faculty, having that moniker associated with my name is kinda cool. I NEVER thought when I left Penn in 1980 I’d be back and working for/with them, both enjoying it and experiencing pride for doing it.

So I wait…... I have appts on Monday and then go from there. For now I have time to do things I’ve missed; get my iPod going, trick out my lap top, and load my PDA. Thanks for all the kind thoughts and support. Some of the thoughts I have in the black recesses of my brain don't warrant all the kindness. And I’ll take it as it makes a huge difference, so thanks, truly I’m blessed and very humbled….

 

 

Thus far, three days on meds and the episodes are now about 25% of the frequency and severity. Amazing, this stuff seems to work! Now, why did it take me 2 yrs to get to this place. Oh well, I'm here now and it seems to be a good thing with no side effects. I also seem to be getting back the edge such that I'm back at 110% from 95%. It feels familiar and I didn't realize how much I missed it.

Interesting development; after all of two days on meds the spells are either abated or significantly decreased. By that I mean I haven't had one since beginning the medication and thus far no side effects. I know, I know shoulda done it a long time ago. Still need to see the results of all the tests and MR scan. I must admit to being a touch nervous about that, one hole in one's head is enough.

So after seeing two great and kind physicians here at UPenn the consensus is that the hole I have in my right temporal lobe is located perfectly to cause these "spells" I keep having. I need to get around to using the word seizure as that is what they are. I indeed have a seizure disorder, temporal lobe seizures to be precise, that in turn cause me these annoying symptoms.

It was moving to be in the neurology clinic waiting area and have two friends from Bots show up. they of course had checked about the appointment time and found us jet lagged and scared before we saw Dr. Anderson. They offered much welcomed support and friendly warmth.

I have since had 12 vials of blood and two sets of blood cultures drawn, and on the 23rd will have an EEG and MR scan in the "super coil" that gives better resolution. As it turns out UPenn has two MR scanners, one for the simple plebeian types with garden variety stuff and a more powerful one that has a higher level of resolution for guys like me.

So there it is; I'm some how screwed up in the head. No news to those that know me, just confirmation of long held suspicions expect. I have started Keppra and thus far, all of two doses into it, am not drooling into my soup or the like. And come to think of it, have not had a seizure yet today, so who knows.....

I have two weeks of enforced rest here (talk to Lynne) to see precisely how screwed up I truly am. The thinking is that the hole in my brain is the culprit, and that the lab should be non revealing. Would for that to be the case.

Otherwise I sit here bored and anxious to get back at it. Botswana has become my (our) home. The frigid cold here is annoying and being away from my project chafes. Having the gang here will help; and will keep me in line and behaving.

Thanks to all for your concern and support! I miss you and would love to here from you.

Mike

Inviting the Holy Spirit....

It’s been an eventful weekend. Yesterday I wrote a presentation on hypertension and included a bunch of handouts that might help my colleagues avoid ancient meds and odd combinations that  really have no place in medicine, even here.  Also it tries to help avoid combinations of three and four meds that are at entry level doses and can be condensed to two, thereby dramatically improving compliance.

Last night we had a third year medicine resident from Penn and her husband, an Assembly of God preacher. A delightful conversation lead to an invite to hear a local preacher this morning. We went out to an area remote from Gabs, to a tent, where we heard a  preacher invite the Holy Spirit into the tent with voice at full volume. It was very eventful and full of emotive singing, praising, speaking at highest volume to about 60 people in a tent in rural Botswana. After an hour of this, we were a touch fatigued from the shouting and yelling. And then, at the end of the service, things returned to the understated conversation voice that is classic Batswana, just like that. It was very interesting and compelling.

The afternoon has been cool believe it or not, with rain and wind, very refreshing. Tough to think we’ll be in Philly in one week…

Three guys, three canes, and a native euro-Batswana

I was in Lobatse today, a town about the size of Hood River 80km southwest of Gabs. I work with the medical staff at the local secondary hospital there. Picture Princess Marina Hospital is one of two tertiary or referral hospitals, and Athalon Hospital in Lobatse is one of many (but less than twenty) secondary hospitals.

These are very familiar places to me as they are run by MO’s or the Bots equivalent of family docs. They are all trained in neighboring countries as Botswana has done a very good job of affording education off shore for its med students but hasn’t figured out how to attract/require them to return. It might start by giving a competitive salary, increasing the number of docs in country, and the like. Interestingly one of the countries that export docs here is Cuba. At last count they had 50-60 physicians spread out all over the country. They come for a two year hitch as they can make more money here than in Cuba. They are well trained and very astute, and bored to the core as there is no night life that can come close to that of Cuba; no passionate music, food, relationships. Yet they come here for a two year hitch and often stay longer.

