October 24, 2016 – And back to neurology clinic at FAME….

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I think we were all quite exhausted on Monday morning after our weekend safari and despite a good night’s rest we were all dragging a bit. We had already spent nine full days seeing neurology patients at FAME and four days of mobile clinic yet it seemed that our patients were still coming in droves. When clinic opened at 8:30am (in Swahili time that’s 2:30 as the day begins at 6am with the sunrise) we immediately had over twenty neurology patients to see us and they were still coming.

Nurse Barbara and Dr. Verena evaluating the young boy with meningoencephalitis

Nurse Barbara, Nurse Safi, and Dr. Verena evaluating the young boy with meningoencephalitis

Meanwhile, there had been an admission last Friday of a young boy who presented with seizures and altered mental status who they wanted us to see. They had done a lumbar puncture on Friday, but not all studies had been run on the fluid and all we were told was that the fluid had been cloudy and there too many white blood cells per HPF (high powered field on the microscope) meaning that he very like had a meningoencephalitis and probably viral given some of his other labs such as elevated liver function tests. He had been put on antibiotics, but when we asked about acyclovir they hadn’t considered it. When I tracked down our pharmacist to ask about obtaining the medication we always put these patients on in case of herpes encephalitis, I discovered that it is virtually unobtainable here having to purchase it from Nairobi at a cost well beyond FAME’s means as it would have cost $500 dollars a day for fourteen days to treat this child. Luckily, it didn’t appear that he needed it though he continued to have some seizures and did remain intermittently febrile. We wracked our brains throughout the day to make sure we weren’t missing anything with this child as he was very ill and we certainly wanted to give him the best chance to improve. We did add one other antibiotic on our way home that evening to cover one other possible infection, but otherwise we had no new thoughts.

Kelley evaluating the young boy with meningoencephalitis

Kelley evaluating the young boy with meningoencephalitis

Documenting the old fashioned way!

Documenting the old fashioned way!

We had our usual compliment of patients that included one Maasai woman who I have seen for several years with seizures. She has remained well controlled on lamotrigine which is the best drug for her given her age and likelihood that she’ll become pregnant in the coming years. She did have a baby last January who I had seen in March as her husband brings her back for follow up religiously every time that I am here. He had invited me to his boma for a goat roast last time I was here and wanted us to come this time, but I explained to him that we were leaving in several times and unfortunately didn’t have time to make it there. We both agreed that we would do it for certain in March and Sokoine now has his phone number and location so we’ll visit earlier in the trip next March. I haven’t yet had someone cook me a goat so that should be very exciting indeed.

Examining our young Maasai woman with epilepsy

Examining our young Maasai woman with epilepsy

Her husband and baby

Her husband and baby

Sometime in the mid morning ( I can’t recall if it was before or after chai), Frank called me over to his office to see a patient who had been brought from a fair distance to see him. It has been billed as a psychiatric patient, but he wasn’t certain and as I walked through the door of his office I immediately recognized what the patient had. She was a fifteen-year-old Maasai girl brought by someone from her school and she had been having strange behaviors and movements for several days. Her family thought that she was possessed, but thankfully she hadn’t yet been touched by any local healers. As soon as I saw her movements I recognized that she had Sydenham’s chorea, a very rare disorder in the States that is caused by an untreated Strep infection. It causes neuropsychiatric manifestations in patients in addition to the infection which is very dangerous as it can cause a bacterial endocarditis that has a predilection for the mitral valve, often destroying it and causing a serious problem if left untreated. I asked Frank to check and he said that she did indeed have a murmur. I explained to the situation to the American teacher who had brought her here and we suggested that she stay here at FAME for several days while we initiated both the antibiotic treatment as well as treatment for her uncontrolled movements. Her mother was called and agreed to travel to FAME from the Arusha area as she wanted to be here if she was going to be admitted. Her movements were very impressive and it took 30 mg of diazepam to get her some rest that night and that dose was repeated again during the night amazingly.

Our 15-year-old with Sydenham's chorea

Our 15-year-old with Sydenham’s chorea

We had diagnosed a young girl with the same disorder back in December 2012, and after over a year of treatment she was finally without any movement or issues, though the last time I saw her was in March of this year. We had impressed upon her family that she would need continuous prophylactic antibiotics for many years to ensure that she didn’t develop another episode of endocarditis, but they moved to Mto wa Mbu and it become more difficult for her to come back here for her checkups. I am hopeful that she’s still receiving the antibiotics to protect her heart. This young woman I saw today will also require the same treatment with immediate antibiotics for the acute infection, long term prophylactic antibiotics (until the age of 40!) and a long course of steroids to control her movements which are the result of an immune-mediated response. It is very rare to see these patients here and extremely rare to see them in the States, so I was quite happy that both Kelley and Laurita would be able to see this patient with such a classic and now rare neurological disorder. It is something that will remain with them forever.

Laurita evaluating an elderly patient with Selina's help

Laurita evaluating an elderly patient with Selina’s help

Kelley evaluating an elderly patient

Kelley evaluating an elderly patient

Kelley and Dr. Gabriel evaluating a patient

Kelley and Dr. Gabriel evaluating a patient

Laurita also had a very complicated patient that came to see us from Arusha and required well over an hour of her time. She was a young woman who had developed eclampsia following a delivery around the first of the year and had suffered two intracranial hemorrhages. She underwent surgery to evacuate them with an excellent recovery initially, but then developed an intracranial abscess requiring additional surgery, suffered seizures, then hydrocephalus needing a shunt placed. She underwent an immediate replacement of her shunt and subsequent to that lost her ability to speak. We had most of her CT scans to review and an MRI that she had obtained in Dar es Salaam as well as her examination. Unfortunately, it appeared that she had suffered some damage from the placement of her first shunt that explained her difficulty speaking and there was very little that we had to offer her as far as treatment or therapy. She was extremely abulic as a result of the frontal lobe damage she had from the initial hemorrhages and with all the deficits, she was extremely disabled. It was a very sad case as even with rehabilitation she will likely recover very little.

