Today was our final day of patient care. Not only was a day of mixed emotions given the fact that we’ll be heading home soon, but we had highs and lows concerning our patients at FAME.

Thobias, or Toby, as his mother and now we call him also, had a single brief seizure last night, but looked like a million bucks this morning! It was such a pleasure to see him awake and chatty and engaging. He’s a lovely child and his mother has been incredibly patients with us. Our plan was to discharge him today if he looked well and indeed he did so we’ve arranged for him to be seen next weekend at our clinic near his home and then back to FAME in a month to check labs, etc. His mother thanked us this morning on rounds and perhaps the most telling thing she said was that when she brought him to us a week ago she never expected him to look as good as he did this morning in such a short time. She was thrilled. Here is a picture of Toby and his mom in the ward and then Toby and Megan right before they left for home.

We were asked to see the niece of one of our clinic officers here, Dr. Isaac. It is his sister-in-law’s daughter who is eight months old and has been having seizures. They had been seen at Kilimanjaro Christian Medical Center prior to seeing us and it didn’t take long to see that the baby had significant problems as she was having repetitive seizures in her mom’s arms that were likely infantile spasms. The baby’s neurological exam was significantly abnormal with hypotonia and probable cortical blindness and she was very small (<3rd %) suggesting that this was West syndrome. This is a disorder with a terrible prognosis and often develops into Lennox-Gastaut syndrome which is a terrible seizure disorder of multiple seizure types and injury. The baby had been started on valproic acid and at least we had something to offer as we probably have the only topiramate in the country here and could start her on that. Having to tell mom, who already had some inkling of the diagnosis the bad news was one of our low points for the day.

While we were seeing the young baby and sent her off for labs, Dr. Mshana was seeing a young boy across the hall in another exam room whose family had brought him in and he was malnourished and apparently hypoglycemic. We weren’t involved in his care, but he was very ill and they moved him to the ward. After we were finished with our baby and I was walking across the courtyard to copy some records for them there were several women sitting and wailing. We weren’t sure what had happened, but found out that the little boy had died. It affected Megan greatly and as it was our time to say goodbye here it reminded both of us of how fragile the balance of life is here. We do what we can to benefit the people here, but there are still many that we cannot help and though we are saddened by that it cannot dissuade us from continuing our work.

We had grilled cheese sandwiches and sliced tomatoes (not Megan who doesn’t like tomatoes) for dinner tonight. We had planned it that was, but it was perfect comfort food for a tough day. Tomorrow we tackle Ngorongoro Crater and will stay at FAME tomorrow night. It has been a remarkable visit to FAME overall and we say over 90 neurology patients in our time here which isn’t the largest number of patients I’ve seen, but they were all pure neurology which hasn’t been so in the past. Megan has been a star as I knew she would and she will leave her mark here as Danielle did in the past. I am already looking forward to my next visit in September when Danielle returns for an encore and hopefully we will have another here with us at the same time so there will be three neurologists practicing at FAME!

Mike

We’ve had wonderful light shows off in the distance over the Lake Eyasi region or on the Crater Rim most every night. They are gorgeous when they are not right on top of you. Last night we have the heavens open up just after bedtime and continue through the night. The rain and wind that hit first, though, was absolutely amazing and very powerful. Anyone who knows me will not be shocked to know where I first went after it began….outside! Yes, in the middle of near hurricane (or is it typhoon over here?) strength winds, sideways rain and constant lightening I went out the back door and stood on our porch for more than half an hour. The lightening was so frequent that it was like daylight and I had no use for my torch. I finally climbed into bed and the storm continued. We had a few tree limbs down here and there, but overall there was no damage here other than some cleanup that was needed.

We had our Friday morning lecture at 8am that was given by Liugi, our lovely Italian internist who is just a gem. He spoke on stroke surprisingly enough which was pretty ballsy considering he had two neurologists in the crowd. We promised not to heckle him.

Thobias was doing great on rounds this morning as you can tell from the pictures attached. No seizures in over 24 hours (please knock on wood for me) and wide awake and alert. If he is doing well tomorrow we will likely discharge him to home. His smile today when he saw us was a sight for sore eyes. He had a great time with Megan’s smart phone as you can see here.

