Note: This blog will follow shortly, but need to finish the week of clinical work first. Thanks for being patient.
We awoke today with the anticipation of our upcoming journey to the Serengeti after lunchtime and were thankful that we had made it home last night with Turtle, as had we had to leave her on the road in Mbulumbulu last night it would have thrown a major wrench into our plans for the day. We had a borrowed alternator and were awaiting a new one to arrive from Arusha, but we were fine to travel to the Serengeti while awaiting the replacement which would most likely not arrive on time for our departure. Regardless, Turtle seemed to be in a much better mood this morning and turned right over for us with a full charge on the battery given the long ride home last night to top it up.
We were planning to work in clinic until around noon today at which time we would leave for our two-night adventure to the Serengeti. Our guide, Leonard’s younger brother, Fred, was coming up this morning to pick up Turtle and give her a good going over before we left to make certain that she was worthy of the adventure we were planning. We went to morning report and learning of a patient with Tb who had been admitted overnight and was reportedly encephalopathic. He would definitely require a lumbar puncture, but we first wanted to evaluate him with a thorough examination as we were unable to obtain any imaging first since our CT scanner was still down. When Lindsay went to evaluate the patient, though, he had a fairly focal examination with some mild left-sided weakness that presented a bit of an issue as we are always taught to obtain an imaging study in this situation to decrease the risk of herniation during the LP. In reality, the patient was awake and despite his examination, we felt very comfortable performing an LP to rule out Tb meningitis which would certainly affect the treatment recommendations.
The patient eventually underwent the lumbar puncture that failed to reveal a significant meningitis so we were then left with the concern of what was causing his examination focality and this would require being sent somewhere for an imaging study. We had also placed the patient on anticonvulsant medications as there was some concern that his mental status could be the result of recurrent seizures and after being placed on medications, there was some sense that he may have improved slightly, so it was recommended that he remain on the medications while his family decided if they could afford traveling to Arusha to get the CT scan of his brain to look for a possible mass lesion. This entire process, of course, took place throughout the weekend while we were traveling and so we weighed in on things upon our return from the Serengeti. In the end, we had to accept the fact that they would go home on AED’s and with a focal examination until the family could raise the funds to obtain a CT scan of the head with hour hope that he wouldn’t deteriorate in the meantime
Hannah decided to donate blood this morning as there is always a need here and her blood was in need be more universally acceptable for infusions. It wasn’t a long process, but she clearly felt the effects so we put her on light duty for the morning or at least a significant part of it. My blood type wasn’t in as much need and I wasn’t considering giving it either way this morning as I did want to feel drained on our trip to the Serengeti. Given Hannah is half my age, I figured that she’d have a much better chance at bouncing back than I would. With their surgical load here, FAME is now able to keep blood here for those cases and can trade blood supplies with other facilities.
We had planned to be finished by around noon time so we could have some sandwiches at the house prior to our departure, but, of course, plans never quite work our as anticipated. What I had hoped would be a well abbreviated clinic since it wasn’t announced turned out to be a little heavier than expected and we ended up seeing nineteen patients or so, about 2/3 of our normal full day volume. Thankfully, we were able to wrap everything up by around 12:30 pm and soon enough we were back at the house eating peanut butter and jelly (or some variation thereof) sandwiches with everyone quite excited for our departure. Fred had taken care of a few things on Turtle (the back door had decided not to want to latch just this morning) including filling up on 70-liter fuel tank that would have to last us several days. We loaded our small bags into the back and covered everything up as it would be a very dusty and long drive today heading up to the Crater rim, around it and then down past Olduvai (actually spelled incorrectly and should be Oldupai with a “p”) Gorge and through the Ngorongoro Conservation Area to Naabi Hill, or the entrance to Serengeti National Park.
