I think just about everyone had a hard time getting up this morning after the exhausting day on safari yesterday so it seemed like a longer walk to morning report than normal. We arrived to the conference room for report to find now one there so left to find out what was going on for the morning. Bumping into Dr. Julius, we discovered that everyone was either attending the code going on currently in Ward 1 or was with the pre-eclamptic patient who presented with seizures in Ward 2. To say the least, it was going to be a very hectic day. We quickly discussed the other ward patients in morning report and then left to see what was in store for the day at the neuro clinic. Once again, there were far fewer patients there than I had expected and compared to what we have seen during past visits. Given that we have the same outreach team that brought in over 400 patients last October, it must be the time of the year and the fact that it is currently planting season here. Patients must decide whether they can neglect their fields to deal with their health and most often, their health will come in second place. It is essentially a matter of survival and without their crops, they have very little else.

So, back to the busy start of the day. The ongoing code in Ward 1 turned out to be a young woman who had a history of about five days of gradually progressive confusion and lethargy, had presented to an outside dispensary where she had been treated and sent home. She had lost consciousness and was rushed to FAME the evening before. In the morning, unfortunately, she had had an arrest requiring her to be resuscitated and eventually intubated. She was now on one of the surgical ventilators in the PACU and without brainstem reflexes. Given the question of brain death, which is something that neurologists do routinely, it was just a matter of time before we were asked to see her. Daniel offered to do the evaluation and went over to the PACU to see her, and, as expected, found the patient to have no brainstem reflexes whatsoever.

Unfortunately, there were several factors that also played a role in the decision making. Patients here are usually not intubated even during a code as there are no long-term ventilators for use in most institutions. As you recall, the baby last week had been physically bagged all night as there was no pediatric ventilator available and the same situation existed for this patient in that there was no long-term ventilator available for her regardless of what anyone would have wanted. This is a basic problem all over Africa in that there are no facilities that can manage these patients requiring this care. I’d fight long and hard if we had a patient with Guillain-Barré syndrome come in needing ventilation given the knowledge that would be expected to recover fully. On the other hand, this patient, now without brainstem reflexes, meaning that she was unable to breath on her own, had an extremely poor prognosis even in the best of circumstances. Dr. Gabriel had spent a significant amount of time with the family to explain the gravity of the situation and prepare them for the fact that their family member was not going to survive. Her ventilator was eventually removed with the family understanding that would pass and that it was clear that she was brain dead, meaning that we had determined death by neurologic criteria rather than the more common cardiopulmonary criteria. Things don’t always go this smoothly with the decision making, of course. Her presentation, Daniel felt, may well have been that of meningitis given her encephalopathy for several days, and given that it hadn’t been fully treated until she arrived to FAME, her prognosis from the get go was incredibly poor.

After dealing with this patient, we were peripherally involved with two patients who had also presented with pre-eclampsia, but were doing well as they had both delivered. In addition to this, there was also a woman who presented with abdominal pain and was eventually found to have a rupture ectopic pregnancy with a very large hemorrhage requiring her to take a trip to the operating theater to stabilize her. It was a very hectic morning for the FAME staff and since things were rather slow for us once again given the vagaries of the planting season here, we were happy out with some of the patients as best we could while staying in our comfort zone. No worries, though, I did not send any of my residents into the OR to assist. The closest thing we have to that here is Jon, soon to be a neuro critical care fellow, who is always more than happy to volunteer for any potential procedures and so far, has been incredibly helpful with the ultrasound machine here looking at hearts and optic nerves (for increased ICP). We haven’t provided him with any central lines yet, much to his dismay, but you never know.

We had a number of children to evaluate this morning, which was fine as they were all relatively straight forward, but it was a bit frustrating as Dan and Marin, our pediatric neurology team, would be arriving around noontime today. One of the children we did see was a little baby with a question of developmental delay as the mother was concerned he wasn’t walking at 12 months since her other children had walked at 9 months. The walking issue was of no concern to us since they were still well within the range, but there were other much subtler signs that were present that did raise some level of concern. It still wasn’t 100%, though, and neither myself nor Adys felt that we say one way or the other. Hence the need to have a full pediatric person with us here as it has always been my contention that I am comfortable evaluating children, but admittedly feel less confident when it comes to floppy babies or early development.

Thankfully, Dan and Marin arrived around noontime as expected and were both prepared to see patients that afternoon, though we only had a few. They had been traveling for several days to get here, making a small detour in Dar es Salaam, but eventually arriving safe and sound into Kilimanjaro International Airport. After having spent the night at the KIA lodge, they were awake and on the road early to join us here for two weeks and the bulk of our clinic. Dan is a pediatric neurologist from Children’s Hospital of Philadelphia, who graciously offered to accompany us for this visit as we didn’t have a pediatric neurology resident along to help with the children. Marin is primarily a pediatric inpatient neurology nurse practitioner, who I am told pretty much runs the ICU service at CHOP, and has been incredibly enthusiastic about the possibility of accompanying us here and has finally made it happen.

Given the rather slow nature of the day, we took the opportunity to run to town for some fabrics as everyone was interested in having some clothes made by one of the shops in town. The fabrics here are incredibly colorful and beautiful and there are many, many shops downtown that offer a wonderful selection of patterns and then it is merely a matter of trying to describe to one of the tailors what it is that you would like to have made. That can often be an issue, though, since most of the women at the shops do not speak English and it’s always just a bit nerve wracking hoping that they understood everything you were trying to convey. Today was only a fabric buying trip and that would not be difficult. Phoebe accompanied us all downtown and in very short order, there was agreement on which fabrics were being purchased. Going to the dressmaker or tailor would wait for another day. I had told Kitashu to call me if any patients came in for us to see while we were away and he called at just after 4 pm to let me know that someone had arrived.

Adys agreed to see the patient with Dr. Carin and it turned out to be a woman with what appeared to be some cognitive impairment when they took the history and she was initially thinking about a neurodegenerative process. The more that Adys got into the history, though, it seemed that the confusion was episodic which wouldn’t necessarily be consistent with a diagnosis such as this. After further questions and the recognition that the patient had underlying diabetes mellitis, it was decided to check a blood sugar. Thank goodness they did as her random blood glucose was 18 (!) meaning that she was severely hypoglycemic and at great risk of suffering injury if it weren’t corrected immediately. We whisked her to the emergency bay to get an IV started and gave her fluids and D50 and within moments she began to perk up. Though she had improved with the D50, I believe it was decided that she would come in the hospital overnight to make sure that she was stable. It was disaster averted and just reinforces the fact that you have to look at the basics first before you begin to consider other things. Had that patient had to wait much longer for us it could have been a very serious problem. The old adage, “if you hear hoofbeats, don’t think of zebras,” doesn’t necessary translate in this part of the world given the number of zebra we see here every day, but it still conveys the necessary concerns of thinking of the basics first.

If it’s Sunday, it must be safari. Sorry, it’s a movie reference for those of you old enough to recall the movie, “If It’s Tuesday, This Must Be Belgium,” a 1969 comedy about a group of tourists traveling through Europe. As has been a tradition since my first coming here, I have always reserved Sundays for going on safari, or as they say here, a game drive. Safari in Kiswahili merely refers to a journey and actually has nothing to do with traveling to a park to view animals. The parks in Northern Tanzania are some of the most amazing parks in all of Africa with the Serengeti and Ngorongoro Crater being at the very top. Tarangire, a wonderful park and home to the elephants here is very large and great to visit, but there has been an overabundance of tsetse flies there of recent, and for anyone who has experienced these heat seeking missiles disguised as an insect knows, their bites are very painful and swell to a nice welt in short order. The fact that they do carry trypanosomiasis (sleeping sickness) as well is much less of a concern here as we haven’t had any cases of this here in forever. The other close park for us in Lake Manyara, a much smaller park that is often overlooked and on far fewer itineraries than the others, though would be our destination for today.

