The last Friday morning of the month is always reserved for a 7:30 am M&M (morbidity and mortality) conference here at FAME – I usually try to attend these, but today’s topic was DKA, or diabetic ketoacidosis, a topic not very dear to my heart. Weighing whether or not to get an extra half hour of sleep, I chose the former and skipped the conference, though with a smidgen of guild, I must admit. Though it’s doubtful that I would have learned anything I could apply directly to my practice of neurology, I’m sure there would have some process issues brought up for discussion that I could have either contributed to or benefited from hearing. It’s very unusual for me to miss this type of meeting, so I must have been tired and felt that I needed the sleep.

The weather seemed to make a bit of a turnaround today as the sun appeared to shine more than the rain fell which lifted everyone’s spirits and brought more patients into clinic. At the dinner I had gone to last night at the Plantation Lodge, the group was planning to go to Ngorongoro Crater the following day which was good as we were scheduled to go on Sunday, and I was anxious to hear just how wet the crater was and whether the roads were all passable. I had only been to the Plantation Lodge once in the last several years for a FAME Board function, but it reminded me of a very funny situation that had occurred back in the fall of 2018 when we had been invited to have dinner there by one of the managers as one of my residents had treated them for a bad back.

The drive to the Plantation Lodge has never been well marked and is truly off the beaten path, so I had stopped shortly after leaving the tarmac to ask a local walking if I was still heading in the right direction. I was, of course, but immediately upon putting my vehicle back into gear, the entire gear shift, from the below the floorboard, came completely off. I was holding the gear shift knob in my hand with about 18” of the shifter attached and nothing coming out of the floor. Needless to say, I was just a bit shocked but then started laughing as it was one of the funniest things I had ever seen, until I realized that we had better figure something out to keep us on schedule as there was no way that I wanted to pass up a free dinner at a very respected lodge. Peter Schwab, then a medical student, was sitting in the front seat next to me, and the two of us began feeling around just below the floorboard and were somehow miraculously able to wedge the gear selector into third gear, but that was going to be about all we could do, and there was certainly no possibility of getting it into another gear while we were moving.

Thankfully, most large four-wheel drive vehicles, at least serios ones, have a transfer case that allows you to shift the vehicle into four-wheel low gear when it’s necessary to have extra low gearing. You can actually shift into and out of low gear when you’re moving very slowly, and this allowed me to start the vehicle in third gear low and then shift quickly into third gear high before we got moving too fast. I managed to drive us the remainder of the way to the Plantation Lodge for dinner and parked on a slight downhill slope to get rolling when it was time to go home. What I didn’t count on, though, was the uphill exit from the parking lot which proved to be a significant impediment as I wasn’t able to get up enough speed to make it up the hill without bogging down.

I had everyone get out of the car to push (mind you, this vehicle is the size of a tank), while I gunned the engine to take off once I let the clutch out. My good friend and colleague, Steve Gluckman, was with us, and all I remember was hearing him groan as I looked behind me in the side mirror to see him bent over in pain as the rear wheel had spun and shot gravel back at him like buckshot. Thankfully, other than a bruise to his thigh, he was uninjured as I had thought I might have seriously hurt him. Everyone jumped back into the car now that I had reached the top of the hill, and we were back on way to FAME with only two usable gears – third gear low and third gear high – but at least our bellies were full after having a wonderful dinner on the house.

We had a respectable number of patients today – 9 – with mostly epilepsy cases and several HIE babies as well as an older cerebral palsy patient. Shannon, of course, evaluated the children with developmental delay, though one again, there is very little for us to help with other than to treat their epilepsy if they have it, spasticity if that’s present, and then to make recommendations for physical therapy which can be quite beneficial even at very young ages to improve their chances of some functional status. With the status quo to have far less prenatal care as well as the widespread belief by many tribes that restricting calories for the mother during pregnancy with the obvious result of having smaller babies with subsequently lead to fewer birth complications. Unfortunately, the latter if obviously untrue and results rather in malnourishment of the fetus and perinatal insults.

