A year or so ago, I was asked to incorporate “wellness days” into our schedule here at FAME in order to accommodate the new program being adopted by residencies to help with the issue of doctor burnout. Though this is indeed a very serious issue that has been at the center of attention for nearly every governing body dealing with any level of medicine, it has been particularly critical in medical residencies where the old ways of working 24/7 and sleepless nights are no longer acceptable. Work hours were instituted, as well as nighttime call rotations, and these have certainly helped, but medical training can still end up being a very dark period for many residents, especially in their early years where now managing incredibly more complicated patients than when I trained over thirty years ago can bring even the most accomplished doctor to their knees. Wellness Days were instituted to allow residents to have a bit of breathing room during their normal busy schedules, allowing them to catch up on personal matters or to just have a free moment where they don’t have to worry about their beepers.

On a side note, I’ll mention a funny story regarding the ringtone on my phone. Since the beginning of cellular phones, I have always kept the old fashioned “telephone” ringtone since that is what I have felt most comfortable with and is what I respond to most readily without having to think about it. About a year ago, while working as an attending on the ward service in the hospital, my phone would ring occasionally during rounds and I would notice an immediate reaction by the residents that would be best characterized as an immediate need for action and their hearts would skip a beat. It turns out that this was a simple Pavlovian response to my ringtone which just happened to be the same ringtone used by the stroke phone that the on call stroke resident would be carrying and responsible for. They asked me (very politely, of course) to change my ring, which I promptly did, but for only about two days as I just could not get used to it and, so, changed my ringtone back to the original tone that worked for me, but was disturbing for the residents.

Now, you might ask why I can’t just turn my ring off when I’m around the residents, which is a very good question, but the answer is that if I do that, I will never remember to turn it back and on and will then wind up missing calls. You might also ask what this has to do with wellness days? First, it was not only the residents who were having their Pavlovian moments with my ringtone, but it was also me as I was unable to alter my behavior after so many years using the same ringtone. But more importantly, the residents were suffering from very strong patterned negative response to the ringtone that had been caused by their days and nights of carrying the stroke phone while on that rotation. It would be interesting to do a study to see how long it takes for them to lose that response, or maybe someone has already looked at that, but regardless, the concept of wellness days is an attempt in some fashion to partially mitigate that behavior.

So now back to our wellness days in Tanzania. My initial response when being asked to incorporate these days was that “every day in Tanzania is a wellness day,” but there was probably just a bit of self-centric thought in that reply as I would be projecting how I feel about my time here without looking at it through their eyes. And regardless, wellness days are now an integral part of the resident scheduling, most often requiring some manner of coverage when at home, though here we are able to not have clinic during that time and all of the residents can take it together. So, since instituting wellness days here, I have simply selected two half-days during the month for the residents to be completely off and to enjoy themselves during what would otherwise be clinic time. Today was one such day with plans to be in clinic during the morning and then spend most of the afternoon at Gibb’s Farm having lunch and relaxing there afterwards.

Our previous Saturday had been very quiet and today was following the same pattern, although the patients did seem to trickle in throughout the morning. I’m not certain that any of the patients were necessarily “blog worthy” in regard to their medical aspects, but we did have another static encephalopathy child at the end of the clinic that came after we had closed registration, but the family had traveled a long way to see us and there was little thought of turning them away. It was a Maasai family and the patient was 9-years-old, having been normal at birth and then suffering a febrile illness in infancy that devastated him neurologically, leaving him with a very severe static encephalopathy and quadriparesis. He had briefly had seizures at the time of the febrile event, but has had none since by their report. He was clearly very well cared for by his family and had already been to rehab where they had been instructed in what types of physical therapy he could benefit from. He was significantly underweight, though, as he had some swallowing difficulties and this was a place where we could certainly intervene. Marissa placed him on some diazepam for his spasticity and contractures and we referred them to a feeding program that is available in Arusha at one of the hospitals there. In such a harsh environment as here in East Africa, we are constantly reminded of how wonderful it is that these children are so wonderfully cared for by their families as there are essentially no social safety nets here to help if anyone is in need. In the past, this would not have necessarily been the case as these children didn’t survive past infancy in most tribal cultures and it is only after the last decade or so that families have elected to keep these children and care for them.

So, after everyone heading back to the house with some of us changing clothes, we loaded into Turtle and made the trek (drive) back up to Gibb’s Farm, using Marissa’s favorite shot cut going there as we would stop in town on our way back to fill up with fuel in Turtle given that we were going to Ngorongoro Crater the following day and I never like traveling without a full tank when possible. Gibb’s Farm, as most you have become accustomed to by reading my blog, is a top tier resort frequently, if not always, ranking among the top several resorts in the world. It is clearly my favorite in the region, for many reasons both sentimental and otherwise, and has been the favorite of the resident that I have brought in the past. I have never stayed at Gibb’s, but I have eaten lunch and dinner there on many occasions and can vouch for both meals being well worth their full price, though we are offered volunteer prices due to our volunteering at FAME. It is their way of acknowledging the work we do for the community and many of those who work at Gibb’s have come to see us both for themselves and their families over the years.

Our lunch at Gibb’s is perhaps everyone’s favorite and I couldn’t think of better wellness afternoon than this, not only for the incredible food that is served, but also for the relaxing atmosphere in one of the most beautiful settings that I have experienced anywhere. We always sit on a table on the veranda with views of the entire countryside, birds singing and the most attentive service that one could ever ask for. Lunch is buffet style with salads, antipasti meats, soup, quiche, samosas and more, all made here on the premises including the cheeses. There are many main courses to select from and fresh baked breads. Coffee, of course, is included with the meal as this is a coffee plantation, after all. And then there are the deserts. After a very long lunch during which we’ve all had several plates and are all in agreement that each of us might very well explode, we decide what we all do for the afternoon. Ray, Marissa, Andrea, Leah and Kyra have all decided that they will hike to the elephant caves that are inside the Ngorongoro Conservation Area (or NCA) a short distance. I have been on the hike several times and chose to sit on the veranda working on my blog while Mike didn’t really have any excuse not to go other than that  he didn’t feel like it and really wanted to finish his book.

The elephant cave walk is about a two hour roundtrip hike traveling uphill on the way into the NCA that crosses atop a very tall waterfall prior to arriving at the caves which are really holes that the elephants dig while extracting necessary minerals from the soil. It is rare to see the elephants there as they usually smell hikers long before they arrive and vanish into the forest. You can see other animals on the hike, though, which is the primary reason that you are accompanied by a ranger from the NCA. While Mike and I relaxed on the veranda doing our busywork, the others enjoyed their hike to the caves and were back shortly after 5 PM. Ray initially informed (more like accused) me that I had forgotten to tell them to bring water (which he bought at the NCA gate before hiking), but then reconsidered, later admitting that any reasonable person planning to take a hike in Africa wouldn’t have to ask if they needed to bring water with them. Regardless, they survived their “ordeal” and made it back to Gibb’s safe and sound. The others decided to take a tour of the gardens at Gibb’s, which are spectacular, while Ray came up to the lodge and join us on the veranda, though his primary motive was clearly the Moscow Mule that he ordered within moments of his arrival. We didn’t leave Gibb’s until well after sunset, having made the most of wellness time there.

We traveled through town rather than taking my shortcut, much to Marissa’s delight, as Turtle needed fuel for the following day. There was still lunch to be made (peanut butter and jelly or PB and honey sandwiches) and putting things together for the journey to the crater tomorrow. We were not leaving until shortly after 6:00 AM, which wasn’t too bad, but everyone wanted to get a decent sleep if possible.

We awakened to our second absolutely gorgeous morning of clear skies and sunshine. Since arriving nearly two weeks ago, we have had simply amazing weather, though the mornings have been typically overcast with the clouds burning off by late morning. Not a soul has complained given that it has been otherwise the perfect temperature wherever we have gone and quite conducive to our activities. Next week, we’ll be traveling for our mobile clinics and the hope is that any precipitation will hold off so the roads remain passable. Slippery mud here can deter travel even for the most robust of vehicles such as our Land Rover and getting stuck on the way to a mobile clinic can be a very depressing experience. We are in the dry season here so the likelihood of a torrential downpour is exceedingly small, thankfully.

Our morning began a bit quietly again, though we had a steady influx of patients throughout the day so that our final number was still respectable in the grand scheme of things. The flow of patients throughout our stay for the month can be very irregular and frustrating as it is not always steady or predictable and typically suffers from whatever factors may be affecting the populace here – weather, planting or harvest season, and elections. They have all affected our patient census in the past at various times.

One of our earlier patients for the day was a gentleman in his 40s who reported a three-year history of right eye visual loss and a two-year history of headaches that had worsened over the last year such that he was waking up night with headaches and associated with vomiting at times. His exam was very abnormal with no vision in his right eye, a right afferent pupillary defect, a right sixth nerve palsy, and an incredibly pale optic disc on the right. It was very clear from his history and examination that he was presenting with a right frontal mass lesion that had caused significant mass effect on the retro-orbital region. We sent him for a CT scan with and without contrast to help define what was present and what we were going to have to deal with for this gentleman. Of course, Ray had already declared where and what we would find on his scan (sort of like calling the pocket for the eight ball when playing pool). The patient went for his CT scan and, of course, the lesion was exactly where he had said it would be – a sphenoid wing meningioma the size of a large apple that was producing significant mass effect on the left hemisphere and causing a great deal of vasogenic edema. It was an ugly scan and hard to believe that he had actually walked into clinic to see us. He was placed on some steroids with the hope that they would help his headaches and the plan was to refer him to the neurosurgeon as soon as would be possible as long as he would be able to afford having something done in the end.

