FAME Neurology Clinic – Day 4

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I will have to admit to you that I am typing this blog about yesterday while lounging in a safari camp in the Southern Serengeti after eating a wonderfully fresh lunch. Yes, we left the security of FAME and Karatu and are now on a three day safari in the Lake Ndutu region. You will have to check back, though, to hear more about that.

Day 4 (Thursday) of our neurology clinics began with Payal’s last nursing lecture on seizure management and, yes, Christyn again performed her magnificent seizure simulation for them. We hadn’t much hope for attendance, but there were plenty of folks including Hannah and Kelley, two longterm volunteer nurses here. Talk about a small world, but Hannah will be starting a masters program in midwifery at Penn beginning in the fall.

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Our started off fast with them bringing a young woman who was unresponsive and had been that way at school earlier in the day. It was readily apparent to both Payal and myself that this did not appear to be a seizure or a syncopal episode and was more than likely a conversion reaction – “swooning” would be a good way to refer to it. After a bit she began to wake up slowly and very shortly she could shake her head yes or no, but still appeared quite somnolent. We brought her back into our office to keep an eye on her and had one of the nurses talk with her. It was very clear that she was extremely depressed and that was confirmed with the information she subsequently gave regarding her parents’ divorce when she was five and that her mother had remarried. I decided to put her a small dose of amitriptyline (“Vitamin A” here) as she was not surprisingly having difficulty with sleep as part of her depression. I spoke with the volunteer who had brought her and she will be seeing one of our long term workers here for counseling in a few weeks.

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Christyn started her day with a young 22 year-old woman with terrible back pain that had started the day before and probably had a radiculopathy based on her story. As Christyn was examining her she suddenly began to vomit. After further questioning she hadn’t been having fevers or abdominal pain recently, but then gave the history that she hadn’t had her period since January. Yes, she was pregnant and with severe back pain. Isaac did an ultrasound on her and found that she had an early pregnancy that was very low in the uterus so we brought Kelley over to look. It didn’t appear to be a viable pregnancy due to its location, but since it didn’t appear viable we decided to treat her with a course of steroids given the intensity of her back pain.

The day continued to pile up with patients and we had to stop taking new patients around lunchtime as we didn’t feel that we could get to everyone and we didn’t want people waiting around all afternoon to be told we couldn’t see them. I didn’t get the final count, but will tell you that we averaged about 30 patients a day for the four days at FAME which is a huge number of neurology patients to see and all of that done by two residents who worked tirelessly and refused to compromise on the care they were providing which is often tough here.

In addition to the outpatients we saw on the last day, Payal also saw two patients on the wards – one was an 18 year-old with the worse case of osteogenesis imperfecta that I have ever seen and who had come in with a fractured right arm. Payal assessed him and then contacted an ortho resident at CHOP to ask him for some advice and then reviewed some YouTube videos about splinting and proceeded to apply an excellent immobilization splint to his arm. A little know-how and a ton of resourcefulness is often what it takes to practice here.

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I also met with Susan (FAME’s co-founder), Brad (FAME’s nursing education coordinator) and Will (FAME’s current volunteer coordinator) to discuss future plans for the neurology program here and implementing some of that during our upcoming October visit. I am bringing residents next time as well as several epileptologists to begin work on our epilepsy project here. The trick is to make sure that we are not overtaxing FAME both as far as housing is concerned (further emphasizing the need to build a “Penn House” here for our use) as well as the staff required for us to see neurology patients. I will begin working on looking for funding for the Penn House and will also try to look at funding to cover the cost of the staff that we utilize for neurology while we are here. Both of these needs are significant now that the program has grown and is very successful. What was once me coming alone and seeing neurology patients as they showed up has now turned into an organized visit with patients coming from far away to be seen by the neurology “fundis” (experts) and many returning again and again.

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Roza Andrea

Roza Andrea, Sokoine (our intepreter) and Payal

We also saw Roza Andrea with Payal today. She is the young women (now fifteen) who we first interacted with by video email in December 2012. She had Sydenham’s chorea – a movement disorder triggered by Strep infection related to bacterial endocarditis and which can cause serious heart problems and even death. This was my fifth time seeing her and she is now symptom free as far as the movements are concerned, but she requires.prophylactic penicillin until the age of 40 and had not been returning to get it since her last visit in September. Luckily she’s still fine, but it may not have been so good. We impressed upon both she and her mother that she is really a miracle and it would be terrible for something to happen at this point. Hopefully she will continue to come back to get her antibiotics going forward. These are often the challenges here. Patients may not return due to lack of understanding or the inability to afford the treatment which may be as little as several dollars.

