October 23, 2017 – More neurology days at FAME….

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Sara reading MRI scans brought by a patient

We had survived our trip to the Central Serengeti, including my kite attack on the crater rim, and had seen spectacular sights there that included the wildebeest migration. It was now time to get back to work seeing neurology patients at FAME. We had asked a number of patients who we had seen at FAME in the first week and a half of our visit to return during this final week to follow up on therapies we had instituted. This included seizure patients in who we had made medication adjustments or needed to check additional labs.

Sara and Baraka examining a young child

It was probably not quite as busy at the start today as it had been during our first scheduled week here, but the volume was quite steady throughout the day necessitating that we again run three rooms. Dr. Ivan was going to work with us today and he was paired with Neena, while we had Baraka and Emmanuel working with us one again. These two translators have worked with us tirelessly for the last several weeks and have been indispensable. Without them we would not have been able to see the number of patients we have seen. We’ve also been able to work with at least one clinician everyday instructing them on the neurologic examination and neurologic diseases.

Whitley and Emmanuel evaluating a patient

Whitley and Emmanuel taking a good history

An interesting patient seen by Sara today included a young boy who was accompanied by his caretaker and had been unable to walk for the last five years. They had originally stopped me outside to show me his MRI scans that had been taken to ask me if there was anything we could for him, but without taking a history or examining him, there was little that I could tell them. After Sara took a good history, it was clear that the boy had had tuberculosis that had affected his spine (Pott’s disease) and he had suffered complete collapse of his fifth thoracic vertebrae with compression of his spinal cord. Essentially, he had a nearly complete transection of his cord at the T5 level with paraplegia and a T5 sensory level. Their question, of course, was whether we could do anything for him or whether there any chance of him improving and we had to give them the news that he would never walk again. We were able to give him some symptomatic medications, though, for his spasticity, that would hopefully be helpful.

Sara and Baraka evaluating a child

Another child Sara evaluated today was a young girl from Dar es Salaam with a very severe epileptic disorder that we’ve seen in the past and who has been on a multitude of medications. One of our previous pediatric neurology residents has continued to be involved in her case and it was believed that she likely had a progressive epileptic encephalopathy, though she had responded to medications after her last visit and was now improving somewhat suggesting that her cognitive issues may well have been related to her frequent seizures rather than a degenerative disorder. That was certainly very good news and, though, she was still not a normal child, she was still functioning significantly better than when she was previously seen and her prognosis was better than previously believed.

Neena and Dr. Ivan evaluating a patient

Whitley and Emmanuel examining a patient.

Another group of patients today had been brought by Dr. Elibariki Lucamay, a very caring general surgeon in Arusha who I had met last March and who had asked about bringing some of his neurological patients to FAME to see us when were here. He brought three seizure patients for us to evaluate, all of whom had been diagnosed perfectly appropriate and were on the correct medications. We made some minor adjustments in doses and recommendations for labs to avoid toxicity, all of which we not only communicated to the patients, but also to Dr. Elibariki who will continue to follow them going forward. We will very likely see them again in March when we’re here, but I’m very confident that they will have excellent care in the meantime.

Sara evaluating a young child with mother

Sara continued to have a busy day as a group of children had been brought from a special school for neurologically impaired children south of town in the direction of Qaru where we had been last week. These children don’t live at the school, but rather with their families and are assisted in their care by the workers at the school who work for an NGO. One of the young girls was clearly autistic, while another young boy had seizures, and a third child was quite delayed with some focal abnormalities and probable cerebral palsy. Interestingly, the mother of the young boy with seizures was very insistent on having a CT scan performed even though the boy had a normal examination and his seizures were not recent nor were they difficult to control.

Sara and Baraka examining a child

Sara evaluating a young child

The day was busy and I believe we ended up seeing another 30 patients which is pretty much our maximum for day here and can be seen in a reasonably comfortable manner making certain we are able to have lunch. They do have teatime here in the British fashion as this was once a British colony and this is no doubt left over from that era. They serve chai masala, a very sweet African tea with lots of cardamom and other spices that is simply to die for (as every resident who has been here with me can attest to) and coffee along with white bread and butter. I’ve never quite understood the bread and butter, but we’re always happy to grab some of the chai while working seeing patients. The mandazi that is so remarkable ended up not being made during the month as the normal cook, Samweli, who I have known forever here, was on his annual leave while we were here.

