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

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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….

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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

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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…

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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.

October 15, 2015 – The Strength in What Remains…

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The Strength in What Remains….

I am taking today’s blog title from an amazing book by Tracy Kidder about a young medical student who survives the genocide in Burundi to find himself in the United States. It’s a true story and so as not to give away too much I will suggest that you find a copy and read it. The inspiration for today’s blog, though, is another amazing story of strength and hope here in Northern Tanzania.

Our day today began with a lecture by Thu on the neurological examination for all the doctors and clinical officers here at FAME. I think it went over incredibly well as she had everyone practicing on each other in the room to see exactly what it is that we do as neurologists. The exam is a very powerful tool for us and in conjunction with the detailed history that we take, it is a means for us to hone in on a localization of the problem at hand. As Thu expressed it, it’s all very simple. We take a history, make a hypothesis, and then test our hypothesis with our examination and make whatever corrections we have to along the way to come up with a theory.

Our very first patient of the day was a young woman who had recently been diagnosed with epilepsy and was on a medication that she was not taking on a regular basis. Thus, she was continuing to have seizures. After taking our history and examining her, though, we had some concern for the type of epilepsy she had and felt that an EEG would help to sort it out as the medication one uses is often dictated by the type of underlying epilepsy the patient has. We brought her over to the ER which is serving as our makeshift EEG lab for the time being and the epilepsy team hooked her up for a study. She was patient No. 1 for this groundbreaking technology at FAME. Amazingly, she had exactly the type of epilepsy that IS NOT well treated by the medication she was taking and she was converted over to a medication more effective for her condition. In fact, the medication she was on can sometimes worsen seizures for patients with her condition. This could certainly make the difference between well controlled and poorly controlled epilepsy which would make all the difference in the world for this young woman.

We saw an early tremor dominant Parkinson’s patient who we had not seen before – Thu was incredibly excited since she will be going into a movement disorder fellowship next year and this was right up her alley. We saw another stroke patient who I first saw in 2011 and continues to follow with us on a regular basis even though he has continued to do well. The hardest thing here is too get patients to remain on their long term medications, though, as it is just something they aren’t used to doing. We had wanted him to remain on aspirin but he had unfortunately stopped it several months ago after his prescription ran out. It is not due to non-compliance, or lack of adherence as they now refer to it, but rather that it’s just something that isn’t build into their culture at the present time. We’ll continue to work on that.

Thu examining my long-term stroke patient

Thu examining my long-term stroke patient

A gentleman came to see us today with right orbital swelling for six months and limited movements of the right eye. After taking our entire history it turned out that they had been to KCMC several months ago and were told that he needed additional testing, butt hadn’t been able to afford it. After our exam we came to the same conclusion as the only deficit was his eye and the differential included infectious etiologies, systemic disease or a mass lesion. Without a CT scan of the brain and orbits, which is very likely what they had recommended at KCMC, we really couldn’t proceed to treat him as we didn’t know what we were treating. They couldn’t afford the CT scan and so other than some basic labs, we had very little to offer him for treatment.

We saw another young child with epilepsy brought in by his mother who clearly had some cognitive delay, though subtle, and was on a very low dose of medication. We decided to have him undergo an EEG (Patient No. 2) that ended up not demonstrating any abnormalities, but was helpful in continuing him on the same medication he had been taking and which also seemed to be helping. It’s amazing how smoothly things run when you have the right equipment and a great EEG tech.

