Sunday, September 29, 2019 – It’s off to Gombe, but first Kigoma….

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On the tarmac – arriving in Kigoma

We awakened quite early to meet our driver at 6 AM for our drive to the Dar airport. As I had mentioned earlier, we had requested bringing breakfast with us since the kitchen wasn’t opening until 6:30, but the breakfasts, which left much to be desired, were comprised of a piece of white bread (not toasted) with some jam, a banana, and a juice. Needless to say, we were all still quite hungry when we arrived at the airport. We went to check in, but were told that check in would be 7 AM for our flight, so we sat and waited. Thankfully, Leah noticed that the small sign about the check in desk had changed and now had our flight so we weren’t last in line, but after having checked in, found that our “new” departure would not be until 9:30 AM, much to our frustration. Thankfully, there was a small snack bar where we were able to get something to eat or drink given our less than satisfying breakfasts. I ordered two samosas and a diet Coke, a very hearty breakfast indeed.

Welcome to Kigoma

Ebola warnings in Kigoma, across the lake from the DRC

It was time for our departure and we all boarded the plane which was a prop plane similar to what we had flown in from Kilimanjaro. The flight was two hours long as it completely crosses Tanzania from east to west, essentially following the same path as the railroad that was built here a number of years ago and can still be taken from Dar if you’re more adventurous. The railroad had been built to help bring goods not only from Western Tanzania, but also from the Congo, DRC, to the ports for export. Kigoma is still a business center for the region and it is the only access point to Gombe Stream National Park, famous for the site of Jane Goodall’s extraordinary work on the wild chimpanzees of Tanzania that began in the early 1960s and still continues today.

The baggage “carousel” at Kigoma

None of us had any idea of what to expect since none of us had ever been to this region before nor did we have much of a description of the area. I guess you can say that we all came based on the thought of visiting such a remote area and getting to see the chimps. But first, we had to land in Kigoma, which is probably one of the tiniest of commercial airports that I have ever been to. The single small building there says “departure lounge” on the right half and “arrival lounge” on the left half. There was nothing in between. The plane taxied onto the tarmac and let everyone off on the opposite of the place from the “lounges,” meaning that we had to first negotiate our way around the plane before we could head towards the terminal building. We had to show our passports to enter, which they recorded asking our destination, while informational signs warning of Ebola symptoms were on the wall behind the desk and at other locations. With the DRC being so close and reported cases of Ebola, no one takes anything for granted around here.

A scene along the “docks”

Our water taxi to Gombe awaits us

The arrival lounge had no chairs or other conveniences, but was really just a square room with a big opening on the tarmac side with a large platform on which they placed luggage as it came in, necessitating that passengers get their bags before they could put additional ones onto it. Of course, our bags were at the bottom of the cart they used to unload everything and then wheel over by hand. Regardless, we all had or baggage, which was a huge plus, and we were now ready to step outside and find our driver. Given the size of the aircraft (small) and the fact that were nearly last to get our luggage, this was a simple affair as there were few drivers left standing in the parking lot. We loaded everything and drove through the outskirts of town, towards the place where we’d find our transportation for the next leg of trip – a boat to take us to Gombe. We pulled up to an area where there were many, many boats of all sizes in the water and pulled up to shore. All were the very common wooden boats of this area, most with engines and some that were very much bigger than others. Joshua, from Gombe Safaris who we had booked with, met us there and introduced us to Juma, who was the captain of the boat we were to take, which though it was one of the smaller ones, looked quite sea worthy and had tarp over the top that was reassuring.

One of Juma’s assistants on our way out to Gombe

Leah and our captain, Juma, who I later discovered can’t swim

Our bags were loaded onto the boat and we all found seats for the two hours that would be necessary to reach the central part of Gombe where we were staying. It was immediately clear to me that we were also bringing the groceries to camp as there was a large basket in the middle of the boat which contained all sorts of fresh produce. There was also a string of freshly caught fish hanging on a nail on the inside of the hull which I was also pretty certain that we’d be eating either tonight or the next day. At some point as we were heading out of the harbor, Juma did suggest that we put on life vests which was probably more appreciated than not given the small size of our boat, the massive size of the lake and the length of our trip. Thankfully, there were no mishaps during the journey as we plied close to the heavily wooded shore, occasionally passing a small fishing village or boats out fishing with their tiny crews. Once we reached the park boundary, though, there no more villages to be seen and we still had quite a ways to go.

Unbeknownst to us at the time, we were looking at tonight’s dinner

At one point, we pulled up along the beach and some guides and visitors came out of the forest and tall grass. They had apparently been looking for some of the chimps, but hadn’t seen any, which was unfortunate as most of them were only on a day trip from Kigoma and were heading back home empty handed. One of the visitors, though, did come back to camp with us. He turned out to be an anesthesiologist from Ireland who had been working in Tanzania and was now traveling on his own before heading back home. He would be spending the next two nights with us in camp and we enjoyed his company. There was also another group of three women who were in camp for two nights, but other than that, we were pretty much alone here. Before we arrived to camp and while still on the water, it began to rain on us, but there were no issues as it was quite refreshing.

