Wednesday, October 7 – A day to finish charts and documentation…

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The primary role of our work here at FAME from my very first visit and including the present has been to work with the doctors and nurses to provide them with all the necessary skills to evaluate and treat neurological illnesses in the residents of Northern Tanzania. By doing so, we would be fulfilling one the main missions of FAME and improving the health of the community relying on them for their medical care. Early on, though, we also realized the need to keep internal documentation of the types of patients that we were seeing and where they were coming from, to what tribes they belong, the diseases that we were treating, and what medications we were using to be certain that we were addressing their needs and would have the necessary resources available for each of their visits. Beginning in 2015, that internal documentation became an organized database that now contains well over 2500 patient-visits and provides an incredible cross-section of the neurological health of a large community in Northern Tanzania and a wealth of information that will enable us to not only continue to provide this care, but to do so in a more efficient and effective manner over time. Furthermore, the knowledge that is gained from this record may well translate to other similar communities in Tanzania, and even throughout Africa, as well as to other specialties beyond neurology.

This database has been continually maintained by the residents who have accompanied me here and, more recently, by a select group of medical students from the University of Pennsylvania who have not only demonstrated a keen interest in neurology, but have also shown their desire to pursue it as a career. Though it has never been the intention of FAME to provide medical students with a global health experience, the volume of data that we have been collecting has made this role very helpful, if not essential. Despite the fact that I saw far fewer patients than we do on a normal visit (140 as opposed to 400), I would still be responsible for making sure that we have all the necessary documentation to input each patient into our database, both new patients and return, as well as additional information for all of our epilepsy patients concerning their seizure control. My plan for today, of course, was to spend as much time as would be necessary to complete that task which was slightly more complex given the new EMR (electronic medical record) that we had just started using the first day I began seeing patients this trip.

Thankfully, FAME had seen fit to actually hire their own IT person who would be managing the EMR internally and that made my life tremendously easier. The EMR that FAME selected would have to be one that would be usable in Tanzania for Tanzanians and was not being developed for the volunteers who are coming, most of whom are very familiar with systems such as Epic that cost millions of dollars to install and would have been total overkill. The main problem that I encountered with the new EMR actually had to do with the report feature as I wanted to be able to pull up all of the neurology patients we had seen for the month and that feature just didn’t exist when I began to play with it. Thankfully, though, Valence, FAME’s new IT specialist, was able to go into the system and find the report that I was looking for which saved me an incredible amount of time. As with every new system, though, there are often oversights that weren’t anticipated and a glaring one that I discovered, at least from neurology’s perspective, was that the data regarding tribe and village was not being recorded in the patient demographics in searchable field. Some of the questions that we had been looking over the last several years had to do with whether there were differences in neurological disease, rates of return, and demographics between the various tribal affiliations and locations throughout the region that we draw from. This information, which had been included in FAME’s older demographic database and on the paper charts, would now require that I go back through all of the paper charts to update our records and make certain that we would have the necessary information to input into the neurology database, otherwise, it would be incomplete.

I came up to clinic around 8:30 am as I knew that Kitashu was going to be there to help me gather all the charts together. Then, I was able to create a list of all the patients we had seen in the EMR which allowed me to tell if one of the paper charts was missing as often happens if someone comes and takes it for various reasons. I sat down to start the process of going through about 120 charts (quite a big stack) when Kitashu came in to ask me if it was possible for me to see a young man whose father had brought him to clinic today as he could not find the boy yesterday. This was somewhat of an interesting excuse and I wasn’t quite sure whether to take it totally seriously, but in the end, it turned out to be very legitimate.

I invited the young man, who was about 24-years-old, and his father to come into the exam room where I had all of the charts strewn across the desk and table after finally getting them chronologically organized. Dr. Adam was there with me to translate, though it turned out that both the son and the father spoke very good English. Despite this, I typically want to have a Swahili speaking person in the room as certain things can be lost in translation and just to be careful, I have always stuck with this practice. When I asked what I could do for them, there was an initial bit of a silence, and then began a very long and saga that involve the son being away at college several years ago, becoming mixed up with other youths smoking marijuana, being sent home from school and the father taking him to the hospital not once, but several times for what sounded mostly like psychiatric admissions rather than just for drug rehab (which is really hard to find in Tanzania for the most part).

Over the last several years, though, the son had been following with district mental health officer and had been on a fairly strong antipsychotic medication, chlorpromazine, that had actually worked very well for him and it was only when he went off of the medication that he would become agitated or aggressive with others. The father was blaming the marijuana for his son’s issues, and even though this might be partly true, after I had clarified that the son did indeed have auditory hallucinations and paranoia, I was completely confidence that this young man, whose issues began initially when he was 18-year-old, had a pretty run of the mill case of schizophrenia that had been well controlled on the chlorpromazine. Though the marijuana may have temporarily made him acutely psychotic, or, should I say, more psychotic, it was not the underlying problem and marijuana or no marijuana, the boy would have had the same issues and needed to be on medications.