Lindsay examining our young seizure patient

Lindsay examining our young seizure patient

Cara hooking up electrodes with Isaac and Danielle looking on

Cara hooking up electrodes with Isaac and Danielle looking on

 

A very compliant EEG patient No. 2

A very compliant EEG patient No. 2

Danielle and Cara reviewing the EEG

Danielle and Cara reviewing the EEG

So now for the story that inspired the title for today. Fatina was brought to FAME today by her friend and eldest son. She is 47-years-old and the single mother of five children and the primary caregiver for her elderly mother. One year ago, during the night and for no apparent reason, people came into her home and threw acid onto her face. Those responsible have never been caught and there was no clear motive to suggest why it may have happened in the first place. She spent two days in the local dispensary in Barazani (about three hours from FAME) before they realized that she needed more extensive care, and was then transferred to KCMC where she only spent three days for them to apply antibiotics, bandage her and send her home. When she arrived home she found that many of her possessions there had been taken by other villagers. The acid has disfigured her face to such a degree that she has lost both of her eyes and is now blind and all that remains of her nose are two small holes for nostrils.

Despite this horrendous injury and disfigurement, she has persevered and has a remarkable attitude. When asked about any sad thoughts, she does admit to some concerns as to how she will continue to care for her children and her elderly mother, but says that she has accepted what has happened to her and is ready to move on. Her only complaint to us was a minor headache. She was an incredibly lovely woman and when she spoke it was quite easy to forget her disfigurement or the ordeal that she had been through. At the end of our visit, she asked if she could have a photo of her with Thu and myself. I think all of us wondered if we would have that amount of strength had we been put through a similar situation. And, almost to add insult to injury, we found today that she also has diabetes as her blood sugar was extremely elevated and that this will also need to be dealt with. As I walked beside her to the lab for her blood work, I could feel the strength and livelihood emanating from this woman who made me realize that in the depth of our struggle for survival, there are always those unlikely individuals who have demonstrated an even superior strength to have risen from further depths and will always give us eternal hope that we may do the same. It is these unlikely encounters that remind of us of our internal strengths. Thank you, Fatina!

October 14, 2015 – We Have An EEG Machine….

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Today was a national holiday in Tanzania – it is the day that Julius Nyerere, the first president and father of the country, died. Tanzania became an independent country only in 1964 and was formed from the union of then Tanganyika and the independent island state of Zanzibar. When Tanzania gained it’s independence, there were eleven college graduates in the country. The current incumbent party has been in power since independence and in just ten days, they will have a national election pitting the current party in power against a coalition of opposition parties. There have been travel warnings to avoid large crowds in cities due to the demonstrations and the chances of being swept up in one, and though we have seen plenty of campaigning around the countryside, it has yet to cause us any issues during our travels. Things will likely become more tense as we get closer to the elections on October 25, so we will have to keep a close watch. We’ve already had to alter our normal schedule and will not be doing the mobile clinics to the villages.

Morning report was at 8:00 am this morning as usual. Dr. Ann and Dr. Gabriel had a very busy night as several victims of a highway robbery had come in during the wee hours and required sutures for wounds they had suffered. This didn’t appear to have anything to do with the upcoming elections, but certainly reinforced why we don’t travel at night on the roads here as something like that would never happen during daylight hours.

A young man had also been admitted overnight that needed our attention in the ward before we started outpatients. He appeared to be more medically ill, but did have an altered mental status so it was decided that he should have a lumbar puncture to rule out and central nervous system infectious process. The is very routine for us so Thu took the opportunity to give Fima some additional instruction in the fine art of performing this procedure and I’m happy to say that it was quite successful. I should give a shout out to Clyde Markowitz back at Penn, and though it pains me to admit it, Thu used Dr. Markowitz’ drawings and instructions to prep Fima and apparently did a wonderful job of it.

Fima performing a lumbar Puncture

Fima performing a lumbar Puncture

The first patient we saw this morning is someone who I have followed for several years after suffering a subcortical infarction and who we have managed with medications since and has done quite well. He is 85-years-old and his two sons continue to take impeccable care of him and it shows in both they attention to him along with how well he continues to do for his age in this country of such difficult health care.

