It had been a very late night for me as the Phillies, who were playing in the National League Championship Series against the Diamondbacks, were now in Arizona and with the time difference, the game would start at 11 pm EAT. There were high hopes given that the Phillies had taken the first two home games in this best of seven series that would determine if they would be going back to the World Series in consecutive years. Obviously, there were very high hopes given the first two games, but as we all know, anything can happen. In addition to the listening (I’m unable to stream the video here) to the game, I was working on posting a blog as I would have no internet at our camp for the weekend.

Vitalis, who had been our amazing guide on the first trip three weeks ago, was again going to be driving us to the Serengeti with virtually the same schedule as before, at least for today. We had planned to leave at 8 am and Turtle, with Vitalis driving, arrived early, which is always a good thing as it is typically the opposite here no matter how hard we try. We still had to buy some provisions and top off our fuel for the weekend, but that would be very quick. The little fuel station just at the junction has lots of take-out breakfast items along with the water we would need for the Serengeti. The “bites” as they are often referred to here were delicious, and one in particular was more than worthy of creating an entire food truck for in Philly for it was that amazing. It was essentially a rolled chapati with an incredibly tasty beef and onion mixture that just hit the spot. There were samosas, vitumbua (incredibly tasty, but greasy rice cakes), doughy donuts, and several other snacks to purchase, but those chapati were to die for and definitely the hit of the morning.

Having topped off the tank, purchased the water and breakfast snacks, it was now time for us to depart town and head for the Ngorongoro Conservation Area gate to begin our weekend journey. There were so many vehicles at the gate that I was glad we came early last weekend when we were going to the crater. Thankfully, though, the wait was not long, and we were soon on our way up my favorite road to the crater rim. While nearly everyone else was stopped at the overlook, we blew past since we had been there less than a week earlier and continued around the rim and past the descent road, now on our way to the Serengeti. But first, there was our stop at Oldupai Gorge and Shifting Sands.

I could never get enough of Oldupai, which is good as I’m there four times a year with the residents. We met with Professor Masaki, my good friend, who gave the residents his orientation talk about the gorge and the many layers as well as the important work that’s been done there by Louis and Mary Leakey and so many others. The museum, which was new about six years ago, is an amazing demonstration of just how important this site is to our knowledge of human evolution and the various lines of our ancestors, some more successful than others. That the Leakeys had spent 28 years here before finding their very first hominin (Zinjanthropus, or Paranthropus boisei – also known as Nutcracker Man) is a true expression of dedication and determination. Though Louis died in 1971, Mary continued her work at Oldupai for over a total of 50 years and their camp is now a living museum. The footprints at nearby Laetoli that were discovered by her team in 1978 was one of the last great finds for this amazing paleontologist whose contributions to science were profound. The footprints, which were made by several Australopithecus afarensis individuals 3.7 million years ago remain as one of the earliest demonstrations of bipedal, or upright, gait. To say that the region surrounding Oldupai is the single most important anthropological site in the world would be an understatement. (For more information on the Ngorongoro-Lengai UNESCO Global Geopark: https://en.unesco.org/global-geoparks/ngorongoro-lengai)

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After finishing at the museum, we now drove back in time as we descended into the gorge and through its many layers, before heading up the other side on our way to Shifting Sands, another remarkable site of a much different nature. Shifting Sands is a unique geologic feature that was created several thousand years ago following a large eruption of Ol Doinyo Lengai, known as the Mountain of God to the Maasai and is considered sacred. It remains an active volcano with the most recent volcanic activity earlier this year and the last eruption just several years ago. Shifting Sands is a large dune that is comprised of black ash that is magnetized and slowly being blown west across the plains by around 15 meters per year. The dune, which is about 5 meters high and many more meters in diameter, has a crescent shaped leading edge that slowly engulfs any vegetation in its path. As the black sand is magnetic, it is never blown away by the wind and the trailing edge remains sharp as any stragglers are quickly attracted back to the main group. As Ol Doinyo Lengai is sacred to the Maasai, so is Shifting Sands.

From Shifting Sands, our route takes us mostly cross country on the most minimalist of trails through regions that are shared by the Maasai herds of cattle, goats, and sheep, and the herds of Thompson and Grant’s gazelles, though in March, during the migration, this region is completely filled with the leading wildebeest herds and the big cats that come out to take advantage. This route is wonderful as it completely bypasses the heavily traveled main road to the Serengeti with its rocks and dust. We intersect this road just before crossing the border into the park but miss the majority of it which is quite preferred in my mind.

At Naabi Gate, the administrative entrance to the park, we stopped for lunch, though avoided the massively crowded lunch area with its tables and benches, instead choosing to eat standing at our vehicle. We were parked at the old gate that was in use until just months ago and walked into the snack shop that is no longer frequented by the tourists given the location of the new gate. Cold Coke Zero hit the spot for me and was a welcome refreshment given all the dust and heat that we’ve been driving through all morning.

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It was now time to pop the top on Turtle and begin our afternoon game drive as we entered the Serengeti and on our way to our camp. There were many large herds of wildebeest and zebra the closer we got to the central region, and it was clear that the head of the migration was here rather than to the north. These huge herds were wonderful to see, though a bit unusual at this time of year when the expectation would be that they had crossed the Mara River to the north and were on their way to Kenya. Though I’m sure that variations such as this are not that unusual, one can’t help but think about climate change and where things are heading in this regard. It had been raining over the last weeks and the Central Serengeti was much greener than we had expected for this time of year.

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Everything was new, of course, for the residents, none of whom had ever seen the immensity that is the Serengeti, and we took our time once we found objects of interest. At one point, we came upon several vehicles whose occupants were gazing into a grassy area with a tree nearby that looked as though it would have been perfect for a leopard. When we asked the clients in the vehicle next to ours what they were looking at, they replied that they had seen a leopard earlier that had run into the grass with a Thompson gazelle but hadn’t seen it surface since. When we asked how long they had been waiting for it to show itself, we were a bit shocked when they replied that they had been there since noon, and it was now 3 pm! That would be true dedication towards finding a leopard and, though we did watch with them for about 15 minutes or so, it was clear that none of us was interested in waiting around for something that we hadn’t seen to begin with. Thankfully, we would get to see several more leopards before the weekend was over.

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At one point, we came across a pair of lions which is usually a tell-tale sign that it’s a couple that has left the pride to mate. This is a rather protracted affair in which the couple spend anywhere from 2 to 5 days mating every 30 minutes like clockwork which is intended to ensure that the female is impregnated. The reason this is necessary has to do with the fact that the male lion’s penis is extremely short making it far less likely that a single mating will end in success. The actual mating may take only a matter of seconds and having witnessed this event on numerous occasions, I can assure you that this is, in fact, the amount of time it takes. Obviously, the protocol they’ve developed has been successful and has managed to overcome any shortcomings (full pun intended) given the number of lions and lion prides that currently exist in the Serengeti and the surrounding regions. Interestingly, at one point during their activities, the male lion became extremely protective and a bit agitated, charging one of the other vehicles with a loud roar that was not easily misunderstood. It was quite clear that he only intended it to be a veiled threat for there was very little for anyone to worry about.