The marker on shore announcing that we were now in the national park

A view along shore

On our way here, Katherine from FAME had texted me that she spoke with a friend of hers who works here at Gombe as a guide and that she had told him we were coming so we should look out for him. “Promise” was his name and as we initially got off the boat and were welcomed, I mentioned that we were looking for Promise as he knew that we were coming. Everyone looked at me like I was a bit crazy and seemed to have no idea who Promise was until finally, one of their faces lit up and then said, “Oh, you mean Ahadi!” Of course, Promise in English translates into Ahadi in Swahili which is what everyone here knew him by. Once we figured that out, all was well and, in very short order, we were able to meet Ahadi, who was as pleasant and reassuring as anyone I could imagine and he proceeded to help orient us to camp.

Tying up the boat as we wait for the trackers

We stopped off before arriving to camp to possibly trek, but only picked up a passenger

One of the first things we learned was that the baboons, who populate the camp along with the staff, can be very pesky at times and are well adept at opening the zippers of the tents requiring that they be locked at all times when you’re not present, unless you’d like to see them playing with your camera equipment high up in the trees or possibly wearing your clothes. Since neither of those things rank high on my to do list, we decided to keep the tent religiously locked when not present. The tents, though not entirely glamping as it was in the Serengeti, are really quite comfortable with two large beds on a permanent platform with running water and electricity (though not 100% dependable which I’ll go into later), a toilet and a shower. Unfortunately, the hot water is not currently working for the tents, but we all pretty much decided that was more than reasonable at such a remote place and cold showers would have to do.

Our boat waiting on shore as they decide whether we’re going to look for chimps

Meals are eaten on the second floor of the rest house (you can choose to either stay in the rest house rooms or the tents with the latter being ever so slightly more expensive) and the food is cooked by, none the less, Juma, our captain. On our way here, he had handed each of a bag lunch on the boat that was a vegetarian burger on a huge bun with secret sauce that was really delicious, along with some mango juice to wash it down. When we finally arrived to camp, we were also offered lunch, by Juma, who must have thought our stomachs were bottomless. Of course, we had to eat the lunch so as not to offend anyone, and considering it was the amazing fresh fish that we had traveled on the boat with us, we weren’t about to argue. Later, though, when Juma asked us about dinner, we all immediately agreed that we were just fine for the evening and really didn’t need anything else to eat.

Making our tent “baboon proof”

Tomorrow would be our first trek to see the chimps and I think that all of us were very excited over the possibility of seeing them in the forest, though at the time, we really had no inkling of what that was going to involve.

Saturday, September 28, 2019 – From FAME to Arusha and on to our various destinations….

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Thankfully, Marissa and Andrea had checked their flights on Air Kenya the day before to notice that they had been moved up an hour. We had originally intended to depart at 8 AM, but given their new departure time, it made more sense to leave a bit earlier so as to make sure we had plenty of time. We had people flying out at various times during the day and given that it is about an hour to get to the airport at Kilimanjaro, I had planned to arrange a shuttle for the Marissa and Andrea who were leaving the earliest. Leah, Mike and myself actually had transport from Arusha as part of our package of travel to Gombe Stream National Park and our flight was leaving at 7:40, while Kyra was departing at 10 PM on Emirates to eventually head to Morocco by way of Dubai. I had asked if Kyra could just come along with us since that made the most sense, and heard back that she could ride with the three of us for no extra fee. And in the end, we didn’t need the shuttle for Marissa and Andrea, who were heading home, as Pendo had to drive to Moshi for a funeral at the same time and could drop them off at the airport which was far better than taking a shuttle, not only in cost, but also for reliability.

We left FAME at about 7 AM, with Phoebe getting up early to say goodbye to us. I know it was sad for everyone to leave, though it was time for them to get home to their family and their other lives. I’ll be back in six months and, besides, FAME has always been constantly on my mind and even more so these days given my new commitment as a board member. We drove through Karatu with all the early activity of the merchants and the buses being boarded for far reaches of the Tanzania – Arusha, Dar, Dadoma, Loliondo – all destinations for everyday travelers on their way for business or to rejoin families. I have never taken a long bus ride in this country, and though it might seem exciting and adventurous, it can also be very dangerous as there are bus accidents all the time here.

We drove down to Manyara and had planned to stop briefly at the African Galleria to say goodbye to Nish and several people had wanted to get a few last pieces of Tanzanian artwork. Though I had said 10 minutes, it turned into closer to 30, which wasn’t a crisis, but I knew that traffic in Arusha can be a problem at times. We eventually left and stopped briefly for gas in Makuyuni, before continuing on to Arusha. The drive was reasonably fast until we reached the outskirts of Arusha and the traffic became a problem. I took a few shortcuts, but even with these, we arrived around 10:30 rather than the 9:30 I had anticipated. Pendo, of course, had a full breakfast on the table waiting for us and we were all starving, given the lack of breakfast items in our house, so it was very much appreciated. After breakfast, Marissa and Andrea gathered their things, loaded them into Pendo’s van and they were off for the airport.