Our elderly stroke patient

Our elderly stroke patient

Young Glory is a delightful nine year old girl who was sent to us for an evaluation regarding a prior history of stroke. One year ago she had presented to her local pediatrician with severe hypertension and headache. She was sent to Dar es Salaam where she worsened and was found to have a pheochromocytoma in the region of the right adrenal gland, but had also suffered a right temperoparietal hemorrhage and right frontal hemorrhage with associated neurologic deficits. She was transferred to a hospital in India where she spent several months earlier this year, with significant improvement in the majority of her deficits, but unfortunately has been left cortically blind from what appears to have been PRES (posterior reversible encephalopathy syndrome) after reading through the MRI reports from Muhimbili University Hospital in Dar as well as the hospital in India. We explained to her father that it was unlikely, though not impossible, that she would regain any of her sight, but on the other hand, she looked fantastic neurologically given everything she had gone through.

Glory

Glory

Naomi is a sweet little soon-to-be seven year old who we’ve seen several times in the past for seizures and was doing very well on the medication we had started 6 months ago while weaning her off of the phenobarbital she had been taking for several years and which was ineffective at the dose she was taking. She had had only a single seizure in the intervening six months and the dose she was taking of the new medication was still relatively low so we were able to increase it without any concern as she was tolerating the medication quite well.

Young Naomi

Young Naomi

While we were seeing patients, the epilepsy group (Danielle, Lindsay and Cara) were on a mission to get the EEG machine up and running and to train the dedicated neuro nurse (Patricia) to perform the EEGs after we’ve all left and gone back to the states. Sahewa (FAME’s anesthetist) was nice enough to volunteer his clean shaven head for them to practice on which took several hours and the training is still ongoing. Once up and running, the EEG will enable to better diagnose and treat epilepsy patients.

The Neuro "Peeps" + Fima

The Neuro “Peeps” + Fima

EEG instruction

EEG instruction

 

Sahewa volunteering as an EEG patient. Easy electrode placement ;-)

Sahewa volunteering as an EEG patient. Easy electrode placement 😉

We have another full day at FAME tomorrow and then it’s off to Rift Valley Children’s Village which is just it sounds like as opposed to an orphanage. More on that later. For now it’s off to bed with thoughts of another successful day under our belts and several more weeks of the same to look forward to. Everything we do here has a major impact on the health of this rural community that is my second home.

October 13, 2015 – The Neuro Team is Now Complete

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The Neuro Team is Now Complete…

It rained overnight and into the morning so our daily walk was out for the day. We all showed up for morning report to hear about the new cases from Dr. Ann, who was on overnight. There were four new cases that they wanted out input on and we immediately went to work. The first case was the mother of the premature baby who had eclampsia ten days prior and, unfortunately, it appears that she had likely suffered a stroke as she was not moving her right side at all and it had been much too long since her delivery and seizures to be related. Hopefully, with aggressive blood pressure control she might improve, but not likely. Meanwhile, her 26 week premature baby is doing amazingly well despite weighing in at well less than one kilo.

Even though our neuro clinic wasn’t supposed to start until tomorrow, the patients began to roll in by early morning and before we even see all the inpatients, I had to break off to start see the outpatients lest they continue to stack up throughout the morning. Thu, our final neurology resident to arrive, and Cara, our EEG tech, made it here by late morning and I put Thu to work seeing patients along with Ali before lunch.

Later, after lunch Cara, Danielle and Lindsay began to work on unpacking and assembling the EEG machine we had brought here to use. It’s quite a complicated process to hook all the cables back up and after a few anxious moments when we weren’t sure it was going to work for us, it finally ran through all of it’s code and seemed to like what it found.

Lindsay, Cara and Danielle after success with the EEG machine

Lindsay, Cara and Danielle after success with the EEG machine

Tomorrow, they will begin to use the machine which will enable us to more accurately diagnosis and treat epilepsy patients here at FAME. It will be a huge accomplishment to successfully implement EEG technology here as it is otherwise available in Northern Tanzania only at Kilimanjaro Christian Medical Center in Moshi, a good four hours away. We will be training two nurses to provide EEG services here at FAME in our absence and we will be reading the studies back in Pennsylvania.