We continued in the direction of our camp, which was located in an area where there lots of herds of wildebeest and zebra, and eventually arrived to camp just after sunset. This was the same camp that I stayed in several weeks ago and it was equally hospitable as it was previously. The camp sits on the hillside and each tent is on an elevated wooden platform with a balcony to sit on and watch the wildlife. The two main tents are wonderfully appointed with comfortable chairs and couches and large dining tables for our meals. Each of our tents were incredibly comfortable with sitting chairs and a lovely bathroom area with two sinks, a shower, and a toilet.

We had enough time to take showers before dinner, and even enough time for a drink after the hot and dusty day that we’d had. Dinner was, of course, amazing and they had vegetarian choices for Kelly that were equally tasty. After dinner, we all retired to our tents and watched the zebras collect within reach of our platform. In fact, as I sat in my tent and did some writing, I could swear that the zebra were practically ready to climb into bed with me. They are very loud eaters (no manners, I suspect) and continued to chomp as I drifted off to sleep. We were leaving at the crack of dawn, or actually beforehand, so it would be an early morning to rise. We would bring breakfast and lunch with us so we could explore as far as possible and were planning to see the Western Corridor of the Serengeti and the Grumeti River.

We were now back on schedule since we had definitely planned to be at FAME today from the very beginning and though our patient volume wasn’t immense, it kept everyone busy. Kelly delivered an excellent morning lecture to the staff on treatment pathways for both seizures, including status epilepticus, and headaches, including migraines. Treatment pathways are important tools in treating patients with these issues as it helps to standardize care as well streamline processes when it is necessary to develop protocols. With the new emergency room about to open in the next month, this will become a more significant issue as patient volume will only increase as will patient acuity lending itself to more chaos unless these treatment pathways become more the standard than the exception. To develop these pathways, she spoke to several FAME doctors, to make sure they made sense as we were no longer in Philadelphia, and spoke with Dr. Amanda, our visiting emergency room physician from Australia as she will be working on similar pathways for other emergency scenarios.

The vast majority of the experience here for the residents is not about learning how to treat new conditions they have never seen before, but rather it is about treating common conditions they see often at home in a low resource setting. The algorithms that are learned and used on a routine basis at home are only as good as the medications and services that are readily available and affordable, and that chasm of medical equity is unfortunately quite vast when traveling to the majority of this continent. Though that situation is certainly improving over time with the efforts of many who have come to help, that change is incredibly slow and most often stymied by factors that are far beyond the control of those who are providing care for anyone in need. The oft quoted, “The economy, stupid” from James Carville during Bill Clinton’s 1992 presidential campaign could easily sum up the situation in most African countries, though it had been used in an entirely different context than what is found here.

Medications and therapies are available in most cases, though they are very often completely unaffordable by the population we are treating here at FAME, necessitating tremendous thoughtfulness and long discussions regarding the actual ability of families here to continue the care that is most appropriate. The first question that families ask regarding their admitted family member will be, “when can we take them home,” and although this may seem to be driven primarily by a sense of responsibility to care for one’s own, and this is certainly part of it, the cost of the hospitalization is more often the driving factor in those decisions. For families that cannot afford to provide care for their loved ones, they will often go home to their community to raise the necessary funds. In a country that has no safety nets, no welfare, and a national health insurance that very few participate in, healthcare is often a secondary concern and survival is primary. To add insult to injury, patients seeking treatment here very often have advanced stages of common treatable conditions whose care has now become more complex and compromised because of this delay.

It is within this environment that FAME has chosen to build a hospital and healthcare facility to provide patient centered care to a region of Northern Tanzania where the population is worse off than the national average in this country that ranks in the bottom 10% internationally. Making a difference has been challenging, but the work that Frank and Susan began nearly 20 years ago has continued and has been successful because of the Tanzanian FAME community they have built since opening in 2008. Those of us who have been privileged enough to have shared in their vision by volunteering at FAME (some of us who have not found a way to leave) have seen what can be done through the generosity of others and the sheer determination of those who care enough about others in the world to have made that difference that counts every single minute of every single day.

Today we saw an adolescent girl complaining of severe headaches that sounded migrainous, but who brought and MRI of her brain that had been done previously and was reportedly abnormal. When we loaded the disc that the family had thankfully brought with them, there was a small region of focal encephalomalacia (loss of brain tissue) in the left posterior parietal region, and though was unlikely to be related to her headaches, was still something that had to be explained. When questioned further, it turned out that she had a head injury when she was only 3 months old and corresponded to the abnormality that we saw on the current study. Crisis averted. She was treated for migraine and will follow up in several months.

Meanwhile, Kelly evaluated a patient that had come from a very long distance to see us for a multitude of unexplained neurologic symptoms. The middle-aged patient had been to numerous specialists including other countries, but no one had figured out the nature of their symptoms. After reviewing all the outside records (and there were many) as well as the outside imaging studies, it seemed clear that the primary problem with the patient was underlying anxiety and, in the end, it was determined that the patient had a functional neurologic disorder (FND). This is a category of diseases that are psychologically based as opposed to physically, though they can often be triggered by some physical symptom. The underlying personality trait for these patients is most often one of underlying and untreated anxiety and, at times, depression though perhaps secondarily.

The treatment for this is therapy, therapy, and more therapy. Medications certainly have a role, but more so at the beginning and the hope is that therapy will then take over as the most effective treatment and medications can be stopped. Thankfully, Kelly has a huge interest in functional neurologic disorders and took charge of this patient’s treatment plan. The family members who had accompanied them were totally on board with the treatment plan and the patient also seemed to have some insight into the situation, a very positive sign for a successful recovery. The family was very pleased for they had been to numerous doctors for treatment and finally had some answers.

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Dennis evaluated a 13-year-old Maasai boy who had been having episodes of loss of consciousness for most his life, typically occurring about twice a month and, given the epigastric rising sensation that occurred with them, were most likely focal temporal lobe seizures. The boy had been seen at a health dispensary three years ago but had been placed on phenobarbital (phenobarbitone) which had not helped for his seizures, and they continued at the same frequency. Given the focal nature of the episodes, the seizures should be very responsive to carbamazepine, a medication specifically tailored for focal onset seizures, and one that is very inexpensive and available here in most duka la dawas (medicine store, or pharmacy). Though phenobarbital is the preferred anti-seizure medication by the WHO because of its availability and its incredibly low cost. Unfortunately, it also has a number of significant side effects including impaired cognitive and slowing development. We use it only in children under the age of 2 and, even then, try to get patients over to another medication as soon as possible.

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As the day finally wound down, it was decided that we would run to Teddy’s house to pick up the clothes the residents had ordered from her. Of course, she had done another fantastic job, and everyone had to show off their new threads, though having ordered nothing from her, I sat in chair on my computer which is what I usually do during a visit to her shop. Over the years, I have tried having her make a few things for me, but I’m pretty finicky about the fit and feel of my clothing (an idiosyncrasy since childhood) and have never felt comfortable in them, unlike all the residents who have absolutely loved the clothes she makes. I did have her make a few gifts for me to bring home, though, but they obviously didn’t have to be tried on and modeled.