After grabbing two cases of water for our trip (remember, this was really more of a guided self-drive that we arranged rather than a safari booked with a company), along with some ice cream bars (have to grab them when you can and I’m so happy to have discovered that Steve is as much an ice cream fanatic as I am), we began the drive to the gate for the Conservation Area. The tarmac ends here and it really is like you are entering another world when you drive through and begin going up and up towards the crater rim through the primordial forest that occupies this region. There are steep, steep canyons and ravines that are constantly to your left going up and the trees from the very bottom stretch nearly all the way in to the top in their attempt to reach the sky. Quite often there are animals on the road as you travel, mostly Cape buffalo and elephant, but occasionally you can see more as we did one morning, spotting a leopard jumping right in front of us onto the road.
Unfortunately, our transit through the gate was a bit delayed due to a small hiccup in our “quotation,” or reservation, that must now be filed online and in advance. After an hour or so, though, we were finally on our way up and over the crater and down into the conservation area that is really a continuation of the Eastern Serengeti. Passing beautiful valleys full of Maasai boma (a boma is a small grouping of huts surrounded by a brush fence to contain livestock where a Maasai family lives, meaning a husband and typically multiple wives, each wife having her own hut for herself and her children) with livestock everywhere being grazed most often by young children tending the large herds that often share the same pasture with zebra and wildebeest. In the open plain you also see Thomson gazelle, the fastest of all the antelope, and Grant’s gazelle, slightly larger than their cousins. We traveled past the Serengeti boundary marked by a large sign and continued on to Naabi Hill, where the entrance station is situated. We had a much better time here, thankfully, and, in fact, they knew who we were as our friend had stopped by earlier to confirm our paperwork was in order, and we proceeded on to the Central Serengeti and our camp.
It was getting towards dusk and the skies were a bit cloudy, making for an incredible sunset thunder clouds in the distance and streaks of lightening. It made for an amazing backdrop to our drive as we sped along the washboard road deeper and deeper into the Serengeti. At one point, there were two vehicles stopped ahead looking at something perched high on a distant kopje, one of the rock outcroppings that distinguish the Central Serengeti. It was clearly a cat and it was far in the distance so it was initially difficult to see what it was, but finally the binoculars were broken out (my cameras were still packed as the light was far too dim to shoot anything) and much to everyone’s surprise, it was a leopard, typically the most difficult of the three more common large cats here to spot. It was a lucky spot and, of course, we would have to see more of them in the daylight to be fully satisfied.
We continued on to Seronera, the name of the central area where the airport, visitors center and any businesses are located, with our camp still a half hour drive in the distance. There are no night game drives allowed here, but since we were in transit to our camp we were fine, yet we were able to experience some of what the night is like here with large herds of zebra traveling in a thin line often crossing the road, or just sitting in it until we were almost upon them. Lots of antelope could be spotted, though now in the woodlands it was impala, hartebeest, eland, and, of course, the numerous wildebeest.
We made it to camp where we were greeted with fresh juice and cool washcloths, given a short introduction to the camp rules (never walk from your tent unattended at night for there were clearly lions and hyena nearby), after which we were all shown to our tents to freshen up before dinner. Meals are a fabulous affair with food that is served to us in bowls that we scoop for ourselves and many of them. The soups here are to die for and I have eaten every imaginable combination of soup in my years visiting camps and lodges. It was off to sleep after our lovely dinner, in tents that were incredibly spacious (we were staying at the Thorn Tree camp if anyone wants to look them up) and luxurious. Tomorrow morning, we would be off for our first game drive.
It was off to Upper Kitete for the day, a trip of less than two hours, but out to the far reaches of the Mbulumbulu area and the top of the escarpment where one can travel only a few kilometers further before running out of land. Before our trip there, though, we had another lecture to give and this morning’s topic would be neurology and pregnancy. This would be an excellent topic for the doctors at FAME considering their focus on maternal and infant health and the increasing number of deliveries every year. Hannah and Amisha, of course, did a wonderful job and at the end of their talk received the “pasha, pasha, pasha, choma” cheer (essentially meaning, warm, warm, warm, burn) from everyone in attendance.
I had planned to bring Turtle up to the clinic this morning to ready for our trip today, but unfortunately it didn’t want to turn over and so I had to track down one of the FAME drivers to jump it for me. I had been concerned about the battery not charging since our trip to Tarangire last Sunday and the plan had been to have a fundi (mechanic) come from Arusha to look at it, but that was going to be later in the day so Turtle had forced the issue just a little bit early. She jumped just fine and seemed to be running well, so it was just a matter of not stalling on the drive to Upper Kitete and then I would have to park her on a hill so we could bump start her for the return trip. More on that later and as they say, best laid plans of mice and men….
