Qaru is a very small town that is south of Karatu and on the road towards Haydom, where there is a larger teaching hospital, but is about three hours away. We had chosen Qaru to visit several years ago when looking for an additional site to hold our neurology mobile clinics and where there was also a nice dispensary that would serve well for us to work in while there. Qaru fit the bill perfectly for its health center had been recently built by an organization wishing to provide this resource to the community. There is a nearby school and in the past, we have been able to interact with the children during their recess time. I had also been fortunate enough to have shared in church choir rehearsal not long ago which was really a treat.

The drive to Qaru is less than 45 minutes and is on a main thoroughfare, albeit gravel, as there are very few paved roads other than the main highway traveling from Arusha to Karatu, as well as the road that travels east from Makuyuni towards Tarangire. Trying to describe what these vehicles take here from the standpoint of abuse would be very difficult. All of the roads have severe washboards, which is the natural effect of vehicles driving over loose surfaces such as sand and gravel. This makes for an incredibly bumpy ride which the vehicles here take day in and day out, giving their suspensions an incredible work out and eventually leading to necessary repairs and breakdowns. More about that later.

Again, it is important to understand that the purpose of our neurology mobile clinics is perhaps less to provide care for patients who cannot reach FAME, but rather to bring the concept to them that neurological diseases can be treated effectively. The villages are not so remote that they are unable to get to a medical facility capable of treating them, but more that their illnesses are just accepted as part of their life without having explored an alternative. This can often be most impressive for patients with epilepsy where it is merely a matter of placing them on the right medication and they can be seizure free or at least nearly so. Epilepsy carries with it a huge social stigma and because of this and the incredibly limited access to adequate medical care in general in third world areas, the percentage of these patients who are treated is appallingly low and in the range of 10%. It can be so rewarding to see one of these patients who are young adults and have never known a life without seizures become seizure free with a simple medication. Thankfully, many of the patients we see are young children with epilepsy and so we are able to place them on the appropriate medications at a much earlier age.

At Qaru, the number of patients waiting for us was rather small that can be for many reasons and is a common occurrence at the mobile clinics. We do advertise the clinics much the same way as we do for those we hold at FAME (where we are always packed), but since we’re at each village only one day, if that happens to be a day of planting or harvest or your cow has run away, then you may not be able to make it. There were several new patients with epilepsy and a few follow ups, as well as our normal smattering of patients with complaints that we couldn’t necessarily attribute to an underlying neurological process. Many of these are musculoskeletal in etiology, but some we’re just unable to attribute to anything. We have many patients, almost exclusively young adults, who complain of hemibody numbness and the only features of their examination will be the finding of sensory abnormalities, often quite patchy and without a good anatomic localization. Of course, we see these patients in the US, but much less frequent than we do here and at home we will evaluate these patients extensively and rarely find a cause for their complaints. Often, you will find some underlying psychological event that may have precipitated the complaints, such as the death of a family member, but other times you won’t and it leaves you very unsatisfied in not being able to have some unifying diagnosis.

During our visit to Qaru, Frank called me to let me know about a patient, a tourist, who had come in with the worst headache of their life associated with vomiting and vertigo. This was obviously very concerning for a subarachnoid hemorrhage and our CT scanner here was unfortunately down so we were unable to get an imaging study. Her examination was non-focal so I recommended performing a lumbar puncture to rule out a hemorrhage. By the time we returned from Qaru, they were just in the process of getting the LP done, so Hannah evaluated the patient instead and then proceeded with obtaining the cerebrospinal fluid. We do not have the LP kits here that we are so used to using at home, and so Hannah went about positioning and prepping the patient with the nurse’s assistance while provided some coaching and moral support.

Managing to keep one’s self sterile in the setting where you have no drape to cover the back (those who perform these procedures will understand the reference) that allows you to constantly check your position with your fingers is not a simple proposition. Kudos to Hannah, though, for only having to change her gloves once during the whole affair as it was quite the challenge. Overall, it proved to be a very difficult procedure and, in the end, it was non-diagnostic as we had entered a venous plexus (this happens on occasion and is not something that can be avoided) and though we did find the CSF space, the fluid would not clear and we were unable to interpret the results. Our concern was high enough for the patient to have had a sub-arachnoid hemorrhage, though, and so we recommended that they be transferred by medivac to Nairobi in the morning as we did not recommend that they fly home to the US without having this fully evaluated.

After Hannah and I had returned home from evaluating this patient, we all decided to head to town for some ice cream (instigated by Steve, I might add). We jumped into Turtle for the short ride to the market area and all picked out an ice cream bar of our choice, then happily enjoyed the treat standing out on the street watching all the locals making their last transactions of the evening and carrying out their final choirs. Tomorrow we would be off for our last mobile clinic to Upper Kitete, which is the furthest away that we travel, so much so that it is also a dead zone for all cellular service which puts us entirely out of reach to the rest of the world and to FAME for the entire day.

Today we were heading to Kambi ya Simba, a small village in the Mbulumbulu ward of the Karatu District and about 45 minutes from FAME. Before our departure, though, there was a lecture to be given and today John and Amisha would be speaking about movement disorders (for example, Parkinson’s disease) in both adult and pediatric neurology. The talk was very well received and they had video examples of some of the more classic cases included some that we had recorded here at FAME.

After the talk, we began to get everything together necessary for our visit to Kambi ya Simba. We would be taking Turtle as our transportation and because the weather was dry, I was going to do the driving to each location this week. The other members of our “crew” would include myself, the four neurology residents, our two interpreters, Emanuel and Shaban, our clinician, Dr. Anne (an assistant medical officer), Kitashu, our social worker, and Kitangile, our nurse. It is a totally self-contained clinic, meaning that we bring all of the medications we will prescribe to see our neurology patients and all of the tools that we would need to provide our care.

I had first gone there in 2011 with the assistance of Paula Gremley and Amiri Bakari Mwinjuma. The pair had been working with FAME in their large monthly mobile clinics to the Lake Eyasi region, and following one of these clinics, at Paula’s suggestion, we went out on a smaller neurology mobile clinic to some villages that we could work with on a daily basis rather than overnighting in the bush. The two clinics included Kambi ya Simba and Upper Kitete, both in the Mbulumbulu ward. That first clinic included myself, Paula and Amiri, a nurse, and a clinical officer. We brought a large box of medications and set up our “office” out in the open in the middle of the village near the church, with the “pharmacy,” comprised of the nurse and her medications, situated a short distance away. This was the extent of our mobile clinics for several years and at that time, I don’t even recall whether Kambi ya Simba even had a dispensary.

The drive to Kambi ya Simba takes us through very extremely fertile farmlands past the Rhotia valley and on to the Mbulumbulu ward. Despite the dry season, there is quite a bit of green as we meander through the hills in this area that sits at the top of the escarpment of the Great Rift Valley and continues until the mountains of the Ngorongoro Highlands meet the drop off and the road ends. This region is populated by the Iraqw tribe almost exclusively and their farms cover the countryside, but not in the way our farms extend over thousands of acres. These are all smaller family-run farms here as there are no large farming corporations here.

As we arrived at Kambi ya Simba, it was clearly evident that the new dispensary completed several years ago has continued to grow even in the last six months since the last time I was here. In addition to the large number of buildings that are here now, they have rebuilt the original dispensary that we had begun to work in and now there is a covered arcade connecting everything. There is even an area to drop patients off who are arriving by car or motorcycle. Amazingly, a large number of patients arrive to clinic on the backs of the motorcycle taxis here called piki-pikis. Watching a nearly paraplegic patient load onto one of these as one two passengers in addition to the driver can be a bit nerve-wracking to the say the least. But this is everyday life here and what people go through to access their medical care. It is a constant reminder for us all that these are struggles that most of us, but unfortunately not all, do not have to encounter at home. There is work to be done far and wide in this regard and we are always grateful to be making a small contribution here.

The clinic today was not as busy as it has been at times in the past and we have a smattering of return and new patients who have all be screened for neurological disorders. Our purpose here is not to supplant the government medical staff here providing care, but rather to work with them and provide specialty care that would not otherwise be available in most of Northern Tanzania. That they are allowing us here to practice in their community is not something that is merely a given, but rather a sign of trust that we respect. We all ate lunch together in our vehicle which is something we’ve done here since the beginning as we did not believe it polite to eat in front of the villagers, many of whom may only eat a single meal each day.

It was their well-baby visit day so there were very many cute babies here (making Amisha and everyone else very happy), all being weighed in their traditional manner, strapped into their personalized harnesses that each of their mothers sews for them, and then attached to a general produce scale. Some babies cry vehemently while others seem to just take it in stride, though most are in the middle, of course, reaching for mom with a clear sense of uneasiness in their eyes yet somehow managing to hold it together for the few moments it takes. These visits are a regular occurrence for them so I’m sure some of them have become accustomed to this ritual. This was all occurring outside of the room marked “vaccination” which Amisha found to be a great advertisement for this incredibly necessary process which is taken very seriously here while at home in the States that very small fraction of children who do not get their vaccinations, mostly for misguided reasons, has been increasing of late.

