Monday and Tuesday, September 29 & 30, 2014 – Final FAME Clinics

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Monday morning was my last full day in clinic and we had neuro patients waiting for us at the get go. Doug and I decided to work together for the day and it was a typical Monday morning meaning that FAME was packed with patients. We were also planning to a skin biopsy on a young child in the ward with horrible eczema who had come in months ago with terrible contractures of all of her limbs and after antibiotics to treat secondary infections and two cleansing bathes per day along with moisturizers and vasoline applications was able to see some progress. Doug was going to do the biopsy as he had seen them done in residency and had done one himself previously.

We saw a smattering of new patients as well as several return patients (all doing well on their new seizure medicines or new dosing of medications) during the morning, but of course took our chai break as it was my second to the last day to experience this simply scrumptious chai masala they make here. In the afternoon we brought the young girl back to prepare her for her biopsy. Suhawa (our nurse anesthetist) gave her some several very potent drugs and she just starred at us and remained wide awake. He next gave her some propofol to put her down and she remained awake and responsive for some time and then seemed to be in a trance with her eyes wide open and blinking, but not responding to our voice. Doug initially didn’t feel all too comfortable performing a procedure on her with her eyes wide open so I suggested he pinch her hard enough to be certain she didn’t feel anything and sure enough, she didn’t. He proceeded to do two punch biopsies on her arm and stitch up the sites. I will bring the specimens back with me to give to a dermatologist at Penn who does tropical medicine and infectious disease as well and send the other to Atlanta to a dermatopathologist.

Doug (surgeon), Dr. Luigi (assistant) and Sahawa (anesthetist)

Doug (surgeon), Dr. Luigi (assistant) and Sahawa (anesthetist)

The first of two punch biopsies

The first of two punch biopsies

The look of success

The look of success

After the procedure we were pretty much finished with clinic and I had messaged Daniel Tewa earlier in the day about stopping by for an hour or so. Daniel Tewa has been a close friend since my first visit to Tanzania on safari. I was with both my children, Daniel and Anna, and had decided that doing several days of volunteering would not only be a worthwhile endeavor, but would hopefully leave a lasting impact on my children (which it has). We were schedule to help with some work at a local school that turned out to be in Daniel Tewa’s village and he helped us with the work of painting. We later visited Daniel at his home where he has built an underground Iraqw house and gives cultural demonstrations for visiting safari groups. A year later when I returned for my first visit to work at FAME I contacted Daniel to see if he would remember me and he surprised me when he also remembered my Daniel and Anna. He is a wealth of information about local culture, Tanzanian history, American history, politics and is one of the most generous individuals I know. He treats me and whoever else I bring as honored guests every time we visit and always insists on having a family dinner when I’m there. Because of scheduling we were unable to spend a dinner with him this trip, but I know that Doug and Kelly will be back in my absence as Daniel made it very clear that they were welcome again.

I awakened on my last day for this visit early for another of our early morning walks. We did a little less than three miles in 40 minutes averaging 4 mph. Doug was giving a lecture on the pediatric neurology exam to the doctors this morning and I would only be able to attend half of it as I had an 8:30 am meeting scheduled with Susan (co-founder and director), Caroline (development coordinator) and William (outreach coordinator and human resources) to discuss the future of the neurology program at FAME. It was a very productive meeting and from it we will develop a timeline of growth and expansion of the neurology program.

Doug lecturing on the pediatric neurologic examination

Doug lecturing on the pediatric neurologic examination

I arrived at clinic a bit late, but rounds had been long so I didn’t miss anything. Stole (pronounced “Schtole”) who is the Norwegian gentleman with the orphanage in Mto wa Mbu arrived with the two brothers with muscular dystrophy who I had seen in March with Megan as well as several other children needing neurologic assessment. The two brothers are interesting as the older brother who no longer ambulatory has significant contractures making one think of Emery-Dreifuss muscular dystrophy, but the distribution isn’t right and his contractures are more likely from muscle weakness and lack of physical therapy. The younger brother has clear pseudohypertrophy of the calves and had a classic Gower sign getting up to come in our office. The two brothers most likely have Duchenne’s muscular dystrophy which is quite unfortunate.
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My ride arrived to take me to Kilimanjaro International Airport around 2:30 pm and I ran around the campus to say goodbye to everyone knowing I’d be back in six months so it is no long quite as difficult. It is a big family and it is so clear the pride everyone has in FAME and what FAME means to each and every employee and their family. There is still much work to be done, but we have come so far. I have been particularly blessed to be a part of such a worthwhile project as FAME that has had such an impact on so very many lives in this incredibly wonderful region that is so underserved. I thank everyone who has helped make this possible for me and for FAME.

