October 27, 2015 – The Wonderful Staff of FAME…

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The Wonderful Staff of FAME… I’m sure I’ve spoken of the fantastic staff at FAME previously, but spending time in the cantina this evening while watching them prepare mandazi with Thu and Paulina made me realize how easy it is to forget what it takes to make a facility like FAME run smoothly. Most of the staff have been here from the very beginning and it is easy to see on a daily basis how incredibly dedicated they are to Frank and Susan, FAME, the patients we see and to the community in general. Ema and George have helped me so many times with my vehicles here, whether it be for a flat tire, pulling me out of the mud after being sunken to my axles, or towing me back to FAME from the Crater entrance after our clutch disintegrated one unfortunate morning. It really isn’t those times that come to mind, though, when I think of them – it is the wonderful greetings I receive from them every morning when I arrive and throughout the day that remind me that this is a family here and not just an ordinary work place.

Ali and Anne Evaluating a Ward Patient

Ali and Anne Evaluating a Ward Patient

Ali, Anne and Thu Evaluating a Ward Patient

Ali, Anne and Thu Evaluating a Ward Patient

Jacob, Mary, Veronica and Sokoine, who sit in reception and keep the outpatient clinic running smoothly every single day despite the tremendous growth we’ve seen at FAME over the six years I’ve been coming. They must triage the patients and determine who we need to see as opposed as the regular clinic patient which can be an incredibly tough job. And even though we see patients who may point to their joints when we ask “shida na nini,” it is easy to remember how tough their job can be at times. Mama Mshana and Safi are the head nurses that run the hospital wards that now number two and can handle a total of 24 patients. The second ward is primarily for maternity so we have a constant flow of mothers and babies including premies like the little Maasai boy we have there now. They are in charge of a fantastic group of nurses that round with us every morning and take such incredible care of their patients. And how can I forget Brad, who is in charge of education for both nurses and doctors and though he has been here for less than a year, it seems like he’s been here from the beginning as well. FAME’s lab, which was built and is run by Joyce, a long-term volunteer who lives here nine months of the year and is home in the States for the other three, has Anthony, our Tanzanian director, Julius and Fatuma, all of whom have been here for many years. They run an amazing facility considering it is in rural Tanzania where we have immediate access to automated blood counts, chemistries and assorted other labs. The residents are amazed at how quickly our results return which is always faster than it is at home. They even ran a solar powered portable lab during our trips to Lake Eyasi for mobile clinics that had most everything other than the automated testing.

Paulina, Thu and Julianna Making Mandazi

Paulina, Thu and Julianna Making Mandazi

The clinical officers that I have worked with most closely and have been here for so long are Dr. Isaac, Dr. Ken and Dr. Anne – they are sponges for knowledge and working with them is a privilege each and every time. Dr. Ivan, who I have worked with since the beginning as a clinical officer and recently returned from two years of Assistant Medical Officer School has always been a steady resource for me regarding local medical information. Dr. Gabriel, the MD I have worked with here has always shown a keen interest in learning as much as he can from us when we’re around. I have enjoyed working with him on our mobile clinics to Lake Eyasi where we took long hikes during our free time into the hills surrounding Gidamilanda.

Thu and Julianna Rolling Mandazi

Thu and Julianna Rolling Mandazi

I cannot forget to mention William Mhapa, who I began working with as an outreach coordinator for my neurology mobile clinics and who is also the main HR person at FAME now because he is so qualified. Without him, our mobile clinics would not have been as successful as they have been in the past. Eva, who has been our housekeeper here from day one, takes such amazing care of us with nearly daily laundry and even making our shoes spotless from time to time given the orange mud and dust we have here. As I’m typing this, Hamsi just ran by our house to the check the borehole below to make sure our water supply is safe. He is definitely the hardest working individual here at FAME as he never stops and essentially keeps the place running whether it be the water supply or the garden for our food that is made every day for the staff.

Double, Double Toil and Trouble - Thu, Paulina and Eliza Making Mandazi

Double, Double Toil and Trouble – Thu, Paulina and Eliza Making Mandazi

And that brings me to the kitchen. Samweli is our head cook who I have known now for five years and does a wonderful job running the kitchen that makes the daily lunch for all the staff here seven days a week as well as dinners Monday through Friday for all the volunteers that are brought to our houses and ready for us at the end of the day. This afternoon, they Julianna and Eliza were making mandazi for tea tomorrow and they had agreed to show Paulina and Thu how to make them. They are essentially like a beignet from New Orleans with a little bit of spice added and are deep fried. Freshly cooked and warm they are simply amazing. They are still delicious the following day, though, and are the highlight of our morning chai masala (African spiced tea) which is served every morning from at around 10:30 to 11:00.

Baby Girl

Baby Girl

Baby Boy

Baby Boy

I am certain that I’ve forgotten to mention more than one of the amazing staff here at FAME and it is not for the fact that they have gone unnoticed. It is only that I cannot immediately recall every one of the lovely people that I have worked with over the last six years while volunteering at FAME. And I have not even begun to mention those volunteers who I have had the honor to work with at various times. And then there is Frank and Susan, Caroline, Joyce, Paulina, Will, Nancy, Jeanne who are the staff that have made it possible for me to have changed my career and who keep this organization running so that I can continue to return time and time again.

Paulina Holding One of the New Babies on the Ward

Paulina Holding One of the New Babies on the Ward

Bonding

Bonding

Happy Grandmother and Granddaughter

Happy Grandmother and Granddaughter

Baby Girls on the Ward

Baby Girls on the Ward

We also made another delivery of baby blankets to our new babies on the ward from the last day. Mildred Staten and her group in Philadelphia are now quite popular here with the new mothers and babies. The babies are not given names until well after their birth so on the wards they are all generic and called either “baby girl of…” or “baby boy of…”, but are still the cutest thing this side of Arusha!