Clinic today was mainly seeing some patients who were left over from Oldeani and Rift Valley Children’s Village last Saturday along with some local patients needing to be evaluated. One young girl and her mom traveled from the Loliondo district where I was last September which is at least 7 hours by private vehicle and longer by bus.

I received a text from Eliza Hatch of Thomson Safari earlier today inviting us up to Gibb’s Farm for a drink this evening and a visit to Gibb’s is something I would never turn down. Eliza is working on a project with Thomson to build a dispensary in the Loliondo district and has consulted with me in the past and I have ideas of possibly using it as another site for our mobile clinics (which would be by air, though, and not driving) where we could provide training for the clinical officers there similar to what we are doing at FAME. They had the entire board of FOTZC (Focus on Tanzanian Communities – Thomson Safari’s non-profit building the dispensary) there so it was good to meet everyone. Megan even got to take a few photos of the bush baby there while I was talking business.

Tomorrow is our last day in clinic and that is always sad for us. We’ll be here tomorrow night and then again on Sunday night after our Ngorongoro Crater safari on Sunday and we leave on Monday morning for Arusha with a short detour to Tarangire National Park on the way.

Mike

Spending time in East Africa in March requires that one keeps an open mind as far as your schedule is concerned. And that may be for many reasons. Weather at this time of the year is most often the biggest concern as the monsoons are right around the corner and the long rains begin to fall. Yesterday we managed to drive around quite a big storm, but on other occasions we haven’t been so lucky. Two years ago while here in April I managed to bury my Land Rover to the axles while en route to mobile clinic. It took us three hours to dig out the vehicle and needless to say we didn’t make it to our clinic. That is why I now come in March.
Another reason is that patients don’t always come to clinic when you plan for them or sometimes they may not be able to make it due to the difficulty of transportation. Our clinic in Upper Kitete left us with few patients to see there today so we scraped the mobile clinic originally scheduled and remained at FAME for the day. The good news is that it gave us plenty of time to spend on young Thobias, our seizure patient.

Our morning began with an hour meeting with his mother. She had told the nurses that she wanted to take him home today and didn’t care if he had any more seizures. We were concerned that something was up and it turned out that she had another young son at home that she was worried about as her husband was an alcoholic and undependable and she didn’t have any family to leave him with. The other issue is that unbeknownst to us she hadn’t anything to eat for several days – she had brought a little bit of food with her and though FAME feeds the patients they do not usually feed the families who stay here (they are often quite large) and she hadn’t said anything to anyone nor had the nurses been aware of it. We were able to take care of simple issue of feeding her, but the other with her son was a bit more complex and took a bit of wrangling. We were finally able to have someone from the Rift Valley Children’s Village come tomorrow to remain here with Thobias so she can go home for a few days to see her other son.

That was all the non-medical aspects of his care. As for his seizures we decided today (with the input from his mother) that his seizures were more numerous on the medication we had started him on and so we had to switch gears and orally loaded him on valproate today as well as stopping his carbamazepine. We all have our fingers crossed at this point. The valproate will cost about 50 cents to a dollar per day which is more than any here can afford so we’ll have to figure out some way to cover the costs for them if it works. We’ll make it happen one way or another.

We visited Daniel Tewa again this evening, but not for dinner. He is just a gem! On our way home we had the most amazing light show in three directions with lots of lightening illuminating all the wonderful clouds on the distance and a gorgeous sunset too boot. It’s been cool in the evenings with short rains in the afternoons and we’re hoping the weather holds for Sunday when we’re planning to go into the Crater on safari. We have two more days left here at FAME and we’ll be making the most of them.

As this trip ends I am already looking forward to my September visit here and counting the days.

Mike

We had some wonderful rains last night to fall asleep to accompanied by frequent lightening in the distant. The morning was clear and beautiful as we readied for another day of mobile clinic in Upper Kitete hoping for more patients today than yesterday. We swung by the ward to check on our two patients, the elderly Masai women with a stroke and the young boy with seizures.