Marissa also had a great case for a pediatric neurologist that she pretty much diagnosed in the waiting room. Years ago, as a neurology resident, I had been taught the term “augenblick diagnosis” which means “in an eye-blink” and is a reference to how our brain processes certain information almost reflexively. This was an augenblick diagnosis for her and she quickly recognized the child as having Rett syndrome, a rare genetic disorder that affects 1 in 10,000 to 15,000 births and is very rarely inherited. This 9-year-old girl had started to have developmental regression at 18 months of age and then began having seizures at three years of age following that. She had briefly been placed on phenobarbital, but it was ineffective for her seizures and the family had stopped the medicine long ago. She was now having about three seizures daily and was severely impaired cognitively, not being able to do anything for herself whatsoever.

She was a very classic case of this syndrome, complete with her handwringing and, though we had very little to offer for the bulk of her symptoms, we were more than willing to tackle her seizures which were clearly a very disabling issue for her. We decided to place her on valproic acid as it would offer the best coverage all around for her events. By the way, the other diagnoses that we consider to be augenblick diagnoses are Parkinson’s disease and some of the other similar movement disorders that we encounter.

In the afternoon, Mike had an interesting encounter with a very elderly Maasai patient and his son who had come to clinic with numerous constitutional symptoms including joint pains and headache and insisted that they wanted to get a CT scan of the head. He had a very hard time getting any detailed history from the patient or the son and the patient’s examination was completely normal, though again, he didn’t seem overly interested in participating in the examination. Overall, he was an extremely frustrating patient for Mike to evaluate, but he clearly did not have any red flag symptoms in his history of findings on his examination. Mike informed the patient and his son that he did not feel that the CT scan was necessary, but the pair remained quite insistent that they had come here for a scan and were not willing to leave without having it done.

We ended up having both Angel and Sangale (who is Maasai) become involved in the situation and we making no progress. At one point, the patient or his son had told them that they came here because FAME has “the mirror that looks at the brain,” referring to the CT scanner. I found this to be an incredibly insightful and profound comment serving to remind us of vast differences in understanding of Western Medicine here. We’ve had similar encounters here in the past, of patients coming and wanting testing that wasn’t indicated or appropriate presuming that it must be the best because it is a new technology unfamiliar to them. This, of course, happens at home in a similar fashion and it is not always the patient who makes this faulty assumption in these cases, but can at times be the physician. I remember when the first MRI came to Arusha a few years ago and was quickly followed by banners strung across several streets around town announcing that “the most advanced radiation therapy” had now arrived in Northern Tanzania. Technologies are only as good as the doctors who are applying them to the care of their patients.

Towards the end of our day, we were called to the emergency room to help with a patient that had fallen from the back of motorcycle and was now confused and lethargic. We went there to find a 50ish-year-old Maasai gentleman on a gurney who was arousable, but not answering questions and was not oriented. He was also not moving his right side as well. His family said that he had fallen from the back of a motorcycle two days ago and that yesterday he had apparently become worse and not as responsive. Of course, he was not wearing a helmet on the motorcycle. Our other patient with the frontal mass was already in radiology having his IV placed, so there was a short delay in getting this patient to CT scan, but he eventually got there. We had been concerned about a subdural hematoma, but his brain was normal and, so, we scanned his cervical spine to make sure that he did not have a fracture that was resulting in his hemiparesis. All that was found was an osteophyte that could have caused a cord contusion perhaps, but nothing else was seen to explain his condition. It was felt that he had a significant concussion and possibly a reversible spine injury, but nothing was unstable and other than observation for the moment, we had no other specific therapy to offer. He was admitted to the inpatient ward and we’d see him again in the morning to check on him.

Our plans for the evening were to visit Daniel Tewa and his family for coffee and dinner. I’ve spoken about Daniel so many times on this blog, so for those of you who are already quite familiar with my story of Daniel, feel free to skip the following paragraph(s). I first met Daniel Tewa in 2009, when, here on safari along with my two children, he had been asked to work with us on our short volunteer stint that we had requested as part of our safari package. We would be painting at the Ayalabee school outside of Karatu and Daniel was to be our host for the three days. We had immediately bonded and he then asked us over to his home to give us a presentation of Iraqw history and culture which is something that he provides for numerous safari guests of various companies throughout the year. When I returned the following year for my first visit to volunteer at FAME, I contacted Daniel and it was if we had just seen each other the day before. He remembered my children’s names and many other details from our prior visit the year before.

On that trip, I visited Daniel and had dinner at his home and with his family. Despite having met hundreds of guests who had come for his demonstrations over the previous years, I had been the first one to contact him and return and was now the first to have ever come to his home for dinner. It was an amazing honor for me and I remember that dinner today like it was yesterday. That was nineteen visits, and nineteen dinners, ago, as he has insisted on every one of my subsequent visits that we come for dinner no matter how large our group is. What used to be just me has gradually grown larger every succeeding year and the dinner has now moved from the small living room of their Bantu house to his daughter, Isabella’s, home which is just a short walk from Daniel’s home and had a larger dining room. Megan Richie was the first to go there with me, and given that she was a vegetarian, not something encountered often here, Daniel’s brother-in-law, who is a chef, had made dinner for us and had more than enough vegetarian dishes to make Megan quite happy. Since that time, we have visited his home on numerous occasions, having dinner at least once each trip, as well as at other times to stop by for coffee. He has adopted me into his family, and I have met nearly all of his twelve children along the way. Whenever I have tried to discuss the fact that our group has increased in size and that perhaps it is becoming a burden for him to have us, he will hear none of it, continuing to insist that we honor his family with each of our visits. It is with this past history between us that I bring each group of residents to his home to share one of my African families with them and to meet this amazing individual.

Daniel’s home is an amalgamation of the old and new Tanzania in some ways. Out back, he has one of the only, if not the only, original style Iraqw houses like that in which he had grown up, but were later outlawed by President Nyerere when he recognized that to build his country after independence in 1961, they needed everyone to live together in larger communities in order to develop an infrastructure that could support the country. College students and others come from far away to study his house and hear his talks. The house is mostly underground, open on only one side, and covered by layers of brush, then grass and then dirt in order to detect anyone walking on top of it at night such as the Maasai who would come to steal their cattle. The Maasai, it turns out, believe that all cattle were God’s gift to them and that they are not stealing cattle, but rather taking what was rightfully theirs. A treaty between the Iraqw and Maasai was not signed until 1986. Daniel shared his spear throwing talents with us (very impressive), while Mike impressed us all by applying his javelin throwing knowledge to the Iraqw spear and succeeding quite handily.

We sat outside with Daniel in the setting sun and eventual strong moonlight having his wonderful African coffee – fresh cow’s milk boiled with the coffee  – and everyone, other than those who are not coffee drinkers or are lactose intolerant, loved it. We eventually walked the short distance to his eldest daughter’s home, Isabella, where we would be eating our dinner. One of his other daughter’s was also there to help and we proceeded to have an amazing meal that everyone loved. It was very special and I know that everyone was very taken with Daniel’s comments about what it meant to him and everyone in Karatu that we were coming to FAME to help. It has been a very, very special relationship that we have had over the years and one that we both greatly cherish.

 

 

 

Today was another educational lecture and Ray had volunteered to do one. He presented the patient who had the subdural hematoma and did it from a perspective of why it wasn’t a stroke. Knowing Ray, who wins teaching awards right and left and is a master clinician, there was little question that he would do a brilliant job of it and he did. We only have 30 minutes to do the presentation and even with his 32 slides, he managed to finish with time to spare. We opened up the clinic door and readied ourselves for clinic, though it seemed that were fewer patients here at the beginning of the day.dd

I had hoped to do some more work in the morning after report, so went with Leah down to the Lilac Café, where I could type without being interrupted. Ray had agreed to cover clinic and only if there was a specific issue that needed my attention, would they be contacting me. Though I most usually partake in coffee here which is served in a French press, I chose this morning to order a Caffé Latte on Leah’s recommendation. It was served in beautiful layers and in a tall glass with a wonderful top layer of steamed milk and a personalized message on it that was written in chocolate. Denis is also a very talented artist who I have brought supplies for over the last trips to keep him painting. He did a wonderful portrait of me for my sixtieth birthday that I have hanging in my apartment at home and was given to me at an amazing surprise party at the Highview Inn that Jackie, Jess ad Paulina had put together.

We have always had an issue with our clinic as far as triaging patients that has occurred for several reasons. Here at FAME, it is much more appropriate medically for patients with non-neurological disease to be seen at the general outpatient clinic (OPD) despite the fact that we have Dr. Annie working with us, who is certainly qualified to treat anything that comes our way. When we make our announcements to the community and on the flyers that are placed around the district, we list the types of neurologic symptoms and conditions that we treat and those are again repeated when the patient is registering. Despite all of this, we will still have patients come complaining of a clearly non-neurological problem – groin swell, goiters, throat pain, etc. Part of the problem is also that we have a flat fee to be seen in our clinic where the patient gets their visit, one month (or sometimes more), and any necessary labs for a flat rate of 5000 Tanzanian shillings or slightly over $2. Their visit is, therefore, subsidized as these services would be costlier if done through the OPD and, hence, the incentive for patients to be seen in the neurology clinic.