Kelley evaluating an elderly gentleman with a history of stroke

Kelley evaluating an elderly gentleman with a history of stroke

Given the complexity of cases today, things were moving a bit slow in the afternoon making it necessary for us to work well into the evening which also meant that Sokoine and Selina would miss the staff bus to town at 4:30 and had to find an alternative means of getting home. Luckily that was taken care of by one of the other FAME staff vehicles as I had work to do this evening along with Laurita and Kelley. We ended up staying in the volunteer office until 8:30pm as they both had to work on their talk for tomorrow morning and needed the use of the Internet, which if you remember, runs incredibly slow if it runs at all. Starvation finally got the better of us, and especially Laurita, so we all went home to eat our prepared dinners of roasted chicken, potatoes and green beans. Somehow, Kelley managed to go back up to the volunteer office to complete her talk, but I’ll have to admit that I was far too exhausted to do any more work and chose rather to go to bed and set my alarm for well before sunrise. We had all worked very hard today and I sensed a bit of frustration in everyone with the late hour that we finished so decided to make sure we wouldn’t run into the same situation tomorrow and planned to speak with Sokoine regarding this in the morning. Regardless, we had seen some very interesting patients once again and fulfilled our purpose for being here, not only in regard to educating the doctors here as well as my residents, but also myself included.

A young Maasai woman with epilepsy

A young Maasai woman with epilepsy

October 23, 2016 – Lions, lions and more lions….

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Spending the night on the African savannah in a tent, even with a hard floor and plumbing, is a very unique experience. Soft breezes continually buffet the fabric in a pleasant and relaxing fashion throughout the night while the nearby nocturnal wildlife make their presence known. Depending on the location, we commonly hear hyenas or lions that sound as though they may be right outside the tent. We were so tired from our safari the day before that we all slept quite soundly and were ready for the new day. I had planned to use the outdoor shower, but reconsidered as it was a bit chilly so I enjoyed my shower inside instead. Before breakfast, I readied my cameras for the day ahead and headed off to the dining tent for another wonderful meal.

Lions on the watch

Lions on the watch

Lions on the watch

Lions on the watch

We ate outside with the soft rays of sunrise beginning to cover the plains in front of us with the start of a new day. Breakfast was a buffet this morning as there were a few more guests at the lodge and we enjoyed eggs, mushrooms, bacon, sausage, potatoes and homemade granola again. Oh yes, the wonderful pancakes or crepes with syrup. All of this was preceded, of course, by the requisite cup(s) of freshly brewed local coffee. As we would not be returning to the lodge after our safari today, we thanked all the staff for their amazing service and picked up our lunch boxes for later in the day. When staying in the tented camps, it is the common practice to give the camp manager a tip to divide among his staff thanking them for their fine service. When we gave the manager our tips, I am not sure that it was totally expected and they were all very thankful for our generosity. This really was an amazing stay for us and it was probably one of the nicest places I have visited in my time here. I will definitely return to the Tarangire Simba Lodge in the future and may well make it part of the resident’s “cultural experience” here.

Pelican in flight

Pelican in flight

Pelican in flight

Pelican in flight

Having battled the tsetse flies yesterday, we were all a bit weary of encountering them again this morning so began our trip with the top down on our vehicle and the windows mostly closed. Yusef had his cracked slightly and Laurita was a bit more daring having her window open about half way much to Kelley’s dismay. We went through the gate again and began our drive through the acacia woodland, or home to the notorious tsetse. A few flies got into the vehicle through Laurita’s window and we were able to dispose of them rather quickly. We didn’t kid ourselves, though, as we knew we would run into them again during the day and only hoped that they would be manageable. We took a different route to the river area this morning and crossed in a dry area as we headed for the public campsites to see what we could find. We quickly ran into a small group of lions positioned strategically on a small hill overlooking one of the prime watering holes in the area. They were clearly planning some type of ambush as there were herds of zebra and wildebeest in the area and we were definitely hoping to be there for the event if at all possible.

An unsuspecting warthog

An unsuspecting warthog

Displaced lions

Displaced lions

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The group included three adult females and three adolescent youngsters. Initially resting, it was clear that they were maintaining a very close watch on the watering hole as well as the surrounding area in hopes of a meal. As we sat watching warthogs meander towards the water and hoping that they wouldn’t see the lions or react in any way, we were rooting for the lions with the hope that they would attack. One of the younger ones at one point charged after a warthog, but it was of no use as they were too far away and easily scurried out of reach of the clumsy lion with ease. There were herds of zebra and wildebeest in the area and one group of zebra were definitely moving slowly towards to the watering hole, The stallion leading the group continually inched closer, but unfortunately, he was moving across one of the access roads and as vehicles came and went from the spectacle, he would get spooked and move away from the water. This went on for some time until finally a group from the other side slowly walked to the watering hole while two of the older felines began to organize for an attack. The zebra had just gotten to the edge of the water when the lions seemed to prematurely jump. They ran down to the beach, but the zebra were to quick for them and were spared another day. At this point, we were not very impressed with the skill of these lions to say the least.

A failed attack

A failed attack

There were over fifteen vehicles now all positioned at various locations around the watering hole in hopes of seeing a successful lion kill. The guides were all trying to predict where the attack would occur and jockeyed each of their vehicles attempting to get the best view for their safari guests. In March of last year, we had followed a group of four females for most of a morning waiting for them to make a kill and were lucky enough to see it happen right in front of us and all alone. A lion kill, or an attack by any of the bigs cats, is perhaps one of the most impressive things I’ve witnessed in nature and an event that is not to be missed if possible. It is truly nature at its most raw and uncensored. It is incredibly powerful and you feel as though you are part of it, though it can only be watched with the realization that it is not a show for our benefit and that the prey would have died whether we were there or not. It is something not to be missed.

Weary lions

Weary lions

We continued to watch the lions for some time hoping that they would be more successful, but when we saw a family of elephants moving towards the watering hole we knew there would soon be some sparks flying. As I mentioned yesterday, lions and elephants are deadly enemies and the elephants would love nothing more than to stomp a lion to death if given the chance. So, as the elephants moved closer, they immediately attracted the attention of the lions who watched carefully as they approached. When the elephants got the scent of the lions and realized where they were, several of them made a beeline for the hill where the lions sat and very quickly displaced them from their resting place. Once the lions were on the retreat, the elephants again focused on the watering hole and began to drink and carouse as if it were a big punch bowl. The lions, meanwhile, having been evicted from their lofty perch above the watering hole, reconvened on the flat nearly in front of us so we could get some great photos, but we had still wanted to see a kill, unfortunately. We had been watching them for the better part of an hour or so at this point and decided to move on to see more things before lunchtime.

