October 18, 2017 – Off to Kambi ya Simba, but first an interesting case…

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It was day three of our mobile clinic week and we would be heading off to Kambi ya Simba, or Lion Camp, today. It is in the Mbulumbulu region of Karatu District that sits between the Ngorongoro Highlands and the escarpment dropping into the Rift Valley below. The land is very fertile with the soil washing down from the Highlands and there are farms the entire way. As you drive further and further along this plateau, though, it becomes narrower and narrower as you reach the end of the road at Lostete, where the steep slopes meet the escarpment. It is a long narrow triangle of land that is some of the most beautiful scenery that you can find anywhere in the world.

Kambi ya Simba is about half-way to Lostete, so today’s drive will be about 45 minutes along a fairly rough and bumpy road (especially according Neena, who was sitting in the back and bouncy seat of the vehicle) that is decent in the dry season and becomes a slip and slide immediately in any rain. I have become hopelessly stuck on this road in the past so, for the better part of valor, I have been willing to have one of the drivers from FAME come with us in the event of a downpour or a breakdown as there is often no cell service out here. As many who know me, I’m rarely a passenger in the States, but here in Tanzania I have learned to tolerate it.

Selina (left) and Angel sitting outside of our exam rooms

At morning report this morning, we heard of a young Maasai boy who came in last night with a story that he had gotten into a fight with another boy a week or so ago and now appeared to have tetanus. It was later found to be a bit more involved (as is often the case as you don’t always get the full story the first time around) and he had apparently had some abdominal symptoms at which point his family had taken him to a dispensary, but he hadn’t improved. They then took him to a local healer who performed a traditional procedure by making incisions over his abdomen and placing crushed tree root into the wounds. It was quite likely that this was the source of the tetanus inoculation and it had nothing to do at all with the fight that had occurred.

The young Maasai boy with tetanus

We all went in to see the boy after morning report as it isn’t often that you get to see a patient with tetanus. He was lying in bed with his back completely arched in an opisthotonic manner quite classic for this condition among others and all of his muscles were in complete spasm. He was moaning in discomfort even though they had given him diazepam and chlorpromazine, as it was clear that he would need more of the medicine to make him comfortable. The only treatment for this condition is really to give tetanus immune globulin and symptomatic medications with muscle relaxants and sedation and to prevent complications. Regardless of what you do, it typically takes a month of more for the condition to abate as you have to develop new nerve endings due to the toxin. Respiratory function can also be compromised so the patient needs to be monitored quite closely.

Neena and Baraka evaluating a patient

The patient’s urine was also very dark and his sodium level was also quite high so we were worried about rhabdomyolysis, or breakdown of his muscle from the severe spasms he was having, which could cause significant kidney damage. We made recommendations for him to be well hydrated, but not to drop his sodium to quickly, which could also create another major neurologic problem for him. At that point, we left for mobile clinic in Kambi ya Simba and planned to see him when we returned late in the day.

Neena examining a patient with Baraka’s assistance

When we travel to Mbulumbulu, there are no services there such a drinking water, food or fuel, so we have to leave with a full tank, water and, most importantly for me (those who know me know how serious I take lunch), food for lunch. We usually grab some Tanzania snack food, mindazi, vitumbua and samosas, before we leave town along with some drinks, such as Fanta Passion or Stoney Tangaweezi. Finally stocked up with lunch, we were on our way. The day was lovely and the drive, although quite dusty and bumpy, was again through some of the most beautiful scenery one can imagine.

Whitley evaluating a patient with Baraka translatign

Whitley and Baraka evaluating a patient

I have been traveling to Kambi ya Simba for mobile clinic since 2011, when I first went there with Paula Gremley and Amiri Mwinjuma, who were two individuals that worked with FAME on the bigger mobile clinics to Lake Eyasi in the past. It was their original idea to bring me there for the neurology mobile clinics and I have carried on the work over the last several years. We originally were doing two days each at Kambi ya Simba and Upper Kitete, but with the addition of Qaru and now doing RVCV on our own, we have reduced all the mobile clinics to a single day at each site.