The father, meanwhile, had done a remarkable job of not only keeping his son safe, but also doing what was clearly the best for this boy by taking him to the hospital on several occasions to try to find help for him. Unfortunately, there are no psychiatrists around to manage these case, which is why we are often seeing them in our clinic, but I did know of a psychologist in Arusha who Frank has referred patients to in the past, and I promised the father that we would reach out to get that information for him as he was willing to do whatever was necessary for his son. Hopefully, we can make that connection for them and find some relief for this very caring father. In the US, the son would undoubtedly be in a group home as he was very well dressed and appeared to be functional on his medications.

I was finally able to get back to my charts, and other than meeting with Susan and Kitashu for a debriefing meeting, I spent the rest of the afternoon working on them and was able to complete perhaps just over half. I had wanted to get in my last bike ride of the visit and was determined to do so as this would be my last opportunity. I hopped on my bike and pedaled down the FAME road into town, paralleling the tarmac along the Tumaini School Road and then connected up with the main road out of town towards Rhotia. It was actually a bit cooler than I had expected, even with the late afternoon sun bearing down on me, and it was great last day for a ride. I returned home, showered and met Abdulhamid in town for my last nyamachoma dinner, one of my favorites here. I took care of a few more charts before bed and knew that I still had a few hours of work to do in the morning.

Monday and Tuesday, October 5 and 6 – Wrap up days for our FAME Neurology Clinic….

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I know that I’ve mentioned the kuni boilers before, but perhaps it would be helpful to mention the story of the hot water situation here at FAME from the beginning. When I had first come to FAME in 2010 to volunteer, they were completely off the grid and on solar power which meant, of course, that any piece of equipment that was used here could not require any significant amperage of electricity. I recall that in the very first volunteer instructions it had said, “absolutely no hair dryers” and, even though I believe that still to be the case, it is more for practical reasons now than it was in the beginning when an appliance drawing that many amps would either blow the circuits or drain the battery. That also meant no conventional hot water heaters. Needless to say, taking an early morning shower in those days, when there was no hot water, was an exercise in speed and efficiency as our water here is well water that has always been ice cold at the outset.

A scenic view of the kuni boiler

I do recall that at one point, Frank had experimented with some fancy low power hot water heaters that were mounted to the outside wall (I do believe there was also a notice on each of them that said, “not be installed outside”), but these never worked probably and I’m not sure that I can recall them to have ever worked properly . Therefore, it was still the ice-cold early morning showers that were still the standard fare for everyone. I should probably mention that even regular homes here that utilize a small hot water heater do not have them running all the time for “on demand” hot water, but rather you must flip a switch on the wall to turn them on and then wait 10-15 minutes for the water to heat before a hot shower. In the early years, traveling on the large mobile clinics to the Lake Eyasi region where we spent 5 days and it was pretty much like camping most of the time, we would take “bucket showers,” where you would have a five-gallon bucket and a cup with which to shower. In the mornings, the village women would boil large pots of water for us to use for our showers and then it was a matter of mixing the hot and cold water in your bucket to get just the right temperature. I remember thinking then that it was the height of luxury to even have hot water in those situations.

The working end of the kuni boiler

When the kuni boilers came into existence at FAME, they were like a Godsend as we now had hot water, most often in the morning, but it would often last throughout the day depending on how many people were utilizing it. When the Raynes House is full, as is often the case when the residents are here, it will often not last long enough for everyone to shower in the morning, unfortunately. Stepping into the shower when you’re expecting a nice hot, or even warm, shower can be more than disappointing to find out that is the not the case. Of course, the kuni boilers are wood fired, meaning that not only do they have to be lit, but they also be loaded with wood and, even though they burn quite efficiently, it still requires that they are loaded with wood which is done by our Maasai askari, or guards, who are patrolling all night to keep us safe, but also stoke and light our kuni boilers in the morning.

Three partners in crime – Dr. James, Christopher and Dr. Adam (l to r)

Meanwhile, back to the power situation at FAME, as it no longer relies simply on solar power. Once the hospital and operating rooms were built, there was always a need for a backup situation as the power demands for these services became greater and greater, and, finally, with the addition of radiology and a CT scanner, the demands far exceeded what could be supplied even with a generator. It was finally the time for FAME to become part of the power grid here, but even that may not be what it seems to those of us in the western world, as power here is not as reliable as it is back home where you may lose it once in great while when a heavy storm comes through. Here, there are constant brown-outs, some which are scheduled, but most which are not. I can’t tell you how many times I have traveled to Arusha, planning to charge my computer and phone when I arrived, only to discover that the power was out here and it was a lost cause. At FAME, thankfully, we now have a generator that will kick on, typically, within six or so seconds from when the power goes out and this is not all too uncommon. Finding a generator large enough to run the necessary equipment here was not easy task as you can imagine, nor was laying the necessary power lines to carry it, but thankfully FAME has had the assistance of a master craftsman for a number of years to help with this planning, Nancy Allard, a rare combination of a an architect trained in Switzerland, and an ICU nurse trained in the US, who came to FAME, like all of us, while on Safari, and decided to move here for a number of years. Though she’s now back in the US working as a nurse, she continues to work on projects for FAME and is responsible for much of the growth that has occurred there. If it had not been for Nancy’s help, the Raynes House would not be what it is for us today.