Lake Manyara sits on the floor of the Great Rift Valley and is well over 50 km long, with the national park nestled between the rift to the west and lake to the east. The lake itself is very shallow and quite alkaline, but not as much as nearby Lake Natron that serves as a major breeding ground for the lesser and greater flamingos that reside in Northern Tanzania. Lake Manyara is also home to the flamingos that, when in flight, can be seen as huge clouds that will appear and disappear as suddenly as it takes the flock to change direction in unison during midflight. Lake Manyara also used to be the home of the Black Rhino who was hunted to extinction in the last decades, but not before Ernest Hemmingway found the time to travel there with his wife and others to bag the rhino with the largest horn. His adventures there were documented in his non-fiction novel, “The Green Hills of Africa,” and is well worth reading, as are all of Hemingway’s novels.

We packed the Land Rover with all of our supplies for the day that included cameras, binoculars, water, food, and first aid supplies. It was dark on awakening and the stars once again blanketed the sky as though they were our escorts on this trip. The five of us and Ann Gilligan piled into the vehicle after some light breakfast and made our way down the FAME road towards the junction with the tarmac and Karatu proper, which was still in night mode with the coming dawn. It was overcast, but we knew the clouds would be lifting soon enough and we all hoped for a wonderful day at the park. The entrance is only about 30 minutes away and is all downhill traveling from the Ngorongoro Highlands making our way to Mto wa Mbu, where the entrance to the park sits. There are hundreds, if not thousands, of giant white storks nesting in the trees at the entrance of the park, each of them launching themselves into free flight on a regular interval in search of whatever branches and debris they can find to construct their nests. From a distance, they appear as stark white flowers on the tops of the enormous trees and it is only on closer inspection that one realizes the full size of these gorgeous creatures.

Entering the park is merely a matter of registering our vehicle for the day and paying the fee for each of us. I used to have a resident’s permit here that allowed me to get into these parks for half price, but the permit became too expensive to make it worth my while so that now I travel with a business instead. Regardless, the fee is quite reasonable for what we’ll see and the cost for each of us is less than $60 USD. As you drive into the park, the first section is a thick forest with streams running through it and across the road. Looking through the brush you can occasionally see a solitary reedbuck or vervet monkeys in the trees, but today it is the baboon troops that are the most abundant. They love to sit in the middle of the road playing and grooming themselves and conveniently move for us only when they’re certain that we’d like to proceed. The baboons here are incredibly healthy with many, many cute babies to show for it, jumping off of branches onto each other and riding on their mother’s backs or, for the really tiny babies, hanging onto their mother’s bellies. We encounter troop after troop of the baboons as we travel through the forest and, thankfully, everyone finally has their fill so that I don’t have to stop for each cute baby seen and we can move onto other animals and out of the forest.

Our next stop after entering the park is the hippo pool and viewing platform. This is a spot where you can get out of your vehicle (as long as there no close hippos or cape buffalo) and walk up onto a viewing platform that normally has an incredible view across the marsh towards a large pool where you often see hippos that appear as large rocks in the water until they roll over or rear up in a minor confrontation. On our way, we did spot a hippo that was still out of the water returning from an overnight foraging expedition. Hippos spend most of the daytime in the water socializing and go out to feed only at night and may travel several miles to find food before returning to their pool. Hippos are the most dangerous animal in Africa, accounting for more deaths than any other and it is often encountering a hippo out of the water that is the problem or coming to close to a baby with the mother around. Underestimating the ferocity and speed of one of these animals can certainly be the last fatal mistake that you make and I now understand why Leonard would always check around the car in all directions before we got out when mother nature called if we were anywhere near a hippo pool.

Unfortunately, the grasses were so tall that you really couldn’t even see the pool or the hippos from the platform, but it was gorgeous just the same and Cape buffalo foraging nearby made it more than worth our while to have traveled out here. On our way out from the viewing area we did see an African Fish Eagle sitting atop a tree eyeing the pond for some prey while a black heron walked along frequently spreading it’s wings outward to form an “umbrella” that shades the water and allows it to hunt for small fish and insects. It would take several steps, then spread its wings for another few steps and the process would repeat itself over and over again, all the while hunting and eating. There were herds of wildebeest, Cape buffalo, and zebra and many, many groups of impala, both harems with their single male and its dozens of females, as well as the bachelor herds, made up of up to dozens of males that continually challenge other males for their harem. Impala are the dominant antelope in the woodland areas while it is the Thompson gazelle and Grant’s gazelle that are in the open plains of the Serengeti. We finally ran across some giraffe, or twiga, at first a few solitary ones and then more in groups as you commonly see them. They are incredibly graceful animals who always look as if they’re running in slow motion, but can pick up speed so very quickly as to be deceiving.

It was everyone’s very first safari which I though was very cool as they were getting some great game viewing, though we still hadn’t seen any elephants. That was to change shortly, for as we turned one corner we ran into what we thought was going to be a small group of elephants, but that very quickly became a huge family of dozens of elephants including may young ones, some much less than six months as they couldn’t quite reach their mother’s stomachs. The elephants were all moving in one direction in a very slow manner, stopping every so often to eat some grass or strip the leaves from some branch of a bush or a tree. They are incredibly majestic and magnificent animals, meandering down from the safety of the hills in the morning to seek food and water during the day before heading back up to the safety of the hills for the night. They have little to fear here as there are no poachers nearby, though occasionally a pride of lions may decide to go after one of their babies when times are tough.

We watched this family of elephants for a very long time as they mostly tolerated us slowing moving our vehicle forward to stay in the middle of the group. As we left, though, one of the larger females took some offense to our being there and took just a bit of an aggressive stance, though it was little more than that in the end and she let us pass by on our way without incident. It was just a bit further until we reached Maji Moto, which means “hot springs” in Kiswahili and marks the spot where there is a picnic area and everyone is able to get out and walk around. It was 11 am as we reached Maji Moto and we had only been in the park for 4 hours now, but had already seen so much. It was time for an early lunch after everyone had a chance to walk out onto the new boardwalk that reaches out into the lake. Adjacent to this there was a group of hippos floating along, again looking like a group of huge smooth rocks until one of them decides to bellow loudly or open its giant mouth widely to display its massive canines. We had a relaxing lunch on the picnic tables once everyone came back from their stroll to the end of the boardwalk, with everyone sharing the peanut butter and jelly sandwiches lovingly made by Jon the night before and the hard boiled eggs. There were also protein bars and mango slices to share.

After lunch, we decided to head further into the park as we were still hoping to see some of the lions that live in the park. I had seen them on a regular basis during previous excursions, but in the last two years or so, they have been much more difficult to find so that whenever I query another guide along the road as we pass, it seems that no one has seen them. Though all lions climb trees to sleep, it seems the lions here are much more prone to spend the day lounging in the branches here to get out of the heat of the day. It’s no hotter here, though, than it is in the Serengeti, so that isn’t really an answer as to why that’s the case in this park. It is some learned behavior that these lions have passed down from generation to generation and I’m not sure it’s known why other than some theories.

Much to everyone’s dismay, we didn’t locate any lions and, in the afternoon, most everyone save Sheena decided to take a little snooze which meant that my driving must not have been that bad as it allowed them to catch some shuteye on four wheel drive roads. Right before we reached Maji Moto on our way back, I spotted two Klipspringers just feet from our vehicle on the side of the road and they just sat there posing for us without ever moving. Klipspringers are a very small mountain antelope that is about the size of a Thompson gazelle, though much stockier with downward pointed hoofs designed for jumping from rock to rock. They are probably one of the most docile of antelopes as they always seem to just sit and pose for us. The dik dik, which we did not see today, is smaller and much more skittish, scurrying into the underbrush as you drive past them. The drive out of the park was much less eventful than the morning which was fine as I think everyone was quite exhausted and I had been driving since 6 am straight through save lunch. It is very tiring driving on a game drive, but something that I absolutely love to do and always hate to give up the assignment to someone else.