When this occurs (a patient with a non-neurological disease) it will often depend on whether the patient is being seen by Dr. Annie with a resident in which case we try to take care of it on our own as long as it’s not going to be too expensive. This morning, Andrea and Annie diagnosed someone with probable cholecystitis and refereed them for an ultrasound and then to be followed up in the OPD. We also tolerate some of the musculoskeletal patients, though have little to do for them other them some ibuprofen.

Today was also exciting as we were expecting to see Abdulhamid Shaban, who Is a senior medical student at Muhimbili University and had worked with us last October as an interpreter, but ended up discovering just how much he loved neurology (how could he not having worked with the likes of Lindsay, Amisha, Hannah and John). Abdulhamid grew up in Karatu and has known FAME for many years, as well as having a family connection there. He is now coming back to work with us again as an interpreter this month as he is on leave, but most importantly, he will be returning with us to Philadelphia where he will be spending a month at Penn for a neurology observorship with our department. This was made possible through the Center for Global Health at the University of Pennsylvania who have graciously agreed to cover the cost of Abdulhamid’s travel and living costs during his stay. It all came about through everyone’s connection with FAME and is a tremendous opportunity for Abdulhamid in his professional career.

In the afternoon, several of us listened to a talk that Marin Jocobwitz and Dan Licht were giving for neurology grand rounds at CHOP about their experiences here working with us last March. Listening to the lecture live from across the globe (thankfully the timing worked out) was truly remarkable and made even more so by the fact that we had Kitashu here listening as well. He was featured in the talk on several occasions and mentioned frequently. We had visited Kitashu’s boma while Dan and Marin were here and seeing his face when she was discussing that visit and other times she referred to him during the talk was really priceless.

Our plans for the evening included dinner and drinks at The Manor Lodge nearby. It is one of the high end resorts in the Karatu region for those who are either coming and going to the Crater and is one of the Elewana Collection of resorts in East Africa. It was designed to look like the South African wine country, which I’ve never visited, but regardless, it’s a beautiful estate with well-manicured lawns and private cottages for the guests. They have a stable with horses, a pool and a large Manor house where the dining room is in addition to a billiard room downstairs that Ray and Kyra were apparently quite happy to see. Looking out from the veranda on the back of the Manor house and looking west, the sun was slowly setting in a nearly cloudless sky. We sat out back on the deck with fire pits burning nearby to help warm as the temperatures dropped along with the sun. They had wonderful drinks (the Moscow Mule is my favorite as it is everywhere here) and hors d’oeuvres and we spent a long time enjoying both before heading off to dinner which we were quite thankful was just across the deck outside rather than in the more formal dining room.

Their dinner is a fixed price five-course meal with choice of entrée. The entrées included a winter beef stew, red snapper, and an eggplant/mozzarella dish. All the dishes were delicious and well-received by everyone. There was more silverware on the table than I’ve seen in any restaurant I think and with each course, both a fork and a knife were removed from the setting in succession. The service was impeccable and the timing of the courses were perfect such that we spent a very long time at dinner which was what we had wished for in such a beautiful location. We had arrived before 5:30 that evening and remained there until after almost 10 PM. It was a night to remember and we had brought Annie with us as she deserved it having worked with us now for over a week.

We arrived home and everyone was pretty exhausted so went to their rooms to hit the sack. Within a few minutes, I heard something out of Leah and Kyra’s room and it turned out that they had muddy water coming out of their sink. When I went in to investigate, I found that the hot water in the sink was the culprit and when the mud quickly cleared, it became like a steam vent at old faithful. Either that or something that we could use to steam milk for our cappuccinos. In any event, there was an issue with the hot water and it was unclear what was the issue and what needed to be done. We would have to wait until the morning to get someone to look at it and discover the situation.

I think everyone slept a little more soundly that night.

Thankfully, Wednesday is a morning for us to sleep in. Between our educational talks at 7:30 AM and arising at the crack of dawn for our game drives on Sundays, it is always a joy to get that extra sleep as the mornings here are so delightfully cool. After morning report, I had planned to meet with Leah at the Lilac Café to discuss some aspects of the work she was doing here with us. The Lilac Café is a small restaurant on campus that came into being with the opening of the inpatient hospital ward as it would be necessary to not only feed the inpatients, but also their families who were visiting. The café is a lovely and relaxing place to spend time and the mornings are even more so. It is so relaxing that you can feel the stress drain from your body half way there. Leah has been spending her mornings there working (I’ve told her that it’s her office) and then coming to shadow us in the afternoons. I don’t think she has yet tired of the Caffé Lattes nor will she do so soon. The Lilac is also where many of FAME’s smaller administrative meetings occur as it’s very conducive to getting things done.

As we left the house on our way to morning report, it began to drizzle just a bit which is really the very precipitation that we’ve had since we’ve been here and very likely the reason the day started a bit slow as patients may have decided to come on another day. If it does begin to rain more seriously, the roads become very muddy and more difficult to travel, but even so, most people here seem to ignore the heavy rains and do what they have to do. It always amazes me at how everyone travels through the mud and dust to get to clinic, but somehow don’t look like they have when they get here. Just walking to clinic on a rainy day, I seem to accumulate a pound of mud on each of my soles making walking just a bit difficult.

With the slow day, the patients trickled in and we still ended up seeing eighteen neurology patients, so not all was lost. An interesting patient that Mike saw today was an older gentleman with a chronic history neck pain that was worsening and he now had difficulty walking. The symptoms had been going on for over two years and he was now myelopathic on examination meaning that we were mostly concerned about him having spinal cord compression secondary to cervical spondylosis or arthritis. The is a very common condition in which the arthritis causes severe narrowing of the spinal canal over a long period of time and eventually compresses the spinal cord. The only treatment for this is to do surgical decompression and fusion of that segment of the cervical spine where you’ve operated. He would need an MRI to confirm the diagnosis prior to any potential intervention. We were back to the same question as before as far as whether the family could afford the surgery and, if they could not, there would be little reason in getting the MRI scan.

I contacted the neurosurgeon again in Arusha at ALMC, or Selian Hospital, and she got back to me rather quickly with a price of 2,000,000 shillings, or about $869 depending on the days exchange rate, for the surgery and fusion, but not for the MRI scan as he would have to get that done first. To be honest, a price of less than $1000 is pretty amazing when you consider that to have the same surgery done in the US would yield a hospital bill of at least $200,000, though that’s not necessarily what the hospital would get paid. That’s the problem with making those comparisons as the hospital wouldn’t really get paid that total amount, but probably something closer to a quarter of that total amount. Regardless, it is still significantly cheaper here in absolute terms, but not in relative terms when you consider what the average per capita income is in Tanzania and even far less here in Karatu District. Mike spoke with the son who indicated that the family was going to sell everything they had to raise money for the MRI and we weren’t able to give them the amount for the surgery, but they were aware that would be an additional amount.

As we had seen all of our patients before lunch (2 PM), we were considering a trip to the village of Manyara where the African Galleria is so that everyone could buy gifts for home. I had also asked Ema to check out Turtle to make sure that she was in excellent running order for our game drive on Sunday as well as the mobile clinics we are planning for next week. He had called Angel while we were at lunch to let us know that he wanted to take Turtle down to town to top off some fluids and when I told her that tomorrow morning would be best, she noted that he was actually already with the car downtown so that we had to scratch our plans to go to the Galleria and would do it another day. I remained back at the clinic to see whether any new patients came in the afternoon (they did not) while everyone else went back to the house to relax. I was happy to sit in clinic and get some typing done which is what I would have been doing at home, so it really wasn’t any kind of a burden.

As I had mentioned previously, connectivity to the outside world here has always been an issue for everyone, including me and my accompanying residents. That’s not to say that there is a lack of infrastructure here to enable one to so, just that it can be a bit complicated at times. To begin with, and to orient those who are not familiar with the communications infrastructure here, everything is based on cell technology. For all practical purposes, there are no land lines here and there is cable technology. On the flip side, there are a great number of cell towers and the coverage overall is excellent. Deep in the Ngorongoro Crater and in the middle of the Serengeti, cell service is excellent and you can make calls and get your email with ease. On the other hand, cell technology can also become easily overloaded depending on the number of people accessing your local cell tower. Sitting in Citizen’s Bank Park (The Phillies home stadium) for a ball game is like being in a cell wasteland as 30,000+ fans are all trying to access the same cell tower.

We had gone to town the other day so that everyone would have local sim cards mostly to access everyone’s email and WhatsApp (our main communications app here) and that seemed to be taken care of. Ke Zhang, FAME’s networking guru and otherwise all around amazing guy (currently a first year interventional radiology resident in Boston), had spent his last visit here working on revamping the WiFi network at FAME and also linking in the volunteer houses which was going to be godsend. They had needed some network switches which I brought when I came, but after plugging in everything, there still was no internet at the houses and so Sangale was working on trying to get things more operational. He eventually found a problem in one of the pairs of fiberoptic cables and once replaced, everything worked like a charm, and we had internet down at the Raynes House. It was like a new era here at FAME.