Just prior to our departure for Teddy’s shop, I had answered the phone at the house (never a good sign) and had been informed that we had a consult in the surgical ward. A patient had come in over the night with a head injury and a very abnormal CT scan that demonstrated a fracture, a traumatic subarachnoid hematoma, and some swelling. As the patient had no surgical indication at the moment, I informed the ward that we would see the patient as soon as we returned from our errand. On our return, Kelly volunteered to run up to see the patient, who unfortunately was poorly responsive and had a right hemiplegia, though again, after reviewing his CT scan, there was no intervention that could be taken other than giving him steroids for the edema that was seen. The hemorrhage would eventually resolve, but unfortunately, it would just take time for him to improve, which would be gradual, and he would need rehab once awake.

We have been seeing an increase in the number of traumatic head injuries, almost all from MTAs, or motor traffic accidents, often on motorcycles (boda bodas or piki pikis) without a helmet, or from pedestrians struck and knocked down by vehicles. Dr. Manjira, our chief of surgery has provided burr holes to a number of patients with subdural hematomas, a life saving procedure, though in patients such as the one above, the injury was not amenable to surgery.

Tomorrow morning, we would be leaving for two nights in the Serengeti and a stay at Dancing Duma, the camp we had used previously. Everyone was incredibly excited, including me, as visiting this remarkable park has never gotten old for me, even after fourteen years of visiting and probably over 50 days in the park.

Even though we had been scheduled to be on mobile clinic today which had been cancelled at the last minute, it was nice to be back home at FAME. After two days of long drives to the Mang’ola region and Lake Eyasi, we could begin the day with a short walk to morning report and then clinic. With the new format of two three-week rotations for the residents, I’ve tried to have the experience relatively equivalent between the two groups within reason though they could never be exactly the same. The busiest of our mobile clinics are, without a doubt, the Rift Valley Children’s Village/Oldeani clinics and those in the Mang’ola region. Kambi ya Simba, where we had gone three weeks ago and is in the Mbulumbulu region, can be hit or miss and depends on the time of year, whether there’s a market day nearby, and to be honest, the phase of the moon. It’s just impossible to predict. The Children’s Village is always busy as we are not only seeing patients from the village, but also the entire community of Oldeani.

The clinic that had been scheduled for today was to be held at a school/orphanage in a nearby town, but in the end did not work out for a number of reasons, all of which were completely out of our control. Having started the mobile clinics well over ten years ago, we have always targeted communities where we could provide neurological services, but ultimately patients would need to come to FAME for their medications and any follow up laboratory testing, if necessary. Traveling to villages that are otherwise inaccessible or where patients can’t get to FAME for follow up would not serve to benefit the patients and, in the end, would fail in improving their health. For this reason, not only is the location of the clinic important, but an understanding with the patient population that they must come back to FAME for their refills of medication.

The two long drives to Mang’ola had taken their toll on the vehicles and they were both in need of some minor repairs after the incredibly bumpy and dusty roads we had taken over the last two days en route and returning from our clinics in the bush. I had driven the stretch Land Rover (Turtle) both days to and from the clinics, and we were having an issue with the temperature gauge not registering properly. Driving long distances in East Africa, it’s not only imperative to have enough water in the engine, but it’s also incredibly important to know what the engine temperature is and to prevent it from overheating. We had this very same problem last March on our drive from Arusha to Karatu, in which the engine overheated and we lost all our water but had no warning as the temperature gauge had also been malfunctioning at that time. We were able to find water at a nearby house, which worked to get us home, but unfortunately, the episode had left us with a warped cylinder head that had to be replaced. So, it was necessary to see if we could fix this problem prior to heading into the Serengeti this weekend with the vehicle.

The short Land Rover (Myrtle) was being driven by Erasmus, a long time FAME driver who doesn’t speak English very well but was trying to tell me that something on it needed to be fixed, but I just wasn’t sure what it was. It had to be simple as he was going to have it fixed today, so I told him OK and to let me know the cost of taking care of the issue. The drivers here at FAME, as well as most the safari guides, are excellent at fixing simple things on the vehicles, and especially the Land Rovers as they need constant upkeep and tweaking, but are also incredibly inexpensive to do so, making them the perfect vehicle for here when costs are an issue. I gave Erasmus both sets of keys to the vehicles and told him he had all day to work on them for me.

Meanwhile, it turned out to be a bit of a slow day considering that we hadn’t been scheduled to be here today. Our clinic schedule is typically made well in advance and the dates that we will be on mobile clinic as well as those that we will be here at FAME are distribute throughout the communities that we serve with announcements in the community centers, churches, and similar settings to get us the best possible visibility and attendance.

There was a very interesting patient in the wards, though, who was an 18-year-old Maasai women who had come in with mental status changes but did not look medically ill at all. The initial concern was that this was most likely an underlying psychiatric illness and very probably a psychosis with catatonia, though we had little in the way to rule other things out. Though we’ve been chatting with someone about getting the capability of doing EEGs here at FAME, we don’t have anything at the moment, and it would have been very reassuring to know that she was not in status epilepticus.

The other concern, though one that would have been very difficult to diagnose here as well as to treat, was an autoimmune encephalitis. This is a category of illnesses that were described less than 20 years but are very scary and difficult to treat in the best of circumstances. The most common of these, known as anti-NMDA-receptor encephalitis, was the first to be described, and has a very interesting presentation. Though it can occur in anyone, it is most commonly seen in young women with a presentation of subacute or acute psychosis that is often followed by mutism and catatonia. This is then followed by a host of other complications that include either focal or generalized seizures, or both, that are difficult to treat, autonomic dysfunction with huge swings in heartrate and blood pressure, and abnormal movements.

There are a number of tests that are supportive of this diagnosis, none of which we can really do here, though one of the common features in the young women presenting with this condition, is the presence of a very specific benign tumor called an ovarian teratoma, that can easily be detected on an abdominal ultrasound. We sent the young women for an ultrasound, that was negative, and though ruling the teratoma out, it did not answer the question of whether this could be anti-NMDAR encephalitis. Other than the catatonia that she presented with though, she had none of the other features and her examination over the rest of the day and evening pointed much more to this being a primary psychiatric diagnosis than anything else and we continued treatment for this. Over the next days, I can say that she slowly improved and what we were eventually able to discharge her home to her family.

Tomorrow would be a scheduled clinic day at FAME with the likelihood of more patients and Friday morning we’d be leaving for the Serengeti for two nights.

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It had been a wonderful visit to Lake Eyasi yesterday afternoon, though it did set us back just a bit on our schedule such that we arrived home just in time for the Monday noon conference back in Philadelphia that just happened to be one of our global health sessions. Malya Sahu, who had been to FAME this last spring, was presenting her experiences having traveled to Zambia for a month-long rotation and had just returned home. Considering that I’m the director of the global health program in neurology, I had wanted to hear what Malya had to say, though I was certain that it had been a good month for her in Zambia as the program there is very robust and full of opportunities given the faculty who are there currently. I am sure that the experience for her was quite a bit different than it had been here at FAME, and I will be interested in meeting with her after my return specifically to discuss some of those comparisons.