Dr. Anne preparing for an important talk in Arusha

The remaining four of us were left at home with the Gabriella, Gabriel, and another young family member, but in very short order, we all fell asleep on the couches in their family room, sleeping quite soundly for well over an hour. When we awakened, I realized that we’d all need something to eat before going to the airport, so we drove over to the Cinema, which is a small upscale mall that has an outside food court where there are a number of restaurants that all vie for your business by putting about six menus on the table, each with different waiters to take your order. This is somewhat of a mzungu hangout as there are lots of expats and young travelers who come here to eat a meal without the fear of getting ill which can often happen at some of the local restaurants if you’re not careful. We each ordered from one of the menus and then had a delicious meal that we finished just in time to head back to the house where Leonard’s sister-in-law, Grace, was waiting to drive us to Impala Hotel nearby where we had planned to meet our ride to the airport. I think everyone commented on what a welcome change it was to finally be in something other than the squeaky and bouncy Land Rover after an entire month, but I took absolutely no offense as I had a bit of the same feeling, though was already missing Turtle.

At the airport, Leah, Mike and I checked in for our Air Tanzania flight to begin our journey to Gombe, while poor Kyra had about four hours to wait for her Emirates flight and they hadn’t even begun checking passengers in yet. She had a long trip to Morocco, but we received word later that she made it safely to meet her husband. Our flight to Dar was uneventful other than a stop in Zanzibar which we had been aware of beforehand. As it was already nighttime, we did not even get a good view of the island.

Mike reaches Nirvana

In Dar, we met our airport shuttle that took us to the Tanzanite Executive Suite, the long awaited highlight for Mike as he had been talking about this ever since we booked our trip months ago. It was obviously more of a joke, though at times he seemed quite genuinely serious about it. After all, it was an “executive suite.” We drove from the airport to what seemed to be the main area of town and the driver eventually delivered us at the hotel after driving through a number of very narrow and bumpy streets. Our bags were brought up to reception, one floor above the street and we were given our rooms on the 8th floor. Everything was extremely clean and we were greeted with a very cold and very fresh glass of mango juice. Since our flight was at 8 AM the following morning, we did ask if we could have breakfast to go (since breakfast was included but would not begin until 6:30), as we’d be leaving for the airport quite early. I think we were all asleep quite quickly despite the long naps we had taken earlier in the day. Tomorrow, we’d be flying to Kigoma and it would be off to Gombe Stream National Park after that.

There had been a tremendous amount of moving parts today given everyone’s different flight times, the travel from Karatu, and the distance to the airport, but all went incredibly well and, amazingly, everyone made it to their destinations as scheduled. Marissa and Andrea would be home tomorrow, while Kyra was on her adventure in Morocco with her husband. Leah, Mike and I were just beginning our expedition to the see the famous chimps of Gombe.

Friday, September 27, 2019 – A day of rest and final errands….

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It was last full day at FAME as everyone would be departing tomorrow morning, most for different destinations. Andrea and Marissa would be heading home first through Nairobi, then Doha and finally back to Philly, arriving on Sunday. Kyra would be leaving for Morocco via Dubai, meeting up with her husband for ten days there before returning home. Mike, Leah and I would be heading first to Dar es Salaam, then to Kigoma en route to Gombe Stream National Park to hopefully see some chimpanzees.

The infinity pool being build at Gibb’s

As I had mentioned, I gave everyone permission to sleep in this morning and miss morning report since they had been getting up early every morning including those on safari. I went to morning report by myself and did my best to represent the neurology team, though there were no overnight neurology patients that needed our attention so it worked it quite well that the entire team wasn’t there. We had decided to have a very large debriefing meeting for the neurology clinic at 9 AM which was perfect as I had just a few things to finish up prior to the meeting regarding patients who we had seen recently and just needed some follow up. The debriefing meeting included most everyone who had anything to do with the neuro clinics, either at FAME or on mobile, and also included the upper management (i.e. Susan, Caroline and William) who are significantly involved with the clinic from a mission, cost and personnel standpoint, respectively.

More grounds at Gibb’s

When we started the meeting, it had been anticipated that we would spend about an hour or perhaps a bit more. The meeting ended up lasting 2 ½ hours and was incredibly produce dealing with lots of aspects of the clinic, from medications and availability to how we would schedule the clinic in the future and what our hopes were for the clinic going forward. There were lots of great ideas and lots of great dialogue such that I’m incredibly hopeful that we will continue to serve the neurological patients of the Karatu district and beyond as we have since 2010 and my very first visit here. FAME has grown tremendously since I first arrived and so has our neurology clinic, now being a part of the Penn and CHOP neurology residencies and the volume of patients that we see while we’re here.

