October 24&25, 2015 – An Election, Blankets for Babies and Ngorongoro Crater…

Standard

An Election, Blankets for Babies and Ngorongoro Crater…

The elections have been weighing heavily on everyone’s minds here, both Tanzanians and ex-pats alike. The ruling party has been in power since their independence and concern over the legitimacy of this election remains quite high. Driving to the airport on Friday night there was a huge gathering for the opposition in Usa River as Northern Tanzania and specifically Arusha district is one of their strongholds. We have been receiving email alerts over the last weeks to steer well clear of any political gatherings both before and after the election as the announcement of the official results from the Sunday, October 25, election will be on Friday, October 30.

To be honest, though, it has been fascinating and exciting to be here during the elections and to date everything has been very peaceful. There is still talk of services being disrupted after the election, such as telephone and power, but that remains to be seen.

I awakened on Saturday morning to another wonderful breakfast with Pendo and her family. I had to spend the night in Arusha as the drive to Karatu at night is very dangerous and is never undertaken except for emergencies. I drove back with Pauline and Joyce, both of whom took the opportunity to hitch a ride with us on Friday and spend time with friends before returning to Karatu with me on Saturday morning. The drive was again the same beautiful regions of the Great Rift Valley that I mentioned earlier and it was a gorgeous day to boot. We arrived back to FAME by noon to find the clinic as quiet as I’ve ever seen it. It was the day before the election and everyone was remaining very cautious not to mention the fact that no one wanted to stray to far from home and possibly miss the opportunity to vote the next day.

Happy Mom and Baby Boy

Happy Mom and Baby Boy

Even Happier Grandmother with Granddaughter

Even Happier Grandmother with Granddaughter

 

Another Happy Mother and Baby with Blanket

Another Happy Mother and Baby with Blanket

Happy Mother Post C-section with Baby and Blanket

Happy Mother Post C-section with Baby and Blanket

The low volume did give us the opportunity to give out baby blankets to the new moms in the maternity ward, though. I had been given fourteen beautiful knitted baby blankets by Mildred Staten of Philadelphia who along with her friends knit blankets for newborn babies and mothers in the Philly area. It was such a generous gift and we brought them here in one of our checked duffels (actually Cara brought them with her) along with EEG supplies and other things for FAME. There had been two C-sections the night before (one of which Ali had the opportunity to fully document with photographs that are amazing) along with another baby that had been born in the last several days. The mothers loved the blankets and we wrapped each of their babies in the blanket and had them held.

Father and Son

Father and Son

Little Premie Maasai Warrior

Little Premie Maasai Warrior

We also gave a blanket to the little Maasai premie who is still fighting with the strongest of wills. He remains under one kilo and is not out the woods by any means. His father came into the nursery while we were there and thanked us for the gift. Being born at 26 weeks would be a challenge anywhere in the world, but is exponentially harder here considering all of the challenges and hurdles of life in general in East Africa. The little Maasai looks so very fragile, but we are repeatedly reminded that he will grow up to be a “warrior” one day.

Pauline and Baby Properly Wrapped in Blanket

Pauline and Baby Properly Wrapped in Blanket

Sunday was election day, of course, and we were heading the Crater knowing that it would be peaceful since the animals are, for the most part, apolitical. Leaving FAME at 6am we passed a polling place burdened with a long line already despite not opening for at least an hour. It was clear that all citizens in this region had plans to take advantage of their right to cast a vote for either the current incumbent party or the opposition party. Again, it will be days before the results are known or announced so there will be at least another week of some unrest and then who knows what will happen. Regardless of the outcome, the hope by all is for a peaceful continuation or transition. Time will tell whether this will be the case.

Hippo Pool in the Crater

Hippo Pool in the Crater

The Ngorongoro Crater is always a magical experience. It is a huge caldera 2000 feet deep and about ten miles in diameter that contains it’s own ecosystems. Most of the animals there do not migrate and it is home to a growing population of black rhino that was at one point endangered. It is the most fun for me to drive in as I’ve gotten to know the roads well having done it several times before and it has easy landmarks with which to guide by. It was a beautiful day, though quite windy, which means that the rhino stay in the low trees as they rely on hearing for defense (even though the adults have no predators there) and won’t stray onto the crater floor without their main sense of detecting danger.