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Given that it was Tuesday, there was another educational lecture schedule and today it was given by Dennis on epilepsy, but rather than speaking about the different types of epilepsy and treatment options, he was planning to show videos of different seizure types and it was up to the audience to tell him whether they thought it was a seizure or not, and, if so, what type of seizure it looked like. If it wasn’t a seizure, most often it was PNEE, or a psychogenic non-epileptic event, sometimes referred to as “pseudoseizures” in the past, but these are events that are not caused by abnormal electrical activity in the brain, but rather are considered a functional neurologic disorder, or FND, and are not treated with anti-seizure medications. If the video did depict a patient having a seizure, then it was whether it was a focal onset seizure, that is coming from one place in the brain, or a generalized convulsion, one involving the entire brain. Focal seizures can certainly generalize, meaning that it will involve both sides of the brain and the patient, by definition, should be unresponsive.

It was an excellent exercise and, for the most part, everyone was on the same page, but the important thing was that Dennis was able to give some good pointers on how we typically determine clinically if someone is having a seizure or not, for the most accurate way to tell is to have them on an EEG and be recording when they are having an event. Unfortunately, we don’t have EEG capability at FAME at the present time, though there are some rather inexpensive units that we are looking at currently. Having a patient come into the ED or to the FAME Hospital who is unresponsive and one wonders if there’s a possibility that they are having something called non-convulsive status epilepticus, i.e., the brain is seizing, but the body is still, then the very best way to detect this is to obtain an EEG as it will show the continuous abnormal activity that can then be intervened upon.

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As we really needed to get on the road as early as possible today so as not to arrive late as we did yesterday, it was decided with would try our very best to depart at 8 am right after the lecture. I think we actually came rather close this goal, though it was probably more like 8:30 am, but either way, we were off on another long drive to the Mang’ola region and the village of Mguba Nyekundu where they have a brand-new clinic space that was far more comfortable than what we’ve had in the past. After last spring’s visit here, I have had a number of pieces of office furniture made, nearly identical to what I gave to Barazani, so they could outfit their new space and we would have a bit better working conditions when we’re there twice a year.

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The village itself is a mere smattering of houses and small structures with no real center of town, and it’s incredibly hot and dusty there. Early in the day, the weather was nicer, and Dennis even got to fly the drone he brought with him, though later in the afternoon, the winds picked up and began to blow pretty steadily with lots of dust and a storm front in the distance over the lake that never really materialized over our clinic. Christopher, our nurse for the clinic, insisted that the storm with never make it to us due to the strong wings (quite the opposite of what I think of at home), though in the end, he was right, and we were never touched with any rain.

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The volume of patients that came to clinic was a bit lighter than expected and, even more disappointing, the patients who we had asked to come from Barazani to see as they weren’t able to be seen yesterday, didn’t show up. There were still a number of new and follow up patients, though, so that it was worth the trip here, and some were a bit more complicated such as a patient that Caroline saw with the history of TB that had reported been treated, but it was unclear whether they had completed the full treatment course or not. Unfortunately, we had little to offer the patient there at Mbuga Nyekundu as we had no labs or other testing, which she very much needed. We spoke with her about coming to FAME to be seen so that we could evaluate her more completely, and there’s still hope that she’ll make it to Karatu to see us, though it’s impossible to be sure.

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We departed from Mang’ola at a very decent time so that we would arrive at home by around 5 pm, and I had contacted our friend, Phillipo, earlier to see if we could visit his home and family to buy some coffee from him. I hadn’t heard back, but figured we’d still drive up there and was glad we did as he was home, as was his wife and daughter, and the residents got the full tour of roasting coffee and then we got to purchase the freshly roasted coffee, though only after spending lots of time and tasting his coffee in a French Press or, as he refers to it, a Phillipo press! His family is always a joy to visit with and I’ve watched his daughter Eliza grow over the last several years. Whenever I show up, she loves for me to put her on my shoulders and walk around and, when I do that, she always has the biggest smile on her face that it’s worth the trip just for that.

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As I’ve mentioned before, Phillipo doesn’t sell his coffee anywhere other than from his home and I’m happy to see that he now often has other tour vehicles there when we arrive. Though I would have loved to have kept him for ourselves, that’s a bit selfish, and I’m glad to see how successful he has been. While we were at his home and under a big roof where he entertains guests, a thunderstorm blew in from over the crater rim and we had lots of thunder and lightning along with some rain that lasted a short while and was fun to watch from our dry little cocoon we were in. The storm quickly passed and when it was time to say goodbye, it was already beginning to dry up outside and we made our way home to have our dinners that were waiting for us. We had planned on third mobile clinic for this group tomorrow, but the location fell through, so instead, we’ll be at FAME, which will certainly be fine with us as well as the other doctors here as they’ll have us home should there be consults to see.

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Though our fun exploring Ngorongoro Crater was now over, and it had been a wonderful day, we were now about to depart for Mang’ola, an even more remote region of Northern Tanzania where the Hadzabe and Datoga tribes live and is quite unique. Mang’ola is a small region at the eastern end of Lake Eyasi, a large saline lake that sits in the Rift Valley and is bordered on the north by the Ngorongoro Conservation Area, but the southern shore of the lake is home to the two dominant tribes in the region. The Datoga are a pastoralist society like the Maasai, while the Hadzabe have remained hunter/gatherers and are considered the bushman of Tanzania. Another unique feature of the Hadzabe is that they speak a click language of which there are only of few peoples on the planet that do and the connection between them remains a mystery.

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When I first came to FAME in 2010, there was a large monthly clinic that came to this region in which literally half of the FAME staff would attend in the Eyasi region quite far down the southern shore of the lake. We would take an all-wheel drive vehicle along with several Land Rovers, doctors, nurses, lab techs, social works and support staff to the region and provide medical care to the Datoga and Hadza tribes for an entire week at several sites. It was a true adventure considering there were few roads, and we were often breaking trail to get to where we needed to be. On one occasion, there had a flash rainstorm in the mountains above and a sudden river appeared to completely block our way until we waited an hour for the water to recede after which we successfully crossed with a bit hard labor to knock down the steep embankment.

Each day, well over one hundred patients would line up for medical care that was provided by the staff, while I circulated to see if there were any neurologic issues that I could help with. It was truly an exciting time being on those expeditions and there were always incredible stories to tell when we got back. That clinic ended in 2012 when the grant that funded it ran out, but over the last several years, we have continued to provide a neurology mobile clinic to two of the health dispensaries in villages that are at the eastern end of the lake and closer to Karatu. Barazani, which is the village we would be traveling to today, lies pretty much on the shore of Eyasi and is a small town that even though it’s completely off the beaten path, there are some tourists who make it here, mainly to visit with the Hadza. There are also some lodges here for those travelers planning to spend several days. The other village, Mbuga Nyekundu, would be our destination for tomorrow and is further southwest of Barazani, but still in Mang’ola region.

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Barazani is about an hour from Karatu on an incredibly dusty (especially in the dry season) and rocky road that essentially loops around Oldeani Mountain and traverses some amazing and diverse landscapes. The road, which is often washed out in the rainy season by torrential downpours coming down from the hills in very sharp and steep canyons. You can easily see in the washes, that are now dry, how the water has carved steep walls and it’s not difficult to imagine what this must look like when the rains come. I’ve driven this road dozens of times and know it very well, though you must be very vigilant when driving it and it is bumpy and rutty and you must anticipate your path through nearly every section.