As a child, I had always dreamed of going to Africa and had always looked to the Leakey’s and Jane Goodall as my heroes unlike other kids. If someone had told me that someday I would be here as a significant part of life, bringing others to experience what I truly love, I never would have believed them. Driving a safari vehicle here and actually guiding safaris is like icing on the cake.

OK, I will now admit to everyone that in the past years, I have purposely neglected to tell everyone that it was birthday on March 9^th. It’s not because of a sense of martyrdom or anything like that, only that I’ve never made a big deal of it my entire life and as I get older, it just seems to be that much less important. I have also managed to spoil surprise birthday parties in the past mostly because of my need to always know what is going on (very much to a fault). When I was 13, my mother managed to plan a surprise birthday party for me at Disneyland during a school trip, nonchalantly saying that she and my brother were planning to go the same day and wouldn’t it be nice to meet for lunch. Of course, she had planned a party for me, having brought a bunch of my friends along and having ordered a big cake for me at one of the restaurants along Main Street. I was having a blast with my friends on the rides and just decided that I would meet my mom and brother later in the afternoon. She was not very happy with me.

For my thirtieth birthday, Kim had planned a big party with all my friends from medical school with the theme of “over the hill.” It was a surprise party and everyone was to wear black as if attending a funeral and the cake was decorated in black and white with a tombstone and “R.I.P.” gracing the top. Knowing my past history, she simply said, “OK, I’m planning a surprise party for you so don’t ask any questions of anyone and make sure you’re available that night.” I understood my marching orders and was able to attend a wonderful get together of all of my school friends who were all dressed in black, and even more wonderful, I have managed to outlive my R.I.P. cake and have enjoyed many more birthdays following. I have now been coming to FAME almost every March since I started (I came one April and found the heavy rains and getting my Land Rover stuck axle deep in the mud were not conducive to our work here) and, as such, spend my birthdays here. Three years ago, Pauline, a prior volunteer coordinator, Jess Weinstein and Jackie Herold, both residents working here with me at the time, planned a surprise party for my 60^th birthday at the Highview Hotel close to FAME with about fifty guests that was a truly amazing get together with dancing and celebration long into the night. Perhaps this should have been a message to me to reconsider my prior approach to this issue.

For this trip, though, I had decided that I would just spill the beans to the others and simply let them know the day of my birthday. We had already made plans to go out to dinner at Gibb’s Farm that night as it is one of my favorite places to eat here and I knew that everyone was looking forward to a relaxing night out and enjoying ourselves. The clinic again began on a very slow pace, similar to what we had seen the day before and most of our patient had been finished by lunchtime (usually around 1-2 pm) so it was decided that we’d head back to the house to relax and asked them to call us if anyone else showed up for the day. I think it was around 3 pm before we finally left for home and having discovered that my internet was out for the week, I was going to run into town for some airtime vouchers which is the way that you load money or airtime onto your phone here to purchase internet bundles. We also needed some extra groceries for our trip to Manyara National Park as we were bringing our own lunch – peanut butter and jam sandwiches, hardboiled eggs, chips and lots of water. You should never travel anywhere here without a sufficient stock of water in case of an emergency or just a plain breakdown, which is not too unusual here if you have read my blogs in the past. Daniel, Jon and I went into town to buy the groceries and airtime vouchers while Sheena and Adys remained behind at home to relax.

Though we had intended to make our lunch before heading out to dinner, by the time we got back home, it was too late for that plan so we relaxed a bit as well and then got ready for our nice dinner and drinks at Gibb’s Farm. It’s always important to get there before well before sunset as the views of the surrounding topography from the veranda are just incredible and like no others. In addition to the five of us, we had invited Ann Gilligan another volunteer at FAME, and anyone else who also wanted to go with us. Ann was the only one that took us up on the offer, which was not surprising as the other everyone else were long term and unable to go that often due the expense. Ann is a nurse practitioner specializing in birth positioning and working here at FAME for a few weeks to see if it would be a good fit for her to come back on a more regular basis. She has been working with Every Mother Counts, a US non-profit that has worked with FAME in the past and had a group working in Arusha this month. Ann decided to check it out here and I suspect that she will become a regular here in the future like most of us have over the year.

Gibb’s Farm, for those who haven’t read my blog before, is an old coffee plantation that used to run as a small village of worker that made everything in house and became a lodge a number of years ago. It was sold several years ago to new owners who have managed to keep the absolute same ambience and feel of the original plantation and have turned it into one of the top destination resorts around. It is not that it is incredibly posh, but rather it is still very Tanzanian, albeit a bit on the pre-colonial side of things. It remains a working farm and most everything is grown there that is served on the table. Sitting on the veranda sipping my Moscow Mule is like taking a time machine back in time 100 years or more. It is beyond relaxing and one can feel the stress of everyday life simply melt from your body with each minute that you’re there. The management of Gibb’s graciously allows us to have dinner there even though we’re not guests of the lodge because of what we are doing here. Many of the staff at Gibb’s or their family are also patients of ours and have known many of them for many years.

Gibb’s also serves as a studio for a number of local artists who use it as their base of operations and paint local scenery and classic views of the region. The lodge itself is decorated with their art, all of which is for sale, and well worth the cost when you are on a trip here. Our dinner was a delicious four course meal with multiple entrée and appetizer choices, all of which are farm to table fresh and very unique recipes. The house bottle of wine matched perfectly and was a welcome addition to the various dishes that were ordered. One cannot go wrong here with anything you order and it is a true pleasure to experience a meal such as this anywhere in the world and even more so here in Tanzania.

After dinner was finished, I heard the waiters banging a drum and beginning to sing “Jambo, Jambo Bwana…,” which is a song of celebration they usually sing here for many things and in this case, it preceded singing “Happy Birthday” to me. The other two tables eating at the time also same to me and it was all great fun and quite a way for me to remember my birthday here in Tanzania with my friends.

We drove home by the short cut that I always use for Gibb’s and can be a bit intimidating for those who are not familiar with the roads in Tanzania and the darkness of the night here. I have driven these roads now for a number of years and feel comfortable on these in most situations, but will admit that in the heavy rains and previously mentioned slip and slide conditions, it can become a nightmare to even the most accomplished drivers. Four-wheel drive is great, but when none of the wheels have any traction, there is very little once can do.

Once safely home, it was time for us to get the lunches for tomorrow made. I worked a bit first on my camera equipment, getting batteries charged and making certain that I had everything needed for the trip to Manyara the following day. When I drive, I obviously am unable to shoot photos, so usually hand over my cameras to the others to take photos. It is a great opportunity for the residents to have the experience of shooting a big DSLR camera with a long safari lens that is perfect for wonderful wildlife shots. The others began to work on the lunches with Jon taking over most of the duties for the peanut butter and jelly sandwiches in a factory-like fashion and Daniel initially working on Ziploc bags of water for the cooler. I think Adys and Sheena were both sharing duties on the hard boiled eggs. The house was filled with music and dance while they were working and it was a real sight. The entire process took less than an hour so that everyone could get to sleep as we were planning to leave bright and early at 6 am so as to get to the park when the gates opened. Everyone’s dreams certainly contained visions of wildlife that night and we were all hyped for tomorrow, even me, having been on dozens and dozens of safaris by this time. There is just something about taking people on their first safari to see the wildlife here that is so exhilarating.