I made it back to the house well before 5 PM and shortly thereafter, Ray, Mike and Kyra went out for an afternoon hike. They were gone for a good bit of time, always a concern here where you can actually run into some stray Cape buffalos or elephants as we’re just on the border with the Conservation Area and many animals will stray over into the coffee fields and towards FAME. Of course, they eventually returned safe and sound having only made a few wrong turns along the path I had shown them last week. Ema was not yet back with Turtle and we had planned to go to Happy Day tonight, so I was getting just a bit worried about that. Of course, he showed up with more than enough time to spare, so at 7 PM we all piled into the Land Rover and departed for town. Happy Day is a small little Pub where, on Wednesday nights, all of the ex-pats in the area will meet to relax and share stories. On arriving there, it was immediately apparent that Happy Day had received a significant remodeling upgrade since my last visit there. The deck now had lovely and colorful outdoor couches rather than the picnic benches that I had become accustomed to over the years since coming to FAME and enjoying evenings at Happy Day. It was quite a welcome change, though, considering how comfortable they were and it easily brought the pub up several notches on the luxury scale in everyone’s mind. It was a great relaxing evening enjoying stories among our group, Reema and Margaret and our friend, Nish, owner of the African Galleria, as most of the other ex-pats had departed earlier.

Tuesdays are our educational days here that begin at 7:30 AM with a half hour lecture by one of the visiting volunteers typically. This would be our first of several lectures during our visit here and Marissa had volunteered to discuss Cerebral Palsy which was incredibly apropos to the day that she was about to have in clinic. The lectures here are sometimes challenging for a number of reasons, only one of which is the language barrier. Though every caregiver at FAME speaks English and both rounds and medical records are in English, it is often difficult to be certain that the language we are using, both the English and medical, are being perfectly understood by the doctors in the audience. Speakers tend to use medical terms that may not be common and it is natural for speakers to sometimes talk fast, both out of some level of anxiety and the time constraints that exist as we only have 30 minutes to cover a topic. I will often briefly stop the talk to make sure that everyone understands what the speaker said or to give the generic name instead of the brand name which is not used here. Over the years, I have become accustomed to doing this as it is not second nature and the clinicians here are far too polite to interrupt a speaker and ask them to clarify. They leave that to Frank and me.

Marissa’s talk was perfectly constructed to cover all of the various types of cerebral palsy, the typical causes and the treatments that can be offered (not many) in these patients. It was at the right level – remember, the clinicians that we work with here are either clinical officers (essentially independently practicing nurse practitioners or physicians assistants), assistant medical officers (two years of additional training beyond the clinical officer) and MDs who have only completed an internship and no residency. Residency trained physicians are more of a rarity here as there is no system to support education such as we have at home in Medicare. Our residency programs are support by Medicare which allows residents to be paid a salary whereas here, one must pay for the majority of residencies (when they are available), which is out of the realm of reality for most individuals, or they will have to have a sponsor. There are very few specialty residencies in the country, too boot.

After Marissa’s talk it was time for morning report and the very first patient presented, by nature of her room, was the young 2-year-old infant with the encephalopathy that we had been following. Her summary was so brief that I nearly missed and wasn’t entirely sure that I had heard it correctly, but 30 minutes before our lecture, she had vomited while her mother was feeding her and then coded after an apparent aspiration. Despite all attempts to resuscitate her, she died. I found all of this out after report, because as I said, I didn’t catch everything when it was originally presented. Marissa and I discussed it after we were certain that she had passed and were both very disappointed that we hadn’t been able to do more this child. She died without a definitive diagnosis which is always frustrating for us, but we had little else to look at. Her second LP had been very benign other than a possible elevated opening pressure which may have indicated elevated intracranial pressure related to whatever process what going on. She very likely died from the aspiration, but her increased ICP and the underlying process she was suffering from also very likely played a significant role in her death. It was very unfortunate and it had affected both Marissa and I as we were the two that had been involved with her case.

The family member of the gentleman with the subdural hematoma from yesterday came in this morning to speak to us, but the patient didn’t come as it was difficult for them to get him here. We explained everything to him and the fact that they would need to go to Arusha for surgery to evacuate the hemorrhage. He would very likely recover some of his function specifically in regard to his confusion and possibly his right sided weakness as well. I had reached out to the neurosurgeon in Arusha to make her aware of the patient and had also asked what funds they would need to bring with them in order to be treated at Arusha Lutheran Medical Center, where she worked. The amount was 500,000 Tanzanian shillings, or about $217, for the surgery and care that was required. The family indicated that he would go back to his village to raise the money and they would travel to Arusha the following day. As the patient had been stable for the last month, we didn’t feel that another day delay would be a huge issue.

Marissa’s day was made up of almost all children with profound neurological disabilities secondary to either birth related injuries or childhood infections that had, unfortunately, occurred previously. Many of the children were cortically blind (typically related to occipital lobe involvement of their prior process) and had profound static encephalopathies, meaning that they had global impairment of cognitive function and were able to do very little, let alone anything for themselves. Most of their stories were very similar, whether their injury had occurred at birth or later, but the most significant fact was that their families had cared for each them impeccably with whatever resources they had. Most of these families bring their children to us with the hope that there is some cure, but unfortunately, that is not the case as there is no primary treatment for them other than to treat symptomatically – physical therapy, treat their epilepsy if it’s present, and possibly their spasticity with baclofen which we do have here. Several of the mothers were in tears when Marissa told them that their children would not recover, others had been aware of this without being told and took the news with far less emotion. Regardless, it was difficult for Marissa as she presented case after case of these children and felt that she had very little to offer them. I reassured her that they were far better off having seen her and that her care would now enable the families to focus on what could be done rather than continually searching for a cure that didn’t exist.

I have spoken on several occasions in the past of Ståle Anda, a wonderful Norwegian man who runs an orphanage in Mto wa Mbu, and cares for many neurologically impaired Maasai children, a number of who have muscular dystrophy and we have seen over the years. Ståle came here several years ago and, like everyone else here, decided to stay and open his orphanage to care for these children whether it was in his orphanage or whether he would assist with their care with them living at home. Either way, he has served as a saint here for many children who would otherwise have been abandoned and died. Ståle couldn’t make it today, but we saw several patients that he sent up including one young man with a muscular dystrophy or congenital myopathy. Unfortunately, the boy was now well into his teens with severe muscle wasting that was mostly proximal as one would expect. Thankfully, this is one of Ray’s areas of interest so he chose to tackle the case with Mike Baer, who is planning to go into neuromuscular disease. There was very little of his history or family history that was obtainable as he was now in the orphanage and given his advanced disease it was very difficult to further characterize his progression of disease over the years that would have been essential to make the diagnosis in the absence of other information such as genetic testing. Ray noted that his best guess in this patient would an autosomal recessive limb-girdle dystrophy, but, unfortunately, that would be the best we could do with the information at hand.

During the day, Frank advised me that a patient was traveling here from Arusha to be seen and that he wanted our help with them as they had developed monocular visual impairment the day prior. The patient was in his mid-fifties with diabetes and hypertension and reported that he had been driving the day before when he suddenly lost most of the vision in his right eye. Frank had Sehewa, our nurse anesthetist/optometrist see him first, and he dilated his eye and did a brief examination, but we felt the problem was going to be vascular and more likely in our realm. He had some hemorrhage on his fundoscopic examination raising the question of central retinal vein occlusion, though it was not florid enough to warrant the “blood and thunder” description that is most often used for this entity. After thoroughly analyzing the case, it was felt that the patient had an ischemic optic neuropathy, which is an ischemic event of the optic nerve, so there was very little else to do at this point other than placing him on aspirin and providing further secondary risk management with a high dose statin and good blood pressure control. The prognosis for his condition would be that 40% of these patients have some recovery of their vision so he would very likely be left with some deficit going forward.

Towards the end of the day, Kyra had an interesting elderly gentleman who presented to clinic, brought by his son who I know, who has had a month-long history of difficulty with gait and back pain. His bowel and bladder function were normal. He had had no prior evaluations and on examination was found to have left leg weakness and right leg sensory changes with about a T7 sensory level making us concerned for a thoracic cord process. Though he did not have any clear symptoms to suggest systemic or pulmonary TB, we frequently worry about Pott’s disease here as we have seen several acute cases and many patients with the sequelae of this very disabling condition. Pott’s disease, or tuberculous involvement of the vertebrae (tuberculous spondylitis), can often present with neurological symptoms due to the erosion and collapse of the vertebral body as well as extension of the infection into the spinal canal, both causing cord compression.

We have had patients come to see us, as with many other catastrophic neurological disorders, many years after their bout with Pott’s disease, who are in a wheelchair with a paraplegia and chronic back pain. We have little to offer these patients other than to treat their pain as the neurological deficits once present are rarely reversible in the condition as with many other conditions affecting the spinal cord. We decided to obtain a plain film of the thoracic spine first as if this study demonstrated bony pathology in the spine it would have answered our question without going to additional testing, though a CT scan at that point would also have been helpful to know the extent of destruction, perhaps. The study, though, was negative, essentially ruling out the condition in regard to it causing his neurologic deficits, and now he would need to undergo an MRI scan of the spine to further visualize what was causing the issue and, hopefully, it would treatable. They had indicated that they would try to go to Arusha to have the MRI done to get the answer.

We made it home that evening after a very long day in clinic and Marissa have seen a tremendous number of devastated children. Ray’s first question for me as I walked through the door was whether we had any Zoloft handy for her. It would be impossible for her, or anyone else for that matter, to have seen that many children with these heart-wrenching stories and not to have been affected as she was. Regardless of the fact that we are doing unquestionable good here, we must also resolve ourselves to the fact much of what we see we are unable to treat, most that would otherwise be untreatable at home, though some that are the result of the limited resources available here and the reality of the region in which we are practicing.

