Saturday, October 27, 2018 – A trip to Kilimanjaro International Airport….

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FAME’s pharmacy

Our time at FAME had now come to an end and it was time to load everything into Turtle for the trip back to Arusha and then to the airport as Lindsay, Steve and Hannah would be flying out this evening. It is no longer as difficult for me as it is for the residents given the fact that I will be returning in less than six months with the next group so for me it’s really not a true goodbye, but rather “baadaye” which means “see you later.” Neena Cherayil coined the term “post Tanzania sadness disorder” to refer to the feeling one has leaving this amazing place and returning home. There is little question that anyone who has worked here will return home with an entirely new perspective on medicine, humanity and equities and will be changed forever and for the better. Working in a low resource area where people are happy and always so appreciative of your presence cannot help but give you a new outlook on life. It is genuinely a gift.

Reviewing the CT scans on our patient

We had planned to be on the road at around 8 am and, to everyone’s credit, we were packed and in the car at 8:15, perhaps a record for getting everyone moving in the morning when it didn’t involve the excitement of traveling to a park to do a game drive. I had planned to stop at the clinic on our way out for everyone to say goodbye as morning report would be ending and it would be a good opportunity to do so. As we were in the hospital ward, though, Sangale, who works in reception, came up to me with a CT scan folder and told me that it was from the gentleman who Hannah had seen the day prior. I had assumed that they would have sent the patient to Arusha for his scan and that he would have been in the hospital when he returned, but, somewhat to my surprise, he had just been discharged and was now sitting in the night office waiting for us to come see him.

Hannah and I reviewing the CT scan with Steve and Mark looking on

I informed Sangale that we were actually about to the hit the road, but that we’d be happy to look at the CT images before we did so. After reviewing the scans, which were very unimpressive (i.e. no large territory infarction, hemorrhage or mass that we could see, but the study was done without contrast as he had very poor renal function and could not have tolerated contrast), we spoke with his sons, one of whom was actually a medical student, to give them our assessment and recommendations. I also spoke with Dr. Gabriel later to let him know what we had discussed with the family and what we were recommending for treatment. It obviously took some time for all of this to occur, so it was now past 9 am and we would be getting a bit of a later start than I had hoped for leaving Karatu.

Charlie waiting outside the hospital ward door

Peter was remaining in Karatu for one more day as there was a Halloween party he had planned on attending and so would be traveling to Arusha on Sunday to meet up with me at the airport for our flights. The morning in Karatu had remained cloudy and with a light rain, but as we traveled along the tarmac with Lake Manyara and the Rift Valley in the distance, the clouds began to break up and the sky was blue in the distance. The drive to Arusha, which I have now done dozens and dozens of times has become so much more routine than it was in the past when there were “diversions,” or detours, every few miles that shunted you off to an old road or trail that was always dusty, dry and bumpy when it was the dry season or a sloppy mess in the rainy season. The drive, which used to take three plus hours is now an easy two hours, even when driving a beast of a vehicle like Turtle. A fast Noah can do it in a fraction of that time.

Looking towards the OPD from the ER

I had wanted to take everyone to the Shanga Shop as we entered town and, though we were running a bit late, everyone still wanted to visit the shop. The Shanga Shop, which is now at the Arusha Coffee Lodge rather than across the street and is now owned by Elewana, a travel company, was started ten years ago to employ local residents with disabilities and to train them to become artisans. Shanga, the organization, continues to employ these individuals who now have the opportunity to support themselves and have learned trades such as glass blowing using recycled glass, sewing, and jewelry making. Their work is lovely and it is always very easy to find things here to bring home as gifts knowing also that it is going to a great cause. I have always managed to sneak in a visit to the Shanga Shop with guests to support them in their efforts.

Looking up towards the laboratory

As we entered Arusha proper, traffic was very heavy despite the fact that it was a Saturday. After some discussion, it was determined that we should probably drive straight to the airport rather than stopping by for everyone to say goodbye to Pendo and her family. Though we weren’t necessarily pushing our luck, I think everyone was very interested in getting to the airport and checked in sooner than later. There is an airport club there and I know that all three of them were excited about finally having access to something a bit faster than our cell service internet that we had been struggling with for the last month.

The canteen at FAME where we eat every lunch

As we parked in the drop off area and unloaded all the luggage from the Land Rover, I was reminded of just how many times I’ve done this now and of what an adventure my fellow travelers had had. Tanzania had truly become their home for the last month and they had weathered the trials and tribulations and have a much better idea of what it is like to live here both for expats and locals alike. They have had to make those medical decisions that are unique to a low resource, low access, third-world country where treatment is far from a given and families must make choices that take into account many more variables than we ever have to consider back at home. They have also survived being stranded in Turtle twice, once with no attached gear shift and another time with a seized alternator (“alternator dege dege”), not to mention having to both bump and push start the car on several occasions. Life is different here in all aspects, and whether it is in regard to health care decisions or vehicle breakdowns, you just have to learn to change your perspective on things and look at them through a different lens. Things are always relative and no more than here can one says that. For, this is Africa, or as everyone has learned, “TIA.”

