As neurologists, our instinct is to observe and start assessing patients from the moment they walk through the door. When I first spotted this child, it was not immediately clear why she had come to see neurology. Having no pre-registration and no prior medical records available, I sat looking at her while the interpreter introduced us to her mother in Swahili. I noted a bright, beautiful, 2-year-old child, who was smiling at me and curious about the clinic visit. Only when her mother started to explain why she had come, did I notice a mildly spastic right arm and leg. Her mom said that she always had weakness on the right side, and although she was now 2 years old, had not yet started walking. It quickly became apparent that the child had suffered a neonatal stroke.
The most important intervention for children who have suffered a neonatal stroke is therapy. This is especially true early in life to help their brain rewire the area that was injured and avoid spasticity and contractures, which can make it permanently difficult to use the limb. I was only a few days into my rotation in Tanzania and had already learned that access to physical therapy, especially in the more rural area where we were practicing, was challenging. I started to feel a sense of frustration, that I had little to offer this family as they likely would not be able to afford a trip to one of the larger cities to get the therapy services she needed. After talking with her mother more and conducting an exam, I learned that she was already pulling to stand and taking steps with very little hand-holding from mom. Despite the weakness, she was able to support herself well on her right leg and also was using the right arm to reach for and hold objects. Her speech and thinking were right on target for her age, my doorway assessment of a bright, curious child was spot-on.
I explained the diagnosis of neonatal stroke to her mother, but I was encouraged by her development so far. Although she will definitely be a left-handed person, and probably walk with some degree of a limp, I was optimistic that she would soon start walking independently, and she would do very well cognitively. It was also impossible not to comment on what a beautiful, “mzuri” child she was. She was one of those kids that as soon as you start to interact with them, you can’t stop smiling. She was engaging, playful, and had an infectious smile.
As the interpreter started to translate, I sat in shock as her mother burst into tears. I wasn’t sure if this was the first time anyone had used the word “stroke”, or if she was upset about my comments on her daughter’s weakness. I felt terrible, and wondered if I had been too direct in my delivery. To my surprise, I then realized her mom was crying tears of happiness. She was relieved to hear my assessment and finally have a diagnosis. She has been told by a doctor in the past that her daughter would never walk, talk, or interact with the world in a meaningful way. This had been weighing on the family for the entirety of her daughter’s life. Not only is this sad, but can be incredibly detrimental to the child. If the family believes there is no hope and does not engage with and support their development, the child can have significantly worse outcomes. Fortunately, this was not the case with my patient.
I was reminded at this moment that healing someone does not always involve doing something. Many people who go into medicine, myself included, are motivated by a desire to “fix” things, either with medication, procedure, or intervention. One of the both challenging and motivating things about neurology is the many diseases for which we still don’t have a “fix. Practicing in the United States where we are surrounded by “cutting edge” research and technology, and heroic survival stories flooding our news feeds, patients come to us expecting miracles, often after irreparable neurologic injury. While we have made some incredible advances, diagnostics and therapies are not available to everyone equally even within the US, and especially less so in most other parts of the world. In this moment, I was reminded of the incredible healing power of knowledge and thoughtful dialogue. In residency, I realize now I had lost sight of this. We are often stressed, rushed, tired, and burned out. I found myself skipping that extra step to explain things a little more slowly, thoroughly, and empathetically. This mzuri child and her mother reminded me how powerful this can be, and is something I will consciously try not to lose sight of upon returning home.
I am certain that I gained more from my experience at FAME than I was able to offer to the patients in my short month there. This is not how it is supposed to be, but I think it is inevitable as I have so much to learn. It serves as motivation to use what I have learned to help others for the rest of my life, both in practicing medicine and in being a kind, responsible, and empathetic human during our short time on earth.