Sara speaking with mom through interpreter

Sara evaluating yet another child

Sara and Baraka evaluating a young patient with mom and school worker looking on.

We had decided to spend the evening working as Whitley was giving her lecture on epilepsy tomorrow that she wanted to finish and we all had some things to do. It’s so very relaxing at the Raynes House and it has been a genuine pleasure to have us all stay in one house and spend so much time together. We’re always able to catch the sunset from our veranda or the kitchen window at the end of the day, reminding us of how lucky we are to be here doing what we’re doing. We are in the final stretch of our time here and only have a few more days to see patients.

Whitley catching up with notes the old fashioned way

Sara catching up with her charts

October 22, 2017 – Another day on the Serengeti….

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We had decided to do a pre-breakfast morning drive departing before sunrise, which meant we were up quite early in the cool night air. Thankfully, there was some hot water already prepared for us to make coffee or tea before our drive which was fine since we knew there would be a nice hot breakfast waiting for us on our return. The night had been restful even with the often not so distant whooping of the hyenas as they were scrounging through the area surrounding camp. I had heard a male lion with his low rumbling roars the night before, but didn’t hear the same last night. With the coming of dawn, the birds were already quite active with their constant calls.

It was cool enough for us all to need either fleece or a shell since having the top up on the vehicle meant a stiff breeze whether you were standing up or not. I always stand when we’re on a drive as it’s my favorite way to view game, though I think the others were mostly sitting and this was probably smart considering my hands were quite cold and nearly freezing from the cold, morning air. As we drove out east from camp, we again spotted groups of wildebeest, though somewhat fewer than yesterday as much of the main herd had moved overnight in the direction of Naabi Hill, where we would be heading after breakfast to depart from the park. We drove from kopje to kopje hoping to spot a kill that was the main purpose of leaving so early. It was also to hopefully catch a glimpse of some animals that you don’t normally see during the day. We had spotted several bat-eared foxes, nocturnal animals, that each quickly ran off to their burrows as soon as they heard us and where they would have been heading shortly regardless.

We were well into the rolling hills and kopjes by the time the sun decided to rise above the horizon and grace us with its warm rays of sunlight though the air remained cool enough for us to remain bundled up. We ran across a small family of elephants moving across the plain heading to an unknown destination. We investigated several kopjes searching for lions, but didn’t spot any this morning much to our dismay, nor did we have the opportunity to see a kill that we had all hoped for. We eventually made our way back to camp at least with the knowledge that we would have another scrumptious breakfast before departing while taking our time to reach Naabi Gate and game viewing along the way.

A group or rock hyrax warming in the early morning sunshine

We enjoyed another amazing breakfast consisting of an omelette, mandazi, bacon, sausage, fruit and, of course, tea, before heading off to our tents to pack up. It was certainly tough for us to depart after only two nights there, but regardless, it was still an adventure that would remain with everyone forever. There is nothing that compares to the Serengeti in its immenseness and diversity, both for its wildlife and topography. It is truly unique and a treasure.

A dwarf mongoose

On our way to Naabi Gate we still had more to see and briefly spotted a hippo out of the water heading home from its nighttime foraging. There were long lines of wildebeest to our left all along the main road as they were moving about looking for the perfect grass to satisfy them. And along with the wildebeest all about, there was a small group of female lions with their many cubs sitting under tree just on the side of the road. Their bellies were all full so they had clearly eaten recently and Simon had spotted some signs of a likely kill nearby just before we came upon the family so that was the likely source of their meal.

We arrived at Naabi Hill in time to depart the Serengeti well under our deadline as we had 48 hours there with the fees we had paid. No one was yet hungry enough for lunch so we all decided to make the trek to the crater rim and have lunch there after traversing the wide plain that passes by Lake Ndutu and Olduapai Gorge. The story on the correct spelling of this very famous site where Louis and Mary Leaky spent much of their lives, making discovery after discovery, is that it was originally misspelled as “Olduvai” by the first westerner to see it. The area was actually named for the sisal plant that grows there and that the Maasai call “Oldupai.” All the maps in Tanzania and the park that bears its name use the correct spelling as do I.

