Saturday’s are usually fairly slow at FAME as weekends here are not what they are in the US. I can only imagine if we had a regular neurology clinic open at Penn or CHOP on a Saturday that the schedule would be overflowing with those patients who wish to avoid taking a day off from work or school. The concept of the weekend, though, is much different in a society where most individuals are not working a normal work week, or working at all for that matter. I don’t mean to say that people aren’t working here, though the unemployment rate is quite high, but rather there are many folks who are farmers or work around the house and are merely not employed. FAME is understaffed a bit on Saturdays and thus, the number of patients we had were much less than we would expect for a weekday. FAME is also open on Sunday mornings, but there is an extra surcharge to be seen and the day is meant for urgent care.
We still had a number of interesting patients that came. Perhaps the most interesting may have been Jamie’s patient whose chief complaint consisted of mutism. She hadn’t always been mute, but had developed it in 2008 after having a number of syncopal episodes that appear to have occurred following some severe psychosocial stresses that have never completely resolved. She was able to communicate by writing her history for us and answering simple questions along the way. She has had no cognitive or functional decline and continues to care for her four children without difficulty so there is no issue of concerns for a progressive neurodegenerative process ongoing. When we examined her, she had an absolutely normal mental status and memory. She had no other cranial nerve deficits and had no difficulty with her swallowing function whatsoever. Her neurologic examination was obviously totally normal. The one thing she did also have was some features of psychosis such as agitation and both visual and auditory hallucinations.
Her main complaint of mutism was clearly a conversion disorder and is best defined as a deficit with no underlying physical cause or explanation that is most often related to some psychologically traumatic event in a person’s past. We see this quite commonly in the US with the most common manifestation being something we refer to as non-epileptic seizures. Patients who have episodes of loss of consciousness and sometimes very convincing for a seizure, but their brain has no corresponding electrical activity during the event that would explain why it was occurring. We see this here in Tanzania, as well, and quite commonly, but to see complete mutism is not so common. Jamie explained to the patient and her family member who accompanied her that there was nothing seriously wrong with her causing these symptoms and that, hopefully, over time they would improve so that she could speak again. We also treated her with a medication for her hallucinations and agitation which I’m sure the family was happy about, but more importantly for her own safety as she had been beaten in the past due to her behavior.
Chris saw several pediatric cases with epilepsy as Nan was working on the young child with the thrombocytopenia and assuring that she was improving. Their blood smear was sent to the US and the feedback received was that it looked like a non-specific parasitic infection and not some leukemia that had all of us a bit worried since we’re so limited her in treating these disorders. Little Grace, who had been cared for by FAME and died a year or so ago after a long battle with this disorder, is certainly still fresh on everyone’s mind here. She looked better on Saturday with improving labs and was more animated giving everyone hope that she was turning the corner.
Chris’ first patient was a young man who was not developmentally normal and was having frequent seizures and needed his medication adjusted. The other young boy was a 17-year-old Maasai lad who was having frequent seizures and had been seen here for some time. He had been on carbamazepine that was initially helping to reduce his seizures, but morning recently they were increasing so we had recommended switching to valproic acid with a tapering of his carbamazepine. Somehow, though, his titration of valproic acid hadn’t occurred as ordered originally yet he had been weaned off of his carbamazepine and he was still on subtherapeutic dosing of the valproic acid. This required a somewhat rapid titration upwards of his valproic acid which will hopefully lessen his seizure frequency going forward.
We finished with patients relatively early in the afternoon which gave us time to catch up on paperwork here and there. Chris has been entering all the charts as we go which hasn’t been an overload since it’s been rather slow. We had plans to have dinner at Gibb’s Farm tonight and wanted to run into town for a few groceries as we also had plans to leave very early in the morning for a safari and would need to bring lunches with us. We all went down together looking for Mangos, bread, milk and other associated goodies (meaning Fanta Passion and Coke Zero). We took a stroll through the vegetable market first, which always an interesting visit and though we found more species of avocado than I knew existed, some the size of mangos, we couldn’t find what we were looking for. It took a trip to the other open market and a helpful local to lead us to a shop where we found what we were looking for. The other items were easy to find in one of the many “supermarkets” that are really small shops with sundries, but were quite sufficient to supply what we needed and is all that counts. We drove Renata home (Daniel’s granddaughter who wants to be a doctor and had spend the day with us) and then headed home to change before leaving for an evening at Gibb’s Farm.