Our small group of lions

Our small group of lions

We drove through the Small Serengeti region of the park, named for the close resemblance to the wide open plains of this famous region of Tanzania several hours away from us. There were herds of zebra, wildebeest and Cape buffalo in this area, though we were really on the lookout for cheetahs as the grasses here are the right height for them to hunt while remaining hidden. This is also the area where we were stuck in the mud for hours last March during the wet season so I am always a bit reticent about driving here even though it’s now dry and someone else is driving. We circled through the Small Serengeti on several roads and eventually drove back towards the river as it was approaching lunchtime and we were heading for a new picnic area on the other side. The main picnic area of Tarangire is typically very crowded with vehicles and people, but has a beautiful overlook of the river and all the animals there are midday. Unfortunately, the Vervet monkeys have also figured out that it is the perfect place to find an easy lunch and they love to harass visitors with the hope that they more score a few scraps here or there. One such pair of Vervets planned a sneak attack on Megan Richie and me a few years ago and turned out to be far more aggressive than we had thought they’d be. I grabbed the food and Megan, having grown up in Indonesia and quite comfortable with these situations, decided that she’d protect me only to find out that one of the monkeys didn’t scare very easily. We were leaving the following day and I was quickly trying to figure out in my mind how I would explain to my chairman having had my resident mauled by a usually cute Vervet monkey in Tanzania. Thankfully, it did not come to that and Megan realized she had met her match so the two of us exited stage right with our food in hand to find another location for lunch. Had they been baboons, I don’t think we would have been so lucky.

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A view from our lunch spot

We crossed the river and drove to the new lunch site which is high up on another overlook with views of much of the park. We didn’t have the picnic lunch we had had yesterday, but rather box lunches with lots of goodies. I’m certain that Laurita gravely missed the wonderful pasta of yesterday, but I knew she would make do with the lunch at hand. A hamburger, samosa, hard boiled egg, apple, and a piece of chocolate again. Not nearly as luxurious, but it quelled our hunger and we sat in the shade for a time before piling back in the Land Cruiser in search of new sights.

A mating pair of lions

A mating pair of lions

We drove to the river and crossed again and headed up a road that we had been on yesterday so I wasn’t quite sure where we were going as this lead to the Silale swamp and I didn’t think we were going back there. Within a few hundred yards, though, we immediately encountered a small group of lions lying in the shade of an Acacia tree. One of the other guides at the lunch area had apparently shared this information with Yusef at the picnic site so he had traveled to this spot with the hope that the lions would still be hanging out here. It was a male and three females and it was close enough to the river crossing where we had seen the group yesterday that they were undoubtedly one in the same. Lions roam over a very large area and are very territorial so you will never see two groups or prides that close. We sat watching them for a number of minutes when the male decided to get up and mosey over to one of the females. She quickly sat up and then it was readily apparent that they were a mating pair when he quickly mounted her. As quickly as it started, it was over and we were all amazed, especially Laurita and Kelley who swore that it was the highlight of their safari to see such an event. I knew that when lions mate they do so every 30 minutes for several days and Yusef informed us that the reason is that the male lion’s penis is very short so this is required to ensure that the female becomes pregnant. Since we knew that there would be another show very soon we decided to wait and were surprised when the male got up again in about 15 minutes readying himself for the next episode. This time he mounted one of the other females so it was obvious that at least two of them were in estrus. Both growl very intensely during the mating and it was again over almost as soon as it started. We were all by ourselves in the middle of nowhere watching these lions so we were in no rush to leave and continued to watch them for some time during which we witnessed a total of four matings with the two females. It is something that I’ve seen a few times before, but never with the enjoyment of listening to Laurita’s and Kelley’s commentaries that were hilarious even if half of them were in Spanish. Regardless, their laughter was the same in any language and equally infectious as you can only imagine the jokes being made at the expense of the lions mating ritual given the very short duration of each encounter despite it going on for days.

An afternoon feast

An afternoon feast

We eventually departed our little pride of procreating lions and were heading along the river in the direction of the main gate. After some time I asked Yusef if we could head back to the lions we had watched in the morning and he informed us that he had heard on the radio that they had actually made a kill while we were engrossed in the lions mating and that was where he was actually heading. So off we went at a somewhat faster clip as we all held on so as not to be thrown into the side of the vehicle which can easily break a rib or at the very least leave you quite bruised. We came upon the watering hole to a gaggle of vehicles with everyone focused on the very same group of lion sitting down to an afternoon meal of fresh wildebeest. The kill had occurred perhaps 30-60 minutes prior to our arrival and several of the lions were already satiated and lying in the shade as the kill was directly in the sun. We watched as one of the adults and the three younger lions all sat along the belly of the prey and quite intently ripping chunks of flesh and cracking bones that was audible to us even 50 yards away. Occasional spats would occur regarding someone’s position in the pecking order or at the kill, but they would only last a moment and then each would immediately go back to their ripping and shredding.

An afternoon feast

An afternoon feast

As we were watching this, a number of elephant families were approaching in the distance on their afternoon trek from the river back to their homes in the hills and they were clearly looking forward to a rest stop at the watering hole. It would be interesting to see what would happen when the elephants approached the watering hole this time as the lions had a kill and we knew what had happened earlier in the day when the elephants had won out. This time, though, the elephants left the lions alone on their side of the watering hole and merely strode to the other side and began drinking and throwing water on their backs. It seemed clear that the elephants knew that the lions would likely defend their kill and wouldn’t be so easily dislodged this time. We eventually left this scene to head out of the park and make our way back to Karatu. We had had a wonderful two days in Tarangire despite the tsetse flies and other than a few bites here and there, they were a distant memory. We had seen the darker side of Kelley (yes, there is a dark side) as she gleefully executed tsetse after tsetse with the assistance of Laurita and me, though it was clear that she enjoyed their demise much more than either of us did.

The drive back to Karatu was unusually quick. We dropped Yusef off on the tarmac as he had to meet with some friends and we made our way back to FAME. Alex had said he was cooking us dinner tonight and little did we know what feast he was planning for us tonight. Kelley and Laurita were in their pajamas when we went over to his house next door and I was wearing my gym shorts and T-shirt. Shortly after our arrival for dinner, the rest of the FAME family showed up – Susan, Frank, Verena, Nurse Barbara and Annie Birch – so we gave excuses for our dress as we hadn’t been aware of the guest list. Joyce wasn’t feeling well so missed an incredible meal of real Gyros with homemade pita, sauce, wonderfully seasoned beef, homegrown lettuce and tomatoes and a rice and feta salad. Alex is an amazing cook and we were grateful for this meal after coming home from our weekend safari. We had seen nearly everything we wanted to see in Tarangire save for a leopard, so the girls will just have to return here someday to realize that experience. They did get to spend time at a wonderful lodge with a wonderful staff which also something to experience here. Needless to say, we were all very much looking forward to our beds this night as were were all very, very tired, but also very fulfilled.

October 22, 2016 – On safari….