Until next trip (March 2014),

Mike

Sunday, September 28, 2014 – Lake Manyara National Park

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Since FAME encourages the volunteers to take one day off a week we usually grab this opportunity to go on safari to one of the local parks. Last Sunday was Tarangire and we had the option of going to Lake Manyara or Ngorongoro Crater today, but the Crater is quite expensive as there is a $200 vehicle fee that isn’t present at the other parks. Lake Manyara is a wonderful park that is often overlooked as it is somewhat smaller than the other parks, but it has several magnificent ecosystems that include the lake and marshes, a wonderful wet forest as you enter the park and some nice woodland areas. It also has most of the animals you see at the other parks save for cheetahs and leopards are very rare or non-existent. It is also known for over 400 species of birds and “tree climbing” lions. All lion actually climb trees to get out of the heat of the day, but in Manyara they have developed a particular propensity for this behavior.

Our vehicle picked us up at 6am as it’s always best to get to the park early to see the best animals. Manyara is only 45 minutes away so we were through the gate quite early and started our adventure. We stopped at the hippo pool and viewing station, but the hippos were already in the water (they forage and feed at night) as it is far to hot for them in the direct sunlight and they easily sunburn. Shortly after the hippo pool we had a great view of a Kingfisher, though I just couldn’t get him to move a little for me to remove the branch from the photo.

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Grey-Headed Kingfisher (This is for Megan!)

Moments later I had one of the greatest thrills of my safari career. I must tell you that I’ve have been an amateur herpetologist since I was young (We owned a pet shop when I was a teenager and my brother and I used to go out on weekends and catch all types of snakes in the nearby hills including rattlesnakes which we kept hidden from our mother before we released them back to the wild) and continued to be a reptile lover with my children. I have been looking for snakes here ever since my first day on safari in 2009 and hadn’t found a single one. As we drove I spotted a wonder eight foot cobra right beside the road and almost close enough to touch. I took some photos but unfortunately our driver didn’t stop in time (a problem that day as it didn’t help with future sightings as well) and the snake immediately slithered into some nearby brush. I finally spotted my snake, though, and it was a glorious one. (After studying this photo, I’m not sure if this a cobra or black mamba – either way it’s one deadly snake!)

imageimageDriving in and out of the various ecosystems we encountered lots of birds, wildebeest, Cape buffalo, elephants, various gazelle, giraffe, vervet and blue monkeys and many, many, many baboon troops. Did I mention there were lots of baboons? Every time you turned a corner there were more baboons who often travel in the road. There were tons of babies so as one of my fellow safari goers commented, “I don’t think the baboons are in much danger of extinction here.”

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Baby Olive Baboon

Heading down to Maji Moto (literally hot water or the hot springs) we ran across a very unique sight of a giraffe with quadruplets! It is not uncommon for them to have one or two babies or perhaps even three. But four is something very unusual.

Rare quadruplet giraffes!

Rare quadruplet giraffes!

Our guide had heard talk of a lion pride just past Maji Moto and as we turned off the main road onto one of the smaller game circuits we spotted them under a tree. It was a very large pride with an adult male, a juvenile male at least five or six females and a number of cubs. We watched them for some time from distance and even had lunch in some nearby shade (in our vehicle of course) before proceeding to observe them from a bit closer vantage point. As we drove close, one of the females took offense and got into a squat position ready to lunge at us, but thankfully she settled back down quickly and decided not to take us on. Considering the top of the vehicle was wide open without cover it could have been an easy meal for her.

One of Lake Manyara's pride of lions

One of Lake Manyara’s pride of lions

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She wasn’t very happy with our invasion of her privacy!

Perhaps the most enjoyable event of the day was watching a very young elephant frolic with his mother and family just like you would imagine a two or three year old child doing. The elephant clearly knew we were there as it keep a close eye on us and often darted behind it’s mom for safety. It would soon forget our presence though and go back to its same playfulness and continue to amuse us.

image imageAs were leaving the park (and using the facilities at the picnic area) I managed to get a nice closeup of a barbit that is a very colorful bird and loves to scavenge morsels from the picnickers but was very disappointed as we had nothing to share as we had already eaten with the lions.

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Red and Yellow Barbet

Warthogs are usually not a subject I’m likely to photograph, but this was just all too appealing. I think it was a contest as to who was the ugliest!

Warring Warthogs!

Warring Warthogs!

And finally, another bird for Megan. Here’s a wonderful bee eater.

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Blue-Breasted Bee-Eater

We left the park and headed back up the Great Rift to home with plans for another wonderful meal at Gibb’s Farm. Doug, Kelly, Joyce (I call her the “lab queen” as she created the lab at FAME and now spends nine months out of the year there after she retired from 20 plus years in academia) and I all took a quick shower (thankfully the kuni boilers still had some hot water) to a bit more presentable. The evening was amazing as it usually is sitting on the veranda at Gibb’s, a setting that I’ve mentioned before, but never fails to be breathtaking. Our four course dinner was equally astonishing and I texted Kim a photo of the menu just to make her drool. After all that when we went to pay the bill they told us our drinks before dinner were complimentary from the manager at Gibb’s. Wow!

I drove the back roads home and we all slept exceptionally well!