Keeping an Eye on Us

Keeping an Eye on Us

A Watchful Bull Cape Buffalo

A Watchful Bull Cape Buffalo

Cory Bustard - Heaviest Flying Bird in Africa

Cory Bustard – Heaviest Flying Bird in Africa

Our Lunch Spot in the Crater

Our Lunch Spot in the Crater

It was also extremely dry in the crater, drier than I had seen before, and the animals were mostly gathered in the wetland areas. We were mainly looking for lions, though, and we found a few before lunch that looked initially like they were possibly hunting. After watching them for half an hour, though, they finally settled down to relax and we were hungry so it was off to the lunch area which is a beautiful lake with hippos and lots of birds.

image

Cape Buffalo Getting Some Facial Work

Cape Buffalo Getting Some Facial Work

Mother Lioness with Toddler

Mother Lioness with Toddler

Mother and Child

Mother and Child

Later, after driving around the crater and not finding any other lions we went back to see what the others we had seen were doing. The whole pride was now visible – there were at least eight females, one baby and the male. The two females were still active and seemed to be challenging some Cape Buffalo, not a typical behavior for so few lions and the big bull buffalo finally made it known to them that he was not happy being stalked by charging them and making sure they knew he was serious. We left the crater without our prize of seeing rhino that day, but knowing we’d be back again another day when it was less windy and hopefully not as dry.

Bathing Hyena on High Alert

Bathing Hyena on High Alert

October 23, 2015 – A Day To Reflect…

Standard

A Day to Reflect….

Having a day to reflect on the good fortune I have had to have come across Tanzania, FAME, Frank and Susan, the Temba Family, and all the others I have met during my six years here is often a rare thing. While on the way to Arusha today taking half our group to the airport to fly out tonight, Cara read us an article she wrote for an EEG monthly newsletter that recounted our history here and, in particular, how I came to be here. I’ve told the story countless times, but hearing it read out loud by someone other than me just seemed to reinforce how amazing the journey has really been and how blessed I am to have been a part of it.

Gloria Sarett, on left, during a water fight while at the University of Colorado, Boulder

Gloria Sarett (Rubenstein), on left, during a water fight while at the University of Colorado, Boulder, early 1950s.

But I also often think of those who were, and continue to be, responsible for instilling in me the qualities that enabled me to find this place. I have been constantly reminded of the adventurous spirit my mother instilled in both my brother and me, from early camping trips to Death Valley in our old beat up station wagon, not knowing a thing about the dirt road we were driving up, to the week long hiking trips we took in the Sierra Nevada and the John Muir Wilderness as young teenagers. It was also the interest in science, though, that she brought to us at young ages, and in me particularly, an interest in anthropology. I recall waking up before sunrise one morning several years while on mobile clinic here to the Lake Eyasi region of the Great Rift Valley and realizing that man took his first footsteps on the very ground on which I was standing. I immediately took my phone and called her, knowing that it would take some serious explaining considering she was in the early stages of dementia, but also knowing that she would somehow understand. These moments are gifts and it is these gifts that make us who we are.

Anna and Daniel at Ngorongoro Crater Camp, 2009

Anna and Daniel at Ngorongoro Crater Camp, 2009

Leonard and the Rubensteins, on Safari, 2009

Leonard and the Rubensteins, on Safari, 2009

The Extended Temba Family, 2011 (minus Gabriella, now 9 months)

The Extended Temba Family, 2011 (minus Gabriella, now 9 months)

While climbing Kilimanjaro with my brother at the beginning of this trip, he commented to me how happy my mother would have been to know that the two of us were together on that mountain at this time in our lives. Both of us were acutely aware that she somehow knew at that very moment and, for that matter, probably knew years before that we would have been together on the side of that mountain doing exactly what she had raised us to do – challenge ourselves and to never stop exploring. Having Nick there with us was an added extra reinforcing that we’ve instilled this same ethic in our six children, all of whom continue to amaze us with their strength and resilience.

The Rubensteins on top of Kilimanjaro - Nick, Jeff and Mike

The Rubensteins on top of Kilimanjaro – Nick, Jeff and Mike

Though I had always dreamed of visiting Africa, it is truly because of my children that I am here and Kim who encouraged me to bring them. In that first auspicious meeting with Dr. Frank, having been brought to an unknown medical clinic by our guide and now good friend (and family), Leonard Temba, I was introduced to an opportunity that has come to fruition many times over, and has become such an essential part of who I am. Having returned home after our safari, there was just something I knew was incomplete, unfulfilled and necessary for me to do. Despite tremendous difficulties at home with my father’s illness and subsequent death and my son’s battle with addiction, we overcame them as a family and with everyone’s support I was able to return to Africa and FAME.

On Mobile Clinic in 2011 With A Young Patient

On Mobile Clinic in 2011 With A Young Patient

So, as I drive my Land Cruiser though Northern Tanzania and regions that are so rich in history beyond what anyone can truly imagine, I am forever thankful to those individuals who have made me who I am and who I continue to be, and I am forever grateful for these opportunities I have had in life and to have shared in the lives of others. These are the blessings that we reflect upon every day we rise and every day we lay to rest.

