I had planned a half day of clinic so we could enjoy a bit of the local scenery here in Karatu – We’ll often have dinner at Gibb’s Farm or somewhere similar before we depart for Ngorongoro Crater in the morning. As had happened prior to our visit with Daniel Tewa, the only way to be certain we’ll get out of clinic on time on any given day is not to be in clinic. It was a very cool morning and, as a morning showerer, I was a bit disappointed when went into the shower only to find that not only did we not have hot water, but there was no pressure on that side of the system. There is always a bit of a battle here about whether we’ll have hot water in the evening or the morning, and though I’m very liberal democrat, I will at times pull rank on others and insist that our hot water is available in the morning, though it really depends on the group. Hot water to the house is supplied by a kuni boiler, and wood fired hot water heater that is shared between two houses, so it often depends on what the other house wants as well. Typically, if the kuni boiler is fired up in the evening, there will be enough water left in the morning to at least give me a tolerable lukewarm shower, though for some reason, that was not to be the case this morning, and I suffered through a very cold and brisk rinse that certainly awakened any slumbering cells that were left in the my body. The issue in fact turned out to be a bit more complex than initially though.
One of the patients brought in this morning was an elderly gentleman who was accompanied by his son and wife and was noted to have several years of severe memory and functional loss as well as a history of heavy drinking that had been stopped shortly after he became sick. Unfortunately, the patient most likely had Wernicke encephalopathy, or worse, Korsakoff syndrome, that are both issues with thiamine deficiency and are often seen in chronic alcoholism which is actually a nutritional deficient state as health caloric intake is substituted by unhealthy intake. Patients who have had gastric bypass procedures that lead to excessive weight loss without the appropriate intake of essential vitamins (such as thiamine and B12), will also develop these conditions.
Wernicke encephalopathy is potentially reversible if it is diagnosed in time and treated aggressively with vitamin supplementation, specifically thiamine, though the diagnosis can often be missed. The clinical triad of confusion, gait dysfunction, and eye movement abnormalities should make anyone think immediately of this condition, though the majority of patients who present do not have the complete triad, or all three of the symptoms, the diagnosis of Wernicke encephalopathy must always be considered for missing them will result in the more permanent condition and devastating condition of Korsakoff syndrome in which patients will have no memory retention and will constantly confabulate. Unfortunately, for our patient, his symptoms had been present for nearly four years and he wasn’t going to improve with any treatment, though we did put him on thiamine just in case it would possibly help him.
Another patient came in with a far less devastating problem, but whose exam and some of her symptoms didn’t quite fit with the normal presentation of what we thought she had and was the most likely scenario. She described bilateral hand numbness that was worse at night, but her examination did not reveal any weakness or sensory changes in the typical locations that one would think for carpal tunnel syndrome, and the provocative maneuvers we typically use (the Tinnel sign, and the Phallen test were both absent or negative) were not present. Regardless, the most common thing she could have was carpal tunnel syndrome as the symptoms were intermittent and bilateral and nothing else would explain the fact that her symptoms were present only at night. We recommended that she fashion wrist extension splints from spoons and Ace bandages which is our standard go to since pharmacies here do not carry them as they do at home.
We finished clinic with plenty of time to spare and proceeded home to gather our things for an afternoon at Gibb’s Farm including lunch at the beginning followed by a hike to the elephant caves (more in a moment), and then an afternoon in the pool. I had originally planned to skip the caves as I’ve done it in the past and was truly looking forward to sitting at Gibb’s drinking gin and tonics or Moscow mules all afternoon. The six of us plus Dr. Anne had an amazing lunch at Gibb’s that was all buffet with an incredible salad and vegetable selection that are all from their gardens and farm fresh. Gibb’s has always been generous to us, and to others, who are volunteering in Karatu and the work that is done for the community. FAME provides care to all of the lodge’s employees in the area as well as to many of the coffee plantations.
