Saturday, September 23 – A half-day clinic and a long visit to Gibb’s Farm including dinner…

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Heading out of the house on our way to clinic in the morning

One the weekend days, there is no formal morning report meaning that everyone gets to sleep in for at least an extra half hour if they so choose. It was pretty clear that our volume would be a bit lower today as things had dropped off a bit yesterday, though once we got started, we heard about a few consults that needed to be taken care of in the wards, one in the medical ward and the other in maternity. In addition to these two new consults, LJ still had her very sick, young Maasai woman in the ward and continued to pursue her very complicated differential.

The woman in maternity who we were asked to see had a history of epilepsy and had been converted some time ago to lamotrigine given her age and the likelihood that she would become pregnant as some point soon, which was obviously the case as we were now consulted to see her in maternity. She had done well on the medication and had been seizure free for some time, though unfortunately, had stopped her medication a week prior to coming to the hospital and delivering by C-section. The day following her delivery (today), she had a generalized tonic-clonic seizure and, hence, we were consulted. Lamotrigine has a unique side effect in that it causes a very severe rash with a potential for a full Stevens-Johnson reaction (essentially severe burns to the skin and potentially fatal) if it is titrated too quickly, making it a more difficult medication to start safely, especially here when there are more concerns for health literacy or in adherence to medication regimens. Patients starting and stopping medications on their own can always be a significant issue, but with lamotrigine, it can be life threatening.

On the road to town. Jenna is co-pilot

Without being 100% certain when she had stopped her medication (i.e., whether it had been days, a week, or several weeks), and obviously not being able to load her on lamotrigine, we had to come up with another solution, and levetiracetam (Keppra) provided exactly what was needed for the situation. Levetiracetam is an antiseizure medication that can be loaded orally or intravenously without concern for a significant adverse effect and provided us with a simple solution. The only problem we have here with using it extensively in patients, is that it is more expensive than the other medications we’re using, and it is not as readily available in duka la dawas (pharmacies) as several other antiseizure medications here in the country. Thankfully, though, it is a medication registered by the Tanzanian drug authority which means that it is not a problem for me to bring in as a donated medication. That doesn’t necessarily help with the availability issue but using it sparingly shouldn’t be a problem. Wajiha came to me with her plan, which was perfect, and that was to place the woman on a levetiracetam bridge, which means loading her on the levetiracetam and continuing it long enough for us to restart the lamotrigine and get it to a therapeutic level. She did suffer a seizure, which no one is ever happy about, but she didn’t appear to have suffered any complications, and we were able to get her back on her antiseizure medication without too much trouble.

Visiting the woodcarvers shop

The other consult that Wajiha saw was a bit more complicated. It was a 54-year-old gentleman who had been well the day prior when he came home from work complaining of a headache in the afternoon. Later that night, he apparently had stopped talking and his family had brought him to FAME at around 9 am obtunded, not moving his right side as much, and not talking. Wajiha had also noted that his right pupil was non-reactive. This was very concerning for a hemorrhagic event, and he was rushed off to the CT scanner to see exactly what was going on. The other piece of history was that he had been involved in a motor vehicle accident two months prior, and may have been complaining of headaches since then, making the likelihood of a traumatic bleed, such as a subdural hematoma, much greater. Two years ago, Sean Grady and Kerry Vaughn, had come to FAME to teach the general surgeons how to perform burr holes just for such occasions, to relieve the pressure from the subdural hematoma, which is very often an emergent, life-threatening event where time is of the essence and sending someone 2 ½ hours to the closest tertiary center isn’t feasible as the patient will die or either suffer permanent neurologic injury as a result. We also brought two manual craniotomy drills at the time and Sean had set these up in the operating theater and trained the nurses on how to prepare for these procedures.

The neuro crew at Gibb’s Farm – Amos, Jenna, Wajiha, Me, Saidi, LJ, and Whitney

The patient did indeed have what appeared to be bilateral acute on chronic subdural hematomas which would make perfect sense given the history. Unfortunately, treating chronic subdurals are a bit more complicated as they usually have what is called “membrane formation,” which means that you often must perform a full craniotomy to remove them otherwise there can be persistent fluid accumulation and what are called recurrent subdural hygromas (fluid) rather than blood, or a recurrent hematoma can occur. You can still treat the acute process with a burr hole as a life-saving procedure, but the patient will ultimately have to undergo a craniotomy to completely fix the problem. We made our recommendations to the treating team, and they were in the process of contacting KCMC for transfer which made perfect sense since, serendipitously, Kerry Vaughn happens to be there for the year as a neurosurgery global fellow.


