With Leah now here, we were fully stocked with pediatric neurologists, something incredibly scarce here in Tanzania, and very much needed considering the volume of hypoxic-ischemic encephalopathy (HIE) babies we see here as well as pediatric epilepsy. From the very beginning, it has been clear that the pediatric volume for us would be considerable as it has consistently represented a third of the patients we see here at FAME, and most often the more complex cases. There is a very high prevalence of epilepsy in Tanzania as well as all of Africa as 90% of epilepsy exists in low to middle countries (LMIC) where there are far fewer neurology experts to take care of these patients. The reasons for this increase in epilepsy compared to high income countries are several, but the most significant are the lack of prenatal care and birth injuries, childhood infections such as malaria, and lastly, traumatic brain injuries.

In addition to the risk that uncontrolled seizures pose for these patients, there is also a considerable risk of injury as a result of falls – either direct trauma from the fall itself or, and often more serious, the risk of severe burns occurring when someone falls into an open cooking fire or spills the boiling porridge on them they are carrying across the room. In the past, we have typically had one or two burn patients here at FAME as inpatients receiving painful treatment for their burns, though, to be honest, I have seen far fewer over the last several years, perhaps due to the effect we’ve had in successfully treating so many patients who had previously been living with uncontrolled seizures. Regardless, though, it is very common for us to see new patients in their third decade who have been having frequent seizures for their entire life, perhaps having been seen once in the past at a dispensary and placed on phenobarbital at a sadly subtherapeutic dose and stopped their medication after becoming discouraged.

We have treated hundreds of epilepsy patients over the years here at FAME, and it has been so very rewarding that the vast majority of these patients have been placed on anti-seizure medications (ASMs) that have controlled their seizures either completely or at least significantly improved their seizure frequency. The struggle, of course, has always come down to keeping patients on medications due primarily to their cost, and rarely to poor adherence. When patients are seen by us in neuro clinic, they will receive one- or two-months’ worth of medication with their visit, but the issue always comes down to whether they will be able to afford the medication in the future when they return for their refills. This issue has been an ongoing struggle given the current economic status of the vast majority of those patients we see at FAME in combination with the near complete lack of health insurance in the country, and the cost of medications. Developing some system to assist with the cost of these medications, especially for our patients with epilepsy, will continue to be a primary goal of our neurology program – we are constantly looking for alternative funding sources and donations.

Meanwhile, it was Leah’s first day in clinic which meant that I would have the opportunity to introduce her to the FAME staff once we were finished discussing cases at morning report. Having mostly been away from the hustle bustle of FAME over the weekend, the three of us (me, Natalie, and Patrick) had rested up quite well while Leah was still probably a bit jet lagged from her travels and having just arrived. We also had another volunteer who arrived at FAME over the weekend. Dr. Veronica is an infectious disease specialist from Verrona, Italy, who is here volunteering for the first time with her family – she will be here for three months, and her two children will be attending school at the Black Rhino International Academy while they’re here. Having two full time infectious disease experts (Dr. Elissa, who has been here full time for the last two and a half years, is a pediatric ID specialist) at FAME is a real treat as there as so many of our inpatients where this is the major discussion – making certain they are on the appropriate anti microbials which always a daily and, at times, continuous discussion, especially in our neuro patients with meningitis or encephalitis.

Over the weekend, there had been a number of trauma cases that had come through the ED, several with head trauma, though we hadn’t been asked to come in to see them. In a way, that’s good as traumatic head injuries with fractures are not necessarily our forte or something we relish seeing given that fact. It’s often helpful to have a good neurologic assessment of the patient, even beyond the Glascow Coma Scale, which is the universal neuro trauma assessment, though is very generalized and doesn’t pick up on the more subtle deficits that are quite often very helpful when assessing for specific injuries and following a patient. One of the patients had a basilar skull fracture that caused significant pneumocephaly (intracranial air), which in itself isn’t a problem, but is more of an indicator of the underlying problem.

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I’m including a number of photos I took over the weekend of the sunbirds enjoying the flowers immediately behind our house. Sunbirds are members of the family Nectariniidae, and are Old World birds that range throughout Africa, Middle East, Asia, and parts of Australia. They have downward curving beaks to drink nectar from flowers and essentially serve the same purpose in nature as hummingbirds in the Americas – it is through convergent evolution that they’ve come to resemble each other so much, though Sunbirds typically do not hoover as hummingbirds do, but rather perch by grasping the plants. They are wonderful birds to watch and equally fun to photograph. I set up my long lens on a tripod and sat out on the veranda taking a few photographs that I think you’ll enjoy. Natalie was sitting on the couch close by working on her computer, but the birds were quite happy to be doing their thing despite our presence.

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Three years ago, with an increased interest in our global neurology program by our residents and an enlarging resident program, the number of resident slots per year was increased from 8 to 16, with two groups of four residents each coming for three weeks twice a year. With this new format, it required a switchover weekend in the middle of each of my six-week trips here. For the first year of this new schedule, I drove the departing residents to the airport, a 3+ hour drive on Saturday, then stayed in Arusha that night (an hour drive), then back to the airport for the next group’s 7:30 am arrival, and back to Karatu on Sunday afternoon. This was an incredibly exhausting weekend schedule for me, and one that was probably not sustainable going forward.

Thankfully, Jill’s wisdom prevailed, and she quickly convinced me that the residents, being “grown ass adults,” were sufficiently capable of making it to the airport as well as to FAME on their own by simply setting up shuttles for them. It was suddenly like a whole new world for me, and though I still stress just a wee bit when the residents are in transit, it has not been enough to drag me back to the old schedule of schlepping on this weekend. And, I haven’t felt guilty for it.

Joe and Jack would be departing on Saturday morning between 9 and 10, then overnighting at the Airport Planet Lodge as their flights weren’t until the following day, and Leah Loerinc would be arriving tomorrow (Sunday) by noontime. This meant that I had almost the entire weekend to relax, as did Natalie and Patrick, hanging out at the house. I had a bunch of work from home to get done, as did Natalie, and Patrick occupied himself with busy work as well. The Raynes House is incredibly comfortable, and though I almost managed to remain in my gym shorts and T-shirt for the entire day, it was still very successful in which we were all able to finish our projects. Late in the afternoon, we did have to put on our work clothes as we were called to the medical ward to see the patient who was found to have a brain tumor, though it required only a brief visit, and as soon as I arrived back home, I was back in my gym shorts and T-shirt as quickly as was humanly possible.

Natalie ended up having to go back to the ED later to see a young child we had seen earlier for seizures and had placed her valproate at that time. The child was having continuing seizures, which wasn’t very surprising once it was made clear that she wasn’t being given the correct dose of medication. She had been on 100 mg bid (twice daily) and still having seizures before seeing us, and the plan had been to increase her to 200 mg bid after her visit. What Natalie discovered was that the family had only been giving the child 200 mg once daily, and not twice daily, which certainly explained why there had been no improvement after our visit. The family was again instructed on how we wanted them to give the medication and seemed to have a better understanding after the second go around.

Natalie made flourless banana pancakes on the stovetop for our breakfast the following morning as we had extra bananas on the verge of turning to mush, and they were very, very delicious, especially with the “exotic safari jam” on top or peanut butter – we’ll definitely be ordering honey with our next shopping list.