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We awakened before sunrise as we had planned to get an early start for our safari today. We all met in the dinning area at 5:45am for an early breakfast and were greeted by the wonderful staff. Fresh coffee and juice, pancakes (crepes), homemade granola and eggs to order were on the menu this day. We talked again about our plans for the day and where we would be heading in the park. I was very excited because I hadn’t been to many regions of Tarangire since my original visit here in 2009, and it is a very large park with some amazing sights. Today we planned to visit the Silale Swamp which was at the very far end of the park and opposite the main gate that I normally used to enter when we come to visit for day trips. It would be at least several hours to reach this region.

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Yusef and Kelley checking in at the Sangaiwe gate

Kelley and Laurita (?) at the gate

Kelley and Laurita (?) at the gate

The Sangaiwe gate was only a few minutes from the lodge and we entered the park just after the gate opened. Like most entrances to the parks, they take no cash and only credit cards so as to minimized theft by the workers which had been a significant problem in the past. Because I have a resident permit, I’m able to get into parks other than Ngorongoro for half the price of the normal day rate of which is a bit over $50 now with the new 18% tax that has been imposed (or finally instituted) after President Magafuli took office last October. Though it was a shock when it occurred overnight, the new prices and taxes for the parks and the Crater will hopefully all be for the best as they are intended to all benefit the wildlife and conservation here. Tourism and the wildlife they have here in Tanzania are their greatest financial assets not to mention the importance to our planet in the preservation of these unique species that have been so impacted by the presence of humans over the last several hundred years.

Smuggler's hide - a hollow Baobob tree

Smuggler’s hide – a hollow Baobob tree

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Lions resting in the shade at midday

The Sangaiwe gate is located about 45 minutes from the river area which is where most of the animals congregate during the dry season. Tarangire is a region that is dominated by a river ecology so that during the dry season all of the animals travel from the surrounding hills to obtain water from the only source available. Families of elephants, large herds of wildebeest, zebra, and Cape buffalo migrate to the river on a daily basis. Meanwhile, Grant’s and Thompson gazelle, who don’t migrate and need much less water are found in the open areas of the park and countless groups of Impala reside in the woodland regions. Waterbuck, reedbuck, elan, and dikdik are scattered amongst the others throughout. Tarangire is also known for it’s exquisite birds including numerous types of vultures, eagles, hawks, plovers and Kelley’s favorite, the Lilac breasted roller.

A lilac-breasted roller in flight

A lilac-breasted roller in flight

A lilac-breasted roller making a landing

A lilac-breasted roller making a landing

As we leave the gate we begin our drive along the higher woodlands that are unfortunately the home to tsetse flies. These are the flies that carry trypanosomiasis, or sleeping sickness, but thankfully don’t in this region of Africa otherwise we would have been in big trouble long ago. The tsetse is a blood sucking fly whose bit is very painful (much worse than a mosquito) and they are masters of stealth until you feel the severe pain of their bite. Humans are obviously not their primary target otherwise they wouldn’t be so numerous and they are usually bothering the other large animals around including all the antelope and the Cape buffalo. They are attracted to anything that moves and this typically means a large animal, but in our case it means our vehicle and, unfortunately, us inside. They are like guided missiles and once locked on their target they are relentless and tireless in their quest to bite us. Since I’m riding behind Kelley and Laurita, I can watch their backs and swat the flies off and all that is available on me are my shoulders as my shirt is flapping enough in the back with the movement of the car and the wind so as to keep them off. The morning was fairly cold and I wore my only fleece which happened to be blue, a color they are attracted to while I had forgotten that they also like black which both Kelley and Laurita were wearing. Oops! Needless to say, we were all a setup for an impending tsetse fly disaster. It wasn’t pretty, but since it was their first exposure to these little conveyors of agony, the girls were only moderately annoyed, but worse was to come later in the day.

A tawny eagle

A tawny eagle

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Once out of the woodlands, the tsetse pandemonium abated and we once again relaxed to enjoy the truly amazing sights of this park. As we traveled along the various river circuits whose trails were dry and dusty, but had been very wet and slippery in March during our visit. The early animals were just arriving to the river while the majority were still traversing the plains from their homes in the hills. When you see several safari vehicles stopped in one location, it usually means some kind of large cat, either a lion, cheetah or leopard, and this morning as we approached one of the river crossings we came upon this scene. Far up the dry river bed was a lioness just laying in the shade, but it was enough to attract a crowd. A family of elephants were milling about high above the river bed, though eventually decided it was time for cool mud and ambled down a path that was immediately next to the relaxing lioness. Not necessarily mortal enemies such as the big cats are to each other (lions will kill cheetahs on sight), elephants do not tolerate lions for a moment and when they realized her presence, they immediately charged after her, chasing her further away from us down the river bed. We turned our vehicle around to follow the lioness and after a few moments spotted the rest of her pride under a tree in the distance, a male and several other females doing what lions do during the which is mostly to sleep.

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The watering hole at midday

Making a stretch for lunch

Making a stretch for lunch

A herd of Cape buffalo

A herd of Cape buffalo

It was still quite early as we began our drive over one of the hills towards the Silale Swamp, a very important natural area for the animals here. The swamp is massive and occupies the majority of the valley it sits in. It is very green even in the dry season and families of elephants can be spotted everywhere along with groups of buffalo. Wildebeest and zebra don’t seem to wallow through the mud of the swamp which I suspect is more for safety reasons as they would probably become mired and when speed is your main defense, that would be serious problem. The Cape buffalo use their size and horns as their defense against predators as well as their strength in numbers while the elephants are much less often targets of predators other than the smaller babies.

Kelley and Laurita getting shots of the cheetahs

Kelley and Laurita getting shots of the cheetahs

A cheetah up close

A cheetah up close

While over on the swamp side, Yusef heard news of some cheetahs a distance away across the river. Initially it was decided we’d lunch first, but then he decided to hightail it to the cheetah sighting so we all held on for dear life while we sped across the countryside in search of the world’s fastest land animal. It turned out that the location was up Tarangire Hill, a landmark far down river and when we came up the location, there were two cheetahs laying in the shade of a bush and several vehicles already watching them. Cheetahs are the most elegant of the cats and it is their speed that they are known for rather than their strength. It was so exciting for Laurita and Kelley to finally get to see a cheetah and now here were two. One cheetah was lying in the middle of the bush and more difficult to see, but it eventually came out and the two cheetahs greeted by washing each other’s face with their tongues. They didn’t seem to be interested in hunting so we watched them for a bit and then left to drive back over to the lunch spot overlooking the Silale swamp.