We had seen our general mix of patients, headaches and epilepsy along with a few arthralgias, before lunch and still had several patients to get to after lunch who had showed up through the morning. The last patient we saw, though, was perhaps the most complicated. He was a gentleman in his thirties who came to see us in a wheelchair because he was unable to walk due to lower extremity “pain.” It is always so difficult from a cultural standpoint here when taking a history as what seems to be the main complaint isn’t always necessarily the case. I have many similar patients here were the main complaint is “pain,” but in actuality their examination belies a much different neurological process. It turns out that this gentleman has lost most of the use of his legs, with no effects in his upper extremities, about ten years prior and had never been evaluated medically other than by the district medical officers he had seem, mostly for other routine illnesses that they had treated.

In all fairness, this wasn’t something that a clinical officer or even an MD with a general background would have likely been able to have figured out given there is so little neurological training here other than what we bring or can be found at only some of the medical schools. His examination was myelopathic (meaning that he had a problem somewhere in his cord) as we surmised even before Lindsay had first tapped on one of his reflexes. The process, though, had occurred gradually over several years and was purely motor as the predominance of his sensory examination was fully intact. Without a sensory level, though, we were unable to tell exactly what level in the spinal cord we were dealing with, but it was clearly thoracic in nature. Going over the various possibilities of a spinal cord process that had occurred gradually over several years, was pure motor in nature, and had also had some subtle fluctuations early on, there seemed to be very few things we could come up with other than possibly a dural arterio-venous fistula of the spinal cord. Having pure motor findings with this entity is more the exception than the rule, but there was little else we could come up with for this gentleman and, perhaps more importantly, nothing that we could do to make him better at this late date. We had spoken to him about obtaining an imaging study, but it would likely make little difference for him and a CT scan, which was much more “affordable” would be far less helpful than an MRI.

Though we tried to explain to him what our thought processes were, in the end, the answer was the same, that very little could be done other than to make him more comfortable by using a medication such as baclofen for his spasticity which we prescribed. In the US, he would have most likely been seen very early on and eventually referred to a tertiary center where he would have undergone vascular imaging and eventually had an interventional process to hopefully fix his problem prior to it having caused permanent deficits. Even in the best of hands, though, this isn’t always a sure-thing and it is also possible that he would have ended up with the same deficits that he has currently.

We left Kambi ya Simba in the mid-afternoon to make our way slowly back to Karatu, once again traveling through the gorgeous countryside that we had traversed earlier in the day. We dropped all the FAME employees in town as it was approaching 4:30 pm, and we drove back up the FAME road to our home for the month with our dinners awaiting us on the counter as they do every weekday. Tonight’s dinner was veggie wraps with delicious hummus and very much appreciated by everyone. Tomorrow we would be heading off in another direction, north towards the town of Qaru, near Endabash.

 

NOTE: I do apologize for the seemingly long delay in getting these blogs posted. After our long days of work in addition to a few added issues (sorry, you’ll have to read the blogs), it is often difficult to sit at the computer and type at night.

After another successful game viewing drive at Tarangire, it was time to get back to neurology, but only for a half day clinic as I had scheduled this afternoon for a wellness day for the residents. Wellness days and wellness in general is a very hot topic as far as training programs are considered, not only for the residents, but also for faculty and other physicians alike. My only argument was really that this entire month is really like one big wellness day, but that wasn’t good enough and so today we would be working only a half day so that the afternoon would be free for the residents to do what they wished. I made several suggestions, but the one that always seems to win out is to go to Gibb’s Farm for their buffet lunch that is not to be missed. So, I decided once again to take one for the team and accompany the group for one of the best meals of our trip. First though, we would be working for the morning and trying to finish by around 1 pm for lunch.

Morning report had some interesting discussions with one of the main ones being about antibiotic use and specifically giving children ampicillin and gentamicin for community-acquired pneumonia where it was argued that gentamicin did not add anything in that situation and was a potentially toxic medication. Now mind you, I had very little input in this discussion considering this is the furthest thing from my practice, but both Amisha and Steve weighed in heavily with their knowledge on the subject. Apparently, this is something that the Tanzanian Health Ministry has also placed a special interest in and is following what it believes to be the WHO recommendations on the matter. Dr. Msuya agreed with their argument and said that he had actually questioned the health ministry on the issue, but had never heard anything back from them and since this was essentially a directive, they would follow it until it was changed or rewritten in some way.

We did here about an interesting patient who had come in on Sunday – a man was attacked by a leopard in Ngorongoro Conservation Area and had suffered a compound fracture of the tibia in addition to a very severe injury of his hand most likely suffered in trying to defend himself. Leopards do not usually attack humans so there was some concern as to whether the leopard could have been rabid, but regardless, they were planning to track it and to kill it. Animals such as this, whether rabid or not, are often very likely to repeat the attacks once it becomes a pattern of theirs. His tibia fracture was significant enough that he was transferred to an orthopedic hospital in Moshi the following day. A few years ago, we had stumbled upon a leopard on the Ngorongoro Crater rim road while driving early one morning to go for a hike at another crater. The leopard had jumped into the road, looked at us and then just sauntered off to the side of the road where he sat for several minutes allowing us to take photos of him. As we drove on, we encountered a park ranger around the next bend, walking with a rifle, thankfully, and informed him of the leopard. Most often, though, these animals are far more afraid of us than we are of them.

Planning for half a day in clinic is always a bit of a crapshoot. I learned long ago that once you start, the work seems to accumulate and fill in whatever the amount of daylight hours there are. When we work a normal full day in clinic, I usually choose a patient number that is less than what we can actually do as I know patients will continue to come and somehow, I will be talked into seeing them. The other problem was that we wouldn’t be at FAME for the next three days as these were our mobile clinics off in the villages so we couldn’t tell people to just come back the following day. There are many patients who have we have been seeing for several years and when they come after we’ve already capped the clinic, it’s hard for me to turn them away. There are no appointments for patients, though we will sometimes see patients with a hardship of some sort over in the OPD so as not to create a huge stir over on our side which is what will happen if were to see patients out of order. It will happen occasionally when we have a pediatric patient as we try to have Amisha see all of those (to keep her happy) if possible.

At one point, Hannah needed to repair her glasses so I sent her to Frank as I knew for certain that he would have at least a dozen tubes in his office. Sure enough, he had more, and Hannah returned to successfully repair her glasses. At the end of clinic, she had to run to the OPD for something so set her glasses on a chair with her charts. Shortly thereafter, we heard John asking whose glasses they were and, sure enough, he had picked them up and promptly glued two of his fingers together. He pulled them apart somewhat painfully and much to our amusement, after which we learned from Hannah that the enzymes in saliva will dissolve the superglue and in a far less painful manner.

We were actually able to get through all of our patient, though with little time to spare, and after collecting everyone in Turtle, we were on our way again to Gibb’s Farm, this time for their scrumptious buffet lunch. Now, if by wellness, we’re talking about mental health, this was certainly the solution. If by wellness, though, we’re talking about physical health, that’s another matter. That’s not to say that the food that is being served isn’t healthy because it absolutely is, but rather it is related to the amount that most of us eat. I won’t name names, and it didn’t occur this trip (Lindsay, Hannah, Amisha, Steve and Peter – I wouldn’t rat you out even if it did involve you, but it didn’t), but in the past, lunch goers have been noted to have three plates of food not including desert! It would be impossible to name all of the dishes, but leave it to say there were probably a dozen variations on vegetable salads, cold cuts, main dishes, a lovely cauliflower soup, cheeses, breads, samosas, quiche and various toppings. The desert selections included fruit, pancetta, a flan-like dish and a date cake. And oh, yes, it also included the famous Gibb’s Farm fresh-brewed coffee. It was truly a lovely and relaxing affair that included the seven of us and Kat, the social media coordinator here at FAME, who was acting as the volunteer coordinator in Alex’s absence as he had seen fit to abandon us and spend the week in Zanzibar.

After our relaxing lunch, we decided to spend some time visiting one of the local artist’s workshop here. Athuman Katongo is a wonderful artist who has been at Gibb’s for several years and I had bought something from him in the past. He makes paper from recycling cardboard and uses the local fabrics to create amazing montages of animals and people. He also makes some wonderful notecards that everyone found attractive and so we purchased probably over a dozen of them from here. His studio was filled not only with his finished artwork, but also with unfinished products that were equally stunning. Being in a paradise like this with such lovely artwork surrounding us in the presence of the artist himself was certainly an incredible treat for all of us.

We had originally thought of going shopping after our lunch, but Frank had texted me that he had a complicated epilepsy patient that had traveled from Arusha and wondered if we’d have time to see him. Frank is a very hard person to say “no” to so most of us drove home from Gibb’s (Hannah and Steve had a nice walk back to FAME through Tloma village) and Amisha and I went to work at the OPD to see the boy while the rest of the group headed back to the house to work on other things such as their presentations and charts. The boy was 14-years-old and had had epilepsy since the age of three, and all of the time poorly controlled. The history was quite convoluted, though thankfully mom spoke perfect English. He had been on multiple combinations of anticonvulsants, but none had ever really been pushed to their maximum nor had they been thought out very well. We came up with a good plan that involved an MRI (he had only had CT scans previously), levetiracetam and the possibility of using lacosamide if the levetiracetam didn’t work well, but they would have to check to see whether they could get it Arusha first. We had seen a patient on it here earlier in the month, but you never know if it was obtained in this country or not as there are some patients who travel to Rwanda for medications. We drew up very specific instructions for them to follow and going forward, they will communicate with us through Frank.