October 21&22, 2015 – Dinner at Carnivore and Psych Day at FAME…

Standard

Dinner at Carnivore and Psych Day at FAME…

Our Wednesday was a somewhat nondescript day which really means it is hard for me to recall specifics about the many cases we saw. There are some days that you just plow through the neurologic cases and though they are all so interesting in their own right, they are often also similar. We’ve had two general neurology teams working while Danielle and Lindsay have been working with Cara and the nurses to teach them EEG in such a short time. If there is an obvious epilepsy case then we try to have Danielle and Lindsay see that patient, but we have to be cognizant of the fact that FAME is running their regular clinic at the same time so we don’t have unlimited clinical officers or translators to work with. So far, though, we managed to run through the patients like a well-oiled machine with few interruptions sorting out those that should be seen by the epilepsy group and those to be seen by general neurology.

Patricia Measuring a Patient For EEG

Patricia Measuring a Patient For EEG

Daniel and Patricia Performing an EEG

Daniel and Patricia Performing an EEG

Later in the day, the nurses were working on firming up their proficiency of performing EEGs checking themselves with measurements for the electrodes and running the EEG machine. They have been remarkable in picking up the necessary skills which gives us confidence that this is something that will be helpful going forward in treating our epilepsy patients in between our visits here. It has already proved invaluable in caring for many of the patients we’ve seen and will continue to be so.

We finished early enough in the afternoon to head to town before dinner to pick up some things at the fabric store that had been ordered by Thu and Fima. Thu had a wonderful skirt made out of lovely fabric and Fima had a pair of pants made that are actually very cool and perfect for working at FAME. The exciting thing, though, is that we had planned to have dinner at Carnivore. Now this might sound a bit intimidating to many of you, but they specialize in serving grilled chicken and chips (french fries) and they are a bit of a local legend. We had all planned to meet there for dinner (twelve of us) and so we had called earlier in the day to order the chickens and chips – It’s like most local Tanzanian restaurants, which have dirt or gravel floors, plastic tables and chairs, music and dim lighting, Carnivore does not disappoint. Add to the wonderful decor a smoky grill in the middle of the restaurant where the cook is grilling your whole chickens before they are pulled off the grilled and very skillfully cut up into pieces using a butcher’s cleaver. Whack, whack, whack and you have a plate of the most wonderfully tasting grilled chicken anywhere. Now, I will warn you that these are not the plump juicy chickens found in most US grocery stores or restaurants, but rather a bit less meaty of a fowl that has had a much harder life than it’s American cousins. Still, we all had enough to eat with the chicken and chips and beer to go around. It was quite a nice evening out for all of the FAME volunteers.

Ali Giving Her Lecture

Ali Giving Her Lecture

Fima assisting Ali

Fima assisting Ali

The following morning began with a lecture by Ali using a case presentation from last week on the gentleman who had suffered an intracranial hemorrhage and was transferred to KCMC. She ran through why we had immediately thought that he had suffered a bleed rather than a stroke and some of the treatment decisions that were made with that in mind. It was an excellent presentation that really gave the doctors here not only the criteria we use to decide clinically whether we think someone has had a stroke versus hemorrhage, but also what to do when initially evaluating along with initial treatment options.

We jumped right into our first patient of the day who was a young 22-year-old Maasai man who was brought by his father and brother because of strange behavior. He had already accosted several of the volunteers (Cara and Pauline) who were shaken up by the affair and it was quite clear that this was going to be one of those cases where I hear “but you’re the closest thing we have to a psychiatrist here in Northern Tanzania” which is the truth unfortunately. We brought the three into the exam room with me standing between the patient and Danielle, Lindsay and Ali and Zawadi, our translator, standing near the door. Lindsay did a great job interviewing the patient and the family so we could have some semblance of what the history had been for this young man. It was quite clear that he was acutely psychotic and also quite agitated and nearly manic. I made the offer to examine the patient which was happily accepted by Lindsay as the patient remained quite physical throughout our interview process and was even perhaps a bit more so with the discussions we were having.

He had gone off to Dar with his brother when he was 18 and the two were working as security guards there. At some point, they were on a beach watching some wazungu (white people) swimming and his brother jumped in to join them. Not knowing how to swim, though, he promptly drowned. The father and brother confirmed this story, but what happened after that wasn’t entirely clear. He eventually made it home to his family and over the last year had acted strangely as he was acting today. He had gone into the forest on his own for part of the time and was continually speaking of things they didn’t understand and roaming around.