After our lecture and morning report, we finally loaded into the Land Rover and were off for our day in Upper Kitete. I had invited Steve to come join us for the day as I had wanted him to see one of our mobile clinics and also thought he might enjoy the day out in the countryside. Turtle has nine seats, but with the coke crates we had borrowed from the Lilac Café, we were able to fit an additional two bodies and so departed with a crew of eleven heading over some of the most beautiful countryside in the world. We took the same road we use to get to Kambi ya Simba and then continue beyond for an equal distance making it almost twice as far as the closer village. Upper Kitete is in the heart of the Iraqw farming communities of the Mbulumbulu area and just outside the village proper there remains some small bungalows there were once a small farming community that had been started as an experiment in socialism here by Julius Nyerere, the founding father of Tanzania. There is a small monument signifying this experience that dated from 1966 and was never purely successful, but remains a testament to the lengths that the early government and Nyerere went in trying to move this country of 120+ tribes and various villages and political systems into a nation that would succeed.
Today, though, Upper Kitete remains a small farming village with a few scattered shops here and there, and families that have been in this region for at least a few generations which is actually a long time here considering the amount of influx there has been in Northern Tanzania. Above us are the tall mountains of the Ngorongoro Highlands and the Ngorongoro Conservation Area and below us is the escarpment overlooking the entire Rift Valley where one can see far north towards Lake Natron and the Kenyan Border and south towards Mto wa Mbu and Lake Manyara. It is truly a magical place that sits at the crossroads on so many levels – culturally, politically, agriculturally and geographically. If I were to consider settling down anywhere in Tanzania, this region would be on the top of my list and that list would not be extensive even considering how beautiful this country is.
We arrived to the Upper Kitete dispensary, which is essentially unchanged from my first visit here other than a new small building adjacent which has yet to be fully furnished, only to find a huge mass of patients that were thankfully not all for us as it was also their well-baby visit day. By scheduling our clinic well in advance, I had hoped not to conflict with their regularly scheduled clinic, but somehow this did not happen meaning that the examination areas would be very tight for us, unfortunately. I must say, though, that seeing the well-baby visits and how diligent these mothers are in bringing their little children with their growth charts and making certain they keep up with their vaccinations. After some negotiation with the clinical officer here we eventually ended up using the two offices that we normally use (the nurses office, otherwise referred to as the bat cave for the distinct smell of guano coming from the opening in the ceiling, and the labor and delivery room that was not currently being used) along with the outside area that we normally use as our pharmacy, but would now serve as our third examination room. The pharmacy was bumped to the end of the outdoor walkway and we just moved all of our patients to the other side of the building to wait for us so as to maintain some notion of privacy.
The clinic was a bit slower than usual and similar to the other mobile clinics this season (other than Rift Valley Children’s Village) and it wasn’t entirely clear to me why. We got through our patients, though, and had our lunch around midday with still a few stragglers to see afterwards. One of our later patients was a gentleman who was brought to us sitting in a chair (not a wheelchair) and we were told that he had been unable to walk for well over ten years. His examination was myelopathic suggesting some sort of cord problem and we felt he most likely had a cervical myelopathy as it had been gradual in onset. We discussed the possibility of an evaluation, but were realistic with him noting that it was very unlikely that we would find anything that would be treatable at this late stage and, therefore, it would not benefit him functionally. The family understood and we did treat him with some baclofen for his spasticity which was the least that we could do for him. As with our patient at Kambi ya Simba who was also paraplegic, he was eventually helped onto the back of a motorcycle by his sons and began his trip home.
One of our traditions at Upper Kitete is to visit a spot called the overlook that was first introduced to me by Paula and Amiri when I had first come here in 2011. It is an incredible location that essentially sits at the edge of the escarpment with a steep two-thousand plus foot drop to the valley far below. In the distance, one can see dust devils rising from the valley floor or rainstorms with lightening that are almost below you at times. I always want to share this with everyone and since none of the people on the trip had been to this spot before it was decided that we would take the five-minute drive to the overlook.