That night we watched Lion King as Steve had never seen it before. Halfway through the movie, we took a break to apply some Korean face masks that Amisha had brought and were intended to make us all feel more luxurious. I can honestly say, at least for myself, that I was unaware of any effect. Tomorrow, we would begin our mobile clinic push, first at Kambi ya Simba, which is about 45 minutes away.

 

 

Considering the wonderful safari we had had the week prior to Lake Manyara, everyone was perfectly happy (or at least willing) to awaken well before sunrise to begin our trek to Tarangire. Animals are more active in the morning hours and the evening and so we had wanted to arrive shortly after the gates open at 6:30 am. Packing the car and hitting the road at 5:30 meant that it was a bit cool and quite dark as the sun wouldn’t be rising for nearly an hour, but it would hopefully get us there shortly after opening. Tarangire is a wonderful park that is a bit larger than Lake Manyara, but still much smaller than Serengeti National Park. Still, there is lots to see there and we would not have time to explore the entire park. The biggest attraction is their population of elephants that rivals any other park in Tanzania, and perhaps Africa. Elephants spend their nights away from the river in the hills, each day making the journey to the river for their water. In the drier months, the river is packed with animals which usually means that lions are nearby and we were certainly hoping to see some today.

The drive was uneventful other than my mandatory run in with the traffic police here. Sure enough, on the other side of Makuyuni, I was stopped for traveling 56 kph in a 50 kph zone. Once again, the zone was not marked, but I was told that it is 50 kph anytime you’re traveling through a populated area, which here means a few buildings and a crosswalk. I handed over my 30,000 TSh (less than $15 USD) and received a receipt on the spot that was spit out by the officer’s handheld device that had registered my details. Needless to say, I drove a bit slower for the remainder of the drive and made sure that I didn’t speed in any area that could be considered “populated.” Oh, and by the way, 50 kph is the same as 31 mph, so you can imagine how hard it is to keep you speed down to that range while driving on a highway.

We pulled in the parking lot at Tarangire and while I went to pay our fees, the rest of the group used the bathrooms and prepared the vehicle for game viewing by popping the tops on Turtle so everyone could stand while we were in the park. Several people also went to the concession stand there to score some coffee which most had missed due to our very early departure from Karatu. Once paid and with everyone back in the vehicle we went through the entrance gate after showing our receipt for having paid our entrance fees.

We were now in the park proper and it was time to get into the mode of game spotting and viewing. I have a navigation application on my iPad in which I have loaded maps of all the areas I drive in as even without cell service here I will never get lost as long as I continue to receive a satellite signal. I have also recorded all the roads that I’ve driven on during my many safaris along with where I’ve seen lions and other interesting sights during our drives. Although I know most of the roads here in Tarangire by heart, it is still helpful to see where I’ve seen things before or to double check regarding a turn or two. Turtle is equipped with a two-way radio that is very helpful as all of the guides talk to each other and share sightings, but unfortunately, they all do so in Swahili which is of little use to me since I speak so little of it.

It took very little time for us to begin spotting the more common animals here that included zebra, wildebeest, warthogs, and impala. As we drove down and crossed over the river, we began to spot the many elephants here along with Cape buffalo and giraffe. The elephants here are the most fascinating, though, in their large extended families that are purely matriarchal and contained many, many babies. Driving along the river, we encountered family after family making their daily journey down to the river to bath and drink and generally carry on. My plan was to continue driving along the river and eventually reaching the Silela Swamp that sits on one end of the park and has a lovely lunch area overlooking this incredibly large area that is usually flooded with water, making it home to many, many animals. Before we get to the swamp and lunch, though, we have quite a bit of territory to cover and it is far from disappointing.

At one point, while watching a family of elephants making their way across the road in front of us, someone spotted a lion directly behind us also crossing the road. We quickly swung Turtle around along with another vehicle that had also been watching the elephants and found that the lioness was one of three who were slowly making their way across the river very likely in search of game. One of them was already across the river under a tree while the one we were watching had stopped on our side in the shade of a tree and yet a third was sitting above us under a tree. Eventually, they all followed the same path ending up in the shade of some trees and probably waiting for a passing herd of wildebeest or zebra. It is difficult to see lions during the day that are doing much else than sleeping so it was great that we at least got to see them walking, even if they were hunting at that very moment.

We had watched the lions for a good amount of time and had decided to get back on track heading for our lunch spot overlooking the Silela Swamp. As we rose higher to cross over the crest of a hill, the swamp came into view and as dry as most of the park was, the swamp was green and luscious and covered with elephants. There were huge herds or families of elephants that were spread across the lush green vegetation and numerous watering holes there were visible and many that were not. It was an amazing sight to see hundreds upon hundreds of these elegant creatures all interacting and enjoying themselves in the water and mud. We pulled into the picnic area with a number of other vehicles already there, but were able to find a nice table with an umbrella to shade us.

The view from the picnic area of the Silela Swamp is just incredible and the weather was absolutely perfect for our day in the park. We enjoyed our lunch of peanut butter sandwiches, in various combinations with jelly, Nutella, honey and bananas, along with hard boiled eggs, cheese, crackers and fruit. Everyone was happy to have some moments to relax with our beautiful views and there was absolutely no rush for us to head back out as we had the entire afternoon to make our way back to the entrance. After lunch, we drove along the edge of the swamp for some time admiring the hundreds and hundreds of elephants, some who were close up and others out in the middle of the swamp, though all enjoying the cool water and mud. Many were playing or flopping down in the mud no doubt to cool off and coat their hide against the insects and heat. Watching them relax and enjoy the day was great to see and gave us all such a sense of warmth and for those moments you can almost forget the outside world and share in their existence.

Along the swamp we were able to see some animals that were not up in the woodlands we had traversed. There were a pair of reedbuck, an antelope mostly spotted around water, and a lone oribi, another antelope that I hadn’t seen before. We doubled back and drove along many more families of elephants before finally leaving the swamp and driving up over one of the hills that parallel the river, spotting a small group of Klipspringers which I hadn’t seen before in this park. Large groups of zebra and wildebeest were absolutely everywhere we turned and there were also many giraffe. Unfortunately, we didn’t see as many lions that we had hoped, but knew that we would see them next weekend in the Serengeti.

We didn’t leave the park until after 5 pm which meant that we would be arriving in Karatu after sunset, always a risky proposition here as driving at dusk is the most difficult with motorcycles and pedestrians popping up in front of you continuously. We were both starving and exhausted, though the exhaustion won out and we decided to head back to the house and scrounge for dinner. We had bread and cheese which was more than enough for us, though, so I made grilled cheese sandwiches for everyone and John has some of his chicken soup he had made along with his sandwich. The remainder of the evening was quite quiet with everyone passing out and heading to bed at various times. We would have a light day at clinic tomorrow for it was a wellness day in the afternoon and we had plans for lunch at Gibb’s Farm, always a highlight of the trip.

We were all quite energetic this morning (or at least I was energetic as the Hannah and John have running every morning) and decided to go out for a walk in the fields beyond the FAME property. FAME sits 2.7 km out of Karatu proper and is pretty much the last establishment on the road before you run into all the coffee plantations that back up to the border of the Ngorongoro Conservation Area. This is a huge region for excellent coffee given all of the volcanic soil and the Ngorongoro Highlands is particularly lush and rich in this regard. From our veranda we look out over fields of coffee as far as we can see into the distance as they run up the many hills and ridges here.

The area that we walk is partially along a dirt road and then onto some trails that cross the fields and are used by the local workers to get to and from work and home. This time of year, the trails are well worn flat and easy to follow or even run on, but in the wet season the fields and trails become a quagmire, so much so that you usually have about a pound or more of clay caked to your shoes. This is fine from an exercise standpoint, but if can difficult to walk with that much muck on your shoes. The morning was absolutely gorgeous and my fleece vest lasted only about fifteen minutes before I was sweating and had to take it off, carrying it with me the rest of the way. We left at about 6:20 am and walked at a brisk pace so that we covered about 3.5 miles and arrived home after an hour, time enough for us to shower and make it to morning report on time.

There were no exciting patients that had come in overnight and we had no clinic patients as were leaving as soon as possible for the village of Oldeani and Rift Valley Children’s Village (RVCV). India Howell (Mama India) founded the children’s village in 2004, and over the years, they have continued to grow such that she now has nearly 100 children that call this their home and call her Mama. The children are all adopted and between she and her Tanzanian partner, Peter, the children are cared for and raised, attending the local schools, then secondary school and eventually college. She has partnered with the community to improve their schools by helping to fund certain programs and she has offered healthcare to the residents of the surrounding community as they knew that a healthy community would only improve the chance of success for their children.

It was on the backdrop of India creating her children’s village in Oldeani that Frank and Susan decided to locate FAME here in Karatu for several reasons, though an important one was its proximity and the fact that they could provide medical care to her children and the community. I guess you could say that the rest is history. Having FAME on the Northern Tanzania safari circuit where it would get some exposure to visits to the area who were interested in the community is perhaps the main reason that I am here having visited in 2009 while volunteering in the village of Ayalabe outside of Karatu. Nancy, our architect/nurse at FAME, came through while on safari several years later with Leonard Temba who was our guide and ended up coming back to FAME to stay after speaking with me in the States and deciding this is what she wanted to do. India had come to Africa in the same fashion. Having climbed Kilimanjaro, she returned to manage a safari lodge and then decided to create a home for orphaned and abandoned children here in Tanzania. Many, many of the expats and volunteers arrived here in the very same fashion, having fallen in love with this country and its people after visiting, not knowing that it would change their lives forever, and, of course, for the better.

