The very neurology mobile clinic that we held was in April 2011, my second trip to FAME. I had gone on the larger FAME mobile clinic to the Lake Eyasi region that was a huge affair as we spent the entire week in the bush, and it was not a specialty clinic, but rather it was general medicine. We would take the FAME all-wheel drive bus that carried our supplies, a few passengers, and on-site it would double as a lab if there was no space else at the facility we were using at the various locations. Patients would travel for days to get to us, and they would form long lines to be registered and given a number. Paula Gremley and her partner Amir were two individuals that were integral to the operation as they would do a lot of the outreach prior to our traveling, and they would also help with all the necessary food arrangements as it was a huge group with all the doctors, nurses, and support staff.

Paula and Amir also ran their own non-profit and it was on this second trip that Paula approached me about going to a few villages in the Mbulumbulu region to see and evaluate patients with neurologic illnesses that she thought was very important. Our team was very small back then and was comprised only of Amir and Paula, me, one clinical officer, and a nurse/pharmacist. The very first location we traveled to was Kambi ya Simba (Lion’s Camp), a village in the Mbulumbulu region of the Karatu District where there was no health center at the time and our clinic was held outdoors out of necessity. Patients sat on a long log in the order they were to be seen and I had a small desk set up in an open area where I would evaluate the patients. Our nurse had a table set up a short distance away and patients would take the scripts I had written up to her so that she could dispense the medications and answer any questions they might have.

Over the years with the development of our neurology global health program, these mobile clinics have become much larger and involved, as we now bring multiple teams of neurologists and travel to multiple sites throughout the Karatu district to deliver neurologic care to those patients unaware of treatments that might benefit them or are unable to get to FAME unless they were sure it was for something worthwhile that they would benefit from. Paula had selected the Mbulumbulu region to begin our mobile clinics based on the need in this region and its proximity to FAME as patients would need to travel to FAME at times for lab work and refills.

That very first clinic was incredibly memorable for many reasons, and I have continued to Travel to Kambi ya Simba every six months for the last 14 years. Probably six or so years ago, the government decided to build a very large health center there, expanding the services available on location, and we now see patients in one of the several buildings on campus, though we still have lots of trouble finding adequate chairs and tables for the room, though this is an issue at every clinic site that we travel to. In addition to Kambi ya Simba in the Mbulumbulu region, we had previously traveled even further out along the escarpment to the village of Upper Kitete, which had been extremely busy at times, though when streamlining our clinic schedule, the village was dropped, and patients were recommended to travel to the nearby Kambi ya Simba clinic instead.

Departing Karatu this morning took a bit of doing given all the logistics. We had the flat on Turtle in Ngorongoro and that tire needed to be replaced, though we would have to travel without the spare for today as we couldn’t get the new tire until tomorrow. That was actually OK since we had a good spare on Myrtle and having flats on both vehicles would be pretty unlikely, and very bad luck if it did occur. For the mobile clinics, we bring all the necessary medications with us along with all the translators, social worker, nurse, and driver for the other vehicle. We finally made it downtown to drop off the flat and get our box lunches and we were off. The road to Kambi ya Simba, which can be very gnarly at times, was nice and smooth (at least for Tanzania) as it had been recently graded. The drive is gorgeous as we travel through lush and fertile valleys with lots of different crops growing along with those tending the fields. The sky was bright and clear.

Arriving to the health center at Kambi ya Simba, there were few patients to be seen initially, but as the day went on, the number of patients continued to build so that by the end we had seen 30 patients which is a good number given we only had three residents to see them. The problem we ran into, though, was that the patients who came later and to be seen later, were the sickest of the bunch, requiring more extensive care. The morning went quickly and before long it was lunchtime, which is always eaten in our vehicle as it would be rude for us to eat in front of our patients given the fact most of them probably did not have enough food at home. That’s a practice I learned very early in my time here and have continued to practice religiously as I believe it to be very true. During our first visit to Kambi ya Simba, though, we were given lunch by the villagers, and I remember fondly sitting down with the villagers for a local meal of chicken stew. It was quite an honor. With the size of our contingent these days, feeding us is no longer a viable proposition for the villagers.

Many of the early patients were those with headaches (kichwa) or the “numb and tinglies” (gonji). Headache is our number one diagnosis that we see here in our neuro clinics, and I suspect with a similar frequency as what we see at home. We treat it virtually the same as we do at home, albeit with far fewer imaging studies as it seems there is less anxiety here about something being really wrong. Tricyclic antidepressants have been the mainstay of headache preventive therapy for many years at home, and it is equally so here in Tanzania.