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We bring both vehicles given the number of people coming on mobile clinic. We had four interpreters with us today as Amos has accepted a job at Rift Valley Children’s Village since their volume has increased with the building of their new health center (build it and they will come) and the situation in the conservation area with the reduction in services in that region. Three of the four interpreters were with us in the stretch Land Rover (Turtle) and Nuru was in Myrtle, or the short Land Rover, along with our nurse, social worker, receptionist to register patients, and a driver for the second vehicle.

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When we arrived, we met with the clinical officer who runs the dispensary before anything else as we were their guests. It’s always customary to say hello and announce our arrival rather than just assume we’re welcome. Each time we come, we greet the person in charge and ask if it is OK for us to set up our portable pharmacy and occupy their exam rooms to evaluate the patients. This is a courtesy that is very important to understand as it is very easy to immediately alienate yourself when you arrive at which point you can expect very little assistance from the staff at the facility. The initial greeting here will set the tone for your entire visit and can make all the difference for what type of assistance you can expect from the local staff.

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Thankfully, the clinical officer at Barazani is well-known to me as we’ve been traveling there for several years, and he has also been a consistent fixture there. A year or so ago, I had wanted to do something for the clinic given how graciously they’ve worked with us and with the help of Kitashu, had office furniture built that included several office desks, chairs, and benches for the waiting room. These were all stamped as having been donated by FAME and were welcomed as their other furniture had been pretty worn out over time and they clearly needed additional furnishings. I had wanted to bring them some other things that would improve patient care at the dispensary, so this time brought two glucometers for measuring blood sugar along with lancets and testing strips for supplies. I had also brought for them four automatic blood pressure cuffs. They were tickled to have received the new equipment and I’m certain were going to put it to good use very quickly.

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Once we were all there in the clinic, it was time to set up the examination rooms for the residents to work in as well as our “pharmacy” or essentially where Christopher would put the medications to distribute when they were prescribed. Lastly, it was a matter of beginning the patient registrations, but before that, I asked Elibariki to say a little something to the patients who had come in an attempt to triage for neurology as we had little interest in seeing patients with musculoskeletal aches and pains or pure orthopedic patients with knee or shoulder pain. Anne had come with us in the past to do this job, but she is now at home with Baby Denzel, and we needed Elibariki to fill in for her until she returns. Despite this triage, though, there a good number of people who seem to slip through every time. It’s not that we don’t want to help, but we’re not there to provide general medical care, as that is done by the dispensary clinical officer, and the last thing we want to do is to step on any toes.

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The residents paired up with our interpreters, who were all clinical officers other than Nuru (she is a pharmacy tech), and they began seeing patients. There were quite a few patients who came to be seen by us and it wasn’t until 2 pm that we finally broke for lunch, with the intention that we’d continue working as long as possible in the afternoon to finish off those who needed to be seen by us. We do have a time limit as far as when we need to leave, though, for leaving much after 4 pm means that we won’t get home until after 5 pm, the typical time for FAME staff to leave for the day. Pushing it back another hour will still get us into Karatu before sunset, but any later than that and we would be driving that road in the dark, which is not very advisable given the poor visibility and the animals that wander onto the road.

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Even though we were running a bit later than expected, when we packed up all our supplies and were preparing for the drive home, it turned out that nearly everyone wanted to visit Lake Eyasi as it is very picturesque, and an incredible experience based on the past times we’ve visited. There are families of fisherman that set up tents and essentially live on the shore, bring in the small sardines that live in the salty water there. They use small dories to row far out onto the lake where they set their nets and then row back in. Once on the beach, the fishermen begin hauling in their huge nets, using harnesses made of burlap sacks that they wrap around their bottoms and then attach to the rope that may be half a mile out or more. They slowly walk backwards, playing tug of war with the nets filled with fish, eventually landing the nets on shore where all the fish can be harvested.

There are literally dozens of makeshift tents and shacks on the beach in which the families live, along with their children, many of whom come out to see us and are offered the extra soft drinks that we have left over from our lunch. They are always so inquisitive when they see us which is certainly understandable as they probably see very few non-Africans here given the remoteness of this place. Playing with the children, they will often rub the hair on my arms with their hands and are fascinated by this. The visuals in this very remote place are just incredible – looking across to the other shore are the mountains of the Ngorongoro Conservation Area that is the home to a great many Maasai and where we had driven several weeks ago on our return from the Serengeti.

After a good amount of time on the beach with more posed photos being taken than one could possibly imagine, we loaded back into the vehicles and started our trek back to Karatu for the evening. The drive was gorgeous for it was the “golden hour,” that being the perfect time for taking photos, and, even though, we were driving non-stop to beat the sunset, the scenery was stunning along the way with the long shadows and intense colors. We would be waking up tomorrow morning and making nearly the same drive to Mbuga Nyekundu for another day of clinic and more adventures.

Though the Serengeti is the premier wildlife park in Africa with its endless plains and the great migration, Ngorongoro Crater is the crown jewel of parks here in Tanzania and elsewhere for its completely unique topography and the diversity of wildlife that exists in such a compact space and immediately reminds one of the Garden of Eden. The crater, which is actually a caldera, or a collapsed volcano, is the largest complete, dry caldera in the world with it ten-mile diameter and its fully encompassing 2000-foot steep walls that protect a population of animals that have no need to migrate and exist here for their entire lives. It is home to numerous species of antelope including very large herds of wildebeest, massive numbers of zebra and Cape buffalo, and a great many lions who roam is large prides. The only two animals that don’t exist at the bottom of the crater are the Nile crocodile, for there are no flowing rivers at the bottom, and the giraffe, as the crater walls are too steep for it to descent. The premier animal to see here, though, is the endangered black rhino, whose numbers have been increasing in recent years due to the strict protection that has been placed on them by the Tanzanian government.

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The crater is a game drive that I feel totally comfortable guiding on my own as it is impossible to get lost in the crater, as opposed to the Serengeti, which is so immense, one can become disoriented and lost for days. The crater is also a wonderful first game drive for those who have never been to Africa. I would never want to miss the Serengeti, though if I had a single day to explore, it would be in the Ngorongoro Crater for it has everything to see without having to drive very far. The crater gate is also only thirty minutes away from FAME, making it incredibly convenient for a day trip. The gate opens at 6:30 am, so I try to arrive as close to that as possible, and once paid and through the gate, we’re driving up the 2000 feet of the crater wall on a very windy and, at times, eerie road that ascends in altitude as it descends in time for the vegetation is entirely primordial. Tall, thin trees reaching up as far as possible to reach the even the smallest rays of sunshine, all covered in vines that hang back down to the ground. It feels as though we are entering the age of dinosaurs and that a T-rex may pop out through the trees at any moment.

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This is one of my favorite drives in Tanzania and perhaps even in the world. We climb and climb in the Land Rover, driving in our lowest gears given the steep inclines and tight turns that are required to reach the top, or the crater rim. It is simply marvelous here and, even more so, unforgettable. Approaching the crater rim, we enter the clouds and visibility drops precipitously so that by the time we’re at the overlook into the crater, there is nothing to see but clouds. No worries, the view is always spectacular on the way home after the clouds have dissipated. There are a few glimpses of the crater floor as we drive around the rim clockwise, heading for the descent road. There are three roads here, one for descent, one for ascent, and one on the opposite side of the crater that is a two-way road. Finally reaching the descent road, I hop out to check in after which we pop the top and begin our descent to the bottom in our lowest gears to brake the engine given the steepness of the grade going down.