He had both hallucinations and delusions as well as paranoid ideations so we suspected he was schizophrenic or at least schizoaffecctive, though there was still a small possibility that this was bipolar disorder, but the issue at hand was that he needed to be slowed down rather quickly as he was a risk to himself and others. He emphatically denied any alcohol or drug use while in Dar or back at home which his family confirmed. We checked all the appropriate labwork to rule out things, thyroid, HIV, syphilis, etc., etc. Luckily, Frank had requested that I bring injectable haloperidol with me this trip just for this occasion so we gave him a 5 mg dose IM and watched him for about 30 minutes. It didn’t slow him down one bit. The rule is that you double the dose each time so I gave him another 10 mg along with 4 mg of lorazepam (another tranquilizer) and he continued at the same pace for perhaps 20 minutes and then began to look slightly drowsy. I asked Sokoine (now also enlisted into the security detail) to ask the patient if he felt sleepy and he told us he can never sleep, and then in less than a minute his head was promptly on his shoulder and he was out like a light. Success!

His labwork was all unremarkable and our diagnosis was acute psychosis, most likely schizophrenia or schizoaffective disorder, but with the small possibility this could be a presentation of bipolar disorder. We treated him with olanzapine, which is an oral antipsychotic, with the hope that this would at least help with this issue, but made sure his family understood that he would likely need another medication such a valproic acid. Frank, of course, didn’t want him to return until I was back in March, but we told the family to return if the medication wasn’t completely helping with the thought that this would likely be the case. We let him sleep for some time and then the family was finally on their way back home to their boma in the Ngorongoro Crater area.

Several patients later we had another psychotic patient, but luckily not nearly as threatening as the earlier one. He was an elderly patient who presented a letter from the district office notifying anyone evaluating him to be aware that he was a longtime psych patient and to take this into account in discussing his complaints. Sure enough, he was off his medications and had been doing tremendously better before when he was on his medications. A new prescription for olanzapine and he was on his way and happy.

At the same time, the epilepsy team was seeing another patient who had been treated for some time and seen by us last visit at which time they had been doing well with no seizures. They were on carbamazepine and were referred back to consider withdrawing medications. They decided to hook them up to the EEG machine and low and behold, they had very frequent generalized discharges meaning that they would likely have seizures off medication, but more importantly, that the carbamazepine was not the right medication for them as it could exacerbate other seizure types. The patient’s medication was promptly converted over to levetiracetam, a much more appropriate medication for this type of epilepsy. Another example of how the EEG machine will clearly change the management of epilepsy here and change patient’s lives going forward.

We had finished all of our neurology patients for the day and I was sitting by the lab checking emails when Danielle came out of the ER ward (where we’re doing our EEGs) and called to me that she needed my help “right away.” Danielle does not overreact, so I promptly dropped everything and ran down the steps to find out that their patient in the EEG lab was having a non-epileptic event during her EEG and was thrashing about on the table requiring restraint. The problem was that she was HIV+ and was putting everyone at risk so we needed to sedate her post haste. I ran to the clinic to grab some injectable medication and ran back to find that she had luckily slowed down in the meantime and didn’t require the medication. Then the long process began of working with the patient to help with her non-epileptic events which is tremendously more complex than treating if she had epilepsy and requires predominantly therapy and some insight by the patient. Lindsay did a fantastic job of talking with the patient using translators, not the easiest considering the topics that were being discussed. She also had a very significant stage II foot ulcer that needed debridement so she was admitted for that and also to keep an eye on her given the new diagnosis of non-epileptic events. Despite the fact that the episode was clearly not a seizure clinically, she probably would not have had it if she weren’t hooked up to the EEG machine, so the technology once again served to greatly impact our care of the patient and will ultimately benefit her greatly. Most importantly, it will keep her off anticonvulsants that would have interfered with her HIV medications so likely saved her on that account as well.

We ended the day at Frank and Susan’s house for a wonderful get together of all the volunteers for the traditional going away as Danielle, Cara and Lindsay will be leaving tomorrow and we will be leaving in a week. Dr. Marcus and his wife, Susanna had also arrived recently and will be leaving in several weeks. Pizza, samosas, cheese and crackers and wine and beer. A feast here that was much appreciated. Pauline acknowledged everyone’s work with FAME hats and lovely Tanzania scrub shirts as gifts and most notably, Frank stayed up well beyond his normal bedtime of 8 to 8:30! It was a wonderful last day for the epilepsy and EEG team and a visit tremendously more successful than any of us had imagined.