Once having ascended to the crater rim, we looked for a good picnic site to have our lunch and soon found one, though I’m sure that Simon had already decided where we were heading. There were some log sections scattered in several areas to sit on and two Marabou Storks who stalking around the area looking for scraps. These are seriously large birds that have a rather ghoulish look about them with very long and sharp beaks that would not be fun to tangle with. They stayed at an appropriate distance, thankfully, and were more intimidating than anything else.

We opened our box lunches from the camp to find a nice array of typical safari food – a cucumber sandwich, a piece of chicken, juice box, cupcake, pasta and a chocolate bar. Everyone was looking forward to the meal since it had been some time since breakfast. I sat quietly eating my piece of chicken, keeping a steady eye on the storks pacing back and forth behind us, to make sure they weren’t going to try something. I had just taken a bite of my chicken and was holding it less than a foot in front of my face when suddenly there was a huge grey blur, a whoosh of air, and I felt the chicken being quickly snatched from my hand. As I looked to my left, I saw what had stolen my chicken and it was a huge black kite with its wings spread soaring off someplace to enjoy his booty that had previously been my lunch.

A ghoulish Marabou stork moments before the aerial attack of the black kite

I should have been aware of this possibility as I have seen these kites dive bomb other unsuspecting victims down on the crater floor at the lunch spot as they can spot prey (or a sandwich) from high in the sky. In fact, we always eat our lunch in the crater in our vehicle just to prevent this occurrence and I had somehow overlooked the fact that these birds would very likely be staking out any lunch spot in the vicinity. Following the event, I was quite calm and merely stated that a bird had just stolen my chicken and which quite impressed Neena as she said that she would have been totally freaked out. Kites are fairly large birds with a wingspan of probably 5 feet, so Neena’s reaction was totally a reasonable one and, for whatever reason, it had just seemed like such a matter-of-fact occurrence to me that I didn’t react. Or perhaps it was that I had seen this happen so many times before that it didn’t entirely surprise me. I hadn’t been injured or even suffered a scrap, so we all went along eating our lunches, though with a bit more caution than before.

Following our lunch, we began our trek around the crater rim once again heading towards the Ngorongoro Gate and, eventually, Karatu. We had planned to have nyama choma for dinner, which translates literally to “burnt meat,” which is essentially barbecued beef, chicken or goat, at one of the local restaurants. We had mentioned to Alex, our volunteer coordinator, about our plans for dinner before we had left on safari, but it turned out he had other plans for the evening, and so, we would be left having not only to find the restaurant on our own, but to also chance ordering our own food, which can be a interesting proposition around here.

At the Ngorongoro overlook

Ke, a longstanding repeat volunteer here at FAME who is from the US and also happens to be a medical student at Yale currently, decided to come along with us also. Ke has come for several months this time to revamp all of the networking here at FAME as well as help on some of the patient information systems that gather data on the patients seen here along with their medical information. The four of us and Ke went to town and after a bit of searching, found the nyama choma restaurant that Alex had recommended. There was a popular soccer match going on so there was a crowd watching that, but we found a few tables to combine and sat down to order dinner.

An overview of Karatu environs from the crater rim

We couldn’t understand the price she was giving us for the nyama choma as it sounded like she was saying 80,000 TSh (T-shillings) per kilo of meat, or bit less than $40, which made absolutely no sense as that would be almost the price of Kobe beef, so Ke and I went up front to check with the cook. The cook sits in a little smokehouse with slabs of meat hanging from hooks from which he slices off chunks and then grills it. The nyama choma was actually 8,000 TSh per kilo or less than $4, a much more reasonable price. We ordered 3 kilos for the five of us along with three plates of “chipsies,” or French fries.

They serve the meat, in this case we think it was beef, but also could have been goat, on a dish with some hot sauce and small piles of salt in which to dip your meat. The meat was chewy, but delicious just the same and I think everyone very much enjoyed it. It was another great ending to a very successful day having started in the Serengeti and ended in our small town of Karatu. Tomorrow we would begin our last week at FAME seeing patients.

October 21, 2017 – A Full Day in the Central Serengeti….