Frank and Susan’s grounds

The residents had a number of things they had wanted to do as well during the morning and they could get very little done considering that those they wanted to see were all in the meeting with me. I had told them the meeting would probably last a bit over an hour, so they were all hunting me down during the meeting, though I was able to tell them at some point when I needed to leave the meeting for a bathroom break as the meeting had been advertised as BYOC (bring your own coffee) since it was being held in administration and not the Lilac Café which used to be the norm. I finally met several of them down at the Lilac after the meeting, though, and quickly discovered that they had ordered what looked like the most delicious breakfast I had seen with eggs, toast, bacon and sausage. I hadn’t eaten any breakfast as we were out of most of the food in the house since we’d be leaving the following morning and we had also run out of all the breakfast bars that had been brought by the residents. Despite the fact that it was nearly lunchtime, I didn’t hesitate one moment when asked if I wanted to order something and replied, “I’ll take one of those.”

Relaxing with a Kilimanjaro and the sunset in the background

I did have a number of errands to run once we were done with the meeting and breakfast, and I had told Daniel Tewa that we’d stop by for coffee at around 1 PM, so it was important to get those things taken care of. I knew that everyone wanted to get their packing done today since we’d be leaving early the following morning, and I was also aware that there was some interest in relaxing for the day, so I left it up to everyone whether they wanted to come to Daniel’s with me or not. In the end, Kyra and Mike agreed to come along as Kyra wanted to visit the wood carver in Tloma Village and Mike wanted to visit the artist Katongo at Gibb’s Farm to possibly pick up a painting.

The spread of munchies at Frank and Susan’s

I had texted Daniel that there would only be three of us, but somehow, he didn’t get the message, and when we arrived to his house, he had coffee cups set up for everyone. I’ve been in this position before, and when it has happened in the past, Daniel always comments half-jokingly, that who’s ever there must drink the coffee for everyone. The coffee he makes is the true African coffee, which is boiled with milk and is absolutely delicious. The only problem with that is that Kyra can’t drink the coffee as it has the milk mixed in and she drank hot chocolate instead, leaving Mike and I alone to finish what Daniel felt was a respectable amount of the coffee. That meant at least three cups each and there is nothing timid about his coffee. We survived the caffeine infusion and, as we were saying our goodbyes to Daniel, he ran back to the sleeping area of his home and brought out seven ½ kilo bags of whole coffee beans for everyone, including Ray, to bring home. He is such an incredibly generous man and has never once asked me for anything in exchange for what he does for us and whenever I try, he just says that we’re family and he’s grateful for what we’re doing for his country.

Lovable Oscar

From Daniel’s, who lives on the road to Gibb’s Farm, we made our way up to Tloma Village, but given all the coffee I had drink, I needed a bathroom, so instead we went to Gibb’s first so I could use their amazing bathroom in the check in area that is wide open to the outside and sports a view of their gardens and livestock. When I bring people here to visit, I always make sure that they visit this bathroom first on our way in. I said hello to all of the waiters that know me, while Mike and Kyra walked with Katongo to his studio to see what painting he had for sale. Mike had wanted a giraffe painting that he had done and was very cool, while Kyra, who hadn’t really been planning to purchase a painting, decided to buy a wonderful lion painting that he had finished with a lion couple on it.

BFFs – ’nuff said

On our way back down from Gibb’s, we did stop at the Wood Carvers where Kyra managed to pick up something small and I picked up two smallish pieces of uncarved ebony to use as stands, but that required some serious haggling, not something I typically enjoy, but I felt he was being unreasonable, so set the stands back down and started to walk away on two occasions before I was able to finally purchase them. With our errands all finished, we were finally able to head back to FAME to finish packing and ready ourselves for our trip to Arusha the next morning before going over to Frank and Susan’s for the evening with all the current volunteers.

Can’t get enough of Oscar

Susan usually tries to have everyone over to their place at least once during their stay here and typically towards the end. Those accompanying me during our trip here really don’t have much interaction with her on a day to day basis as her role at FAME is more administrative than it is directly medical, and so the most interaction that everyone has is with Frank, whose personality is generally bigger than life and hard to miss. The visits to Frank and Susan’s house, though, allow everyone the chance to meet Susan in a more social setting and also allows Susan a chance to get to the know the residents better. For tonight’s event, it involved lots of munchies like popcorn, samosas, cheese and toast (there was apparently a run on crackers in Karatu and none were available) along with lots of beverages.

Nicky and Oscar

Nicky, their little sheepdog/dachshund mix (yes, her body habitus is quite bizarre) was out on the deck with everyone, along with Elvis, their Sekoke cat (a rare mix of domesticated and wild African cat from Kenya), who pretty much buddied up to Kyra, our cat lover, but in the end settled on Andrea’s lap for the longest of time. Oscar, their three-year old Rhodesian Ridgeback, was let out a little bit later so as not to knock every glass off the table and managed to make friends with everyone, but Mike turned out to be his real buddy as the two shared one large chair and appeared quite the couple. Frank typically disappears at 8 PM, his usual bedtime, but actually lasted until 8:30 tonight and in his usual custom, vanished for his bedtime without a good night so as not to break up the party. It’s always an incredibly relaxing evening where everyone can share whatever stories they like. Joyce Cuff and her sister Terry were also there, so it was fun sharing our old stories of the big mobile clinic to Lake Eyasi with everyone else. We also had a new volunteer, Greg, an internal medicine doc, there so he was also able to hear some of our old stories about FAME from ten years ago. It was a wonderful night and I think everyone walked home with a better appreciation of what FAME had been and has now become over the years.