Sara working on the neurologic examination with Dr. Jacob

The volume at Kambi ya Simba was adequate, but not overwhelming. Unfortunately, I don’t believe we had any children for Sara to see today, but she worked with Dr. Jacob, a new clinical officer, and instructed him on the neurologic examination and taking a good neurologic history. Neena and Whitley worked together which meant that they alternated seeing patients. Baraka translated for them and things went well. We worked through the patients, taking a short time out for lunch and we’re on our way home at a decent time considering the 45-minute drive back to Karatu.

Sara working with Dr. Jacob

Wednesday nights have become a social night in Karatu for all the expats, mostly volunteers, working anywhere in the vicinity and it was once again a rather large turnout. We had eaten our dinner at home beforehand, so only went to see everyone, have a drink and head home at a very decent time. Whitley and Neena were doing an add-on educational lecture in the morning at 7:30am so we couldn’t really stay out too late. Being able to share similar experiences with everyone else in town is a good thing, I think, as it has become a larger community over the last several years and everyone has a fine sense of purpose.

October 17, 2017 – Rift Valley Children’s Village….

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Neena’s headache talk

It was Tuesday morning again and time for another education meeting during which I have the residents each cover a topic that Dr. Msuya, who is in charge of coordinating education for the doctors, chooses would be most beneficial for them to hear. This morning’s talk was on headache and Neena was giving the talk. She made it interactive and decided to have the rest of us pretent we each had one of the more common headache syndromes and that we would answer questions that she was pose to us as if taking a history from a patient.Whitley played a mzungu with a migraine and dressed the part of a safari going with migraine headaches. Neena selected me to play the role of a “bebe,” who is an old woman as in grandmother and who had muscle contraction or tension headaches. Sara played the part of a patient with a chronic daily headache. The talk went well and we did get the Tanzania doctors to participate which is often not easy for they are for the most part, quite a quiet bunch on the whole.

Whitley playing the role of a Mzungu with a migraine

Rift Valley Children’s Village, near the village of Oldeani, is an oasis in the center of paradise. Started over ten years ago by India Howell, it is a haven for children who have been orphaned or otherwise abandoned by their families for one reason or another and are in need of a home. India and her Tanzanian business partner, Peter, adopt all of the children who come when they are infants or older and remain here in separate houses run by “house mamas” until they are ready for college or to move on to other occupations. She has volunteers from the US that spend months up to a year working with the children and all of the children attend the government school that is physically next to the village. They have a nurse who provides physicals not only to the children who live there, but also to the residents of the community that is next to the village as India identified very early that no matter how well she took care of her kids, that if the community wasn’t healthy, it would affect her children negatively. This is perhaps an example of what we now know in global health. If you don’t use resources to help ensure your neighbors health, then it will very likely eventually your health negatively as there are no borders for diseases.

Schoolboys at Rift Valley Children’s Village

Dr. Anne and Sara evaluating a young women with microcephaly and static encephalopathy

The drive to RVCV is also a gorgeous one as it traverses some of the highlands and travels through more coffee plantations. The region is inhabited by farmers and coffee workers. Arriving to the gate of RVCV you realize that you are in a special place quite quickly. The children are one big family. As we drive in, there are quite a few patients waiting, though fortunately it turns out that many of them are for general medicine and will seeing the RVCH nurse during the day while we’re there. We have enough patients, though, to keep us busy and get started working in three rooms for the residents which will mean that things will go along quite speedily today. Dr. Anne will work with Sara today, while we have both Baraka and Emmanuel there to translate for us in the other rooms. They are both quite familiar with the Children’s Village.