Our clinic today was to be the first of the announced clinics here at FAME for this trip, meaning that the community was given a schedule of the days that we would be seeing patients and it was announced in the churches and public events, as well as fliers being placed around town the adjacent communities. This is accomplished by our outreach team at FAME which is currently made up of Angel and Kitashu, both of whom are social workers at FAME in their normal day jobs, but handle this task for us and have done so over the last few years. In addition to the announcements that are made in Karatu and its environs, they also travel out to the villages where we will be holding mobile clinics and the nearby villages for the specific dates that we’ll be visiting them. It is mostly a very successful process and FAME also has other programs that are similarly announced, such as cervical cancer screening, with all the programs benefiting from the lessons learned as these announcements are being made. There is also sweet spot as to their timing so as not to make them too early or too late in which case they become much less effective.

Following morning report, I must admit that it’s always a bit anxiety provoking as I walk down the walkway between the hospital and the operating theater and first look upon our neurology clinic “waiting room.” It can be a mob scene, especially on the first day of one of these clinics, but for some reason, today was not such a day and the crowd appeared to be quite manageable. When we have far more patients than I know we can see comfortably in one day, we will begin to hand out numbers for the following day and ask patients to return in the morning. We do have to sort through those patients who have traveled far, though, as it’s difficult to ask someone who lives seven hours away to come back in the morning. Surprisingly, though, patients can usually find a friend or family member in town who they can stay with and come back in the morning.  It is a different culture altogether here in this regard as one is considered to be related as long as you come from the same village and, as long as your related, then it is perfectly appropriate to expect things such as a meal or a place to stay for the night.

So, our first full announced clinic did not turn out to be quite as crazy as they normally are, but then that clinic is typically reserved for the first Monday that we’re here and that is the second week. The lower than normal volume may have been related to that or it may have been related to other factors such as the time of year and whether it is planting or harvest time. Whatever the reason, I was actually a bit relieved given the prospect of having some semblance of sanity for the day. It was also a blessing given the fact that I agreed to give up our ER bay (one of “clinic” rooms) to Dr. Gabriel for a few hours this morning so that he could endoscope a patient. That meant that we’d be down to two stations for seeing patients until he was finished with his procedure. In the end, we actually used the room while the patient was recovering behind some curtains as we did need to get started using it.

The day was made of the usual suspects – headaches, anxiety, and GBM. The later abbreviation, which strikes fear in the heart of any knowing neurologist, definitely threw me off here when I first ran into it. Thankfully, it does not stand for glioblastoma multiforme, a highly malignant brain tumor with a very prognosis and short life expectancy, but rather generalized body malaise, or someone complaining of basically total body pain and very likely without a unifying diagnosis. Not a patient that excites us at all as this is rarely secondary to a neurological condition meaning that it’s not something I want to be treating here to begin with. One of my long-term patients who I have been seeing since 2011 did return with her mother (also a patient of ours) today for follow up. She has been on anticonvulsant medications, doing well for many years, and it has been a pleasure to watch her grow up while under my care. Overall, the day was rather nondescript from a patient perspective and other than an inpatient consult that Adys did later in the afternoon, it was pretty much bread and butter neurology; that is, the usual suspects mentioned at the beginning of the paragraph.

Adys’ patient had undergone a procedure with spinal block a week or so ago and had developed a severe headache that was worse when he stood up. This was particularly concerning for a post LP headache, or low pressure headache and which we would treat with a blood patch, where a small amount of the patient’s own blood is placed into the epidural space and essentially patches the leak that is presumably the cause of the problem. Unfortunate for us and the patient, though, was the fact that the person who performs these blood patches was not around. The other option was to give the patient caffeine sodium benzoate intravenously, but the only IV caffeine that was available here were 5 mg vials of caffeine citrate and, though I could find a reference on how to convert the two forms of caffeine, I didn’t feel comfortable injecting something into a patient’s vein only to find out that it would cause some unexplained condition considering that we weren’t treating a lethal condition to begin with even if it was bothering him so severely. So, in the end, we chose to give the patient a high dose of IV dexamethasone, a corticosteroid, that could possibly decrease the inflammation and potentially reduce his headache. I did seem to actually work as later he reported that his headache was improved, but it was decided to keep him in the ward overnight to continue him on IV fluids and just to make certain that he was actually getting better.

I certainly can’t leave out the fact that today was also International Women’s Day 2019. The theme as noted by the UN for this year was, “Think Equal, Build Smart, Innovate for Change.” Here in East Africa this is so very apparent as education for so many years has been reserved only for men as it is in so many other parts of the world and efforts to change this have been ongoing, but are still so necessary. There are many non-profit groups that have been trying to change this by offering scholarships to young girls so that they can continue in school and these should be supported wholeheartedly for it is often through these programs that change will occur as we’ve seen in so many other areas. My good friend, Barbara Poole, has been active in this arena for many years, as she has been in the US, and has had programs here in Tanzania just to focus on this need. She has had programs that have taught women to organize into groups to better market their trade and also programs to sponsor girls in secondary school where they are very underrepresented and it is very expensive for families to send their children to these schools that are only partially supported by the government. It is through these initiatives that society will eventually achieve equality for women and I celebrate all those who are working for this cause. Today at FAME, Katherine, our communications director, spent the day visiting all the women working here to allow them to express their gratitude for this movement and the need for continued vigilance until there is full equality.

Since we were actually able to get back to the house at a decent time, I decided to work on the guacamole that I had bought the ingredients for a few days before. The avocadoes here are quite large and were just perfect so Sheena and I worked on concocting a Tanzanian version of the traditional Mexican dish that contained onion, garlic, lime juice, salt and pepper in addition to the main ingredient. We had it with chapati and chips of all sorts other than potatoes. There were casaba chips, plantain chips and sweet potato chips that when perfect with the dish. Dinner that night was a version of a BLT with the lettuce, so essentially a BT, that was on very thick homemade bread that was just a bit much for the sandwich. I tried putting on some of the guacamole and cheese, but even then, it was difficult to eat due to its dryness so I ended up just eating the parts of the sandwich separately and it was all fine.

 

Later that evening, we had the most magnificent display of lightning and occasional thunder. The entire sky was lit up continuously to our east with cloud to cloud lightening that would occasionally result in an intense bolt of lightning shooting across the sky looking like a mad scientist was preparing to create another Frankenstein. It was just another awesome display of nature here that reminds us of the uniqueness of this part of the globe.

 

 

Having survived the first day of clinic, albeit a bit slower since it was unannounced, was certainly a positive sign and the residents should absolutely have felt a keen sense of accomplishment over that fact. Being thrown into a completely different process as back home, without the necessary hoops that we have to jump through in regard to our documentation gives one a sense of freedom, but it is also new for each of them who have not had to write notes in some time now that the electronic medical record has virtually taken over the medical world. All that those of us used to hold sacred, most of all, our patient interactions have changed now that the computer keyboard has entered the picture and sits in between the doctor and their patient. It is a sad reality in the end.

Medicine here is as it should be. It is without the clutter of the electronic medical records, insurance verifications or HMO referrals. We don’t have the millions of dollars’ worth of tests to order, and even if we did, there wouldn’t be anywhere to send the patients for treatment. What we have here is our clinical acumen, some basic laboratory tests and the patients. They come to see us as there are no other accessible neurologists in Northern Tanzania that come on a regular basis and certainly no others in the Karatu district or for hours in any direction. Last visit, we saw over 400 neurology patients in the short time that we were here and the numbers have steadily grown over the years as have the numbers of patients seen annually here at FAME. Dr. Anne, who we are working with for much of this trip and who has worked with me for several years now, has such a tremendously better understanding of neurology than do nearly all other clinicians in the region and, if all goes well, I am hopeful that we will continue with her education so that in addition to seeing the other patients she sees, she will also care for our neurology patients in between our visits along with those new patients that come in to be seen. This will create a more sustainable neurology presence here in Tanzania and begin to build on the work that we’ve completed so far.