Hannah having one more Tanzanian beer in the Tanzanite Club at the airport

My drive home to the Tembas was without event. No run-ins with the traffic police, no breakdowns, and no “diversions.” Gabby was thrilled to see me and little Gabriel is now becoming more accustomed to seeing me, this mzungu with a beard, in his home. For this is really my home, too, and I am a so glad to be here.

 

 

Friday, October 26, 2018 – What, a free day at FAME?

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I can’t recall the last time (if ever) that I’ve had a full free day at FAME to do with as we please. That is such an incredible luxury given the normally packed schedule that we have here or frantically trying to fit everything in before we leave. I had felt bad that I had been under the weather for several days and perhaps not best of hosts for the residents during that time (mostly, I had dearly missed attending Lindsay’s birthday party at the Golden Sparrow) and now we were down to a smaller group with both Amisha and John having departed yesterday each on their own journey. It was our last day to attend morning report, so Steve, Hannah and myself walked over to the conference room at 8 am with Peter meeting us there since he was staying in town. Meanwhile, Lindsay had decided to take the opportunity to remain at the house and catch up on things. She has constantly reminded me that she’s not a morning person, so I guess this was her opportunity to take advantage of our schedule.

The veranda of the Raynes House with our new garden

Despite the fact that we did not have clinic this morning and, therefore had not planned to see any patients, work seemed to have tracked us down and there were two consults waiting for us in the ward. The first was a gentleman who came in overnight after having suffered what was believed to be a stroke. The other was a young child who had jumped from the third floor of a building to escape a fire and had apparently not suffered any fractures or serious injuries. After morning report, Hannah and I went to the ward to divide and conquer. We only had one set of tools since I had already broken down the ophthalmoscope kits I had loaned the residents and Hannah didn’t really think she’d need her other tools so left them at the house. I must have had some intuition as I had brought my bag with me and loaned everything to Hannah who would be seeing the man with the possible stroke. The young girl who had jumped to safety was amazingly intact neurologically after having plummeted three stories, suffering only some bruising and a swollen upper lip where she had bumped her face when she hit the ground. Despite the fact that she seemed to be doing well, Dr. Gabriel had requested that I evaluate her neurologically just to be certain that they weren’t missing anything. So, while Hannah worked on the other consult request, I had a wonderfully reassuring visit with an incredibly pleasant young girl who was sitting in bed playing with a surgical glove blown up like a balloon. She was moving everything quite well with only some minor soreness of her left ankle and the swollen upper lip to give any hint of the trauma that she had recently suffered.

Our patient of the morning

The gentlemen that Hannah was evaluating had a bit more of an interesting history in that his wife and sons clearly described what would have been a seizure when he first presented, but still had focal unilateral weakness. A simple explanation would have been that he had suffered a seizure and following that, had persistent weakness on one side that is otherwise known as a Todd’s palsy and can be seen following a moderate convulsive seizure and can last for hours to days. The seizure, though, hadn’t seemed significant enough to have caused a prolonged Todd’s paralysis and therefore, that didn’t seem to be the answer. There were other complicating factors as well and so we recommended that he undergo a CT scan to make sure that he didn’t have an underlying lesion that would have made seizures more likely than not. The scan would have to be done two hours away in Arusha, unfortunately, as the CT scanner at FAME was still down due a power supply issue, so his family would have to take him by private vehicle to have this done.

Honey in our house. “Used as medicine to cure chest and alcers”

As every visit to FAME seems to have its own unique successes and hurdles, we usually try to set up a debriefing meeting at the end with all parties involved to sort out what we need to focus on for the next visit and what we need to change. I had arranged to meet with Susan, Caroline (development coordinator), Alex and Angel at 11 am at the Lilac Café, which is located just a short walk from reception and is not only a lovely place to have such a meeting, but is also great for breakfast, lunch or dinner. Their coffee is to die for and if I am ever searching for the residents in the morning, it will usually be a good bet that they are having coffee at the Lilac. As good as their coffee might be, their cappuccinos are even more so and that’s exactly what I ordered for the meeting. Denis, who is the wonderful artist who painted a portrait of me for my sixtieth birthday, runs the Lilac most days and sells his artwork out of the café. I have a number of his pieces in the Raynes House and I have supported his work over the years by bringing him supplies such as staple guns and staples, as well as canvas.