Our stroke patient was 88 years-old and came in our first day here last week with a very large stroke affecting the left side of her brain such that she couldn’t move either her arm or her leg, had a facial droop and had a global aphasia. She was also nearly obtunded which was a problem with the size of her stroke and we worried about her swelling. I’m happy to say that she amazed us all and regained most of the use of her leg so she could actually stand and walk some and was understanding speech quite well. She was also swatting at anyone who walked behind her as she was quite vain and didn’t want to chance anyone seeing her open hospital gown. Megan worked on a word board for her as her family took her home this morning and we also instructed them on what physical therapy to do. That’s a huge difference here. Families want to know when they can take their family member home and care for them. Here’s a photo of her with two family members just before discharge:

Our young boy with seizures isn’t do quite as well. We’re forging ahead trying to get him up on carbamazepine, but will decide tomorrow morning whether to load him on phenytoin as he’s continued to have a few seizures most days though his carbamazepine isn’t fully up to speed yet. He’s a very tough case where an EEG would make all the difference in the world – hear that Danielle? More later on this one.

Off to Upper Kitete where there weren’t as many patients as last year, but we had some very good pathology. Our first case was a gentleman who supposedly had arthritic complaints and when he got up to go to the exam room it was clear to both Megan and me that he was walking with a spastic gait! He was a heavy drinker and we’re suspecting B12 deficiency, but need to get some other tests including a CT scan of the c-spine, but will wait for the other test results to come back first.

We had a woman with headaches since 2002 and who on exam was obese and had a right APD with loss of vision that was gradual on further questioning. We’re suspecting pseudotumor cerebri or benign intracranial hypertension. We put her on topiramate and asked her to lose some weight. Here’s a photo of her, Megan and Dr. Ken:

We saw several more patients including a wonderful old Bebe (elderly woman in Swahili) with a postural tremor who we put on propranolol as her BP was somewhat high and we could kill two birds with one stone.

I played frisbee (or as Will has tried to train me to say, “threw the disc”) with the kids again today as my leg was somewhat better and I just made sure I didn’t make any sudden moves with my left leg. It is much better today.

As we were finishing patients a huge storm began to role in with lots of lightening and heavy rains so we closed up shop and packed up as quickly as possible. We escaped just in front of the heavy rains and managed to skirt around the storm, but it rained quite heavily for a very short period of time here in Karatu as evidenced by this photo of the street just next to the marketplace that was completely flooded.

It’s times like this that make you appreciate the difficulty of living here. The clouds cleared and we had a lovely, albeit cold, evening for dinner with Joyce on her veranda and a quite evening to finally catch up on emails and reading. We had planned to go back to Upper Kitete tomorrow, but the volume of patients right now is low for some reason so we’ll work here at FAME unless we’re asked to go somewhere else. It’s disappointing not to have the same volume for this one clinic that we’ve had in the past, but there are many reasons why that might happen and one of them isn’t lack of need. We’ll be back and I’m sure there will be patients.

Mike

We had our second day of mobile clinic today at a different village much further along the escarpment – Upper Kitete. It’s about an hour and a half or more to get there and is another gorgeous drive through wonderful hills and farmland. It is almost as far as one can drive along the escarpment as the Ngorongoro Conservation Area comes down to the rim and all roads end at that point. We got to the village and were told that there were a number of patients there earlier, but that they had gone home (perhaps to work the fields) and would come back later. We saw one gentleman with joint problems from osteoarthrosis (arthritis for all non-medical people reading this) which is not a neurological problem but we thought since we didn’t have any other patients we may as well take care of him. I was able to see a very nice Parkinson’s patient I’ve seen several times before who does better on his meds but they keep stopping them when they run out and it’s back to square one. I explain to the family every time that he needs to stay on the meds, but it just doesn’t seem to get through. They don’t have carbidopa/levadopa here, but I brought a bunch last year and have plenty to last for them.

Unfortunately, none of the patients came back to see us so we ended up just relaxing the rest of day, having a nice lunch in a beautiful location and visiting with some of the villagers. I spent a few minutes with cute young girls showing them photos and videos of animals on my iPad. They spoke Iraqw so it was strange to hear the names of the animals in that language as opposed to Swahili.