FAME has a very significant focus on education here for both the nurses and the doctors. It is one of the major foundations of their mission here in Northern Tanzania. Not only to do they sponsor nurses, clinical officers, assistant medical officers and doctors for continuing education, but they also have two weekly educational sessions that are provided either by the FAME doctors or by the visiting volunteers. Over the years, we have provided countless lectures on various aspects of neurology that have been given by every resident who has accompanied me. I did these in the beginning, but have felt that it should really be the residents providing these talks as part of their educational process once they began to come with me on a regular basis. It has worked out incredibly well and we have typically asked the FAME staff to tell us what they would like to hear about. Wednesday evening, Dr. Gabriel had asked if it would be possible for us to provide a talk the following morning which was a bit of concern considering that we were heading over to Happy Day in the late evening and I wasn’t sure if the residents had any canned talks to give to the doctors here in such short order. Jon volunteered and I actually suggested that we discuss the pre-eclamptic woman from yesterday in somewhat of a “professor rounds” format that I felt would be useful for the other doctors to see how we approached these types of cases. Jon did an excellent job presenting the case with the help of the others commenting along the way and though it was a bit tough at times to get the others to participate, I think that everyone got the picture of what we do with these cases in regard to a differential diagnosis, evaluations, and management. Again, she was a very complex case that provided an excellent opportunity for lively discussion.

Our clinic today was about the same size as yesterday and considering that it was still unannounced, I was happy to see that we had a fair number of patients coming. Of the interesting cases of the day, Jon saw a young boy who had had what sounded like a psychotic break as an adolescent, where he suddenly began hallucinating (thinking his classmates were a pack of hyenas) and then began running away from home and biting people that tried to stop him. Over a few years, he had become non-verbal, was no longer ambulating and then several months ago began having episodes of extremity shaking that were arrhythmic so didn’t sound like seizures necessarily, but would also have eye fluttering. When Jon saw him, none of the episodes of arrhythmic activity were seen, but he did seem to have some eye fluttering. His case was very difficult to sort out and the boy was completely non-functional in his current state. We all went down the various list of disorders that we felt were likely, less likely and completely unlikely.

We were initially discussing entities such as non-convulsive status epilepticus, an epileptic encephalopathy or possibly something psychiatric in nature, but considering we were from Penn, we couldn’t leave out the possibility of an autoimmune encephalitis. Just to clarify this, a the autoimmune encephalidites, of which a fairly famous one, namely NMDA receptor encephalitis, are a group of disorders that can present in very many flavors and much of the early work in this was done at Penn, where we continue to see patients transferred to our institution on a regular basis to be evaluated for these disorders. Often enough, though, patients who come in will be found to have some either specific or more generalized autoantibodies that may full well be the problem at hand and in need of treatment. Other than steroids, though, we have little else that we could try here to treat anyone with this disorder.

Considering diagnoses that we could possibly treat here, it was decided to give the child a benzodiazepine challenge to see if he was possibly in non-convulsive status or ictal stupor. This is a diagnostic procedure where we give a valium-like medication to a patient who is encephalopathic, which would in normal patient or someone not seizing, cause them to become sleepier, but in a patient,  who is actually having ongoing seizures, it will cause them to paradoxically wake up. In the correct clinical setting, this is an incredibly impressive maneuver and one that will usually cause medical students to immediately consider neurology as their career. A patient who is otherwise unresponsive will suddenly awaken in a very “Lazarus-like” moment that will certainly produce lots of oohs and ahhs from those observing. We gave the young boy a 2 mg IM injection of lorazepam (we didn’t have IV access in the child) and set him aside in the emergency room, under observation of course, and otherwise went about our work seeing other patients. Jon went back to assess the child on several occasions and he did appear more alert and the eye fluttering that he had observed earlier did appear to have resolved. Not quite a Lazarus moment, but it was enough for us to consider the option of placing the child on valproic acid (Depakote) and having him come back to see us in a week. We loaded him orally on the medication and asked them to return at the end of next week to reassess the child. It’s a long-shot, but that’s often the very best we can do here. Had we had access to an EEG machine, things would have been entirely different as we could have immediately known whether the child was in status or not. We would have to work with the next best thing, though, by loading the child on a very good anti-convulsant medication and see him back in short order.

We had not made it to the ward all day, though we knew from rounds that the woman we believed to have PRES had been doing better overnight as we had been told that by the morning she was awake and appropriate and moving all of her extremities. We went back to evaluate her late in the day and, indeed as billed, she was quite alert and fully oriented. Her vision was fine as well, but she still had asymmetric weakness with a left upper extremity drift and some facial asymmetry. Her blood pressures had been just in the range that we had requested and she had continued to receive magnesium overnight so her reflexes remained suppressed. With everything we say, we were still leaning much more towards PRES, but with her continued deficits it was very likely that she had suffered some ischemic injuries along the way. Our CT scan was still down and we debated whether there was still a need to image her or not as she had improved, and given the very low likelihood of venous sinus thrombosis, which would have required anticoagulation, we didn’t feel that it was necessary at the moment. If she continued to improve, we were quite comfortable with our diagnosis and would continue to treat her at PRES.

Unfortunately, the young infant who had suffered the hypoxic brain injury did not fare as well which had been entirely expected. When Jon had had the goals of care discussion previously, and into the evening, the family had indicated that they were still interested in pursuing treatment, possibly being transferred to another hospital, but thankfully our message had gotten through and it had been decided to withdraw care from the child who was extremely unlikely to have survived, let alone had any semblance of a life with any quality. The child died peacefully during the day with medications to make her more comfortable and everyone felt that the right thing had been done. Making a difference isn’t just about saving lives, but it is about preventing suffering and helping patients and families through that process.

We all went back to the house with a sense of accomplishment from the day, in the patients that we helped and those others that we had worked with here at FAME. It was a quite evening that ended with an amazing display of celestial brilliance as we all wondered outside to gaze at the heavens. It was a completely clear night that offered a glimpse of what we rarely can see in North America except in a few places and even more unique that we’re in the southern hemisphere. As our eyes became even more adjusted, it was readily apparent that there almost more stars than there was darkness here. As you looked at any particular constellation, you would immediately begin to see that there are stars beyond that until you realized the huge immensity of our universe. And, at the same it becomes readily apparent that we are just a small dot in someone else’s night sky and you quickly realize how tiny our significance is in the grand scheme of things and that we are not at the center of the universe.

Having settled into the Raynes house yesterday evening, it was everyone’s first morning waking up in this paradise, save me of course. It was a beautiful morning with full sunshine quite early as the sun rose behind our house and cast long shadows towards the hills to our west. The sky was as sparkling clear as one could imagine and the songs of the many bird species fill the air with a lightness that is so very special here. There are no sounds of the city or civilization here other than the occasional vehicle or groups of children that come along the road from the coffee farms down the way. FAME sits six kilometers high out of town on a dirt road that is in decent condition as long as it hasn’t been raining much, but can become a bit of a slip and slide at times. It is literally beyond peaceful here and you have to pinch yourself almost every day to make sure you’re not either sleeping or in heaven. At least that’s how I feel about it here which must be pretty obvious as this will be my 18^th visit to FAME.