GIbb’s Farm is a must visit for anyone coming to Karatu, at least for a visit and dinner, if not to overnight in their amazing cottages. Gibb’s is an institution here, from having been a working coffee plantation only in the distant past to a lodge in more recent years, but has always maintained it’s identify as a working farm. They have their own dairy cows and livestock, woodworking shop, impressive gardens and, most of all, their coffee plants that produce the amazing Ngorongoro Highlands coffee that we’ve all come love about this region. It is particularly addicting. We’ve all come to love this place that I first visited in 2009, and have visited again on each of my subsequent trips here, along with the residents and others that I now introduce to this wonderfully relaxing and always endearing resort. Like the coffee, it is also addicting.
We had made the decision to visit Gibb’s well enough before sunset to allow everyone to walk around and explore. The gardens that descend from the entrance to the grounds are spectacular with every native plant imaginable growing here that produces something to eat or cook with along with coffee plants and at the bottom sits a large tree with a platform that gives a wonderful view of the surrounding gardens. This is where they have the “Tembo fire” each night for guests to hear stories about Tanzania from the local Maasai and Iraqw. There are new livestock enclosures that were recently opened so we visited the cows and burros that were there as we thought that they might like some stroking. We had wanted to catch sunset on the veranda (a must) so forsook the Tembo fire and all walked to where there is the most spectacular view of the surrounding hills and countryside, with FAME sitting across the valley seeming so close you could almost touch it.
Having drinks with your friends and watching the sunset unfold in front of you with the subtle changes in hues and tones is perhaps one of the most relaxing times I have ever known. Nan chose to walk around the grounds some more in search of more wonderful flowers that she could photograph and returned after about 45 minutes to join us for drinks, though was thoroughly disappointed (not really) when they didn’t have pineapple juice for her Pina Colada so had water instead. The rest of us were quite pleased with our Moscow Mules (Jamie and I – copper mugs and all) and Chris with his Tangawezi Twist (ginger beer with tequila). We sat well into darkness as the birds continue their calls and a few bats begin to appear, chasing after the many insects that come out at night. A small platform nearer the entrance to the lodge summons bushbabies from the trees with the help of fresh bananas and we listen as they fight amongst themselves in the trees beyond our view as to who gets to eat first. Some stars begin to come out, but it is a nearly full moon so they are not as numerous as they will be in a few weeks when the stars blanket the sky in an uninterrupted display of magnificence that only the heavens can provide. We will all be here for that and are looking forward to seeing it in the Southern Serengeti as we chase the great migration if all goes as planned.
Dinner is served from 7pm on so we eventually made our way into the dinning room well after all the other guests (there were only three other parties seated) where the tables are already set for each party that is scheduled to eat that night. There was more silverware at each setting than I think we have in our entire house. I know many of the servers having been visiting now for the last seven years on a semiannual basis and they all greet me as Dr. Mike and some of them tell me how their family member that I’ve seen in the past is doing. It’s a very small community and FAME is an essential fixture here providing not only an amazing level of healthcare, but also a large number of jobs in a region where the only other industry is tourism. It is for these reasons that those who are part of the FAME family have such a dedication and that FAME has a dedication to them as well.
We had a lovely dinner that night with each of us ordering a different one of the four entrees from the fixed price menu and each of them being delicious. It is an elegant experience considering that we’re normally eating beans and rice for lunch and have our dinners available for us each evening at FAME in a hot pot brought to our house. Don’t get me wrong, though, the meals at FAME are delicious, but they don’t come close to what we’re served at Gibb’s which makes it so special for us. After dinner, and a phone call home for Jamie using the wifi at GIbb’s, we all got started preparing our lunches for the following day when we’d be on safari at Lake Manyara. We would be up bright and early to depart before sunrise so we could get the park as they opened.