A muddy alleyway in the Karatu Market area

Our meeting this morning ran quite long and the group had planned to go to Gibb’s Farm for lunch on our last day in Karatu and it always very difficult not to entertain a visit a to this magical place. I ran home after the meeting and gathered everyone up to pile into Turtle and make the drive to Gibb’s. We had hoped to walk to Gibb’s, but with the continued rain overnight, even though it wasn’t raining heavily at the moment, we knew that it would be incredibly messy to have made the 30-minute walk down through the quarry and then up to Tloma Village with Gibb’s just beyond. Despite the earlier rain, it was still quite lovely there and the weather opened up long enough for us to eat out on the veranda without getting rained on with any consequence. The gorgeous jacaranda tree that sits just off the patio there was now missing about half of its luminescent blossoms as they had plummeted to the ground in the heavy rains that fell overnight.

Chickens for sale

We all once again enjoyed the truly wonderful buffet lunch that chief Andrew had prepared and it would be difficult to recall all of the incredible dishes that were included. Most everything is grown on the Farm at Gibb’s so it all is amazingly fresh. After lunch we went to visit Katongo, the artist, in his studio there at Gibb’s to see what recent projects he was working on and it was so great to see him once again. He is so talented and the fact that he has been given space to work by the Gibb’s Farm management is an excellent opportunity for him as many, many guests come by to shop.

Chicken coup with chickens for sale

On the way home, Steve had reminded me that he wanted to look for a pair of Maasai sandals that are made out of old tires, and so we once again headed downtown to the market area. Thankfully, the sun was out, but that wasn’t nearly enough to dry up the mud and puddles of water that had accumulated after the rains of the day and night before. You had to be very careful where you walked so as not to slip, but more importantly, not to step into muddy hole that would engulf your shoe and quite possible yank it right off of your foot. In our search for the right sandal kiosk, we bumped into Daniel Tewa’s daughter, Isabella, who had made us dinner a week or so before, and a friend of hers helped to find us the right shop. Steve picked out a pair that he liked after trying on several and then the bargaining began. The seller had quoted initially 35,000 TSh (about $15.50), but Steve wasn’t interested in that price and so after a few rounds back and forth along with Isabella’s friend telling the sellers that we were important doctors who worked at FAME (I’m not certain if that helped or hurt to be honest and it was probably the latter) the price came down. The rock bottom price from the vendor came down to 25,000 TSh, though Steve and he were finally able to settle on a total of 20,000 TSh, or about $7.85. The sandals were very, very nice and will probably last a lifetime.

Steve trying on his Maasai sandals

We were home a bit after 4pm and settled in to getting packed and ready for our departure the following day. I had planned to head over to Daniel Tewa’s home at around 5:30 pm that evening as I wanted to say goodbye since I wouldn’t see him again until March 2019, when we would return in the spring. I wasn’t sure who would be coming with me and, as it turned out, everyone was either a bit pooped or wanted to get work done, so I drove over to the other side of town by myself in the rain. The roads by now were again becoming quite slippery so I decided not to take my shortcut which can become quite adventurous in the rain and getting myself stuck (quite unlikely driving a Land Rover, but it’s happened before) the day before we were leaving was not something that I was enthusiastic about doing.

A mud soaked alleyway

I arrived at Daniel’s and it was immediately clear to me that he had expected more of us and, in fact, had had his wife Elizabeth make coffee for eight. I felt bad that they had gone to this much trouble for us and jokingly said that I would drink enough coffee for several of us. He took me seriously, I think, as he continued to refill my coffee mug as we sat and talked about American politics, the upcoming elections and some of the craziness that had been going on in the news. Daniel’s perspective, though, was also on international politics and I felt some uninformed as we chatted, realizing just how little we as Americans pay attention to politics outside of our little sphere. It was now well past sunset and I had had at least three strong cups of his coffee that would quite likely have me wired for some time and hopefully not keep me up all night, but it was time for me to depart. We do this each time I come, knowing that it will be another six months until I return, but also with the confidence that we have truly formed a very special and lifelong friendship that can only come from mutual respect and admiration for one another.

 

Our plan was to leave in the morning as close to 8 am as possible so we would arrive in Arusha with plenty of time to do some last-minute shopping and still visit Pendo and her family. Everything was packed and what wasn’t would get thrown in our duffels in the morning. It was sad to leave, but we’d been here for a month and it was now time for us to return to our day jobs. The experience here had been amazing for the residents and it would be something that they would always remember, as well as being incredibly formative in their education.

 

 

Thursday, October 25, 2018 – Our last day of clinic and the departure of both Amisha and John…

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The entire FAME medical team, Tanzanians and volunteers

It was an exciting day for many reasons that included it being our very last clinic (a half day unannounced) for the season as well as he fact that both Amisha and John would be departing today on their own journeys. It had rained all night and for the very time this visit, we had to pull out our rain shells to walk to clinic for lecture and morning report. Even with the often dense morning clouds each day, there just hadn’t been any real moisture. It was as if we receiving a message from someone that we had completed our mission and it was now time to depart. Karatu in the rain takes on a completely different personality and having experienced each on numerous occasions, I have come to know them well.