October 26, 2015 – A Triumph for the Epilepsy Team…

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A Triumph for the Epilepsy Team…

Our morning began with an unfortunate case that had just arrived to the ward of a ten-year-old boy with a several month history of inability to walk, was non-verbal and poorly attending, and unable or refusing to eat. He was severely emaciated and his examination suggested to us that he likely had a central process such as a brain tumor or mass. His mental status (eyes open and awake, but not responding to us) was concerning for the possibility of non-convulsive status epilepticus. The only way to rule this out would be to get an EEG. I spoke with Daniel and Patricia (two of our three nurses who were trained over the last weeks) and they immediately jumped into action with no hesitation or trepidation.

Daniel and Patricia Applying Electrodes To Our Ward Patient

Daniel and Patricia Applying Electrodes To Our Ward Patient

Within an hour, they had the boy in the ER suite (our makeshift EEG lab) and were preparing to get the study underway. I checked in on them from time to time, but they required no assistance which was just an amazing situation considering they had just been trained. The study revealed only diffuse slowing, perhaps greater on the right than left, that suggested his mental status was related to the underlying process and not the fact that he was having continuous seizures. The fact that we were able to determine this was a triumph for the epilepsy team and Cara who had worked so hard over the last several weeks to make this possible. Without this information we would have been left with this question unanswered and unable to have treated him in the same manner.

Thu and Dr. Anne Evaluating Our Epilepsy Patient

Thu and Dr. Anne Evaluating Our Epilepsy Patient

Daniel and Patricia Setting Up the EEG Study

Daniel and Patricia Setting Up the EEG Study

Daniel Monitoring the EEG Study

Daniel Monitoring the EEG Study

Looking On During the EEG of Our Epilepsy Patient

Looking On During the EEG of Our Epilepsy Patient

Our third patient in the office that morning was a 28-year-old woman with at least a ten year history of month episodes that were very concerning for seizure. She had been on a very low dose of phenobarbital briefly without benefit, but had been taking no medications in some time. The family also gave the history that she remained confused for up to a week after her seizures and the last event had been six days ago. She was clearly confused and our concern again was for the possibility of non-convulsive status epilepticus as the cause of her mental status. Enter the new FAME EEG team who immediately said “hamna shida” (no problem in Kiswahili) and that they would do it for us shortly. They brought the patient to the lab and performed another complete EEG that clearly ruled out status epilepticus for us and meant that her mental status was not secondary to ongoing seizure activity which allowed us to proceed with treating her after taking this off the table.

Amazingly, the first day of clinic after the epilepsy team leaves we have two patients who presented with the question of non-convulsive status epilepticus that would not have been answered had it not been for the fact that FAME now has a crack EEG team trained who jumped right in handled the situation. Kudos to Cara Linenbroker for her excellent training of the nurses here and to Danielle and Lindsay who worked with them as far as interpreting abnormalities. We are setting up a mechanism of getting the studies to Penn and for the time being select images from the study will be sent home to be read. Ultimately, we’ll be able to send home the entire study and have it read remotely from the States and this process will greatly enhance our treatment of epilepsy patients here at FAME, even in our absence.

A Tanzanian Ambulance!

A Tanzanian Ambulance!

During the middle of the day, we heard a foreign sound here at FAME – an ambulance! For the entire time I’ve worked here at FAME I have never seen an ambulance on an emergency call and the reason for this is that there are no services here for the most part. There are no rescue squads, no ambulances, no EMTs. You’re essentially on your own if you get into trouble. Early this morning, Frank and Fima had responded to a call from one of the lodges here that one of their guests had collapsed and on arrival the patient had already expired, very likely from a massive heart attack, despite thirty minutes of CPR.

FAME Staff Responding to Ambulance Arrival

FAME Staff Responding to Ambulance Arrival

Transporting the Patient to the Ward

Transporting the Patient to the Ward

The ambulance arrived at FAME and everyone immediately responded to ge the patient to the ward and evaluated as soon as possible. He was unstable on arrival and quickly stabilized and appears to have had a heart attack, but is in need of a catheterization that will likely be done in Dar es Salaam at Muhimbili University in the coming days.

The General Neuro Team - Thu, Me, Ali and Popi Sitting in Front

The General Neuro Team – Thu, Me, Ali and Popi Sitting in Front

It was actually the quietest Monday in memory as people are still on edge about the election and staying at home. They are releasing results of individual polling areas, but the final vote is not to be announced until Thursday or Friday. Everyone is still praying for peace regardless of the outcome. We spent the evening with Daniel Tewa and his family again, this time for a lovely dinner at his daughter’s, Isabella’s, house. Afterwards he had Thu wearing a wedding skirt this time and we took the opportunity to take some more photos of everyone.

From Left - Fima, Pauline, Brad, Serena Tewa, Thu and Me

From Left – Fima, Pauline, Brad, Serena Tewa, Thu and Me

From Left - Pauline, Fima, Elizabeth Tewa, Thu, Me, Daniel Tewa, Brad

From Left – Pauline, Fima, Elizabeth Tewa, Thu, Me, Daniel Tewa, Brad

Cheering the Election?

Cheering the Election?

Daniel is such a wealth of knowledge of the Iraqw culture and of Tanzania in general and is the most generous person in the world. He has opened his home to everyone I have introduced him to and has become like family to me. We are so privileged to have him as our friend.

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

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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.

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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…

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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 ago 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…

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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.