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

Thursday, September 18, 2014 – Old Friends and Muscular Dystrophy

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Our first three days of clinic have been amazing in regard to the number of patients we’ve seen and the diversity of diagnoses. Lots of epilepsy to keep Danielle happy and lots of pediatrics to keep Doug happy as a clam. We had another very busy day and in the first four days were we’ve now seen 94 neurology patients with lots of mobile clinics to go.

Most of the patients we see here at FAME are either Maasai, Chagga or Iraqw with a smattering of other tribes. There are actually 120+ tribes in Tanzania which is an amazing diversity and has been a real challenge since their independence to unit the country. This diversity, though, is what makes Tanzania the country that it is both culturally and aesthetically. Practicing at FAME in the Karatu district we often need multiple interpreters to help with our evaluation. Most of the Maasai women from the boma do not speak Swahili and only speak Maa (Maasai literally means those who speak Maa) and we often run into Maasai men who only speak Maa. There are few Maa interpreters, but we have several here at FAME which is a real bonus so we don’t require double translation. Same with the Iraqw language as none of these languages have very much in common. We deal with this everywhere we travel often using local townspeople to help us with the translating duties.

Monday we got to see Roza in followup. She is the 15 year-old that Danielle and I diagnosed with Syndenham’s chorea in December 2012 and who we have followed since then. It is an amazing story of making a diagnosis by internet, initiating treatment prior to arriving and then following up to finally see the patient in person. Danielle and I first evaluated Roza in March of 2013, I saw her by myself the following September and then Megan and I saw her together last March. When I last saw her the movements were persistent and bothersome for her, but this visit they are now almost imperceptible and she has blossomed into a beautiful young woman who has so much ahead of her. She is doing well in school and just took her national examinations to see whether she can continue in school or not. She is very optimistic and has reason to be. Roza’s story encapsulates the importance of FAME, it’s mission and our work. Had they not sent the video of her when they did and had Danielle and I not seen it right away Roza very likely wouldn’t be here to grace us with her lovely smile. She was that sick and in need of the right treatment and it is a very tough diagnosis for a non-neurologist to make.

Roza on the left with Danielle and Roza's mom

Roza on the left with Danielle and Roza’s mom

Doug got some amazing experience with neuromuscular cases over the last two days seeing a number of boys brought by a Norwegian gentleman who runs an orphanage in Mto wa Mbu (Mosquito River) and also helps out with the local Maasai. He brought a young boy back who I had seen last September and diagnosed with muscular dystrophy (probably Duchenne). He is obviously no better, but also not much worse and I had initiated steroid therapy last year when I had originally seen him so that may have helped a bit. Doug also saw two of three brothers with muscular dystrophy yesterday. Now keep in mind that Doug is pretty certain that he’s never cared for an outpatient muscular dystrophy patient in his training career to date. He’s seen and diagnosed three so far here and has more on their way from Mto wa Mbu coming. An amazing teaching experience!

A young Maasai boy with muscular dystrophy and his mom

A young Maasai boy with muscular dystrophy and his mom

Doug examining our patient

Doug examining our patient

Finally, Danielle and I had the privilege to see elderly Maasai women today who was so amazingly elegant and just glowed with a sense of grace. Her facial expressions had both of us totally in enthralled and it was impossible to watch her and not have such a sense of security and warmth. This is Tanzania. Danielle also spent the day teaching Dr. Isaac the neurologic examination and by the end of the day he was a pro.

Danielle evaluating a very elegant patient with Dr. Isaac assisting

Danielle evaluating a very elegant patient with Dr. Isaac assisting

Another successful day in clinic with Danielle and Doug. Many more to come.

Lala salama,

Mike

September 15-17, 2014 – FAME Neurology Clinic

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I apologize for the long pause in emails, but things got hopping here pretty much from the get go and we’ve finally had chance to catch our breath.

Sunday after our safari was pretty much a day of rest and unpacking. We didn’t work, but were able to catch lunch with everyone in the canteen – my favorite, rice and beans with some Mchicha (a dark green vegetable similar to spinach but chewier) on the side. The weather has been cooler than usual with a bit of rain here and there so everything is green rather than the normal dry season shade of brown. Doug (our pediatric neurology volunteer) arrived right around 5 pm after 40+ hours of travel. His last flight was through Addis Ababa with an overnight layover that I’m sure he will never do again.