Later, we played frisbee or throwing the disc as Will, our volunteer coordinator who was along the for trip, tells it is referred to now and no one says frisbee any longer. The kids picked it up real fast which was a bit more than I can say for myself. We played for thirty minutes or so just tossing it with the kids until I decided to do a fancy catch, jumped into the air to tap the disc and felt something pull immediately in my left calf. I made the catch and landed on my right leg hopping as I couldn’t put any weight on the left. Now I can’t push off at all on my left leg as it seems I may have a small tear in my calf according to Dr. Chris who has it wrapped in a compression bandage and it will be elevated tonight when sleeping. I’ll live, but it’s a bit painful to walk right now.

After my embarrassing frisbee injury we drove out to the Overlook again which is one of my favorite places to visit. We sit up on top of the escarpment and it’s about 2500 feet straight down to the Rift Valley below. You can see for such a long distance both up and down the valley. Here’s a shot of Megan, Patricia and William overlooking the valley.

The ride home was uneventful though I did get this shot of a normally loaded truck speeding past us.

We have a big rainstorm with lots of thunder and lightening going on right now which always worries me about the roads tomorrow as we’re planning to head out to Upper Kitete again. We’ll have to assess the road situation in the morning and see what the plans are.

Mike

Safari in Kiswahili really means journey so I guess technically we were on safari again today, but not in a national park. Our journey today took us to the village of Kambi ya Simba (Lion Camp) which is about an hour’s drive from Karatu and FAME. The village sits in a very fertile valley some kilometers west of the village of Rhotia and is on top of the escarpment of the Great Rift Valley and high above the Masai Steppe. I have been coming to this village for the last two or three years to do what I’ve coined as a “mini mobile clinic” in deference to the five day, near campaign style mobile clinic that we used to run at Lake Eyasi (where the Hadzabe or the last hunter gathers in Tanzania live) and whose funding ran out a bit over one year ago. This is why neurology mini mobile clinics have become an important part of FAME’s services and one of their main outreach programs.

We arrived to the village to find a fair number of patients waiting for us, but it turned out to be a very manageable 21 patients which is pretty reasonable for neurologists to see in one day if Megan and I worked separately which was fine. Every patient we saw was totally appropriate from a neurological standpoint which is a great improvement over past clinics I’ve run. This is mostly because William, our outreach coordinator, has really worked hard to educate not only himself, but also the communities on what type of medicine we’re offering.

We worked at Kambi ya Simba until around 4:30 pm and then left for home. The clinical officer there worked at FAME briefly and while we were seeing patients asked if William and I could come over to his house for a minute. I didn’t want to insult him and so we did go to visit him quickly only to find out that he had a huge spread of food for us along with his two infants. The only problem was that we had already eaten our lunch which meant that I had to manage to squeeze a second lunch so as not offend and dishonor his family.

Good news regarding young Toby, the boy from Oldeani that we brought back to FAME with us on Saturday. As best we could tell this evening he hadn’t had any further seizures today which was  a big step forward for him. The stroke patient was also moving her right leg spontaneously which means she may at some point be able to at least weight bear and stand on the leg.

It’s late here and we’ve got another mobile clinic tomorrow at Upper Kitete which is further along the rift than Kambi ya Simba and takes nearly twice as long to get to.

Hopefully more pictures soon when I get a chance to look at them.

Love,

Mike

Today was a wonderful day. It had nothing to do with the fact it was my birthday (as I am unfortunately away from my family), but rather I am somewhere that I have come to love as a second home and doing something that I think is meaningful and helpful to others and enjoying every minute of every day doing it. And while having all of that I am still able to get away and do several things that I also truly love – to drive on my own in East Africa, the cradle of humanity, and to take a group of friends on safari with me as their driver/guide to one of the most beautiful parks in Northern Tanzania.

We got up very early so we could get to the park, but stopped by the hospital to see our young seizure patient only to find him having another seizure. We had to give him some more valium and reeducate the nurses as to what a non-convulsant seizure looks like and to treat it with diazepam.

The weather for our safari was awesome. Not a cloud in the sky until the end of the day. We got through the gate at about 7:30 am and I think we were probably the first vehicle in other than the few tourists who had stayed at one of the two pricey resorts within the park. We immediately saw tons of monkeys – baboons, blue and vervet. They were just about everywhere and lots of little babies since this is the right time for them. We even saw a large group of blue and vervet youngsters playing together which is something none of had ever seen before. There were large herds of Cape buffalo, zebra and wildebeest and we got a good view of some hippos and their babies albeit from a distance (not nearly as close a view as Danielle and I had last March in the Crater).