October 20, 2015 – Stroke, Psychosis, Epilepsy and a Concussion…

Standard

Stroke, Psychosis, Epilepsy and a Concussion…

A Patient of Ours

A Lovely Patient of Ours

Our day began with one of our three weekly lectures by visiting doctors to the staff here at FAME. Thu did an amazing job discussing a case presentation of the young woman who we did the first EEG on here and it helped immensely in directing her management. It related to the different seizure types and which medications were appropriate and she did it in a way that kept everyone engaged throughout the entirety of the presentation. The selection of the best antiepileptic medication can be very difficult at times and she gave an easily understood and concise explanation on how we go about making those decisions.

Thu Giving Her Case Presentation

Thu Giving Her Case Presentation

Thu Giving Her Case Presentation

Thu Giving Her Case Presentation

Our first patient of the day was a gentleman who had suffered several strokes in the past and had been treated at Muhimbili Hospital in Dar es Salaam and was then transferred to a hospital in India. We had to sift through all of his outside records along with outside scans from Muhimbili University in Dar as well as the hospital in India to review his history prior to seeing him. He had previously been a pilot for Precision Air and had had his first stroke last year with left sided numbness primarily and no permanent deficits. In April of this year, though, he had a more significant event that left him with left sided weakness and on review of his MRI scans he was noted to have severe subcortical disease and micro-hemorrhages in addition to an acute right basal ganglia acute infarct on DWI. The most concerning finding, though, was that he had the micro-hemorrhages (suggesting amyloid angiopathy) and was placed on aspirin and clopidogril – dual antiplatelet therapy in a patient with an existing propensity to bleed – which had a very worrisome risk benefit ratio. These areas are not black and white, but certainly places where we can offer help in treating patients based on current practices that might otherwise not be appreciated.

Our Stroke Patient

Our Stroke Patient

Microhemorrhages on the MRI Scan

Microhemorrhages on the MRI Scan

Loads of Subcortical Disease

Loads of Subcortical Disease

 

 

 

We saw a young man that I had first seen six months ago with psychosis who I had been concerned about either alcohol abuse or schizophrenia as he was the right age group. He returned today with his mother who noted that he had been much improved when taking the medication I had prescribed, Olanzapine (an antipsychotic), for two months, but that the medication was too expensive for them to buy and he was back to being very psychotic and difficult to control. They also adamantly denied alcohol or other substances so it was pretty clear that he has a primary psychiatric disorder with severe psychosis and all we can help with is symptom management at this point. We decided to give them three months of medication that will be covered under the subsidized small neuro visit fee and will have to figure out whether we can cover the cost of the medication they will need until I return again in March. These issues are the ones that we are currently working on – how can we get patients the medications they need if they can’t afford them. Such are the trials and tribulations of practicing medicine in rural Tanzania.

Thu Seeing Our Psychotic Patient

Thu Seeing Our Psychotic Patient

Meanwhile, the epilepsy team continued to roll along seeing any patients with potential seizures and doing EEGs when needed. Cara has been instructing several of the nurses here in how to apply the electrodes and perform the study and they have been doing great. We also have the EEG machine now fully set up on it’s own stand that was configured here and looks just like it did prior to leaving the states. The hope is that studies will be performed going forward and Danielle will be reading them at home and communicating the results. The infrastructure isn’t fully implemented yet as far as getting full studies home on the internet, but once the radiology center is up and running it will need to have that capability and we will hopefully be able to piggyback on that. For now, we will use the traditional technology for transmitting information home – cell phone images or videos and email. It works surprisingly well and has allowed us to make some amazing diagnoses like our patient with Sydenham’s chorea several years ago who has done so well since then.

Cara Teaching Nurse Daniel How to Perform EEGs

Cara Teaching Nurse Daniel How to Perform EEGs

Cara Teaching Nurse Daniel How to Perform EEGs

Cara Teaching Nurse Daniel How to Perform EEGs

Cara Teaching Nurse Daniel How to Perform EEGs

Cara Teaching Nurse Daniel How to Perform EEGs

 

I ended my day later in the evening after a phone call from the American School for Field Studies down the valley in Rhotia called with a young man who had suffered a concussion the day before and was now vomiting. We told them to bring him up and luckily he looked fine and had a normal examination so was just suffering from post-concussive symptoms. We see many similar undergrads at Penn and hopefully he will begin feeling better very shortly. Brain rest and refrain from any physical activities until he is symptom-free. Many treatments are universal.

Lindsay Seeing a Patient from Oldeani with Isaac, Danielle and Ali Looking On

Lindsay Seeing a Patient from Oldeani with Isaac, Danielle and Ali Looking On

October 19, 2015 – Practicing Palliative Care in Northern Tanzania….

Standard

Practicing Palliative Care in Northern Tanzania….