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I had awakened early today with the anticipation of viewing sunrise as there is nothing more magical than sitting out on the Serengeti Plain with all the sounds of nature around you and nothing else, while the horizon to the east begins its transition from a soft glow to the brightness of the new day. There is nothing like a sunrise on the Serengeti for all the reasons you can imagine and no matter how many times I’ve seen it before, it never fails to amaze me that I am here and experiencing it. The night was cool with steady breezes along with the frequent howls of the hyenas and an occasional low growl of the male lion to remind us were we were. I had slept exceptionally well last night and we were all looking forward to the full day we were planning to spend on a game drive.

With the sun fully up by 6:30am, I wondered over to the dining area to see if they had hot water for tea, which, of course, they did, so made myself a mug of Kilimanjaro Earl Grey and sat in a chair looking over the area in front of our camp just admiring the many sights and sounds that filled the air. Several groups of animals such as topis, zebra and even a small band of wildebeest, made their way by the camp in their daily trek looking for their perfect grass. It is like their daily commute, though certainly much less congested than those that we know.

Working on my blog before breakfast with the omelette chef in the background (he made a delicious omelette!)

The camp crew is up very early so had prepared everything already for breakfast, another buffet style meal, though now had a table out front to make eggs to order, including omelettes made to order. The omelette chef was wearing his white apron and chef’s hat as if we were in any fine restaurant for breakfast. As everyone met at the arranged time of 7am for our meal we had to keep reminding ourselves that we were in the middle of the Serengeti. The food was again delicious including the little mini mandazi, small pastries that were similar to donut holes, though not as sweet so were eaten with a bit of honey.

A Dik-Dik around one of the kopjes

Simon had brought the car around already and after breakfast, we grabbed our cameras and things we’d need for a full day away from camp along with our lunch boxes, and headed out for adventure. The air was cool with the sun low still low in the sky, but you could still feel the warmth of its rays on your skin in welcome contrast. We initially drove off to the east of camp out of the hills and towards the many kopjes that dominate the topography of this region of the Serengeti. Kopjes are small outcroppings of rocks that are like little islands in a sea of grass, each one serving as its own community. Lion prides will often remain around a single kopje for a time and then move to others in their territory as they serve as a fantastic vantage point to look out over the plain and to plan their next meal. They do this very much as the cheetah do on their termite hills. These islands of life also include smaller animals such as the dik-dik (the smallest of the antelope), the rock hyrax (a small animal that looks like a rodent, but is actually a relative of the elephant) and various reptiles including the blue and red agama lizard.

In the Serengeti National Park, you must drive on established trails, but they pretty much crisscross everywhere between the kopjes, often consisting of two very narrow tire tracks. We traveled from kopje to kopje heading further east into the bush until we finally came upon what seemed like an endless sea of wildebeest. Each time you thought that you had seen the bulk of the herd, though, you crested a hill and realized that it continued for ever and in all directions. We were in the middle of the main group of wildebeest that made up the Great Migration, the largest single movement of land animals in the world. They migrate in a circular motion following the grasses and were now in the Central Serengeti, but would soon move on to another more promising area depending on the weather. There are about two million wildebeest that migrate between the Serengeti and the Maasai Mara (the contiguous land across the border into Kenya) and even though we weren’t counting the animals before us, I am certain that we were seeing hundreds of thousands of wildebeest stretching out over the hills before us.

As we meandered along the trails amidst the herds of wildebeest, we would occasionally run across their predators, the lions here, that feast on the migration when it is here. One male lion slept in the shade of a kopje alongside its half eaten wildebeest kill from the morning or night before. Another, particularly handsome, male lion that we ran across was walking from a nearby watering hole to one of the larger kopjes as the wildebeest kept a wary eye on him to make sure he wasn’t still interested in them. He eventually meandered over to the kopjes and climbed to its highest point looking like a scene from The Lion King movie. We ran across many other lions that day, many with cubs and all of who looked quite healthy clearly relating to the presence of the wildebeest in the area. We had hoped to see a kill today, but it was not to be, though we were very happy to have seen the Great Migration in all of its glory.