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The lodge had packed us a picnic lunch rather than the usual lunch boxes and we found the perfect table that had a great view of the swamp with all it’s elephants and flocks of birds laid out before us. Lunch included a large container of pasta with ham, peppers and onions that was out of this world good, hamburgers, small individual quiches, apples for desert along with a small chocolate bar. We were all starving as we had stopped for a later lunch and it was so relaxing to sit in the shade and share such a feast among friends. The leftover pasta and anything else went to some young workers who were digging a new foundation near the bathroom in the heat of the midday.

A male secretary bird strutting his stuff

A male secretary bird strutting his stuff

Mr. and Mrs. Ostrich (with the Mrs. putting on a show for him)

Mr. and Mrs. Ostrich (with the Mrs. putting on a show for him)

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After our rest, we all climbed back in the Land Cruiser for our second half of the day and decided to head back to visit the cheetahs we had seen before. They were still there, though perhaps somewhat more visible as they had adjusted themselves to avoid the strong midday sun. They were still the same gorgeous creatures we had seen just recently and were interacting again with each other. Cheetahs are typically solitary animals who hunt alone as well, but you will occasionally see them in pairs and much less frequently three of them together. When this happens, they are all of the same sex and almost undoubtedly males and often brothers. Females never travel together. Two years ago I had seen a threesome of males here in Tarangire on the small Serengeti drive. We decided finally to leave our two cheetahs, though it was admittedly difficult as they were the first for Laurita and Kelley and they are definitely amazing animals to see up close.

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A cheetah greeting

A cheetah greeting

The remainder of our afternoon was spent driving along the river in search of other sights, but the tsetse flies were definitely becoming more of a nuisance and I was quite worried about Kelley’s sanity. She seemed to be our tsetse magnet, that person you always like to have along as the biting insects seem to favor them for some reason giving the others a bit of a reprieve. Unfortunately, Kelley was not quite as enthusiastic with her assumed role and had taken it upon herself to personally annihilate as many of these pests as she could using one of my work gloves I had brought along in the car. She enlisted Laurita who seemed to muster a similar hatred for the flies and chose to use the other glove as her weapon of choice. Between the two of them, they managed to scatter the lifeless carcasses all over the floor in short time. I would not want to run into these two in a dark alley if they had a grudge for any reason and especially if I saw them carrying those work gloves. Traveling back through the acacia woodlands where the bulk of the tsetse flies were earlier in the day, first Kelley and then Laurita covered themselves up in Maasai shukas (blankets that we had in the car) so very little of them was exposed for the flies, but they were somehow still occasionally finding their target and there would be on onslaught of brief action before covering themselves up again. I certainly wasn’t immune to the flies, but did seem to have less of them bothering me along the way so enjoyed watching the two of them ranting and raving in between my less frequent run ins with these devils.

The pair of cheetahs

The pair of cheetahs

A male waterbuck striking a pose

A male waterbuck striking a pose

We arrived back to camp just before six which was perfect as the gate to the park closes then and we had to be out by then. We were again greeted with cold washcloths and looked forward to relaxing for a few moments in our rooms though Laurita apparently went right to the observation deck where she could get internet coverage. Both girls are avidly playing in the resident fantasy football league and had to make sure their lineups were set for the following day. We later all met on the deck and enjoyed a cold beer together after a long day in the vehicle on our game drives. We had seen so much that day and we enjoyed reminiscing about the events including the war with the tsetse flies. We sat outside under the stars for dinner and later laid again on the deck to watch the Milky Way and shooting stars and this time even decided to try some long exposure photos. I had somehow left my quick release plate at home so my tripod was useless and we used a towel to prop up our cameras and get some photos. It was finally time for bed so off we went to our tents for a relaxing night with thoughts of more game drives tomorrow.

The Milky Way

The Milky Way

A shooting star

A shooting star

October 21, 2016 – A day to catch up…..

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Having spent the last four days continuing our “neuromobile” as someone close named it, we were looking for a little break to catch up on our administrative work. For the last several years, we have been collecting general data on the patients we’re seeing here, such as age, tribe, location of visit, return or new, diagnosis and medications we’re prescribing. It is helpful not only with the keeping track of our volume and demographics, but also something as simple as knowing what medications to order extra of before we arrive. In addition to our general neurology database, we also have been collecting somewhat different information regarding our epilepsy patients, such as seizure control and dose changes.

So, as we had not advertised today as a neurology day (that will continue next week), we decided that it would be a perfect day to begin gather data for our database. Somehow, I have managed to avoid participating directly in the data entry and Laurita and Kelley did not let me down as they immediately offered to do the work. Besides, I did have several other duties to attend to like catching up on my blog and, perhaps more importantly, get our vehicle since we had plans to leave later in the afternoon on safari which would be quite difficult without it. Soja called and told me everything had been repaired and it was ready to pick me up so I hitched a ride down with Moshe, who is in charge of everything that goes on at FAME. I had been sitting in back of the stretch Rover that was about to head to town with a number of FAME employees, but was rescued by Moshe at the last minute. The vehicle was finished and though it was a bit more expensive for the repairs than I had anticipated, it was still only a fraction of what it would have cost in the US. The steering rack and all bearings had been rebuilt and replaced, the hinges on the bonnet (hood) had been completely replaced, the emergency brake that hadn’t worked since the vehicle had been rebuilt was completely repaired and lastly, he had built a latch to keep the room from dropping on our heads when it was up on safari. All that for a little over $400!

I drove the Land Cruiser home and then finished posting my blogs when I got word that Yusef, our driver had arrived to FAME. We found Yusef and all when to have a quick lunch in FAME’s canteen before our departure. We had just a few things to finish up with and so Yusef checked out the vehicle and got it ready for our weekend safari. We ended up leaving right around 3pm which is what we had planned since I thought it would take about two hours to get to our lodge. That was a bit optimistic, though, as the Simba Tarangire Lodge is on the opposite end of Tarangire near a new entrance gate built in the Kigoma region adjacent to Lake Burunge. On the way, Yusef was stopped for speeding in a 50 kph zone. The traffic police have now begun to use electronic devices to record speed and I am very certain it was done as a revenue generator rather than a deterrent to speed. After talking with the officer for a bit of time, Yusef came back to the car and informed us that he would have to pay a penalty for his speeding and asked if we might have an extra 10,000 TSh, or about $5 – far more reasonable than any speeding ticket would have been in the US.