Reunited, we walked to clinic on Monday morning mostly refreshed and ready for new challenges. Rounds in the hospital ward here begin at 8:30 am and there was a little Masai boy on the ward who had been waiting there for a week or so for us to see. It was tough from the descriptions to tell exactly what he had, but when we say him it was very clear to the three of us that he had some post encephalitic encephalopathy with frequent seizures (multifocal) and probably progressing into Lennox-Gastaut syndrome. Very sad, but at least we were able to identify for everyone what the actual seizures were and to make some medication changes to benefit him. Overall prognosis, though, is very, very poor. That was just the beginning.

Doug examining a young Maasai boy who presented in status epilepticus

Doug examining a young Maasai boy who presented in status epilepticus

We walked to clinic a little late after our rounds and found that there was already a line of patients waiting for us. We split into two groups with Doug and Danielle seeing most of the pediatric and epilepsy patients while I saw most everything else neurologic. The patients we’ve seen for the last three days have been great neurology patients with lots of epilepsy for Danielle and lots of peds for Doug. They’ve seen newly diagnosed muscular dystrophy and a case Ohtahara syndrome among others. The clinic had a record setting day on Monday breaking 100 patients for the first time and beat it on Tuesday with 112 patients. We contributed 21 patients on Monday, 26 patients on Tuesday and 22 patients again today.

Unfortunately, because of the volume we weren’t able to work with clinical officers and had to use interpreters which means we weren’t able to do as much teaching as we’d like, but we still have lots of time here.

After work today we ran down to town and walked around for a while taking in all the wonderful sights. Doug summed it up well by describing the scenes as “authentic.” This is such a different culture here and something that is so hard to actually describe in print. It is an amazingly vibrant world here full of so many colors, so many different sounds and smells that your senses are on high alert. Anyone with even a thread of adventure couldn’t help but be totally in their element. This is a place for those wanting adventure and they will find it immediately.

Lala salama,

Mike

Saturday, September 13, 2014 – The Serengeti and Oldupai Gorge

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Our last morning in the Serengeti waking to the sounds of all the wonderful animals. The hyenas were pretty active last night which means that they probably found some kill to scavenge nearby and were fighting over it. It was another beautiful day with bright sunshine at breakfast and ready for our game viewing as we leave the park through the southern entrance at Naabi Hill that borders the Ngorongoro Conservation Area. I was in the Southern Serengeti two years ago in April watching the great migration there with huge herds of wildebeest with their babies and all the big cats that come with the game animals. Then it was green and lush with the heavy rains. Now it is brown and dusty and dry. It really reminds you of the seasons here – it is wet or dry.

A scary Cape buffalo

A scary Cape buffalo

Shortly after the start of our drive we came upon two cheetah hunting together. They were either two males or two females as the opposite sex do not spend time together in the cheetah world. They could have been siblings or just close friends joining forces. We watched them for a bit until we had to leave as we had to be through the Naabi Gate by 10 am and we still had a ways to go.

A pair of hunting cheetah

A pair of hunting cheetah

The view from up high on Naabi Hill is fantastic as you can see in all directions for many, many miles. It isn’t the border of the park, but where most visitors see the Serengeti for the first time. The actual border is a few kilometers down the road and is quite inauspicious.

Danielle, Abuu and me atop Naabi Hill

Danielle, Abuu and me atop Naabi Hill

Our next stop was to Oldupai Gorge which was a spur of the moment thing as I had been there once before but had never driven down into the Gorge which we were hoping to do this time. Oldupai (which is the correct spelling as the original and better known Olduvai was a misspelling by the first European visitors of the Maasai name for a plant that is all over the area and is the Oldupai plant) Gorge is the mecca of anthropological sites and is perhaps the most important site on earth. Louis and Mary Leakey (well, really Mary mostly) found a fossil there dating to 1.9 million years ago that was named Zinjanthropus and was the oldest fossils to date of ancient man. We went through the museum there and then listened to a short lecture by a local guide, Lucas, who was a local Iraqw elder from Karatu who knew an immense amount about the gorge, the Leakeys and anthropology. We drove down to one site to find fossilized bone fragments (of game, not humans) lying all over the surface from 1.6 to 1.9 million years ago. Then we went to the “zinj site” which is where Mary first saw the exposed jaw of Zinjanthropus and change the who world of anthropology with her find and continued to work there for many years, long after her husband’s death.

Collecting fossils in Oldupai Gorge (too bad I couldn't bring them home!)

Collecting fossils in Oldupai Gorge (too bad I couldn’t bring them home!)