We eventually made our way back to Seronera, the cluster of lodges and camps in the Central Serengeti, and where the airport sits. We decided to have lunch outside the visitor center there and then begin our afternoon game drive. We had seen lots of lions and cheetah in the morning, but we still hadn’t seen a leopard, so that was our main focus for the remainder of the day and with any luck, we’d find one. Leopards are most commonly found in river areas where they rest in their tree during the day and typically hunting at night. Leopards drag their prey into their to protect it from lions and hyenas and so they can feed on it over time. You can often spot what is left of old leopard kills hanging in the trees after they’ve abandoned the carcass and sought a new kill. They are quite powerful and one of their favorite animals to prey on are baby and younger wildebeest, carrying the entire animal into the tree with them.

During the afternoon we found many, many more lions, some with cubs and even found a group of four cheetah, which is very uncommon as they are solitary animals who typically hunt along. This group was made up of a mother and three adolescents who were probably all about ready to leave the nest. They were resting under a tree to avoid the hot sun which was unfortunate as it would have been amazing to have seen this group hunt. Cheetah will typically not pursue large prey on their own, sticking mainly with Thompson gazelle or impala, but in a group such as this they could have easily have tackled a wildebeest and that would have been a sight, For now we have to just be happy to watch them for a bit and then move on.

A bee-eater

A grey crowned crane

We eventually ran across a telltale sign of a leopard which is a large group of safari vehicles all stopped on the road. Sure enough, when we were finally upon them as we had originally seen them in the distance (the vehicles, that is), there was a beautiful leopard sitting up in her tree (the way it was straddling the branch made it more likely it was a female) resting, but awake and moving around. She didn’t have a kill with her that we could see, but she didn’t look interested in hunting so she had probably eaten that night. With the sighting of leopard, Neena, Whitley, and Sara had now seen the African big five consisting of the elephant, Cape buffalo, lion, leopard and rhino, albeit the rhino from quite a distance on the crater floor through binoculars from the overlook. Black rhinos in Tanzania are very endangered with perhaps only 200 existing in the wild, less than 30 of those being in the crater and the remainder in the Northern Serengeti primarily. I have had the luck to see eight rhinos in one day on the crater floor which was amazing luck and had actually seen a mother and calf in the Northern Serengeti before. White rhinos, that are almost twice the size of the black rhino, live in the southern part of the continent and are far more numerous as they are not endangered.

After spotting the leopard, with our game drive near complete, we continued to look for more animals as we roamed along the river area eventually heading back in the direction of our camp. We ran across more lions on the way, including an unusual group of four juvenile males, probably brothers, who were sleeping together under a tree in the shade. Though the females do most of the hunting for a pride, these four males would certainly be a dominant force when hunting together and would each eventually begin to look for their very own pride to adopt or take by force.

One of the smaller kopjes

Coke’s hartebeest

Our day had been quite worthy of the safari experience everyone had hoped for and the Serengeti once again did not fail to impress. I have been here numerous times and have seen the migration in the south and the north (even a difficult to see river crossing at the Mara River), but had never seen the migration spread out in front of me in such a fashion. As far as the eye could see, on every hilltop, in every direction, and then far beyond as we traveled through this conflagration of wildebeest there were more and more animals that were just never ending. Their honking was not deafening, but it was constant and reassuring, even soothing at times as we drove amongst the herd, that reminded us all of the importance of this miracle of nature that has existed long before civilization and long before humankind as we know it today. These animals migrated long before our ancestors’ ancestors and very likely were responsible for their survival.

We returned to camp well before sunset and with time enough for us all to relax and shower as the dust during the day was all encompassing. It was a lovely evening, much as the day had been for the air was never hot nor the humidity high. We all looked forward to another wonderful dinner and, of course, we weren’t disappointed. Sitting at our table that faced out overlooking the savannah in the fading sunlight, it was clear to each of us that what we had encountered today was truly a gift that would remain with each of us for the rest of our lives. It is difficult to fully describe the feeling one has driving through such an immense area as the Serengeti and to see what we have seen today, but save it to say that it is an experience of a lifetime.

October 20, 2017 – It’s morning report and then off to the Serengeti….