Dr. Adam testing his pediatric skills

As is usually the case, I set aside several days at the end of our scheduled clinic to see follow up patients and to wrap things up if there were still things that needed to be dealt with. We had asked the mother with the young baby with infantile spasms to return today to see us, and, somewhat embarrassingly, none of us realized initially that we had seen them several weeks ago and proceeded to take a completely new history until we finally realized our mistake. We had placed the child on high dose steroids, and though it was unlikely that we would see any reduction in the child’s seizures given the amount of time that they had been occurring, we had still felt it worth an attempt. As expected, she had not noticed any change in the frequency, and so, we discontinued them and started the child on valproate gradually titrating to a therapeutic dose. Ultimately, though, the child was severely impaired and delayed and it would be very unlikely that they would improve in function which is what we tried to explain in the most compassionate, but realistic manner possible.

Dr. Adam examining a young patient

We also evaluated a young Maasai man who we had seen in the past, who doesn’t necessarily have a neurological issue, but came to us last March with a very unique problem that we are still not 100% clear of what it is, but our experts at CHOP have weighed in and feel that it is very likely just an indolent osteomyelitis of the skull rather than anything else more exotic (though, I must say, this is certainly not something you see every day). He has essentially had a progressive course that has deformed his skull and has caused not only numerous eruptions of his scalp to occur, but has also had problems with his vision due to misalignment of his eyes from his skull deformities, which is what initially brought him to see us in the first place. He has been placed on a number of antibiotic courses in the past including intravenous antibiotics, but nothing that has likely been long enough to fully suppress the ongoing infection. Hopefully, we will be able to get on top of this sometime in the near future, but it’s quite difficult given the many limitations posed by what is available.

Patient and his mother

Tuesday was our last official day in clinic for this trip and I had decided to spend Wednesday working on completing charts and would leave Karatu on Thursday morning to head for Arusha. It was my last day to work with everyone who had been so amazingly helpful in making the clinic run so smoothly and I was grateful that, despite the absence of the residents, we were still able to see in the neighborhood of 140 neurology patients that we had either contacted to come for follow up visits or who had been referred from the other doctors at FAME to come see us. There were also those who just happened to come at the right time with a neurological problem and were directed to us by reception. I am certain that there were also some “word of mouth” referrals that had heard about our presence from others who had seen us, which was certainly fine as long as they had a neurological problem for us to evaluate.

Abdulhamid doing a pupillary exam

I had missed working with Dr. Anne, who had unfortunately broken her ankle just prior to our arrival and had been laid up at home with her leg elevated for the entire month, but I know that she will be back working with us again in the future. There are always silver linings, though, and this one turned out to be in the form of Dr. Adam, someone who I had not had the chance to work with in the past as he had just come following our rather sudden departure in March with the COVID crisis looming. Adam, who was an incredibly quick learner and a remarkably capable physician, found neurology fascinating and will very likely become our second “FAME Neurologist,” someone who will have the necessary skills to follow and manage our patients there, but also the ability to evaluate and diagnose the more common neurological illnesses that we see. He and Dr. Anne will also be able to communicate their assessments of the more complex neurological patients so that we can assist remotely in those diagnoses as well.

My little black kitty friend escaping the heat outside of the cantina (or catina)

I said goodbye to both Abdulhamid and Revo, my two incredibly capable brand new graduates who have worked with me on several occasions now and will hopefully work with me again in the future. I know that would be working at FAME the following day, though not seeing patients, and so I would not have to bid farewell to anyone else this day.

 

 

Sunday, October 4 – FAME Safari No. 2, a trip to Tarangire….

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It has been such a special trip the prior Sunday and, having decided not spend three days traveling in the Serengeti on my own but rather have a few days to myself, today was a perfect day to once again host a group mostly made up of FAME employees to Tarangire. As I have mentioned before, most of the residents here have not gone on a game drive to any of the parks for several reasons despite the greatly reduced entrance fee for Tanzanian citizens. One of the reasons, of course, is the cost of hiring a vehicle and a driver for the day as this is mostly out of the reach for the average Tanzanian. The other reason is more of a cultural one that also considers the issue of cost and that is the difference between a society with disposable income and one that defines things based on necessity. For those of us in the West, we often consider travel as a necessity, but, in truth, it is not for you can’t provide for your family with travel and it is quite the opposite. The benefit of travel to us is provide relaxation or, at other times, to provide a sense of adventure to our lives by broadening our experiences. This is not the case for the vast majority of the world, though, where the knowledge of where your, or your family’s, next meal is going to come from is not always readily apparent.