I had heard from Leah earlier this morning that she had gotten through immigration and customs at the airport and was on her way to FAME with Vitalis who had picked her up at the airport. They arrived to Karatu around noontime, which was perfect as we were planning to eat lunch on campus, and then later had dinner plans at the Omega View Hotel, as well as a dip in their pool. We hadn’t been to the Omega View yet, but it is a rather new hotel in town and someone I had known from the past is now their manager. He had invited us to come over for dinner and a swim, though really didn’t know what to expect. It was a nice relaxing time at the pool, and as is the case for most pools here in Karatu, it was unheated and quite refreshing. After a short swim and lounging at the pool, we all headed up to dinner in their dining room on the top floor (5^th) with amazing views of Karatu that I haven’t seen before. Their buffet dinner was delicious and very reasonably priced. We had also been shown two of their rooms which were very clean and large. For anyone needing a place to lodge for a short time, it was very nice, indeed.

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Given Leah’s jet lag, we were all amazed that she was still awake through dinner. We arrived home, though, and she promptly hit the sack which was totally understandable after the several days journey to get here. We would be back in clinic at FAME for the entire week, and LJ would be arriving on Saturday morning in time to accompany us for our Ngorongoro Crater trip this coming Sunday.

On the last Friday of the month, FAME clinicians present an M&M conference in which a case is chosen to review, and to discuss what went right and what went wrong. M&M conferences are considered peer review, and anything contained in the presentation, discussion, or the ultimate recommendations that arise as a result of the case are protected and, at least in the United States, are not discoverable from a legal perspective meaning that what is discussed in an M&M conference is not admissible in court. The reason for this, and for peer reviews in general, is to allow a forum in which everyone is free to express their opinions, and not necessarily to point fingers, but rather to move forward and to improve the delivery of health care. There are no sanctions or punishments that arise from these conferences as it is meant as a learning experience for all involved.

As such, it would be improper for me to discuss any of the details of the M&M conference, though, on the other hand, I can certainly comment on the general topic as I think it would be helpful. When I discuss with others at home what we have here at FAME, I am always asked the question, “Do you have an ICU?” My response has always been consistent and straight forward. “Well, we don’t have an ICU per se, but we do have many critically ill patients who we are caring for at FAME.” That may sound very strange to those who are used to practicing in hospitals where there are very strict criteria for which patients are on the floor, which patients are in the ICU, and which patients are in the step-down unit in between the previous two. These criteria consider a patient’s vital signs, level of acuity (or acuity score), acute organ dysfunction, physiological instability, and the need for advanced interventions such as mechanical ventilation or pressure support with medications. In addition, a patient’s prognosis is considered as well as goals of care to determine whether the patient would benefit from the level of support offered by an ICU.

At FAME, we do not have an ICU and are unable to provide prolonged ventilatory support (as I have mentioned previously) as the only ventilators we have here are for the operating theater of which there are two. That is the case in many hospitals here in Africa – it is not a thing to have patients on ventilators for prolonged periods of time and there are very few ICU beds that exist in Northern Tanzania for any circumstances unless the patient is suffering from a very clearly and quickly reversible process. What we are able to do, though, is to identify those patients who require a higher level of care in regard to more frequent vital signs and nursing checks, and to use one of the rooms in our medical ward that will serve as a step-down unit where these patients with a higher level of acuity can be placed and cared for more closely. M&M conferences are a learning experience that provides a forum for new ideas and overall improvement in our healthcare delivery.

As it was Jack and Joe’s last day in clinic, I made sure to make that announcement once morning report was completed. It also gave the two a chance to thank everyone at FAME for their hospitality and acceptance. I can’t recall if I’ve mentioned it before, but it requires a special attitude for people to volunteer at FAME, and to work side by side with such qualified Tanzanian clinicians as we have here, without managing to offend someone along the way. Thankfully, every resident, fellow, and colleague who I’ve brought to FAME have understood that nuance, which is critical for anyone working anywhere in the global health field, and any others who have volunteer at FAME are of the ilk to understand this with very rare exceptions.

We had been asked to see a patient in the ward who had lower extremity weakness as well as extensive lymphadenopathy of the neck, the latter having been biopsied in the past with no clear diagnosis. When the team went to see the patient, it turned out that her lower extremity weakness had actually began well over a year ago when she noted that she had bent over and developed acute weakness of both of her legs, and that they had remained weak since that time with no real progression, though her weakness was so severe that it would have been difficult for it to have progressed very much. On examination, she was found to have a spastic paraparesis with severe contractures and had a T4 sensory level suggesting a spinal process either two levels above or below the T4 level.

Unfortunately, with her condition having started over one year ago, there was very little we could offer as far as investigations that would have led to some treatment of her condition, though we could certainly offer some symptomatic treatment for her spasticity. We obviously had lots of curiosity as to what had caused her underlying spinal process but as it would not help to reverse anything of her weakness or improve her function, there was little reason to spend anyone else’s money. Of course, the differential for the problem was a bit broad, but the rather acute nature suggested perhaps a spinal infarct or sudden cord compression from a thoracic disc or Pott’s disease (tuberculosis of the spine and collapse of the vertebrae with compression). How to connect the lymphadenopathy of the neck with cord process wasn’t clear. Sending the patient for an MRI would certainly have been interesting for us as it would have shown whatever the underlying process was but wouldn’t have led to treatment or changed her overall outcome or function.

This is often the dilemma we face here when resources are so scarce, and patients are paying for the majority of their investigations and treatment. Though we do subsidize the neurology clinic somewhat (visit, medications for a month or more, and laboratory studies all for about $2 USD), we are unable to sustainably cover the cost of a CT scan (approximately $90-100). Things here are never done out of academic interest, nor for curiosity, ever. The patients we see often have difficulty affording the even the visit fee, in which case we will have them speak with our social workers and often figure a way for us to cover their cost without it appearing to be a gift, which is also a big no-no here and is a quick way to completely alienate all those Tanzanian clinicians who are otherwise unable to provide the same financial gifts that we can. This is true in aspect to what we do here and is a rule that is strictly adhered to at all times – we never reach in our pockets to help a patient in need without first going through our social workers who will first assess the patient’s need and then, with the greatest of sensitivity so as to be certain it does not appear as a gift, make whatever services available to the patient under the guise of an unnamed benevolent fund rather than from the visiting mzungu (non-Tanzania) doctor. Although this entire process may sound quite frivolous, I can assure you from having to undo completely innocent actions in the past, it is totally necessary.

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At the very end of the day, the team saw a 50-year-old patient in the ED who had come in after a seizure and was encephalopathic. Though her history wasn’t entirely helpful and the report was that she had only recently (days) developed any problems, she did have some focality on her examination, so it was felt that a CT scan of the head was an appropriate study for her. Though we didn’t get the CT results until the following day, it wasn’t a very good picture her problem appears to be a high-grade multi-centric glioma involving the deep left hemisphere and left temporal lobe and, perhaps more importantly, would not be resectable given its location. I sent the images to the neurosurgeon in Moshi at Kilimanjaro Christian Medical Center, and she agreed with the assessment, though suggested that perhaps she might be a candidate for temozolomide and radiation. We will discuss a possible referral with the family, and whether this is something they would be willing to consider, though ultimately, we will have to convey that her prognosis is very poor.

As it was Jack and Joe’s last day in clinic as well as their last night in Karatu, everyone decided that we would go out to celebrate at the Lilac Oasis with the entire neuro team. Our translators have been wonderful, and it would be a way to show our appreciation as going out like this would not be something they would normally do. The Lilac Oasis has been open for a few years and is still a work in progress, though what has been completed so far is really gorgeous – a lovely bar/club with live music and karaoke, a beautiful restaurant, and an outdoor venue for music with a “Dunga,” or a converted safari supply truck serving drinks and food. The landscaping for the entire facility, complete with ponds and running streams, is really spectacular. We sat in the bar having drinks and ordered food which, as is typical of almost every restaurant in Africa, took well over an hour to prepare and serve. They moved us to the restaurant in the end so we’d be more comfortable, which was fine, as it was getting late and we would be leaving after eating. Everyone seemed to enjoy a nice night out together.