After running some errands in town and dinner on Joyce’s veranda, we all began packing for our trip the next day to Lake Ndutu.

FAME Neurology Clinic – Day 3 (hump day)

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Having recovered from our incredible dinner the night before at Gibb’s Farm, I arose early to finish my blog regarding the prior days. Posting my blogs has become part obsession and part therapy, but either way it’s an important way for me to share these experiences that would otherwise be so hard to convey after returning to “civilization.” I’ve mastered the transition between cultures without a problem, but the real issue for is trying to relate experiences from one culture to the other. Trying to describe a patient encounter here to someone at home is just very difficult when the other person hasn’t experienced what it’s like here and vice versa. Because of that, it’s much easier for me to describe those events while I’m still here rather than when I return. Hence, my blog.

We began our clinic day with Payal’s nursing lecture on seizure management that was reasonably well attended, but either way we were there to support her. In fact, Christyn served as her epilepsy patient during her patient simulation. There were lots of great questions from the nurses and it’s always tough to tailor recommendations to what’s available here, but she did a great job of it.

Payal giving her seizure management lecture to the nurses

Payal giving her seizure management lecture to the nurses

Christyn doing a seizure patient simulation helping out Payal

Christyn doing a seizure patient simulation helping out Payal

We had another totally swamped day with the same number of patients being seen as Monday. We’ve seen 91 patients in the three days that we’ve been at FAME which is amazing both from the standpoint of what Christyn and Payal have done as well as the fact that all of the patients have been genuine neurology patients so the message was clearly conveyed to the community by William, our outreach coordinator. Payal was working with Dr. Isaac again and Christyn with Sokoine as an interpreter. They were both subjected today to the experience of multiple translators as we had several patients who only spoke Iraqw and needed a family member to translate from Swahili and Payal had a young Maasai woman whose husband didn’t speak Swahili either and they brought a translator with them.

Payal’s Maasai woman presented other obstacles that are often encountered here with the Maasai specifically. The Maasai have traditionally practiced polygamy and the women often do not leave the boma while the men regularly attend the local markets so speak Swahili out of necessity. The patient was having episodes of unresponsiveness that were just about to be interpreted as possible seizures though the history to that point was supplied exclusively by the husband and not until the men were asked to leave the room and a female Maasai interpreter was enlisted was the true story apparent. She was sixteen and had been married at nine. She had been pregnant three times with three children. Her episodes were limited to when she was pregnant and were clearly syncopal and not epileptic. Thankfully the more accurate history was obtained and she avoided a trial of unnecessary medication.

Payal after evaluating two syndromic siblings

Payal after evaluating two syndromic siblings

I sat down for lunch and was immediately summoned to meet with a surgeon that we had met the night before at Gibb’s Farm and I had invited to have a look around FAME. In fact, he brought the entire safari group he was with so I spent about 30 minutes showing off the facilities here at FAME and totally impressing the group. It is hard not to marvel at the medical facility here and what can be accomplished with an idea and lots and lots of energy.

In the afternoon I worked with Christyn and the interesting patients continued. We saw an elderly gentleman with a one year history of generalized weakness and muscle wasting and symptoms of neuropathy. He denied coughing or fever and we decided to check for all the likely suspects including HIV, syphilis, and finally TB. Of course everything was negative other than his sputum for AFB – he had active pulmonary tuberculosis as an explanation for his gradual decline over the last year. Even neurologists can diagnose pulmonary disease.

We also saw a depressed woman who was also complaining of memory loss and decided to check her for syphilis along with thyroid function only to find that she had the former so we had to counseled her on STDs and had to have her come back to be tested for others by the women’s health nurse practitioner.

We again ended up seeing 34 patients today and finished a bit late. We were heading to Daniel Tewa’s home for dinner and wanted to get over there in the daylight, but on arriving home to get the vehicle found that I had a flat tire. It took probably 20 minutes to figure out the jack for the Land Rover as it is one of those hijack models given the height of the vehicle. I finally got the tire changed and we were off to Daniel’s. He is just the amazing individual and always a pleasure to visit. I have visited with him every time I’ve been here and have brought all the residents accompanying me to visit with him as well. We went up to his daughter, Isabella’s home for dinner that was all local Iraqw dishes and were amazing. They are so gracious and remind us over and over again how we honor them by visiting and sharing a meal with them. We fell quite the same, that it is such an honor to spend time with them for despite the struggles often encountered here just to provide for their own family that they bring us into their home and share their evening meal with us. It is a relationship of mutual respect and love and Daniel constantly reminds us that they are our Tanzanian family.