Jenna and Amos

We had several headache patients in clinic this morning, at least two of who needed occipital nerve blocks, one of which had pretty classic occipital neuralgia. These are often referred to as “rams horn headaches” as they start on either side in the occipital region and radiate up over your head, usually unilateral, ending at your eye. They are caused by irritation of the lesser and greater occipital nerves, which is often caused by compression (often during the night caused by your pillow on the back of the head, or by excessive muscle tension and spasm of the cervical paraspinal muscles), and by injecting a local anesthetic (lidocaine) and Depo-Medrol (a long acting injectable steroid) over these two nerves, either unilaterally or bilaterally, you can relieve the pain either permanently or at least for several months. We do plenty of these procedures at home and it is something that I teach the residents how to do with their patients so they can become proficient and have this in their toolbox when treating headache patients. We see plenty of headaches here, and with the often-heavy loads women carry on their heads while working or doing household chores, many will have significant cervicalgia, or neck muscle spasm, leading the occipital neuralgia. Whitney had not done a tremendous number of these at home, so I assisted with her patient, which the other was done by Wajiha who had already done a number at home and was comfortable doing them on her own.


With the lighter volume of the day, we had decided to work until 1 pm today and head to Gibb’s Farm for the afternoon followed by dinner there. I have spoken about Gibb’s so often, I’m sure that I’m repeating myself, but it is an incredibly lovely lodge that used to be a working coffee plantation and farm with more of a guesthouse atmosphere. The coffee plantation has been long since sold off, and though they still have a wonderful garden where they grow most of their vegetables for the restaurant, it is no longer merely a guesthouse, but rather has become one of the top resorts here in the Ngorongoro Highlands. An infinity pool was completed several years ago and the restaurant, which has always been top notch, continues to impress anyone who is lucky enough to eat there. Gibb’s Farm has also always been very supportive of FAME as well as the volunteers who come here to give their time and energy. From my very first visit volunteering at FAME in 2010, I have enjoyed visiting Gibb’s for an occasional meal and have always felt so at home there. I am always greeted by the staff and have come to know many of them very well. Nick and Sally, who have managed Gibb’s Farm now for the last several years, have always been the most gracious hosts and have gone out of their way to make us feel welcome and, even though we are not spending the night there, we are always treated as if we were.

With the lighter volume of the day, we had decided to work until 1 pm today and head to Gibb’s Farm for the afternoon followed by dinner there. I have spoken about Gibb’s so often, I’m sure that I’m repeating myself, but it is an incredibly lovely lodge that used to be a working coffee plantation and farm with more of a guesthouse atmosphere. The coffee plantation has been long since sold off, and though they still have a wonderful garden where they grow most of their vegetables for the restaurant, it is no longer merely a guesthouse, but rather has become one of the top resorts here in the Ngorongoro Highlands. An infinity pool was completed several years ago and the restaurant, which has always been top notch, continues to impress anyone who is lucky enough to eat there. Gibb’s Farm has also always been very supportive of FAME as well as the volunteers who come here to give their time and energy. From my very first visit volunteering at FAME in 2010, I have enjoyed visiting Gibb’s for an occasional meal and have always felt so at home there. I am always greeted by the staff and have come to know many of them very well. Nick and Sally, who have managed Gibb’s Farm now for the last several years, have always been the most gracious hosts and have gone out of their way to make us feel welcome and, even though we are not spending the night there, we are always treated as if we were.

Poolside after their swim

As it was a gorgeous day outside, there were certainly plans to swim by the residents and so everyone brought their suits with them to Gibb’s, though we had a few stops to make prior to heading in that direction. We actually hadn’t exchanged any money since we’d been here as I had received shillings from Pendo for some things I had brought to her from Doha, but we were almost out of those and the residents were in need of exchanging their own dollars in case they ran across the need to purchase anything such as the visit to the wood carver or the painter on the way to Gibb’s Farm. In the early years, there were numerous “Exchange Bureaus” to be found on almost any street corner so that you could get Tanzanian shillings without an issue, but this changed about five years ago when it was discovered that some of the money exchanges were actually laundering money, not necessarily for illegal activities, but rather with the goal of tax evasion. Overnight, the exchange bureaus were closed down and, after that, one could only exchange money at the bank which was problematic given their hours of operation and lack of weekend availability.