The topics for our morning education lectures that we deliver are always selected by the FAME clinical staff which is a very important point and a basic premise for anyone involved in global or community health programs. The people who know best in regard to what is needed, whether it be educational lectures, supplies, training, or volunteers, for that matter, are those on the ground and who are familiar with the lay of the land. Barging in with the attitude that “we know what’s best for you and what is needed” will inevitably end in failure of the program and a relationship that is irreparable. Hence, the topics for our lectures are always decided upon by the clinical staff and communicated to us by the education officer for FAME (who currently happens to be Dr. Jacob). Often there may be recent cases or events unbeknownst to us that effect what topics they wish to hear from us. This morning’s topic, mood disorders and psychosis including their effect on health care workers, to be delivered by Dr. Joe, was a particularly timely subject that had been requested and would be followed up in the future by additional talks.

Though we are not psychiatrists, by any means, neurology residents, and neurologists in general, do receive extra training in psychiatry and we do share the same board in the United States, though they are completely different certifications. As there are so very few neurologists here in Tanzania, there are equally few psychiatrists, and, as Dr. Frank continually reminds me, we are the closest thing to a psychiatrist here in Tanzania meaning that the burden of evaluating and treating many of these patients falls to the neuro team. Several years ago, we did have a graduated medical student, Phillip Bradshaw, with us who was planning to apply for psychiatry residency (and is now finishing us his residency at Penn), who was a great help in evaluating these often difficult patients, and even Noor ul Sahar Khan, who had been with us in the spring as a visiting guest after finishing medical school in Pakistan and was interested in pursuing psychiatry, were incredibly helpful as they were both willing to spend that extra time that is often necessary with these patients.

Dr. Joe’s talk contained a great deal of material concerning this very important topic and, amazingly, he was able to get everything in that he had planned to do and was still under the 45-minute mark which is what the educational talks are allotted. He even left a little time for questions, though there were so many that followed, we went way overtime. As morning report was to follow the talk, as is usually the case, it kept getting delayed with all the important questions that were being asked, though it was clear no one was going to pull the plug given the critical nature of the material.  Amazingly, I think we may have ended up going over by thirty minutes, but it was perfectly fine, and everyone understood. Joe also developed a number of treatment pathways that he presented and will be useful for the staff going forward when dealing with these patients in our absence as it often falls to the primary care doctors to deal with these issues.

Once we made it to clinic, there was a huge Lilac Café order placed for everyone in the neuro clinic, including a number of chapati mayai and plain chapati – I stuck with my standard two beef samosas that I often enjoy in the morning. The staff from the Lilac bring our order to the clinic and it usually gets set on my desk where there are no patients being seen.

A young Maasai child came into clinic for follow up with a history of febrile convulsions, though they were slightly atypical as being a bit prolonged. Normally, we would not necessarily place this patient on anti-seizure medication, or at least we would think long and hard about it, though this family lived in the Loliondo district which is near the Kenya border and a seven-hour bus ride over rough roads from Karatu. Given the distance they would have to travel to receive care or any follow up, it was decided to start the child on levetiracetam until they outgrew the risk for febrile convulsions at which point we would then consider tapering off the medication as long as they hadn’t had any further seizures. Sometimes, you must consider all the different variables when recommending treatment options and, in this case, the family felt most comfortable with this plan.

Another interesting patient that was seen today was an 18-year-old young man who had come to FAME 10 days ago after a large tree branch fell from a tree and struck him on the head causing loss of consciousness. He was admitted to the medical ward after obtaining a CT scan that demonstrated a very wicked right temporal fracture as well as small epidural and parenchymal hematomas. He spent two days in the hospital with the complaint of a headache and then discharged home with paracetamol. We didn’t see him, unfortunately, though he wasn’t described as having any focal neurologic signs.

He was returning today for routine follow up and, amazingly, wasn’t complaining of a headache. He did note that he had some subtle numbness of his left hand, but his neuro exam was otherwise non-focal. He is one incredibly lucky patient as his injuries and the outcome could have been significantly different had his epidural been much larger – epidural hematomas are almost always associated with traumatic skull fractures and are the result of a lacerated artery leading to a high-pressure lenticular shaped hemorrhage that often requires at least a burr hole and often a craniotomy to ligate the bleeding vessel. They are typically the most emergent types of intracranial hemorrhage as far as surgical treatment is concerned, though given the small size of his epidural and the lack of further expansion, he was able to tolerate it without requiring a surgical procedure. The small parenchymal hemorrhage seen in the right parietal region clearly explained his left hand numbness and will most likely resolve over time. His skull fracture will heal over time as well, though we told him to make sure he stayed away from falling branches for a while as having another head injury in the near future could be very serious and compounded by his existing fracture before it heals. If one had been able to find a bicycle or hockey helmet in Karatu, I would have told him to wear one for several months, but they’re nowhere to found here.

The afternoon was fairly quiet with only a smattering of our typical patients, and we were home at a decent time when I received a message from Susan informing me that there had been a serious car accident nearby and several injured tourists were being brought to our emergency room. She wanted to make sure we were available to come in for any possible head injuries among the victims, which we were, of course, though it soon became apparent that there was at least one patient with multiple traumatic injuries that were life-threatening, and she thought it best that we didn’t crowd the ED until we were needed. It wasn’t until several hours later that William called to ask us to come to the ED to evaluate one of the patients with only a minor head injury who had wanted to be discharged, so several of the group headed up to take care of that. Thankfully, they had suffered no severe injuries and were fine to go home. The following morning, we were called into the ward to see one of the other patients who had also been in the accident and had suffered a minor head injury, but they too were neurologically intact and required no additional care from our standpoint.

Since its inception in 2008, FAME has served to provide urgent and emergent care not only to the residents of the Karatu District, but also to those tourists who come to Tanzania to enjoy their truly remarkable and unique parks. The Northern Safari Circuit, which includes Lake Manyara NP, Tarangire NP, Ngorongoro Conservation Area and Ngorongoro Crater, and Serengeti NP essentially encircle FAME, making it the most accessible medical facility, and I would argue the finest, to receive these patients for their initial emergency care and triage. As part of FAME’s commitment to providing this world class medical care, we opened a fully equipped eight bed emergency room, something unheard of in this region, and have developed emergency and trauma protocols with the assistance of several emergency and trauma care volunteers, but which continues to run and further enhanced by our amazing all-Tanzanian staff that has taken on this challenge and never looked back.

It was, once again, the large morning report with a packed conference room and folks at the window trying to listen – we have a larger conference room on our FAME wish list if anyone would like to donate towards it or fund it in one fell swoop. The case we had yesterday of the young man who had been brought in after losing consciousness and who we had ultimately diagnosed with primary generalized epilepsy had been so significant that I felt compelled to make an announcement at the end of report. Had Dr. Dahaye not recognized the posterior shoulder dislocation (not always an easy diagnosis to make as you have to consider it), the patient would have very likely been sent home as a simple syncopal episode, and we would never have been consulted. I wanted everyone at the meeting to know what wonderful teamwork had occurred and that FAME had once again come through in changing someone’s life for the better. It’s these types of successes that make it all worthwhile and you can look back on the next time you’re incredibly frustrated, realizing that you can make a difference.