Discussing the case

There are many children from the village to be seen, most with epilepsy and others with developmental delay, but there are also many adults from the nearby villages who have come to be seen. Some are new and others have been seen previously. A number of students were there to be evaluated by us to rule out neurologic issues as they were having difficulty in school, but we sometimes didn’t have the entire picture as they were unaccompanied for the visit. The children were very helpful, though, and could often give us surprisingly detailed histories.

Dr. Anne and one of the school boys.

Rift Valley Children’s Village has a large cadre of volunteers working there at any one time in addition to others working on associated projects such as microfinance and the Rift Valley Woman’s Group. Lunchtime is always a pleasure for us at RVCV, for as much as I love the rice and beans served at FAME for lunch, the meal there is always something new and is made fresh by the mamas who do all the cooking there. Today’s lunch consisted of freshly baked rolls, tuna salad and sliced cheese, along with salad and a wonderfully fresh soup that was either cream of celery or something very similar. For desert they had a fruit salad that was also incredibly fresh. Other times I’ve been there, we’ve had various cookies and sometimes cake for desert as well, but it was probably best that they had just the fruit salad today as I had seconds on the soup and probably would have overeaten.

Whitley evaluating a patient with complaints of memory loss

We had more patients for the afternoon, but it wasn’t overwhelming by any means. Again, with three rooms for the residents it meant that we were able to plow through patients quite quickly. After we were all finished, we still had plenty of time to run through all of the cases with Gretchen, their nurse, to go over the plan for each so she could follow up on them and make sure they were getting their necessary labs and refills. The trip home from RVCV is always gorgeous as I take a slightly different route that travels through rich farmland and small clusters of little structures where those who farm the land live. The homes are typically of thatched roofs and wooden sides and very basic. I’m sure it’s what they have lived in for hundreds of years in this region.

Whitley evaluating a patient with complaints of memory loss

We arrived home early enough to check on patients in the ward who we had been consulted on earlier and then get home in plenty of time to do some work. It was great to be able to relax and catch up on things.

October 16, 2017 – A day in Qaru….

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Sara and me prior to clinic starting in Qaru

Today we would begin our week of mobile clinics, traveling to villages in the more remote areas of Karatu district to provide neurological care, though most patients could make it to FAME if necessary. Glen was also leaving today, heading back to Botswana for some important meetings there regarding the Botswana-Penn Partnership and future goals for the program. His visit here had been productive and having the support of the Penn Center for Global Health has been essential for the continuation of our program and to determine future directions that will benefit FAME and possibly Penn.

Angel (second from left) triaging patients for us at the beginning of clinic

Whitley evaluating a patient with Emmanuel

It’s always a bit stressful for me when we start the week of mobile clinics as there are a number of logistics that need to be taken care of. Angel will be the point person for this visit, making certain that we have everything we need before we depart since we will always be an hour or more from home and there’s no running back to grab something forgotten. I have been traveling to Kambi ya Simba and Upper Kitete for 6-7 years to do a mobile clinic in those locations and we’ve recently added Qaru to our list of sites. The idea of our mobile clinics is to provide only neurological care to these communities as they have district health offices and clinical officers there who can provide general medical care. The villages are not remote enough that patients cannot get to FAME as we often have them come to get labs checked there after they’ve been on the medication for a month and to assess any possible adverse effects. Most of these patients, though, don’t realize that they have conditions that are treatable which is our main purpose here. There really is very little in neurology more gratifying than treating an epilepsy patient who has been seizing their entire life without ever ave been treated.

Neena and Dr. Anne evaluating a patient

Whitley evaluating an elderly patient with Sara working on her notes

The group we had today for mobile clinic included the three residents, me, Alex, one translator (Emmanuel), one clinician (Dr. Anne), Angel and Selena, our nurse who would be dispensing medications at clinic. We stopped at the tarmac at the end of the FAME road to buy things for lunch and get some bottled water and sodas for the day as we’d need something to drink. Our lunch consisted of lots of pastries – beef samosas, chapatti, vitumbua (fried rice cakes), and mandazi. Our course, most of us opted for the wazungu favorite drink of Fanta Passion. Once outfitted with our food and hydration, we embarked down the main road heading south of town in the direction of Qaru.