We all loaded into Turtle, now repaired and running well, and began our drive towards the village of Oldeani along a lovely route through cultivated fields and eventually arriving to the coffee plantations that surround the children’s village. Working in the coffee fields is the main employment for the local villages here which is steady, though very physical, work. There is a very stark contrast driving past the homes of the adjacent village and then through the gates of RVCV where the buildings are brick and in good repair and the grounds are well kept. There are close to 100 children living here until they are ready to go away to school and possibly the university. Daniel, who grew here and worked as a translator for us over the last several years just found out that he would be attending clinical officer school which is a fantastic achievement and made everyone proud. Emanuel, one of our previous translators (not the current Emanuel working with us) recently graduated from nursing school and is now applying for jobs. Most of the children here excel in school and go on to college which is no small achievement here where the government decides who gets to go and who doesn’t and is based on their oft-changing rules.

Driving into the parking circle in front of the administrative offices, there is a huge gathering of patients sitting on benches and waiting to be seen. Our first thought is how we are possibly going to see all these patients in one day starting at 10 am and we’re all relieved to find that the patients are not all neurology as nurse Gretchen is seeing patients today in their regular clinic. Still, as we arrive to the area where we’ll be working, it seems there are quite a few patients for us so we make sure with Kitashu that the patients are going to be properly screened and I revisit the criteria with him that we use here. We try not to see back or extremity pain, but rather weakness and numbness as these are neurologic complaints and not osteoarthritic in nature. We have worked hard to train those that help supervise these clinics where it is essential for multiple reasons that we’re seeing neurology and not pain or orthopedic problems. First, it’s not what we’re here to do and it gives us less time to work on what we’re good at doing. Secondly, we have limited funds and if they see us for the reduced single fee that covers labs and meds also, it takes away resources from those that may have needed it. Triage, though, it really tough. We commonly have patients come through who have told the nurse one thing and then it changes when they come in to see us. At FAME, it’s easy for us to send them over to the outpatient department, but here they would have to see Gretchen and she was definitely going to be a bit overwhelmed today.

Many of the patients here we’ve seen before, some for as long as I’ve been coming. We see some of the children from RVCV with epilepsy or ADHD, but there are more patients from the community that are seen. This is an Iraqw community and so almost all of the villagers we see are from this tribe which is very similar to our other mobile clinics which are also in Iraqw communities. We probably see a larger percentage of epilepsy patients here than at other clinics, but otherwise, there is the typical smattering of diagnoses. Several of the patients are new to the clinic and we’ve diagnosed them with chronic illnesses such as epilepsy and they will require continued medications going forward. One of the patient had unfortunately come from a very long distance near Lake Eyasi meaning that they were out of the catchment area for the clinic and their continued care would not be covered as it was for the other patients. This is always an unfortunate position to be in because the medications can be expensive and it doesn’t serve much of a purpose to put a patient on a medication that works, but is not sustainable in the long run.

One of the highlights of our visit here is lunch as it is served in the kitchen house where all the volunteers at the children’s village eat every day. It is always fresh and delicious and there are often home baked desserts, but unfortunately not today. After lunch we went to the small duka (store) where they have for sale items made by the Rift Valley Women’s Cooperative, a group that is being supported and managed by the RVCV and has their handicrafts in lodges and shops throughout. It is beautiful work and I think all of us made sure we purchased something there. As we were shopping, we could hear the band playing for a local wedding. The wedding party typically is in a car followed by a van or truck loaded with musicians who play tunes that almost like a mariachi band to me – drum, trombone, and trumpet blaring while they are driving through town. After we walked back to clinic, the wedding procession came into the children’s village and parked with the bride and groom getting out to take pictures right in front of the administration building. One of them had apparently worked here in the past.

We had planned to finish early, but somehow the time got away from us and the afternoon stretched to after five. It wasn’t late for us, but I felt bad for the FAME staff that were with us as they would be getting home rather late. John had plans to cook dinner tonight and as soon as we arrived back home, everyone went into action with John calling out the orders. Hannah and Amisha went to cook rice at Steve’s while Lindsay and I stayed here to help John. Dicing ginger and onion, hot peppers and tomatoes while John worked on the cooking the chicken, sliced eggplant and green beans. We ended up having a real feast and all sat around the table enjoying our spoils. Peter had difficulty getting here on time, but there was more than enough for him to eat. He was going to spend the night here since we’d be leaving before dawn to drive to Tarangire in the morning. It would be another exciting game drive in the home of the elephants.

I had felt a stomach bug coming on the night before and, sure enough, it had managed to keep me up part of the night and I felt pretty ill in the morning. I took my GI cocktail consisting of loperamide and azithromycin, that I’ve thankfully not had to use often, grabbed a peanut butter Clif bar and made my way up to morning report, hoping for the best. Whether it was the azithromycin or the bug, I felt pretty nauseated most of the morning, along with general stomach cramps, and took the opportunity to lay down on our patient exam table in the hallway where the event was, of course, quickly memorialized (with John photobombing the picture). When I stopped by his office, Frank gave me some secnidazole to cover giardia along with some Zofran, but I decided to tough it out with what I’d already taken and, amazingly, after about six hours felt tremendously better and back to my normal self. Having a stomach bug is not an uncommon occurrence here and at least one or two per trip will end up taking a course of azithromycin and loperamide at some point during the visit.

This was the last day of our big FAME neurology clinic that was announced to the general community and is where we see most of our patients during the visit here. Tomorrow, we would begin our neurology mobile clinics to the villages in the district, with the first being Rift Valley Children’s Village and the following week, towns in Mbulumbulu and Endabash areas. Most mornings we have had a tremendous number of patients show and thankfully it has wound down over the week so we did not have to turn anyone away today. Our meningitis patient in the ward has continued to struggle as has our ability to confirm his diagnosis, unfortunately. He has had some continued fevers and his mental status has remained poor, though he has not had any further seizures in several days. Our concern is that he was febrile and possibly seizing for five days before presenting to us which is now becoming a bit more worrisome as he may have suffered significant injury before having arrived here. We will continue his antibiotics for now and have decided to obtain a CT scan as soon as ours is operational as it has been down for the last week due to a power supply failure that will require a visit from GE to fix.

One of the early patients today was a young child that had come from Arusha to see us for possible autism. They had not been aware that they needed to register and we had come close to our maximum for the day that meant they may have to wait until the afternoon to be seen. Considering he was clearly somewhat hyperactive and running all over the place, it was probably to our benefit to see him sooner than later and this was certainly not unreasonable considering their confusion in not having registered. Amisha walked past him on several occasions over the morning and in doing so, she pretty much confirmed her suspicions that the child was indeed on the spectrum. When they finally got in to see us, she spent a great deal of time counseling his mother on how to work with him and what he would need for the future. He was already in a special school in Arusha and they were accompanied by a worker from the school who was also interested in what the child needed. Thankfully I had remembered from our last visit that Dr. Gabriel had reached out to a special rehab center in Arusha that deals specifically with children on the spectrum so we were able to give them the information on how to contact this program. Hopefully, this will help going forward and provide him the therapy that is needed over the next years.

Our clinic runs in a very similar fashion as our resident clinic at home and, as I have mentioned before, we are running three exam rooms until our registration desk has freed up when we can create a fourth examination “room” in the entrance way of the emergency room. I am typically standing outside to hear about the patients from each of the residents after they have evaluated them and formulated a plan of action. As they present each case, most often with the clinician working with them (or in the case of Shaban, a fourth-year medical student at Muhimbili University here in Tanzania), I am able to do some teaching regarding the disease or treatment course. Sometimes, I may go over part of the examination with them, but most often it is not necessary, and the resident can merely finish up with counseling and giving whatever prescriptions are necessary.

Today, an ambulance arrived midday to bring a patient to FAME who was reported to have eclampsia. In general, ambulances are not seen very commonly in Tanzania and, to be honest, I’m not sure if they are private or government supported. The staff rushed out to unload the patient and she was immediately brought to Ward 2 which is the maternity ward for the moment until the new maternity wing is finished. This new building will have 25 beds with multiple labor rooms compared to the current ward which has perhaps 7 or 8 beds, two labor rooms and a room for neonates in incubators. The new maternity facility is a much-needed addition to FAME which has been growing in its number of births annually since the first in 2014. Doug Smith, a prior pediatric neurology fellow who accompanied me here in 2014, was the pediatrician who attended the very first delivery at FAME.

Half-way through the day, Siana, our head nurse, came to see me about a patient who had been brought from Arusha and asked if we could possibly see the patient on the OPD (Outpatient Department) side so as not to disrupt our clinic or cause issues with those patients who had been waiting to be seen. The woman had been displaying psychotic behavior and her family had brought her from a fair distance to see us and given the nature of the problem, I thought it best to honor Siana’s request as she is someone who has worked here from the very beginning and rarely, if ever, asks me for a favor. The patient had a very good story for a post-partum psychosis, but was also very depressed which complicated the picture a bit. In these cases, it can be touch to tell whether the depression is primary (as it is so common) and she has psychotic features, or whether she has a primary psychosis and the depression is secondary. As a rule, we rarely start two medications at the same time as then you don’t know which one is working if the patient improves and should they have a side effect, you’re limited in your ability to tell which medication caused it. As the antidepressant would take much longer to work, we chose to put her on the antipsychotic medication first and monitor her. Depending on her response to that medication, we will decide whether or not she should start the antidepressant at a later date.