We eventually made the turn off the tarmac traveling to our lodge near the Sangaiwe gate of Tarangire. Not the best marked route such that we had to ask several townspeople all the way even while I was using my GPS navigation program knowing the coordinates of the lodge, we still were able to make it there and all before sunset. The Simba Tarangire Lodge is a relatively new facility and we were extended resident rates due to our working at FAME. It is a hybrid lodge/camp model where the “tents” are permanent with hard floors, bathroom with plumbing and hot water, an indoor and an outdoor shower, all overlooking Lake Burunge outside the park, but in the middle of a wildlife reserve so that herds of zebra and wildebeest roam in our view towards to the lake.

Sunset from the pool deck

Sunset from the pool deck

We were greeted with cold washcloths and cold juice as we got out of our vehicle from our long drive and the staff couldn’t have been more pleasant and helpful. They gave us a little rundown on the grounds, where meals were served, where we could watch sunset and then were our rooms were. You’re not able to walk to or from your rooms at night or in the dark as there are lots of dangerous animals close by that would not be very pleasant or safe to meet up with in the dark or otherwise. Laurita and Kelley were staying in one tent and I had my own for the two nights. We dropped our things off in the rooms and made a beeline for the observation deck that looked out towards the lake and was the best spot for viewing sunsets which was about to happen. We sat on the deck enjoying a cold beer after the day and couldn’t help but think of all the amazing things we’ve already done this trip and the amazing safari we were about to have.

Relaxing on the observation deck after our drive to the lodge

Relaxing on the observation deck after our drive to the lodge

We had asked for dinner at 7:30 and there was a choice of grilled chicken or pork chops. Yusef joined us for dinner as it the custom with safari guides here and we sat down to enjoy an incredible meal of vegetable crepes, followed by a wonderful vegetable bisque with homemade rolls and then our main course. Both the chicken and pork were great though I thought the pork was really exceptional. Desert was a delicious caramel flan-like dish (notice the Hispanic influence on the description that Laurita just gave me).

My lovely tent

My lovely tent

The view outside

The view outside

After dinner, we all sat out on the pool (Yes, they actually had a swimming pool) deck and stared up in the sky fully lit with stars the most beautiful Milky Way any of us had seen in some time. There was to had been a meteor shower this night, but we weren’t entirely clear if that included being in the Southern Hemisphere and half-way around the world or not. Regardless, we all saw a number of shooting stars somehow with me seeing less even though we were all looking at the same sky. As we sat on the edge of the deck and furthest away from the lights of the lodge, the askari continually came by to check the bushes just beyond our feet for any overenthusiastic animals that may have decided to take a closer look. Lions do roam these premises as the many bones of previous victims are readily apparent immediately upon leaving the confines of our camp. It was just a bit unnerving to Kelley and Laurita who pulled their feet closer in hopes of avoiding any curious felines. We all eventually realized it was way past our bedtimes considering we had to get up early for breakfast which was at 6:15am so we could get an early start on our first day of safari. We were all escorted back to our tents by spear wielding askari who continually shined their flashlights in all directions as you are not allowed to walk alone in camp after dark for obvious reasons.

I was fairly certain we’d all sleep well that night until I heard all the animal sounds that I was sure were new for Kelley and Laurita and could disrupt their sleep. I’ve heard them so many times here that they’re more relaxing to me and I drifted off to sleep after some reading with thoughts of a successful game drive in the morning.

October 20, 2016 – The more difficult side of medicine….

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More kids

More kids

We had our second day of clinic scheduled today at Rift Valley and had planned to leave a bit later in the morning as they had wanted us to stay later to see some children who were taking their exams in class. I was also supposed to hear from Soja this morning regarding our vehicle. Frank uses an expression here, “TIA” which isn’t what most neurologists think it is, but rather “this is Africa.” It encompasses life here which not only often unpredictable, but also most often not as expected. Time runs differently here and plans that have been made must often be changed to accommodate the unexpected. Having lived and traveled in this paradise now for a combined one year with all my trips I can attest to this as it has so often intersected with my life here in so many ways.

Dr. Laurita evaluating a patient

Dr. Laurita evaluating a patient

At morning report we learned of two patients that they wanted us to see in the wards, both admitted overnight, and both of whom were believed to have a neurological problem. Since I had to deal with the vehicle, I had Kelley and Laurita do the consults in the wards. Laurita’s patient was one who had come in with what was described as a psychotic episode and had a history of this occurring one before. He turned out to have a heavy alcohol history and each episode had occurred in the setting of heavy use. As she went to examine her patient, she immediately noted that his eyes were not conjugate (i.e. they didn’t move together) and, indeed, he had bilateral ophthalmoplegias which clearly defined his problem as a Wernicke’s encephalopathy secondary to thiamine deficiency as a result of his alcoholism. This is a potentially reversible problem by replacing thiamine before they receive any dextrose in their IV fluids, but unfortunately they had no thiamine in stock here. We had the pharmacy order it for us to come in by the following morning and meanwhile made sure they knew not to give him any dextrose containing IV fluids.

Dr. Kelley and Dr. Mary

Dr. Kelley and Dr. Mary

I had been unable to reach Soja regarding our vehicle which was not yet here, so I headed back to the wards to check on how the consults were going. I first visited Laurita who ran things by me and then entered the next room where Kelley’s patient was. Unfortunately, things were not going so well with this consult. As I entered, Kelley was doing chest compressions on the patient while he was being ventilated by a visiting nurse with an ambu bag. This had apparently been going on for about five minutes or so. Nurses from the ward and one clinical officer were also there. I helped with the code to the best of my ability (remember, we are neurologists) by sharing in the chest compressions and asked for the code cart and, eventually, Dr. Frank to intubate the patient. Without going into further details, I will tell you that the code was not successful and it was very tragic as this was a thirty-year-old patient who had come in late the night before with a poor mental status for which we had been asked to see him late that morning. When Kelley had gone into the room to do the consult he had thready pulse and irregular breathing. Despite intubating him we were never able to oxygenate him leading us to believe that this was likely a pulmonary embolus.

Dr. Kelley and Dr. Mary with a shy patient

Dr. Kelley and Dr. Mary with a shy patient

Certainly, the mood of our visit changed in one fell swoop and it quickly brought to us the often cold reality of life here. Despite our presence and our best efforts, we can only do so much. For Kelley, though, it was tough defeat way too close to home and as we stood in the room after it was over debriefing for a moment, I could see how personally she took it and knew she would need time by herself to gather her thoughts. Events like this can happen to anyone, anywhere, but when you spend your life training to save lives and reduce suffering, it is not something you can ever prepare for in any fashion. I knew that it would take some time for her to resolve things in her own mind and we needed to give her as much room as possible to do this on her own.