Sara and Emmanuel examining a happy little boy with epilepsy and delay

examining an elderly women with back pain and numbness

Qaru is about 45 minutes south of Karatu on the road to Endabash and we had first visited this site last March when it had been very productive with many good patients for us. The road is very good save for long stretches of washboard bumps that are mostly annoying, but can still produce back and next pain. We pass through several other villages that all look quite similar, but we eventually come to Qaru after passing right through it realizing our mistake only a moment later and turning around after we told our Tanzanian friends in the vehicle that we were just checking in on them to make sure they were paying attention.

examining an elderly women with back pain and numbness

examining an elderly women with back pain and numbness

Sara and Emmanuel examining an elderly women with back pain and numbness

The district health center at Qaru is a very nice facility and had room enough for us to run three exam rooms, but the patient load started out slow so we used only two exam rooms for patients. It was very clean and the building we were in was quite separate from the main clinic where the routine medical patients were being seen by their district clinical officer. Most of the patients had been there in the morning, but had gone home since we hadn’t yet arrived and so they slowly filtered back in throughout the day. The volume of patients at our mobile clinics can be quite variable and may depend on the season (e.g. harvest time) or perhaps just what has been going on recently in the village.

Sara examining the little girl with abnormal movements

Sara examining the little girl with abnormal movements

The most interesting patient we saw today was a young child that Sara evaluated. She was seven years old and had definite developmental delays, but she was extremely social and interacted well with us. She was completely unable to walk, though, and had abnormal movements that looked mostly like a combination of both chorea and ataxia. On her examination, she was very hypotonic and was actually unable to stand on her own because she was so floppy in combination with the ataxia and her movements. She would sit on the ground with her legs flexed at the knees and splayed outward, scooting herself along until she found something she could grab onto and try to pull herself up, most often unsuccessfully. She didn’t have convulsive seizures, but she did have interesting sudden tonic extensions of entire body that looked somewhat myoclonic in nature. She was a lovely young girl who with a problem that appeared to be either congenital or genetic, perhaps mitochondrial, and would be something quite unlikely to have any treatment per se, but it would be nice to identify her problem. She had three younger siblings, all of whom were normal neurologically and very loving parents.

Sara and Neena discussing our little girl with the abnormal movements and myoclonic seizures

Patients continued to straggle in throughout the day and we worked until 5pm since we didn’t want to turn away patients as we wouldn’t be coming back and we weren’t confident they would get to FAME if we had asked them to. I believe we saw perhaps 14 patients for the day – not a bad day, but we certainly would have preferred more. We continue to get the word out about our clinics and the Qaru clinic added last visit was somewhat in response to the District Medical Officer having asked if we could go elsewhere in addition to the Mbulumbulu region where we had been going for several years. Our neurology mobile program is one that has been based on bringing the awareness of neurological disease to these remote villages rather than trying to see as many patients as possible.

Selena (sitting furthest) running our pharmacy

A happy crew in the Land Cruiser

The drive home from Qaru had beautiful views of the region south of Karatu and off into the distance. The soft lighting of the evening was in sharp contrast to the strong equatorial sun from earlier in the day. We arrived home before 6pm and had planned to work most of the evening as Neena was doing her presentation on headache the following morning and this required our participation as headache patients. Tomorrow, following the presentation, we would be traveling to Rift Valley Children’s Village for another mobile clinic.

The driver’s view on the road home from Qaru

October 15, 2017 – Tarangire National Park…

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It was Sunday again so in keeping with our tradition of “safari Sundays” while here on rotation, so we all awakened very early for a 5:30am departure from Karatu. The trip to Tarangire takes about 1:30 hours as we travel down the escarpment and through the village of Mto wa Mbu (Mosquito River) that lies at one end of Lake Manyara and traverse the valley towards Makuyuni where rather than turning left towards Arusha, we turn right in the direction of Babati. The north entrance to Tarangire National Park is on the way to Babati and just south of the shores of Lake Manyara.