Everyone fared for themselves for breakfast (either eggs or cereal) and then readied themselves for the short walk to clinic and morning report at the start of the day. Morning report became a daily feature here once the hospital opened necessitating overnight coverage on the ward, and hence morning report where the overnight doctor gives everyone and update on the ward patients and any overnight admissions. Dr. Jacob, one of the newer clinical officers at FAME had been on overnight and went through the ward list of patients giving updates on each. There is always some discussion on many of the patients along the way and, at times, this can become quite vocal, but it is always for the purpose of educating and never degrading. Clinicians here come in three flavors; medical doctors, which is obvious, clinical officers, who are similar to an advanced practitioner or nurse practitioner, and assistant medical officers, who are somewhere in between the other two. FAME started with few MDs and mostly clinical officers, but now employs four MDs, five AMOs and five COs, all Tanzanian. All of the clinicians are generalists, though a number of them have extra training in certain areas that enable them to provide additional services to patients here at FAME.

During morning report, we listen intently for any patients that may need our services so that we can see then in the ward during the day providing our consultative services and often managing much of their care if they are primarily neurological in nature. This morning they presented an unfortunate case of a one-year-old child who had presented overnight with a prior history of cough who had been taken to an outside dispensary and given some treatment but sent home. The child hadn’t improved and the family decided to bring the child to FAME, though she had a prolonged respiratory arrest (perhaps up to two hours) prior to arriving and was resuscitated when she got here. The child had been intubated and was being bagged now (meaning someone sitting at the bedside constantly squeezing a bag to provide air to her lungs) as there are no pediatric ventilators here. She had also had a seizure in the morning and was given diazepam at the time. It was unclear what we were dealing with, though was most likely a primary respiratory process and not neurologic in nature, and given the history, we weren’t expecting much in the way of neurological function. With clinic starting for us and already having patients waiting, we decided that Jon would head over to the ward to see the baby and do an assessment while the others would begin seeing outpatients.

Our assessment of the little baby was not very encouraging, but we really hadn’t expected much more. She had no respiratory drive, and the only brainstem reflexes we could find were bilateral corneal reflexes. She had no response to pain, no oculocephalic responses and her pupils weren’t reactive. This was certainly consistent with a severe hypoxic injury as we knew had occurred and there was very little that we could see that was positive. Unfortunately, we were concerned that the diazepam she had received that morning could cloud her exam and we felt strongly that we should continue to watch the baby for approximately 24 hours. Later that day, she had recovered one pupillary response, but was otherwise unchanged and Jon went to have a “goals of care” discussion with the family, something that is always difficult when a child is involved and that much more complicated when dealing with the cultural considerations that must be considered. It was decided to continue watching the child overnight, but our expectations were grim regardless.

This was an unannounced day for clinic meaning that we had not made an effort to let the community know that we were here, but rather we would see patients who had been called to come in and were either follow up patients we had seen previously or were those patients who had been recommended to see us when we arrived. There were a fair number of patients already waiting for us and I had wanted this to be a slow day so that everyone would have the time to get their feet under them and learn the system here. Though the documentation in the chart is universal, writing prescriptions, requesting labs and radiology and just about everything else is very much different than what we do in the States. It doesn’t take long, though, for everyone to get up to speed and we were through our morning patients in no time. We were working with Dr. Anne who I have worked with for a number of years now and a fantastic clinician. She was an amazing clinical officer and is now an even more amazing assistant medical officer. At least half of the patients today seemed to be children which was unfortunate given the fact that we’ll have two pediatric neurologists here with us beginning on Monday. Later in the day, I was over in the OPD where they were checking in a very small infant who had obvious developmental delay and seemed to have an episode while in triage that raised concern for a seizure. Dr. Ken asked if we could see the child, and when I learned that they were from Karatu, I immediately suggested that they return next week to see to one of the peds folks.

We had planned to head downtown to pick up sim cards for the residents immediately after clinic, but of course, nothing works to plan. We were asked to see a woman who had just arrived this afternoon with a history of having given birth one week prior and had eclampsia with high blood pressure. She had been discharged home and the day prior to presenting here had developed a headache, then intermittent right sided weakness and finally confusion. Her blood pressures were moderately elevated and she was completely encephalopathic on examination, being unable to follow all but a single verbal command. She had roving eye movements and did not seem to track or blink to threat. She was moving all of her extremities, but seemed to move the right side less easily. Though FAME has had a CT scan for the last several years, it has been out of commission since our last visit here and is awaiting the blessing of the atomic development commission in Tanzania so that it can be switched on and used to scan patients.

Without the CT scanner, though, it meant going through a laundry-list of diagnoses and not beginning any treatment that might be harmful for any one of the top diagnoses. The main concern would have been whether or not we felt that she might have a hemorrhage given her headache, but the leading diagnoses were PRES, or posterior reversible encephalopathy syndrome, or RCVS, or reversible cerebral vasoconstriction syndrome. A third diagnosis, that being venous sinus thrombosis was also a consideration, but her presentation wasn’t as classic for that entity making it less likely. All of these entities are more commonly seen in the setting of pregnancy or being post-partum, but PRES remained our leading diagnosis and, luckily, treating her blood pressure (normalizing it) was the most important treatment at hand. For venous sinus thrombosis, the treatment would have been placing her on anticoagulation, but without having a CT scan to rule out hemorrhage, that was entirely not an option. We ordered magnesium and blood pressure control and hoped for the best.

Despite our emergent patient at the end of the day, we were still able to make it to town to purchase the sim cards and at long last, the residents were now back in touch with the rest of the world through their phones and all was in balance again. There was plenty of daylight remaining for us to do some shopping in the vegetable markets here and we managed to pick up everything we needed for some good guacamole other than the cilantro, though I’m not sure how hard we really searched. It was back to home for dinner, which tonight was comprised of a delicious meatloaf and mashed potatoes. It was Wednesday night which is the evening that all of the volunteers in Karatu get together at Happy Day pub and so I drove everyone down to enjoy the warm company of others from many countries who have come to this part of the world for one reason or another, but everyone with an interest in helping others less fortunate. It’s a wonderful feeling to be part of such a club.

Despite the heavy rain and thunderstorm, I think everyone slept like logs needing to catch on their sleep deprivation and recharge their batteries. It’s amazing what a good night’s sleep under mosquito netting can do for you. We had arranged for all of us to travel together for a visit to James’ auntie where we finally be able to evaluate her tremor and to determine exactly what we were dealing with. The morning had been clear, but it began to pour as we left the house for our short drive to James’ home where we all scrambled onto the porch so as not be soaked. Our patient was waiting for us in the house and we all sat in the living room to commence with our evaluation. I had forgotten that Adys is planning to go into movement disorders and should have turned everything over to her from the get go, but I proceeded to obtain a thorough history from regarding the tremor and any other associated symptoms that she not have realized was significant. Other than her tremor, though, she had little in the way of other symptoms that we look for when dealing with Parkinson’s disease and its associated disorders.

As I had mentioned previously, Parkinson’s disease is a diagnosis that is often made on observation and only confirmed with the examination. Everyone gave their thoughts based solely on their observation and then I turned over the neurological examination to Adys after asking who wanted to take the honors and her colleagues immediately deferring to her. The tremor was predominately resting and only slightly noticeable when using her arms or maintaining posture. It was very asymmetric and predominantly right sided. It activated significantly with any distraction and with gait while she also had diminished arm swing on the right. Afterwards, we discussed her case, putting together all of the aspects of her history and her examination and decided that she most likely had tremor dominant Parkinson’s disease, a subset of these patients with a typically better prognosis for disabling rigidity and gait dysfunction as well as dementia. Explaining something like this can be rather daunting, but she was a very insightful woman who was clearly absorbing much of what we had to tell her. She had read much on the diagnosis of Parkinson’s disease and was clearly scared once we had started the process of evaluating her, but in the end, after explaining everything to here, she was a bit reassured by what we had to tell her. It would require a few medication trials going forward, but I was fairly confident that we would eventually find something that would work for her. We departed their home with lots of sincere thanks and gratitude for having come to see her and the possibility of visiting her in Tanga prior to some of leaving for home. She was the lovely woman and I am hopeful that we will be able to make something like this happen.