Our crew at the entry gate

So, it was with this in mind, that I once again offered to take a group to Tarangire, one of my favorite parks to drive in for several reasons. The animal viewing is superb and, in particular, the birds as well as the elephants which are the most numerous in this park. Another reason is the ease of driving there as the park is completely centered around its river ecology and the Tarangire River. In the dry season, which we were in now, the animals must all travel to the river for their water so huge families of elephants come from the surrounding hills to make their way to the river by midday and then travel back to the hills for safety later in the afternoon. The park is usually entered through the main gate, which was recently replaced with a very new building in which to register for the visit. I have driven here dozens and dozens of times and have a typical route that I take for the best chance to catch lions early on. While I was registering at the gate and taking care of payment, the others were taking care of popping the tops on Turtle and securing everything  for our game drive. Revo sat up front with me and also had the ability to stand up, though had no protection over his head from the sun as did the others in the back.

Mother giraffe and baby

As we made our way to one of the watering holes where I have encountered lion prides on several occasions and even have seen a kill after the fact, we saw numerous impala that included both large harems (a male with his many females) and bachelor herds that comprise only males that have not been successful in acquiring their own harem, but could one day challenge for that dominant role. The male of a harem can be replaced by a challenger at any time and, unlike lions, where the conquering male will kill off any of the offspring of his predecessor, a victorious male impala will not do this. Just before the watering hole, we ran into a huge gang of banded mongoose that were on both sides of the road and, despite the fact they are usually quite skittish and scatter as soon as you stop, this group continued their quest for food (typically insects and small reptiles) in our presence and much to everyone’s delight watching them. I have actually never seen them remain at their business for as long as they did this day.

Zebra at the watering hole

There were a few giraffe along with zebra in the region of the watering hole, but not a feline to found when you need one, so we moved on connecting back to the main road that led us down to the first river crossing. Once on the other side, there are numerous “river circuits” that leave the main road and loop close to the river and then back again. Depending on the season, these routes can be quite an adventure on their own with huge pools of water submerging the trail for some distance. I had learned long ago that it’s not good practice to enter one of these pools without first seeing tire tracks entering and, hopefully, leaving on the far side just to be certain you won’t spend the day trying to figure a way out. I will tell you that I have not learned that the hard way in the past and am thankful that I drive a Land Rover as they will rarely ever became hopelessly stuck, in contrast to the Land Cruiser, which can. Some of you may recall, though, that there have two exceptions to this in my past, one of which occurred in bad weather on an incredibly slippery road, and the other, here in Tarangire, that was my fault for driving on a trail that I was familiar with in the dry season rather than the wet, and I became hopelessly stuck in the mud. We were miles from anywhere late in the day and it had started to rain on us in place where there was no hope in our hiking out given the lions, elephants and Cape buffalo in the area. We were rescued by Leonard, who just happened to be in the park, and a very sturdy row that we used to pull me out.

Thirsty zebra

After driving a bit down the river on our way to my favorite lunch area in the Selela Swamp, we encountered several very large families of elephants. As we were watching one, we say another crossing the road far ahead and went to watch the second group. When they were finished crossing, I backed up the Land Rover to watch the first group who had just completed their crossing as well and paid particular attention not to get too close or to threaten them as there were little ones with the group. Watching out of my side mirrors, I had a perfect view of the road, but what I failed to see was that a male from the group had apparently taken offense to our approach, regardless of the distance, and was making a bee line for the road and our vehicle. I heard lots of commotion in the back, which is not all that unusual as I have had plenty of guests become a bit unnerved by the proximity of these huge animals as they walk close to the vehicle. I had turned the vehicle off, as I always do when we are stopped watching animals, and especially elephants, as they are less threatened by the quiet and if someone is taking photos, it makes for a sharper photo with the lack of vibration. Suddenly, I heard Abdulhamid yelling, “Dr. Mike, drive the car!!,” as, unbeknownst to me, he had flown from the very back of the Land Rover, where he had been watching the suddenly charging and trumpeting male elephant, to just behind my front seat, clearly for the effect of getting me to listen as quickly as possible and get the vehicle moving.

All lined up quenching their thirst

Regardless of the sense of urgency that everyone felt, it would be incredibly unlikely for an elephant to strike a safari vehicle in this situation, and I have no question that it was more for show than anything else, but it still seemed like a good idea for me to start the engine, engage the transmission, and move. And to do so quickly as I didn’t necessarily wish to test my hypothesis when it involved the safety of the others. As I slung the vehicle into gear and stepped on the gas, I could now see the elephant standing in the road and am pretty certain that I heard him trumpet a victory salute just for effect. There were several videos of the event, though I must admit that I am not proud of any of them as even though I don’t believe I had encroached on their space and have been around them as a driver many, many times, it should always be one’s intention never to stress or threaten these animals in any way and I felt as though it was a bit of a failure on my part for having done so.