Then as we came around a turn there was a large female lion just walking right in our view and I think we all screamed. She walked into some bushes and we drove forward a bit but couldn’t find her. Just about that time another vehicle came from the other direction as we were backing up to the original spot and we told them what we saw. We looked for her once again and then went back again to the original spot and the other vehicle had spotted the pride sitting under some trees. There were eight in all and three of them were larger cubs! We sat and watched them mostly sleeping for quite a while. We came back later in the day but they had moved to another location by then.

We eventually saw a number of elephants and giraffe along with many herds of impala, both harems and the bachelor herds. Lots and lots of birds which made Megan quite happy as she is definitely a bird person having a cockatoo at home as a pet. The large hornbills were fabulous.

We eventually left the park at 5:30 – ten full hours of safari!

The young boy in the ward had three seizures during the day which broke with valium and we’ll reassess him today. In between his seizures he’s awake and normal. We’ll have to get him under control soon.

Love,

Mike

Today we were scheduled to go to the Rift Valley Children’s Village and small adjacent village of Oldeani. Fame runs a clinic there twice a month, but this was the first time we had done a neurology mobile clinic side by side. We packed up all of our medicines and supplies and drove separately from for the 45 minute drive through beautiful countryside to reach the Children’s Village. We were met by India Howell and quickly saw the large group of patients to be seen by us, not to mention the patients there for the regular clinic. There were 20+ patients for us to see and they were all very appropriate neurology patients which means they take longer than the regular patients the other side was seeing. The photo I’ve included is just our group of neurology patients and not the general medicine patients. Not just deworming and giving antibiotics, but taking seizure histories and the such is quite a bit more time consuming.

After seeing several patients, though, we were quickly called out of our room for a young man who had collapsed out front. Luckily it was a patient we had seen yesterday at FAME and who we had asked to come back and see us today which he had done I guess in a sense. He was having continuous non-convulsive seizures and was unresponsive. We wanted to give him some IM Valium which took a bit longer to get organized then we wished, but eventually got taken care of. You can see in one of the photos Megan attending to the young boy with his mom and a nurse to give his IM injection. Several Mamas stood around him holding their skirts in a way so as to give him some privacy considering the crowd of patients we had. And as we couldn’t convince anyone to watch him for us to make sure he didn’t stop breathing, we simply put him in a chair in our room so we could keep an eye on him and continued seeing patients with him in the chair. His mom came in and out and he basically kept seizing for another 4+ hours even with another dose of Valium. We had no way of putting in an IV.

Later in the afternoon it was readily apparent that the kid was not waking up so we made the decision to bring he and his mother back to FAME to get an IV in him. We carried him to the car and put him in the front seat with Megan and got everything loaded. We were unable to see probably nine additional patients which was unfortunate, but we’ll have them come to FAME and see them next Friday. As we drove out of the gate of the village to find Tobias’ mother and were waiting near their home suddenly he amazingly just woke up and looked at Megan. His mother hoped in and we decided to bring them back to FAME regardless. He chatted with Megan the whole way back to town and played with the toy giraffe she uses to examine children. On the way back and almost to the tarmac, the Land Cruiser started smoking a little and we had to stop to check things out. Turns out we had lost the AC belt, but since we don’t use the AC ever here and the car didn’t seem to be overheating I felt it was probable smoking when the belt disintegrated and wouldn’t cause any further harm so off we went. We dropped all the employees with us off at their homes on our way through town so it ended up being just Megan and me along with Tobias and his mother in the car. As we were just about to get to the gate at FAME he looked like he went to sleep, but off course was having another seizure. I had to carry him into the ward unannounced and put him in a bed. He was in tonic extension at the time and still remained otherwise non-convulsive. We got an IV in him quickly this time and gave him some more Valium and he snapped out of it pretty quickly.