This is the start of our first full week of neurology clinic at FAME and typically our biggest day. Because we had actually decided to announce the clinics on Friday and Saturday, though, it seemed less crazy today than normal. That may also have had to do with our new space and the fact that some of our patients were waiting outside and some inside giving us the perception that there were a few less patients. Regardless, we had plenty of patients waiting for us at the start of the day. Interestingly, each of our visits during the year, one in the dry season (our fall) and one in the wet season (our spring), have consistently had a significant difference in the number of patients with the busier season being the dry now by a factor of one-third. Over the last several years, we have seen approximately 400 patients in the dry and 300 patients in the wet season, consistently. The reason for this seems to be not only the difficulty in transportation in the wet season as some of the roads to the more remote areas may be impassable, but also the fact that some of the planting occurs in the wet season. Either way, the experience for the doctors here and the residents has continued to be a positive one and, for this reason, we have continued to come back year after year. We’ve already seen approximately 75 patients in our first three days of work here which, though not a record, has certainly been a good start for us.

Morning report was rather short, and the first thing that we noticed is that we did not hear about our poor Hadza woman which would mean that she had passed about Saturday night into Sunday morning given that we were not at report yesterday. We confirmed this fact later after report and were grateful to hear that her suffering was not prolonged. She was really not on support of any kind as she had not received feeding and her IVF had been stopped. There was nothing in her appearance to suggest that she was suffering any physical pain so there was no need for us to administer anything from that standpoint. She had very likely slowly slipped away as a result of her intracranial hemorrhage and probable hydrocephalus.

Though the volume of patients seemed lighter than normal, we still managed to see the same number of patients that we had on the other days and the neurological illnesses that we saw remained essentially the same with an excellent distribution of disorders. The pathology that we see here is actually excellent from a teaching perspective and the residents have a great learning experience from that standpoint as do the FAME medical staff that we’re working with and any others sharing in the experience.

The case of the day, probably, was a gentleman of about 80-years-old that Mike saw who had been normal until about one month ago, and then had begun to lose his ability to walk and communicate properly. There had been some concern as to whether he was encephalopathic or aphasic on his examination as it is always more difficult to determine this when you’re dealing with one and sometimes two translators, but there was very little question that he had a right hemiparesis with increased tone. There was no history of trauma and he had not complained of a headache at any time. Our main suspicion was that he had an underlying mass lesion or a stroke and it would be necessary for us to get a CT scan of the brain with and without contrast with the possibility of a mass being on the differential. MRI scans are so much more sensitive for detecting tumors, but the closest MRI scanner to us is in Arusha and the cost is more than double that of the CT. Thankfully, the family was able to raise the funds necessary for the CT scan (200,000 Shillings, or about $86) and returned with the payment in several hours.

The price of the CT scan, though quite significant for local residents here, is dramatically less than it would be in the US (by magnitudes) and the cost can often be a hurdle that can’t be overcome here. In East Africa, patients and family members will go their village or other family members to help with the cost of medical care as these burdens are considered to be shared and not that of the individual. This is a very significant feature of the culture here and has to do with how community property is viewed. A wonderful discussion of this phenomenon can be found in African Friends and Money Matters that is well written and discusses specifically how both money and knowledge are shared in East Africa and are completely opposite of how we approach these issues at home in our own culture. Also, the issue here is that although there is a national health insurance that Tanzanians can buy into, most do not and have to pay out of pocket for any medical expenses that are necessary. This then necessitates that  patients are charged for services they receive at FAME and, though they are very, very reasonable, they can be quite out of reach for others. Both Angel and Kitashu will often work with patients to assess what they can afford and if there is anything that can be done for them, they will do it. If medical care were totally free at FAME, they would be immediately swamped with patients from all over the country who would have traveled days to get here for free medical care. That system would immediately fail as there would be no sustainability.

In addition to the issue of a patient being able to pay for their medical care (which, by the way is very reasonable at less than $2 for a new patient visit), it is imperative that one considers what you will do with the results of a positive test before it’s ordered. Sending someone for a costly test such as a CT scan or MRI scan should also include a discussion of what you might find and where that might lead in regard to potential treatments. Obtaining a scan demonstrating something that requires surgery when the patient or family is unable to afford the cost of surgery is really a needless study. Of course, that discussion will also include all of the possible alternatives such as traveling to Dar es Salaam if one has the government insurance perhaps, but in the end, to be seen in Northern Tanzania or elsewhere, one must have the necessary funds to pay or, at the very least, to provide a deposit. There are very few, if any, social safety nets here which can often be a struggle.

Our patient returned towards the end of the day to have his CT scan and we were rather thankful that they were able to do it. The scan demonstrated a very large chronic (old) subdural hematoma with midline shift that was clearly causing his neurologic deficits. There had been no history of trauma or complaint of headaches and, yet, he had a finding that we usually associate with both of these factors. Given the amount of compression and midline shift, doing nothing at this point would probably ensure that he would worsen at some point and what he really needed to have done was to undergo an evacuation of hematoma which would hopefully relieve the pressure on his brain enough for it to rebound somewhat, though the expectation would be that he would not fully recover. At his age, it would be likely that the brain would not have enough resilience to reoccupy the space vacated by the evacuated blood. This can result in the situation where he will be more likely to reaccumulate fluid in the space, otherwise known as a subdural hygroma, or, worse yet, have a recurrent hemorrhage back into the same space. We discussed the CT scan with the patient’s son, who had accompanied his father to clinic, and rather than admitting him to the hospital since he had been stable for a month, he went home to return tomorrow morning so we could discuss the various options for treatment.

As we had no internet at the house – just for perspective, we have never had internet at any of the houses – everyone (save Mike) wanted to stop by the Vodacom shop after work to get local sim cards for their phones so they would be able to contact the outside world on a more reliable basis than borrowing the data from my iPad (not that this was an issue, of course – please read that with a bit of sarcasm). We loaded into Turtle at the end of clinic and with little time to spare and made our way to the Voda shop with Phoebe in tow to help out if needed. The group piled into the shop to make their transactions while I waited out front with the vehicle and made lots of new friends, while also seeing many old ones, during the time I was out there. Stopping on the street anywhere in town we are very likely to attract attention and over the many years of being here, many of the local “street merchants” know me by name. I never buy anything from them, but they somehow continue to tolerate me and there are several young boys who I have seen grow up on the street trying to make ends meet. After about 45 minutes, everyone finally emerged from the shop with smiles on their faces, a definite sign that they had been successful in their quest.

We drove back to FAME as our dinners were there waiting for us as was the veranda and a cold beer (for some of us). It had been Ray’s first day in clinic and I was genuinely interested in his impression of the patients and how things went. It was clear that he had an amazing time staffing the residents as I had imagined he would, for here it is medicine the way medicine was meant to be practiced (sorry for those who have heard this multiple times before from me). It is medicine for medicine’s sake and no other. We are the lucky ones to have had the opportunity to work here in this amazing country and with these amazing people.

Everything was settling down for the evening when I received a message from Dr. Gabriel that they had admitted a 30-year-old gentleman with the worst headache of his life. After asking a few questions and realizing that Gabriel wasn’t in the ward, most of us decided to head up to the ward and check out the patient. The story was just a bit different, though we certainly had some concerns about the patient, mostly from an infectious standpoint (he had a low grade temp) and had recommended a lumbar puncture to rule out meningitis. The LP would most likely not get done until the morning as the lab was apparently not set up at night to do the cell counts, so we told them to call us if he worsened, but that he should be placed on antibiotics if he spiked a greater temp than where he was. It was back to the house and we relaxed for the remainder of the night as we had our educational talk to attend at 7:30 the following morning.

 

As many of you have come to know, Sundays here are reserved for me to take the team to a National Park on a game drive. Just as an FYI, “safari” in Swahili simply means “journey,” and has no specific relationship to a game drive. The work has become synonymous with traveling to the parks to see wild life and has stuck, obviously evidenced by the huge Safari industry that exists here in Tanzania and other African countries that have built up this aspect of their economy. If someone here asks you how your safari was, there are asking you how your travel here was and not how your game drive went. Today, we had decided to go to Lake Manyara National Park which is very close and is a great first experience for those who have not been here before or have not been on a game drive. It’s also one of my favorite parks for several reasons. It has spectacular views with a very diverse landscape and it’s incredibly easy for me to navigate as the lake is on one side of the road and the sheer cliffs of the escarpment are on the other side of the road. It’s difficult to make a wrong turn here. There are plenty of elephants and hippos here along with all of the other normal players and they also have plenty of Klipspringers, a small rock antelope that can very scarce in other parks and is not often seen. Everyone was very excited to be going on a game drive today.

Prior to this trip, I had convinced Ray Price, our residency program director and colleague, to come with me to Tanzania with us for at least a part of the month. In turn, Ray had somehow convinced his wife to let him come with us despite having two small children at home, though I do believe his mother-in-law was still a bit skeptical of the proposed arrangement. Ray has been a huge part of this program since my move to Penn and has made it possible for me to bring the number of residents that I do. The rotation has also become a large part of our residency program and has attracted top candidates who have an interest in global health. Ray had had a meeting to attend in Minneapolis last week, so had made arrangements to fly from there into Kilimanjaro and then meet up with us at the park entrance at 6:45 AM, taking a very early (3:30 AM pickup) transport from the airport hotel where he slept a few hours before meeting his driver. Everything went like clockwork in that he made his three flights, got to the hotel, met his driver and then met us at the designated spot which was incredibly impressive considering all of the moving parts we had to deal with. Unfortunately, Ray made it to the meeting place, but his luggage did not as sadly, KLM had left it behind in Amsterdam to arrive on the next flight in and since there is only one flight a day, it would be coming in tonight and hopefully delivered to FAME tomorrow. Thankfully, he had packed an extra pair of safari pants and shirt in his carry-on luggage and I was able to loan him an extra safari hat that I had.