Abdulhamid drawing up the medications for the occipital nerve block

Anne demonstrating an occipital nerve block for Abdulhamid

This is just a little blip in the weather, though, and not a full change of seasons. That will occur in January and February with the short rains, then followed in April and May by the heavy rains or monsoons. In the dry season, Karatu is warm and dusty (I mean, really dusty) and the hot afternoons (never over 90 degrees though) can suck some of your energy, but overall it remains just lovely. With the rain, the dust is gone, but you are left with a tremendous muck that sticks to everything. A short walk outside can leave you with several pounds of mud on each shoe that is great if you’re wishing a hardcore workout, but otherwise is a real nuisance to scrap off. Running can be treacherous on uneven ground and you have to be very careful not to twist anything when falling while a mud bath can be almost a sure bet.

Abdulhamid performing an occipital nerve block

Abdulhamid performing an occipital nerve block with Dr. Anne

Amisha’s friend who she will be traveling with for the next two weeks arrived in Arusha last night and would be doing a game drive in Manyara today before coming to FAME and then heading off to the Crater. We received messages throughout the day and knew there were scheduled to arrive to Karatu later in the afternoon having plenty of time to get to the Serena Lodge on the Crater rim to spend the night before descending into the Crater itself. John, who would be climbing Kilimanjaro starting tomorrow, would need to leave for Moshi to spend the night prior to beginning his trek. We would be dropping him off to take a public Noah, which is slightly larger and faster than a dala dala, but equally crowded. John is a seasoned world traveler and quite adventurous. He also discovered that he would be the only climber on his trip, which I think we were all very jealous of considering the quite solitude of seven days on the mountain with just you, the guide and four or five porters. Lots of reading and meditating was in his future.

Charlie guarding the walkway between the hospital wards and the operating theater

So, as we walked through the steady rain towards our final lecture and clinic, each gaining pound of mud with every step, we were all able to begin reflecting on the month we’ve had here at FAME. We knew that we were approaching the 400 patient threshold for our month which would be a first and really has little to do with the number of residents seeing patients and more to do with the fantastic outreach effort that FAME has done for us with kudos to Angel, Kitashu and Alex. The lecture this morning was to be given by Mark and Monica and despite the topic being far removed from neurology (they were covering the guidelines on fetal monitoring that determines when a baby is doing just fine and is happy where they are (comfy in mommy’s tummy), versus when things aren’t going so well and time is of the essence in getting the baby out. There is a need for them to speak a common language when they are speaking to each other and that is what was covered. I actually found it very interesting despite being about as far removed as one can be from baby catching at this point in my career,  other than the occasional pre-ecclampsia/eclampsia patients that we deal with and are often a neurologic emergency.

A wet day at FAME

After morning report, we walked over to our now well-familiar neurology area where we have been stationed for the last month and has been our home at FAME. Both Kitashu and Angel were there to help us as they have been so essential to our work here and have really made this all happen for us without as much of a hiccup. Abdulhamid (Dr. Shaban) was also there for his last day of translating (which has been so incredibly helpful to us) and discovering neurology. He is still convinced he wants to be a cardiologist, but for the moment, we can continue to fool ourselves and are content in knowing that he will be the very best neurologically trained cardiologist in the country if he does indeed continue on that path. Grace Mshana was also there again to help us and it was so great to have had her work with us for these last four days as we were down one translator with Emanual having had to leave for school. Grace’s father, Dr. Mshana, now retired, was the first doctor I had met here in 2009, when he, Frank and I had sat down to “discuss” a few cases and which has now literally become thousands of neurology patients since that first fateful visit.

A view from in front of the laboratory

Lindsay trying on John’s sleeping bag for size before his departure to Kili (in the Raynes House)

Writing this now, days later, I can’t recall the cases we had seen that morning, though there were a number of them, once again trickling in as the morning went on. We had one patient with a fairly classic occipital neuralgia and we were able to have Anne do one more injection under our supervision as she will be the go to doctor at FAME for these in the future. I will be leaving the medications for her to do them before we return in March. Abdulhamid actually assisted her and I believe has a very good feel for these as well, so much so that I suspect he will wish he had access to them in the future when he is seeing patients and wishes we were there.

Hannah at the Maasai market

Sugar cane at the Market

The plan was to have lunch and then drive John down to the bus station in Karatu where he would find his Noah. One last wonderful lunch at FAME for him (it was pilau day which is everyone’s favorite lunch) and then home to pick up his gear for the climb. He would be shipping the remainder of his things home with us as would be Amisha and they were sharing one of my large duffels so that she wouldn’t have to lug the stuff around with her to the Serengeti, Zanzibar and Capetown (rough, I know, but someone has to do it). I also needed some extra cash here as I still had to pay for Turtle’s repairs and drawing out 400,000 TSh (or about $177 USD) out of the ATM at a time was becoming cumbersome. Go figure how the resident is able to make several withdrawals in the same day while the attending can only make one. I will look into that once I return.