After lunch, the plan was for everyone to hike to the Elephant Caves, which I was going to hang out at Gibb’s and relax a bit. In addition, Anil and his family were going to meet everyone at the starting point for the hike. The Elephant Caves comprise a hillside that has been essentially excavated by the local elephants who come each evening to dig at the clay with their tusks, extracting valuable and essential minerals for their help. Elephants digging at the hillside to obtain these minerals isn’t necessarily unique as there are plenty of examples all over the place, but the magnitude of these caves is tremendously larger than in the other locations. It’s rare to encounter the elephants at the site, though I have in the past and have been thankful that we’ve had a guard with us carrying a rifle. Elephants are not one of the Big 5 for no reason at all.
I got a bit of FOMO (fear of missing out) during our lunch when I discovered that Annie had planned to accompany them, and I certainly did not wish to be shown up by my FAME neurology protégée. So, after lunch, we all took the shortcut out of Gibb’s to get to the road up to the Elephant Caves. The spot where we entered the road was about a third of the way up an incredibly steep thoroughfare, and though I hadn’t yet regretted my choice of accompanying them, it did cross my mind. Anil and family were coming by bijaji to join us at the entry gate to the trail, and it turned out their driver just dropped them off at the bottom of the slope rather than having any discussion. They finally make it to the gate and then it was a matter of everyone making payment to the Ngorongoro Conservation Area Administration whose internet was incredibly slow.
We began the hike on switchbacks that took higher and higher until we finally reached the Elephant Caves. We had a guide, Johanes, and a ranger with us, the latter telling us that it was her job to protect us, though she immediately went off with Annie on some shortcuts and wasn’t with us for a significant portion of the hike. The day was gorgeous – exactly the right temperature, clear skies, and occasional breezes. There were no elephants at the caves save for a young calf that had apparently been killed in a collapse, though I’m not certain how accurate that was given its body was sitting at the mouth of the largest cave and fully exposed. Regardless, it smelled sufficiently to keep everyone steering clear of the carcass, and needless to say, no one explored the larger cave where it sat.
We started back down the trail to head back to Gibb’s, but first we would travel to the bottom of an incredible waterfall that I hadn’t been to previously. In the past, we had always hiked to the top of the waterfall, which was certainly an impressive sight, but paled in comparison to where Johanes took us. Apparently, during the pandemic when there were few tourists, they had built an incredibly steep trail to the bottom of the waterfall that gave access to all the separate pools and the cool breeze with the lovely mist. This was just an intermediate point along the falls, and they continued beyond where we were sitting, though there was access to the lower levels. I so wanted to jump into one of the lovely pools to feel the cool waters (probably similar to the shower I had taken in the morning), but that wasn’t allowed and probably for good reason. As steep as the trail had been going down, it was exhausting coming back up to the main trail, and we made our way back to the ranger station where we had started. I’m so glad that I had gone with everyone and I would have been sad to have missed the experience, especially with those falls.
In short order, we were back to the tranquility and beauty of Gibb’s Farm, sitting around pool and having drinks. The Tloma Village Choir came to perform at 5:30 pm for the lodge guests as they often do. We eventually made our way back home after sunset with all of us as well as Anil, Izabela, and their two children in Turtle. With all the sweat and grime from the hike, I had been looking forward to a nice hot shower, but there was little in the way of hot water. Worse yet, I hadn’t realized that the water had been contaminated with mud, so when I went to dry myself off, the towel had turned brown. I thought perhaps that I was just extra dirty, but when I stepped out of the bathroom, I was immediately questioned about whether I had noticed that the water was brown, which I hadn’t. I realized that I had just taken a shower in muddy water, so immediately jumped back in with only cold water to get myself clean. It turned out that the hot water to our two houses was not working properly as there was a leak allowing the brown mud to seep into the system. I have taken many cold showers here at FAME and remembered quickly that there is more to happiness than just a warm shower.