Thursday, September 26, 2019 – Our last day of neuro clinic….

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Surfing the hallway with one of Marissa’s little patients

It had now been nearly a month that we’d been away from home and three full weeks of seeing patient here at FAME. At had no indication by anyone’s mood or actions that they were homesick or tired of this place, but rather that it was becoming a second home as it has with me over the years. Today was our last day of neuro clinic, albeit unannounced, but we knew from the past that patients would come regardless and, besides, we had told several to come back today to see us in follow up or to have studies done. It was 18th clinic day, all told, and we were nearing 400 patient visits which is what our fall trips have been consistently running as opposed to the spring trips which are usually around 300 patients. I believe that had it not been for the extended coffee picking this month, we would have seen many more as that is the major employment in this area and, as I’ve mentioned before, the season is only around 40 days so that to miss the opportunity of making the equivalent of $2 USD for a day of picking can be extremely costly for most residents here. Whenever we’re driving down the road to town in the morning, coffee pickers are walking up the road towards the fields with their 5 gallon buckets in hand, ready for their work that will bring some shillings to their family and food on the table.

Group photo after our last patient for fall 2019

It was also everyone’s last morning report as the residents and Leah had already let me know that they would be sleeping in tomorrow rather than coming to report since we had no clinic. I had absolutely no issue as they had all earned that luxury given the days of hard work they had put in and the fact that we’d be getting up early on Saturday to leave for Arusha. Andrea had volunteered today to give the educational lecture on the different types of tremor and how to evaluate and treat them. Since she will be going into movement disorders, this is obviously her passion and it showed in her lecture which was complete, well-organized and well-received by the FAME clinicians. Also, as it was our last morning for the team to be at report, there were words of thanks by all the doctors, but especially by Dr. Anne, who had spent the month with us as she will be the FAME neurologist going forward, and Dr. Gabriel, FAME’s head doctor and someone who I have known now for many years. After the words of thanks came the mandatory claps, which are usually three, but this morning were six, the extra three as a sincere sign of appreciation. “Pasha, pasha, pasha, choma…” and then the six claps by everyone around the table.

The neuro team relaxing at the Lilac after our last clinic for sodas

Before this, though, Jacob, the overnight doctor, presented the ward and maternity cases to the group for any overnight changes. Our gentleman that Kyra had admitted with Wernicke encephalopathy had improved and was much less ataxic and less encephalopathic this morning after his supratherapeutic doses of thiamine which was great to see as we were worried about the oral thiamine replacement we had given him. As we had walked to report, we had noticed the FAME ambulance backed up the walkway near the ward which was a good sign as it meant that they were readying the patient with the meningioma for transport this morning to Arusha. Unfortunately, what we discovered from Jacob was that the patient had markedly improved overnight in regard to his encephalopathy (theoretically, a good thing) and that he was now refusing to be transferred to Arusha (a bad thing) after he found out the expense of surgery, despite the fact that his family was agreeable to him going and had already raised the money necessary to have him treated. Jacob had already. spent a great deal of time with him before rounds and the patient was adamant about not going and his family was now beginning to waffle.

An impromtu vote of confidence for Leah’s success as a neurologist (note – Leah’s eyes are shut)

The steroids would not continue to hold him for very long and his edema would eventually begin to reaccumulate and worsen and, if nothing were done for him, it was very likely that he would die due to complete obstruction of his ventricles and hydrocephalus. Mike went back after rounds to reassure me that the patient had capacity to make this decision as well as to make sure that his family was also well aware of the consequences. He was and they were, though they later indicated that they would likely drive themselves to Arusha rather than in the ambulance and were planning to see the neurosurgeon.  We made sure to make Dr. Rabiel, the neurosurgeon in Arusha, aware of the change in circumstances as Dr. Gabriel had called her yesterday afternoon and that we were hopeful that he would see her sooner rather than later as there was little question that he would be worsening in short order if nothing were done. If we had been at home, we would have made him sign something discharging him against medical advice, or AMA, but that would have been solely out of concern for medical legal reasons and of that we had little concern here.