Our plan was to switch him from phenobarb to carbamazepine and so we quickly got his first dose in tonight before he seized again. What an experience and it certainly rivals Danielle’s seizing infant from last year. Very little can prepare you for such experiences and Megan did a stellar job given the very tough situation. These are the memories that will remain with us forever.

We ended the evening with a nice get together at the Lilac Cafe for all the volunteers and some local ex-pats I’ve met before. Tomorrow we’ll be on safari in Lake Manyara and then we start our mobile clinics on Monday. Another busy week here.

More remarkable adventures to come.

Mike

Well, we’ve finished our fourth day of neurology clinic at FAME and will be starting the mobile clinic portion of our visit tomorrow. It has been the best clinic so far in regard to the volume of true neurology patients here at FAME and William, our outreach coordinator has done a remarkable job recruiting patients for us. Tomorrow we head to Oldeani and the Rift Valley Children’s Village. The RVCV is an amazing home to around 80 or so children that have been adopted by India Howell as it is her concept that this should be the children’s home and that they should feel safe and not worry about being taken from their family.

We started off today by seeing three boys being brought from Mto wa Mbu who have been unable to walk for some time. The first was a Masai orphan who has been unable to walk for several years and his weakness has not been progressive. We believe he suffered polio or a similar viral illness affecting the spinal cord. Then we saw two brothers with a progressive muscular disorder and most likely a muscular dystrophy, but which one? We immediately contacted our gurus at Penn to see what they thought and got responses very quickly. Here is a photo of the three boys, the two brothers being on the outside.

We seemed to be pulled in all directions today and Megan and I had to split up again to get everything done. I saw a good epilepsy case at the end of the day as did Megan and we regrouped in the ward to finish up examining our stroke patient who had improved some.

After clinic we took care of our emails to the specialists at home and then drove up to Gibb’s Farm for drinks on their veranda which has one of the most spectacular views of all time with lots of birds and other wildlife surrounding us. Dinner there was amazing as usual and at $25 (local’s price) it is one of the best buys around.

Tomorrow is Oldeani as I mentioned and then Sunday we will be on safari at Lake Manyara.

Mike

Well, I spent half and hour last night and again early this morning typing my daily log only to have it vanish from my iPad when I was inserting a photo…..ouch! Megan had a lecture to give this morning at 8am so we had to run up a bit early to set up and now I’m behind. Luckily, it was raining last night which means the patients come up a little later in the morning so I have a few free moments….I think.

Thursdays are supposed to be slow here, but someone must have announced a special rate or something as we were pretty much swamped throughout the day. Megan and I started off seeing patients together, but had to split up after lunch to get everyone seen. We had a family with pretty classic migraines and medication overuse headaches. The usual complement of “GBM” or general body malaise with aches and pains. The last patient was a cute 9 year-old boy with a two year history of sleepiness that was mostly in the morning and was unable to stay awake in the office with us. A pretty good MSLT watching him with near zero sleep latency. No history of cataplexy, but pretty certain he has narcolepsy and was able to put him on some Ritalin and will see him in a week. Also sent an email off to Larry Brown at CHOP and had a reply from Larry and another sleep specialist there within an hour. Pretty good seeing a kid here and having feedback from the best pediatric hospital in the US that quickly.

Had dinner last night with my friend Daniel Tewa. I visit with him and his family at least once while I’m here and it’s great for whoever’s with me to come along and visit a Tanzanian family in the area. Daniel is also Iraqw, one of the indigenous tribes in Karatu and has an Iraqw underground house on his farm that we got to see. Dinner is usually an experience as it is a traditional meal, but since Megan is a vegetarian and they weren’t sure what to do, his daughter (whose house we were eating at) had her uncle come help cook. Problem is that he was a chef at Gibb’s Farm for a time and prepared an incredible meal. Megan wasn’t subjected to some of the unusual foods that Danielle got to try last year (much appreciated) though we did each get to drink warm whole milk with dinner. Daniel and his family are very special and treat us like their family so it is a wonderful experience.

Got to run and see patients right now.

Here is a photo of Daniel’s daughter at the grinding stone in his original Iraqw house alongside a wonderful huge twined storage basket. Craig, Sheila, Brian and Bob will very much appreciate the basket. Also a photo of a busy clinic yesterday.

Later,

Mike