We had no plans for the evening other than relaxing while Shannon had planned to go out for a run. She had changed into her running gear and was just about to head out the door when Saidi called me to tell me that a leopard had been spotted on campus and that everyone should remain inside for the evening. Though Shannon was obviously disappointed that she couldn’t go running, she would have been far more despondent had she taken off a few minutes earlier and bumped into a cat several times larger than Matilda and not nearly as friendly. Shortly after Saidi’s phone call, Susan texted me to let me know that not only had the leopard been spotted on campus, that it had actually been seen around the volunteer houses. This was an incredibly unusual situation for these animals typically do not wander anywhere near occupied structures and even when there is an attack reported, they are most often in more remote areas along paths or trails. For an animal like a leopard to come close to human contact it would surely have lost its way and would be doing anything in its power to remove itself from the situation. Other than the child in the conservation area that was attacked outside his school while using the outhouse, most other attacks have all occurred when people have been walking in the dark in areas where they probably shouldn’t be.

As I have everyone working five days straight to begin their time here, I now schedule our first Saturday as a half day so the residents can pick some activity to do. Today, we were planning to go the African Galleria in the late afternoon so everyone could do some shopping, and then we would stay for dinner as the food at the Ol’ Mesera is as good as any around. The clinic was very slow today with only three patients, though they were interesting cases as far as teaching goes. One was an elderly gentleman who came with a weeklong history of a facial palsy that was clearly peripheral (meaning it involved his facial nerve and not a brain problem) and there were no other specific risk factors other than he had a history of diabetes. In the United States, the first thing we think about when someone presents with a peripheral facial palsy is whether they could have Lyme disease as this is very often the presenting symptom and Lyme disease is endemic in the US, especially in the Northeast. Though Lyme disease exists in Tanzania, it is by no means endemic, and the leading non-idiopathic cause of Bell’s Palsy is HIV infection, which you should reflexively check in a patient like we do Lyme disease in the US. Thankfully, his HIV status was non-reactive, and it is most likely that his facial palsy is idiopathic, though we now know that many of these are actually secondary to Herpes zoster or Herpes simplex.

One of the other patients seen today is a long-term patient of mine who I first saw in 2011 with symptoms that were classic for bipolar disorder (and more specifically bipolar II) and has been stable on medications for the last fifteen years. When he had first come to see me, it wasn’t entirely clear what his problem was, but the more we talked, the more it was clear that he had an underlying psychiatric disorder that had caused him to be dysfunctional, losing his job and family. I placed him on lamotrigine, a medication that has proven very effective for bipolar II and his life turned around. Though he did not recover everything he had lost previously, he has remained extremely functional since starting the medication and has stabilized further over the last several years with the addition of olanzapine to his medication regimen. Every time I see him, he thanks me profusely for having recognized his problem so long ago and placed him on the correct medications so that his life has been more normal and productive over these last years.

I heard from Annie Birch today regarding the weather in the crater for our expedition tomorrow. Annie has been a fixture here in Karatu since long before I was coming and now manages her own safari company, Aurora Africa, which does small custom safaris to Tanzania and elsewhere. She is an amazing authority on anything to do with Tanzania or travel, and much more. She is a great resource. She was in charge of the group I had dinner with on Thursday and even though she hadn’t been able to go to the crater on Friday as she had stayed back with one of the travelers who wasn’t feeling well (and had come to FAME), it was great to hear from her that the crater was as magnificent as ever and there were no problems with the roads there. Taking my own group and guiding there always carries its own portion of anxiety given all the things that can happen – vehicle breakdowns (yes, this happens nearly every trip), no good animal sightings (has never happened, but I worry about it just the same), or problems with our paperwork. I’ve always been up to the task and really look forward to it each and every time, but it is a lot of responsibility just the same. Regardless, it remains a dream come true of mine to be driving a Land Rover through East Africa, and there is absolutely no substitute for that, at least for me.

The residents spent over an hour shopping at the African Galleria while I sat outside in the restaurant for most of the time, having drinks with Nish as well as two local friends, Will and Alex. Will had worked for the RVCV for several years in administration and is now doing consulting work in Karatu. Alex, who is from Liverpool, has been working for the RVCV and the Tanzanian Children’s Fund (TCF), their parent organization for nine years working with the school programs they fund. Dinner was great as usual, and we got home at a decent time as we’d be getting up before sunrise to head to the crater – we’d also be taking our three Tanzanian translators with us as they don’t get to go very frequently, and I figured I could spring for the $5 entrance fees for them.