After lunch, more and more patients began to appear and the small grassy slope across from where I was sitting suddenly filled up with several children that were clearly dealing with static encephalopathies of varying severity as their parents (mostly mothers) were caring for them while they waited. At one point, an elderly gentleman sitting across from Joe, and I began to vomit, and it was quite obvious that he was having a seizure. His family was dealing with him, and though we wanted to get him in a room sooner than later, the rooms were already filled with patients so he would have to wait until we had a free room. He woke up after his seizure, which was good thing, but then proceeded to have another shortly after Leah began to evaluate him.

His wife informed us that he had a heavy alcohol history of at least 5 years but had stopped drinking about a week prior as he hadn’t felt well. Seizures seen in the setting of alcohol withdrawal typically occur within 48 hours of discontinuation of drinking, so this was a bit far out and, though not impossible, raised concern for some other process. Also, his seizures were clearly focal and alcohol withdrawal seizures are most often generalized, though again, focal seizures are possible. When there are several atypical features (the time course and focality of the seizures for this patient), it always makes us worry that we’re dealing with something else. Our recommendation to his family was that we bring him back to FAME with us to admit him for his alcohol withdrawal and to prevent further seizures. One problem was that we had run out of levetiracetam as we hadn’t brought enough with us today, so we didn’t have anything that we could load quickly. His family was not prepared for us to bring him to FAME, so instead, we gave him some carbamazepine (we were worried about using valproate without first having labs to check for alcoholic hepatitis) and hoped for the best. The family agreed to come to FAME on Thursday, so hopefully we will see him again.

Meanwhile, the children with the static encephalopathies and seizures were the last to be seen, and one of them was very likely in non-convulsive status epilepticus when we saw as the family said that he had been sick and less responsive for the last several days. Marissa and Jenn had evaluated him, and it was clear that he was not doing well and needed more aggressive care. Again, being out of levetiracetam was a real problem as we had nothing else that would act quickly enough, so Marissa crushed 3 mg of lorazepam tablets (a benzodiazepine), mixed in a bottle cap with water and delivered it to him orally with a syringe. It did seem to help somewhat, but the child definitely needed to come back with us to FAME to be admitted and further evaluated. We finished up with clinic and loaded he and his mother into the back of Myrtle.

Given the number of patients, clinic lasted much longer than we had anticipated, and it was almost 6 pm before we departed. The sun sets around 6:30 pm here and our drive is directly west heading home meaning that we would have the sun directly into our eyes for most of the drive home which a real problem navigating the narrow, windy, and dusty roads that we travel on here. Though all of us are more than happy to stay late working seeing amazing neurology cases, that is not particularly true for all the FAME staff that we’re working with, and I feel bad for them as they have families at home waiting for them. Joe was sitting in the front passenger seat as I was driving and there were times that the visibility from the dust was nearly zero. Between oncoming traffic and pedestrians walking on both sides of the road, there were one or two times that I had to come to a nearly complete stop as I couldn’t see a thing with the dust and the sun.

We arrived back to FAME and the young boy in status was taken to the ED where he spent the night as there were no beds in the ward for him that night. Marissa and Gina spent some time with the ED attending as we felt the boy needed antibiotics and antiviral agents (he was now febrile) as well as a lumbar puncture with concern for a CNS infectious process. He was also loaded on levetiracetam by nasogastric tube. I had to drive Joe up to Gibb’s Farm as he and Sandy were now bunking there (rough life, I know), and, by the time I returned, everyone was already back at the house eating dinner. Marissa was still unsettled with the boy’s presentation and treatment, so the two of us went up to the ED after dinner to check on him. There was a tourist there as well who had unfortunately fractured her femur while on vacation, so there was a bit going on at the time, but we were eventually able to help direct some of the child’s care with the help of Gina, who had also come up as we needed an ophthalmoscope in preparation for a lumbar puncture.

Also, Evan Rosenberg, our fourth resident, had arrived in Kilimanjaro this morning and to FAME shortly after noon. We would be incorporating him into our clinics beginning tomorrow and he would have an on-the-job orientation. It has been an incredibly long day, and it was not until late that our work was done. Everyone was a bit exhausted, and we had our mobile clinics beginning tomorrow at Rift Valley Children’s Village.