Tuesday, March 29 – It’s all about localization…then off to Kambi ya Simba…

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It’s all about localization…

The case of the young girl in the ward yesterday evening had significantly affected each of us given the magnitude of her brain injury and the fact that we would never know exactly what had happened to her. Overnight, we had queried just about everyone we could think of to see if they had any good thoughts as there would still have to be a conversation with her family about the fact that any further care would be futile at this point. In the end, no one had any better guess than we did last night, but the clear consensus was that it was some type of infection that had most likely been what brought her to the hospital in the first place a month ago. Natalie planned to speak with the family as there hadn’t been a chance earlier after the CT scan as they had already left the hospital. This would certainly not be an easy task.

Dr. Anne informing the patients about what types of ailments we treat

This morning was one of the two mornings that we had been asked to give a neurology lecture to the staff and, as last week’s lecture had been given by Peter and Natalie, today it was Alex and Savannah’s turn to enlighten everyone on the wonders of neurology. Their chosen topic was “localization,” which is the art of determining where in the neurologic system a lesion might exist or exactly which part of the nervous system is affected in a specific patient. This is the essence of what we do as neurologists every day and purpose of our lengthy histories and physical examinations. In fact, I will often tell my residents and medical students that if you don’t have a good idea of what is going on after taking your history alone, then there is a good chance that we are going to figure out exactly what is going on. While taking the history, we are formulating what the problem is and designing our examination which is where we test our hypotheses, though sometimes have to redirect.

Natalie and Abdulhamid getting ready for clinic
Two of our exam rooms

Alex and Savannah gave a wonderful lecture that would have made Ray Price, their program director, very proud. This is a subject that isn’t the easiest to grasp unless you’re  incredibly interested, or otherwise a nerd like most of us neurologists. The FAME staff, though, were remarkably attentive and very much engaged with the subject which I was thrilled to see. After they went through the basics, they went over a few of the cases that we had seen at FAME to use as examples of how we think of localization as we’re evaluating our patients.

Alex, Natalie and Abdulhamid
Hear no evil, speak no evil, see no evil

Despite having completed our mobile clinics the week before last with two visits to the Mang’ola region and two to the Rift Valley Children’s Village, Kitashu felt as though it would still be good for us to return to the Mbulumbulu region and spend a day at Kambi ya Simba (“Lion’s Camp”). Kambi ya Simba had actually been the location of my very first neurology mobile clinic back in 2011, when I had been brought here by Paula Gremley and her partner, Amir, two individuals who had been an important part of coordinating FAME’s larger mobile clinics to the Lake Eyasi region in the early days. It was Paula who had suggested creating a smaller neurology mobile clinic and should really be credited with recognizing the need for these visits.

Peter and Anne working together

Mbulumbulu is an absolutely gorgeous region of lush farms that lies in the area between the top of the escarpment having risen from the Rift Valley and high mountain slopes coming down from the Ngorongoro Conservation Area. At the far end of this land, where the mountains meet the escarpment, you can travel no further and will find the village of Losetete. The region forms sort of a long acute triangle with the point being this distant spot where the land ends and the base being formed by the tarmac traveling from Rhotia to the village of Manyara. Kambi ya Simba sits at about the dead center of this triangle and the village of Upper Kitete, where we have previously held our clinics is closer to the point. The land in this region is very hilly and the roads very treacherous during the rainy season. Unfortunately, we would not be traveling as far as Upper Kitete today as this is the location of a wonderful overlook perched thousands of feet above the floor of the Rift Valley with an unobstructed 180° view of the valley below with Lake Manyara to the south and the approach to Lake Natron to the north.

Kitashu, Christopher and Nuruana sitting at our “pharmacy”
Peter and Anne working together

Several years ago, I was contacted by a gentleman who had worked for the Peace Corps in Upper Kitete back in the mid 1960s and had somehow found mention of the village in my blog. He sent me photos that he still had of Upper Kitete when elephant hunting was still a thing and there had been lots of attention to the area from the new government trying to start State operated farms as there had been much interest in by Nyerere in creating many socialist projects, farming one of them. It’s difficult to imagine what this part of the country must have been like in those days as they were in the process of creating a brand new government with more than 120 tribes to navigate, all of whom lived in their own villages and spoke their own languages. Imagine creating an infrastructure trying to build roads, a dependable supply chain and a system of policing. Somehow, though, Julius Nyerere managed to do all this successfully with but a handful of Tanzanian college graduates existing in the country at that time, and continued to lead his country, first as prime minister and then president, for 24 years. He is considered the father of the country and referred to as Babu (grandfather) and also Mwalimu (teacher), for that was his education.

