It was hump day of the last week of the rotation for this group of residents who would be departing on Saturday, though the Tarangire group (more below) would be coming today and we could typically expect them to bring a dozen patients for us to see. In morning report today, we heard about a patient who had come in last night with something quite unique to this part of the world – a lion attack! The attack had occurred on the other side of Lake Manyara from us in the Manyara district and a town called Minjugu, where a Maasai had been herding his cattle when he suddenly noticed that a lion had decided to attack one of his cows. He ran towards the lion shaking his walking stick in the hope of scaring it off when suddenly, and perhaps unexpectedly, the lion decided to turn on him rather than run off, attacking him about the head with its paws and causing very significant lacerations and abrasions to his left face and orbit. Apparently, some friends who witnessed the attack ran to his aid and chased the lion away, otherwise the outcome would have been far worse than just the possibility of losing an eye. His CT scan demonstrated a fracture of his left zygomatic bone extending into the frontal and sphenoid bones as well as significant subcutaneous and a small amount of intracranial and intra-orbital emphysema (air).

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Animal encounters are, unfortunately, quite a common occurrence here, and the outcome most often is in favor of the animals. I continually remind everyone that Tanzania’s national parks have been placed where the greatest concentration of animals exist, but that the parks are not fenced meaning that animals can roam freely in and out of the parks and across the countryside. They obviously shy away from heavily populated regions such as the major cities, but here in the more rural districts, the wildlife is ever present. We’ve had baboon monkey bites, hyena bites (a very tragic story of a Maasai woman whose infant was taken from their boma by a hyena during which she was bitten through the hand trying to fight it off), and a rhino attack (thankfully, not with its horn). Last year, we had a young boy that was attacked by a leopard while going to the bathroom outside his school and was thankfully rescued before being dragged into the forest for dinner. There were also several leopard attacks nearby FAME last year – though thankfully, none were fatal. Several years ago, a Maasai herding his cattle in the conservation area ran across a very angry elephant and didn’t fare very well – the elephant attacked him with its tusks that perforated him a number of times, then stood over him not allowing his friends to help him. By the time he was rushed to FAME (at least an hour drive in a bumpy vehicle), he was really beyond help and expired overnight.

(As I’m writing this blog the following week, we were called by multiple individuals to let us know that a leopard was spotted on campus near the volunteer houses and that we should remain indoors this evening. Shannon was just about to go out running – needless to say, she didn’t)

I had mentioned that it was the day we had arranged for our Tarangire group to come visit the neurology clinic. Several years ago, one of the local Maasai chiefs, Chief Lobulu, from the Tarangire region, just outside Tarangire National Park, brought several epilepsy cases for us to see. His village is outside the Karatu district where we have permission to work, and therefore, we were unable to go to his village for a mobile clinic. He was so happy with the care that his villagers were receiving that he continued to bring patients every visit and their numbers have grown. By far, the bulk of the patients from Tarangire that we’re seeing at epilepsy patients, though we have also seen children with CP and hypoxic-ischemic encephalopathy. Several years ago, he had brought two older teenage boys with Down syndrome to see us, and though we had little to offer from a medical perspective, I raised money to send the two to vocational school for them to learn a trade as they were both highly functioning.

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Today, Chief Lobulu had brought around a dozen patients, all wedged into a tiny dala dala, or one of the little minivans that ply between villages and are the main means of transport short of riding a bijaji (a tuk tuk or three-wheeled motorized vehicle) or a boda boda (motorcycle taxi). There were a number of follow up patients, but also a number of new ones to be seen. The group usually comes for much of the day, and the Chief makes certain that all the patients are seen. He has been incredibly dedicated to his villagers, and, because of that, we’ve tried to make sure he’s able to keep these patients coming back, for without his help, I’m sure they would be lost to follow up which would serve no purpose in the long run. The area where their villages are is extremely poor, very similar or perhaps even worse than the conservation area, and the people there have very little to call their own. I had visited the Chief Lobulu’s village and home in the past to visit the two boys with Down syndrome, and it’s a very, very dry and dusty place with very little in the way of local grazing for their cattle.

Meanwhile, the patient in the ward who had suffered the hypertensive hemorrhage with ventricular extension was seen again in the hospital and seemed to be slightly less arousable with some increased weakness. Patients with intraventricular blood are at risk for developing hydrocephalus as the normal drainage, or uptake, of the CSF back into the venous system becomes sluggish as if blocking the drain in your sink – the ventricles enlarge, causing increased intracranial pressure and mass effect, that is manifested initially be worsening mental status and eventual brainstem compression eventually leading to the potential of herniation. Needless to say, this isn’t a good thing to have happen, so the clinical situation prompted us to order a repeat CT scan to confirm whether or not he was developing hydrocephalus, which, if present, would have required an urgent transfer for an EVD, or external ventricular drain, to lower his intracranial pressure by draining his spinal fluid. Thankfully, his only showed the expected evolution of his primary hemorrhage without any evidence of hydrocephalus, and his mental status had merely been fluctuating as so often can occur.

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Meanwhile, Jill and I had been invited out to dinner at the home of our good friend, India Howell, or Mama India, as she is known here. India, with her Tanzanian business partner, Peter Leon Mmassy, had founded the Rift Valley Children’s Village, or RVCV, in 2004, and is one of the principal reasons that Frank and Susan decided on Karatu as the location for FAME when it opened in 2008. Prior to FAME opening, India had been bringing her children to Arusha to see Frank for their medical care, which at the time was a four plus hour drive on dirt roads. RVCV is located about 45 minutes outside of Karatu, so the proximity was key for providing the medical care to the children as well as to the village of Oldeani where it is located. India is now retired and living down the road from FAME, where her children who are now grown and working can often visit her or come for dinner. Whenever I’ve been at her place, there are several of her older children home visiting and sharing dinner. Her story is remarkable and since we’ll be visiting RVCV in several weeks for our mobile clinics, I’ll tell it them. Save it say that dinner and the company this evening was wonderful.