First, though, we had to bump start Turtle, which entails having everyone push downhill and getting enough speed to pop the clutch in second gear and start the engine. It worked like a charm, but now the challenge was to drive to the end of the earth at this precipice known as the Overlook, without stalling the car as we’d be facing the wrong direction to bump start it again. I decided not to drive all of the way out and stopped about 100 yards from the edge where I could remain with the car and keep the engine running. This worked reasonably well and gave everyone a chance to experience the Overlook, spend some time taking photos, and then we could eventually be on our way. I kept the engine running while successfully turning our behemoth vehicle, which has the turning radius of a supertanker (I had later mentioned the Exxon Valdeez to the residents who had absolutely no idea what I was talking about), around to get us moving in the right direction. Not an easy task even in the best of circumstances and certainly not with a steep ravine on one side of us.
Once on our way heading back to Karatu with our engine still purring we were looking forward to getting home for dinner and arriving well before sunset. Well, that was our plan until Turtle developed a rather nasty sound under the hood that was clearly engine related and didn’t seem to want to go away. All I could really do at that point was to keep driving and hope for the best, but apparently that was not meant to be. After a few minutes of a pretty nasty screeching sound, Turtle just died and regardless of putting the clutch in, I could just not keep her running. We got out and lifted the hood to see a bunch of smoke coming from the alternator which had decided to give up the ghost not very far from Upper Kitete which meant that we were well over an hour from Karatu and essentially in the middle of nowhere. The alternator had seized up (i.e. its bearings had frozen), but Lindsay fondly coined the phrase, “alternator dege dege,” where dege dege means seizure in Swahili. And you will also recall that there is absolutely no cell service in Upper Kitete, but thankfully, we had a few bars that allowed us to send an SOS to FAME. I first texted Frank, who in turn contacted Moshi, who essentially keeps FAME running and deals with all the infrastructure there. Moshi contacted Soja, FAME’s mechanic, who I eventually spoke with and said he would see what he could do.
So here we were, stranded on a road that ends just past Upper Kitete, with barely any cell service, a beast of a vehicle that was unfortunately lacking a functioning alternator, and ten passengers in addition to myself with the sun setting in the next hour. Life tells us to always make the best of things which is what everyone did. Of course, there were locals that were walking up and down the road, everyone checking in to see what was going on along with constant motorcycles and a few other vehicles traveling in either direction. Hannah and Lindsay decided to climb on top of Turtle and relax a bit, while John decided to spend his time practicing his climbing moves by circling Turtle using hand and foot holds without touching the ground. Steve took a few walks and everyone else just sat around biding their time.
Thankfully, Soja found a used alternator he could borrow and called to tell us that he was on his way. It would be at least an hour from when he called, though, to reach us so it was just a matter of continuing to occupy ourselves in the interim. Soja arrived with the spare alternator which he and his assistant managed to install in an amazingly short amount of time as well as installing a new belt for us and had Turtle once again purring, albeit after another bump start considering our battery was still dead as a doornail. Once again powered and ready for action, we loaded everyone back in and were on the road within two hours of our initial breakdown. Considering where we were, not only in East Africa, but well over an hour off the tarmac and in need of an alternator, and with no AAA in the same hemisphere, it was a small miracle that we were able to be rescued successfully and would be sleeping in our own beds tonight.
The drive home was, of course, a bit on the difficult side considering the sun had set long ago and driving here after sunset is not something that you would elect to do if given the choice. Dusty roads, tons of people walking and appearing as merely shadows, combined with oncoming vehicles all adds up to a challenge that gives one a sincere sense of accomplishment when arriving home safe and sound. Once again, everyone could breathe a huge sigh of relief that we were home safely and everyone would have incredible stories to tell about the experience. Tomorrow we would have a half day of clinic in the morning and then head to the Serengeti for the weekend. It was certainly something to look forward to and especially considering what we had just been through.
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.