A young epilepsy patient, Dorthea, who I have seen for the last four years came in again today with her mother. She continues to do quite well and is so much happier now with fewer seizures.

My young epilepsy patient, Dorthea

My young epilepsy patient, Dorthea

Dorthea's mother

Dorthea’s mother

We finished the patients for the afternoon and all piled into the Land Cruiser for a visit downtown. Karatu is such a colorful village with lots of businesses and people filling the streets. There is lots of activity going on all around you. We returned home for our chapati with vegetables and beans for dinner and a quiet evening of typing blogs and reading.

Tomorrow will be our formal neuro clinic her at FAME and it will likely be very busy. We will have two neuro teams seeing patients and the epilepsy team seeing epilepsy patients specifically and now having access to EEG data. This is definitely an exciting time to have the neuro team here as well as Fima who will helping with the medicine patients and the general ward service.

October 10-12, 2015 – Back to FAME at last…

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Back to FAME at last….

I realized that I had forgotten to include the wonderful little ceremony that took place on our last morning of the Kilimanjaro climb. Following breakfast, our entire support crew assembled in front of the mess tent along with the five of us. Traditionally, tips are given to each member based on their job in addition to any distinguishing service they may have provided. It is also traditional for climbers to give some of their spare or non-essential gear to members of the crew as a sign of how well they did taking care of us. We had all brought our gear into the mess tent and divided it up so that each porter would get something and we also set aside individually tips that we wanted to present members with for a specific service they provided. I said a few words to let everyone know what an awesome time we had and then one by one we handed each of them their gift from us and shook hands or hugged. It had been a tough climb that would never have been possible without them.

After the gifts were handed out, all the porters and guides performed a song about Kilimanjaro for us that included our names and was wonderful to watch and hear.

We all spent the night at my friends home and began our slow recovery back to the present. The following day (Saturday, October 10), I dropped Danielle and Lindsay off at the Arusha airport as they were flying to Zanzibar and then my brother and nephew later that evening at the larger Kilimanjaro International Airport for their return trip home. The following day, Ali and Fima, newlyweds who had been honeymooning in Zanzibar, arrived into the Arusha airport and spent the night at Pendo’s as well, with plans for early departure the following day (Monday) for FAME.

We had all finished breakfast and were preparing to depart when I heard some rustling from the bathroom around the corner. I got up to investigate and then heard a distinct knocking only to find Fima locked in the bathroom! The handle was no longer releasing the latch and he was trapped behind a wooden door with the only other opening being a heavily barred window. There was literally no escape from the bathroom without destroying the door, something that we were very reluctant to do. We began by unscrewing the door latches which ended up helping somewhat, but the door still didn’t release. The hinge pins were impossible to tap out and even it they had been easier, there was no clearance to pull the door forward. Thankfully, Fima made one last try at the door latch and this time he was able to pry it loose and extricate himself. The ordeal was over and other than a little PTSD, Fima is no worse for the wear on this one.

We made our journey west to FAME over the new roads that are so much quicker than the old and arrived in time for my favorite lunch, rice and beans. It feels so good to be back here, my second home, and a place of so many miracles. We visited a 26 week premature Masaai baby born by C-section as his mother had eclampsia. Unfortunately, she is not back to normal neurologically and will be one of our first consults waiting for us in the morning. Before Ali and Fima’s orientation tour was over, though, we were called into service for the head of the local police who was brought in after having a severe headache and then becoming agitated and confused with very high blood pressure. His exam was suggestive of an intracranial bleed and he was transferred to Kilimanjaro Christian Medical Center for a CT scan and management. Soon we’ll have our own scanner here at FAME.

Danielle and Lindsay arrived from Zanzibar and we are now waiting only for Thu and Cara to arrive tomorrow from Arusha and we will have our entire neuro team here ready for work.

October 9, 2015 – Saying Goodbye to the Mountain

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Saying Goodbye to the Mountain….