Lala salama,

Mike

Friday and Saturday, September 26 & 27, 2014 – Arusha and Kilimanjaro International Airport

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Danielle and I were heading to Arusha today as I had planned to take her to the airport tonight for her trip home and we had wanted to see Leonard’s kids and Pendo again before we left. Danielle was scheduled to give another lecture this morning on medications for epilepsy which was from 8-9 am and Dr. Frank had asked her (or perhaps guilted her) to see a women with severe headaches and a significant pyschosocial history requiring some finesse that Danielle could certainly provide. She was taking care of that issue when Jacob asked if I could possibly see a patient that had come the day prior when I was on mobile and had come back to see me.

This is an excellent example of the local health care and why it is so necessary to do what we’re doing here. The patient was a 40ish year-old gentleman who three weeks prior had been found down with no apparent witnesses and was unconscious with blood coming from his nose and ears. Anyone worth their weight would immediately tell you that you need to rule out a basilar skull fracture with that history all. Here, though, he was admitted to the outside local hospital where he woke up after 16 hours with a severe headache for which they gave him paracetamol (tylenol) for pain and discharged him after 3 days. He still wasn’t right after two days and his family brought him back to the local hospital where he was admitted for three days again and discharged. They finally brought him to us and I sent him for a CT scan in Arusha (not everyone can afford that) and contacted Sean Grady at Penn who is chairman of neurosugery and a good friend. Sean got back to me within hours with a recommendation and hopefully I’ll see the patient back before I leave or Doug will take care of it after I’m gone. Chances are he won’t need anything done, but it was very risky not to have imaged him earlier on. The fact that he hasn’t deteriorated in the three weeks is a good sign and he may be lucky.

Danielle finished with her case about the same time and then it was lots of good byes for her, a final cup of chai masala (the absolutely wonderful tea they make here with all different spices and sugar and the bees love as much as we do so we often have to fight them for it!) and we hit the road for Arusha. It is a wonderful countryside with Masai bomas scattered throughout and a small (very small) town here and there. Coming into Arusha is the going to the big city with traffic, pollution and commotion, but it has it’s own character. It is real and authentic and everyone is out living their daily lives. The streets are full of people walking from place to place, doing business and it is very lively. I’ve included some photos courtesy of Danielle since I was driving 😉
imageimageimageimageWe did a few quick errands and then went to visit Pendo and the boys. Lennox and Lee are now five and eight and I have known them for four years. They have transformed into fine young gentlemen and it is so great to see them every visit. Visiting a Tanzanian home isn’t an easy task here as it almost always entails a meal otherwise it would be interpreted as rude by the host. Pendo hadn’t expected us as she thought we coming the following day (a miscommunication thanks to Leonard who was away guiding a safari). Pendo said she’d put something “quick”  together for us before we left for the airport and what was to be a simple meal turned into a delicious lunch of salad, grilled chicken and grilled vegetables that took them nearly two hours to prepare. That left us more time to visit with the kids but unfortunately less time to eat and even less time to get to the airport. We made it there in time, but Danielle was last in line to check in for her flight to Amsterdam.

Since I was staying in Arusha that night (it is not very safe to drive at night here because of animals and crazy drivers) and leaving the next more back to FAME I anticipated the same issue with breakfast so I texted the clinic and told not to expect me until noon for patients. I had a very nice breakfast of eggs, toast and jam, and fresh cut fruit and then had to say my goodbyes. I would not be seeing Pendo and the boys again until March and these partings get more difficult every year. Pendo is also pregnant, due in early February so there will be a new one the next time I am here.

Lennox and Lee modeling their new threads

Lennox and Lee modeling their new threads

I arrived back in Karatu and to FAME a little after noon and had patients waiting for me so it was right to work. The first gentleman spoke very good English so I didn’t need an interpreter and he gave an amazing history. He had been through University and subsequent certification, but told me he had a difficult time concentrating since he was in high school and that he had always had tremendous energy, but would go through periods of depression as well. 20 years ago a doctor had put him on amitriptyline at low doses as he couldn’t sleep and he has been taking it ever since. He had never been diagnosed by anyone here and clearly had bipolar disorder and unfortunately his marriage had failed due to not being treated for this. He was very hypomanic in the office and told him I could treat him with either of two medications, one of which I had brought, lamotrigine (though it is also available here in Tanzania). He was worried about the cost of the medication which would be about 25 to 50 cents a day (quite a bit for a Tanzanian budget for a month and on a long term basis), but I was able to give him two months of it now to see if it would work and we would go from there. I am very hopeful that this will change his life for the better. Also of note, when I asked about siblings and parents it is likely that his father and several siblings also have similar problems.

I saw an elderly women with myelopathy (spinal cord disease) probably from vitamin B12 deficiency who we will medicate and hopefully make better. I saw several other patients with more typical problems and my final patient of the day was a women coming to see me with headache, sore and swollen throat and neuropathy symptoms of a little over one year duration. Thankfully, Dr. Gabriel was with me as the women had a swollen tongue with a friable lesion on it and huge, firm lymph nodes on both sides of her neck. She most likely has a malignancy and will be getting a fine needle aspirate of one of her nodes on Tuesday (the lab is not set up here yet to do tissue biopsies though hopefully soon).