Clinic was incredibly slow today, as was FAME in general, which must have had something to do again with the planting/harvesting cycle since other than tourism here in Karatu, most everyone are farmers in the Iraqw community. For teatime today, they had made chapati for everyone as they were organizing Valence’s wedding committee (Valence is our IT fundi, or specialist, here at FAME, and critical for the day-to-day operations over the last five years ever since FAME adopted an EMR) and it was a bit of a pre-celebration. Weddings, at least those that I have been involved in here in Karatu, are not funded by the family, but by the couple’s friends, who each contribute to a fund, and it is up to the wedding committee to make sure there are enough donations in the fund. When I had attended a Maasai wedding in Arusha many years ago that was for one my co-workers here at FAME, it was far different as the bride’s family, who lived in the city rather than in a boma, had funded it. It was lovely affair with lots of dancing and singing and tons of food, but there had not been a wedding committee nor donations to pay for the ceremony.

The chapati was a welcome addition to our daily chai – really masala tea that is a mixture of spices and honey – as typically they have only plain white bread to eat in the morning which I have never really understood, though everyone seems love it. Chapati, on the other hand, is so incredibly delicious that it’s impossible to pass it up. A welcome transplant from India and an excellent reminder of India’s contribution to the African continent and the culture here, chapati is a wonderful flatbread that is a staple eaten with any meal of the day. Once I told my team about chapati mayai (mayai is eggs in Kiswahili), it was all over – eggs and cheese rolled into a chapati, which is essentially an African breakfast burrito. That became the standing order for the team from the Lilac Café each morning for the rest of the week.

Lunch on Wednesday is pilau, which is typically everyone’s favorite, though I’m still partial to the rice and beans served most days – it is my favorite food here and I dream of it when I return home each time. Pilau is rice cooked in beef broth with pieces of meat mixed in and is served with a wonderful coleslaw made here. And, of course, it requires huge helpings of pili pili, or their homemade salsa fresca, at least for me. The other plus for today’s lunch was that there were crates of soda on the floor of the canteen for everyone to choose from, again in honor of Valence’s wedding committee selection. Even though we had no input whatsoever in the wedding activities, we were quite happy share in the benefits.

Given how slow it was in clinic today, and the fact that we had not yet visited the African Galleria, now called Safariland, with Jack and Joe, it was decided that we would close shop an hour early and head down the road. The African Galleria (I like that name better than Safariland), which has been a staple of our visits here since it opened twelve or so years ago, is not only a shopping destination for African art and souvenirs, but also for the last five years, has been home to a wonderful restaurant (Ol’ Mesera) that has hosted many meals for our groups. Their collection of both local and international gems is also outstanding and not to be missed whether you’re planning to purchase something or not – Tanzanite, mined only in Tanzania, is an amazing gemstone that turns a brilliant violet-blue when heated, and Tsavorite, mined only in Kenya and Tanzania, is an equally brilliant sparkling green garnet that is even rarer.

Everyone did some shopping today (I picked up a very large rosewood salad bowl), and afterwards, we stopped in the restaurant for some snacks. Their cheese samosas are to die for, and their potato fritters are equally delicious. Had we stayed for dinner, we would have been sharing their skewers of roasted chicken, paneer and beets, and their delicious barbecued short ribs, but that will be for our next visit as we had dinner waiting at home and nothing here is allowed to go to waste.

Since it was Tuesday, it was once again time for an educational lecture – today, Jack would be delivering the third in a series of epilepsy talks, this one covering the subject of status epilepticus. This is a very serious condition in which a convulsive seizure lasts for greater than five minutes or one has multiple seizures without returning to normal in between. The distinction between status epilepticus, or SE for short, and a brief convulsive seizure is that the former can not only cause permanent injury to the brain but can also be life threatening with a significant mortality the longer the event continues. Therefore, the recognition and emergent treatment of SE are essential to preventing death or brain injury from occurring in this patient population. The causes of SE can merely be an underlying diagnosis of epilepsy with non-compliance on their anti-seizure medications (ASMs), though this can also occur even in the setting of therapeutic levels of an ASM. The other causes of SE, such as metabolic (i.e. hyponatremia) or structural (i.e. stroke or tumor) always need to be screened for as the treatment in addition to stopping the SE acutely, includes any necessary management of an underlying cause.

In the US, patients with SE will often need to be intubated, either because of the status itself and the inability to protect their airway, or the treatment of the SE which includes benzodiazepines that can impair respiratory drive and airway protection. Unfortunately, here at FAME and in much of Africa, there are very few, if any, ventilators available for use once a patient is intubated (there are two ventilators here at FAME that are used in our surgical theaters), and therefore, one must be very cautious when using medications that will ultimately lead down that path.

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Jack presented an excellent and incredibly comprehensive treatment pathway for FAME that can be followed by all our clinicians when patients present in SE. There was a great deal of discussion prior to developing the pathway as well as during the meeting regarding the issue of the initial benzodiazepine to administer as it has been a long-standing practice at FAME not to administer midazolam, a very rapid onset benzo, without having the nurse anesthetist present in the event the patient could require some respiratory support. Our proposal, though, was to administer the midazolam intramuscularly rather than intravenously, a route that would be essentially equally effective and would not pose those same risks. Thankfully, everyone came together and there was ultimately a consensus by all parties involved and the protocol with the IM administration of midazolam was given a formal blessing. Helpful to the discussion was the fact that there were numerous studies demonstrating the far greater risk of injury from continuing to seize than there was for the potential of respiratory suppression. Having a status epilepticus treatment pathway available was another one of the goals that Cat, Julian, and our team had for this visit, and it was now complete.

Natalie, who had arrived in Tanzania last evening via Zurich and overnighted at the KIA Lodge adjacent to the airport, would be arriving to FAME this morning and was a very welcome member of our neuro team. Natalie had been here three years ago as one of our peds neuro residents and would now be returning as a fully trained stroke attending working at both Penn and CHOP. She would be adding a significant amount of expertise in not only the world of cerebrovascular disease, a very prevalent problem here in Sub-Saharan Africa due to untreated hypertension, but she would also serve as one of our pediatric neurologists, a very important position considering pediatrics represents about a third of the patients we see here at FAME and on our mobile clinics. The fact that previous residents who had accompanied me to FAME as part of our global neurology program, such as Cat, Natalie, and soon LJ, have elected to return as faculty, despite the significant financial and work related issues they have to overcome to get here, is a clear indication of the positive impact this experience has on our trainees. Each and every person who has worked here with me over the years, well over 100 of them, has not only made a huge difference in the lives of those less fortunate, but will also continue to do so over their careers.

One of the patients that was seen today was a woman who had originally presented several months prior with right arm sensory and motor changes and was subsequently found to have a large mass in the left parietal region that easily explained her symptoms and deficits. She had undergone an MRI as well and had been told by the neurosurgeon at KCMC that she should have the mass excised and sought a second opinion from us as to what our recommendations would be. She had already been placed on steroids for the edema that was present which was certainly something we would have suggested, but as far as what to recommend for the primary treatment of the mass was something just a bit out of our wheelhouse. I did offer to have the MRI loaded into our system so that Dr. Alex, our neuroradiologist back home who reads all our scans officially, could review it and make sure he agreed with the report we had from NSK where she had had the study. Unfortunately, he agreed with their read that the mass represented a high-grade glioma, a diagnosis that has a very poor prognosis whether she was living in Tanzania or in the US.