Of the other interesting patients that we had for the day was the 91-year-old Maasai gentleman with the primarily proximal lower extremity weakness who we thought was mostly myelopathic, but without apparent sensory changes and normal ESR and ALT/AST (proxies for a CPK which we do not have here). He underwent his CT scan of the cervical and thoracic spine that were unremarkable as far as any destructive lesions anywhere, though I will admit that my abilities to look at CT scans of the spine in regard to the cord or other soft tissues aspects is a bit lacking since we rarely do them for obvious reasons as the MRI has become the gold standard for evaluating the spine. We remained at a loss for his diagnosis considering other possibilities such as spinal AVM or an inflammatory myelitis, both of which would be very difficult to diagnose with access only to a CT scanner. Unfortunately, we sent him home without a diagnosis, but will still be thinking about him with the idea of coming up with something.

Possible cysticercosis of the muscle

On a completely different note, though, we had a rather frustrating woman who came in with complaints that seemed mostly non-neurologic, but we decided to evaluate her none the less. She did have a swollen left lower leg that we really couldn’t ignore and sent her for an ultrasound, that was negative for a DVT, but Dr. Gabriel did note that she had some tenderness and pain to palpation and suggested that we get a plain film to rule out a fracture or other pathology despite her lack of trauma. We went ahead and ordered the plain X-ray of the foot, not something we normally do, only to notice that there some hyperdensities posteriorly that were in the soft tissue above the ankle. We had no idea what these were, but were surprised when Dr. Alex, our radiologist, read them as calcifications that could be suggestive of cysticercosis of the muscle.

A sagital view of our gentleman with progressive cerebellar ataxia

Now, this was a twist as we are totally aware that neurocysticercosis (pork tape worm cysts in the brain which are one of the most common causes of epilepsy worldwide) is present in this area (though it’s unclear if we’ve actually seen any to date), but in researching the possibility of cysticercosis of the muscle, it turns out that it is very rare and that if it is seen, patients should be screened for asymptomatic neurocysticercosis as this entity is so much more common than involvement of any other organ system. The following day, Dr. Gabriel did call the family explaining to them our concern and recommending a CT scan of the brain, but they elected not to do it and it was unclear if this was due to the cost or whether due to a local belief that X-rays take away years from someone’s life. Either way, it wasn’t going to be done which was unfortunate from an academic standpoint as it would have been very interesting to have answered that question.

Our favorite dinner spot

So, we had lots of commotion for the afternoon with all of these complex patients, but we did have something very much to look forward to as we had made dinner reservations at Gibb’s Farm for the six of us this night and it was a much anticipated event. We had actually finished everything up a bit earlier than anticipated, but most importantly, we had exceeded the previous number for patients for a trip by one, having had 405 patient visits for the month and still wondered what the number would have been were it not for the extended coffee picking season. We did have to run back to Teddy’s, now the all-time favorite FAME seamstress as there had been a few other things she was making for people that needed to be picked up. We decided to do this on our way to Gibb’s and, as expected, there can never be a short visit to Teddy when bringing along a female majority. I do apologize if there is something a bit sexist about that statement, but having visited her shop multiple times now on three separate trips, I believe I have the clear data to validate my observations if anyone wishes to challenge me.

Chicken dish at Gibb’s

Winning dessert at Gibb’s

We finished up at Teddy’s and then made our way up to Gibb’s for our dinner. None of the others had dinner there before, so I knew it was going to be a real treat for all of them tonight. We had arrived after sunset with plans to have some drinks before dinner, but they had a table all ready for us and since everyone was more than ready to eat, we decided instead to be seated and get drinks with our dinner. Visiting Gibb’s for me is always such a pleasure, not only for its wonderful setting and the scenery, but also for the fact that all of the waiters there, most of who have been there for years, know me and greet me with hearty handshake and hug. I have cared for a number of them or their families over the last ten years and they all know the work I have done at FAME and are appreciative of it. Visiting Gibb’s Farm is clearly one of the highlights of the residents’ visit to FAME and I always make sure that we make it here at least once for dinner and once for lunch during our month long stay. I am sure that one can find other lodges that may have some better attribute here or there, but when it comes down to the entire package, there is really no other that comes close to Gibb’s Farm.

Suave and debonair

We finished dinner early enough for everyone to spend time in the gift shop with both Mike and Kyra finding wonderful bathrobes to purchase. Everyone had worn their new Tanzanian attire except for me and Mike, who had decided not to wear his infamous jumper to dinner, so he wore the bathrobe that he had purchased and I wore Kyra’s bathrobe for a group photo in front of the Gibb’s fireplace. It was a great ending to a wonderful evening.

Our group after dinner at Gibb’s

Night scene at Gibb’s

Wednesday, September 25, 2019 – A very busy afternoon…and then the Sparrow….

Standard

Dr. Anne and Marissa evaluating a patient

Our morning report was very interesting today in that one of the patients who presented yesterday emergently to FAME was a young gentleman who had been attacked by a Cape buffalo. These events remind us that we’re definitely not in downtown Philadelphia as there is very little violent crime here other than the attacks by wild animals. Baboon or monkey bites have been relative common in the past given the total lack of fear these animals have at the Ngorongoro entrance gate and the picnic areas in Tarangire. At the gate, the baboons will very quickly enter any open window in a vehicle, target the lunch boxes or any food and be back out in a quick flash unless someone tries to stop them which they don’t appreciate and will quickly. provide a very nasty and dirty bite. Last year, a very unfortunate Maasai man from the NCA was brought in after being essentially eviscerated by an aggravated elephant and did not survive the night from his injuries. A Maasai women came in a few years ago with nasty hand wounds after tangling with a hyena who had successfully taken her infant from her hut and had to be referred to KCMC for more specific orthopedic repairs. Her infant was never found.