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Whitley’s rhino….in her dreams (hint, it’s two dimensional)

We hadn’t scheduled to today as a full day in clinic so as to allow us to leave by noon for a weekend safari that has become standard fare during this elective. Going on a game drive to one of the parks that are close is great, but having a chance to spend the night in a tented-camp is just something that goes far beyond. Last March, we traveled to Lake Ndutu, which is where the migration is that time of year. Unfortunately for us at the time, it was also far more wet than usual leading to our spending the day in the mud digging not only ourselves out, but also five or six other safari vehicles. Though it wasn’t the classic game drive we had expected, it was still an incredible experience that no one would forget.

Intrepid travelers on their way into the Serengeti

Atop Naabi Hill overlooking the Serengeti

This weekend, though, we were heading to the Central Serengeti. We had planned to leave a bit earlier than originally scheduled, as it is a reasonable long drive there from Karatu, albeit absolutely spectacular. Leaving town, you head to the Ngorongoro gate where you enter the Ngorongoro Conservation Area. Here, there are usually troops of baboons looking to steal your lunchbox from the car through even the smallest opening in the window, This happened to us last March and is always an exciting affair, especially when we were all sitting in the car to experience it. After leaving the gate, you’re driving up the crater rim through what seems like a primordial forest with deep ravines and trees that seem like they rise forever from the bottom. The road winds slowly to the top where you come upon an overlook that has a spectacular view of the crater which is 10 miles across, with steep walls that are 2000 feet.

A friendly face

Wildebeest

Seeing the crater for the first time is always an experience and I love bringing people here to see it. You then leave the overlook to drive about a third of the way around the crater towards the descent road (into the crater) where you leave the rim and descend onto the far eastern reaches of the Serengeti where Oldupai Gorge is located. The drive here is along a very rough and flat road that goes on forever until you reach the Southern Serengeti where Lake Ndutu is. It is here where you find the wildebeest migration in March and April as they follow the grasses (and where we got hopelessly stuck in the mud last trip). The road here turns northwest towards Naabi Hill and Naabi Gate which is the official entrance to the Serengeti from this direction. It is also the only road to western Tanzania, Mwanza and Lake Victoria so trucks travel this route commonly along with buses carrying locals back and forth to both sides of the Serengeti. It is here at Naabi Hill that we will begin our journey.

Cheetah on a termite hill

But I’m getting a bit ahead of myself, as we still need to attend morning report and then get everything prepared for the trip. Thankfully, there were no new consults for us and I had already let reception know that we wouldn’t be seeing any new patients today since we had all next week to see people. We had arranged for a driver/guide for this trip since I’m not as familiar with driving in the Serengeti as it is an incredibly immense park that seems to go on forever, hence the meaning of the Maa (language of the Maasai) word “serengit” which is “endless plains.” Simon, a good friend and guide who I have known for several years, would be traveling from Arusha this morning to meet us for the trip. We had planned to meet between 9 and 9:30am, but he had some car trouble in Mto wa Mbu requiring him to take a dala dala to Karatu and was a bit late. No matter, though, since I had forgotten to order lunch boxes for our drive and didn’t end up doing so until this morning meaning that they were still being prepared. We eventually left FAME by around 10:45am and met Simon in town, lunch boxes secured, just needed to fill our tanks with enough diesel fuel for the drive. We were finally off for the Ngorongoro gate, paid our fees and were on our way to the Serengeti with all the excitement one can imagine for such an adventure.

A group of lions resting

Naabi gate is almost always bustling with activity as anyone heading to the Serengeti has to pass through here, unless, of course, they have chosen to fly, in which case they will have missed half of the experience traveling through this vast park. We had decided to break into our lunch boxes here as there are lots of picnic tables and there is also a nice walk to the top of Naabi Hill with a nearly unobstructed view in all directions. Once finished with lunch, we popped the top on the Land Cruiser and began our trek to the Central Serengeti where our camp would be. We had planned to do a game drive on our way and were in the region of the Maasai Kopjes (a kopje, phonetically “käpē”, which means “little head,” is the Dutch/Afrikaans term for rock outcroppings) when it began to rain and then pour necessitating a rather rapid lowering of our roof to prevent our bags from becoming drenched.

Hyenas competing with vultures

Even with the rain, though, we had had a chance to see a lone cheetah sitting atop a termite mound (their favorite spot for a 360o view of the plain), tons of wildebeest, several lions including a mating pair (though not caught in the act), and a pair of hyenas devouring some kill with a host of vultures eyeing them quite aggressively, all before arriving to our camp by around 5pm or so. The rain had stopped, as it usually does here in the afternoon, and we were able to enjoy our arrival at camp without having to run for immediate cover.