I think I lost count of the number of patients we saw today and it wasn’t the busiest day we’ve had. It had more to do with the type of patients we had today and I mean that in a very good way. It was the type of patients we saw and what we had to offer them that was so important. And that doesn’t always mean that we have a cure, but we often have answers so they will not have to continue searching which may mean being seen at numerous institutions and still not finding what they are looking for. We may be limited in our ability to order diagnostic tests – an MRI is a 12 hour bus ride away and far out of the reach financially for most Tanzanians – but we have the skills to make those diagnoses which we can help and those that we can’t. It may not always be possible to put a name to something, but if it matters as to what treatment we have to offer we will make every effort to do so.

This morning was very significant for me in that I received word regarding some major funding that will keep our neurology program and partnership with Penn here at FAME quite solid for a quite a few years. I will share more on this matter in the coming months, but leave it to say that I was quite ecstatic over the news this morning.

Ali Evaluating a Young Boy with Microcephaly and Severe Developmental Delay

Ali Evaluating a Young Boy with Microcephaly and Severe Developmental Delay

Shortly after seeing our first patient today, a gentleman walked into our office asking whether we could see his daughter who had been diagnosed with a brain tumor and had undergone surgery. We told him we’d be happy to evaluate her and offer our suggestions if he would bring her later in the day. I wasn’t involved in the evaluation as I was seeing our pediatric neuromuscular patients with Thu, but Ali, Lindsay and Danielle proceeded to review the daughter’s history. After only two months of unilateral symptoms she was found to have an enhancing mass in the right hemisphere and eventually referred to India for biopsy and surgery. The mass was determined to be a grade IV astrocytoma, otherwise known as a glioblastoma multiforme, and has a horrible prognosis. The parents had actually been told this when she was discharged, but had not shared this with their 18-year-old daughter who was very bright and intact cognitively. As Ali will be going into palliative care, this was the perfect case for her and she explained to the parents that it was very important to share with their daughter that she was dying and that she was probably already aware of it as most patients are without being told. The parents said that they would consider Ali’s recommendation, so in the meantime Ali spent time speaking with the patient about her current symptoms and beginning to manage those. Meanwhile, Ali is planning to do a home palliative care visit next week along with Brad (an NP here and education specialist who has an interest in palliative care as well) and who will be following the patient after we leave.

The family was incredibly comfortable with Ali’s explanations and ultimately the burden of their daughter’s illness will be partially lifted from their shoulders. Like any parent, they are trying to protect their child from the evil of her illness, but children are smart, especially an 18-year-old, who they know is on the internet and most likely researching her symptoms so is almost undoubtedly already aware that she is dying. Their visit with Ali was so impactful and exactly what was necessary, but which is so often neglected. I said goodbye to her parents when they were leaving with their daughter having been loaded into their car and told them that they had seen the very best person possible for them to have seen. Though her life expectancy is probably only six to nine months, it will now hopefully be spent with quality time with her family and management of her symptoms to make her as comfortable as possible and without the burden of trying to continue to extend her life which is not possible.

We also saw a one-year-old patient back who was having trouble holding its head up and the mom had brought him in last week to see us. Ali had taken a short video that we sent along with the history to Doug Smith at CHOP who also checked with our pediatric neuromuscular colleagues there. We were concerned about a muscular disorder and they agreed based on the history of the video that is what the child most likely had. We examined the mother to see if there was any possibility of this being a congenital problem and there was some suggestion of that in her exam, but alas neither category of disorders would have a treatment so we had to recommend a wait and watch strategy along with follow up for the time being.

Ali Creating a New Tanzanian Neurologist!

Ali Creating a New Tanzanian Neurologist!

The rest of the day continued at a busy pace, but with teamwork everyone was seen by either Danielle or myself along with the residents and we even had an EEG or two interspersed along with the evaluations. A new volunteer coming from England but having worked in Tanzania previously was coming with his wife today and needed my room in Joyce’s house so it was off to be Frank and Susan’s houseguest for the rest of the week until a room opens up for me in one of the volunteer houses. We enjoyed dinner together on the veranda and some wonderful crepes made by Pauline in traditional French tradition without measuring cups or spoons. They were delicious. Off to bed and another day tomorrow.

October 17&18, 2015 – A dinner at Gibb’s Farm and Lake Manyara

Standard

A dinner at Gibb’s Farm and Lake Manyara…

It was the most quiet Saturday I can remember for quite some time and I am sure that the national elections have something to do with it. I don’t think local townspeople are traveling nearly as much as they normally would and the safari traffic is also down somewhat. People are just a bit edgy as it comes down to the home stretch with the election now only one week away.