Clearly the best case of the day, and quite possibly of the month, for the reason that it demonstrated the full effect of the work we’ve been doing here at FAME not only over the last weeks, but for the last 15 years, was a young man who presented to FAME after being found down and having dislocated his shoulder. But it was not just any old dislocation, it was a very specific type, a posterior dislocation, that occurs most often in patients who have a generalized convulsion and dislocate their shoulder in the process of seizing. As morning report was ending as we were out of time due to the number of questions after Dr. Jack’s amazing talk, Dr. Dahaye (Regina) simply stated that she had a patient who had been brought in and had a posterior dislocation of the shoulder, fully aware of the significance of the event, and asked if we could see the patient. The neuro team was quickly on the case, and what was found, was that this 24-year-old young man, in addition to having fallen and lost consciousness causing his presentation (which was unwitnessed), also had about a year history of brief episodes of altered sensorium, without convulsion, as well as jerks of his arms. These jerks were most suggestive of myoclonus, a phenomenon very commonly seen in patients with a specific type of epilepsy – juvenile myoclonic epilepsy, or JME – that typically presents in adolescence, though can occur later in some patients.

With this history, we were concerned enough that the patient had underlying epilepsy, and probably a primary generalized epilepsy, that we planned on starting him on an anti-seizure medication to prevent further events. The commonly used medications for this type of epilepsy and that we have here are valproic acid (Depakote), levetiracetam (Keppra), and lamotrigine (Lamictal). Carbamazepine (Tegretol), perhaps the most commonly and cheapest used medication here other than phenobarbital, is a medication that is typically avoided in patients with this type of epilepsy as it can cause worsening of their seizures. We elected to put him on valproic acid as it would be the most accessible medication at the local duka la dawas (pharmacies) if he ever needed to refill the medication elsewhere and was an excellent choice for the type of epilepsy we felt he had clinically. It was also the least expensive of the three alternatives.

Though it wasn’t likely to change what our recommendations were going to be today (i.e. we were going to start him on an anti-seizure medication regardless), we also discussed obtaining an EEG as that could help us in the long-term management, such as deciding if and when we would contemplate tapering his medication in the future. We texted Jacob to see if he was available to do an EEG before the patient was discharged home, and, thankfully, he was. Even more so, he was thrilled to help out with the case. After applying the Brain Capture cap, he gelled the electrodes and checked the impedances which were all excellent. Jacob completed and uploaded the EEG to the cloud, though Cat and Julian were still in the air en route to Philadelphia, and despite the fact that we were communicating with Cat on the flight, her internet wasn’t anywhere close to what was needed for her to have read the study mid-flight. We explained to the patient that we would have the results of the EEG later in the day, but that we would start him on his medication prior to being discharged as we weren’t depending on the EEG results anyways.

Cat and Julian’s flight was set to arrive at around 9:00 am in Philadelphia, or 4:00 pm our time in Karatu. Within several hours of her landing, we received word from Cat in our WhatsApp group that she had looked at the EEG, and that it had indeed demonstrated a single well-defined generalized discharge consistent with a primary generalized epilepsy, and very likely JME. In less than 12 hours, we had gone from a FAME clinician being appropriately suspicious of a posterior dislocation of the shoulder in an otherwise generic episode of loss of consciousness and concerned about epilepsy, to having the patient evaluated by neurology with additional concerns for a specific type of epilepsy, deciding to treat the patient with a specific medication for that epilepsy, and finally confirming the diagnosis with an abnormal EEG that was consistent with a primary generalized epilepsy. Kudos to Dr. Dahaye for her wonderful clinical acumen that brought the patient to our attention, kudos to the neuro team for seeing the patient and being suspicious, kudos to Jacob for his diligence in obtaining a wonderful EEG, and finally, kudos to Cat and Julian for setting up the whole process that gave us the ability to treat this patient in such an unparalleled manner that would never have been otherwise possible.

After our exciting weekend in the Serengeti, it was nice be back home at FAME for a full week of seeing neuro patients before our new “group” would be arriving. It was also sad that Julian and Cat were departing today as they had only planned to spend two weeks here, and even though they had huge aspirations for what they wanted to complete while here, they had been incredibly successful in setting up not only the process for obtaining EEGs, but also an entire epilepsy handbook that will serve our neurology patients going forward. I have no doubt that this will not be last we’ll see of both of them here at FAME, and that would be fantastic to have them come again considering the amazing work they’ve already done.

The reason I have the “group” in quotations above is that I have only a single resident coming this weekend who will be replacing Jack and Joe, rather than the typical four residents as there had been coverage issues back at home. Thankfully, our trip in March will be back up to the full complement of residents (two groups of four). For the current trip, though, with the reduced number of residents, it’s been very helpful to have had three junior attendings, all been whom had been here previously, commit to coming to assist in seeing our neuro patients – Cat, who’s departing today and had been here four years ago; Natalie, who will arriving tomorrow and was here three years ago; and LJ, who was here two years ago and will be arriving in a week. Each of them will contribute tremendously, as they had in the past, to the neurologic health of the Karatu community.

Meanwhile, the district OB/Gyn specialist was giving a talk this morning at 7:30 am regarding government recommendations and practices (there are significantly more directives from the ministry of health here in Tanzania then there are at home), which was about as far away from neurology as one could get so we weren’t planning to attend the lecture. As I’ve mentioned in the past, Monday morning report is very crowded as anyone who is clinically oriented comes to these three days a week and getting there early is essential to finding a seat. We arrived a little before 8 am with lots of people waiting to get into the conference room, but the talk, which had been allotted 30 minutes continued on until 8:30 when morning report finally got under way.

It had been a very busy weekend for FAME with several concerning neurology patients that we learned about this morning in report, though I don’t believe we could have contributed any additional recommendations to what was ultimately done for the patients. One was an elderly gentleman with uncontrolled hypertension who had come in with a very large basal ganglia hemorrhage that had intraventricular spread with marked mass effect. There was little that could be done here at FAME other than supportive care and, to be honest, I’m not certain there was much that anyone could do for the patient anywhere, though the family had apparently requested the patient be transferred. They were sent to KCMC for a possible EVD (external ventricular drain) placement, a procedure that could be lifesaving, though, as I had mentioned several weeks ago in a similar case, it would be very unlikely to change the patient’s ultimate functional status.

The other patient who came in yesterday, who was much more of a neurosurgery patient than a neurology patient, was a young man who had suffered a traumatic brain injury secondary to a motor vehicle accident and had a very abnormal CT scan. He clearly had a subdural hematoma, for which they performed a burr hole, though he also had significant subarachnoid and some parenchymal hemorrhage along with marked mass effect that were indicative of the amount of trauma his brain had actually suffered. Despite the burr hole that was placed and maximum supportive care, he succumbed to his injuries in the early morning hours. Traumatic brain injury is a huge issue here in Tanzania and a major contributor not only to morbidity, but also to DALYs, or disability-adjusted life years. DALYs are a measure of the overall burden of disease, injury and/or risk factors on a population and represents not only “years of life lost,” or YLLs, due to premature mortality, but also the “years lived with disability,” or YLDs. Essentially, one DALY represents one year of life lost from full health, whether through disability or death.