Hyena close up

The camp was simply amazing. It was in a very secluded location with a great view out front of animals constantly traversing to and fro. We were welcomed with cool washcloths to wipe off the dust and grime and then invited into the lounge where we were treated to juice before our briefing on the camp. The lounge was a tent with sofas and chairs, a charging station and a bar. Next to it was the mess tent where all the dining tables were already arranged and set for each visiting party. We were taken to our tents (the girls stayed in one and I had an entire tent to myself) and were each given another brief orientation to the lights, shower, toilet, etc. You’re not allowed to walk around camp by yourself after dark, so all you would have to do is flash your flashlight towards the mess tent and someone would come running to escort you to wherever you needed to go. If you felt threatened at night, there were whistles in each tent that you could use to summon help. The tents were just spectacular.

After seeing the inside of their tent

Sara, Neena and Whitley in from of their tent

Dinner was served at 7:30pm and it was buffet style with an amazing eggplant soup, salads, beef, chicken, rice, beans and several other dishes. Everything was delicious and, best of all, we were smack in the middle of the Serengeti having an incredible meal. You couldn’t ask for anything more. After dinner, we all sat around the campfire, referred to everywhere as “bush TV,” for a bit before retiring to our tents for the night. We had planned to meet at 7am for breakfast and a departure time of 7:30am for our day on the Serengeti. It had been a wonderful day of travel and game viewing, but we had the entire day tomorrow to look for animals.

Roughing it in the Central Serengeti

Inside our tents

The washroom in the tent

October 19, 2017 – Off to Upper Kitete for the day…..

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The dispensary at Upper Kitete with our Land Cruiser parked out front

This was our last day of mobile clinic, as we would be providing the remainder of our patient care and education at FAME rather than in the villages. Upper Kitete would be our last visit for the week and it is the furthest away of all the clinics we currently provide. Yesterday, Neena had commented that Kambi ya Simba is a very remote area because of how far down a single dirt road you must travel to get there. Well, Upper Kitete travels down the very same road, only it is at least twice as far if not more. I guess that makes Upper Kitete doubly remote. It is a long way out, but well worth the drive if not just for the beauty of it all. It is the second to the last village on the plateau with the road ending at Lostete, and despite this, there are still multiple buses daily that ply this route.

A view from the dispensary of the surroundings in Upper Kitete

Before leaving for Upper Kitete, though, both Whitley and Neena had volunteered to give short lectures on CT scans and CSF analysis, respectively. It was probably silly for us to think that it could have been done in one session (45 minutes), so in the end, they covered everything in a little over an hour. But since it was so important and everyone from the lab and radiology had also come to hear the session, Gabriel felt that it should be completed today and not run into another day’s session. They were both very good lectures considering it is always a bit difficult to decide just how in-depth to make them considering we are not giving it to neurologists, but to general practitioners, many of whom have never worked or been instructed in neurology before.

Whitley’s talk on CT scans

A full house for Whitley’s and Neena’s lectures

Neena’s talk on CSF studies

After rounds we went to see the boy with tetanus who had been doing much better overnight. He had looked better yesterday evening with an increase in his symptomatic medications, but he still hadn’t received the tetanus immune globulin, as they hadn’t been able to find it yet in Arusha. Thankfully, though, he was more comfortable with the additional muscle relaxants and sedation so that he wasn’t continually crying out like he had been. His urine was also much more clear rather than the dark brown it had been when we first saw him.

A crowd for clinic at Upper Kitete

Patients waiting to be seen at Upper Kitete

We finally got everyone corralled into the Land Cruiser and we were off for Upper Kitete with George driving again given the rough road and long distance. Also, Upper Kitete has no cell service so having a breakdown there means you would have to send word with someone heading towards home and hope that rescue would be coming before nightfall. It’s not happened to us in the past and I will continue to do my best to prevent it from ever occurring as the accommodations there would be difficult at best. We secured lunch in town yet once again and were then fully provisioned for our trek into Mbulumbulu and the far reaches of Karatu district.