Chopping sugar cane

The bus station in Karatu is a large square of pavement surrounded by small shops and transportation offices with services traveling anywhere you’d like to go in Tanzania. There are little white signs on stands (like in NYC at a taxi stand) that I didn’t spot, but either Lindsay or Hannah (along for the ride) did and sure enough, there was one that said Arusha/Moshi. John got out into the muck, walked up to the back of the Noah and in two seconds flash, his pack was stored in the back (thankfully not on the top or in his lap) and he was climbing into the vehicle. The cost of public Noah. Is 7000 TSh to Arusha, or just over $3, but I will warn you that they fit probably 20 seats into the space that we would put 7, or maybe a max of 9. Thankfully, he is very experienced, very tolerant, and, despite being 6’ 2”, very thin. No way would I ever consider that journey and it makes me anxious now writing this just thinking about having to use the bathroom crammed in there. Nope, not me.

Eyes wide watching the skill of the machete

Enjoying their sugar cane

After leaving John at the station, we drove to Soja’s home so that I could drop of the rest of the money to his wife for our repairs and as we drove by the market grounds, I realized that it was Maasai Market Day, which occurs on the 7th and 25th of each month in Karatu. It had been raining all morning night and morning and as we drove by, you could just see that it was a huge mud pit of several acres in size. Lindsay and Hannah, though, asked me to drop them off there so they could go adventure for the afternoon, much to my surprise. I never would have let one of them go by themselves as being the only mzungu (foreigner) walking through the market with goats, cows, food cooking on open fires, bales of donated clothes from the US and every nick nack you could ever imagine for sale would be just incredibly daunting, but the two of them together would be just fine and was confident that they would enjoy themselves.

A muddy mess

They said that they would catch a ride home which wouldn’t be an issue given the weather and every mode of taxi driver waiting at the entrance to take patrons of the fair home or bring them there. They tried some sugar cane, which I think they equated to chewing on sweet wood, but I recall spending lots of lazy afternoons as a child in Southern California enjoying the delicacy. So much for my memories. Hannah had joked with me about buying a goat before jumping out of the car and, even though, I trusted that she wouldn’t, I do recall shouting something out the window to her (I think it included profanities so I won’t repeat it) given her wild side and even the remotest possibility that something like that might happen. Thankfully, I’m very confident that our bags were animal free after packing them. The two of them shared a bajaji home (the little three-wheeled, half car, half motorcycle) sans goat or anything else resembling wildlife.

Lindsay and Hannah on their ride home in the bijaji

Amisha’s friend and guide rolled in around 3:30 pm if I remember correctly, and it was time for her to depart for the Crater. Their guide was the person who had arranged much of our quotations (invoices) for the Conservation Area and Serengeti on our trip the weekend before and I had spoken with him on several occasions both this trip and several before, so it was nice to finally meet Quoro. His first name is actually Englebert, and his father was a significant politician from the area and someone that Daniel Tewa had worked with previously. I had also met Quoro’s wife at Tanangire two weeks prior as she is a warden there and upon my registering us, she was asking me questions about our work as she was very interested in it. I had given her my card and later learned that it was his wife which he discovered when she reported having met me and given him my name. It is an incredibly small world here.

Hannah and Lindsay’s bijaji up at FAME

With John and Amisha now gone, there were five of us left including Peter and Steve. We had absolutely no plans for the day tomorrow other than my debriefing meeting with Susan, Caroline, Alex and Angel and trying to get up to Gibb’s one last time for lunch. I had also wanted to visit with Daniel one last time and would do that in the evening. The rain continued into the evening and throughout the night for our final full day at FAME.

 

 

 

 

 

 

 

Wednesday, October 24, 2018 – Our last full day in clinic for the season….

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It had been a wonderful party the night before and everyone I think everyone had a sense that this had been their home away from home for the last month. It goes without question that FAME has become my second home considering that this is my seventeenth trip here and I’ve now spent well over a cumulative year of my life having lived in Karatu, but I believe it is equally so for those who have made this their first trip. FAME is not only an incredible medical facility, but it is also a self-sustained community that now includes 150 “residents,” many of who have been here from the very beginning. Outside of the coffee plantations, whose work is seasonal, FAME certainly has to be the largest stable employer in the region and so there are many, many families who depend on FAME for its continued existence along with the community, which is healthier because of their presence.