A banded mongoose

Tarangire is a park that is dominated by river ecology and during the dry season, all of the animals must travel daily down to the river for their water as the many other watering holes are all dry. Tarangire is also home to an incredible population of elephants who travel daily from the protection of the hills during the night down to the river during the morning hours and back in the evening. There are huge herds of elephants wherever you look with many, many babies confirming the health of these wonderful animals. In addition to the elephants, there are also tremendous herds of wildebeest, zebra, and impala primarily with a smattering of waterbuck, eland, and Coke’s hartebeest. There are also lots of giraffe with many babies. As for predators, there are lions, cheetah and an occasional leopard. And then there are the monkeys. Numerous baboon tribes roam throughout the park along with vervet and blue monkeys.

A vervet monkey at the main lunch spot

An impala at the water’s edge

We arrived to the park sometime after 7am as I had to get gas in Mto wa Mbu and they thought I had “four” instead of “full’ so had put in only 40,000 TSh worth of diesel fuel when I needed at least twice that. It took me some time to eventually speak with another attendant who’s English was quite good and he suggested that I they just finish off the fill, pay for it and then do the second fill which is how we handled it and all went quite seamlessly, though we had spent more time at the service station than I had anticipated.

Shockingly, this is not a blue monkey, but rather a vervet monkey

An elephant keeping a very close eye on us.

Once back on the road, the sun was slowly creeping up behind the mountains to announce the new day with a sky of orange predicting the impending sunrise. It was overcast as we reached Makuyuni, but the weather overall was amazing and there was still al cool breeze from the dawn as the sun had yet to warm things up and was still quite low in the sky. We made our way to the park entrance along a 7 km dirt road with many irregularly spaced speed bumps and washboards that are sufficient to loosen any precious dental fillings with ease. I will always remember the entrance to Tarangire as it was the very first park we entered in 2009 when I was here with Daniel and Anna and up until that point, we had not been on safari nor seen a wild animal. Though it only seems like yesterday, I have been on so many safaris since then that it also seems like the distant past at times. Regardless, each safari is different and I see something new each trip not to mention the pleasure of taking the residents on safari as well and for most of whom this is their first experience traveling to Africa so it is also their first experience on safari.

We were heading the river that runs through the park and dominates life here, especially in the dry season when it center of all activities considering it is the only water source as all others have completely dried up. As we were descending down to cross over the river, though, there were several vehicles stopped which is usually a good sign that there are cats around. Off to the side of the road and a short bit away were two cheetahs resting in the shade of a tree. Cheetahs are usually solitary animals, but will travel in pairs as two brothers or two sisters, but never mixed. They are such gorgeous and majestic creatures that I can never see too many of them. It was getting warm so they were in the shade and relaxing as much as possible at least until the sun begins to dip in the late afternoon. We’re on our way after a few minutes of viewing and several photos and looking forward to the remainder of the day and what else we might see.

Coming down to the river, there were huge herds of wildebeest and zebra all in constant movement making their way towards the river either in single or as a group. The river is their lifeline at this time of year for without it, life would cease and the herds would move elsewhere. We traveled along the south side of the river for a time, moving in and out of the brush and eventually crossing it at a narrowing. On the north side there we again ran across another group of cheetahs, two at least and possibly more, sitting in the shade of the trees with the heat of the day increasing. We were traveling towards the Silala Swamp, a very large area on the south end of the park where, during the wet season, there are many animals congregating in the large wet areas. As we crested the hill to view the wide expanse of the swamp and stop at the picnic area for lunch that looks out over the area, we saw hundreds of elephants stretched along the open area off into the distance. They were broken up into families, but this was a sight I had never seen here, so many elephants in one place and all mixed together. There were also zebra and wildebeest throughout, but the impressive sight really was the number of elephants.