Nuruana registering patients
Anne with one of our special patients

There had been rains in the recent days, though the roads were quite manageable on our way in the morning. Traveling along these rutted dirt roads that are bordered by huge, often luxurious, farms growing colorful crops, it difficult to imagine how this area has been more developed over time as it would have scooped up immediately by real estate investors had anything close to this existed in the US. The land is quite hilly, so we are constantly going up or coming down from the many ridges into the gullies where the streams flow and turn into raging rivers when the rain becomes more intense. As we pulled into the Kambi ya Simba health dispensary, a sprawling group of clinical buildings, wards, maternity rooms and more, it was unclear to most of us just what our work was going to entail here. There were a few patients already present, but not the numbers that had typically seen in the past when there may be crowds of patients lining the buildings waiting to see us on our arrival.

Some very tough critics…

Though there were only a handful of patients that we could see as we pulled up to the buildings, there were plenty more waiting for us in their homes who were soon called, coming to clinic on time. Several years ago, the president of Tanzania had visited Kambi ya Simba, dedicating the health dispensary as a model facility and promising to provide many new services at the facility. We had come to town within days of the celebration and all of the flags and flowers were still present from the original event making us feel incredibly welcome as if it were all for us, though we knew it wasn’t. Kambi ya Simba is one of the largest villages in the Mbulumbulu region making it a natural for this upgraded health dispensary, though it has never been entirely clear to that they have been able to utilize everything that was developed there given the amount of staffing they have been provided. I’m sure it will come in time, but for the moment, and over the last years, they have been very gracious to us for allowing us to come and utilized some of their space to provide the neurology services for the area.

We made due initially with three rooms to work in, though later Natalie decided to see one child outside on the benches as it was getting late for us. As in the recent past, we had Christopher along with us to run our “pharmacy,” dispensing medications that we had written scripts for. There were a number of epilepsy patients as would be expected and a great number of headache patients. Natalie’s final patient, though, was a very young child who had obviously had some type of perinatal injury and had a hemiparesis, but both of his parents, who had accompanied him to the visit, were incredibly attentive to him so that he was in fantastic shape in regard to have absolutely no contractures or significant spasticity. Natalie spent a great deal of time with the parents, as she always does, and when she told them that she was confident their child would be walking soon enough, the mother broke into tears of happiness as she had been told differently in the past by other care givers and to expect the worse. These types of interactions, that instill reasonable hope in parents and family, are very important as otherwise, the child could have been neglected, or worse, abandoned. These parents were so grateful that Natalie had shared this prognosis with them.

Natalie and Nuruana evaluating the young child outside with his parents

During our day at Kambi ya Simba, the skies opened up and there was a truly magnificent downpour that made it difficult to hear things underneath the tin roofed buildings due to the very distinctive sound of the large rain drops striking the metal. Hearing out of only my right ear (due to my episode of labyrinthitis six years ago and loss of hearing in my left ear that has never returned) can be a handicap even in the best of times, but downpours like these can completely incapacitate me. And not only my hearing, but I now also had to worry about the roads driving home that were sure to have become a bit soupy with the onslaught of moisture. Thankfully, though, the rains seemed have abated before it was time for us to leave and, in the end, though soupy they were, there were no close calls on our way to the tarmac.

And thankfully so, for we had been invited to have dinner at the African Galleria once again by Nish Dodhia, who had offered to cover the cost of our drinks for the evening. Given how delicious the food is at the Ol’ Masera restaurant, though, we were all more than willing to go for dinner on our own dime, or should I say Shilling, and opt for the drinks. Their cheese samosas are absolutely to die for and their pumpkin soup has got to be the best I’ve ever tasted. Ke had taken a taxi down from Karatu to meet us for dinner and it was a wonderful time of friendship and dancing in the open restaurant with the wonderfully clear night air of the African sky surrounding all of us. Our remaining days here were getting fewer and fewer and we certainly wanted to make the most of every one of them.

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