Kitashu and Amisha evaluating a Maasai patient

It was a morning to sleep in an extra half an hour since there was no lecture today and we could contemplate what we have accomplished for the month with the satisfaction of knowing that we’ve contributed to this great work that is so rewarding to the soul. At morning report today, we discussed one of the surviving hypoxic-ischemic encephalopathy (HIE) babies that had been born last week, this one to the mother who was in status epilepticus during delivery, virtually assuring that the baby would have suffered significant birth trauma. In fact, this baby had appeared to have suffered a severe HIE injury, while the other baby that passed away had appeared milder. The baby had no suck and no means of nutrition and a decision had to be made as far as what to do for it going forward.

 

A discussion had occurred yesterday with the parents and had included Kitashu as he is also Maasai and he would be best at communicating the nuances that were required when discussing these things. The child had absolutely no hope for any independent life even if it were able to survive and would most likely be bedridden and non-communicative at best. The family had chosen not to continue care for the child and everyone at report felt very comfortable with the family’s decision. It was also decided that the baby would be moved in with the mother, which had not happened yet, so that they could bond before the baby finally passed, and, of course, exquisite attention would be paid to the baby to assure that there no signs of suffering.

Lindsay, John and Abdulhamid evaluating a patient

I related a story to everyone that I had been told by one of the FAME clinicians when I first began working here, that just a few years ago it was the custom of the Maasai and many other tribes living in the bush, to let these birth injured babies die of starvation by feeding them animal fat so they would not be hungry, but also would not survive as their life was harsh and they were unable to care for them. There are no value judgements here, just the harsh reality of trying to survive in a world that few of us could ever know. At that moment, though, with all of us sitting together in report, I think each one of us in our own way came just that much closer to possibly understanding.

 

It was now time to see what was waiting for us in our “waiting room.” It was the last day of our advertised clinic and though one would have suspected some manner of procrastination by patients, waiting until the last day (I know that I would have likely taken that strategy) to be seen, there was a much smaller crowd than we had been accustomed to over the last weeks. It was a bit surprising, though, in that even with the small number of patients we had, they seemed to multiply and continued to accumulate. By no means did we have anywhere near the numbers that had during our first ten days, but it was still a presentable tally for the day.

Walking by the vegetable garden on the way to clinic

We had no plans for the later in the evening as both John and Amisha would be packing for their departures tomorrow, John to Kilimanjaro and Amisha off on safari again with a friend who was arriving into Arusha this evening. Tomorrow was a half day of unannounced clinic and Friday was a free day for those of us remaining at FAME so we were on our home stretch. The weather was supposed to be turning as well with rain beginning tonight, so no one knew what tomorrow would bring. We had had the loveliest weather so far for the entire month with temperatures that barely varied from day to day, cool overcast mornings that broke into beautiful sunshine, amazingly star-filled nights earlier in the month without the moon and lovely moonlit nights for the remainder. No matter what was in store for us, nothing could take away what we’ve had and what we’ve experienced together.

Tuesday, October 23, 2018 – A visit with Dr. Steve….

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Steve, giving his antibiotic lecture

I still wasn’t feeling well despite having stayed home from the Golden Sparrow, missed out on the celebration and went to bed early that night, so I spoke to Steve about seeing him in the morning to see if he could figure something out for me. I probably haven’t gone into enough detail about Steve’s background, but leave it to say that he is the doctor’s doctor. Simply put, he is an amazing clinician and diagnostician who is one of our university’s treasures. In addition, he has a career devoted not only to medicine and education, but also to global health and, in particular, HIV and infectious disease. He build the Botswana-Penn Partnership around their nearly hopeless HIV infection rate and developing a program that was hugely successful and resulted in the creation of a national medical school in a country where there was previously none.

Amisha and one of her pediatric patients

So, what better person to bring along with us this month, especially considering my current dilemma. But first there was the morning educational lecture and morning report to get through before I could get to Dr. Steve. Today’s lecture was actually going to be given by Steve and was a fairly basic talk on antibiotics that I very much appreciated given the fact that it has been over 30 years since I’ve covered this stuff. Despite a very dry subject matter, he managed to keep everyone’s attention as far as I could tell and there were lots of good questions clearly indicating that people were getting something on the subject.

Amisha and a well-dressed patient

I was feeling so poorly that I don’t recall much of morning report, but once it was over, I immediately went to our clinic area hoping to make certain that things were reasonably organized and would be moving in the right direction relatively quickly so the residents could start seeing patients and be ready to present when I returned from Steve’s visit. Things looked good and so Steve and I wandered over to the OPD where we grabbed and room and he took a good look at me as well as doing an examination. Thankfully, it wasn’t anything serious, but as poorly as I felt, it would need some attention. I managed to maintain some semblance of composure throughout the morning, lunch and into the afternoon, but as the day wore on, I was feeling tremendously worse to the point that I didn’t feel I could continue working any longer and need to head home to either get horizontal on my bed or else I’d be getting horizontal someplace else and it very likely would not be voluntary nor in a place of my choosing.