After the commotion of being chased by an elephant, it seemed that we had probably encountered the most exciting event for the day and, though this did eventually prove to be the case, we had lots of exploring still to do I the park. The next river crossing, which is real crossing and not a bridge, was unfortunately washed out, but was not apparent until I had driven all the way down to it, requiring that we turn around, head back to the main road, and look for the final crossing which was a cement platform placed across the river bed and typically intact. Had that not been the case, it would have been a very long drive all the way back to the first crossing. Thankfully, we were in good shape and, once on the other side of the river, began to make our way towards the lunch spot overlooking Selela Swamp.

Thirsty zebra

I guess it would be appropriate here to also mention one of the not so favorite attractions of Tarangire that seems to have become more prevalent in the recent years, much to everyone’s displeasure. These are the tsetse flies that are most common in wooded regions which is much of what Tarangire is made of in addition to the river area. Tsetse flies, which are most famous for carrying trypanosomiasis, or sleeping sickness, are absolutely an incredibly annoying biting fly that inflicts a very painful wound and also sucks your blood which it’s at it. They are like heat seeking missiles with a single mission in mind and they are relentless in their execution. Though they are incredible slow, they are also very sturdy and quite difficult to kill if unless you are planning to something other than just swatting them. It usually requires that you either trap them with your hand and actually crush them (yes, I know that is gross, but if you’ve ever been bitten by one you would certainly understand) or you smash them against the window with a book or something very solid. I cannot count the amount of times that I’ve seen them simply swatted like you would any other fly and have them just turn around, laugh at you, and fly away. Their bites are not only very painful, but they also leave a nasty wound that causes a large welt and will often last for days. Simply put, they are not fun at all. Just ask any of my residents who have encountered them.

Our lunch spot overlooking Selela Swamp with distant fires burning

Today wasn’t the worst of days that I have seen, but they were still quite bothersome to those in the back which is mostly were they seem to collect when driving and though that might be a plus for me as the driver, I do feel bad listening to everyone else swatting and cursing these little bastards. I have seen the sweetest of individuals completely transform when they’ve been introduced to these miniature torture machines. I won’t mention any names (Megan, Lauda, Kelley, Mindy, Susannah, Amisha and others), but please rest assured that even the most composed have quickly become a blubbering mess encountering the mighty tsetse. The one thing we have to be thankful for is that sleeping sickness is not endemic in any of the Tanzanian regions to which we travel.

A reedbuck in the swamp

Much of the lower portions of Tarangire had been burned recently, a practice that helps regenerate the grasses, and so we passed through very long stretches of blackness and ashes blowing with the wind. Dust devils rose to extreme heights as we made our way to the lunch area at Selela Swamp that was thankfully not thick with tsetse flies as that would have been incredibly uncomfortable. After a nice a relaxing lunch on the picnic benches, I set a course to drive along the swamp in the direction of the river, a route I had never taken before. As we drove along, I was convinced that there was a connection between the river road and the one we were on, but just couldn’t seem to find it, so ended up driving a short distance in the wrong direction before taking out my trusty iPad with its navigation package (thank you MotionX GPS), which I guess is akin to stopping at a service station for a guy, and, with Revo’s help, found the connection I had known must exist and we were back on the right track finally.

A pregnant lioness on the far river bank

Heading back, Kitashu spotted two lions, one, a pregnant lioness which was an impossible find across the river on the far bank and virtually invisible, and the other, a young male, was much closer and had a kill hidden nearby. The male got up and began walking back to his kill, which, as we followed it slowly in reverse along the road, was at least a day old and quite easily identified by its rancid and very pungent odor. The male then walked off in the direction of the female and we lost him in the undergrowth. Here, in the parks, you must remain on the roads and, though they may consist of two tire tracks through the grass, it’s still the rule and there are heavy fines if you are caught violating them. And, I am sure, they would love nothing more than giving a mzungu driver such a fine if they were given the chance. In the Ngorongoro Conservation Area, there is no such rule, so you are able to follow predators, but at a good distance, of course.

Young male lion with a full belly

By now, it was well into the midafternoon and we had at least an hour’s drive to get back to the main gate. Though the park is open until 6 pm, everyone was quite tired as we had left Karatu at 6 am, and game viewing can be very exhausting, not to mention game driving. We arrived to the gate around 4 pm to exit the park and on our way back to the tarmac discovered that it was market day in the village there. Kitashu’s sister lives in the area, so he called her and we waited in the center of the commotion for her to come while we were offered just about everything you can imagine to buy, perhaps short of a goat or a cow. Our next stop was in Mto wa Mbu, where the bananas are particularly good and I think everyone in the vehicle purchased a huge bunch of the fruit. I asked for 4 bananas as payment for my driving for the day, but was given 8 and wasn’t sure how I’d eat them in only the several days I had left at FAME, but I’d give it a try. We arrived back in Karatu by sunset, all quite exhausted, but very satisfied with the day having seen lions, which were Abdulhamid’s request in addition to the elephants, which they had gotten their fill of rather up close and personal. I think everyone had a wonderful day of game viewing and I was quite happy to have made it possible for them.