Jackel on the prowl

Southern Ground Hornbill

We sat on a picnic bench and table for our lunch along with a very large group of adolescents from the US that were on a group safari and had also stopped for lunch. They were traveling in the large vehicles used for this purpose that are like troop carries with seats and lots of storage down below for tents, food and personal belongings. These groups normally stay at the public campsites rather than at the tented camps or lodges that are far more expensive.

While at lunch I had spoken with a safari guide, who was somewhat taken aback that I was actually driving and guiding our vehicle, and learned that there was a lion about two kilometers down the road along the edge of the swamp. We drove down to the edge of the swamp after lunch and just about where predicted there was a solitary female lion sitting under a tree. She appeared to be covered in mud (or blood?) so I suspect she had probably taken some prey in the wet mud not to far from where she was sitting. She got up a few times, but for the most part was quite content to be resting during the heat of the day.

We had also had word that there might be a leopard in the other direction along the swamp so we decided to drive that way and up into the hills eventually looping around in the vicinity of the Tarangire Sopa Lodge. There were several families of elephants wallowing in the mud quite close to the road and there was definitely some jockeying for position go on. There were lots of rumbling noises coming from the groups, a sound just like what the tyrannosaurus rex made in the movie, Jurassic Park. It is a low baritone sound that you can feel in your bones. That was fairly frequent along with other less frequent trumpeting sounds that were clearly some communication of displeasure or warning made as the families jostled amongst themselves vying for the best mud. We watched them for several minutes and eventually departed in quest of our leopard.

Cheetah

We drove slow and kept our eyes peeled hopeful that we would fine the third species of big cat for the day, but alas it was not to be. Leopard’s are certainly quite elusive and the most difficult of them to fine, but I thought we had a good chance given the reports we had heard. I have seen many leopards over the last years, but the others will have to wait for a sighting perhaps in the Central Serengeti where we’ll be this coming weekend.

Baby elephant nursing

Traveling back towards the main gate we spotted many more animals and even another cheetah back on the main road. It was a long day for us having entered the park before 7:30am and not reaching the gate to exit until perhaps 3:30pm. That’s quite a long safari and I think everyone, including me, was quite tired from the day. We grabbed some cold Fantas before hitting the tarmac and were then on our way home. A quick stop at our friend’s art gallery to buy more presents for home and we were back to FAME in no time. We were all quite dusty and tired from the day, but thankfully Alex, our intrepid volunteer coordinator, had offered to make us dinner after our safari. We had homemade tortillas, corn salsa, grilled peppers and grilled meat. Glen made a cucumber and salsa appetizer to go along and we were all quite happy with a well-cooked meal at home.

Whitley in her National Geographic photographer pose

Tomorrow we will begin our mobile clinic week so will miss the lunches here at FAME. We begin at Qaru, south of Karatu, then Rift Valley Children’s Village on Tuesday, Kambi ya Simba on Wednesday and ending with Upper Kitete on Thursday. We’ll organize everything in the morning and be ready to hit the road by hopefully 9am or so.

October 14, 2017 – Julius Nyerere Day….

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Saturdays are typically very slow as I have mentioned in the past, but today was very, very quiet it seemed as we showed up in our neuro clinic following morning report. It was unclear why, until we were told that it was actually a national holiday, Julius Nyerere Day, and workers all over stayed at home rather than go into work. Nyerere was the first president of Tanzania, their George Washington. He was an amazing man who had been educated in Uganda then England and in 1961, became the countries prime minister, and later after the formation of the United Republic of Tanzania when Tanganyika and Zanzibar united, became the first president. They had very few resources at the time including other qualified college graduates that could help, but they persevered and eventually brought a country consisting of 120 unique tribes, each with their own language and living in their own villages, together for the benefit of all and a means of creating an infrastructure to best serve the country. He is simply known here as “teacher.”