A bulletin board in the peds ward

My departure from clinic was somewhat of a blur to me, but I recall sitting outside on one of the seats in our “waiting room” and noting that we were pretty much done with clinic except for few last patients that were being seen. Frank walked up to me as he usually does and was holding the MRI folder of a patient we had seen earlier wishing to discuss the case with me. I merely said that it wasn’t a good time for me and, taking one look, I think he must have agreed as didn’t continue pursing the discussion. Next, I recall Amisha telling me that she was pretty certain she had a young girl with Rett’s syndrome, a very rare degenerative disorder affecting young girls and very often with seizures. On any other occasion, I would have been incredibly excited to have discussed the case with her and to have seen the child, but all I could muster was something to the effect of, “you know more about Rett’s than I do,” which I probably mumbled as I made my way from the chair to standing with the intention of doing my very best to walk home and pass out on my bed.

The courtyard area of FAME

Alex, who is an incredible cook and has proven to me on numerous occasions, had offered to cook a feast of Mexican food for our dinners tonight, but in midst of my feeling so poorly, I apparently hadn’t communicated the plans properly to everyone. In the past, we’ve had a final dinner for our month that all the volunteers and local ex-pats associated with FAME attend and we’ve done it our house since it’s larger. The neuro crew thought that the dinner was just for us and considering that Lindsay wasn’t eating beef at the moment, and Amisha, never, decided to order the regular dinner (an equally delicious veggie wrap with hummus) from the kitchen staff creating a bit of an uproar (I say that in some exaggeration given the incredible congenial atmosphere at FAME). What they didn’t know, of course, that it was a huge affair and Alex, knowing their dietary restrictions, had created his very own vegan “taco” filling made with cashews and spices that tasted just like the real thing and was delicious.

Patient entrance to the lab

I had slept the entire afternoon and evening and awakened to everyone in the house, amazingly still alive, and, more importantly, with a bit of an appetite considering the spread that Alex had created for everyone. Chapatis for wraps, the most tender marinated beef, his vegan “taco” mix, and Spanish rice, while others brought guacamole with plantain chips. The house was completely full of people and the conversations were lively. Despite my early issues, it was a wonderful relaxing time for everyone to share their experiences and, considering the group we had, they were quite extensive and varied. The combined years of international medical work in that room were immense, from the seasoned travelers to the newer initiates, but there was clearly a common dedication and an energy that could have lit a city.

Mussa working in the lab

Monday, October 22, 2018 – Another big day in clinic….

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Amisha evaluating one of her many children

We had survived our trek back from the Serengeti despite a bit of car trouble on the way home and I would have to arrange some repairs with Soja once again to keep everything in proper running order. It was already a given that he would be swapping out the borrowed alternator for the new one he had ordered in Arusha and had arrived after we had left for the Serengeti. Now he would also have to repair the one rear shock mount that had broken (thankfully, the Land Rover has two shocks for each rear wheel) and the seal for the opposite rear wheel that was leaking significantly spraying grease over the wheel.

Amisha and Grace Mshana evaluating a patient. Grace is the daugher of Dr. Mshana, who was the first Tanzanian doctor to work at FAME and now retired, and Mama Mshana, who still runs the child and maternal health clinic at FAME. She’s a statistics expert and pitched in to help by translating for us

These were both simple matters, as it turns out, and he would get the vehicle back to me at the end of the day. I know it sounds like Turtle has had more trouble than one vehicle should have, but I will point out that we had just acquired the vehicle and hadn’t time to really put it through its paces. Besides, Land Rovers, which do happen to be my favorite off-road vehicle here, do take a lot of TLC with constant repairs and upkeep compared to the alternative Land Cruiser, but it is much, much less expensive to work on Land Rovers than it is on their Japanese brethren. Safari companies run 95% plus Land Cruisers these days, while private vehicles are 95% plus Land Rovers for those reasons. Having driven both of these vehicles extensively here over the last years, I will say that I much prefer the stability and toughness of the Land Rover over the Land Cruiser. In the end, of course, it is very much personal preference.

Grace and Amisha evaluating a patient

Amisha has a fan

At morning report we were able to hear about the patients from over the weekend, including our gentleman with the question of Tb and his focal examination. Also, we had the addition of two volunteers who had arrived yesterday, Mark and Monica, who were both obstetricians from the Midwest and had been to FAME twice in the past. They were staying with Steve in his house, so he no longer had a bachelor pad to himself. Knowing Steve, I’m sure he enjoyed the company there, though we continued to have him over for dinner each night which had been the normal course of things for our entire time here. It was also Lindsay’s birthday (no, I won’t divulge her actual age here) and so, in addition to her special breakfast at the house, there was a loud round of “Happy Birthday” sung at report by all in attendance, mzungu and Tanzanian alike. I will say that I’ve had my birthday here nearly every year since 2011, and though I don’t recall ever having been sung to in morning report, I did have one of the very best birthdays of my life two years ago for my sixtieth that was orchestrated by Jess Weinstein, Jackie Herold and Pauline Diaz (our volunteer coordinator at the time) and was an all-out surprise bash held at the Highview Lodge overlooking FAME.