Walking to his kill

Friday and Saturday, October 2 and October 3 – Some much needed downtime for Dr. Mike….

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When planning my trip several months ago, knowing that I would have total freedom as I would be alone for the month, I had thought that visiting the Serengeti in the midst of the pandemic, when there would be very few, if any, visitors there would be a great idea. Now, having spent several weeks at FAME on my own, I’ve come to realize the tremendous value of just having a day or two to myself and having blocks of downtime to both do busy work and relax. I’ve also realized that I haven’t spent enough time in my hammock reading, a crucial error on my part and some very serious poor planning. Not that it was planned this way, but the poles in the back of the house are the absolute perfect distance apart for hammocks, of which I have three at the house as it became impossible for me to reserve a spot when the residents are here. Here alone, I’ve set up one that I have all to myself now, but have had little opportunity to get in it until this morning. In the afternoons, unfortunately, the sun beams directly down on the back of the house making it unsuitable for hammock time, but the mornings are absolutely perfect for reading in the hammock as it is at sunset. That is, until the mosquitos decide to descent upon us and chase us indoors for the evening.

Beautiful weather out one window….

My plans for the two days was to finish a bunch of work that I had left over from Penn and also to get to my patient messages that were sitting in my inbox and needed me to attend to them. I also had some outside writing to do and was planning to get that done, as well. Both of those had to wait a bit for me to spend a few minutes, or maybe more than a few, in the hammock reading my book and just plain relaxing. I literally did not have any plans for the day that required me to leave the house, though that changed in short order when Nish invited me to come to the gallery for lunch as his cook was going to make us twice-baked potatoes, an opportunity that I did not wish to miss. After my hammock time and some work, I made the short journey down to the gallery and had a relaxing lunch with Nish. The potatoes were definitely worth the trip and very much lived up to their billing, so much so that Nish gave me the extra ones to bring home with me and have for dinner. Certainly not traditional Tanzanian culinary fare, but comfort food just the same.

And a dark sky out the other

I worked late into the evening, having my gifted dinner along with the some of the dinner that had been prepared for me by Samwell, a vegetable stew that went along great with the potatoes and I saved the chapati for the following day to make quesadillas, another non-traditional food item here, but one that is easy to make and very tasty indeed. I had been productive day for me, but not overwhelming as had been able to get my necessary downtime in and wet to bed that night not only feeling quite rested, but also very satisfied with the work that I had been able to accomplish.

Sunset from the veranda

For Saturday, I had promised Daniel Tewa that we would visit a friend of his together as she had apparently been hospitalized back in April, but he had given me no further information on what her affliction had been. I completed some work in the morning and headed over to this home at 1pm as we had previously arranged so that Isabella, his eldest daughter (Daniel has 11 children of his own and one adopted) could drive us to Qaru. I knew the village well as we had done several mobile clinics there until a bit over one year ago when we had switched to Mang’ola on Lake Eyasi which had a much better attendance. Isabella had a small Suzuki four-wheel drive that was quite comfortable on the tarmac, but was clearly not made for the incredibly bumpy road that was to take us to Qaru that day. The roads here are like washboards, terribly rippled so that it feels as though your teeth are going to fall out after just a short while on them. I had always thought that it was due to the vehicle traffic on the road, but learned after googling that it was actually due to the effect of water running over the flat surface of the road and having a natural rippling effect that leaves the roads this way. The Suzuki was so light that at times it seemed to want the leave the roadway altogether as it shimmied sideways from the bouncing.

Explaining the concept of a homonymous hemianopia and neglect to the others.

We finally arrived to the village of Qaru and it turned out that his friend was staying with the nurse from the clinic who lived immediately next door to the dispensary where we had held our mobile clinics in the past. It was quite helpful that I knew my way around as I’m not sure that either Daniel or Isabella knew exactly where we were heading. We were greeted outside by the nurse who was caring for her and led into an inner courtyard and then into her room. As we entered and said hello to her lying in her bed, it was immediately clear to me that she had suffered a stroke as she was not moving her left side well at all and she didn’t seem to be looking very well to the left either. The fact that she had suffered the stroke was quite unfortunate enough, but to add insult to injury, her bed was positioned against the right side of the room such that she has been staring mostly at that wall for over four months and the full extent of her deficits, which included not only the left-sided field cut, but also some degree of neglect, had never been fully explained to everyone.

Daniel addressing his friend from the correct side after my explanation,.

