March 21, 2017 – Upper Kitete…..

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It rained pretty heavily overnight and once again we were heading out to Mbulumbulu for our mobile clinic, today visiting Upper Kitete, which is our furthest clinic and about an hour and a half drive along the rift. From Upper Kitete there is an overlook that we often visit that sits 2000 feet above the Great Rift Valley with a view down to Lake Manyara that is just spectacular when the weather is clear as it goes on forever. Today, though, I am more worried about the roads since we’re heading back towards Kambi ya Simba and beyond where it doesn’t take much rain to make it treacherous.

Chris doing his chalk talk on stroke

Thankfully, we’ve been able to recruit George Mila, a long time employee of FAME and someone who has helped me out in the past when I’ve needed it. George will drive us to Upper Kitete so if the roads are bad or if rains while we’re out there, we’ll be sure to make it home or at least we’ll have someone with more know how who can help us out of a bind. With Glen traveling with us today that will make ten for a Land Cruiser that only seats eight. We normally use the refrigerator in the back for an extra seat, which we did today as well, but to seat ten, I am sitting on a soft drink crate with a cushion, wedged between the third row that will serve as my seat for the drive today. It was remarkably comfortable, despite the bumpy road and long drive, though I’m not sure I’d recommend it to anyone if they had a choice.

Chris demonstrating how to do the NIH Stroke Scale using Jamie as his “patient”

Tuesday mornings are for education, so before our drive to Upper Kitete, Chris delivered a lecture on stroke for the doctors that he had been requested to give. Chris is a master educator and provided an interactive chalk talk on a propped up white board using markers to run through the vascular anatomy of the brain, the NIH Strok Scale, and finally treatment rationale. Chris did an excellent job and though the participation of the Tanzanian doctors wasn’t brisk at first, they eventually chimed in with some of the answers. Jamie served as Chris’ “patient” to demonstrate the NIHSS and how to rapidly assess a patient to determine the size of their stroke. There were many excellent questions after he was finished with his talk that clearly demonstrated not only how important this subject is, but also how much they had gained from the presentation that Chris had given. We have always given these talks since I’ve been coming here and now the residents give them as they are all incredibly educators which is one of their key roles back home for the medical students and they provide the same here for all the medical officers and nurses.

The Upper Kitete Dispensary. Rain water collection container and our parked vehicle

The drive to Upper Kitete was quite uneventful as to any incidents, though the beauty of this region would compare to any in the world. The fields are lush and green as far as the eye can see and we pass tractors and workers along the way going to and coming from their daily labors. It’s quiet and serene here that belies the difficulties of life here, given the remoteness and occasional struggles to make do. It is a much simpler life for certain. Upper Kitete is the second to the last village on the road we’re traveling that ends as the mountains meet the escarpment and it is no longer possible to travel further by vehicle.

Chris seeing a patient with Angel’s help

Nan evaluating a patient with Sokoine’s help

The dispensary at Upper Kitete is a bit more primitive than that of Kambi ya Simba. The two rooms we usually use are cramped and not ideal, but we’ve always made do. The one office has a square hole in the ceiling where there is a large colony of bats that can often be heard and there is always the aroma of bat urine, but I have never seen one fly out during the day so I am comfortable that everyone is safe. The other room we use is the labor and delivery room where there are two beds and a very small amount of space between them. As long as there are no patients in labor, we’re safe to use the room. Today, we were also given the dispensary’s clinical officer’s office to use which actually had a nice desk and bed in it on which to examine patients. Everyone got to work and Jamie drew the short straw meaning she would see patients in the “bat room,” though it took just a tad of convincing that she needn’t worry about the little creatures. Nan worked in the L&D room and Chris ended up in the office as this came available later and he was in the right place at the right time.

A young patient waiting to be seen

Nan and Angel evaluating a patient with hip pain

We had a smattering of the usual patients with headaches, neuropathy and seizures with none that stood out remarkably, though Chris’ last patient was one that took a bit more in the way of thought. He was a young boy of 5 whose grandmother was raising him and gave us a history of “drop attacks” that began at one year of age and had continued. When we hear the term “drop attacks” we usually think immediately of Lennox-Gastaut syndrome which is a devastating epileptic encephalopathy where children loose milestones and suffer injuries due to the multiple seizure types. We were also given a history that the child may have had spasms when younger, another worrisome feature suggesting infantile spasms. But he looked way too good to have either of these conditions and, in fact, his examination demonstrated normal cognition which went along with what his grandmother was telling us.

Our young child with seizures. Glen Gaulton, Sokoine and Dispensary Clinical Officer looking on

Glen Gaulton and Sokoine with patient

Getting a high five from our young patient once he’s more awake

He appeared initially to be a bit sedated which wasn’t surprising as he was on 90 mg of phenobarbital, but he later awakened to fully participate in his evaluation which was also very encouraging. We wanted to convert him to valproic acid, but before doing so, he needed to get labs to make sure there were no metabolic issues that can be seen in certain children and which would be a problem if we put him on this medication. In the end, we convinced them to come to FAME next week to have the lab work done at which point we’d decide whether to switch him to valproic acid or not.

Chris evaluating a patient with Sokoine’s help

At the end of the clinic day, the clouds were rolling in from the valley below and we could hear thunder in the distance. We packed up and hit the road, skipping the overlook as the weather was closing in fast on us. It began to rain and did so most of the way back to the tarmac. We had wanted to stop at a friend’s shop in the village of Manyara so took a different road back and made it there just in time before they closed. I had wanted to get some wall hangings and items for the new house and was successful in doing so, while the others were looking for gifts to bring home with them. We eventually got back on the road and made it to Karatu in time to watch the sunset with dinner. Glen made us a great tomato, cucumber, onion salad to go with our cheesy pasta that Samweli made us for dinner. We relaxed for the rest of the evening with Jamie, Nan and Glen watching Lost in Translation on Nan’s laptop. It was a good day at Upper Kitete and we made it back safely. Tomorrow would be a new clinic location at the village of Qaru in the Endabash area of the Karatu district. Glen would also be leaving tomorrow morning and it has been great having him here to see what we have been doing at FAME.

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