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)

 

Friday, October 19, 2018 – A half day clinic and then off to the Serengeti….

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Sending a young child off to Arusha in FAME’s ambulance

We awoke today with the anticipation of our upcoming journey to the Serengeti after lunchtime and were thankful that we had made it home last night with Turtle, as had we had to leave her on the road in Mbulumbulu last night it would have thrown a major wrench into our plans for the day. We had a borrowed alternator and were awaiting a new one to arrive from Arusha, but we were fine to travel to the Serengeti while awaiting the replacement which would most likely not arrive on time for our departure. Regardless, Turtle seemed to be in a much better mood this morning and turned right over for us with a full charge on the battery given the long ride home last night to top it up.

Dr. Shaban and Hannah evaluating a patient together

Amisha and Emanuel evaluating a patient

We were planning to work in clinic until around noon today at which time we would leave for our two-night adventure to the Serengeti. Our guide, Leonard’s younger brother, Fred, was coming up this morning to pick up Turtle and give her a good going over before we left to make certain that she was worthy of the adventure we were planning. We went to morning report and learning of a patient with Tb who had been admitted overnight and was reportedly encephalopathic. He would definitely require a lumbar puncture, but we first wanted to evaluate him with a thorough examination as we were unable to obtain any imaging first since our CT scanner was still down. When Lindsay went to evaluate the patient, though, he had a fairly focal examination with some mild left-sided weakness that presented a bit of an issue as we are always taught to obtain an imaging study in this situation to decrease the risk of herniation during the LP. In reality, the patient was awake and despite his examination, we felt very comfortable performing an LP to rule out Tb meningitis which would certainly affect the treatment recommendations.

Amisha and Emanuel evaluating a patient

Emanuel enjoying one of Amisha’s patients

The patient eventually underwent the lumbar puncture that failed to reveal a significant meningitis so we were then left with the concern of what was causing his examination focality and this would require being sent somewhere for an imaging study. We had also placed the patient on anticonvulsant medications as there was some concern that his mental status could be the result of recurrent seizures and after being placed on medications, there was some sense that he may have improved slightly, so it was recommended that he remain on the medications while his family decided if they could afford traveling to Arusha to get the CT scan of his brain to look for a possible mass lesion. This entire process, of course, took place throughout the weekend while we were traveling and so we weighed in on things upon our return from the Serengeti. In the end, we had to accept the fact that they would go home on AED’s and with a focal examination until the family could raise the funds to obtain a CT scan of the head with hour hope that he wouldn’t deteriorate in the meantime

Dr. Shaban and Hannah evaluating a patient together

Dr. Shaban examining a patient under Hannah’s supervision

Hannah decided to donate blood this morning as there is always a need here and her blood was in need be more universally acceptable for infusions. It wasn’t a long process, but she clearly felt the effects so we put her on light duty for the morning or at least a significant part of it. My blood type wasn’t in as much need and I wasn’t considering giving it either way this morning as I did want to feel drained on our trip to the Serengeti. Given Hannah is half my age, I figured that she’d have a much better chance at bouncing back than I would. With their surgical load here, FAME is now able to keep blood here for those cases and can trade blood supplies with other facilities.

Kitashu and Lindsay evaluating a patient

Hannah enjoying one of her patients

We had planned to be finished by around noon time so we could have some sandwiches at the house prior to our departure, but, of course, plans never quite work our as anticipated. What I had hoped would be a well abbreviated clinic since it wasn’t announced turned out to be a little heavier than expected and we ended up seeing nineteen patients or so, about 2/3 of our normal full day volume. Thankfully, we were able to wrap everything up by around 12:30 pm and soon enough we were back at the house eating peanut butter and jelly (or some variation thereof) sandwiches with everyone quite excited for our departure. Fred had taken care of a few things on Turtle (the back door had decided not to want to latch just this morning) including filling up on 70-liter fuel tank that would have to last us several days. We loaded our small bags into the back and covered everything up as it would be a very dusty and long drive today heading up to the Crater rim, around it and then down past Olduvai (actually spelled incorrectly and should be Oldupai with a “p”) Gorge and through the Ngorongoro Conservation Area to Naabi Hill, or the entrance to Serengeti National Park.

Ice cream at Deus Market on another day

In Karatu at the market with a friend

After grabbing two cases of water for our trip (remember, this was really more of a guided self-drive that we arranged rather than a safari booked with a company), along with some ice cream bars (have to grab them when you can and I’m so happy to have discovered that Steve is as much an ice cream fanatic as I am), we began the drive to the gate for the Conservation Area. The tarmac ends here and it really is like you are entering another world when you drive through and begin going up and up towards the crater rim through the primordial forest that occupies this region. There are steep, steep canyons and ravines that are constantly to your left going up and the trees from the very bottom stretch nearly all the way in to the top in their attempt to reach the sky. Quite often there are animals on the road as you travel, mostly Cape buffalo and elephant, but occasionally you can see more as we did one morning, spotting a leopard jumping right in front of us onto the road.