The rain had mostly stopped by the time we left for home and when we arrived, it was thankfully no longer storming so that we all remained dry prior to our departure for Karatu. We had lots to load and having had to do so in the rain would have been perfectly demoralizing. We were finally on the road sometime after noon and I had decided that we would stop in Makyuni for fuel as we made our way towards to the Great Rift Valley and up into the Ngorongoro Highlands. It is normally a gorgeous drive, but this time of year, everything is incredibly plush and green. We refueled in Makyuni and picked up snacks for the completion of our drive. We were now going to be crossing the Great Rift Valley and on through the town of Mto wa Mbu, or Mosquito River, before climbing up the steep escarpment towards the Ngorongoro Highlands and Karatu. The scenery traveling along the valley floor by the mouth of Lake Manyara is pretty spectacular, but I have never felt it really prepares you for what you will see once on top of the rift and into the beautiful highlands where the most amazing coffee grows in the incredibly rich soil here along with the many other crops that are grown locally here.

We rise up and up until we are finally in the village of Rhotia where we begin the descent into the Rhotia Valley below with the village of Karatu off in the distance to the west. Even in the wet season, Karatu seems dusty in the distance which continually gives it that frontier look, as it is the last outpost before departing for the Serengeti and parts beyond. The tarmac ends some 15 kilometers beyond the town as you travel through the Ngorongoro Gate and into the NCA, or Ngorongoro Conservation Area. Beyond that is the crater and then you descend into Serengeti while passing by Oldupai Gorge, where Louis and Mary Leakey built their careers by finding oldest man here (Mary) and creating a dynasty (Louis) that included Jane Goodall and her incredible groundbreaking work with the chimpanzees of the Gombe. This area is so rich in the history of not only humankind, but also of the earth as it was millions of years ago. Ngorongoro Crater is a caldera created by the collapse of an enormous volcano three million years ago and represents the largest dry caldera in the world, and is its own ecosystem where the animals have no need to migrate. We are in a region that is rich in both geological and evolutionary history.

We finally arrived to FAME late in the afternoon as the clinics were closing and the residents finally had the opportunity to see where they would be spending the next month of their training. We would begin our clinic in the morning, though it would unannounced and hopefully somewhat less crowded than our clinics normally are. Our new volunteer coordinator, Phoebe, as Alex is now in Kenya as executive director of another NGO, had anticipated our arrival and we had our dinners waiting for us once we had unloaded the car. Perhaps equally important, she had also supplied our house with a case of Safari beer which was very much appreciated after the long and hot drive that we had had coming here today. We eventually all sat on the veranda eating our dinners, with the warm glow of the sunset in front of us along with our cold beers. There are few things in life that can equal these moments or the friends we share them with. It is these moments that will shape our lives forever and I am forever grateful that I have been able to share them with others.

It has been inordinately hot here for some time and though the big rains have not yet started, it had decided to pour overnight. The air was clear and cool this morning and I had finally caught up with sleep deficit well-earned on the flights over. The mornings here are cool and delightful with a soft breeze, the roosters crowing (not beginning at sunrise, though, as one would imagine, but well before) and the sounds of the surrounding community slowly coming to life. I had set up a meeting this morning at 10 am with some friends for coffee and would then make my way back to the airport to pick up the residents who were all arriving together later this afternoon. We would all be staying with Leonard and Pendo tonight, a tradition that began many years ago with my initial trips and then somehow morphing into having one, then two and now four residents all staying here in their small house. I have offered numerous times to find other arrangements for this large group, but they will have none of it, insisting that they are honored to have us here as their guests and that it is the least they can do for us. It is so special for all of us to have this opportunity. I am part of the Temba family here and have watched their children grow over the last ten years, but for the residents it is a rare opportunity to spend time in a Tanzanian home and to have a glimpse of the life here which is far different than ours at home.

I have mentioned Africa-time so often in my blogs, but it is such an important concept to grasp, for not doing so will only lead to tremendous frustration and angst in one’s day. Life is at a much slower pace here and you must adapt to that fact and plan for it every day. Trying to get out of the house for a meeting can be a lesson real lesson in frustration. If only I had a transporter like the Enterprise that would enable me to suddenly be where I need to be leaving only a split second prior. Now that would be cool. I ended up leaving the house at 9:45 am for a 10 am meeting that was on the other side of an incredibly busy Arusha bustling with traffic. I had to drop Leonard off someplace first on the way and actually made it through town very quickly only to find myself thwarted by a huge “diversion,” or detour, on the other side of the airport where the new bypass is crossing the main road. This is a muddy trail with traffic traveling in both directions and everyone trying their very best to miss the huge muddy pools that are created not by the rain, but by the water trucks constantly wetting it down to avoid dust. I’m not sure which is worse. I eventually made it to my destination some 20 minutes late with my friends totally understanding knowing full well what it had taken to get there.

I made it home just in time to rest a few minutes and then leave for the airport to pick up the residents who would be arriving in a few hours. I had hoped to get there early before their flight landed, but again was waiting for someone to drop off something off for me prior to my  trek to the airport. I once again ended up leaving behind schedule and ended up getting there moments before they landed, but all was well since the trip was uneventful for them. I had asked Jon, though, to bring a duffel over for me that I ended up having to pay customs on which is another story entirely. I was less concerned with having to pay the customs than I was with the amount of time it had taken to get through everything (over an hour) which meant that the others had to sit around waiting for me until I completed the process. The final step was going to the new mobile bank outside to deposit money into the customs account, then go back in and wait for the transaction to show up on their system at which time they would give me my paperwork. It was a major hassle that I cannot recommend to anyone and well worth avoiding at all costs.

Once clear of our delay at customs, we were finally able to get onto the road and make our way back to Arusha. Everyone had made it safely and that’s what really counts. They were all incredibly exhausted as they had spent the prior evening at the Souq Waqif in Doha and gotten up early to catch their flight to Kilimanjaro. It was the beginning of an incredible journey for them and I was so happy to have everyone here together. They are all each such amazingly capable individuals and there has never been a need for me to worry, but they are still my responsibility and having them travel half way around the world is something that I take very seriously.

We arrived back to the Temba’s home where we all be staying tonight and enjoyed an amazing dinner that Pendo had been working on. We relaxed after dinner, but it wasn’t long before everyone looked as though they were going to pass out. Daniel and Adys lasted the longest, but it was only a matter of time before they to found it impossible to remain awake. I continued to work on my blog into the wee hours and eventually made my way to bed. It rained and thundered most of that night, but we all slept deeply with thoughts of arriving to FAME the following day.

It seems as if I had just left, though it’s been a solid five months home. I guess that’s a good thing as it must mean that I have the proper balance between these two vastly different, though somehow similar, parts of my life as it exists today. Flying over here has now become virtually routine for me which is pretty impressive considering the sixteen hour layover in Doha that we now have thanks to a schedule change likely the result of a smart marketing executive trying to expose travelers to this country. I had already made the decision not to let anyone fly through Nairobi again as our last visit was a real nightmare with a luggage debacle that was not very much fun. We all had to spend the night at the Nairobi airport which leaves much to be desired, but I do understand that they are updating their services which I’m sure will be a major plus for those that travel I the future. For now, though, we’ll just steer clear of the place. The luggage debacle, for those that don’t recall, occurred because the flight from Nairobi to Kilimanjaro was on a significantly smaller plane that didn’t seem to be able to accommodate all of our luggage. I arrived without either of my duffels and Lindsay arrived without her duffel of personal gear. John’s duffel containing items for FAME showed up long after our arrival to FAME necessitating that it be sent by bus from Arusha and thankfully arrived.