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I will let the photos, all taken by Dennis, describe for you what our day in the crater was like. These photos are selected from the 1000 or so photos he took with my Nikon D750, and long telephoto zoom that I let him use, having discovered what it was like to be on a true photo safari in Africa.

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There are many holidays here in Tanzania, and it is impossible to keep track of all of them. Most the time, I’m not sure that anyone here knows what each specific holiday is observing, either, but it’s quite clear that it will be observed, meaning that the majority of staff will have the day off. As much as we would love to see patients today, it is really not our choice at all as that would require at least some of the FAME staff to be working with us and that would mean overtime for them, not to mention that they would not be with their families.

For Fien’s flight this evening, she would need to leave the FAME campus around 10 am to be sure to make it to the airport on time, and we had pre-arranged a car to pick her up and bring her there. In typical Fien style, she made absolutely certain that all her financial obligations were taken care of prior to her departure and then it, it was just a matter of saying all the goodbyes. She had met with all the translators and clinicians yesterday who she had worked with over the last three weeks and had developed close attachments to. That’s what happens here as everyone is so warm and friendly.

With no clinic or morning report to attend today, everyone was able to get just a few more minutes of sleep before heading out for planned activities. The residents had decided that they would hike up to the elephant caves, a trail that begins at the boundary of the conservation area next door to Gibb’s Farm and, with the protection of a ranger, ascends further up the crater rim to an area that is frequented by elephants, though not in the manner that you might imagine. Elephants require several minerals in their diet that can only be obtained by scraping and digging holes in the soil with their tusks and then consuming what is dug up. Driving up to the crater rim, there are obvious signs of where the elephants have been scrapping the soil slopes that border the road. The elephant caves happen to be a site where they have found it easy to scrape up the soil and have essentially created large caves in doing so. On rare occasions, one can find a herd of elephants at the caves, but most often, there are no elephants in sight, and only the caves to explore.

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Departing for the caves is from a ranger station that sits adjacent to the Gibb’s Farm property and is within the conservation area. There are rangers there to guide hikers and the rangers are armed as the hiking will be through the conservation area with its full menagerie of animals including Cape buffalo and leopards, and, of course, elephants, all of whom would be more than happy to cause trouble if given a reason. I had planned to go hiking with them, though in the end, led them down to the brick quarry and on to the Tloma village road as it was an easy walk from there up to Gibb’s and next door to the start of the elephant cave hike.

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The brick quarry next to FAME is one of the larger ones in the region and is where many of the bricks used in Tloma Village and Karatu are made. The heavy clay is dug and laid out to cut in the form of bricks which are then stacked, leaving small spaces between the bricks, into very large structures about ten-by-ten-by-ten feet with one or two triangular fire boxes in the bottom of the stack. The outside of the bricks is then covered with mud and/or dung which is allowed to dry before they are ready to fire. Wood logs are then placed into the fire boxes and the stack is ready to be fired. Once cooled, the fired bricks are ready to use for construction. To be honest, who owns the quarry and who does the brick forming and firing is beyond me, though I know that you must buy bricks that you plan to use, so there must be some business aspect of the entire process. Never having had a need to purchase bricks here, though, I really  am not certain how that process takes place.

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I walked back up to FAME once I dropped the group off on the other side of the quarry and set out to doing the work I had planned. I did ask them to let me know when they arrived at the ranger station as I wasn’t sure how I’d explain having lost a group of residents to Ray Price, their program director, or, more importantly, who would fill in for them back in Philadelphia. Luckily, I heard from them at the appropriate time that they had made it and were about to begin their hike up to the elephant caves. In addition to the hike that they were about to take, there is a much more adventuresome hike that leaves from Gibb’s Farm in the morning and ascends all the way to the crater rim before returning by vehicle to Karatu. That is an entire day’s journey, whereas the elephant caves take only a few hours.

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Once they were back from their hike, they texted me that they were ready to be picked up at the ranger station and I was on my way. As I pulled into the small parking lot at the ranger station to find the three intrepid hikers perched on log, the very first thing I heard from them was, “hey Rubes, do you happen to have a credit card with you?” In an attempt to thwart theft or embezzlement at the various parks and government installations, cash can no longer be taken, and it is only credit cards or paid online advance reservations. I guess had I wished to have some quiet time alone at the house, I could have said “no,” in which case there would have been a reasonable chance that the rangers would have taken them to the police station, though, in the end, I would very likely have had to bail them out and that may have been complicated.

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They ran my credit card to pay for the three of them at which point they were released to my custody, and we were on our way home in short order. After a quick stop in town for some lunch items as we would be heading into the crater the following day, we drove back to FAME and took advantage of my favorite lunch, rice, and beans. Their plan for the afternoon was to head over to the Highview Hotel for a swim as we’re allowed to use their pool as volunteers.  I remained at home once again to work, though did head to Frank and Susan’s at sunset to visit with them as well as Annie Birch and Mama India, both of whom were visiting for the evening. Darkness fell quite quickly and by the time I arrived home, the others had returned from Highview, and it was decided that we’d head over to the Lilac to order dinner but return home as it would take an hour to make, and they would deliver it for us. We would be heading to the crater early in the morning and everyone was excited for that.

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It was Fien’s last day in clinic as she would be departing tomorrow morning for home after what has seemed like an amazing three-week experience for her given the fact that she had come with very little knowledge of exactly what to expect, and other than a Zoom communication and some emails, knew very little about those she was about to spend every day with. Equally so, other than having met Fien once on Zoom, I had no way of knowing for certain how she would mix with the other residents or what her work ethic would be, though I can honestly say I was fully confident things would work out for the best given our brief meeting and my knowledge of the residents who would be spending time here. Despite all the research and reassurances that one makes in advance, there is always a leap of faith that must be made in the end, and, in this case, things worked out better than any of us could have hoped for. Fien’s presence over the last three weeks provided a tremendous experience for my residents to work with someone from a completely different training program and to discover, that in the end, they were all on equal footing. Hopefully, this will open the door for similar incredibly successful experiences in the future.

Our morning was a bit disorienting for as we approached the large conference room for morning report, there were others standing outside the room waiting to enter. Apparently, there had been a doctors’ meeting at 7:30 am that was purely administrative and had yet to finish, so the rest of us, including FAME staff, were redirected to the smaller education room in the administration building to hold morning report as best we could without the FAME doctors. Anne had come in the morning as her presence at the doctors’ meeting had been required so that she would work with us now and then head home for the afternoon.

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I had Fien round with the inpatient team on the ward since she had been the one most involved with the management for the status patient and could best assess how he was doing in regard to any persistent neurologic deficits. Again, we had already completed a CT scan yesterday due to his persistent altered level of consciousness and concern for a process that had produced his seizures, but the scan had not revealed anything concerning and was unchanged from one that had been obtained a years ago demonstrating only atrophy. When Fien finally returned to the neurology clinic, she reported that the seizure patient had been more alert and, even though he wasn’t following commands, he was attending the examiner and awake. Considering the length of time that he had been seizing yesterday and the number of medications he had received, these were very positive signs indeed.