Young Thobias whom we have seen over the years

Young Thobias whom we have seen over the years

In this setting, I discovered that our vehicle still needed more repairs and was not ready so sought out Susan to see about borrowing one of FAME’s Land Rovers to use for our clinic which I knew wouldn’t be an issue. We all eventually piled into their stretch Rover and stopped by Soja’s on the way to get all the meds and supplies that had been left in our Land Cruiser and we would need for the day at Oldeani. It was another beautiful day and we arrived to RVCV about an hour later then we had anticipated originally. We began again to see our patients, though there were fewer than we had hoped. We had a wonderful lunch this day of homemade squash and carrot soup, homemade bread with tuna and cheese, potato and ham salad and a green salad. After lunch we saw the few remaining patients and then headed for home. We stopped by Soja’s on the way, but our vehicle was still being worked on so were on our way back to FAME without it again.

Dr. Laurita evaluating a non-compliant seizure patient

Dr. Laurita evaluating a non-compliant seizure patient

This night we had plans for dinner at Gibb’s Farm. It is another one of those magical places that is a must for us and I bring every volunteer here for dinner. It is a five star resort, but in an entirely local fashion where everything is as it was when it was a coffee plantation and they serve five star home grown food. Their veranda is spectacular with it’s view of Karatu from high above and off towards Lake Eyasi in the distance. It sits high on the Ngorongoro Crater rim and immediately adjacent to the Conservation Area. I know most of the waiters there and we sat on the veranda through sunset and dark having drinks prior to going inside for dinner. We were served an amazing four course meal with silverware than anyone could count. The homemade bread and butter melted in our mouths. Dinner took over two hours and it was so relaxing. We didn’t leave until after 10pm and were all more than ready for bed with the day’s activities before us. It was another incredible day and even with the events that occurred, we were still grateful to be here. As with anything, we are formed by those experiences we learn from and, in such a way, become who we are today and are better for it. We change the lives of those who we interact with and by doing so are changed ourselves.

Relaxing on the veranda at Gibb's Farm

Relaxing on the veranda at Gibb’s Farm

A nice panorama from the veranda

A nice panorama from the veranda

October 19, 2016 – Day 1 of Rift Valley Children’s Village and Oldeani….

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It is hump day, but in no way does this reflect our sentiments as we all wish we could continue our for weeks more. Today we will be traveling to the village of Oldeani, about 30 minutes away and the location of Rift Valley Children’s Village which I have spoken of many times before. Mama India, or India Howell, is from Boston and came here well over twelve years ago much in the way we all end up coming to Tanzania. You will find that the majority of ex-pats working and living here originally came on vacation to safari and fell in love with the people and country deciding to discard their former life in the US for one of doing good here. India founded Rift Valley Children’s Village, or RVCV for short, about twelve years ago as a sanctuary for abandoned and orphaned children here. She realized, though, that these children would never feel safe unless they knew this was their home and so she and her business partner, Peter, have adopted all of the children who live there. There are now some 100 children there, from infants to the late teens, and when they are ready for college they leave the village to make a new life, but Mama India and Peter will always be their parents. She partnered with the local village to improve first the primary school and now the secondary school so all her kids as well as those in the village will have a chance to go on with their education. She has also sponsored visits from FAME on a regular basis to provide free health care to the villagers so the community will be healthier, benefiting her children. Unfortunately, the grant to fund that health care has ended, but the neurology visits, which we have done in conjunction with the FAME general medicine visits since 2011, were beneficial enough to continue and so we are going it alone for the first time since I’ve been here to see both villagers and children with neurological disease.

It's all about the children

It’s all about the children

The drive to Oldeani is quite simply another with the same spectacular views as the rest I have described. The road there is off of the tarmac that heads to the Ngorongoro gate and travels along ridges and down into deep valleys where we cross now dry creek beds that are raging in the wet season. We eventually arrive at coffee plantations that surround the village of Oldeani and the Children’s Village and as we pull through the gates of RVCV we see our patients sitting outside the clinic rooms where we will see them. There are not the usual crowds here that I’m used to seeing when FAME also does their clinic, but there are enough for us to get started. Dr. Badyano has today and tomorrow off, so Dr. Mary is working with us and today she will be working with Kelley. The majority of patients here are children so I bounce back and forth between the rooms to check on Laurita and Kelley as we go. Several we are asked to see because of poor attention in school and possible delays and others because of epilepsy. They are split with follow up patients, for whom most we have prior notes, and new patients.

Our young microcephalic child finally warming up to us

Our young microcephalic child finally warming up to us

A giggle monster

A giggle monster

RVCV is perhaps one of the best volunteer jobs to get in Tanzania given the prestige of the facility and the opportunity work in such a magical place. The children all live in different houses with house “mamas” who care for them and the volunteers focus mainly on their activities during the day and helping with education of children not yet in school. We always look forward to lunch at RVCV as we eat what their volunteers eat and it is always one of the best lunches you could ever imagine. Today is quesadillas, fried beans, ground meat, salsa Fresca and fresh fruit. Oh yes, and cake for dessert. Simply delicious. Though we all definitely feel like napping after such a lunch, we fight the urge and forge on to see the afternoon patients which are quite few. The numbers are down most likely as we didn’t advertise here to the community since we weren’t sure until recently that we would be having this clinic.

Kelley and Dr. Mary evaluating a seizure patient

Kelley and Dr. Mary evaluating a seizure patient

Hyperventilating a suspected primary generalized seizure patient

Hyperventilating a suspected primary generalized seizure patient

Dr. Mary and Dr. Kelley evaluating a patient

Dr. Mary and Dr. Kelley evaluating a patient

We left early enough to enjoy a different route I know heading back with more amazing scenery of rural homes and fields of crops that are healthy and full. We arrived back to Karatu to make another visit to the dress shops for everyone to pick up things, order new things and try on clothes that have been ordered. Selina accompanied us again to help with translation as the women in the dress shop speak no English whatsoever. We travel back to FAME and I drove my vehicle down to Soja, who is the mechanic that works on all of FAME’s vehicles and is a good friend of Frank’s. Alex followed me in the old RAV so I wouldn’t have the walk the fair distance back to FAME. The Land Cruiser was leaking power steering fluid and needed to have the steering rack rebuilt. I was assured by Soja that we’d get it back the following morning so I could drive it to Oldeani again as we had a second day of clinic there tomorrow.

October 18, 2016 – On to Upper Kitete…..