In Lobatse I met with the medical staff and discussed OB (a 39wk gestation woman with a subjective sense of decreased fetal movement), which lead to a discussion of litigation which is rather common here. Suits are filed against the Health Ministry as they are the employer of the docs here for the most part. After the suit settles as they all do there is an inquisition about the case and it apparently can get rather animated. It was an amazing discussion about how we all practice “cover our ass” medicine even if we are 11time zones away. And more to the point, how do we maintain confidence in our care after said inquisition, how do we continue to practice evidence based medicine even if we are in a resource poor area, a very informative and lively conversation with 8 docs from five countries.

Things always quiet down from 1:00-2:00pm for lunch. I hopped in the car and headed over to the civic center (read regional government) for discussions and to gain permission to travel and teach in the surrounding and more rural clinics. I still need to jump through lots of hoops but am getting close. Back to the OPD to mentor the docs there.

We discussed optimal dosing of one med before adding another, stopping antiquated medications such as methyldopa (still on the formulary here), not using 3gms of metformin and instead spending time getting a 24h recall of food intake and initiating some diet counseling, and the like. All of this is time consuming and therefore frowned upon when one is charged with seeing and treating 50-75 pts in a day. So it is a hoot to have these conversations and see the wheels spin.

As I was waiting to begin the OPD I notice three elderly men standing under a tree with three walking sticks all involved in animated conversation. I was impressed that this social intercourse was so sell developed and present everywhere here; conversation, smiles, laughter, always laughter. They were each here for refills of their blood pressure meds and had to register early in the morning, go without food to maintain their place in line through lunch and wait to be seen, for less than 5min sometime in the middle of the afternoon. Always gracious, smiling, grateful.

I met a rarity today, a euro-Batswana who was 78, born in this country before it was one, who was fluent in several languages, who was full of historical perspective on her experience here in the bush low these many years. What a treat and privilege. 

The Blog is back!

Us at Cape Point, SA

And what an extraordinary time we had in the Cape Town area of South Africa! We set out by air on 25/12 and arrived in Simon’s Town at a B&B that evening. In 24 short hours we were different people. This has happened more than once in my life wherein I/we are rather beat up and in desperate need of a break, only we are in it too deep to notice. Boulders Guest House was the appropriate remedy. It is on False Bay, on the other side of the cape from Cape Town, a very quaint and quiet place that is all of 30m from the water and has African Penguins everywhere.

In the morning I would awake and go outside very early and watch the sunrise, see the bird life (mostly the penguins), relax and renew, while Lynne would sleep in. The penguins are amazing in that they seem so clumsy on land and are sleek torpedoes under water. In point of fact they are fairly fleet on land as well. After night fall they head inland and often are heard calling (a donkey like bray, hence the original name Jackass Penguin) from drainage ditches, rain water outflows, under cars, and in back yards. This is nesting season and as they mate for life they are paired up not only on the beach but way up in the scrub as well.

We went out to the cape on two occasions where we saw unique bird and plant life, the mixing of two oceans, and baboons that walk by you with a casualness borne of familiarity with human cousins. Heaven help you if you have food in your vehicle or on your person, it will be contested with fierce determination and you’ll lose. We drove around the bottom of False Bay and up into the wine country, past tree farms, and the like, very familiar to a Northwesterner.

After eight days it was good to come home to a weekend here before we get at it next week. I say “home” with a little oomph behind it as we agreed that we are from the States but now our home is here in Bots. It took awhile to make the transition but it feels good to have made it.

And in two short weeks we’ll be heading to Philly(!) so I can have my head examined. I have been having what I call “spells” ever since the first month I returned from Sudan. That would be October 2006 and yes they have gone undiagnosed for that long. They are a lot like one’s computer returning to the desktop for 5s and then back to what one was doing, disorienting but not serious. I and a psychiatrist had always thought they were some variety of PTSD as Sudan was challenging at many different levels. After a couple of years, a trial of meds, and one superficial workup (my responsibility not any doc’s) I have decided these bother me more than before. So Lynne and I will travel to Philly to get them worked up at Penn. They are probably seizure variants and can be treated, but for the most part are just really annoying.

Our kids are understandably vested in this, being a touch, what?---touchy, about my initial reluctance to undergo a full workup as the episodes have become rather usual if not inconvenient. Being the red blooded “guy” and stubborn doc that I am I didn’t want to worry anyone and didn’t want to take the time to work these up, feeling they’d either go away with time or I would get used to them; nope. So after trying to work them up here but risking significant fragmentation of care and incurring the disapproval of valued and cherished daughters-in-law, to say nothing of their spice, I’m headed to Bryn Athyn, PA in two weeks to stay with family and get my bleeping head examined at Penn. I never in my life thought I tread those hallowed halls, much less that they’d let me back in.

That’s more than enough for now, Happy New Year!