Dr. Julius came to us in the afternoon with a child who had severe anemia and was very, very sick. This wasn’t a neurology case, but Amisha (in her gen peds mode) and Steve began to work on the case to come up with a diagnosis. The child was found to have hepatosplenomegaly (enlargement of the liver and spleen) which narrowed the differential a bit, but it was necessary to do a blood smear to narrow it down further. Steve went into action, taking Amisha and Hannah with him to the lab and helping to get the blood smear prepared and read. Unfortunately, the slide was loaded with atypical lymphocytes suggesting that the child suffered from either lymphoma or a lymphocytic leukemia. Further investigations would be necessary, but in the meantime, the pediatric oncology service in Muhimbili would be contacted to arrange for the child to be seen in Dar es Salaam.

We finished with enough daylight left to head into town to do some shopping for groceries as John had planned to make General Tso’s chicken on Saturday night after our return from mobile clinic. Our dinners are prepared for us on Monday through Friday, though we are left to fend for ourselves on the weekend nights, which is really not a problem as it often gives us an excuse to have a nice meal as we did at Gibb’s Farm last Saturday. We were looking for some frozen boneless chicken breasts and John was having a heck of a time finding any as they weren’t available at our normal market. I should say that the street on which we shop has little markets one after the other that all carry the same supplies and it is entirely unclear to me why anyone would necessarily choose one market over another, unless of course one was owned by a family member or something. Our little market (where FAME does most of its shopping) is Deus Super Market (Not to be confused with the Deus Mini Market which is only several doors down) which is a small shop about the width of two tiny aisles with shelves on both sides and is about 15 feet before it steps down to an area where the freezer is along with other stock. John walked up and down the street looking in different shops, as well as enlisting the help of one very nice shop owner who took him to a local butcher, but in the end, he opted for the frozen whole chicken that we’d defrost in the refrigerator and he would chop up without the benefit of a meat cleaver or good butcher knife. He also found all the necessary vegetables in the vegetable market and Hannah and Amisha went on a mission to buy bulk rice.

We traveled home well after dark, some of us having eaten already and others still needing to eat. The stars were once again magnificent with the milky way forming a brilliant swath across the night sky and the planets shimmering brightly as if you could reach out and touch them. The constellations look as they actually should here and it is far easier to learn them when you can make out their shapes with far less imagination than is necessary at home. We are all looking forward to seeing the stars while on safari in the Serengeti where it is truly the darkest that one can possibly imagine. We have been feeling a number of fairly substantial earthquakes that have occurred while we’ve been here, none that have been strong enough to have caused damage, but certainly will get your attention. It is not at all surprising, though, considering that the area here is entirely volcanic with several active volcanoes in the near vicinity (Ol Doinyo Lengai, or the Mountain of God to the Maasai, is one such mountain that erupted here in the last several years) having erupted recently enough for people to remember. Having grown up in the San Fernando Valley of Southern California, I was quite used to earthquakes having felt hundreds and lived through one large one in 1971 and then moving to Mammoth Lakes, California, working for the Forest Service after college and during graduate school, where earthquakes were a nightly occurrence and our main road out of town doubled as an earthquake/volcanic eruption evacuation route. Still, there is just something unsettling sitting through an earthquake as you’re just never quite sure when it’s going to be over.

We were heading to Rift Valley Children’s Village in the morning for our first mobile clinic, and it is always a bit hectic making sure we have everything that we need in regard to supplies. I had asked Patricia, a nurse here at FAME and who has accompanied me on numerous mobile clinics, to make sure that the box of medications and supplies were ready for us as she was off for the weekend. Angel was also away tomorrow, so Kitashu would be coming with us instead and organizing the clinic. I think everyone was looking forward to RVCV which is always an inspiring visit.

 

Limping our vehicle home last night felt like a major accomplishment considering the alternative would have been a massive headache trying to get Turtle towed back here to FAME while still managing to supervise our neurology clinic for the day. It was really essential for us to fix it as we’d need it for Saturday which was going to be our first neurology mobile clinic to Rift Valley Children’s Village and on Sunday we were planning to go on safari to Tarangire National Park. But having a vehicle here to use is truly a double-edged sword. Having grown up in California and been of age in the 1970s, everyone had a car and drove wherever they needed to go. I’ve owned a car from the age of 16 and really couldn’t imagine ever living without one if only for the independence and freedom. I now live in downtown Philadelphia and ride my bike to work every day so I only drive on weekends or vacation, but I still can’t live without one.

So, it goes without saying that I’ve always had a vehicle here to use from my early visits and have never considered being without one. Oh yes, the double-edged sword part of the deal is that as great as it is to have a vehicle here, it is equally as disappointing when that vehicle breaks down and leaves you stranded. There is no AAA here to call and tow you to the nearest repair shop. Help is not always a phone call away. The other part of this equation that must be appreciated also is that vehicles here just are the same as they are in the US. It’s not that they are built differently, but rather that they are used tremendously longer and the miles they’ve drive, or really kilometers, have been much more difficult than at home. These vehicles are truly driven off-road. Where at home perhaps an SUV is driven 95% on pavement and 5% off-road (which is being incredibly generous, I imagine), here their vehicles are easily driven 95% on very rough dirt roads and the pavement, which has speed bumps in every town, is not the same as what we have at home. Needless to say, these vehicles take a beating and are constantly in need of repairing something to keep them running smoothly.

Over the last few years, we’ve had some significant break downs in some very remote spots and have been incredibly lucky that we’ve made it home each time, though each one clearly altered our plans and caused us not to be able to do certain things. Despite all of this pain and suffering, having a vehicle here to use not only for our mobile clinics, but also to visit friends, go on safaris and transport us from the airport to FAME has been critical. The neurology mobile clinics have been critical to our efforts here, as we visit the remote villages of the Mbulumbulu region and see patients who live in these villages and are either unable or unaware that they should travel to FAME for their medical care. Many of these patients are unaware that they have conditions that are treatable such as epilepsy and only require a diagnosis to begin treatment that can often be lifechanging for them.

I will have to admit, though, that having a vehicle here in East Africa where I am driving through regions that I had only dreamed about visiting, let alone driving, has been a dream come true for me and something that I wouldn’t have considered any other way. I think it has contributed much to my ability to have been successful here not only in what we are trying to accomplish, but also as a part of the community. Every trip I take anywhere, I see people who know me from FAME, whether it is in downtown Karatu, or as far away as the Serengeti. And I am so happy to be a part of their community here and treated as family by many.

Our fundi (Swahili for expert) was coming in the morning which was a good thing since not only did he have to fix the transmission with the broken bearing, but he now also had to reattach the stick shift that had come completely off the night before. By 9 am I was getting a bit worried since he hadn’t yet arrived (he had told me 8:30-9 am – remember, “TIA”), but I bumped into Anton from the lab who had translated last evening and he told me that he had just gotten into a NOAH (a small minivan, but much nicer than the Dala Dala) coming from Arusha and should be in by lunchtime. He finally arrived at around 1 pm and took the keys from me to go fix Turtle and said he be back by evening time with everything fixed and operational.

Meanwhile, we had a full day of neuro clinic to get started and one of the first patients was the young women with the rheumatic heart disease that Lindsay had seen. She and Steve had placed her on some furosemide to see if it would make her feel better and it apparently did, so the while they worked on coming up with something temporizing, they also put in motion referring to the cardiac center at Muhimbili University Medical Center where they could evaluate her, but it would be very unlikely that they would do anything for her beyond that (i.e. surgery) if she were unable to contribute something towards her having that kind of procedure. It is unfortunate, but if she were a child, any necessary heart surgery would be completely covered by the government and they do not cover it for young adults.

We had had a similar problem previously with a young (but not young enough) Down syndrome patient we had here in whom we had diagnosed leukemia and were told by the center at Muhimbili that they were unable to treat her as they were only currently treating leukemia in children and not in adults. It was very difficult at the time to have had to tell this mother who had cared for her disabled child for so many years that there was no treatment for her daughter in Tanzania and that the cost for her treatment elsewhere was something that could not be paid for even by an average person in the US, let alone Tanzania. We will contact one of the cardiologists at Muhimbili for our young woman with rheumatic heart disease and at least have her evaluated to see what is available for her, but I don’t think we have high hopes that she will get what is really necessary which is surgery.

Our young Maasai women her presented with venous sinus thrombosis and a venous infarct in the setting of pregnancy and probable anticardiolipin antibody syndrome (we have no way to confirm the latter diagnosis here, but have no doubt given her clinical history) has done amazingly well, so much so that was walking outside with her mother and husband and had little in the way of any apparent deficits. During her seizures, she had bitten her tongue badly and her lip, but she seemed to be otherwise unscathed. She did have a somewhat flat affect, but this is always a bit difficult to fully interpret in many very traditional Maasai women as it is purely cultural. She speaks Swahili, so it is not a language issue, but as I have mentioned in the past, many Maasai woman who never really leave the boma speak only Maa and therefore it is difficult as we are communicating with both a Maa and Swahili speaking interpreter unless we’re lucky enough to have a Maasai interpreter working with us.