I took the opportunity to explain not only to her caretakers, but also to Daniel, that if you wanted her to pay full attention when addressing her, you would need to do so from her right side. This can be difficult to explain to those fluent in English, so it took a bit of extra time to fully explain the nature of a homonymous hemianopia to them and the fact that it was actually both eyes that didn’t see to the left and not just her left eye. Once I explained this to Daniel, he immediately tested the hypothesis by speaking to her from the left then moving to her right and comparing her attention. She immediately perked up when addressed from her right and Daniel was convinced. I instructed them to move her bed to the other side of the room so that she would be able to participate much better with visitors and it would help her rehab. They were doing physical therapy, so that part of the equation had already been dealt with in a satisfactory manner.

Greeting Daniel’s friend once I explained how to properly do it.

We all said our goodbyes after a brief, though thorough visit and loaded back into the Suzuki for our return trip. The road seemed to be definitively bumpier on the way back, but I’m certain that was only in my imagination or perhaps had to do with the fact that intense midday sun seemed to be continuously in our faces. I was texting Susan the drive home and, between the sun and the bumps, there were some very serious autocorrections that I did not catch until after they were sent and we both had a great laugh over it. Arriving back to Daniel’s home, and even though I needed to get back to do some work, it is always customary for he and I to sit in his small living room and share some of his amazing African coffee. No else in the family drinks and I think he looks forward to my visits so that he can enjoy it with someone. The coffee is boiled with fresh milk from his cows and with a little bit of sugar, is truly to die for if you consider yourself even a touch of a coffee lover. Though I have weaned myself from the addiction over the last several years, I do still love a good cup of coffee every once in a while, and it is occasions such as these that are the very best in which to savor that wonderful taste. The coffee of the Ngorongoro Highlands is some of the very best in the world and, having been prepared in Daniel’s home, it is a very special treat indeed.

I drove home, now well caffeinated, to sit down to some serious work at the kitchen table with my music playing. I did take a break to make some vegetable fried rice with a supply that I had taken during lunch a few days ago, making it with the sesame oil that had been found in town for me specifically for this occasion. Tomorrow, I would be taking some of the FAME gang on safari to Tarangire for the day and I planned to bring my leftovers from dinner with me for lunch.

Thursday, October 1 – A few very sick patients….

Standard

A mother and our patient

In the absence of our normal neurology lectures that are given by the residents when they are here with me, our synchronous virtual lecture series continued with today’s session being a case conference format that would be given by my Tanzanian neurology team on the ground here. I had asked Dr. Adam, Abdulhamid, and Revo to each select a case that they had seen in the last weeks and present them to everyone here plus Mike Baer and Kelley Humbert, both veterans of the FAME Tanzania rotation, who had graciously agreed to sacrifice their sleep as the talk would be from 12:30-1:30 am East Coast time! It was a great exercise for my three awesome colleagues here as the format would require that they present the history, examination and differential with a discussion between each as a way of explaining their thought processes of each case. Mike, Kelley and I each weighed along the way asking questions as did the other docs here. It was a great inaugural case presentation session to our new neurology virtual lecture series and we forward to more of these in the future. For those of you with an interest in what was presented, Abdulhamid presented our patient with ALS, Adam presented a case of Parkinson’s disease, and Revo presented a case of absence epilepsy.

One of our younger patients

Our cases for the day were our typical grouping of epilepsy, headaches and numbness, but we did have one case in the ward and another that came in later in the day that garnered a bit of extra attention from us. We did hear at morning report that there was a woman on the ward service who had come in awake, but was now unresponsive and was clearly in need of our expertise to determine what was going on with her. I had asked Abdulhamid and Revo to head to the inpatient ward to evaluate her while Adam and I would get started on seeing outpatients that had already arrived that morning. When they came back a bit later, the story was not very good at all. She had apparently undergone a total abdominal hysterectomy several weeks prior and was recovering at home, but had come in the day prior with a headache and overnight had declined to where she was no longer responsive and her neurological examination was not very promising. She did not localize or respond to painful stimuli and her pupils were large and poorly responsive. We asked them to send her immediately for a CT scan of the head and, what we found, was not necessarily what we had expected, but fully explained her poor examination.

A higher cut of our patient with the bilateral subdurals and midline shift

She had bilateral acute on subacute subdural hematomas with significant midline shift of the brain, or simply put, she had bleeding over the brain that was putting significant pressure more on one side then the other which was why she was no longer responsive. We were initially unable to obtain any history of a fall, though apparently later the family may have told the staff that she had indeed fallen. Regardless of whether she had or not, we now had the answer to why she was doing so poorly and I met with Dr. Lisso, the doctor on for the day covering the inpatients, to tell him that I felt it was really unlikely that sending her to the neurosurgeon in Arusha would change the eventual outcome as I didn’t think she would survive either way. I verified that he was quite comfortable with the information I had given him and was also comfortable conveying that to the patient’s family. I went back to evaluating our outpatients when, sometime later, our FAME ambulance pulled up to the loading area just outside the night office where we were seeing patients and my presumption that it was for this patient with the subdural was correct. Apparently, the family had decided that they wished to do everything possible despite the fact that it would almost certainly be futile to do so. I heard later, that the patient did have surgery and her hematoma evacuated, but that she had not survived the ordeal after all. Though it had been clear to me that it was unlikely she would survive based on her exam and CT scan, the family had apparently wanted to make an attempt as unlikely it was that she would survive. That is the prerogative of the family in this situation and certainly not something that we can decide for them as long as they have a clear understanding of the likelihood of success.