I worked only the afternoon, but it was another wonderfully successful day of patients and teaching (Gabriel was fascinated with the exam of the women with the myelopathy) and I only have a few more left. It’s always a bit easier for me to leave as I know I’ll be back in six months and again after that.

We’re going on safari to Lake Manyara tomorrow, Sunday, and everyone always looks forward to that.

Lala salama,

Mike

Thursday, September 25, 2014 – Mobile Clinic in Upper Kitete

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Awakened to a somewhat cool morning for our walk. No matter, it is still breathtaking here even with the breeze and the views of the Ngorongoro Highlands are as lovely as ever. We usually try to do a 2.5 to 3.5 mile brisk walk in the morning which takes us about 45 minutes to an hour. We start at 6:30 am which is sunrise here. I should also mention that in Swahili time that would be 12:30 as they use 6 am as 12 and 7 am as 1. Most of the signs here are in both Western and Swahili time. That’s because on the equator the sun usually rises and sets around the same time all year and life is much simpler.

We learned yesterday that a young Maasai boy with cutaneous anthrax was admitted and on rounds Doug spent some time examining him. Cutaneous anthrax, though uncommon, is not rare here and it’s the third case I’ve seen since working at FAME. It is contracted by eating an animal that has been dead for some time and laying on the ground where the anthrax spores become an issue. This boy has it inside his mouth and his lower jaw and neck are quite swollen. It is very treatable with antibiotics but has to be done early and his airway will be closely monitored.

Doug evaluating suspected cutaneous anthrax patient

Doug evaluating suspected cutaneous anthrax patient

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Lesion on the lower alveolar surface

Lesion on the lower alveolar surface

We needed to leave earlier today to reach Upper Kitete which is a good 1-1/2 hours away and we didn’t want to arrive after lunch. The drive is very bumpy and there are always great sights such as Land Cruisers packed to overflow and then some or today where a bus couldn’t make it up the hill fully loaded so that most of the passengers had to get out and walk it first before the bus could follow. On arrival to Upper Kitete they are having their well-baby checkups for the government dispensary so we are surrounded by dozens of the cutest kids you can imagine all there to be weighed on the hanging scale. We had to wait until most of the clinic was finished before we could start, but it was a great picture of the local community to see all the children and moms.

Waiting room at Upper Kitete

Waiting room at Upper Kitete

Dr. Isaac helping out with baby weights for well-baby clinic

Dr. Isaac helping out with baby weights for well-baby clinic

Our very first patient was a woman who was accompanied by her husband and the complaint was that she was having episodes of unresponsiveness. It’s always quite difficult to sort out patients with non-epileptic events (what we used to call pseudo-seizures) as it often relies tremendously on having the patient come into the hospital for a prolonged video EEG during which we hopefully record an event that doesn’t have epileptic activity on the EEG. We don’t have EEG here yet, though that is one of our next projects and something Danielle is working on. The next best thing, though, is for them to have one of their typical events right in front of us and that’s just what this patient did. Several minutes into her visit while obtaining the history from she and her husband, she looked slightly agitated, stood up and promptly dropped to the ground (with the assistance of Doug and Isaac, of course). We put her on the bed and her eyes were fluttering and she had no convulsive movements and minutes later awakened. The tough part then is to begin a thorough history looking for clues as to why she’s subconsciously doing this – usually stress with a spouse, sexual abuse, etc., etc. Not the easiest history to obtain. Despite Doug and Danielle’s best efforts, though, we weren’t able to come up with anything. They were educated that these aren’t seizures and may be related to stress and hopefully some insight for them may help.

Patient with non-epileptic events moments prior to having an episode

Patient with non-epileptic events moments prior to having an episode

Danielle had her compliment of seizure patients today with a mother with very typical JME (juvenile myoclonic epilepsy) who had been having seizures her whole life and a her little girl with seizures very likely also JME but too early to diagnose. It is a autosomal dominant gene so typically runs in families like this. Danielle placed her on levetiracitam (available only because we bring large quantities of it with us) as she’s still planning on having more children. This will hopefully change her life and also give her daughter a good chance of seizure control (her daughter was on phenobarb and doing well).

Our incredible outreach coordinator, William, screening a new neurology patient

Our incredible outreach coordinator, William, screening a new neurology patient

I saw three women with very typical migraine and two of them with medication overuse headaches causing them to have daily headaches. The selection of medications to control their headaches was different in each based on factors such as still wishing to have children, frequency of migraine, etc. which is exactly how we do it at home. We have some medications that we brought with us (such as sumitriptan or Imitrex), but mostly it is medications available here that we can use which is always the best.