We returned home at 10pm and after such an amazing meal I don’t think we lasted that long before bed.

One more thing. I’ve linked Payal’s blog to mine, but just in case, you should all visit it as well. It’s wonderful and another perspective of this amazing trip:

http://www.lionsdontbite.blogspot.com

FAME Neurology Clinic – Days 1 and 2

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It’s an early day leaving the house as Payal has her first of three lectures to give to the nursing staff today. Brad, our new education coordinator told us yesterday that there was a significant chance that no one would show up for today’s lecture as the nurses would have to be picked up early from town to make a lecture that early and in all likelihood they will have forgotten over the weekend. He was right. Sahawa, our nurse anesthetist, was the only one to show for the lecture, but that was fine since it gave Payal a good chance to practice her lecture as she will be giving it on two other occasions so all the nurses have a chance to hear it.

After lecture it was off to our neurology clinic here at FAME. As they have outgrown the outpatient clinic even without our specialty clinic our plan was to see patients across the courtyard in the emergency room and night doctor’s office. That would allow us to have two rooms working at a time and we had one clinical officer to work with a resident and an interpreter with the other. I would hang out mostly with the interpreter/resident pair as that would require a bit more supervision.

Busy day at FAME

Busy day at FAME

Karatu Ambulance Service

Karatu Ambulance Service

Busy day at FAME

Busy day at FAME

 

 

I will begin by telling you that Monday turned out to be a record setting day at FAME due to the numbers of patients and our Monday neurology clinic ended up being the greatest number of neurology patients we’ve seen in a day here – thirty-four. It is really a testament to the work by our outreach coordinator, William Mhapa, who is a real powerhouse. Every patient we saw was an appropriate neurology patient which is so important so as not to waste our time trying to triage during the day with so limited an amount of time to do everything. Payal was seeing all the pediatrics and Christyn was seeing all of the adults.

Christyn examining a patient

Christyn examining a patient

Payal evaluating a young girl with hemiplegia and epilepsy who I have followed for four years

Payal evaluating a young girl with hemiplegia and epilepsy who I have followed for four years

I will have to say that a great majority of the adult patients were headache patients, but otherwise we had a great diversity of diagnoses in both the adult and pediatric patients seen. We worked until rather late and I drove Sokoine, our interpreter, back to town since we had made him miss the vehicle heading down having worked so late. We also drove two bebes (older women) who were at the clinic late down to town. We had dinner on Joyce’s large veranda with everyone including two surgeons who are visiting for just the week deciding if they would like to commit to a longer term relationship. They would be a great asset to FAME as there are many surgical cases that come through but most of all wound care for all the burns they see here many of whom are children.

Christyn giving her stroke lecture

Christyn giving her stroke lecture

Tuesday mornings begin with the doctor’s education lecture at 7:30 and Christyn did an amazing job covering hemorrhagic and ischemic stroke using two case studies that were interactive. It was very well attended with all the doctors, visiting nurse practitioners, and clinical officers and there were lots of questions. We’ve given the lecture numerous times before, but since it’s something they don’t do on a regular basis it very hard to change how people practice. The same problem exists back home, though, and is not unique to East Africa. We are going to begin writing protocols for them to use here for management of neurologic problems like stroke and status epilepticus that should help greatly going forward.

Christyn evaluating a young Maasai women with epilepsy

Christyn evaluating a young Maasai women with epilepsy

Christyn and I saw a gentleman with a history of atrial fibrillation that came in with a complaint of headache. His headache had been present for several years, but a year ago he had had onset of focal neurologic symptoms including a complaint of some language difficulty and had gone to Arusha to have a CT scan at Aga Khan which they hadn’t brought with them. They told us that nothing was found on the CT scan which didn’t make sense so they went home (luckily they lived very close) and brought in the scan. Of course it wasn’t normal, but showed an acute left posterior MCA infarct as well as at least one other subcortical infarct. It was obvious that he needed to be on Coumadin to prevent any further events and that was taken care of.