Iraqw choir from the Tloma Village

More recently, there are now official exchange bureaus opening that have better hours and ease of use and require you to present your passport to avoid any similar scandals as have happened in the past. It should be noted here that exchanging any more than several hundred dollars requires one to bring a wheelbarrow or moving van with them as the largest bill here is 10,000 Tanzanian shillings, or $4 USD, at the current conversion rate of approximately 2500 Tsh to the dollar. Exchanging $1000 would require you to receive 250 10,000 shilling notes, certainly not something that will fit in your wallet, or even in your pocket. After exchanging our money at the new exchange bureau in town, it was time to stop by the Deus Market, which I have been going to since 2010 for the sole reason that I was told to go there and have some belief that there has always been some connection between them and FAME, though they have also been helpful and friendly when we’ve shopped there. We needed to pick up some water for our trip to the crater tomorrow as I would be taking the group and needed to make certain that we had essential supplies.

We picked up Saidi on our way as he would be joining us for dinner, and Amos was tagging along as we were planning to visit Athumani, an artist friend that I have known for years and have several pieces of his at home and in my office. I had only discovered at our last visit, that Athumani is also very active within the youth of Karatu and teaching them art as a means of being able to support themselves even if they were not planning to pursue art as a full-time career in the future.  Athumani’s art is very colorful and I’ve loved it ever since I first met him as an artist in residence at Gibb’s Farm, though he has since moved on and has a small stand where he displays his art on the side of the Gibb’s Farm road just shy of the lodge where is his next door to the wood carvers and Phillipo, who has a small family coffee farm and roasts our coffee for us personally. A few things were purchased from Mbuga, the wood carver, and we finally on our way to Gibb’s as we would be visiting Phillipo on another day.


Arriving to Gibb’s Farm is difficult to describe for those who have not previously been initiated to the sheer beauty of Tanzania and the Ngorongoro Highlands. Dramatic is an understatement. Perhaps breathtaking may be closer to the truth. Gibb’s Farm is an island of calm nestled at the foot of the Ngorongoro Crater Rim and adjacent to the Ngorongoro Conservation Area. Driving up the incredibly bumpy and, on occasion, near impassable road to anything but Land Rovers and Land Cruisers, one could not possibly imagine that such a place exists at the other end of the journey, yet, upon passing through the gate, it becomes readily apparent in very short order that you have stumbled upon something very, very special. The views are immense and ever changing throughout the day and the season, and the landscape is just impeccable. The view from their veranda and the pool area goes on forever in the distance. The plants and flowers are amazing.

Two workaholics before dinner

Everyone in the group went for a swim except for me as I had to deal with some shida (trouble) with Turtle as one of the rear doors had decided to unlatch and swing open without warning on the rough road which is not an acceptable thing, especially when you’re on a game drive and there are animals about. Nor if the person in that seat happens to be sleeping. I took the vehicle to the fundi (specialist) at Gibb’s to see what they could do for it, but he only changed one bolt to a longer one which I didn’t think would fix the problem (spoiler alert – it didn’t work during our Crater drive the following day). After their swim, everyone sat around the pool relaxing and that included Saidi, FAME’s volunteer coordinator who was also joining us for dinner, and Amos, one of our translators and a friend of Athumani, who had come along with us for the afternoon.

Beetroot risotto

At 5:30 pm, the local Iraqw choir from Tloma Village came up to sing for all the guests. I have seen them many times and they never disappoint, though singing at Gibb’s with the backdrop of the view over the acres of coffee plants and all the other greenery and the valley beyond, it is difficult for anything to go wrong in that situation. In addition, to the choir singing, they had set up a very nice outdoor bar for all the guests to which we were invited as well. Some of our group did not drink, but for those that did, which included me, the gin and tonic with a sprig of rosemary was delightful and a perfect finale to an absolutely lovely afternoon.

Deconstructed tiramisu

We were set up for dinner at the outside table on the veranda and it could not have been more perfect. Though the weather was a bit cool, light throws had been placed on each of our chairs and everyone but me seemed to take advantage of them. Dinner was delicious as usual and the dessert of “deconstructed tiramisu was a perfect complement to the evening. We departed Gibb’s Farm, all commenting on what a great night it had been as well as how very full we were. We would be leaving early for the Crater tomorrow morning, so I stopped to top off the tank on the Land Rover at the Bamprass station that is open all night. We still had lunch to make for our safari when we got home.

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