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