Another Denis creation

So, the gentleman who ran afoul of the Cape buffalo was actually a bit lucky in that what he had was a bit hemopneumothorax that needed to be drained, and though there was concern that he would need ICU level care (not available at FAME), a chest tube overnight seemed to stabilize him. There was concern for his mental status in the morning and we were asked to evaluate him from a neuro perspective. Mike went to see him in the ward and he was totally intact to the degree that I joked that he followed commands better than 90% of the patients that we were seeing in clinic. He was a lucky individual as Cape buffalos can be very, very dangerous in situations where they feel threatened and they unlike many animals as they will defend themselves. If you’ve ever seen the video of the Cape buffalo completely upending an adult lion, throwing it at least ten feet in the air in a tumbling fashion, and using its razor sharp horns, you can certainly understand the need to avoid them at all costs. There had been talk of transferring him, but he looked so good I the morning the decision was to keep him at FAME and to continue treating his injuries.

Someone assisting me with my blog

We had a patient come today who was following up from our clinic in Mang’ola last week and he had looked mostly cerebellar on examination. He was now encephalopathic and tremendously worse such that we were fairly confident his diagnosis was Wernicke encephalopathy, which often occurs in the setting of alcohol abuse and is the result of dietary deficiencies usually related to thiamine deficiency. If it is severe and irreversible and more associated with confabulation, we call it Korsikoff syndrome. In the US, patients with a history of alcohol abuse are immediately given what is called a “banana bag” intravenously that contains thiamine, magnesium and folate primarily  which effectively prevents the acute exacerbation of Wernicke that can occur when patients are given dextrose intravenously prior to correcting their vitamin deficiencies. We have no banana bag here nor IV thiamine for that matter, but we did have thiamine tables to send with the only proviso that we are unable to know for certain whether it’s being fully absorbed or not. Regardless, it was the only thing that we had and so it was five tablets every eight hours for several days to totally supplement and correct a presumed thiamine deficiency. Kyra had seen the patient in Mang’ola, so also evaluated the patient here and we all agreed that he should be admitted to make sure that he got his thiamine. With Dr. Anne’s assistance, this was taken care of and Kyra wrote the orders for him to receive thiamine as well as some other vitamins, none of which were quite as important as the former supplement, though.

Mike evaluating the ED patient in the ward

Mike evaluating the ED patient in the ward with the help of Dr. Jacob

In the midst of everything going on, a young patient with an IV was wheeled into our clinic space on a gurney by one of the nurses saying that he had been sent to us directly from the OPD to be evaluated for episodes of unresponsiveness. There was really nowhere to place him with all the patients sitting waiting to be seen, so he was wheeled into one of the unused rooms in the ward, but I insisted that there be a nurse with him as we had no one to spare that could monitor him. Though this hadn’t happened yet this visit, it is not all too uncommon for patients to brought to us in this fashion having come in unresponsive, many times after having “swooned” at school or work. I recall one time that a patient was delivered to us in this manner and after briefly examining the patient and getting the history, it was clear to me that it was not anything serious and that they would wake up eventually. We left the patient on the gurney nearby, monitoring them occasionally until, sure enough, they awakened and were back to their normal self-following what we refer to as PNEE, or a psychogenic non-epileptic episode. These are a form conversion disorder and are most commonly a response to underlaying stresses, though it takes a good deal of time and therapy to determine exactly what they are and how to best deal with them.

Mike evaluating the ED patient in the ward

For our patient, though, it was much simpler as after having taken an accurate history and examining him, it was quite clear that this was just a matter of several episodes of syncope in a patient who had been dehydrated. These are patients that we are often asked to evaluate at home to determine that they don’t have a neurological cause for their loss of consciousness, such as seizure, so it not at all that unreasonable to have us evaluate patients such as these, though typically it will be done in the ER if it is acute and they are not wheeled into our offices.

CT of patient with large right sphenoid meningioma

At the same time as the syncopal patient arrived in clinic, we had been called over to see a patient in the ER who had arrived unresponsive after having developed a severe headache, vomited and become less responsive the night before. Mike went over to see him right away (which is why we had no immediate person to evaluate the syncopal patient) and the patient was moving all extremities, but not following any commands and was very poorly responsive. We were most concerned about a subarachnoid hemorrhage and without any focality on his examination, this would have been suggestive of an aneurysmal bleed without significant parenchymal injury. We had another patient already in the scanner at the moment which had to be completed first, but he would be getting his study very soon and he was moved to the ward while he waited as it was clear he needed to be admitted.