Ali Evaluating Our Stroke Patient

Ali Evaluating Our Stroke Patient

Ali, Fima, Sikonya, and Our Stroke Patient

Ali, Fima, Sikonya, and Our Stroke Patient

We did end up seeing a patient from Daniel Tewa’s village who had been referred to us specifically. She was a youngish woman who had a stroke a couple of years back affecting her left side and she and the family were concerned that she wasn’t as functional as she had been previously. It turned out that she had never been seen in a hospital after the event and specifically had never had physical therapy. She was walking, but based on her exam we felt that she may be capable of walking and doing much more for herself if she only had physical and occupational therapy which would be available to her at the regional rehabilitation center in Monduli. The family was willing to take her there (it is very close to Arusha) and we made the referral in addition to putting her on all the necessary medications to reduce her risk of recurrent stroke.

A Helper in Reception

A Helper in Reception

At the same time, Danielle and Lindsay were seeing a young woman with epilepsy who was doing well on the medication she had been taking, but they performed an EEG on her confirming that she had a focal epilepsy and that the medication she was taking was the best for her to be on. Having the availability of the EEG has been extremely helpful in not only diagnosing patients, but even more importantly, in helping to select the proper medication for them.

The Veranda at Gibb's Farm

The Veranda at Gibb’s Farm

The View From Gibb's Farm

The View From Gibb’s Farm

We finished early and were all able to catch up on lots of necessary work such as lectures that the residents and Fima are giving and work on the internet including our emails. We were able to get back to our bungalows early to clean up for dinner as we had made reservations for dinner at Gibb’s Farm which is always one of the highlights of our visits to FAME. Gibb’s Farm was one of the original lodges in the area and has been a working farm for many, many years. It is very difficult to describe the Gibb’s Farm, but it has a magical ambience that allows one to realize that you’re still in Tanzania, but it is luxurious in a totally natural manner. The dinners are a multi-course affair and 90% of the food you eat has been grown or produced on the farm. The management has been gracious enough to allow us to come at a reduced rate for FAME volunteers because of the work we do and we are always so grateful to visit. Before dinner, of course, we enjoy their veranda and front lawn which has the most spectacular view in Karatu from high up in the Ngorongoro Highlands with FAME sitting smack in the middle of the valley looking out. The dinner left absolutely nothing to be desired and Peter and Gilbert who served us were as welcoming as ever – I am there only several times a year, but I always feel as though it’s like my local restaurant when I show up and am greeted by them.

Our Penn Crew and Pauline (Minus the Guys)

Our Penn Crew and Pauline (Minus the Guys)

We arrived home from Gibb’s fairly late and had to prepare our lunches for our safari to Lake Manyara early the next morning. Our plan was to leave at 6 am and we were on the road very close to that time. After picking up some waters at the market we were on our way down the rift to Lake Manyara National Park which has become a mainstay for me to bring volunteers there. It was the seven of us from Penn plus Pauline, FAME’s volunteer coordinator, who had never been there before.

Lake Manyara (Photo by Fima)

Lake Manyara (Photo by Fima)

A Cute Baby - Lake Manyara (Photo by Fima)

A Cute Baby – Lake Manyara (Photo by Fima)

Elephants in Manyara (photo by Fima)

Elephants in Manyara (photo by Fima)

Lake Manyara (Photo by Fima)

Lake Manyara (Photo by Fima)

Since I was driving, I gave my camera and big lens to Fima to use and so the pictures I have included for today were actually shot by Fima. I want to give credit where credit is due! We were the second car into the park for the morning and it remained fairly empty with a rare vehicle seen until around noontime when we were mostly through the park and others began to come. We saw lots of elephants, giraffe, wildebeest, impala, baboons, vervet monkeys, Cape buffalo, warthogs, zebra, hippos and a multitude of cool birds. What we didn’t see today, though searched very hard to find, were the lions. I had seen large prides my last two visits to Manyara, but today it was not meant to be. We left the park at around 3pm and traveled home after stopping for a cold Fanta Passion (passionfruit), my new favorite drink and right up there with Stoney Tangawezi (strong ginger ale made here) which I have always love.

A View of Our Volunteer Housing

A View of Our Volunteer Housing

Sunday we’re on our own for dinner so Fima had volunteered to cook tonight and we had a wonderful sardine spaghetti and salad and all ate together. It was a fine end to a very nice weekend. Danielle, Cara and Lindsay have four more days at the clinic and then head home, while Thu, Fima, Ali and I are here for the next two weeks. It will be interesting to see how things go as the election gets closer and hopefully it won’t be a problem as far as our traveling is concerned.

October 16, 2015 – A Quiet Day in Rift Valley…

Standard

A Quiet Day in Rift Valley….