The combination of a Saturday and Julius Nyerere Day, though, decimated our clinic volume and after a very slow start, the clinic remained slow as we moved on towards lunchtime. Sara saw a young woman, actually adolescent, who we had treated in the past for seizures, but had run out of medication and was no longer having seizures, but was now complaining of headaches that were very likely migrainous in nature. It was great that she was no longer having any seizures and we were perfectly comfortable now treating her headaches that would be a much easier proposition. We did make sure that her mother realized, though, that she was not totally out of the woods and to make sure to come back should she have seizures again. Unfortunately, we do not have topiramate (Topamax) here which would be the perfect drug to use in this situation to give us extra insurance as far as covering both the headaches and the seizures.

Whitley evaluating a patient with Emmanuel

Whitley’s highlight of the day was doing a consult on a patient in the ward who had been admitted yesterday with recent onset of psychosis. The patient had remained quite psychotic overnight and the story was much more concerning for a rapidly progressive dementia than anything else. Two daughters were present, but neither of them had been living with her so were not totally aware of the recent history. Whitley had a bit of a handful examining her (the patient was spitting on her caregivers including Whitley), but eventually had gotten enough information to begin a workup. All of her routine dementia labs (RPR, HIV, TSH) were negative or normal so it was decided that she would probably benefit from a lumbar puncture to help direct our future recommendations. An autoimmune encephalitis was certainly in the differential, but trying to evaluate that here would only be less difficult than trying to treat it if that were indeed the diagnosis. None of the therapies other than steroids would really be available here so our inability to confirm such a diagnosis would only be disappointing from an academic purpose.

Neena examining a patient with Baraka’s assisting

Neena saw a patient with primary insomnia as well as another patient with carpal tunnel syndrome and Whitley had a patient with back pain and “numbness,” a common complaint that we see here that isn’t often the more typical neuropathy symptoms that we see back at home. This is usually numbness involving an entire limb or one side of the body in the absence of findings on examination and most often in a patient without much else medically or too young to consider a vascular etiology (i.e. stroke).

We all went to lunch (my favorite, rice and beans) and discussed what we’d do with the afternoon since we had no more patients for the day. Neena decided to stay at the Lilac Café (excellent internet) to work on her presentation for Tuesday morning while the rest of us went downtown to get phone cards to recharge our internet and also to walk around town a little bit. Glen ended up buying ingredients to make a nice cucumber and salsa for dinner tomorrow night and I purchased a shovel for the Land Cruiser that I wish we had had last March when we were stuck down in the Southern Serengeti deep in the mud with numerous other vehicles and it took us half the day to get ourselves out.

Sara evaluating a seizure patient with Emmanuel

For dinner, we had made plans to go to the Plantation Lodge, another of the great traditional lodges here in Tanzania. We made it there around sunset and it was again an absolutely gorgeous evening so we all sat on the outside patio to have drinks. They had provided a table full of appetizers for us so when Neena, Whitley and Sara disappeared, it didn’t take a detective to figure out where they had gone for the moment. They eventually made it back to our table so we all ordered drinks, including my Moscow Mule, and relaxed in the amazing glow of sunset and the sounds of the Ngorongoro Highlands quite close reminding us that we were all definitely in paradise. There was no rush to get to our table for dinner as we were only one of two parties there that night, the other being the owner of the lodge with some of her guests from Germany. Dinner was a delicious meal with tasty beef filets as the main course along with vegetables while dessert was an ice cream creation that we all quickly devoured.

We arrived home much later than we normally do for a dinner which was significant as we were all getting up quite early to head to Tarangire National Park for a safari. The park opens at 6:30am and is about an hour and a half away so we all decided on leaving at 5:30am in the dark so we’d have an early start on the animals. So it was off to bed for everyone with a very early awakening and the hope that we’d have hot water that early in the morning. Our water heaters are wood burning “kuni” boilers that the askari (Maasai watchman/guards) fire up morning early, but we weren’t sure just how early that meant.