CT of patient with large right sphenoid meningioma

He eventually had his study and it was not at all what any of us had expected. He had a very large, right sphenoid wing mass that was homogeneously enhancing and causing significant mass effect on his right lateral ventricle with right to left shift of the midline. There appeared to be some involvement of the cavernous sinus as well. The mass was most likely a meningioma and it was almost identical to the mass we had found in a gentleman two weeks prior, though that patient had a more gradual history over several years including complete loss of vision on the right secondary to optic nerve involvement. We were really unable to get any relevant history in our current patient given his severe encephalopathy. We spoke with his family at length regarding the fact that he had a potentially very treatable problem, but would need to be referred to the neurosurgeon in Arusha and transferred there the first thing in the morning as nighttime transfers are dangerous, risking the life of not on the patient, but also the lives of the support staff involved in the transfer. The family was agreeable so I proceeded to contact the neurosurgeon, as I had done several times already during this visit, to find out what the expectation would be for the amount of money they would need up front. We placed the patient on intravenous dexamethasone at the end of the day to help with some of his swelling and went back to finishing our work in the neuro clinic. We arranged for his transfer first thing in the morning by the FAME ambulance.

CT of our patient with progressive cerebellar ataxia

There are several important events that occur here in Karatu on Wednesdays. First, it’s meatloaf night for our dinner and Samwell cooks a very mean and moist meatloaf with some tanginess from a barbecue sauce that he uses and is probably homemade. It comes with a large side of mashed potatoes as well as green beans to add some color. I don’t know about the rest, but the meatloaf was clearly Mike’s and my favorite of the various dinners that we’re provided by the FAME kitchen five nights a week as part of room and board while volunteering here. In addition to these dinners (we have to fend for ourselves on the weekends), we’re also provided lunch every day which is perhaps my favorite food of all – five days a week it’s rice and beans with a local spinach made even more tasty by Samwell’s homemade pili pili, or hot sauce, that is made from the local hot peppers here which are very, very hot. This combination of food, the beans, rice, spinach and pili pili, may be my all-time favorite meal that I would choose if I were ever stranded on a deserted island. Tuesdays we have ugali, the East African staple that is a stiff porridge made from maize, and meat, while on Thursdays we have perhaps everyone else’s favorite, pilau, which is brown rice (cooked in meat stock) mixed with beef and then a coleslaw-like salad to go with it. Both of these, of course are made that much tastier by the addition of Samwell’s pili pili.

Yes, we even enjoyed a bit of Konyagi, The Spirit of the Nation

The second event that occurs on Wednesdays is our Happy Day night. Happy Day is a long-standing local pub that also has small bungalows where many of the long term volunteers at FAME have lived in the past, including Peter Schwab, the medical student who worked with us last October and is now a neurology resident at Penn. Happy Day (note the “Day” and not “Days” so as not to be confused with that popular sitcom) has been an institution here in Karatu since my very first trip, but has changed its ambience since taken over by new management. What used to be uncomfortable picnic benches on the outside deck are now very comfortable outdoor sofas and pillows, lots of them. It has been a tradition for years that all the ex-pats working in Karatu and surrounding areas come to Happy Day on Wednesday night to socialize and share stories. Frequent attendees include much of the staff from the School for Field Studies in Rhotia, which is quite close and is field school where college students come for study abroad programs. The mix of individuals depends on who is in town and who is around and is different every Wednesday night.

Andrea and Marissa enjoying themselves

The third event on Wednesdays is much less of a sure thing and really depends on how much energy everyone has and what we have planned for the following day. If everyone is up to it, and that is not always the case, we will all make our way over to the other local hotspot which is the Golden Sparrow. “The Sparrow” hasn’t been around forever, but was the creation of the owner of the previous dance club which was called “Carnivore,” and was a little hole in the wall place that served the most scrumptious, though also the scrawniest, barbecued chicken and chips along with drinks. Seating for dinner was mostly outside on a dirt floor where they cooked the chicken whole on a huge grill and then literally whacked it into pieces with a huge cleaver before bringing it to your table to eat while dancing occurred inside on a tiny little dance floor that was nestled amidst the bar tables and stools.

The gang at the Sparrow

Carnivore is no more and the owner, Martha, created a true dance club that would rival anything in a larger town and includes a DJ, disco lights and televisions around the dance floor. I will have to admit that in the past, there has been dancing on the tables though I will not mention any names (Mindy, Susan, Susannah, Whitley and Neena, I believe), but the tables have been changed and it’s no longer possible to do so. There is a very large outside seating area for dinners where they still serve their delicious chicken, but the most fun occurs inside on the dance floor. This night, we all loaded into Turtle and drove over to the Sparrow to let off some steam as we had working very hard for the month and were looking forward to our final day of clinic the next day, though no one really wanted to leave. Yes, there was dancing tonight, but none on the tables and we left before midnight to make sure that we’d all be in OK shape for the following day. It wa an incredibly enjoyable time, but not something that can happen every Wednesday night, that’s for sure.