It was another early morning for me, not only due to the fact that we had planned to leave for RVCV by 8 am, but also because there was a patient in the ward that Dr. Gabriel had asked me to see prior to our departure. This was a woman in her 50s who had been brought to FAME after developing rather rapid onset of right sided weakness by history and who had undergone a CT scan of the brain that demonstrated an enhancing mass lesion in the left frontoparietal region with a significant amount of mass effect and edema. The radiology techs were not yet in so I was not able to view the study myself but based on the report from Dr. Alex, our radiologist in the US reading our studies here, it seemed pretty apparent that we were either dealing with a metastasis or primary brain tumor like a glioblastoma multiforme. She was also HIV positive and without knowing her CD4 count it was difficult to tell whether she was immunocompromised or not as that would certainly impact our differential with things such as toxoplasmosis if indeed her CD4 count was low.
Based on the description of the CT scan, I was pleasantly surprised to find her awake, though she had significant left hemispheric deficits indicating that most of her hemisphere was not functional. She had a left gaze preference, complete right visual field loss, was globally aphasic, had a dense right hemiplegia and, finally, complete loss of any response to painful stimuli on the rights. The fact that she was still awake given her examination with such extensive involvement of the left hemisphere was quite remarkable. I wrote up my consult making the recommendation to place her on steroids given the extensive amount of edema that was seen on the CT scan and we packed up for our departure to RVCV. Later in the morning, I was able to speak with Gabriel about the patient and learned that they were transferring her to Dar es Salaam at the family’s request, but that he would be certain to give her the steroids before she left. The following day, I finally had a free moment to review her scan for myself and was again very impressed that her level of consciousness had been as good as it was prior to her transfer. That is typically an indication that the process has been more of a chronic one as the patient is able to “tolerate” the edema without significant change until one day it just becomes too much and is the straw that finally breaks the camel’s back, resulting in a sudden neurological change in status that appears to be more acute even though the process had been going on for a longer period of time.
The drive to RVCV is, of course, one of my favorites and some of the most stunning landscape one can find everywhere. The region is populated primarily by the Iraqw, one of the two most common tribes that we treat here in the Karatu district, with the other being the Maasai who are most populous in the Ngorongoro Conservation Area where they graze their large herds of cattle, goats and sheep. This morning, the clouds have burned off my earlier than yesterday and the warmth of the sun was a welcome addition and harbinger of another wonderful ahead of us. We arrive quite early, so much so that Katie, the nurse at RVCV, had just prepared her breakfast and coffee thinking that we must still be in transit. There was absolutely no rush for us to get started, of course, and we had the entire day in which to see our patients at a very comfortable pace. Though we had planned to see a greater number of patients today, we were under no deadlines such as the board update call I had from the day prior and we could stay until we were finished.
We again decided to use the two rooms and two teams that we had done the day before and which had worked out incredibly well. For the day, we had about an equal split of epilepsy and headache patients, though we also saw a Parkinson’s patient who had quite significant impairment and was off his medications as they had run out. I was devastated when I learned that somehow our carbidopa/levodopa (Sinemet) supply had been left out of the box of medications that we had brought, but realized that it wouldn’t be difficult to send the medications to him on the following day. This morning, we had actually met one of our patients from yesterday along the road to give her a supply of fluoxetine (Prozac) that hadn’t been available to pack, but had arrived while we were gone. The handoff went without a hitch and is often how things are done here on mobile clinics as no matter how hard we try, there is always the chance that something might be left behind or still on order as we set out for clinic that might only be an hour away by vehicle, but often many more hours by public transport or on foot.
We once again took our break for a delicious lunch made by the house mamas and one of the volunteers had even baked some delicious chocolate cookies that were the perfect dessert for such a day. After we had made it through our day of patients and before leaving, we had decided to visit the duka (shop) where the Rift Valley Women’s Group sell most of their merchandise through. This program is one that has been around for some time in connection with the RVCV and has been a mechanism for training and marketing of items that are made by the women of Oldeani for sale in many of the lodges throughout the Northern Tanzania. Arturo has been helping to manage and grow the group for the last three years and has done a remarkable job, though will be leaving in the near future. I always bring the residents here to buy gifts for home given the excellent cause that the money is going towards and the fact that all of the items are remarkably well made and very affordable for what they are. We had visited the duka yesterday and done a fair amount of shopping, though it was a unanimous consensus that we all visit the shop again today for there were still a few items calling our names. It is such a wonderful project that it is almost impossible not to want to find something there.
Driving home, we all stopped to take a few photos at a spot that not only overlooked the beautiful fields that seemed to go on endlessly into the distance, but also that mountains that formed the eastern rim of the crater and Mt. Ngorongoro, the tallest of them that also lays to the east of the crater. It was a really glorious afternoon with the sun shining strong and a stiff breeze afoot. It was the kind of afternoon that reminds one of all the reasons for coming to East Africa in the first place, and, for me, Tanzania specifically. I was driving a vehicle full of Tanzanians and we were all here for the very same reason, which was to help the residents of Northern Tanzania with their neurological issues while also leaving behind a legacy that would continue to provide this care in my absence. With the group of doctors, nurses and social workers I was transporting this day, there was little question in my mind as to the security of that dream.
Having arrived home at a decent hour with plenty of daylight remaining, I decided to head out for another of my mountain bike rides exploring the environs of Karatu. I have been trying to take a different route each trip just to learn the various areas, many of which I have never been to previously during my many trips here. There is a short cut that I always take to get to Gibb’s Farm and also to Daniel Tewa’s home, so I had set my mind to taking this short cut, but knew that there would be one steep downhill section that might pose a bit of an issue. As I approached the section, I slowed to a snail’s pace and thought that I would just cruise down it slowly, but apparently that was not the tact I should have taken. Shortly after starting the descent, my front tire promptly slipped in some loose soil and down into a rut that crossed up my handlebars and threw me over the front. Thankfully, I was traveling extremely slowly and found that my greatest injury was too my pride, though I did get a rather nasty road rash (though I was not on tarmac) on my right thigh and right forearm. Surely it was a badge of honor for having taken my first spill in my incredibly short mountain bike career, but I was no worse for the wear and got back in the saddle to finish my ride.