I know that I have mentioned Rift Valley Children’s Village in past blogs, but for those who don’t recall, I will give a brief description. The Children’s Village is not an orphanage, but rather a children’s home where Mama India (India Howell) is the legal guardian for all the children who live there. It is simply an amazing place where there are housemothers for each house where like-aged children reside and care for each other. It is built next door to a primary school where the children attend along with the children from the village of Oldeani and nearly all pass the standard seven exams as opposed to the 30% national average. The children leave when they go away to college.

Lindsay explaining squiggly lines

Lindsay explaining squiggly lines

Lindsay lecturing on the basics of EEG for the doctors

Lindsay lecturing on the basics of EEG for the doctors

In addition to helping with the school, Mama India also provides health care for the children there along with the villagers and FAME travels there twice monthly for a two day clinic to see all the patients. We have typically provided neurologic services for these clinics when they coincide with our visits and today was one of those days. We left the epilepsy crew at FAME while I brought Ali and Thu, as well as Fima, to see patients. Our volunteer coordinator, Pauline, and our translator, Angel, also traveled with us. It is a lovely 45 minute drive to RVCV traveling through the Ngorongoro Highlands with rich farmland and coffee plantations.

Ali and Thu working diligently seeing patients

Ali and Thu working diligently seeing patients

We had hoped for many patients to see, but even though the regular clinic had over 70 patients, we had only a handful due to the fact that Kira, the RVCV nurse, had received word late of our visit and hadn’t enough time to notify the villages in the area. We did end up seeing a number of return patients, though, as well as one woman who I referred to be seen at FAME by the epilepsy group along with having an EEG done as she had a very good story for seizures.

Comforting a crying baby we're evaluating

Comforting a crying baby we’re evaluating

Thobias and mom

Thobias and mom

Among the patients seen was young Thobias, who we had originally seen last year for prolonged episodes of unresponsiveness felt to be possible seizures, but it later turned out that there was significant emotional overlay as he had witnessed his brother’s murder and the episodes were non-epileptic in nature and have responded well to fluoxetine. He sure had given us a scare in the past, but at the present he is doing very well with no further episodes and his mother is quite happy.

Fima - a closet pediatrician?

Fima – a closet pediatrician?

Fima working with the medicine folks at Rift Valley

Fima working with the medicine folks at Rift Valley

After finishing our work at Rift Valley Children’s Village including a wonderful lunch that they prepare for their own volunteers and share with us, we departed for Karatu. It was a slow afternoon here at FAME so we jumped at the opportunity to head into town to the fabric store as several of the volunteers wanted to have skirts or pants made out of the lovely and colorful fabrics they have here.

Enjoying the local children in Karatu

Enjoying the local children in Karatu

After our shopping trip in town we went to visit with my close friend, Daniel Tewa, and his family. I had first met Daniel in 2009 when my children and I were volunteering at a local school for several days and one of the first people I contacted on my first return trip here was Daniel – we have become close friends since and I always look forward to having dinner with his family and having our long discussions that last late into the night. Since there was such a large group of us this time, I suggested we just come over in the evening and spend some time, but not stay for dinner. Daniel was his charming self winning everyone’s affection immediately after meeting him. They served coffee and then his daughters unexpectedly brought out fruit plates for everyone to enjoy.

The highlight of every trip to Daniel’s, though, is hearing his stories of the Iraqw people, the Iraqw language they speak and the Iraqw house that he built in the 1990’s for demonstration. He spent the first 20 years of his life in such a house, which is built mostly underground with a dirt and grass dome over the top and was done for defense from the Maasai who they were always fighting with to protect their cattle. The Maasai believe that all cattle were God’s gift to them so they were only coming to retrieve their “property.” A truce was finally made between the Iraqw and the Maasai in the 1980s. Daniel brought out his shields, clubs and spears and demonstrated how they would use them to defend theirselves. Fima tried throwing them and then Daniel brought out a wedding skirt for Ali to wear and stand next to Fima with his spear and shield. It was a great photo opportunity and we have named the photo the “Tanzanian Gothic.”

Ali and Fima - "Tanzanian Gothic"

Ali and Fima – “Tanzanian Gothic”

We then proceeded to a tour of Daniel’s methane gas production from his cows – when I first met Daniel this was the only power they had for the farm. They heated, cooked and got light from the methane gas stored and made from the cows manure and urine. The residual manure goes to fertilize his fields. It’s an ingenious set up and now is supplemented by solar power, but is still a mainstay of their farm. It is essentially being “off the grid” where there is none. Daniel and his family gave us gifts as we left hugging and kissing after such a warm reception as it always is. I will be back to visit with Daniel and his family for dinner one night without such a crowd and very much look forward to that special time.