Payal evaluating a young man with delay and previous surgery - no history available

Payal evaluating a young man with delay and previous surgery – no history available

At noon, Payal had gone to lunch at the Lilac Cafe (the little restaurant on campus) since lunch for the workers was Ugali and meat and Christyn had already gone up to the canteen. I was just walking up when one of the nurses brought a young boy over from the clinic who had just seized and was post-ictal. He was on a gurney and quite stable at the time so I put him in Payal’s room with his mom and went to grab a quick bite. Payal returned to find the boy in her exam room, but I got to her quickly to explain the situation and it turned out that he had been refusing his medications and it was unclear how much he had been getting. His mother was excellent and described how they were crushing the medication and putting it in his mouth while holding his nose so he would have to swallow, but it was still unclear if he was getting the full dose. We wheeled him into the hallway as Payal wanted him to stay until he was awake and functioning, but he later had another brief seizure that she was able to witness and she wanted him to come in at least overnight to observe him. Mom didn’t have the money needed to pay for the night in the hospital (20,000 TSh or less then $12) so we told her we would take care of the cost for the visit. I had been given some money by a generous friend to help with situations, but either way, we would have merely reached in our own pockets if necessary and that is how it happens here so often.

Patients are put on medications that cost a pittance in our minds, but are out of the question for them so they are stopped and their problem returns and that’s very often seizures. We now have a grant from LinkedIn to work on epilepsy here that will hopefully allow us to subsidize the cost of lifelong medications for these epilepsy patients and allow them to remain seizure free.We are also hoping to bring an EEG machine here in October to allow us to more accurately diagnose our patients rather than doing it by trial and error and seeing whether a medication works or makes them worse to know that it’s the right one. Danielle Becker will be working on that project and given the impact that uncontrolled epilepsy has on one’s life it should make a tremendous difference to overall health of the region here. Epilepsy is incredibly prevalent in Sub-Saharan Africa and the overall impact on disability and health is tremendous. Though this will be a huge undertaking it will clearly make a difference for the residents here on many levels. I am looking forward to watching that happen during my tenure here.

Since it was my birthday on Monday and though I had managed to keep it quiet, it somehow leaked out (thanks to Facebook with Kim and Susan) and we had a get together at the Lilac after work. A bunch of us had also made plans to go to Gibb’s Farm for dinner (having nothing to do with my birthday) so we headed up there after a quick visit at the Lilac. Gibb’s Farm is the true Shangi La and they offer a local’s rate of $25 for a four course dinner that would rival anything and is probably one of the finer dinners one can eat in Africa. The view from Gibb’s is also spectacular and we sit on the veranda there for at least an hour before dinner is served so it is a whole evening affair. Of course, Joyce wouldn’t allow me to pay for anything since it was my birthday the day before and it was such an enjoyable evening that I didn’t fight her on it (she reminded me to respect my elders!). We drove down the long road back from Gibb’s at 10PM and there were so many stars in the sky that is was absolutely crazy. The Milky Way rode over our heads in total brilliance. I was looking forward to a restful night in the cool air of the Ngorongoro Highlands with all the relaxing sounds of the wild here. I closed my eyes to the distant howl of a lonely hyena disturbing the local dogs and wondered what tomorrow would bring.

Lake Manyara National Park

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I’ve written several times before about Lake Manyara as it is always a regular on my safari circuit, but not only due to its close proximity to Karatu. True, it’s only thirty minutes down the rift and is a bit smaller than Tarangire and doesn’t have the reputation of Ngorongoro Crater, but it is a park that is very unique with much to offer. It is almost a hidden jewel as it is often overlooked and left off many a safari itinerary. Lake Manyara was formed millions of years ago with the Great Rift Valley and for that reason the geography is unlike any other park here.

We awakened early and packed our safari consisting mainly of our camera equipment and lunches, but somehow managed to forget the fantastic peanut butter and jelly sandwiches I made in the fridge – we were left with bananas and Cliff Bars for the journey but knew we’d survive. Arriving at the gate a bit before 7:30 we were the very first group to enter the park that morning. Amazingly we practically had the who park to ourselves for most of the day. It was probably two hours before we saw another vehicle.