Turtle, during a moment of rest at FAME

Admiring the truly magnificent Ngorongoro Crater

Unfortunately, our transit through the gate was a bit delayed due to a small hiccup in our “quotation,” or reservation, that must now be filed online and in advance. After an hour or so, though, we were finally on our way up and over the crater and down into the conservation area that is really a continuation of the Eastern Serengeti. Passing beautiful valleys full of Maasai boma (a boma is a small grouping of huts surrounded by a brush fence to contain livestock where a Maasai family lives, meaning a husband and typically multiple wives, each wife having her own hut for herself and her children) with livestock everywhere being grazed most often by young children tending the large herds that often share the same pasture with zebra and wildebeest. In the open plain you also see Thomson gazelle, the fastest of all the antelope, and Grant’s gazelle, slightly larger than their cousins. We traveled past the Serengeti boundary marked by a large sign and continued on to Naabi Hill, where the entrance station is situated. We had a much better time here, thankfully, and, in fact, they knew who we were as our friend had stopped by earlier to confirm our paperwork was in order, and we proceeded on to the Central Serengeti and our camp.

The neuro crew at Ngorongoro Crater Overlook

The Serengeti boundary

It was getting towards dusk and the skies were a bit cloudy, making for an incredible sunset thunder clouds in the distance and streaks of lightening. It made for an amazing backdrop to our drive as we sped along the washboard road deeper and deeper into the Serengeti. At one point, there were two vehicles stopped ahead looking at something perched high on a distant kopje, one of the rock outcroppings that distinguish the Central Serengeti. It was clearly a cat and it was far in the distance so it was initially difficult to see what it was, but finally the binoculars were broken out (my cameras were still packed as the light was far too dim to shoot anything) and much to everyone’s surprise, it was a leopard, typically the most difficult of the three more common large cats here to spot. It was a lucky spot and, of course, we would have to see more of them in the daylight to be fully satisfied.

John, Amisha, Lindsay, Fred, Steve and Hannah (in her favorite spot) at the Serengeti boundary

Turtle on the Serengeti

We continued on to Seronera, the name of the central area where the airport, visitors center and any businesses are located, with our camp still a half hour drive in the distance. There are no night game drives allowed here, but since we were in transit to our camp we were fine, yet we were able to experience some of what the night is like here with large herds of zebra traveling in a thin line often crossing the road, or just sitting in it until we were almost upon them. Lots of antelope could be spotted, though now in the woodlands it was impala, hartebeest, eland, and, of course, the numerous wildebeest.

The drive to the Serengeti in Turtle from my seat in the back

We made it to camp where we were greeted with fresh juice and cool washcloths, given a short introduction to the camp rules (never walk from your tent unattended at night for there were clearly lions and hyena nearby), after which we were all shown to our tents to freshen up before dinner. Meals are a fabulous affair with food that is served to us in bowls that we scoop for ourselves and many of them. The soups here are to die for and I have eaten every imaginable combination of soup in my years visiting camps and lodges. It was off to sleep after our lovely dinner, in tents that were incredibly spacious (we were staying at the Thorn Tree camp if anyone wants to look them up) and luxurious. Tomorrow morning, we would be off for our first game drive.

Hannah in her own room in the tent

 

Thursday, October 18, 2018 – If it’s Thursday, this must be Upper Kitete, our last mobile clinic of the trip….

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Amisha and Hannah doing their Neurology in Pregnancy talk

It was off to Upper Kitete for the day, a trip of less than two hours, but out to the far reaches of the Mbulumbulu area and the top of the escarpment where one can travel only a few kilometers further before running out of land. Before our trip there, though, we had another lecture to give and this morning’s topic would be neurology and pregnancy. This would be an excellent topic for the doctors at FAME considering their focus on maternal and infant health and the increasing number of deliveries every year. Hannah and Amisha, of course, did a wonderful job and at the end of their talk received the “pasha, pasha, pasha, choma” cheer (essentially meaning, warm, warm, warm, burn) from everyone in attendance.