At one point during the day, Lindsay and I met with the patient, her mother and her husband so that Lindsay could do a final examination on her (in which she found only the subtlest of deficits) and we could answer any final questions that they may have. I took the opportunity to tell them how incredibly fortunate they were to have had Lindsay assess her when she arrived as her diagnosis is one that can often be very difficult even with all the tools we have at home and that the fact that she was treated so quickly was very likely the reason she had done so well. We had also made sure that all of the clinicians here are now well aware of this entity and how it needs to be treated, though I will have to admit that even in the best of circumstances, these patients can often do poorly and putting a someone on anticoagulation with even a very small amount of blood in their head can go rapidly south and without the availability of a neurosurgeon, vascular imaging and repeated CT scans, it can be a bit trying to even the most hearty vascular neurologists.

Our other patients for the day were a general smattering of neurology and general medicine. Amisha evaluated a very interesting patient baby who was cognitively intact, but way behind in motor skills and was found on examination to have a significant decrease in axial muscle tone and had a very poor such. After reviewing all of our pediatric neuromuscular disease we felt that she most likely had congenital myotonic dystropy. On further exam of her mother (who was only 24), she also had some features suggesting myotonia which would make the diagnosis a very reasonable one, though without further testing, of course, it was really not 100% as is often the case here. Hannah had a case of a young patient with a Bell’s palsy (facial weakness) that was clearly peripheral on examination and had occurred two months prior with incomplete recovery. In the US, we always check for Lyme disease as it is a common cause of Bell’s palsy there, but here you have to check an HIV as it is the most common infectious cause of a facial palsy. The HIV test was negative so there was little else for us to do in an uncomplicated facial palsy, though we would typically obtain an MRI scan after four months if there were very poor recovery to rule out a tumor.

Hannah also saw a women who came in with symptoms of depression and when she took the history (and reviewed the chart), it turned out that had been seen several months ago with a new breast mass and was recommended to have it biopsied, which she hadn’t done as she was afraid. The mass was now larger and she an axillary lymph node on examination that was worrisome. We convinced her that it was best for her to get the biopsy (which was set up for the same day by Dr. Kelley, a US surgeon doing a fellowship here for the year) and we also placed her on fluoxetine, an excellent SSRI antidepressant medication that we have here to use. John also saw a patient with prostatitis, clearly not a neurological problem, but he had complained of numbness and pain and so was put in our clinic. John artfully obtained a urinalysis and then recommended that he be seen in the general clinic at a later date.

Our fundi for Turtle finally arrived from Arusha around 1 pm and I gave him the additional news of the disconnected stick shift that would require him to take the vehicle to town so that he would have the ability to weld it back on. He said that he would need several hours to do the work so I gave him the keys and hoped for the best. By the time we were finished with clinic he was still not back, but Anton was going to be around and said that he would have one of the Maasai askari come find me at the house when the fundi had returned. I was a bit under the weather with a stomach bug and decided not to eat the dinner that was made for us that night (Peter was over and happily took me up on my offer to have my dinner rather than heading home to make something) and so I sat down to have a bowl of corn flakes with the very last morsels that were left in the box. Having just poured the milk into the bowl, the askari came knocking at the door to let me know that the fundi had returned. As much as it is difficult to understand how one could possibly look forward to a small bowl of corn flakes (half of which were crumbs), I reluctantly parted with my dinner for the moment knowing full well that on my return I would basically have corn mush for dinner. It goes without saying that the corn flakes here are like everything else meaning that they are not even close to the corn flakes we have at home.

I met with the fundi and, thankfully, Anton, since the fundi didn’t speak a word of English, to find out what he had done and what the damages were going to be. He first told me that he had spent about $50 USD in parts (that was additional to the $30 I had given him the night before for the bearing he needed to buy) and that the labor cost was about $100. Not really knowing if this was reasonable or not, I got Jones on the phone to be certain. He spoke with the fundi and the labor cost was reduced to $70, to the total cost I gave him was $120, far less than it would have been in the States, but still a hefty amount for here and what I used to paying for any repairs. When they had to remove our drive shaft in Ngorongoro Crater at the Sopa Lodge on a Sunday in March, they had worked for two hours and had asked for 20,000 TSh, or less than $10, and I had given than an extra $5 considering how amazing that was. This fundi had traveled from Arusha twice, though, and brought extra help with him today, so all things considered, this was quite reasonable and, most importantly, I now had all five gears working and stick shift that was actually connected to the vehicle.

We were a happy family again, all of us and Turtle, which gave everyone a good feeling and that night we decided to watch a movie. Lindsay and Amisha crashed early, but John, Hannah and I watched Bridesmaids and made popcorn and thoroughly enjoyed the evening with laughs. It was my first time to have seen the movie. Tomorrow would be our last advertised neurology clinic of the big push week as Saturday we were heading to Rift Valley Children’s Village.

 

 

 

I think everyone was still reeling a bit from the wonderful dinner the night before, both from a standpoint of being quite full, as well as the feeling that we had all experience something very special with Daniel Tewa’s family. Morning report was at its regular time and there was no educational talk so we all walked to the hospital at 8 am to hear about the inpatients and any new admissions that had come in overnight.

As we were heading out last night, we were asked to come see a patient who had just been admitted with a new stroke, but when Lindsay and John went to see the patient, it turned out that he had actually had the stroke, a complete right middle cerebral syndrome, three weeks prior and had been admitted at Haydom Hospital, a teaching hospital several hours to the south of us. As they did not have a CT scanner and the patient was not improving, the family brought him here with the anticipation of getting a CT scan and possibly having something that we could do for the patient. Unfortunately, he had a completed stroke and had they brought him anywhere in Tanzania, there would not have been therapy for him. Haydom had been providing him with all of the appropriate therapy including physiotherapy, but his stroke was something that was very dense and he had profound weakness with no improvement since the onset. We spoke with the family at length to let them know that he did not need a CT scan now nor would it have impacted his care had he gotten one when he initially presented to Haydom. It would have been a waste of their money and what he really needed was the physical therapy and aspirin, but he also had dense neglect on the left side that would impair his functional recovery most likely.

Despite the fact that this had been reiterated to the family on morning rounds, they still had questions that required John to go back later in the morning to reiterate to the family that the CT scan wouldn’t help or change anything and that there was no reason to get one. The third time the message seemed to get across and the family was satisfied with our explanation and accepting of the fact that he could go home.

The Maasai woman with the venous sinus thrombosis was continuing to improve and was now awake and talkative. She had no apparent neurological deficits on examination and it was quite likely that the small right frontal stroke was clinically silent as it seemed to be in front of the motor strip. She had a very stoic attitude which is so often common among the Maasai and it was unclear that this had anything to do with the stroke she had suffered. She was doing amazingly well, all things considered and our plan now was to switch her to oral anticoagulation from the enoxaparin (which is subcutaneous) and to continue her on the phenytoin considering that she presented in status. The medications do interfere with each other’s metabolism, though as long as the phenytoin dose remains stable, they should be able to get her on the correct dose of warfarin. One of the main issues that we needed to settle for her was whether or not she had any plans for pregnancy in the near future as this would affect our plans for anticoagulation as well as what we would do with her anticonvulsant medications.

These discussions are very personal for many reasons that not only include the obvious, but they are even more so with the Maasai. The person who makes these decisions is ultimately the husband and the Maasai value children almost more than anything else. Therefore, Kitashu, who is Maasai, was enlisted to help with this discussion. Once the necessary information had been conveyed to the husband so that he could make a decision as to whether or not they would be having children in the near future, he gave a very wonderful reply. His reply was simply, “I love children, but I love my wife more.” When I heard what his reply was, I was incredibly impressed and touched on so many levels. Considering the risks of her becoming pregnant again with her probable underlying antiphospholipid antibody syndrome and the fact that she had already suffered a venous sinus thrombosis, it made absolute sense to delay having another child.

As for our other ward patient, the child in who we suspected meningitis but had a negative spinal fluid, they were more awake and crying, but still appeared very sick. We were still unsure of a diagnosis given the spinal fluid and began to suspect a more systemic infectious process, though we had very little to go on. The decision was to continue the antibiotic we had them on and continue to watch for now. We had no other testing to suggest at the present.

Clinic was busier than yesterday, but not totally crazy as it was on other days. Lindsay ended up seeing a young woman that had been referred to us, though her complaints were not neurological in origin and Lindsay remained quite persistent in trying to ferret out exactly what was going on with her. Thankfully, she recognized her symptoms as being those of rheumatic heart disease and the patient’s examination findings further confirmed that she had severe valvular disease and would need rather immediate attention. We enlisted the assistance of Steve since this was really a pure medicine case and he was certain that the patient in the US would have been referred for immediate valve replacements and admitted directly to the hospital. Unfortunately, we do not have access to that type of care here so it was decided that they would try some diuretics and have her come back in the morning to see if it made her feel any better.

At the very end of the day, as Hannah and I were walking back towards clinic after staffing a patient, we suddenly became aware that one of our patients waiting to see us was having a seizure on one of the benches, As we walked up, he was leaning over and in the midst of a generalized convulsion so that we needed to make sure he didn’t hurt himself. The seizure lasted perhaps 45 seconds and then he was just postictal and fairly out of it. This lasted for several minutes after which he became very agitated, insisting to get up and walk around when he was clearly unaware of where he was or who we were, We tried to keep him from standing up as we were worried that he would fall and injure himself, but he was quite strong and I quickly realized that someone was going to get injured and I was worried that it was wasn’t likely going to be him. Hannah lasted longer in the ring than I did, but eventually a number of the FAME staff came to our rescue. He remained a handful for some time and we actually had to give him two IM injections of a benzodiazepam to slow him down. Unfortunately, his family had left him there alone and so we had to wait for them to come back to get any history on how he’d been doing since last seeing us six months ago. He was finally quite and Hannah was able to finish getting his history from one of his family members.