Christyn and Payal - Safari photographers at large

Christyn and Payal – Safari photographers at large

We saw everything to see there during the day much to Christyn’s and Payal’s delight. It’s always so exciting for me to take friends on their very first safari here in Tanzania and to share the beauty and wildlife of the area with them. I had brought several camera bodies and lenses for them to use while here and with the very first baboon troop we ran across their shutters were furiously clicking away. There was no reason for me to tell them that we’d see dozens more baboon troops during the day and by the end they would be merely saying “look, more baboons.” We drove to the first hippo pool, but after the sun comes up most of the hippos are wallowing in the mud and water so their hard to see. Driving away from the pool, though, Christyn spotted a hippo right next to the road ambling along in the mud, sinking up to it’s knees with every step under its massive weight. We sat watching for several minutes as it mostly ignored us and then disappeared into the brush and reeds.

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We saw lots and lots of giraffes and a few elephants and had our meager lunch at Maji Moto (hot water) sitting under the trees at the mouth of one of the hot springs. Hearing the trickling water and the quiet sounds of Africa were amazingly relaxing and had it not been for the fact that we would have either been attacked by one of the nearby Cape buffalos or eaten alive by the bugs we would have all taken a nap in the tall grass leading out to the lake. Thankfully we all had our wits about us and chose to head back to civilization in the form of our Land Rover.

A baby dik dik

A baby dik dik

After lunch we headed further south along the road in search of a lion pride. I had seen a very nice pride last September and had them marked on my iPad’s GPS. As we turned off the main road towards the lakeshore and the prior pride sighting on my GPS we saw two vehicles off to the side near the hippo pools. One rule of safari driving is that if you don’t find it yourself (which is often the case) then you look for someone who did find it and head in their direction. As we drove up alongside one of the vehicles and were looking over at the hippos, one of the guests in the vehicle asked us if we had seen the lion pride. When someone asks you this it is usually attached to a long dissertation on how to get to wherever the sighting was and then only to find out that whatever you might be looking for has moved on. This was not the case as he merely pointed in the opposite direction of the hippos towards some trees and there under a tree were ten plus lions led by two very healthy males.

Our pride of lions in Manyara

Our pride of lions in Manyara

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The lions were all sleeping as they do most of the day, but almost immediately several of the lions got up and started to walk away or move around. The other vehicles which had driven away towards the hippos quickly reversed course and came back in our direction. We drove a tad bit closer to the lions on the trail of the other vehicles and then sat and watched them for a good bit of time. They are just so very majestic and grand. Payal and Christyn really wanted to see the lions so it was great to have found them.

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We spent the rest of the time in the park looking for more elephants after a return visit to the lions and the hippos. We ended up spending almost eight hours driving in the park which is a good amount of time.

Having essentially skipped lunch (Cliff Bars and bananas just don’t cut it for hungry explorers I’ve found) we were definitely willing to accept Kelley’s suggestion of pizza for dinner at a small club down the road. Payal wanted to call it a night so ate one of our forgotten PB&Js while Christyn and I (the more food oriented members of this party) decided to go for the pizza. You might wonder whether it’s really possible to get good pizza in East Africa or not. Leaving all suspense aside I will answer the question for you in advance. It is not possible. We sat down outside and the weather was gorgeous so we definitely had that going for us. The beer was fairly cold (another plus), but unfortunately they weren’t making pizza that night. Not a problem as they had other things on their menu that sounded very appetizing. Problem was that none of them were available either – not any of the pastas and not the local version of beef barbecue. I ordered pepper steak, Christyn the fish and Kelley (who was now with us) the chicken. The waitress came back ten or fifteen minutes later to tell me that there was no pepper steak so I went with the fish. An hour and a half later, she came out with our food. The fist was a whole local fish deep fried and served with fries. Kelley’s chicken was too touch and gamey for her to even bite into.

We arrived home so late and tired from the safari and our dinner experience that I fell asleep trying to type my blog while Christyn hiked up to use the internet at the clinic. We have our first day at FAME tomorrow for our dedicated neurology clinic and are all very much looking forward to it.

Rift Valley Children’s Village, part two….

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So we left off with Payal on her way back from Arusha after escorting an infant with Meningitis there for care. Meanwhile, we had to get back up to Rift Valley Children’s Village for day two of our neurology clinic so I drove everyone up in my vehicle and we left a driver and vehicle back at FAME to bring Payal after she arrived. It turns out that she came home with the patient and parents as they didn’t want to stay in Arusha for treatment and rather chose to come to FAME. Not surprising as you shall see.