Whitley taking a history from a patient in the “bat cave”

Whitley examining a patient at Upper Kitete

We’ve been using the same dispensary at Upper Kitete since I started going there in 2011 (Kambi ya Simba’s dispensary had been fully updated a few years ago prior to a visit by the prime minister), and the facility could use a good revamping. There is an outdoor alcove where we’ve set up our pharmacy in the past, but today it was being used for well baby visits by the clinical office (more in a minute) so we set that up at the end of the outdoor walkway outside of the labor room. The labor room that has served as one of our exam rooms in the past was now unusable for us as there was a patient in labor in the room (I guess that makes sense) with women running in and out during our clinic. That meant that we only had two exam rooms to use. One was the nurse’s office that I affectionately call the “bat cave” as there is a square piece of the ceiling missing in one corner of the room and one can often hear the squeaking of bats during the day and the room has a faint smell of bat droppings that is at first a bit unnerving. This was Whitley’s room for the day and though it wasn’t something she cherished, she stood in there like a trooper and didn’t complain. The other exam room was the clinical officer’s room which actually worked out quite well and it was gracious of him to allow us to use it for the day. Sara and Neena worked out of this room and alternated on patients.

Sara and Baraka examining a very pleasant patient

Whitley gathering a history on a patient

Whitley worked with Dr. Jacob for the day and Baraka translated for Sara and Neena. Dr. Jacob is new to FAME and had never worked with us before, so Whitley was again working with him on the neurologic examination along with how to take a good neurologic history.

Dr. Jacob examining a patient

Neena and Baraka getting a history from a patient

When we arrived at the dispensary, there were many, many patients there which was certainly encouraging, but it would have also been quite a handful for us to manage there in a day since we’re usually starting at around 11am by the time we get everything set up. Thankfully, about half of the patients waiting were for the well-baby clinic where they all get their weights checked along with a general checkup. The baby’s are weighed on a simple mercantile scale and each baby has their own handmade, unique sling for them to sit in during the procedure. Most babies are fine with the process, swinging contentedly as their mothers attach them to the scale and then there are others who scream bloody murder as they’re weighed. I brought Sara out to watch as it was certainly something she had never seen before and certainly wasn’t how things were done at CHOP.

A mother weighs her baby

Once we finally figured out who was there to see us, we were able to begin triaging patients and making a list. We had old notes with us for patients who had been seen there previously, as it is obviously imperative that we maintain some sense of continuity. Once the list was made and it was checked to see if we had old notes for those we had seen before, it was clear to begin seeing patients. As the day wore on, the list seemed to always have the same number remaining, as patients seemed to show up throughout the day. Regardless, it was not overwhelming and we were able to see all the patients necessary, that is except for a gentleman who showed up after 4pm and it was impossible for us to see him and still get back to Karatu in the daylight hours.

Neena examining a patient with Baraka’s help

Sara and Baraka examining a very pleasant patient

All patients were interesting, but Sara saw a young girl with cognitive impairment since birth along with generalized weakness, hypotonia and very myopathic looking facial features that were very suspicious for some form of congenital myopathy. She had been brought in by her grandmother so it was difficult to look for any hereditary features and her grandmother wasn’t very helpful in giving us any details of her past history or developmental milestones. We are unable to check muscle enzymes here so we wouldn’t have that to help us and it was decided that she would come back to see us when we returned in March.

Sara examining a young patient at Upper Kitete

A young patient at Upper Kitete

The clinic finished late, which was unfortunate as I had hoped to show the residents “The Overlook” which has become somewhat of a tradition – it is a spot in Upper Kitete that sits high on the escarpment and provides an incredible view of the Rift Valley below. I’ve been there many times, but today was a bit hazy with all the dust being driven into the air so it probably wouldn’t have been as spectacular as normal and missing it wasn’t such a tragedy. We didn’t arrive home until well after 6pm with the sun going down quickly. We were planning to head for the Central Serengeti tomorrow after morning report barring any complicated consultations in the wards. We spent the evening packing, but did have to run down to the clinic for one late night outpatient consult on an expat. We all slept well that night with the anticipation of going on safari for the weekend.

Sara and Baraka gathering a history

Sara examining a patient at Upper Kitete