Our day didn’t begin quite as early as Ray’s, though we were up and out of the house a minute or two after 6 AM to make the 40 minute or so drive down to Manyara. We had our lunches, lots of water, camera gear, binoculars and lots of snacks (The hot and spicy Cheez-Its were a particularly popular choice for the trip). It was very overcast on our drive down towards Mto wa Mbu and remained that way throughout most of the day which was fine with us as it kept the temperature down, though on the occasion when the sun peeked through, the direct equatorial sun made its presence known and things heated up very quickly. Ray was in the parking lot waiting as we arrived to the park and, after a brief reunion, I went to pay our fees to enter the park. To begin with, I should mention that there are very few non-safari company guides who check in at the parks in general. Self-drives are perfectly legitimate here, but it’s just that they are by far the minority of vehicles in the park at any one time and that is by a magnitude of difference. On a day long drive in a park I may see one other safari vehicle driven by a non-guide. The problem this morning though was that the credit card machine was apparently not working, so after several attempts, I was told just to drive in the park and I could pay later when I was exciting. I was just a bit surprised at this as the parks here are very closely guarded national treasures and entrance to each of them is heavily scrutinized by armed park guards.

After using the restrooms, we popped the top on the vehicle and readied it for our game drive which included breaking out my camera equipment. I drove to the gate informing the guard that I was told to pay on my way out with the feeling that I was somehow going to be either arrested or shot on the spot at some point passing through, but thankfully neither of these events took place. For those of you who are worried, though, I will reassure you that Andrea is my designated alternate driver as she is the only other one here who can drive a stick shift. No worries, as I’ve reassured her that driving on the right hand side and shifting with your left hand isn’t really that tough.

Driving into the park, one first encounters a dense forest that goes on for several kilometers and though there are abundant animals here, they are somewhat hard to spot through the vegetation. Both greater and lesser hornbills fly overhead from tree to tree and you very quickly come across one of the many baboon troops that populate the park and love to sit in the road. The troops have consistently had many babies which is always good to see as it is a sign of the troop’s health. Our first stop is going to be the old hippo pool and platform, though, over the years, the pool has become overgrown and the platform quite rickety. Fortunately, there are still hippos here, they are just more difficult to see at times and are in different places. Driving up to the area, we quickly come across a large herd of Cape buffalo resting in the morning hours. Cape buffalo can be very dangerous animals when they are threatened and they are one of the only animals that will defend themselves against predators (lions) by forming a semicircle with the males facing our and ready to use their incredibly impressive and sharp horns to skewer whatever may be threatening them.

One animal more dangerous than the buffalo, though, is the hippo and we ran into one rather quickly who was crossing the road in front of us with her calf, making her even that much more dangerous. We quickly noticed that she was injured as she was unable to place any weight on her right front leg and was having difficulty lowering herself into the water. We remained a good distance from her while she was on land, but once in the water we were able to approach her and her calf as hippos are much more secure off land and would rarely attack. We watched the two from a close distance for some time before finishing our drive around the marsh where there were tremendous numbers of migrating birds that including pelicans, storks and flamingos. A beautiful African Fish Eagle sat very still on a nearby tree watching over the wetlands spotting for its next prey.

The weather remained overcast for most of the day and the temperature was on the cooler side making for a more pleasant drive. During the drive, we did encounter our fair share of tsetse flies which were quite annoying for everyone other than Ray and I as they somehow stayed away from the front seat which was quite OK with me. Their bite is very painful and they are very difficult to detect until after they’ve bitten. The rule in the vehicle is that it’s fair game whenever a fly is spotted on someone to strike it as hard as is necessary to kill it. They are very slow and easy to swat, but unfortunately, they are very hardy and difficult to kill. When you think you’ve done one in, it simply flies away so it’s necessary to either crush them in your hand or stomp on them with your foot. The tsetse are famous for carrying sleeping sickness, or trypanosomiasis, but there is essentially none in Tanzania. Regardless, their bite is quite painful and develops into a nasty welt that may last for days. And, oh yes, they laugh at even the most powerful of bug sprays.

We spotted all the usual suspects on the drive that included elephants, giraffes, impala, wildebeest, zebra, wart hogs, and buffalo. We also spotted several pairs of klipspringers, which are the small rock antelope that live in certain areas of parks, but are most often seen here at Manyara. By the time we reached the picnic area at Maji Moto (hot water), named for the hot springs there, it was lunchtime. We had made sandwiches and hardboiled eggs with lots of snacks and sat together at a picnic table under a shade overlooking the lake. Before lunch, everyone had a chance to walk out onto the new boardwalk that reaches out into the lake while I sat with the vehicle.

Spending time on a game drive can be incredibly exhausting and we had begun our drive a little after seven. By the time we left the park after 3 PM, we had been there for eight hours straight with most of it driving other than our lunch. It had become a bit warmer in the afternoon, but overall, the weather had been just perfect for the entire day. Everyone had had a wonderful time in the park and I had enjoyed driving them. We stopped into the African Galleria on the way home and made it back to Karatu in time for dinner, so stopped at the downtown Lilac Café where we waiting the standard 45 minutes for our dinner, but everyone enjoyed it. We introduced Ray to the Raynes House where he settled in, though still without his luggage. Hopefully, it would be on the KLM flight arriving tonight and delivered tomorrow, but there was no way of knowing that for sure. Tomorrow we would begin our busy week-long neurology clinic at FAME and, the following week, the mobile clinics.

 

 

Saturdays at FAME can often be a bit slower than weekdays and the staff is a bit lighter, but we’re open for the entire day to see patients. Things worked out rather well for us today and even though there were the same number of patients as we had on the prior two days, it was just that much more efficient so it looked like we would be finishing a bit early. The day was filled with mostly headaches, an essential tremor and Marissa had to deal with a full term 1.6 KG infant. Our little two-year-old child who was febrile and encephalopathic seemed to be doing a bit better and her fever curve seemed to be trending downward. We still recommended another lumbar puncture since the previous one done ten days or so ago had been totally bland. Her case remained a mystery and, though she was improving, she remained on multiple therapies which isn’t the most comfortable thing for us.

The big news of the day perhaps was the Hadza woman with the hemorrhage who we had scanned yesterday and admitted to the ward. At morning report, we learned that she had had another seizure and was now worse than she had been when we had last seen her. She was no longer very responsive and wasn’t really moving her right side as spontaneously as she had the day before. All this was very worrisome, though we didn’t have a very good feel about her to begin with. We sent her for a repeat head CT with contrast along with a CT of her chest and abdomen to look for any source of a hemorrhagic metastasis (we hadn’t seen a met and it was just in our differential, so we didn’t want to move her twice to CT scanner if it was needed. The chest and abdomen scans were unrevealing, but unfortunately, the head CT demonstrated further progression of her now clearly subarachnoid blood extending into her ventricular system including her fourth ventricle which was enlarged. She was quickly developing hydrocephalus and would very likely herniate and die if she didn’t have an EVD (extra-ventricular drain) placed which was something that we could not do here at FAME and she would have to be sent to either Arusha or KCMC (Kilimanjaro Christian Medical Center) to have that done.

The real problem was that she had suffered a devastating neurologic injury that, even with the EVD, she would not recover from in any sense to become independent or even a reasonable quality of life. She had already damaged her dominant hemisphere which made her aphasic and would very likely not be moving her right side again. Referring her to Arusha or to KCMC was clearly the wrong thing to do and everyone agreed that we should make her comfortable and allow her to pass in a dignified manner. This would absolutely need to be discussed with her family, which was the next step, and something that can often be difficult through translators. I recall a number of years ago when I had to tell a young Maasai mother that her eleven-year-old son who I had just diagnosed with muscular dystrophy would very likely not grow up to be a Maasai warrior. Using a Maasai interpreter, I had carefully and compassionately chosen my words and allowed her plenty of opportunity to ask me questions along the way and she did have some. She listened with what had seemed almost like a detached affect and I had thought to myself how different we were culturally, but the in the end we were both parents of children who only wanted the best for them – to grow up healthy and suffer no pain. She had remained stoic and emotionless for what seemed for such a long time, but then suddenly broke down in tears and it was very clear to me at that moment, as it always has been throughout my life, that we were of the very same cloth despite whatever outward differences were obvious. Looking into her face was as if I were looking into a mirror.

Our Hadza patient was from a dying tribe, a group of ancient and anthropologically very distinct people that represent the last of the hunter gatherers in Tanzania, still speak click language, hunt with bows and arrows, and are most closely related to the bushman of Southern Africa. They number perhaps 1500 individuals and live in the Lake Eyasi region where they are being slowly displaced due to the loss of their game. They are now left to hunt dik dik (the smallest of antelopes in Africa) and baboons for subsistence. Their large game is now gone and other tribes have begun grazing cattle on their land. Our patient was a member of this unique group of people who will very likely not survive the coming decades and she was brought here for us to treat only to find that the best option was to let her die in peace. She wasn’t the last of her tribe, but she certainly could have been. Her daughter, who was the only member of her family who had traveled with her, remained at her bedside.