As usual, I had planned to depart on Friday, with the residents following me a day later so that I would have time to get situated here before picking them up. I awakened on Friday morning in Philadelphia to a fairly good snowfall and an accumulation on the ground. It brought back memories of my flight last year that was delayed by six hours due to a massive Nor’easter that had dumped boatloads of snow and gale force winds onto the city as I was preparing to depart for the airport. The Uber price to the airport had suddenly risen by a factor of five, but since I had no choice needing to get to my flight, I bit the bullet and ordered a vehicle to pick me up. Upon entering the car, a gust of wind caught the door and literally ripped it off of its hinges. We were able to close it somehow and make our way to the airport with the driver insisting on opening it up for me on our arrival with some trepidation. I made it to my flight with plenty of time to spare, only to have my flight delayed by six hours leaving us the only passengers in the international terminal as the airport closed (including the American Express Centurion Club) early in the face of the massive flight cancellations. I didn’t get to visit Doha that trip given the flight delay, but was very much looking forward to visiting the city this time around.

With the sixteen hour layover, which seems like an inordinate amount of time, Qatar Airways has graciously (recall that smart marketing executive) offered to have passengers spend the night in the city at one of the hotels there for free, or to upgrade to a five star hotel for a mere $23. It’s basically a little mini vacation on our way here and the residents loved it a year ago, sending me photos, perhaps to rub it in just a bit considering the flight troubles that I had experienced. So, I was obviously very much looking forward to this brief exploration of a Middle Eastern, something that I hadn’t been able to do previously. There is much to see in Doha, which will be holding the World Cup soon, but my main interest was in seeing the Souq Waqif, a traditional marketplace in Doha that is at least 100 years old and was restored to its more authentic current state in the last two decades. I arrived to my hotel, just across the street from the Souq, just before sunset and refreshed myself with a nice shower after my 12+ hour flight, airport time and taxi ride. I arrived to the marketplace in the dark only to find myself in the midst of wonderful maze of appropriately lit alleyways, all branching off from a larger main passage way and then themselves branching again and again. Thankfully, there are small green lit signs indicating how to get back to the main thoroughfare for anyone who might become a bit anxious or lost amongst the wonderful shops that are all organized into different sections. There are the perfume shops, the fabric shops, the tailor shops (for everything Arabic), cookware shops, food shops, and just about any other specialized item that one may possibly need. The shops selling the more touristy items are all on the main drag as are most the many, many restaurants and hookah bars.

Finding a restaurant was no small task as there were so many of them and I finally took the plunge after identifying one where there enough locals to make me feel comfortable. I had a meal of way too much chicken and turmeric rice, chick peas and some curry- pasta dish that was also quite delicious. Later, while continuing to explore, I found what looked like a truly amazing restaurant with tons of locals and some tourists and sent the location to the residents on my phone like any good chief resident would do. They found it the following evening and found that it lived up to the hype I gave it so it will be certain that you’ll know where to find me during my fall visit here on my way to FAME. While exploring the various passage ways, I heard an incredible squawking very close by and followed the sound, quickly arriving to one of the alleys, or actually several of the alleys, where the pet shops were. Birds greatly outnumbered any other type of animal there and the bird shops had cages full of African Grey parrots along with just about any other rare parrot that you could image coming from Africa and then some. I also found fish shops, with many of the same fish I used to keep, and small rodents like hamsters. There was even a cage full of sugar gliders, which the shopkeeper was seemed very impressed that I recognized, but given my long history with animals of all types, it wasn’t much of a stretch. I left the marketplace at around 10 pm while it was still going strong, but I was still quite exhausted and considering I had spent another three hours there walking around, I was quite ready to seek the horizontal position and to close my eyes. The marketplace had not disappointed in any way and I’m looking forward to going back again in the near future.

I had arranged for the same taxi driver to pick me up at 6:30 am to give us enough time to get to the airport, and received a text from him right around then that he couldn’t make it, but had sent another driver to get me and all was well. We made it there in plenty of time so that I was able to some window shopping at the many upscale stores in the newly renovated Doha airport before making my way to my gate among the seemingly hundreds of other gates at this massive airport. The flight to Kilimanjaro was thankfully shorter than the one to Doha, but still longer than a typical transcontinental North American flight and, with no entertainment whatsoever onboard, it gave me plenty of time to catch up on some necessary work that needed completing.

I sat up front in economy so was into the terminal very quickly and able to get my business visa form filled out and processed much ahead of the other travelers. I grabbed my bags and whisked through customs only to find that Leonard and Pendo had been waiting in their car a bit longer, thinking that I would be delayed, as is usually the case, at some point along the process. Within minutes, though, we were skirting along the tarmac heading back to their home in Njiro, where I would be reunited with Gabby, now four, and Gabriel, now almost two. Their other two children, Lennox and Lee, had unfortunately left that morning to head back to boarding school in Nairobi.

It was an uneventful evening for the most part, but Leonard had wanted me to stop by and visit the family of a good friend who had recently lost his father. Funerals here are huge affairs that will usually last 3-5 days with the immediate family hosting all the extended family and friends and feeding everyone continuously for the several days. I had been to Leonard’s mother’s funeral a number of years ago that was held at the plot of land where they had lived when he was young and was high up on the slopes of Mt. Kilimanjaro. The local villagers all met to discuss who would now be in charge of the family, including the grown children, now that she was gone. I felt so privileged to have been invited to this incredible ceremony and touched by the wonderful sense of family and friendship that existed there.

As we arrived at the family’s home so that I could give my sympathies to his friend’s father’s wife and family, I was brought around the back of the house where huge pots were stacked on the ground in front of the kitchen building that had been used to feed the upwards of 1000 guests over the last several days. As I met his auntie, I immediately noticed her shaking hand, for that’s what we neurologists do all the time. We notice those things that others may not, simply because it’s what we do for a living. I am constantly telling the residents that we miss much of our exam these days by having our patients roomed for us and not greeting them in the waiting room to walk them back. Observation is very much of neurology, and there are many diagnoses that can be initially considered by merely watching someone get up out of chair or walk back into your exam room. Our history and examination are there to confirm things for us, but to miss this first observational period is a real crime and a victim of those practices that serve to make us more efficient and revenue neutral, but often at the expense of what medicine was meant to be.

I quietly and privately asked his auntie how long she had had the tremor and she said it had been there for several years, but was worsening over time. I hadn’t wanted to intrude, but she was clearly interested in speaking with me about it and didn’t mind doing so in front of her family. They were all astonished when they asked me what kind of a doctor I was and I simply replied, “that kind of doctor.” We all chatted for some time, Leonard’s friend, his mom, his auntie and several other family members as I was trying to figure out just how I was going to examine her which would be necessary to confirm her diagnosis. I had suspected that this may very well be Parkinson’s disease, but it would take further questioning and an examination to confirm things. It turned out that she lives on the coast in the district of Tanga, a six hour drive in the opposite direction from FAME, so I offered to come back with the residents to see her on Tuesday morning prior to our departure for FAME.

It always seems that these thing occur for a reason and I was clearly brought here tonight for a purpose that no one had realized in advance. Planning is important, but one must always have the ability to be flexible and to make things work even if that wasn’t part of your initial plan. I think we all had smiles on our faces that evening, realizing that our meeting was not one of happenstance, but rather one of a higher meaning. The residents would be arriving tomorrow and I would be picking them up in the late afternoon. It was the start of another month of global neurology and it had already begun for me a few days early.