Who said neurologists don’t use stethoscopes

The other case we saw was equally interesting and had a far better outcome than the previous one. In the afternoon and, in fact, in the middle of dealing with our ward patient, we saw a young man in his mid-thirties with a seven year history of diabetes that was most likely adult onset and not juvenile. He had been blind for a few years secondary to diabetic retinopathy and had not been walking for nearly a year with symptoms of neuropathy in his legs, though his weakness didn’t seem to be from a severe length depended neuropathy and very likely from another diabetic related process such as a diabetic amyotrophy, which is a more proximal process with muscle wasting, though he did not have the classic pain I’d expect from this disorder. He was in a wheelchair when he came into the room and had his head down and was very quiet overall. He had been seen at FAME about a month ago for his diabetes and at the time had a Hgb1c that was simply listed as “>14.5,” which is dramatically high (it should be under 6 in a normal person and perhaps around 7 in a well-controlled diabetic) and clearly indicated that he was in dire need of better glucose control. He was put on insulin at that time and had been using it since.

Abdulhamid examining a patient

Abdulhamid examining a patient

As the visit progressed and we were able to get him up onto the table to examine him, he seemed to be less and less engaged with the questions that were being asked of him and had difficulty even following directions during the examination. As I was typing my notes for the visit while the others were questioning him and examining him, I think it dawned on all of us at the same to time that he was getting more and more hypoglycemic before our eyes. As Adam ran to get a glucometer, we were told that his blood sugar had been 72 that morning and that he had taken his morning insulin rather than adjusting the dose. When we checked his blood sugar it was 50, which is exceedingly low for a diabetic and we were worried that he was still dropping. We threw him back into his wheelchair and around the corner into the ER where we put an IV catheter into him and immediately started a glucose drip. He was admitted to the ward as we weren’t about to send him home given this experience and he clearly needed some serious education regarding insulin and his blood sugars. No necessarily a neurological problem, but we were able to intervene and very likely saved him from any more serious injury from becoming even more hypoglycemic than he turned out to be in the end. Unfortunately, he later went home from the ward without us actually having a chance to fully examine him regarding his weakness, but given the story, I was fairly certain this was going to be a diabetic related issue and that the treatment would be control of his blood sugar in the end.

Neurologists in action along with Siana

With all of our excitement, the day went long and I had been invited to Abdulhamid’s aunt’s home for a visit after work. This was where I should have used my instincts and knowledge of their hospitality here when I asked Abdulhamid whether this was for dinner or not and he had told that it wasn’t. I had a nice dinner of spaghetti and vegetables that Samwell had prepared for dinner and then picked up Abdulhamid at the tarmac junction to drive him to his aunts as no one at her home spoke English. As I have mentioned before, Asha, his aunt, has been head of housekeeping at FAME for many years and it was really through her that he and I had been introduced in the first place. I recall when we were making the plans for his trip to Philadelphia how appreciative she had been and I despite the language barrier, I just know how she felt. Not only was she incredibly proud of her nephew, but she was incredibly grateful for the opportunity that had presented itself through FAME.

Abdulhamid’s well-behaved little cousins

So, as you might have guessed, he and I sat in the living room of her wonderfully remodeled house, while she worked in the kitchen for what I knew was soon to come. It was quite clear to me that I was now going to be expected to eat my second dinner that evening and it was not long at all before this premonition came to fruition. Asha’s son was also home to join us at her dinner table, which is unusual in most small Tanzanian homes were dinner is usually served on the low table that serves alternatively as a coffee table in front of the couch. I will have to admit, though, that I did not have trouble with my second dinner as Asha is a wonderful cook and her roasted chicken was absolutely delicious, so much so that I know I had a second, and quite possibly a third, helping of the chicken along with ugali and watermelon. It was a great way to end the evening with a dinner from a very gracious and thankful host who has been a part of the FAME family for many years. I know that she is very well respected in her position there and, as I have mentioned before, though it may have been an honor for her to have me here for dinner, the real honor was truly mine as I have been taken in here as family and am forever grateful for these opportunities I’ve been given.

A gorgeous sunset from the back porch

A gorgeous sunset from the back porch

A gorgeous sunset from the back porch

A gorgeous sunset from the back porch

A gorgeous sunset from the back porch