Based on a 2021 study published in The Lancet Neurology and contributed to by a WHO analysis of the Global Burden of Disease, Injuries, and Risk Factor Study from the same year, neurologic conditions were the leading cause of ill health and disability worldwide with greater than 1 in 3 people worldwide currently affected by a neurological condition. Over 80% of neurological deaths and health loss occur in low- and middle-income countries (LMIC) where there is far less access to medical care and treatment, having 70 times LESS neurological professionals than in high-income countries. Based on the study published, the top ten neurological conditions contributing to loss of health in 2021 were stroke, neonatal encephalopathy, migraine, dementia, diabetic neuropathy, meningitis, epilepsy, neurologic complications of preterm birth, autism spectrum disorder, and nervous system cancers (Global, regional, and national burden of disorders affecting the nervous system, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021 Steinmetz, Jaimie D et al.,The Lancet Neurology, Volume 23, Issue 4, 344 – 381). I am always surprised when I am asked the question of “why neurology” in regard to global health as the data regarding the need for improved access to neurological care in LMIC is overwhelming.

On our arrival to clinic this morning, there were a number of teenagers in wheelchairs, none of whom were particularly familiar to me, though I had no doubt where they had come from. For a number of years, a Norwegian gentleman, Ståle Anda, has maintained an orphanage in Mto wa Mbu, Tumaini Home, that has taken in children with neurologic and other medical conditions who could no longer be cared for by their families. For a long time, there were three or four adolescent boys with Duchene muscular dystrophy (two of whom were brothers) that would be brought in to see us. Ståle would drive up from Lake Manyara in his old Land Rover Defender with half a dozen wheelchairs stacked on top and a car full of children to see us in clinic. None of the children were early enough in their disease to treat with steroids (used only in Duchene when children are still ambulatory), so most of what we did was to make physical therapy recommendations and to treat them symptomatically. I haven’t seen Ståle since the beginning of the pandemic, though, and I’m fairly certain that our group of muscular dystrophy boys have passed on by now.

I didn’t see Ståle with this group of children either, though I had no doubt of where they had come from as it would require someone with an incredibly huge heart to have taken these children in, and that would have been at Tumaini Home. Sure enough, I eventually saw someone sitting with the group and introduced myself, only to find that it was Ståle’s sister, and all made sense. The boys in the wheelchairs each had very significant choreoathetoid movements, as well as some contractures, reasonably normal mental status, though obtaining their birth history was virtually impossible as none of their parents were present. Without the birth history, we couldn’t say for certain that we were dealing with hypoxic-ischemic injury (i.e. cerebral palsy), but their histories also didn’t necessarily match with acquired syndromes such as Wilson’s disease, and it was unlikely that we were dealing with a genetic disorder in so many children. We were able to offer possibly symptomatic treatments for their movements and quite possibly their contractures, but we really had little else we could provide for these young men.

In addition to the teenage boys with the abnormal movements, there were numerous children to be seen in clinic, many with epilepsy and, of course, our two epileptologists just departed for home and our pediatric neurologist (Natalie) wouldn’t be arriving until tomorrow morning. The general outpatient clinic was packed which is very typical for a Monday morning here at FAME, and we had a steady flow of patients in addition to the children from Tumaini Home. With only two residents here to see patients (Jack and Joe), we eventually had Dr. Annie see patients on her own to keep things moving and to get all the patients seen by late afternoon. Things went smoothly as they always tend to do here since the pressures to see patients is quite different here than at home and the patients are tremendously more tolerant of waiting to be seen, if needed. The day ended well, and we spend a quite evening in the Raynes House with our beautiful views of sunset and the constant songs of the many birds.

 

It had been a remarkable weekend overall with plenty of big cat viewing, and even though we hadn’t found the big herds of the migration, we had seen nearly 80 lions, several leopards, and more than a handful of cheetahs. We had not seen any kills, but those are really hit and miss, and one can never truly have an expectation of seeing one. It had been decided that we would be leaving a bit earlier than our usual departure on Sunday, though we would still have breakfast at the camp rather than on the trail. We had some delicious oatmeal and fruit, and all had made to order omelettes from the kitchen. Once finished, we all loaded into Turtle, Vitalis still having to climb over the stick shift to reach the driver’s seat and said our goodbyes to the camp staff who were all out to see us off. I have been coming to Dancing Duma since it opened several years ago, and many of the staff have been there from the get-go and will be there when I return.

Our plan for the day was to head to Moru Kopjes first, an area where one can occasionally see rhinos, and then head south towards the Kisini airstrip and ranger station, eventually turning to the east in the direction of Lake Ndutu. We have driven this route often as the wildebeest herds are there in the spring, though so are the rains and flooded roads that can often be impassable as we discovered last April when we became hopelessly stuck and had to be rescued. This time of year, though, there would be absolutely no difficulty as far as the roads were concerned as everything was so incredibly dry and dusty.

The Moru Kopjes sit up above the plains below with spectacular views and are host to the main rhino research facility in the Serengeti as well as a rhino reserve where they are constantly tracked by the rangers. There is a steep extra charge to see the rhinos there, unless of course one wanders out from the reserve as there are no fences. I’ve seen rhinos here several times before, but you really can’t count on it. In Moru Kopjes, though, we spotted another leopard hiding in the tall grass and clearly looking for prey, though there were only Thompson gazelle that were a fair distance away. A lonely warthog was also meandering around in the distance but was heading directly towards the leopard. Leopards do not really chase their prey down, but rather stealthily sneak up on them and then suddenly pounce. It was doubtful that the leopard could even get close to the warthog unless it were right on top of him and our hopes of seeing a kill were soon dashed when the warthog reversed direction for now good reason as I’m sure it hadn’t seen its potential attacker. We’d have to leave the scene once again unsatisfied.

The route to Kisini takes you almost directly south and into a more forested area of the Serengeti before reaching the airstrip and ranger station that constitute this waypoint. The airstrip there is incredibly remote and is made up of a single small building with radio equipment alongside the landing strip. Vitalis told us that the ranger was offering to take us to see one of the rhinos that were in the area, which of course was something we’d be interested in as the only rhino we had seen so far was in the crater and was a long distance away. The ranger, carrying his carbine rifle, got into our vehicle to guide us in the direction of the rhino, but it soon became apparent that we were more or less searching for it, though it’s always hard to imagine how you would hide something the size of a VW bus. As we were driving across the landscape, though, there was suddenly a large noise at the front of Turtle and a scraping sound as we tried to drive. Vitalis and the ranger got out to check what had happened, and it turned out that our winch, which sits up under the front bumper, had come loose on one side and completely dropped to the ground. This was indeed a problem for us as unfortunately we didn’t have any rope in the car to tie it back up under the bumper. We ended up sacrificing the passenger side seat belt, which actually worked great, and after jacking up the winch housing, were able to secure it back into the bumper with several loops of the seat belt.

Once we were back in action, we continued to search for the rhino until finally we heard the ranger say that he had seen it in this area yesterday which gave us very little confidence that we would actually find it. I had thought perhaps that he was in contact with the rhino trackers who were radioing the location of the rhino to him, but we had no such luck after all. We eventually had to give up the chase and make our way back to the airstrip to drop off the ranger with the entire expedition taking around two hours. Though we hadn’t found a rhino, we had at least seen a large swath of the Southern Serengeti that I was unfamiliar with. One bonus was that we also found four more cheetahs – one at the end of the airstrip and a trio comprised of a mother and two nearly full-grown children, a male and a female. That had brought our total of cheetahs for the weekend up to 13.

While driving around the big marsh at Lake Ndutu, we ran across most of a giraffe carcass that had only been partially eaten, and a short distance away, two male lions (related of course) snoozing with full bellies. It’s pretty unusual for an adult giraffe to be taken as their kicks can be lethal, so Vitalis thought that it must have taken at least six or seven lionesses to have accomplished such a feat, though they were nowhere to be found at the moment. With the wildebeest and zebra no longer in the vicinity, the lions must have been fairly desperate to have gone after a full-grown giraffe.