A true pediatrician!

In my calendar for our clinics, I had indicated which of the clinics should be announced to the community, but unfortunately there was a small communication glitch in that I did not specifically say “not” to announce those other clinics. This week (Monday-Wednesday) was therefore announced to the community and I hadn’t actually planned it that way. We had been instructing many of our follow up patients to come either today or this week and given the appearance of the crowd waiting to register to see us, there was quite possibly going to be an issue with our volume for the day. Amisha had a great idea of giving the follow up patients whom we instruct to come back to check in something to identify them so they don’t get caught up in the chaos that seems too often occur at the beginning of the day where it is also often that we may reach our maximum number of patients to be seen.

Believe it or not, Amisha was willing to share, at least momentarily

It frequently occurs that we’ve reached that maximum number and a long-standing patient of ours may show up who I do not want to turn away and so they just get added to the list. Though there is so often a huge crowd out front that it’s difficult to tell which patients are where in line, but if you somehow call a patient out of sequence, it can often create a stir. We would identify the pediatric cases and save them for Amisha, but we would always have to be careful not to put them too far ahead in the lineup. Considering that many patients may have to wait the better part of the day to see us, it’s certainly understandable.

Lindsay and Kitashu evaluating a patient

Luckily, today we were able to locate our follow up patients with reasonable success and had them all seen without missing a beat. Amisha was totally thrilled as several patients who she had started on anticonvulsants were now seizure-free, and, although it had only been several weeks, it was a very good sign that we were at least heading in the right direction with their therapy.

Amisha and Grace Mshana evaluating a patient.

We had decided to have dinner at the Golden Sparrow to celebrate Lindsay’s birthday as we hadn’t been there yet this visit and the residents had heard all about it from past participants at FAME. Unfortunately for me, I still felt a bit under the weather with a GI issue (very atypical for me on these trips) and, so, by the time dinner rolled around, the best I could do was to shuttle everyone down to the Sparrow and have them promise to behave themselves (the last part is a lie). There did have some “adults” along with them in the form of Steve, Mark, Monica, and Lisa, the respiratory tech volunteering for the month, and, therefore, I had some reasonable expectations that no one would get into too much trouble.

Birthday girl and Hannah. Partners in crime.

Lindsay (birthday girl), Anne and Hannah with Peter to Lindsay’s right and Selena to Hannah’s left.

As a bit of history for those who have not been following this blog for long, there was once a small bar here by the name of Carnivore that served the best grilled chicken in Karatu. In fact, that’s all they really served; grilled chicken, chips (French fries) and fried plantains. Oh yes, and lots of beer and wine. It was a great place for dinner and was very, very cheap and, to make things even better, they had a tiny dance floor inside that we had taken advantage of on several occasions. About a year or so ago, Martha, who owned Carnivore, decided to close it down and build a new establishment called Golden Sparrow, which still serves the same amazing grilled chicken, but is much larger and “classier,” which clearly needs to be qualified to a degree as we are speaking of Karatu. What has really changed, though, is the tiny dance floor, which at Carnivore was more of an afterthought, as it has been transformed into a small nightclub with a much-improved dance floor, a DJ that takes requests, and a full bar that is there to serve. Though we have always maintained a definite air of civility in relation to the Sparrow, it has also been said from time to time, “what happens at the Sparrow, stays at the Sparrow.”

Monica and Kat playing with their cell phones

Incriminating evidence?

The first group to experience the Sparrow was Jamie Podell, Chris Perrone and Nan Lin, though I will divulge that not all of them decided to participate in the nightclub action and I will leave it up to you to figure out who did and who didn’t. The next group in October of last year, Neena Cherayil, Whitely Aamodt and Sara Fridinger had absolutely no qualms, as you may have already guessed, and the last group equally so. The Sparrow has now become more of a tradition for us, along with our meals at Gibb’s Farm, and to miss it for me was something significant as I so enjoy celebrating with the residents who work so hard at what they do and deserve the time to let off some steam, all within reason, of course. Though the “adults” did come home a bit earlier this night, the remainder of the group made it home safely as I had no doubt that they would. Besides, now that Lindsay is an entire year older, there was little question in my mind that she would act accordingly (please read the sarcasm in that comment).

Hannah, Abdulhamid (Dr. Shaban), Dr. Anne and Peter

Kathrine (FAME social media coordinator), Anne, Abdulhamid, Peter, Amisha, John and Hannah cramming into a selfie (kind of reminds me of how many people you can fit in a telephone booth)