I would love to be able to tell you that our trip down from Upper Mweke Camp was uneventful, but it wasn’t quite that simple. Coffee, breakfast and breaking down camp were all on schedule and we began our long descent, first passing the Lower Mweke Camp where the trail turns from descending slippery, wet rocks to steps cut into the dirt ground that in the rain forest can be a bit treacherous. The porters practically run by us as they “pass” on the right and we try to stay out of their way.

Porters on the Trail

Porters on the Trail

Leading the Pack

Leading the Pack

I felt pretty good and was leading the group (normally the responsibility of one of the guides) as everyone felt well. We had a good pace to descend well ahead of schedule when we encountered a bit a slippery area and watched as a porter went down with all his baggage and luckily didn’t hurt himself. Immediately after watching this accident and restarting our trek, I somehow slipped in almost the exact same location, going down forward, face first, without getting my hands up in time to protect myself. I recall slamming my face into a long smooth rock that I saw coming, but couldn’t do anything about it. With a huge thump and a thud I came to rest with my head downhill and just lay there, first trying to determine what I had injured. I thought I had put a tooth through my lip and luckily hadn’t, but I could see some blood covering my nose so I knew something was amiss. Danielle saw me not moving and was really worried, but everyone was atop me quickly, helping me to slowly get to my knees and access the situation. Amazingly, all I had was a gash over the bridge of my nose, probably from my sunglasses, a thoroughly scraped nose and bruised and swollen lips. The guides dressed my wounds and we continued on after a few minutes, albeit a bit slower. Lots of jokes about “you should see the other guy” were heard, but all in all I was very, very lucky that I hadn’t broken anything or done more serious damage to myself. Sorry, no photos of my injuries.

We signed out at the Mweke Gate and got our Kilimanjaro certificates. The ordeal was over and we all reflected on the experience. To a person, it was the toughest thing any of us had ever done in our lives. Also to a person, none of us would choose to do it again in similar conditions. It was an experience that will never be forgotten, nor can it be taken away. For each of us, we will be able to tell of our struggle and survival on Kilimanjaro, a normally gentle and kind mountain, that chose on our day to challenge each of us as we had never been challenged before. I’m very glad I did it and am also very glad that it’s over.

October 8, 2015 – The Climb…

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The Climb….

We were awakened at 11 pm to begin dressing for our ascent and with one peek out the flap of the tent it was readily apparent that this was not going to be a typical night on Kilimanjaro. The wind was blowing strongly and there was a driving pelt of hail or frozen rain quite audible as it struck the sides of our tents. Three layers on the bottom and four layers on the top. Check. Two pairs of socks. Check. Gaiters. Check. Lots of water in our Camelbaks. Check. Headlamp with new batteries. Check. Gloves. Check. Balaclava and hat. Check (except my hat was still wet from the day before so Dickson loaned me one of his).

We all met in the mess tent and the guides checked individually with each of us to assure them we had everything we needed to make the climb. We’d come a long way and so far everyone had dodged any hint of altitude sickness of any significance. We’d been very lucky.

We stepped out of the mess tent at midnight as had been planned and entered into a world we hadn’t quite anticipated. The trail is usually clear all the way to the summit with perhaps a dusting of snow at times. What we encountered was a blinding snowstorm with strong winds and low visibility that left your entire world as the small patch of trail illuminated by your headlamp and the knowledge that we were being led by skilled guides. When I tell you that it was cold, it does not give it justice. We all had hand warmers in our gloves, some with double gloves and most with toe warmers in their shoes. Our fingers and toes still froze almost immediately. My Camelbak, which has an insulated hose on it for skiing, froze within half an hour and was useless until well into my descent.