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Ten years ago, just a stone’s throw away from where the giraffe lay, I had seen four female lions ambush a group of zebras by the watering hole when we were visiting Ndutu in the spring. The lions conducted the ambush a bit clumsily (their timing was off) and, in the end, were unable to catch any of the adults, but did manage to nab the baby who couldn’t run as fast as their parents. The four lionesses devoured their prize in very short order as we stood by and watched. I have a video of the event that was taken by one of my residents, and in the background you can hear the four women in the vehicle with me excitedly shouting, “Oh my god, oh my god,” when the lions began their ambush, but when it was clear who they were going to catch, it changed to, “not the baby, not the baby.” I explained, as I always do, that it’s the circle of life and that it would have happened had we been here or not. The animals here are not putting on a show or trying to impress us, it’s a matter of survival and a part of nature.

The drive from Ndutu home travels through some of the most picturesque landscape in the Ngorongoro Conservation Area in the Endulen region as you gradually ascend to the rim of the crater through huge groups of Maasai bomas and villages. This was the way we had traveled last April, but leaving Ndutu, there was so much water from the rains, the road was essentially underwater and eventually proved impassable. We become stuck and had to be rescued by the Rangers, but not until a failed hike out in the dark through the water and mud with hyenas running not far from us. The site where this had occurred along with the river that was flowing just beyond it were completely bone dry now as we passed them.

We made it to the Ngorongoro gate with five minutes to spare, which is our typical MO despite our best intentions to get there early. We had dinner plans that night at a new lodge where Dr. Annie’s sister is now the manager (The Ngorongoro Haradali), and we made it home just in time to take showers and head off to dinner. I sent Turtle back to Arusha with Vitalis as there were now a number of things that needed to be fixed. The driver’s door was stuck, the winch housing had practically fallen out and was now being held on by the passenger seatbelt we had sacrificed, and we had been push starting the car for the entire day as the brushes on the starter switch needed replacing. We make it through the weekend, though, and all was pretty much par for the course as far as Turtle goes. It’s always something here, but somehow we manage.

Sunrise on the Serengeti is an event that is unlike any other, and the reason that we typically arise very early in the morning to depart well before breakfast and in the dark. Vitalis had given orders that we were all to meet at the main tent early enough for a 6:00 am departure which was about half an hour prior to sunrise. Thankfully, there was coffee and cookies available for everyone as I think there would have been a mutiny had the others been forced to depart without their caffeine. We were in the vehicle and driving off shortly after our set time and heading to a location where sunrise wouldn’t be blocked by any of the mountains that surrounded our camp. Both breakfast and lunch had been prepared for us by the camp kitchen and were safely stowed in Turtle for us to enjoy at a later time.

I had almost forgotten to mention “Swahili Time” to everyone reading this who isn’t already aware of this distinction. When living only miles from the equator, the length of a day changes negligibly throughout the year and sunrise and sunset occur at essentially the same time as well. There is obviously no need for a spring or fall time change which means that Tanzania is either seven or eight hours ahead of our East Coast time depending on the time of year. Swahili Time uses our 6:00 am as essentially midnight, meaning that 1:00 here is really the same as our 7:00 am and so on through 6:00 pm when the numbers reset. They don’t really use am or pm here, but everything is listed in both Swahili Time and Western time when it’s posted on businesses, and since very little happens at night, there is very little confusion, though adding asubuhi (morning), mchana (afternoon), jioni (evening), or usiku (night) can be added after any time to clarify what part of the day you are referring to. Therefore, FAME’s outpatient hours are 8:30 am through 4:30 pm, or 2:30 through 10:30 in Swahili Time.

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Shortly after sunrise, we came upon two safari vehicles watching what turned out to be a leopard sitting on the ground under a tree and well-hidden except for its head that protruded slightly above the surrounding grasses. It was clearly looking for prey, and there were a group of zebras nearby who were prime candidates. There was also a mother cheetah and her cub strolling fairly close by the leopard which was a bit surprising. All of the big cats are mortal enemies and, if given the chance, a leopard would certainly kill a cheetah given the fact they were competing for the very same food sources. None of us wanted to see that and, thankfully, the two cheetah strolled on by the leopard without incident. None of us though had a similar sense of attachment to the group of zebras that were nonchalantly meandering in close proximity to the leopard and completely oblivious of its presence. In fact, and I’m pretty certain of those though some of the others might not be willing to admit it, we were all secretly hoping that the leopard would suddenly leap from its hiding place and pounce on one of the zebras. Despite our practically willing the leopard to take action, though, it was apparently not the appropriate time, and the circle of life would have to find another occasion to take place.

It was still quite early, and we had already seen a leopard and two cheetahs, so the day was shaping up quite well for spotting some of the more difficult animals to see here. Our drive took us around to the west of Seronera, the location of the airport and visitor’s center, and we eventually made our way to the little conclave of kiosks and picnic tables adjacent to the visit center where we would eat our breakfast. After breakfast, Vitalis would take Turtle to one of the many workshops in the area to see if he could get the driver’s door unstuck, though in the end, it was a leaky fuel injector that needed repair and the door would have to wait for another time to fix and Vitalis would have to continue climbing over the stick shift to reach the driver’s seat. Breakfast was a fine spread that included toast, hard boiled eggs, fruit, pancakes, mandazi, sausages, coffee, chai, and all the condiments one could imagine.

After breakfast, we made our way north and in very short time, ran across a leopard sleeping in a tree atop one of the many Kopjes in the area. Unfortunately, given that it was high season, there were dozens of other vehicles looking at the same leopard and it was like a game of Tetris with everyone jostling to get the perfect view of the sleeping feline. Leopards are very shy animals that are solitary other than a mother and her cubs, sleeping most of the day in a secluded tree somewhere, and coming out typically at dusk to beginning their primarily nocturnal hunting. I’ve been to the Serengeti when we’ve spotted no leopards at all, and on other trips have found half a dozen as it’s pretty much hit or miss for these oft elusive cats. Leopard cubs will stay with their mother for up to two years during which time they will learn all the necessary life skills for survival.

Shortly after spotting the leopard, we happened upon a very large group of lions that included many young ones, all sleeping after having recently devoured a fresh zebra kill. This pride of lions was in very stark contrast to the ones we had seen yesterday who were incredibly thin and malnourished and it was clear that these individuals had been tremendously successful in their hunting. From here, we continued north in the direction of Ikoma, eventually arriving to the Toboro Plains, a vast expanse of rolling hills only interrupted by underground streams easily identified by the lines of trees that grow above them. It was a gorgeous region that I had never been to before, and we drove far enough north that we were only a couple of hours from the Mara River or the Kenyan border but unfortunately didn’t have enough time to drive all the way there. The Mara River is where the migration crossings are the most impressive with huge herds of wildebeest and zebra crossing north into the Maasai Mara where they are often met by groups of enormous Nile crocodiles determined to prevent them from crossing and rather to make dinner. I was lucky enough to see a crossing once, but it’s never a sure thing when visiting the Northern Serengeti.

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We eventually had to turn around and head south towards Seronera where we found another huge pride of lions – at least 16 of them – with a recent wildebeest kill who were all eating. They were behind some trees and not totally visible, but you could easily see them eating and the poor wildebeest’s legs stretched up into the air, no longer moving under their own power, but rather from the tugging of the hungry lions. This was another extremely healthy pride who were obviously very successful and clearly sustaining their young.