Dr. Badyana accompanied both Mike and I to speak with the daughter as we had already spoken with Dr. Frank who had agreed wholeheartedly with our plan as had Daudi Peterson who has sent her to us in the first place. Knowing that the daughter, who was alone here in Karatu, could be easily overwhelmed, I sat next to her on a small seat and began to explain to her what had happened to her mother and why she was getting worse. I showed her images on my phone from the CT scan that I’m fairly certain she understood as I would have expected any family in the US to understand. It wasn’t a medical lesson, but merely a means of demonstrating to her that something very bad had happened to her mother and that regardless of what we did, she likely not going to survive nor recover in any meaningful fashion. Badyana did an excellent job of interpreting this rather complex set of circumstances. She had few questions, but made it clear that she didn’t feel comfortable making decisions without knowing that Daudi was aware of things and we told her that he was, but that I would also try to reach him if I could. As with the Maasai mother several years ago, I could have been having this same conversation with a patient’s family in the US. Despite her ancient heritage and the differences between our worlds, I was very comfortable that she understood the gravity of the situation and the fact that her mother was going to die. I consider these moments one of the greatest honors in practicing medicine, to help a patient or family through this process.

Meanwhile, on the complete opposite end to spectrum, I went with Marissa to the nursery to evaluate the little 1.6 Kg full-term baby who had come in the night before. Her mother had gone to KLH (Karatu Lutheran Hospital, the local government hospital in Karatu) in labor and with polyhydramnios. She had a C-section there and the baby was immediately sent to us, while the mother remained at KLH as she was post-op from her section. The baby looked wonderful and seemed to be completely intact neurologically which was obviously a very good thing. She was tiny and was receiving IV fluids, was urinating, but hadn’t had a stool yet. Of course, I am of very little help in these situations, working next to pediatrician, but I stayed for moral support as Marissa did her complete assessment and made her recommendations. I am merely a facilitator here and can help answer questions or offer common sense, but anything more specific than that came directly from Marissa. We would continue to follow the baby here and were looking forward to the mother arriving to feed her and to see exactly how she was functioning at that point. As we were heading to Lake Manyara on Sunday, we wanted to make sure that everything was doing well and would evaluate her again on Monday.

We were finished in clinic and it was market day in Karatu, so we decided that I would drop the group off in the market and then we would head up to Gibb’s Farm for drinks and to watch the sunset. Every town with a Maasai population has a market day usually two times a month in which all the Maasai from the surrounding bomas will come to town to sell their livestock and other wares. There are also lots of others selling things at the market and, most notable, those selling used clothing that arrives in huge 4x4x6 foot bales, or thereabouts, that are bound tightly and have been shipped primarily from the US. They are comprised of donated clothing and it is not uncommon see a T-shirt with the losing team as the champion as they are all shipped here after the game. I’ve mentioned a wonderful book before, The Blue Sweater, in which the title comes from this practice of selling donated clothing in Africa, but the book itself is about how one individual can realize their dreams and change people’s lives, though, unfortunately, as is often the case, politics get in the way to nearly unravel all the good that is done. It takes place in Rwanda so it takes very little imagination to understand the consequences that take place in the book. It is well worth reading and I highly recommend it.

I dropped the group off at the Maasai Market, which is a sea of humanity selling everything under the sun, literally. My only instruction to them was not to buy any livestock, but everything else was fair game. I was heading into town to buy groceries for our house and our safari the following day. I told them I’d be back in an hour to pick them up at the same spot I dropped them off. I received a text from Marissa in probably 30 minutes that they were done and needed to be rescued. This was not surprising as the market is incredibly overwhelming and claustrophobic while the entire time you’re being followed and hounded by individuals trying to sell you something. Telling them “no” is not always sufficient and it can be very, very intimidating to say the least. I wanted them to experience it, but was not surprised with the quick rescue call and I quickly finished my shopping and drove back to the fairgrounds where my group looked a bit harried, but still together and smiling. No one had bought a thing as they hadn’t wanted to open the flood gates.

We drove home from the market to change and then head up for a relaxing evening at Gibb’s Farm. The back road that I take to Gibb’s can be a bit intimidating for those uninitiated, but it saves time and, besides, it a blast for me to drive. As long as it hasn’t rained, in which the entire road becomes a slip and slide event, I always enjoy driving this short cut. Despite their fears, we made it to Gibb’s in one piece to enjoy the amazing scenery of this world-class resort that ranks in the very top echelon of five-star destination resorts. I have one resident, who upon visiting Gibb’s, decided that she was going to get married there (you know who you are) and another who is planning to renew her wedding vows at some point in the future. (you also know who you are). It is that beautiful and spellbinding and it never fails to take everyone’s breath away with every visit. We found Margaret and Reema, the two anesthesiologists from UCSD, still there from their earlier lunch that day and an empty table on the veranda for all of us to sit and watch the sunset. It was incredibly relaxing and worth every minute as we sat until long after sunset enjoying our drinks and just sharing stories. I drove Reema and Margaret home so they wouldn’t have to get a taxi and, yes, I took the same exciting short cut just for effect. We made it home with plenty of time for Marissa to cook dinner (we hadn’t eaten yet) and to prepare lunch for the following day at Lake Manyara. I had very little to do as the residents and Leah had pretty much taken care of everything by the time I turned around. We were planning to leave before sunrise, so everyone made it to bed early with thoughts of all the wild animals that we’d see tomorrow.

 

 

It’s another gorgeous morning, though heavily overcast. No worries as it will burn off well before noontime and the skies will clear. The temperatures have all been much less than the team had anticipated which is a frequent misperception. Though the sun here on the equator can be brutal, shining directly down upon you, the days are very comfortable and the nights are rather cool. Doha was an oven with temperatures well over 100°, but here it is pleasant and the walk to work is always a joy. It’s our second day of clinic and at morning report we learned of a patient, a Hadza from the Lake Eyasi region, who had been sent in overnight with a headache and was now in the ward waiting to be seen by us. Once we checked to see what there was to be seen  in clinic, I would have one of the residents break off and see the inpatient. The Hadza, or Hadzabe, are one of the bushman populations of Africa and are the last hunter gatherers still in existence here in Tanzania. They live in the Lake Eyasi region which is a very remote area and where we used to do a rather large week-long mobile clinic every month to provide medical care to the Hadza as well as the Datoga, who were another tribe in the Lake Eyasi region. We no longer do these mobile clinics as the project ended when the grant funding had ended. We had made good contacts in this region, though, and continue to see patients referred to us based on the work that FAME had done there previously.

This morning, I had opened up the ward where our exam rooms are so that Angel could get to her computer before we were done with morning report, but somehow, instead of the patients waiting outside where they sit before being brought in, they ended up in the ward and it was a bit of a mob scene. Angel quickly got things under control, though, and we were able to get started essentially on time. Marissa had a steady flow of pediatric cases, but several of them had very depressing histories of either hypoxic-ischemic injury at birth or some meningoencephalitis as an infant that left them with severe static encephalopathies, a few with seizures, and all completely non-functional. We had very little to offer in terms of treatment other than to give them their seizure medications and some baclofen for their spasticity. Marissa was incredibly impressed with the care one of the children had been receiving as they had absolutely no contractures and had been receiving physical therapy. One of the children had gone through about two hours of resuscitation at birth and was very devastated neurologically. This is certainly part of the resident’s education here in regard to unintended consequences meaning that you have to consider all of the consequences of your actions and that what we often perceive as doing good came result in a dramatic outcome that may create an unreasonable burden for another.

By midmorning, Mike had been able to see the women from Lake Eyasi and the story was a bit different than just a headache. This is quite common for us here as patients are not always as they are “billed” and the story may be entirely different than what you were told once you get an accurate history. She was a 55-year-old woman who had been complaining of a headache over the last month and two weeks ago, she had had a generalized convulsion. Since that time, she had been completely mute and on examination she had impaired language function and a right hemiparesis. Having the history of the preceding headache, the seizure, and now the focal examination made us extremely concerned about a focal left hemispheric lesion. We set her up for a CT scan with and without contrast that was done mid-afternoon and demonstrated what a large hemorrhage with what we felt was vasogenic edema associated raising concern for an underlying mass lesion. Unfortunately, when she was given contrast, she had not been NPO and she promptly vomited and became diaphoretic. At least this wouldn’t preclude giving her contrast again as long as she had been NPO prior so as not to have the same problem. Meanwhile, we would also add CT scans of the chest and abdomen to rule out a primary mass lesion, though in the end, it wasn’t clear what we could actually treat in any of these scenarios. Having a primary brain tumor or systemic cancer with a brain met would clearly have a very poor prognosis regardless of what her underlying process was and we would very likely have a goals of care discussion with her and her family.

Our clinic day ended up being about the same size as the day prior, 25 patients and more than enough children to keep Marissa happy. We weren’t able to get back to the little girl in the ward with the encephalopathy until the end of the day and Marissa and I went over her case again. Despite having been on multiple therapies including anti-TB, anti-viral, etc., etc., she hadn’t really improved, but on the other hand, she wasn’t getting worse. We decided to recommend a repeat lumbar puncture for the morning  and, possibly, a repeat CT scan.