Patient waiting to be seen at Upper Kitete

Patients waiting to be seen at Upper Kitete

We didn’t get home until after 6 pm (sunset) and Frank and Susan had a wonderful get together for everyone last night at their place as Danielle is leaving tomorrow (Friday). It’s so rewarding to see all the volunteers together along with the others who really make this place run. Ultimately, though, it will be the Tanzanians themselves who will provide the link to the future and that is the goal.

Lala salama,

Mike

Wednesday, September 24, 2014 – Upper Kitete Neuorlogy Mobile Clinic

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Danielle and I did a long loop walking early this morning which was great. The weather was perfect and the views were amazing as usual. We will typically do 2.5 to 3.5 miles in 45-60 minutes and maintain a fairly quick pace. The sun comes up as we walk and all of life here begins to awaken with the new day.

Rounds in the morning are always quite unpredictable. Last night a woman two weeks postpartum came in quite hypertensive, but it seems the staff didn’t want to disturb Kelly who is here to set up their women’s health program. Despite our best efforts it is often difficult to change things here and the term “urgency” in Tanzania, let alone “emergency” is often lost in translation. This is undoubtedly one of the very best medical facilities in all of Tanzania, though the pace of progress in the face of years of cultural and societal habits is often very, very slow. This is a work in progress.

We also had a little 4 year-old in the ward with respiratory stridor for five (!) months with plans to bronch her today for what we thought would be a foreign body. In the end it turns out she has large papillomas nearly completely obstructing her vocal cords likely secondary to HPV from birth. She had to remain intubated and was sent to Arusha Lutheran Medical Center where there is a visiting pediatric surgeon and ENT. Hopefully something can be done for her, but it’s very possible she’ll need to be trached either way.

After sorting out Kelly’s issues with her patient in the ward we were finally able to get on our way to Upper Kitete. This village is a bit further on the Rift than Kambi ya Simba and is about 1-1/2 hours away. We’ve had very big clinics there in the past, but by the time we arrived today (close to noon) a few patients have returned home, but for the most part it’s very light. In the future we will spend only one day in each village (rather than the two as we’re doing now) and the DMO (District Medical Officer) here in Karatu has taken notice of our clinics and has asked if it would be possible for us to select a few other villages in which to provide neurology care. William (our amazing outreach coordinator) and I will discuss this further and likely have new sites for our March visit.

Most of the "Neuro Team" (is Doug playing with kids again?)

Most of the “Neuro Team” (is Doug playing with kids again?)

Doug and Diana evaluating a patient in Upper Kitete's nurse's office

Doug and Diana evaluating a patient in Upper Kitete’s nurse’s office

Danielle and Dr. Isaac evaluating a patient in Upper Kitete

Danielle and Dr. Isaac evaluating a patient in Upper Kitete

Evaluating a patient in the "Labour Room" at Upper Kitete

Evaluating a patient in the “Labour Room” at Upper Kitete

Monica, our nurse, manning the pharmacy in Upper Kitete with another satisfied customer

Monica, our nurse, manning the pharmacy in Upper Kitete with another satisfied customer

The cases today are basic musculoskeletal with a few neuropathies and headaches thrown in which is often the case. Our last case of the day is a gentleman whoI have seen at least twice before with fairly advanced Parkinson disease and probably some superimposed dementia. I started him on carbidopa/levadopa in March 2013, that worked quite well so that he was actually ambulatory, but he has now been off his medicines for the last month and is very, very rigid. So rigid, if fact, that he can’t ambulate and is essentially housebound, if not bed bound. We’ve decided to see him as our last patient of the day and we’ve brought a large bottle of carbidopa/levadopa with us thankfully that we have enough to give them for three months which is when a FAME team will stop by again to refill medications. He would be very difficult to transport to FAME so if it were not for our mobile clinic who wouldn’t be seeing anyone. I’ve explained to his family that we will do our best, but that there will likely be a time when his medications won’t work as well as they have in the past. His wife is very good and thanks us for our visit and trying to help him.

Obtaining a history during our house call

Obtaining a history during our house call

Examining our Parkinson patient

Examining our Parkinson patient

Contemplating a treatment plan

Contemplating a treatment plan

After our clinic we’ve decided to visit the overlook which is a spot on the Great Rift that looks down 2000+ feet into the Great Rift Valley for miles and miles. You can see Mto wa Mbu and Lake Manyara in one direction and the valley floor leading to Lake Natron and Oldoinyo Lengai in the other. It is truly one of the most amazing sights I’ve ever seen and is even more spectacular considering we are standing atop the birthplace of humanity. All Homo sapiens can trace their lineage back to a spot very close. For now though, we are here and marvel at the landscape unfolding before us.

The "Overlook"

The “Overlook”

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Delivering eye patches to our facial palsy patient from the day before

Driving home we met the little boy with Bell’s palsy waiting for us on the road as we had requested. We dropped off eye patches and eye drops to them in the morning and realized we didn’t have any photos of the boy trying to close his eyes. Of course, this was another opportunity for Doug to get his fix of kids and hand out more toys.

Doug in his element!

Doug in his element!