I hadn’t mentioned previously, but our Land Rover (now officially named “Turtle”) had had a few minor problems while on our game drive at Lake Manyara last Sunday. The stick shift (which by the way is on my left-hand side since this is a right-hand drive vehicle) didn’t seem to want to fully engage into first or third gear at various times as it seemed to be physically limited by the console in front of it. This became an issue when trying to make a rather steep ascent, which is essentially what these vehicles are known for, though if I just shifted into four-wheel low I was able to use the second gear in low to compensate. I did this for much of our drive at Manyara whenever I was unable to shift into first gear which worked reasonably well, but when driving home from there up the steep rift, I only had second and fourth gear which took a bit more ingenuity and planning. We really didn’t need the use the vehicle much, but driving up to Gibb’s Farm was a bit of an issue and so, we had a fundi (expert) come from Arusha to look at the vehicle and see if he could fix it for me. He was supposed to have been here in the morning, but ended up arriving at around 4 pm. He didn’t speak English, so I used Anton from the lab to help translate for me and I explained to him what the problem with the vehicle was. He took it for a test drive and promptly announced that it needed something called a pilot bearing which he would have to buy in Arusha and would then come back in the morning to fix it which would take around five or six hours.

Having been driving the vehicle as it was in Manyara and up to Gibb’s Farm, I thought there should be no problem for us to take it to the Plantation Lodge where we had been invited to have dinner tonight. We all loaded into Turtle and were on our way around 5:45 pm, hoping to make it there by sunset and enjoy some drinks and appetizers before dinner. The turnoff to the lodge is very difficult to see, but we made it (having to turn around only once) and were quickly on our way along a small dirt road that is typically for the lodges that are out of town. About half-way there we stopped at a fork in the road to ask a couple if we were heading in the right direction, which I was pretty certain we were, and they directed us to continue on in the same direction.

Then, as I went to shift the vehicle into first gear, the entire gear shift column came off in my hand! I was a bit stunned for a moment until I realized what had happened and then realized that we were in neutral so that we had little chance of getting it back into some gear to at least be able to drive. Realizing that our dinner was waiting for us at the lodge and knowing that this called for extreme measures (i.e. there was nothing that was going to keep us from making this dinner), I quickly called Alex and asked if he could call a Noah (the local vans for hire) to come pick us up and take us the rest of the way. That would mean, though, that we’d have to leave Turtle there and I’d have to deal with the nightmare of getting it back to FAME on the following day. Peter was sitting up front with me and after speaking with Alex, we put our heads together to see if we could come up with some other solution than the Noah. I pulled up the boot to see where the shifter had broken off and we still had some remnants of the plate attached to the transmission. We realized that we could possibly push the plate forward to hopefully engage third gear and, sure enough, Peter was able to force it into gear as we had hoped. That meant that I was in third gear as the only driving gear, but I could shift into four-wheel drive low which effectively gave me another gear to use.

I got the vehicle moving forward in the direction of the lodge (and, of course, our dinner) and, as long as I kept up some good momentum, I was able to get us to the lodge safely. Pulling into the parking area I almost forgot we had no reverse, but was reminded by Steve and pulled us around so we were pointing forward without obstruction when it was time to leave. Our dinner was delicious and we spent several hours on the veranda enjoying everyone’s company. When it was time to leave, we all headed to the car and prepared ourselves for the interesting ride home with only two gears. There was a bit of a steep part of the driveway, though, as we were leaving and I was unable to get Turtle up it even in third-gear low, possibly because he the engine wasn’t warm. Backing down was a bit of treat considering I had no reverse lights (since I had no reverse gear) and I needed to have someone get out and direct me as the driveway was quite curvy at the spot where we were.

I tried two runs up the hill, but was unable to make it each time and so finally, everyone got out of the vehicle to help push it over the hump. We tried again once, but were unable to make it up in which case, I backed down the steep grade again for a final go. This time, I really revved the engine and made a mad dash up the hill noticing some wheel spin as I did and surely hoping that no one was hit with any of the stones that I heard striking our underside. I kept my foot on the gas until we arrived at the top of the small hill and then waited for everyone to load back into the vehicle. Steve was one of the last and I found out that he had been hit by some of the stones, but said that he was mostly uninjured which I was pretty thankful for. Once moving, I drove most of the way using only third gear, but if needed I could easily shift into low and then have a whole ton of traction to get us moving on the incline if needed. We dropped Peter off near Happy Day and then drove up the FAME road and to our house, the entire time trying not to really stop for anything if we could help it.

The fundi would be coming in the morning to fix Turtle and I now had a new problem to tell him about and that he could hopefully weld back the shift lever for us. It was a lovely night out even with the vehicle dilemma and it made for more interesting stories in the future. Once again, we all just kept saying, “TIA,” and this time really meant it.

 

 

 

 

It was Tuesday so it was our turn to give the educational lecture this morning and Lindsay prepared a talk on neurological emergencies using the patient with venous sinus thrombosis as a case study since she had so many of the key features that would be considered emergent. The talk was very well attended and Lindsay did an excellent job which is sometimes difficult here given the nature of the what we are actually doing here (neurology is a pretty touchy feely topic at times). Using the case that we had admitted the day prior made it totally applicable and far easier to relate. She did her talk in the allotted time and covered everything that she had planned in that time.

Morning report was next and we heard about our patient and how she had done overnight. Her seizures had stopped the night before with our phenytoin and she was awake, but still fairly encephalopathic which is not surprising considering she had been having near continuous seizures the day before, as well as a new stroke, albeit small. Just the fact that she was no longer seizing and was somewhat awake was pretty much of a miracle as far as we were all concerned. We were keeping our fingers crossed though, as we all knew there was still plenty that could go wrong and we had little in the way of anything to offer should she have a complication.

Arriving at clinic, it seemed that we had seen many of the patients who had come the day before and so there were fewer that had been bumped to today. Patients lined up, of course, to be seen and we began our process of getting everyone through for the day. We again planned to use three stations and interpreters/clinicians for the morning until all the patients had been registered and then would expand to the four stations. The desk we used for the fourth station was the same one that was being used by Angel to register patients, so when she was finished we moved the desk into the entrance area for the emergency room and we were good to go with four teams seeing patients. We had never had to do this before, but our volume this time seemed more than sufficient to warrant it.

Many of the patients that return to clinic each day have been coming for many years and a number of them were seen by me as far back as 2010 when I had first come to FAME. One of these patients is a lovely young woman who I had originally seen in 2011 with uncontrolled seizures and who has been on several medication trials, but is now doing remarkable well with her seizures, so much so that she is now second in her class at school as a fifteen-year-old. She has come religiously each and every time that I have been here and has been the model of a compliant patient. It is always such a pleasure to see both she and her mother each time they come to clinic.

Our clinic finished a bit early today so that we all had a chance to get home and relax a bit before heading off to dinner at Daniel’s. Daniel Tewa is someone who I have known from my first visit to Tanzania when I was here on safari with my two children and was volunteering for a few days in a school very near Daniel’s home. We were helping to paint the school and as Daniel was one of the village council members, he came out and worked with us on the project. He is also the local historian for the Iraqw tribe and has safari companies bring guests to his home to tell them about the history of this area and his tribe where he demonstrates local dances and also shares his traditional Iraqw house with guests and often scholars who have come to study it. I had always remembered Daniel from that visit and when I returned the following year to work at FAME, I contacted him and, amazingly, he remembered me and my children (including their names) from the year before. I was invited for dinner and since that time, Daniel has been gracious enough to have us visit with him and his family and share a dinner. I have done this on every subsequent visit to Karatu and he constantly reminds me that I am a member of his family and that his home is mine. He is a wonderful man who has raised eleven children of his own and one adopted and has sent then all to college. His knowledge of the world and world affairs is impeccable and yet he has never traveled outside of the country.

When I texted Daniel to arrange for a visit and told him there were seven of us, his comment to me was that was only half the size of his family and so not to worry, we were welcome for dinner. After we arrived, we sat under some trees in front of his house which is where he entertains, and had true African coffee. It is boiled with fresh milk from his cows and is absolutely delicious. We went around the circle for everyone to tell him what state they were from so he could tell us facts about the state that even we did not know. We eventually meandered over to his Iraqw underground house which he built in the 1990s as an example as these houses had been destroyed years prior when the government declared that all 126 tribes in Tanzania had to move into villages rather than remain separate as they could not develop an infrastructure otherwise.

The house he built is smaller than the one he had grown up in, but the design is the same. Large families lived in these houses to protect themselves and their livestock at night primarily from the Maasai who would often take their cattle. The Iraqw and Maasai were at odds for many years and it was not until 1986 that they finally signed a treaty that had been forged by the prime minister of Tanzania who was a Maasai. The house has room for one family to sleep, about a dozen cattle, and food storage, preparation and cooking. In this house, there is one large granary, though there would be several in a larger house. The house forms a dome that is several feet high and is covered by dirt and grass, while underneath this roof there is a layer of leafy material that is a natural insecticide to protect the structure below. This house has sat here since the early 1990s without a leak or damage until about two years ago, when two elephants walked across the top of it and caused one of the beams to break. Otherwise, it has lasted for over 25 years and has served to as a monument to the Iraqw culture and tradition.