On returning home, several at the house wanted to go for a walk and I hadn’t yet taken everyone out to show them the walking trails around FAME, so in order not to lose anyone to the remoteness and unfamiliarity of this location, I took Marissa, Kyra and Andrea out for short walk. The area around FAME is primarily comprised of coffee plantations that back up the Ngorongoro Conservation Area and other fields growing an assortment of crops from pole peas to other legumes to maize. The weather was just gorgeous for a walk with the rolling fields most immediate in front of us with a few small herds of grazing livestock and their owners. In the distance, the Ngorongoro Highlands dominate the horizon rising up to the crater rim and the crater beyond. It’s incredibly placid scenery that I have become so accustomed to over the years, but is almost shocking to those who see it for the first time as this is not how one imagines Africa, perhaps. This is our Africa, though, and why I have continued to come back year after year.

It was Phoebe’s (the FAME volunteer coordinator) birthday today and she had invited all of us to come down to the Patamu Lodge at 7:30 PM for dinner and drinks. As we had our dinners prepared for us already, we decided to eat at the house and then head down. Neither Mike, Kyra nor Marissa were up to the adventure, so Leah, Andrea and I joined Dr. Joyce, Joyce Cuff and her sister Terri and we all drove down to the road to meet Phoebe, her friends and others from FAME near the tarmac at Patamu. Phoebe had also made a vegan chocolate cake that she thankfully cut before their food arrived (it typically takes up to an hour here for your food to be served) as we hadn’t planned on staying for the entire evening as we were all exhausted from the day. The cake was delicious (and messy) and we made it back home by around 9 PM. Mike had gone to bed already while the rest of us glanced at the stars for a bit, though the moon was brighter than hoped. Everyone retired early except for Leah, who had work to do on her emails, and me, working on my blog until the wee hours.

 

It’s like the first day of school for everyone, but me, of course. They have all been waiting to get started and today is the day. Mornings here are just so different than they are at home, mostly for the obvious reason that this is just different here. We have a schedule and have to be at morning report at 8 am today, but there are no pressures, no phone calls to make, no charts to close, no RVU targets to worry about. Everyone has had whatever they wish for breakfast (for me, it’s corn flakes, milk and a banana) and we head out the front door of the Raynes House (whether the front or the back door is a much debated topic here) to walk to the clinic. It’s a short 5 minute walk passing by the other volunteer houses (there are four of them) and through a gate that now leads past the new 25-bed material health ward that was just opened last month. FAME’s dedication to maternal and child health has been one of its main missions since the very beginning and this facility is yet another step towards reducing both infant mortality and obstetric morbidity. The number of deliveries has continued to increase on a regular basis ever since the first here at FAME in 2014 (attended by one of our pediatric neurology residents, Doug Smith, by the way).

Morning report takes place at 8 AM every day and where we hear about the patients currently on the ward and any new admissions that have come in overnight. There will frequently be neurology patients in the ward and it is very common that the patients who have come in overnight were admitted for neurologic reasons like stroke or headache. Today, we heard of a two-year-old child who had been admitted perhaps ten days ago and has been encephalopathic the entire time with intermittent seizures. She had undergone a lumbar puncture that was unrevealing and a CT scan that also read as normal. She had been maintained on antibiotics and anti-TB medications but had not been improving. This was definitely something that Marissa was going to look into as soon as we got to clinic.

We finished morning report at 8:30 AM and made our way over to where we would be holding our neurology clinics. Since the maternity patients had previously been held in Ward 2, but had now been more to the new maternity wing, such that Ward 2 was now empty. Not only would we have three complete examination rooms, but we had a large vitals room and plenty of space at the old nurses station for Angel to check in patients and do triage. I was made well-aware, though, that having this space for now did not imply in any fashion that I would have it in the future and that I should not expect to have anything near this perfect when I came back in March. Over the prior years, we had made our makeshift home at the night physician’s office, the emergency room and the hallway in between where we would often house an additional two stations for a total of four teams working at a time if that was what was necessary. This arrangement had managed to serve us well and we were certainly able to see our patients, but I have to admit that having the entire Ward 2 to ourselves was a real treat and we all looked forward to working in this new space.

Dr. Annie would be working with us again as she was the clinician here that had had the most interest in neurology going forward, though she also serves several other significant roles for FAME and we would have to be cognizant of that going forward. In addition to Annie, who would also be helping us translate, we had a senior medical student from KCMC (Kilimanjaro Christian Medical Center) who was on his vacation and had asked to spend time with us while also being willing to translate. Abdulhamid Shaban will be returning to help next week, so for this week we were planning to use either Angel of Kitashu (our social workers) to help as well, though they were also responsible for social work duties on campus which could be a real balancing act trying to serve both roles.

One of the big issues for our clinics has always been triaging patients. Since we do subsidize the clinics by offering to see patients, provide them with one month’s worth of medication, and check any labs all for the flat rate of 5000 Tanzania shillings (just a little bit more than $2 USD), it becomes very important that we limit our care to only those patients who have neurological conditions or problems. It would be impossible for us to see every patient who wanted to see us for other reasons and that is not our role here. I had originally begun triaging patients with William Mhapa (who is now the incredibly accomplished head of HR here at FAME while continuing to add degrees to his name) a number of years ago, though over the last several years, it has been both Angel and Kitashu that help with the triage. We’re willing to see any patient with neurological symptoms, but not those who have simple arthritis or some other joint pain. Again, it’s not a matter of not wanting to see patients, only the fact that we have a specific purpose here and do not have unlimited funds. FAME does charge patients for their care, albeit a very small amount, and a significant portion of their operating budget is made up of patient fees. Providing a mechanism for patients to avoid paying those fees would be ultimately self-defeating to the sustainability of FAME.

For our first morning, which was also unannounced, we had a fairly large group of patients show up to be evaluated. In the end, we did see 25 patients in clinic and another three patients on the wards – mostly children or newborns who were evaluated by Marissa. Everything worked incredibly smoothly and there were no real hitches that occurred throughout the entire day. The residents were incredibly efficient and the stack of charts for the waiting patients was decreasing in height very quickly. After lunch, though, Mike was seeing a patient who we had been treating for epilepsy, but who had apparently run out of her medication several weeks ago. While he was taking her history, she began to have what looked like shivering to him, but within a few moments, she developed a very loud ictal cry that reverberated off of the walls. She began to have a very clear cut generalized convulsion and was unresponsive. Several of us walked into the room to see what was up and if we could offer any assistance, but she began to have tonic stiffening of her entire body with an arching back such that she was very quickly launching herself out of her chair. Our main focus at that time was to lay her on the floor as quickly as possible while protecting her head and keeping her from aspirating by turning her head to one side. Her seizure lasted for about for about two minutes and she didn’t have a long post-ictal period, but there was very little question about what we had just witnessed (a generalized convulsion) nor was there any question regarding what needed to be done. We restarted the patient’s carbamazepine and stressed the importance of remaining compliant on the medication so something similar would not happen again. This is often not as easy as it sounds (convincing the patient to take their medications) despite the obvious results of not doing so. This is no different here than it is at home.

When Marissa went to see the young child that had been mentioned at morning report, she had found them having a focal seizure and was probably in status. This required her giving diazepam to the patient and also maximizing her phenobarbital dosing which eventually broke the seizures, but the child remained quite lethargic and our concern remained that it was whatever had been causing the seizures and the child’s presentation to begin with. We had little to go on so would very likely have to begin repeating tests that might have changed.

Another fun thing for the day was giving out baby blankets that I had brought from home to the new mothers and their babies. Mildred Staten, a wonderful women who I know from home has been knitting baby blankets at home with a group of friends (she recently told me they were called the knitwitts) for new mothers in some of the nearby hospitals in Philadelphia and had asked me some time ago whether this is something that might be appreciated at FAME. She took my very enthusiastic “yes” literally and has given me a large number of blankets on two occasions in the past, and had contacted me about a week prior to my departure this trip with news that she had accumulated another large group of blankets for me to bring. It is truly an act of love and goodness to pass on your own creations such as these blankets to travel overseas to a far off land to be given to those who you do not even know or have never seen. Today, I had asked Katherine, FAME’s communications director, to distribute some of these blankets to the mothers and their babies and to take photos of them as long as they were agreeable.

Since we were finishing on time today, we had decided to go downtown so that everyone could see what Karatu looked like, but then we had also decided to visit Katherine’s tailor, Teddy, who I have visited on a few occasions in the past with residents so that they could have her make items of clothing for them. The fabric here is just spectacularly colorful and beginning with my first trips here I have fallen in love with the nearly unlimited patterns. Those who have accompanied me have also loved these fabrics and have chosen to make many different pieces of clothing from skirts to shirts, pants to aprons, bowties to bags, and even a sport coat. We went to the fabric store first and then visited Teddy where everyone gave her orders and she took personal measurements to make sure that everything fit perfectly. All I was having made were some shoulder bags. Mike Baer was having perhaps the most unusual item of clothing made, though, that anyone has asked for on my trips. He was requesting that Teddy make him a jump suit, tailored to fit. I must admit that I hadn’t expected that, but we’ll just have to see what the finished product looks like when it is done. I’ll be sure to have him model it and share those photos with you.

It was now after dark and we made our way home from town up the FAME road that I have now driven hundreds of times. We were all starving as our dinners were waiting here for us at the Raynes House and we were all exhausted from the busy day in clinic and shopping afterwards. We would continue our work in the morning and all looked forward to the new and interesting patients that were awaiting us.