Our guide, Lucas, me and Abuu holding some monster fossils at the site where Mary Leaky found Zinjanthropus

Our guide, Lucas, me and Abuu holding some monster fossils at the site where Mary Leaky found Zinjanthropus

After Oldupai it was back to FAME and the end of our fantastic journey in the Serengeti and the beginning of our next journey seeing patients and educating the doctors and nurses here about treating neurologic diseases.

Mike

Friday, September 12, 2014 – Lions, Leopards, Cheetah, Serval and more…

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Our last full day in the Serengeti. We had decided to go on an early morning game drive before sunrise and brought both breakfast and lunch boxes with us so we could stay out all day. It was another completely gorgeous day with not a cloud in the sky and very brisk. As we headed out along the Seven Hills Road (named obviously for the seven hills in a line) and reached the first hill we decided to have breakfast with some of the local inhabitants so had a family of rock hyrax sunning on some rocks nearby in the early morning rays and I’m sure thoroughly enjoying our company or perhaps somehow imaging we might throw them a morsel of the delicious egg sandwich the camp packed for us.

A family of rock hyrax

A family of rock hyrax

We had some amazing sightings today and the first was a cheetah hunting who we were able to follow along for some time and looked multiple times like it was going to take off after some gazelle nearby but the grasses were much too short (well planned by the gazelle) for too long a distance for the cheetah to make the surprise run necessary to get the jump on them so the game was finally over.

A lovely cheetah

A lovely cheetah

After leaving the cheetah and looking for game Abuu heard about a leopard on the short wave and we were off to the races. We arrived at the site with at least 30 other safari vehicles which was a real sight. The guest of honor was in the tall grasses and after a short jaunt climbed a nearby tree with ease and made himself comfortable. Abuu explained he was a male because his back legs were not straddling a branch, but both on the same side so as not to sing soprano. At  this point we celebrated as Danielle had ” bagged” her big five – that being the elephant, lion, rhino , Cape buffalo, and last but not least, the leopard. These were named by the original big game hunters in Africa (Hemingway included) as the five game animals that you needed to kill or they would kill you. We are now bagging them with cameras thankfully and they will hopefully continue to thrive that way.

A lounging leopard

A lounging leopard

We next drove to the Lake Magadi region of the Serengeti near the Moru Kopjes and found the largest herd of Zebra that Abuu had ever seen. They were making a river crossing near some elephant and Cape buffalo and all were a bit on the nervous side it seemed. The herd essentially split into several lines to cross the river and went around the car on both sides. They were so noisy it was incredible as each stallion maintained command of his family and there were so many of them. We decided to have lunch and continue to watch the herd for some time. There were flamingos (both greater and lesser) on Lake Magadi and close by to the road was a lone lion cub sitting on tree branch looking very afraid and very alone. It was probably left by it’s mother while she was hunting, but lions are not the best of parents in this regard and it was unclear when or whether this little cubs mother would come back before it was lost to some predator. Very sad, but that’s daily life in the Serengeti.

An enormous herd of zebra

An enormous herd of zebra

And many more....

And many more….

On our way back to the Seronera area we found another serval cat, this one deciding to cross the road right in front of us for photos. They are such an interesting cat with very long legs and a bright orange coat.

A not so shy Serval Cat

A not so shy Serval Cat

The finale of the day, though, was when Abuu heard something on the radio and raced to find another leopard walking across the high grass in full sight. It walked for some time with lots of safari cars following and looking like it was planning to hunt some of the antelope in the distance. We watched it in this mode for perhaps 45 minutes when it finally decided to give up and climb a tall tree nearby. We continued to watch it in the tree and were about to leave when Danielle said we should stay another two minutes. The sun had mostly set, but shortly thereafter the leopard climbed out of the tree and began to walk through the grasses again. It finally seemed to settle sitting on a downed tree nearby and as it was getting quite late it was time for us to head back to camp. Driving in the Serengeti is permitted during daylight hours only and they are pretty strict on monitoring this.

A rare leopard on the move

A rare leopard on the move

An amazing close-up of the elusive leopard

An amazing close-up of the elusive leopard

Coming down from its perch

Coming down from its perch

Back to camp for dinner and our last night on the Serengeti. Tomorrow we head out through Naabi gate in the Southern Serengeti and then back to Karatu to work at FAME. We’ll pass by Oldupai Gorge where Louis and Mary Leaky did all of their monumental work on early man.

Best,

Mike