We have been seeing a greatly increased volume of patients coming in after motor vehicle accidents, or what are referred to here as MTAs, being motor traffic accidents. We have also seen several pedestrian vs. vehicle accidents, mostly someone being knocked over by a motorcycle when they are crossing the street. This is one of the reasons for the higher incidence of epilepsy here in that the head trauma leads to brain injury which leads to a seizure focus and focal onset epilepsy. There was a very lucky patient in the ward today who had come in after being struck by a motorcycle with prolonged loss of consciousness and a fracture of her temporal bone who thankfully did not suffer an underlying epidural or subdural hematoma.

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As I have mentioned previously, the FAME surgical staff is now equipped to deal with both epidural and subdural hematomas by placing a burr hole using one of the two manual cranium drills that were brought here over a year ago when Sean Grady and Kerry Vaughn visited FAME specifically for that purpose. Sean had previously taught general surgeons in the lower portion of Alaska how to do these procedures as trying to transfer patients with life-threatening bleeding such as a subdural or epidural hematoma is usually unsuccessful as they often worsen and die in route to the tertiary center. More complicated patients such as those with chronic subdural hematomas that would require a craniotomy flap have to be sent to the neurosurgeon at KCMC, more than 3 hours away.

We had many patients waiting to be seen in the morning and, even though we had planned to work only until 2 pm today so we could make it up to Gibb’s Farm for dinner, it seemed like that wasn’t going to be in the cards for us today. In the end, the gods must have been shining on us for it seemed that everything suddenly cleared just in time for us to have our late lunch and then head back to the house to finish to relax a bit before heading out. This group hadn’t yet been to Gibb’s Farm, so it was essential that we get there early enough, not only to explore the grounds, but also to watch the sunset from there are it has one of the very best views of that around.

Gibb’s Farm is truly in its own league and must be one of the most beautiful places on earth when everything is considered. Once a colonial coffee farm that was totally self-contained with their own dairy, wood shop for making furniture, vegetable garden, village for the workers and health clinic, it has now become a truly remarkable destination resort and home base for visiting many of the parks in the area, especially Ngorongoro Crater, and a launching point for the Serengeti. Having never officially stayed there, I can’t comment from that standpoint, but I have toured their rooms, which are just lovely, and have eaten many a meal in their dining room as well as on their veranda outdoors. Their service, cuisine, and ambiance are really impeccable, and visiting Gibb’s must be one of the highlights of the resident’s stay here in Tanzania. I always make sure that any visiting faculty who have accompanied me to FAME are brought here as it is a bit of luxury, but in a style very much Tanzania, and always memorable.

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FAME volunteers are given a discount for the lunches and dinners at Gibb’s Farm, mostly in recognition of the fact that they are here helping the community, but also because many of the volunteers are here on a shoestring budget and having a small break in the cost makes it possible for many to go. Even more than the discount, though, we are always made to feel so incredibly welcome despite the fact we are not actually paying guests at the resort. Being here, doing what we are doing, though, makes everyone a welcome and honored guest of the community which is always a very nice feeling.

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The view from the veranda or the lawn in front of it is one of the more spectacular in the region, and coming here at sunset makes it even more gorgeous. Once we arrive and I’ve oriented everyone to their new surroundings, my usual habit is to plop myself down on the veranda and have a Moscow mule, which is somehow made all that more refreshing because I am here at Gibb’s. Today, the others have decided to join themselves on the lawn in front of me taking photos of each other with the magnificent backdrop of the view along with all the incredible vegetation that exists there. The lighting here in the golden hour before sunset is to die for.

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The last time I was here several weeks ago, the Tloma Village Choir was performing in the evening, but tonight, it would be an Iraqw cultural group of singers and dancers. I had not seen them before, though a similar group had performed one night while Jill and I were staying at the Ngorongoro Crater Lodge last April. There were two musicians, one with handheld drum and the other with a two-string instrument that was played with a bow much like a violin. There were four women dancing and everyone pitched in with the singing. The group leader was quite funny and a real character while telling stories of Iraqw culture for they are the dominant tribe in the Karatu district and have been in this region for at least 1000 years. Of course, audience participation was mandatory as the leader wouldn’t take no for an answer, and after all the women in our group got to dance, it was my and Dennis’s time to move into formation to dance. It was a real workout trying to keep up with the dancers and I was very happy that the dance ended when it did as I wasn’t sure I was going to be able to finish it.

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After the Iraqw group performance was over, there was still enough light for the residents to all walk over to the vegetable gardens, though, as I’ve mentioned before, a blanket of darkness falls very quickly here at the equator and can often catch you off guard. Thankfully, everyone’s phone now has a flashlight, so they were able to make it back to the main lodge without incident. A table had been set up for us outside on the veranda, which was actually perfect for the evening wasn’t too cool or too hot, but just right. There were light throws on each of our chairs if anyone felt they needed it and several of the others put them on after a bit. Dinner was scrumptious, as usual, and we all left that evening quite full and satisfied. My friend, Nish, from the African Galleria, did join us at the end of dinner and purchased several bottles of very nice champaign which was certainly a nice touch to the evening.

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We were off tomorrow as it was a holiday here and, given that the clinic had been slow, it was felt that the staff should have the day off. Fien wasn’t leaving until 10 am so there was no rush to bed. Everyone had enjoyed the evening thoroughly.

As we were planning to work a shorter day tomorrow, this would be our last full day of clinic for Fien and of the week. We had anticipated a morning lecture at 7:30 am, though as we left the house to walk to campus, Leslie, who was outside exercising (yes, some of the volunteers do exercise on a regular basis), informed us that there was no lecture. We all reversed direction, quite thankful that we all now had an extra 30 minutes of down time, which I, of course, used for a quick cup of tea prior to starting our morning clinic. When we arrived at the education room in the admin building, where the education lecture and morning report take place on Thursdays, all the doctors were present and were having a session in Swahili that, regardless of the language, was clearly somewhat of a “gripe” session in which Dr. Gabriel was soliciting things that were being done right and those that weren’t. The session continued for another 10-15 minutes after we arrived and given that a small amount of it was in English, we got the gist of the conversation.

Things got busy even before our clinic started as there was a middle-aged patient who had come into the ED earlier with severe hyperglycemia in the setting of diabetes, but more concerning for us is that he was in status epilepticus, though had a history of seizures and who had not been taking his home medications, unfortunately. In reviewing his records, he had been seen before with similar issues and had actually had a CT scan, which had been commented on in the chart as showing some focal hypodensity, though the official read was unfortunately missing, and it would take some time to bring up his old study. In the ED, Fien was mostly working on the patient, who continued to have mostly focal status, though was not waking up between events. Dr. Amanda, along with an ER resident from Scotland who just happened to spending the day at FAME, worked to keep his respiratory status stable without intubating him as we have no ventilators to use on patients outside of surgical theater.