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We eventually made our way back to Seronera and to the fuel station as we always do at this point in our trip as there are no fuel stations for the entire drive home and there is no AAA here in Tanzania to bail you out should you end up empty. We had been driving essentially non-stop both yesterday and today, as well as all the way from Karatu, and it required less than $50 in diesel to completely fill the tank with about 35 liters of fuel. The Land Rovers are amazingly fuel efficient which is what they are known for. We arrived back in camp just in time for sunset and another lovely dinner. Tomorrow we would be having breakfast in camp and then leaving with lunchboxes for another full day of game drives on our way back home to Karatu.

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As many of you have gathered by now, in addition to the work that we do at FAME and in the mobile clinics, we also have a number of activities that I’ve included in this global health elective or rotation that have less to do with medicine and neurology, and more to do with Tanzania’s colorful cultures and wildlife. As important as it is to familiarize yourself with the general practices of the physicians here, it is equally important that one fully appreciates the people and the land. Last weekend, I had the privilege to take my team to Ngorongoro Crater, perhaps the single most spectacular game reserve in the world when speaking about numbers of animals in a concentrated area and the geologic diversity of such a place. This weekend, we will travel to the Serengeti National Park, the quintessential and most famous of all African game parks.

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The word Serengeti is derived from the word “seringit,” which in Kimaa (the language of the Maasai people) means “endless plains,” and once you’ve been there, you’ll know exactly what that means. Regardless of how far you can see, when you reach the next horizon, it just goes on and on from there and continues endlessly. I have lost count how many days I’ve spent in the Serengeti over the last 15 years, and without question, I can tell you that it never ever gets old. You could spend a lifetime exploring the park and you would not cover everything for it is larger than the state of Connecticut.

Vitalis arrived at the Raynes House shortly before 8:00 am and everyone was packed and ready for our adventure. We were again bringing lunch for the day with us but would stop by the Olympic fuel station heading out of town to top off Turtle and pick up some snacks (mandazi, samosas, etc.) for breakfast on the road. To get to the Serengeti, we would be taking the very same route as we did last weekend, but on the other side of the crater would continue on rather than taking the descent road to the bottom. The tarmac ends at the Lodoare Gate entering the Ngorongoro Conservation Area, and from there all the way across the Serengeti to Lake Victoria in the northeast corner of Tanzania, the road is not paved. Any transportation across the country – buses, trucks, tractor trailers – all have to take the same road up to the crater rim and through the Serengeti, to reach the other side of the country and Lake Victoria. There have been proposals over the last years to pave the road that have all been defeated by environmental groups given the risk of disruption to the great migration and other wildlife movement. It would also completely change the character of Serengeti National Park in a negative way, so I’m glad it’s been defeated, though there have been frequent attempts to slide it through under the radar and I’m not overly optimistic that the road will remain unpaved forever.

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Our first stop as is usually the case, will be at Oldupai Gorge. Discovered in 1911 to have early animal fossils by a German neurologist researching trypanosomiasis, the Gorge later became the life work of Louis and Mary Leakey with the eventual discover of Zinjanthropus, or Nutcracker Man, in 1959, oldest man at the time. The Gorge, which was originally misspelled in 1911 as “Olduvai,” and has since existed by that name in the majority of western publications, was actually named “Oldupai” after the Maasai word for the native sisal plant that dominates the landscape in this region and is very important to the local wildlife as a source of water. Oldupai Gorge is the single most important archaeological site in the world and continues to be a source of new discoveries and continuing research. Most importantly, all three human ancestral lineages, Australopithecus, Homo habilis, and Home erectus, have been found at the Gorge, and also amazingly co-existed here. We met up with Professor Masaki, one of the curators at the Gorge and someone I’ve known now for almost 10-years, for a short talk at the overlook and a visit to the museum before departing the visitor’s center and driving through the Gorge on our way to Shifting Sands.

Our visit to Shifting Sands not only allows us to see this remarkable geologic feature but also means that we can bypass the main Serengeti road which is tremendously dusty and bumpy with vehicles traveling at high speeds kicking up stones from the roadway with the risk of shattering your windshield (which happened to us previously on our way into the park). Shifting Sands is a huge mound of black sand that was ejected from Ol’ Doinyo Lengai several thousand years ago and has continued to cross the Serengeti plain by 5 meters a year, being blown by the wind, from where it was originally deposited. The sand has a very high iron content and is heavily magnetized, so the entire pile remains very intact as it is slowly moving in a single direction year after year, swallowing any small plants or bushes in its path. Given that Ol’ Doinyo Lengai, meaning “Mountain of God” in Maa, is sacred to the Maasai, so is Shifting Sands a sacred location for them.

We continued on through the bush on our own private path on the opposite side of the Gorge, seeing no other vehicles then entire way despite knowing that the main road was completely packed with those either en route to the Serengeti, or returning home. Once meeting up with the main road, though, we were back among all those coming and going, and reaching Naabi Gate, entrance to the park, there were easily 100 safari vehicles sitting in the parking lot, all with their guests eating lunch and preparing to enter. The minute Vitalis stepped out of Turtle to check in at the ranger station, and then shut his door, we were unable to reopen it. This is not an all too unusual situation as the bumpy roads loosen essentially every bolt on the car, including the door latches, which can then jamb, often quite irreversibly unless one removes the door completely which was not possible at that point given the lack of a workshop. This meant that Vitalis would have to enter the passenger side and climb over the stick shift to reach the driver’s seat. Vitalis is by no means a small person, so getting in and out of the car was not going to be an easy feat until the door was fixed.

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From Naabi Gate, we descended onto the vast Serengeti proper and began our formal game drive for the afternoon, heading first in the direction of Gol Kopjes in search of big cats. It wasn’t long before we first came upon a cheetah mother with four older cubs, a hugely remarkable accomplishment given the harsh environment and the constant threat from the other apex predators who are constantly competing for prey. Cheetah will very often have their prey taken from them by nearly all the other predators – hyena, lions, leopards, and jackals. Once the cheetah catches and kills its prey, it will typically eat it on the spot and very quickly so as not to have it poached by one of the others. Cheetah will not defend their kill, nor their young for that matter, and their best defense has always been their speed and avoiding trouble as much as possible. This mother clearly knew her business and her cubs were quite lucky to have her as well as the lessons she was teaching them.

Shortly after spotting our cheetah family, we ran across a very large group of perhaps a dozen lion cubs and younger adolescents, all of whom were very, very thin with their ribs and hip bones strikingly prominent. It’s all a matter of how much prey is available and most of the migration was far to the north and west. The pride in this location wasn’t doing as well as they would be had it been earlier in the season with game aplenty. I felt fairly certain that some of these individuals would not be seeing another season.

From the Gol Kopjes, we traveled all the way to the Maasai Kopjes, so named for the Maasai had a large village here prior to it becoming a park. These Kopjes are quite large and stretch a good distance with lots of resident wildlife. The mornings are the best time to spot the animals here and we were arriving well into the late afternoon. Kopjes are the large rock outcroppings (think Pride Rock from the Lion King) that dominate the landscape of the Central Serengeti. All life here is centered on these islands of biodiversity where you can often find a lion pride sitting atop the rocks surveying their territory for any signs of prey off in the distance. Leopards will also occupy the trees or high spots in the Kopjes as long as there are no lions nearby.

Departing Maasai Kopjes, the sun was becoming quite low in the sky, and it was time for us to head to camp as we still had a significant amount of road to cover. We had to travel southwest in the direction of the Sopa Lodge that was located quite close to our camp, Dancing Duma, where dinner and cold drinks were waiting for us. It had been a great afternoon of game viewing, and we were all looking forward to more tomorrow.