The rest of the story was that Payal, her patient and their parents (who are friends of Rift Valley FAME) were met with a experience at the top hospital in Arusha of total frustration. After receiving antibiotics at FAME, the baby improved on their way to Arusha, but her story was still quite scary for meningitis and because of her focal examination we were unable to do a spinal tap safely without first obtaining an imaging study. Hence, the need for the CT scan. After running a gauntlet in registration after arriving at the hospital and being told that the CT scanner would not be available again until Monday morning (it was Friday night) except for emergencies and the only way for that to happen would be them to be seen by the on call pediatrician, but no one was available until Monday. They were finally directed to the emergency room where they were met by a rude and insulting doctor on call who later turned out to be an intern. He wasn’t interested in listening to Payal one bit and told them he wasn’t going to order a CT scan for the baby. Payal was obviously incredibly angry with the doctor who ended up throwing the chart in the air and walking away. They were then essentially kicked out of the emergency room which is when they called me and I, in turn, called Frank who subsequently called the head of the hospital who I’m sure was totally mortified over the situation.

Shortly thereafter, they were escorted back into the hospital and told that the CT tech was on their in to the hospital. The baby ended up getting a contrasted CT (with way more contrast then she needed so thank goodness her kidneys are functioning fine) that was abnormal in that it showed evidence of meningeal inflammation or meningitis. They offered to admit her to the hospital, but neither Payal nor her parents had any faith whatsoever in the hospital at that point and they took her to their home in Arusha with IV intact and brought her to FAME this morning.

Had the child’s family not had connections with FAME and RVCV it is very clear what would have happened. It’s doubtful she would have ever been assessed by anyone who would have recognized the problem and far less likely that she would have been referred to a hospital for a CT scan. Whether should would have received the proper antibiotics is quite unlikely. Even if her family had taken her to the hospital on their own they would have run into the same reception at the hospital and the child would have died due to the lack of access of competent medical care. Solely because of Payal’s persistence in the matter and recognizing what needed to be done and sticking to her guns, the child ended up with the appropriate treatment and is alive today. I have known her father for several years and he is the most unassuming, gentle and giving man you could ever meet. He is greatly troubled by this experience, knowing that had he been a regular Tanzanian his child would very likely be dead. These are the issues we wrestle with every day here.

Payal returned to RVCV before noon which was a good thing considering our list of patients somehow kept growing throughout the day. Payal saw the children for the most part and Christyn saw the adults while I bounced between both rooms. Try not to believe Christyn if she tells you that I occasionally dozed while she was taking a history – she will confirm, though, that I was awake for any necessary decision making ­čśë We amazingly made it through everyone there to be seen though had to let the regular FAME clinic staff leave before us as it was late.

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Back at FAME we thought we’d relax for the evening, but Payal had to check on her patient and we had a gentleman admitted to the ward earlier in the day for tremor and ataxia. I had seen him a few years earlier and converted him to Dilantin and without boring everyone with the details, his Dilantin dose had been significantly increased in January after an admission. Hopefully all the neurologists reading this got the answer as quickly as Christyn and I did – Dilantin toxicity. His Dilantin is now discontinued and he is on levetiracetam! We made it home in time for grilled cheese sandwiches, tomatoes, avocados and left over fruit from Payal’s missed dinner the night before. It was glorious!

Such are the stories and experiences here that we encounter everyday. Tomorrow (Sunday) is our day of rest – don’t forget we are only neurologists – and we’ll be off on safari to Lake Manyara for the day. Look forward to sharing that with you.

Rift Valley Children’s Village and more….

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A wonderful clear morning to sit on our veranda with a spectacular view of the Ngorongoro Highlands and coffee plantations covering the hillsides up to the border with the NCA (Ngorongoro Conservation Area). Birds that are unfamiliar to the ear continuously chirping and breakfast with Payal’s delicious Tea Masala complete this nearly perfect picture of serenity.

It’s our first morning to report to work since we’ve arrived and we’re scheduled to travel to the Rift Valley Children’s Village for neurology clinic both today and tomorrow. We have our usual delay getting things ready for the clinic as we must remember everything since you can’t come back and pick it up. Luckily, we’ll bc coming back tomorrow so it’s not to difficult to bring it the next day. We’re having lots of internet shida (Kiswahili for “trouble”) so I have to sit outside the clinic to get yesterday’s blog posted but it doesn’t happen as the internet is just that slow. Don’t ever take your high speed internet via cable for granted again. It can get much, much worse, trust me.