Compounding the issue, the only IV antiseizure medication we have is phenobarbital, which can only be used at real loading doses if you’re ready to intubate and ventilate the patient and that was not something we were intending to do. The patient received significant amounts of midazolam, a short-acting benzodiazepine, that, again, is an issue when it comes to breathing. Stuck between a rock and a hard place, with Dr. Amanda and Dr. Anna (our Scottish ED resident) maintaining constant jaw retraction to keep his airway open while we asked for an NG tube to be placed that would enable us to get some longer acting anti-seizure meds on board. With the NG tube now placed, we first gave him a levetiracetam load of 3 grams, which, if we had been in the US would have been immediately effective, but not so when giving it via the NG tube. To be honest, status epilepticus is a condition that is treated as an emergency, so I am very doubtful that there are guidelines anywhere referring to the use of an NG tube, though, as I have said often before, this is Africa.

By about this time, the CT scan done the prior year was finally made available for our review and was completely normal, which made me feel better as I was a concerned that the hypodensity someone had described last year could have been something more concerning, but at least that was not case. Waiting a full 30 minutes for the levetiracetam to work, which it hadn’t (he was continuing to have very brief focal seizures, but was not waking up in between), we then decided to give him a loading dose of sodium valproate through his NG tube. He eventually stopped seizing (thankfully), but given the amount of time he had been, he was not waking up. He was admitted to the ward with decent oxygenation, and, over the course of the day, seemed to become a bit less obtunded for us. Fien had an excellent lesson on how to manage status without IV antiseizure medications, something I’m not sure she had imagined doing previously.

At the same time as we were dealing with the seizing patient in the ED, Dennis was asked to see a young child in the ward with a bulging fontanelle and some developmental delay. Though he was pretty certain the child was going to have hydrocephalus, when they did an ultrasound of the head (possible with the open fontanelle), the ventricles looked normal, and it didn’t give us an explanation at all for the delay and the finding on exam. He also checked the baby’s thyroid as that was also on the differential (a simple blood test that is available at FAME) and it was essentially normal. With no good answer and an adequate ultrasound, he didn’t want to expose the baby to radiation from a CT if it wasn’t necessary so we recommended that they come back to see us in a few weeks when we would still be around.

Later in the day, we were asked to see a young Maasai boy who had been brought to FAME from the conservation area after having fallen over a cliff and had a serious head injury. The story was that two days earlier, the boy had been herding the family’s livestock when he slipped while standing on a rock at the edge of an overlook and fell approximately 50 feet, striking his face and head when he landed. The child had remained with his family for two days, but wasn’t getting better, so he was brought out of the conservation district by bus to FAME. In looking at the boy’s CT scan, he had very serious fractures of the right very much greater than the left orbits, right frontal skull fracture, and severe contusion of the right frontofrontal brain with some subarachnoid blood. He had no subdural or epidural hematoma, something that would have required immediate surgery, but his orbital fractures were something that would require an ENT specialist. He was not alert and his eyes were pretty much swollen shut. We recommended transfer to KCMC where he could be seen emergently and, thankfully, he was transferred before it got too late as ambulance transfers are very risky in the dark.

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It was a very busy morning which was great as it went quite quickly for us, and before we knew it, lunch had rolled around. Thursdays are pilau day, typically one of the favorites for everyone, that is except for the vegetarians in the group. The pilau, being rice cooked with meat and seasonings and accompanied most often by a cabbage slaw, is definitely delicious, though I am still totally partial to the lunch that is served for five out of seven lunches and that is the rice and beans with mchicha on the side and lots of pili pili. As I have mentioned numerous times in this blog, I think of this lunch often when I am home and miss it dearly the moment, I leave FAME.

Our evening activity tonight, which was rather impromptu, was an invitation for us all to attend Teddy’s son’s first birthday party. Teddy, the tailor who has taken such wonderful care of the residents over the last several years and has also now taken Dorthea in as an apprentice, had her first baby last year at this time. Not only was Allan born while we were here a year ago, but we have watched him grow and have enjoyed seeing him on each of our visits to her shop. Birthday celebrations, and especially the first, are huge events here in Tanzania, and a time for family and friends alike to gather and show respect. Being invited to such a celebration was an honor for us and something not to be missed. There were plenty of kids from the neighborhood in attendance, but more significantly, there were lots of adult. Allan, of course, will remember very little of the party, but his mother will, and it was a chance for us to congratulate her on such a handsome young man and to give a gift for his future.

Another tradition here, which I happen to love, is that birthday cake is cut into bite sized squares and then fed by birthday person with a toothpick to each of the attendees. Allen could not do this, of course, so it was left up to Teddy and everyone filed by to receive their piece of cake delivered directly into their mouth. I did this for my 60^th birthday at the Highview and remember everyone dance in line to file by for me to place a piece of my cake in their mouth with a toothpick, just like a mother bird feeding her chick in the nest. After our little piece of cake, we were all invited to partake in a lovely dinner that she had prepared for everyone. It was buffet style and Babu (meaning grandfather), or I, was invited to come up and get the very first plate of food for which I was obviously touched and incredibly honored. It was a lovely evening, and I am sure that it was something the residents will not soon forget.

I am going to take a lesson out of the playbook of Heather Cox Richardson, one of my favorite daily reads for US and world politics as well as historical references (her daily blog is a must), though rather than taking Sunday off, I’m going to pause today on writing much for the blog and, instead, share with you pictures of our daily life here in Karatu.

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Before I do that, though, I’ll tell you about a consult the residents did late last night after returning home from Teddy’s. There was a patient of approximately 50-years-old who had been either treated or admitted in Rhotia for a new headache of about seven days or so that was quite severe and hadn’t responded to standard analgesics. She came to FAME in evening and had been admitted to the ward for evaluation. Though her headache had migrainous features, she had really never had headaches this severe in the past and had never sought medical attention. Her examination was completely within normal limits and, most importantly, she had no focal findings nor evidence of meningismus (the resistance to flexion of the neck seen in patients with meningitis). In short, she had a very reassuring examination.

So, the question at hand was what to do about this patient’s headache and whether there were any concerns that she had a more ominous process that would potentially cause her immediate harm. In treating headache at home, we will often refer to what we call red flag symptoms or signs, which includes the history that we obtain. If one has these “red flags,” then we worry that the headache may be secondary to some other ongoing condition and the patient requires further evaluation, most commonly an imaging study (a CT scan in the emergency room or an MRI as an outpatient). New onset headache over the age of 50 is one of these red flags and this patient certainly fit the bill as she really had no prior history.

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Though these “rules” are certainly based in good clinical practice, they must be tempered for the environment where one is practicing, for the difference in resources makes this vastly clear. Ordering tests for what is a possibility, despite how remote that may be, is a phenomenon that exists only in countries of unlimited resources, if there are any of these that truly exist. In the United States, of course, where there are few restrictions for ordering tests, or at least few that cannot be circumvented, billions of dollars are spent ruling out conditions that may have only the very slightest chance of being present, or possibly no chance at all. It is clear that we cannot continue that course for our healthcare budget continues to grow astronomically and will be impossible to sustain for much longer.

Here, in Tanzania, with our limited resources, the question I had for my team when I came to the ward to staff the patient was much different. When they had finished presenting her case to me and we had finished discussing all the possibilities, my question was simple. “What do you think is most likely going on with this patient and what would you like to do to treat her?” In the end, we performed no tests nor any imaging. She had a headache and a totally normal examination. We gave her a large dose of IV steroids that we often use at home in the emergency department to break headaches, and the following morning she was headache free and was discharged home.

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