Two young children attending the well-baby clinic

I had planned to bring Turtle up to the clinic this morning to ready for our trip today, but unfortunately it didn’t want to turn over and so I had to track down one of the FAME drivers to jump it for me. I had been concerned about the battery not charging since our trip to Tarangire last Sunday and the plan had been to have a fundi (mechanic) come from Arusha to look at it, but that was going to be later in the day so Turtle had forced the issue just a little bit early. She jumped just fine and seemed to be running well, so it was just a matter of not stalling on the drive to Upper Kitete and then I would have to park her on a hill so we could bump start her for the return trip. More on that later and as they say, best laid plans of mice and men….

Amisha and Dr. Shaban in the bat cave

Weighing a baby at the well-baby clinic

After our lecture and morning report, we finally loaded into the Land Rover and were off for our day in Upper Kitete. I had invited Steve to come join us for the day as I had wanted him to see one of our mobile clinics and also thought he might enjoy the day out in the countryside. Turtle has nine seats, but with the coke crates we had borrowed from the Lilac Café, we were able to fit an additional two bodies and so departed with a crew of eleven heading over some of the most beautiful countryside in the world. We took the same road we use to get to Kambi ya Simba and then continue beyond for an equal distance making it almost twice as far as the closer village. Upper Kitete is in the heart of the Iraqw farming communities of the Mbulumbulu area and just outside the village proper there remains some small bungalows there were once a small farming community that had been started as an experiment in socialism here by Julius Nyerere, the founding father of Tanzania. There is a small monument signifying this experience that dated from 1966 and was never purely successful, but remains a testament to the lengths that the early government and Nyerere went in trying to move this country of 120+ tribes and various villages and political systems into a nation that would succeed.

Amisha enjoying the gen peds side of things

Kitangile and crew screening our patients

Dr. Anne and Lindsay evaluating a patient with knee pain

Steve helping out with our patient with knee pain

Today, though, Upper Kitete remains a small farming village with a few scattered shops here and there, and families that have been in this region for at least a few generations which is actually a long time here considering the amount of influx there has been in Northern Tanzania. Above us are the tall mountains of the Ngorongoro Highlands and the Ngorongoro Conservation Area and below us is the escarpment overlooking the entire Rift Valley where one can see far north towards Lake Natron and the Kenyan Border and south towards Mto wa Mbu and Lake Manyara. It is truly a magical place that sits at the crossroads on so many levels – culturally, politically, agriculturally and geographically. If I were to consider settling down anywhere in Tanzania, this region would be on the top of my list and that list would not be extensive even considering how beautiful this country is.

Hannah instructing a patient on the Epley maneuver using Dr. Shaban as her assistant

Hannah demonstrating the Epley maneuver using Dr. Shabon

We arrived to the Upper Kitete dispensary, which is essentially unchanged from my first visit here other than a new small building adjacent which has yet to be fully furnished, only to find a huge mass of patients that were thankfully not all for us as it was also their well-baby visit day. By scheduling our clinic well in advance, I had hoped not to conflict with their regularly scheduled clinic, but somehow this did not happen meaning that the examination areas would be very tight for us, unfortunately. I must say, though, that seeing the well-baby visits and how diligent these mothers are in bringing their little children with their growth charts and making certain they keep up with their vaccinations. After some negotiation with the clinical officer here we eventually ended up using the two offices that we normally use (the nurses office, otherwise referred to as the bat cave for the distinct smell of guano coming from the opening in the ceiling, and the labor and delivery room that was not currently being used) along with the outside area that we normally use as our pharmacy, but would now serve as our third examination room. The pharmacy was bumped to the end of the outdoor walkway and we just moved all of our patients to the other side of the building to wait for us so as to maintain some notion of privacy.

Patient being carried in by family members

Lindsay and Dr. Anne working in our “open” examination room

Dr. Anne and Lindsay evaluating a patient

The clinic was a bit slower than usual and similar to the other mobile clinics this season (other than Rift Valley Children’s Village) and it wasn’t entirely clear to me why. We got through our patients, though, and had our lunch around midday with still a few stragglers to see afterwards. One of our later patients was a gentleman who was brought to us sitting in a chair (not a wheelchair) and we were told that he had been unable to walk for well over ten years. His examination was myelopathic suggesting some sort of cord problem and we felt he most likely had a cervical myelopathy as it had been gradual in onset. We discussed the possibility of an evaluation, but were realistic with him noting that it was very unlikely that we would find anything that would be treatable at this late stage and, therefore, it would not benefit him functionally. The family understood and we did treat him with some baclofen for his spasticity which was the least that we could do for him. As with our patient at Kambi ya Simba who was also paraplegic, he was eventually helped onto the back of a motorcycle by his sons and began his trip home.