We arrive home just before sunset and will prepare for another day at Upper Kitete tomorrow. We hope to have more patients.

Asante sana (Thank you very much) for everyone’s support.

Mike

Tuesday, September 23, 2014 – Kambi ya Simba Neurology Mobile Clinic

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The morning began with rounds at 8:30 am, though I had to excuse myself for the first part so I could work on rounding up meds and supplies for the second day of mobile clinic (those things we realized we didn’t bring with us on day one such as antihypertensives for a patient complaining of headache who had never had their pressure taken before and was very, very high). When I returned to the end of rounds (mainly to drag Danielle and Doug away) it turned out one of our patients was found to have active pulmonary tuberculosis with a young baby and needed to be transferred requiring some active discussion. So much for leaving on time.

Government building for used for our clinic

Government building for used for our clinic

Getting weighed at a well-baby visit to the dispensary

Getting weighed at a well-baby visit to the dispensary

We finally got on the road which entails several stops to pick up lunch (samosas, quiche, an interesting rice cake, and variously flavored Fanta drinks) prior to really making our way to Kambi ya Simba for day two. We suspected the day would be a bit slower, but we had several good patients. One was a stroke patient with a significant hemiplegia who had been seen at a hospital a month or so ago and was told he had a pneumonia. It was a great teaching case for Dr. Isaac as he had Danielle working with him so they went over the abnormal neurologic examination as well as all the aspects of out patient stroke treatment.

Danielle and Dr. Isaac evaluating a stroke patient

Danielle instructing Dr. Isaac on the neurological examination

Danielle and Dr. Isaac evaluating a stroke patient

Danielle and Dr. Isaac evaluating a stroke patient

Our final patient thrilled Doug as it was a child with a facial palsy of two months duration. In the US we usually check for Lyme disease, but in Africa any patient presenting with a facial palsy (Bell’s palsy) must get screened for HIV. He had been to the hospital at the onset of his weakness and we were able to determine through his mother that he had his HIV status checked and it was negative. Thankfully as he was a very cute little boy. He had incomplete eye closure though with risk for injury at night due to corneal abrasion and they have been given no instructions for eye care whatsoever. So at least we were able to help in that regard. We’re meeting them tomorrow morning on our way to Upper Kitete as we didn’t have eye patches with us, but will fashion some prior to leaving tomorrow morning.

Proof that Dr. Doug can really evaluate outpatient adult neurology (Diana interpreting)

Proof that Dr. Doug can really evaluate outpatient adult neurology (Diana interpreting)

Our little boy with facial palsy being evaluated by Dr. Doug (in his element now!)

Our little boy with facial palsy being evaluated by Dr. Doug (in his element now!)

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On our way home we received a text that Doug’s pediatric skills were needed back at FAME so we arrived to find a three year old with respiratory distress of two months duration that didn’t respond to any asthma treatment and who X-ray was unimpressive except for some atelectasis. The child would desaturate every time she dozed and she was really using her accessory muscles to breath. Doug is convinced she must have aspirated a foreign object and she’s now scheduled to be bronched tomorrow morning.

A quiet evening back at the house just talking with Danielle, Doug, Joyce and Kelly. Tuesday is Tanzania’s version of mac and cheese. Not bad, but leaves a little bit to be desired.

Kesho!

Mike

Monday, September 22, 2014 – Our Neurology Mobile Clinics

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Today was our first mobile neurology clinic to the Mbulumbulu region of the Upper Rift. I’ve now been coming to this area for at least three years so patients are familiar with us and we are seeing many follow up patients from earlier visits. William (our outreach coordinator for these clinics as well as the neurology clinics at FAME and responsible for making everything work and having patients for us) spoke with me today about the possibility of expanding our mobile clinics to other villages on the other side of Karatu. Seems we’ve attracted some attention here.

Doug and Diana evaluating an elderly Iraqw woman and her son

Doug and Diana evaluating an elderly Iraqw woman and her son

Danielle and Dr. Isaac evaluating an epilepsy patient

Danielle and Dr. Isaac evaluating an epilepsy patient

Our first two days are scheduled in Kambi ya Simba (lion camp) which is the closer of the two villages and about 45 minutes away. We split into two groups with Doug and I working together with Diana as our translator and Danielle working with Dr. Isaac to mainly see the epilepsy cases. We were swamped, but had a steady group of patients and were able to finish up by around 4:30 pm. The best case of the day was probably non-neurologic and was a six month little child who ended up having ambiguous genitalia. Doug was able to examine “her” and determine that she will need to be seen at KCMC (Kilimanjaro Christian Medical Center) and have a very thorough evaluation including genetics to determine her actual gender. Doug had never seen a case of ambiguous genitalia before let alone make the diagnosis so that was a huge thrill for him.

Assessing an elderly Iraqw woman's gait

Assessing an elderly Iraqw woman’s gait

Kelly (Women's Health), Diana, Doug and Me

Kelly (Women’s Health), Diana, Doug and Me

Our lunch break in the Land Rover

Our lunch break in the Land Rover

Home after a long day, sunset on the veranda and dinner. Such is life here in Tanzania. Tomorrow we will most likely be up at Kambi ya Simba again.