It had now become dark so the group walked back over to Daniel’s present day, Bantu-style house to go inside so he could show us the wedding skirts that Elizabeth, his wife, continues to make for family and for sale. They are an incredibly lovely affair that are made out of dyed goatskin and heavily beaded with stories of marriage, children and life in general. These would be worn by the bride on her wedding day and she would be escorted by her family in front of the elders of the village. The skirts were worn topless and the bride would be decorated with many beaded necklaces and other jewelry. In Africa, as it is many, many parts of the world, a woman’s breasts are not considered private.

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Daniel brought out several wedding skirts along with a daily-wear undyed goatskin skirt that Lindsay wore, while Amisha and Hannah modeled the wedding skirts. He told us all about the wedding ceremony and then taught everyone how to dance and celebrate. The best was the drumming in which the skirt is held taught across the thighs while kneeling and forms the drumhead. The drummer sits on a large pot that is held between the legs while kneeling and serves as the resonator. It worked incredibly well as a drum and was an amazingly effective set up. Daniel first demonstrated the drumming followed by Lindsay while everyone else danced and sang. It was a pretty special moment.

It was time for dinner and so the group began to walk from Daniel’s farm to Isabella’s house. Isabella is the oldest of his 12 children and is a teacher. His other children are all scattered around the country primarily working in various cities for the government or are privately employed. Isabella’s house is much more modern and much larger than her father’s so it easily managed all of us sitting in the front room where they served us shish kabobs of the some of the most tender beef I have ever tasted along with vegetables that they grilled outside. We then sat down at the dining table to enjoy an incredible meal of vegetables, rice, beef and chicken. I think a mashed pumpkin dish was everyone’s favorite, but the other dishes were all equally delicious. If each of us didn’t have seconds on our own, Daniel would be sure to make us do so and everyone had their fill and then some.

And if this spectacular dinner wasn’t enough, Isabella then brought out a desert that resembled bananas Foster with pineapple and equally scrumptious along with watermelon slices. At this point, everyone was more than full, but the deserts were too amazing to ever think of passing up and, again, Daniel was there to make sure that everyone’s plate had something in it. And when we thought that everything was finally over, Isabella brought out a platter of drinks that included beers and Stoney Tangaweezi (our favorite ginger ale here). There was no way that any of could consider finishing an entire drink so we split them between us otherwise I don’t think any of us would have been able to move.

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We walked back to Daniel’s house in the dark, all feeling not only full with our incredible dinner, but also with the experience we’d had as it was clear that Daniel and his family had treated us not only as honored guests, but also as visiting family. This is why Tanzania has become my second home. Even though we are here to help and have volunteered our time to improve the health of this community, we are treated as family rather than visitors by everyone and we have never felt like outsiders. They are gracious and loving and it is impossible not to fall under the spell of this amazing country.

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We were all reasonable fatigued following our day long safari to Manyara, though luckily, we didn’t have an educational conference in the morning so got an extra half hour of sleep with morning report beginning at 8 am. Interestingly, our baby who looked for all the world to have meningitis per physical exam (bulging fontanelle and meningismus) didn’t have the most important finding necessary for the diagnosis, abnormal spinal fluid. Both the red and white blood cell counts were normal as was the protein. The baby was still no awake and the diagnosis was now in question, but he had received phenobarbital for his seizures and may have been sedated from the medication. We kept him on his antibiotics as he remained febrile and we were now considering that this may have been a case of bacteremia or sepsis rather than meningitis so continued he antibiotics. The baby’s head had also appeared slightly large and there were thoughts of doing a CT scan on the child, though an ultrasound of the head would certainly give us a clue as to whether there were enlarged ventricles or not and that study would be far less expensive for the family. The ultrasound was done and the ventricles looked perfectly normal so we took that issue off the table.

Clinic was again quite busy and on our arrival at 8:30 am following morning report, there were many, many patients who had already lined up to see us that day. Angel sat outside calling names and doing some triage so we would not see non-neurological patients, but the charts continued to pile up. We began as we did the other mornings, using three stations to see patients until Angel had screened everyone and completed the charts for us. Once she was done with that, we were in high gear once again with four stations to see patients. We have the doctor’s night office, the emergency room and the hallway in between where we have one exam table that is shared by the two groups seeing patients on either end of the hallway. It actually works very well and as each resident has finished their patient and is ready to present, they come outside where we either sit or stand to discuss their findings and a plan. I definitely have the most beautiful office in the world here with the fresh air, sounds of basket weavers and love birds and the incredibly relaxing nature of seeing outpatients here who come to clinic and are grateful to see us. It is impossible not be affected in a positive way by the nature of practicing medicine here despite the fact that we have so little resources at our disposal.

Perhaps one of the most interesting patients we’ve seen here arrived sometime around lunchtime to the hospital ward. She was a woman in her early 20’s who had reportedly suffered a spontaneous abortion about 2-3 weeks ago and came in to the hospital after complaining of a severe headache and then beginning to seize. Lindsay went over to see her right away and she was continuing to have discreet seizures, but was not waking up in between and was therefore in status epilepticus, a true neurological emergency. She, herself, had a history of multiple spontaneous abortions, all occurring later in each pregnancy than early, and both her mother and aunt had had a similar problem of later term spontaneous abortions.

With this clinical information, Lindsay came to several conclusions regarding this woman’s history and her current course. First, the timing of this event along with the seizures were very concerning for the presence of sagittal sinus thrombosis, a disorder that is often seen in pregnancy and post-partum, where blood clots form within the sagittal sinus which drains venous blood from most of the brain and can lead to something called venous infarcts, or strokes. This can often present with seizures and given the situation, it was very concerning that she had sagittal sinus thrombosis. With her history of recurrent late term abortions and her family history of similar issues, it was also pretty clear that she had a condition called anti-cardiolipin antibody syndrome (APLS) which is an autoimmune disorder that causes abnormal clotting leading to stroke, early abortions and other complications.

These patients can have very impressive presentations and most often end up in the neurological intensive care unit, intubated and on IV anticonvulsant medications to treat their seizures at least in the short term until things quiet down. It goes without saying that they undergo multiple imaging studies including a CT venogram and regular CT scans of the head to monitor, typically on a daily or more frequent basis. In rural East Africa, though, we have access to very few of these interventions. Although we have access to a CT scan, it must be paid for by the family in advance. We have no ventilators to place patients on and, therefore, intubation is not an option here. The only IV anticonvulsant medication we have here is phenobarbital which, if we tried to load an adult on this for status, would certainly suppress their breathing to the degree that they would require intubation and ventilation. We only have oral anticonvulsants available to us and there was no way that she was going to be able to take any PO given her mental status and continued seizures.

So, in these situations, you must be creative and think outside the box. Lindsay and our Maasai interpreter (Kitashu) spoke with the family about the gravity of the situation and whether they would be willing for us to do a CT scan. The issue we had was that she was not awake and, therefore, we really couldn’t confirm her examination in regard to worrying about her having a large hemorrhage that may preclude us from anti-coagulating her. Meanwhile, we put in a naso-gastric tube so we could get an anticonvulsant into her and even though we had levetiracetam and valproate, I elected to use phenytoin as I was most comfortable with this from past experience in these situations. We gave her one gram to start down the tube and crossed our fingers.

Thankfully, her family was agreeable to obtaining the CT scan as were really hesitant to anticoagulate her without imaging. There was little question in our minds that she had venous sinus thrombosis, the real issue was just that we didn’t want to hurt her. Venous sinus thrombosis and venous infarcts are treated with anticoagulation even if there is some bleeding present, but the difference is that the patient is in an ICU and being scanned every six hours to rule out and chance of the hemorrhage worsening which could easily cause significant harm or death. She went for her CT scan and we went back to look at it as soon as she was back from the scanner. She had a right frontal hypodensity consistent with a venous infarct as well as some wisps of blood associated, but she didn’t have any significant frank hemorrhage that would have precluded us from anticoagulating her. We were also quite confident that her scan demonstrated superior sagittal sinus thrombosis as it stopped abruptly at its midpoint and approximately where we saw the right frontal infarct to be present.

We had decided that we would anticoagulate her regardless of whether we had seen anything that looked like sinus thrombosis or not, just as long as we didn’t see anything that would prevent us from treating her. In the end, though, we felt very confident in the diagnosis and our plan and forged ahead in treating her with enoxaparin 1 mg /kg twice daily to anticoagulate her and prevent any further propagation of the clot and, hopefully, any new strokes from occurring. She was now fully anticoagulated and had received a gram of phenytoin that would hopefully break her seizures. We would have to wait overnight to see how she did with our treatment and hope for the best. We had done all that we could at this point with the resources available to us.

We had no plans for the evening and I think each of us was more than happy to take a break from our busy schedule. We had plans to go out for the next two nights to dinner so we all settled in for the evening with our wonderful meals of grilled chicken, potatoes and green beans that has been prepared by Samwell here at FAME. Just a touch of chili sauce and it became a feast. Tomorrow night, we would be visiting my dear friend Daniel Tewa and his family for a visit and dinner. This is one of the highlights of our trip here.