Amisha Lindsay and Dr. Anne with one of their adorable patients

Lindsay taking a breather

Dr. Mike taking a break

One of our traditions at Upper Kitete is to visit a spot called the overlook that was first introduced to me by Paula and Amiri when I had first come here in 2011. It is an incredible location that essentially sits at the edge of the escarpment with a steep two-thousand plus foot drop to the valley far below. In the distance, one can see dust devils rising from the valley floor or rainstorms with lightening that are almost below you at times. I always want to share this with everyone and since none of the people on the trip had been to this spot before it was decided that we would take the five-minute drive to the overlook.

The view from the Overlook

Lindsay at the Overlook

Steve doing his Karate Kid imitation at the Overlook

First, though, we had to bump start Turtle, which entails having everyone push downhill and getting enough speed to pop the clutch in second gear and start the engine. It worked like a charm, but now the challenge was to drive to the end of the earth at this precipice known as the Overlook, without stalling the car as we’d be facing the wrong direction to bump start it again. I decided not to drive all of the way out and stopped about 100 yards from the edge where I could remain with the car and keep the engine running. This worked reasonably well and gave everyone a chance to experience the Overlook, spend some time taking photos, and then we could eventually be on our way. I kept the engine running while successfully turning our behemoth vehicle, which has the turning radius of a supertanker (I had later mentioned the Exxon Valdeez to the residents who had absolutely no idea what I was talking about), around to get us moving in the right direction. Not an easy task even in the best of circumstances and certainly not with a steep ravine on one side of us.

Everyone putting in their two cents regarding Turtle

Talking to Soja on the phone

Once on our way heading back to Karatu with our engine still purring we were looking forward to getting home for dinner and arriving well before sunset. Well, that was our plan until Turtle developed a rather nasty sound under the hood that was clearly engine related and didn’t seem to want to go away. All I could really do at that point was to keep driving and hope for the best, but apparently that was not meant to be. After a few minutes of a pretty nasty screeching sound, Turtle just died and regardless of putting the clutch in, I could just not keep her running. We got out and lifted the hood to see a bunch of smoke coming from the alternator which had decided to give up the ghost not very far from Upper Kitete which meant that we were well over an hour from Karatu and essentially in the middle of nowhere. The alternator had seized up (i.e. its bearings had frozen), but Lindsay fondly coined the phrase, “alternator dege dege,” where dege dege means seizure in Swahili. And you will also recall that there is absolutely no cell service in Upper Kitete, but thankfully, we had a few bars that allowed us to send an SOS to FAME. I first texted Frank, who in turn contacted Moshi, who essentially keeps FAME running and deals with all the infrastructure there. Moshi contacted Soja, FAME’s mechanic, who I eventually spoke with and said he would see what he could do.

A selfie during our downtown with Turtle

Hannah enjoying the view from the top of Turtle

So here we were, stranded on a road that ends just past Upper Kitete, with barely any cell service, a beast of a vehicle that was unfortunately lacking a functioning alternator, and ten passengers in addition to myself with the sun setting in the next hour. Life tells us to always make the best of things which is what everyone did. Of course, there were locals that were walking up and down the road, everyone checking in to see what was going on along with constant motorcycles and a few other vehicles traveling in either direction. Hannah and Lindsay decided to climb on top of Turtle and relax a bit, while John decided to spend his time practicing his climbing moves by circling Turtle using hand and foot holds without touching the ground. Steve took a few walks and everyone else just sat around biding their time.

Replacing the alternator

Working on the alternator

Thankfully, Soja found a used alternator he could borrow and called to tell us that he was on his way. It would be at least an hour from when he called, though, to reach us so it was just a matter of continuing to occupy ourselves in the interim. Soja arrived with the spare alternator which he and his assistant managed to install in an amazingly short amount of time as well as installing a new belt for us and had Turtle once again purring, albeit after another bump start considering our battery was still dead as a doornail. Once again powered and ready for action, we loaded everyone back in and were on the road within two hours of our initial breakdown. Considering where we were, not only in East Africa, but well over an hour off the tarmac and in need of an alternator, and with no AAA in the same hemisphere, it was a small miracle that we were able to be rescued successfully and would be sleeping in our own beds tonight.

Supervising the repairs

The drive home was, of course, a bit on the difficult side considering the sun had set long ago and driving here after sunset is not something that you would elect to do if given the choice. Dusty roads, tons of people walking and appearing as merely shadows, combined with oncoming vehicles all adds up to a challenge that gives one a sincere sense of accomplishment when arriving home safe and sound. Once again, everyone could breathe a huge sigh of relief that we were home safely and everyone would have incredible stories to tell about the experience. Tomorrow we would have a half day of clinic in the morning and then head to the Serengeti for the weekend. It was certainly something to look forward to and especially considering what we had just been through.

Dispensary sign at Upper Kitete