Lala salama,

Mike

Sunday, September 21, 2014 – Tarangire National Park

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We awakened bright and early today in preparation for our safari to Tarangire. We’re packing lunches (Tanzanian peanut butter and fruit spread, granola bars) for the trip and thankfully the askari have fired up the kuni boilers (wood fired hot water heaters that work amazingly well….as long as their fired up before we need to shower). The safari car is picking us up at 6 am so I’m up at 5:15 am to shower and get my camera equipment together.

Danielle has decided to go on a hike today with two of her Tanzanian friends to the elephant caves up on the crater rim. She had a great time, but I don’t have all the details or the photos just yet. More later on her trip.

Our safari vehicle was filled with me, Dr. Doug, Kelly (a women’s health NP helping set up a program here), Ke (pronounced “Kay” and an MD/PhD student at Yale who is working with FAME on their website and other systems), Luigi (an Italian internist who has been here for a year and is staying on), and his wife, Cindy, who is a lawyer with the Dutch military, a language specialist working on her 12th or 13th language – Chinese!- and is also an amazing photography with more camera equipment than you can imagine). We started our trek to Tarangire, about 1-1/2 hours away and known for it’s elephants and birds (that’s to make Megan jealous, but it is true) and made it to the gate just after 8 am.

A Lilac-breasted Roller

A Lilac-breasted Roller

A Magpie Shrike

A Magpie Shrike

As billed we saw lots and lots of elephants. There are huge families that move from the hills down to the river as it’s the dry season right now and this daily trip is a necessity for them. There are many, many little ones which is great to see as it means the herds are healthy and sustainable.

En route to the river on a dry day

En route to the river on a dry day

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Playful wrestling

Playful wrestling

Doug hadn’t yet seen a wild leopard or cheetah yet so those were among our top priorities. We got to see a beautiful leopard sitting in a baobab tree and though far away was quite clear through our camera lenses and binoculars. The leopard has to be the perfect combination of strength, speed and stealth so they are a perfect killing machine and though they will steer clear of lions for reasons of survival, they still have it over the other cats for these reasons.

Who's watching who??

Who’s watching who??

We ran across three (!) cheetahs sitting in the shade under a tree who were eventually disturbed by our presence and sat up for photos. We had seen the two cheetahs hunting in the Serengeti the other day and I mentioned that it’s unusual to see more than one adult together unless they are of the same sex. They are traditionally solitary animals but are so much more effective when hunting together as they can bring down bigger prey. We didn’t get to see these three hunt in the hot mid day sun though I’m sure it would have been simply amazing.

A trio of cheetah - a rare site

A trio of cheetah – a rare site

Tarangire National Park is based on the river system there while Lake Manyara has developed around the lake and the tropical forest. The Serengeti’s strength is in its vast and wide open plains. During the dry season the river is where life exists in the park.

Socializing at the river

Socializing at the river

We drove along the river for a long ways and didn’t see a whole ton more as far as cats are concerned, but did see two lions laying a good distance away. At least we knew they were there.  On the way back to the main gate we were virtually swarmed by the infamous tsetse fly and I think I took the brunt of it as I wasn’t reacting to them. I have a huge welt on my forearm and one on my neck, but they seem to have benefited from some oral steroids and a steroid cream thankfully. Oh, and a little citrizine helped reduce the itching as well.

After arriving home, Danielle and I went back up to Gibb’s to visit Leonard as we won’t see him before we leave since he’ll be going on safari again in a few days. We were able to spend some time with him last night since he was there with his tour group as well and that was great. We got home late and had grilled cheese sandwiches (a staple back home and a luxury here) and sliced tomatoes before bedtime.

We have our first real mobile clinic to Kambi ya Simba tomorrow and I have things to prepare in the morning so will have to get up a bit early.

Lala salama,

Mike

Saturday, September 20, 2014 – Rift Valley Children’s Village and Oldeani

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Doug and I were scheduled to go to Rift Valley Children’s Village today for the mobile clinic, but there were two young girls for us to see who Danielle had originally seen in March of last year and we felt it best for her to be there for their follow up. We had room in the FAME support vehicle and we hadn’t announced a neurology clinic at FAME for Saturday so it was decided that would work. We made rounds in the hospital ward at FAME and then hit the road for Oldeani, the local village next to the Children’s Village.

Playtime at Rift Valley Children's Village

Playtime at Rift Valley Children’s Village

I’ve probably mentioned RVCV before, but it never hurts to do it again. India Howell, or Mama India as she is known to her children is a woman of amazing vision and heart. Essentially, she built a Children’s Village where she has adopted all the children who live there until they are 18 so they feel it is their home, partnered with the village to improve the public school where her children attend, and has funded a twice monthly clinic by FAME to maintain the health of not only her children, but also the local children attending school with them along with all the villagers. Visiting RVCV is an incredibly uplifting experience that makes one immediately realize what is possible to achieve here. Unfortunately, given the level of poverty and corruption it is also quite apparent of the massive resources it would take to make more than the dent we put here in the Rift Valley a reality for the country. Still that is not a reason not to continue with the work we are doing here to make life a little better in our little corner of Tanzania. The good news is that there are many others here working towards to the same goal so perhaps it will someday be a reality.