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Every Tuesday morning is reserved for an education meeting with the doctors and it is typically given by the visiting volunteers whether it be neurology, on/gyn, cardiology, medicine, or infectious disease. Usually, FAME has only one specialty come to visit at a time as it can otherwise become a bit unwieldy as resources here such as the doctors and nurses are quite limited. FAME’s mission is for western volunteers to share their knowledge and expertise with the staff here whether nurses or doctors.

Morning lecture

Morning lecture

The request for this morning’s lecture was Parkinson’s disease so Kelley and Laurita spent the evening (and some of the night for Kelley who stayed up quite late) preparing a PowerPoint presentation for the doctors. Dr. Msuya is in charge of the educational programs and Dr. Lisso, who is the head doctor, oversees all of the programs here including which doctors we work with on given days. The morning lectures are supposed to be 30 minutes long and we were running a few minutes late this morning so it was already going to be a challenge to get everything in. Dr. Lisso is usually a stickler with time and I have seen him cut off presenters in mid-sentence before, so when they were pushing 45 minutes for their lecture and Lisso hadn’t yet interrupted them, it was clear that they had everyone’s attention. Both did a great job with their presentations and there were tons of great questions afterwards which was a clear sign that they had also done an excellent job stimulating interest.

Our patients waiting at Upper Kitete

Our patients waiting at Upper Kitete

After morning report, we began organizing for our trip to Upper Kitete. This is another village along the Great Rift in the Mbulumbulu region that is past Kambi ya Simba on the same road and about twice as far. The scenery on the drive is equally stunning, and perhaps even more so, as the border of the Ngorongoro Conservation Area and mountain range that marks it closes in towards the rift narrowing the plateau of rich farmlands we are traversing until it is no more. This is where the mountains that include Empakaai Crater meet the escarpment of the rift and drop off to the floor of the Great Rift Valley leading northward to Oldoinyo Lengai, Lake Natron and, eventually the border with Kenya. Upper Kitete is the second to the last village along this plateau with Lositete being the last and along a rough and often impassable road.

We also attract a following of children....

We also attract a following of children….

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The health center in Upper Kitete is quite old and a new building that was recently completed was not yet ready for our use. We had a number of patients waiting for us as we arrived and others came once the word of our presence seemed to circulate. The clinical officer there was trying to be helpful, but was a bit too enthusiastic at times and gave a long speech to the patients telling them what we were there for and how the clinic would proceed. I don’t think it was very helpful, though, and we had to once again screen our patients to make sure we were seeing neurological problems and not just everyday aches and pains. We started off using the medical officer’s office and one of the rooms we normally use that I affectionately call the “bat cave.” In the corner of the room there is a large opening in the ceiling where you can often hear the bats as they spend the day in the attic. The smell of bat urine and guano is also noticeable, but only mildly so as it’s not all too offensive. I’ve never seen a bat flying or otherwise in all the times I’ve come here so I think we’re pretty safe in not encountering one as we work. The labor and delivery room, which we normally use as our second room was unfortunately occupied by a patient and not available to us.

Dr. Badyano and Dr. Laurita evaluating a patient in the bat cave

Dr. Badyano and Dr. Laurita evaluating a patient in the bat cave

Kelley and Laurita began seeing patients, Laurita in the bat cave and Kelley in the office. Sokoine had showed me a young girl who was screening and who had a “crooked neck” that he wasn’t sure was neurologic or not. I took one look at her and unwrapped the fabric she had covering her head and neck, and it was quite clear that she had torticollis, a very definite neurological disorder. Laurita ended up seeing her, but I didn’t tell her my diagnosis so she could make it herself, which of course she did in very short order. It had come on acutely a month prior and was very uncomfortable for her. We have very few of the medications here to treat it, but we did have diazepam (Valium) that was prescribed in very small doses. We also told her to use warm compresses along with the diazepam and asked that she return to FAME in two weeks to see how she was doing.

Our young patient with torticollis

Our young patient with torticollis

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The rest of the patients were a smattering of typical pathology – headaches, seizures, numbness and tingling being the most common complaints. At midday we had our lunch of Tanzanian street food again with a few new items having been added to our menu. One was a skewer of goat meat, a few vegetables and boiled, peeled potato that wasn’t bad. The samosas, though, were the best of the bunch and very much appreciated by each of us.

At one point during the day, Kelley came looking for me as her patient was in need of occipital nerve blocks and she needed my assistance in performing them. I went to the vehicle to get the medications and when I came back she was no where to be found. I went to every room looking for her and asked the others if they knew where she was. No one knew. I proceeded to pop my head in every room to look and it reminded me of something from a slapstick comedy. The nurse was seeing babies in the medical office, Laurita and Badyano were in the bat cave seeing patients and when I opened the door of labor and delivery, I unexpectedly walked in on the clinical officer performing a pelvic exam on his patient. I called Kelley’s name several times with no response and was getting pretty angry at one point that I couldn’t find her and none of our support staff were aware of her location. I called for Kelley on one last occasion and heard a faint reply coming from the new building which I had been told wasn’t ready for us. She and Selina had been directed there after the medical office had been needed again for baby visits. I finally relaxed a bit after learning that I hadn’t actually lost one of my residents in Africa which would have been difficult to explain, especially to Dr. Price, our residency director. I fear that he would make me cover the remainder of their duties which isn’t something I’d even like to think about.

A clinical discussion

A clinical discussion

Following my brief lapse in sanity, I helped Kelley with the occipital nerve blocks which are something we often do in the US for patients whose headaches are from inflammation and can often be relieved with a combination of a steroid and a local anesthetic. The patient tolerated the procedure just fine and was on his way in short order.

A moment of down time

A moment of down time

We finished seeing patients at not too late an hour and decided to return directly to Karatu and FAME. The drive back was on a different road that parallels the escarpment that falls off to the Great Rift Valley and the views are spectacular. You can see for many miles down to Lake Manyara and up towards the village of Engaruka, a very important historical and archeological site in the history of the Maasai in this region. I know it seems like everywhere we go here in Tanzania the scenery is totally amazing, but that is the truth. This country has possibly the most diverse and beautiful of any on this earth. No matter which direction you turn you are seeing something entirely new.

After dropping all the FAME staff off in town other than Ema, our driver and who lives next to FAME, we returned to catch up on email after which we sat on the veranda and watched another colorful sunset. It is so relaxing to just sit and look off into the distance with its lovely jacaranda trees of unique purple lavender and the coffee plantations beyond. The distant mountains are all overlap in a gorgeous sketch marking the horizon and lands beyond. We are all so lucky to be here and to experience this land and these gracious people in such a fashion. We are their guests, but are truly treated like family and for that we are so grateful. This experience is like no other.