We trudged up snowy switchbacks that seemed endless, one foot in front of the other, taking two breaths for every step at times. What you could see in front of you, though, was the endless line of headlamps of other climbers who had left earlier than us, many of whom we would soon catch and pass, which was a treacherous feat given that the trail was wide enough for only one to walk. We followed our guides, though, wherever they took us as our lives were now literally in their hands. This was tougher than I could have ever imagined or had ever done before. Tougher than jumping out of a plane, driving 150+ mph on a race track, diving 100+ feet underwater, or anything I had done fighting forest fires in the Sierra spending sixteen hours cutting fire line in the blazing heat. None of us had prepared ourselves mentally for this. We relied on each other for the strength to continue and had I been with strangers I don’t think I could have continued. Nick felt ill most of the way up and Lindsay and Danielle were bastions of willpower the entire climb. Jeff and I just kept pushing ourselves and reaching deep down for what it took to make it to the top.

What should have been a five hour climb to Stella’s Point, ended up as seven and half hours and put us behind schedule. The sun had come up just below Stella’s Point and even though it was only for a brief moment, it gave us that extra strength to push it to the top. We regrouped at Stella’s and began our “walk” to Uhuru Peak. This was no piece of cake, either, as there was easily over a foot of snow on the crater rim and the winds were whipping us at we all felt had to be greater than 50 mph and were pretty constant. Fellow climbers were now passing us on their way down giving us words of encouragement that we were very near our goal. I took whatever strength I had left and just kept walking with Danielle behind me and we somehow separated ourselves from the others making it to the top with our guide a few minutes ahead. It was so surreal to finally be there at the top of Africa. The visibility was now improving slightly and we could see forever – across the clouds to the south and west and into the crater far below to the east. The wind was still dramatic as was the temperature and we needed to begin our descent fairly quickly as everyone was feeling the extreme effects of the weather at this point. We hugged and congratulated and cheered and took our group photo at the summit, after clearing all the snow from it, of course.

Success!

Success!

My camera, all 3+ lbs of it that was lugged to the summit was useless as the battery was completely dead in the frigid cold (only to recover back at base camp). Our summit photo, though, doesn’t come close to conveying the amount of pain each of us had suffered to get us to that point. We summited at 8:30 am, a full two and a half hours behind schedule!

The Rubensteins - Nick, Jeff and Mike

The Rubensteins – Nick, Jeff and Mike

As every climber knows, a successful ascent requires a successful descent. Now, we had to get down off this mountain! The descent trail is a different trail that doesn’t switchback and is normally a piece of cake in the dry conditions normally seen on the mountain.

Glacier After the Summit

Glacier After the Summit

After the Summit

After the Summit

After the Summit

After the Summit

There was now a good foot of fresh snow, slush and ice atop the trail making it a real challenge. I had the hardest time as I’ve never liked going downhill on slippery ice and snow, unless of course I have skis on. I will tell you my experience getting down, but I know everyone had some trouble with the descent.

Beginning Our Descent

Beginning Our Descent

Each guide took a group and Emanuel stayed at my side, arm in arm, for at least half the way down until two of our porters met us and also helped. Emanuel was exhausted as each time I stopped to gather myself he was then sitting briefly which I had never really seen him do before. Soon Dickson met us with some fresh pineapple juice for me to drink and joined our group helping me down to camp. I explained to them what the word “entourage” meant – I trusted them with my life at that point. I finally convinced them to let me walk on my own for the last hour back to camp, but it took some doing as they all wanted to help so much. They were certainly my heroes.

I walked into camp at perhaps 1:00 pm while the others made it down a bit before me. We were wiped out to say the least. The plan had been for brunch, which was now going to be lunch, and to hike to the lower camp on the trail that afternoon. Ema changed that to the higher camp which was only to be a two hour hike. We rested for a little over an hour, had a wonderful lunch and then broke camp. The hike to the Upper Mweka Camp was entirely uneventful other than the fact that we were all wiped out as we had been climbing since midnight with only a short break. We dined our last incredible dinner and all went right to sleep, having absolutely no energy remaining in our bodies. Tomorrow we would descend the Mweka route to the Kilimanjaro gate and be picked up for our ride back to Arusha.