Patients waiting to be seen at the Rift Valley/Oldeani clinic

Patients waiting to be seen at the Rift Valley/Oldeani clinic

The clinic at RVCV was spent seeing a mix of patients and even though it was the second day, a number of new patients showed up who had either heard that we were there or just happened by. Either way we were able to see some epilepsy cases for Danielle while Doug pinch hit in his role as a pediatrician and helped out with 16 general pediatrics cases. It was a good showing.

Danielle and Diana (our incredible interpreter) evaluating a RVCV patient

Danielle and Diana (our incredible interpreter) evaluating a RVCV patient

We returned from our clinic at RVCV and all decided to go up to Gibb’s Farm to relax on their veranda that has one of the most amazing views in all of Tanzania (I’m sure some will argue that the view from the top of Mount Kilimanjaro may be more breathtaking, but then again you don’t have to spend six days getting to Gibb’s). Gibb’s is an old coffee plantation and community that has been around for many years here and was made into a five star resort that rivals any in Africa. They grow all their own food, cattle, have a wood shop to make all their own furniture and even have a small clinic there for the worker (though send many to FAME). We all sat on the veranda admiring the incredible view and decided to take them up on their local’s price for dinner of $25 for a four course absolutely amazing meal lasting over 1-1/2 hours. Roasted vegetables and a lovely mozzarella, beet and tomato soup, and a choice of four dishes for the main course. I had roasted turkey breast with couscous cake and a sauce of nuts and dates. Dessert for me was Tanzanian vanilla ice cream and chocolate sauce. Yikes! Needless to say, this was a dinner worthy of any restaurant in New York, Philadelphia or San Francisco and couldn’t be found in any of them for mere $25.

We didn’t get home from Gibb’s Farm until 9:30 or so which is very late for here and we had to pack food and supplies for our safari the following day. Hey, someone’s got to do it 😉

More later,

Mike

Friday, September 19, 2014 – FAME and Rift Valley Children’s Village

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No walk this morning as we have clinical lecture on Friday mornings and today Danielle was giving a talk on status epilepticus. The group of clinical officers, assistant medical officers, doctors, and nurses we have at FAME are all like sponges for information. They are an amazing group and the discussion we most often have after lectures is a clear indication of their desire to learn as much as possible from us. Epilepsy is one of the more common neurologic illnesses (if not the most common) we treat here and most likely the result of all the childhood infections such as cerebral malaria and meningitis in addition to trauma. They have had numerous patients present in status over the last months so Danielle’s lecture is quite apropos to the patient population here.

Danielle giving a lecture on status epilepticus

Danielle giving a lecture on status epilepticus

Today is the day that Danielle and Doug are scheduled to go to Rift Valley Children’s Village on a mobile clinic while I’ve decided to stay back at FAME to see the neurology patients still flocking here. This will be the very first mobile clinic that I’ve not gone on to supervise and it feels a bit like sending your children off for their first day of school. I can’t think of anyone more capable than Danielle so I have no worries that end. Last year I had to leave her behind at FAME to care for an acute stroke patient (Frank wanted both of us to stay but we negotiated) and she had an incredible experience of not only caring for the stroke patient, but also an infant in status and a psychotic Brit from Zanzibar all while I was completely out of telephone communication as there is none at Upper Kitete on the Rift.

The day back at FAME was crazy and I ended up seeing 18 patients with Dr. Isaac by my side. He is becoming a very good neurologist having worked with us now for several days as well as past visits. We also had to send 9 patients away telling them we would call them when we’d be available as next week we will all be on mobile and tomorrow we may all be heading to Rift Valley Children’s village.

Patients waiting to be seen at FAME

Patients waiting to be seen at FAME

Watching health videos while waiting to be seen

Watching health videos while waiting to be seen

The young boy with the post encephalic encephalopathy and probable Lennox-Gastaut left today because his father didn’t want to stay any longer. He looked better on valproic acid and we had him up to the dose we wanted so it was probably fine and we’ll get him back soon to check him out. We also have an acute hypertensive hemorrhage patient in the wards who presented two days ago and is looking much better. Don’t forget, we have no CT scan so this is all based on clinical presentation and his response to treatment. Such is life in the bush. We have an amazing facility here with resources that match anything in Northern Tanzania, but we practice by clinical acumen obtaining tests only if absolutely necessary as they are very costly for the patients to get in Arusha. Some day we hope to have a CT scanner here as it would certainly assist us in these diagnoses. In the meantime we will continue as we are providing the very best of medical care in an area that otherwise has very little.

Thanks everyone for your support,

Mike