The drive to RVCV wasn’t entirely uneventful as I watched the temperature gauge on our Land Rover continually climb but luckily just made it there before overheating. Thinking it just needed some water we discovered that the radiator fan had unthreaded during the drive and was no longer attached! With the help of one of the FAME drivers (who had come up in the other vehicle) the fan was reattached and cinched down tightly. That would not have been good in the middle of the Serengeti or down in Ngorongoro Crater. We’ll have it looked at tomorrow.

image Clinic was busy and I had Christyn and Payal working together with me observing for the first shift. We saw mostly kids making Payal quite happy though there was enough for Christyn and I to contribute along the way as well. We ate lunch around 1:30 and then returned to clinic only to find the infant of a friend in the exam room with Dr. Isaac. She had apparently had a prolonged seizure during a nap and they had given her some diazepam before we arrived. What was immediately apparent to the three of us was that she wasn’t moving her left side very much and when we questioned her dad, it was clear that she had had a focal seizure. And she was quit febrile. She had had a simple febrile convulsion back in November, but this was quite different. Payal jumped into action (I can’t tell you how reassuring it is to have a pediatric neurologist along with us!) and decided that we needed to initially move the child to FAME for antibiotics and then to Arusha for a CT scan to rule out an abscess or empyema.

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After some discussion it was decided that Payal would travel ┬áthem all the way to Arusha just in case something should happen en route. Meanwhile, Christyn and I continued seeing more patients at RVCV and she was so excited when we finally got a real adult neurology case at the end – a ninety year-old women with headache who likely had occipital neuralgia and Christyn was able to do an occipital nerve block on her since I had brought the necessary supplies with me. Full service neurology!

We got back to FAME before Payal had left as they were still infusing antibiotics and then they were off to Arusha. Frank had notified the head of the hospital that they were coming, but somehow the message never got through. Payal called me around 9pm to let me know that when they had arrived in the ER there, the doctor had no interest in listening to her nor were they planning to do a CT on the child. I ended up speaking with Frank and Susan who then called the hospital head again and made things happen. It’s the next morning now and I did hear from Payal that the CT scan showed evidence of meningitis, but no other abnormalities so all is well and the baby is admitted there to finish her course of antibiotics. Payal is on her way back to Karatu and will be here in several hours. I’ll get the full story from her when she’s back.

I’m sure there are many lessons to be had with that story, but I haven’t had time to digest it and should probably wait for Payal to fill me in on the details regardless. We spent last evening with Frank and Susan on their veranda doing lots of brainstorming for FAME and how the neurology program here will fit in over the coming years. There is clearly a huge need for neurology here in Northern Tanzania just given the high prevalence of epilepsy and we hope to make that a focal point of our project going forward. For now, though, we are seeing lots and lots of patients and we haven’t even begun our neurology clinic at FAME that will be all next week. I suspect Monday will be mobbed.

The Great Rift Valley

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Traveling west from Arusha to Karatu crosses some of the most amazing landscape on Earth – specifically through the Great Rift Valley of East Africa. Across the valley and finally to the town of Mtu wa Mbu (or mosquito river) which is a rough and tumble frontier town with lots of shops and street hawkers selling their wares to safari guests as the vehicles stop on the roadside for view the scenery. The Rift Valley complex, though, contains some of the most fertile land to be seen in Northern Tanzania and traveling from the dust valley floor up the escarpment, one encounters almost the sense that you are discovering Shangri La. Early man must have felt the same as they have inhabited this area for as long as man has existed – we are traveling through the cradle of humanity and despite having taken this drive dozens of times now, it has not lost one ounce of its impact for me. The importance of civilizations and their impact on the present day can always be debated, but without a birthplace there wouldn’t be man at all.

Karatu sits atop the escarpment and in the Ngorongoro Highlands, some of the richest coffee growing acreage anywhere on earth. Ascending from Karatu you will immediately encounter Ngorongoro Crater, an ancient collapsed volcano that is so representative of this regions violent and dramatic past. On the other side of the Crater is Oldupai Gorge (the correct spelling rather than the originally misspelled “Olduvai” that was first published and stuck for many, many years) where Louis and Mary Leaky did find our earliest ancestors.

Having essentially minored in physical anthropology as an undergraduate, you must understand that this region has always been my Mecca. Several years ago I had the opportunity to work with the Hadza, or Hadzabe, who live adjacent to Lake Eyasi and are the last hunter – gatherers in Tanzania. The significance of this region was clearly evident to me as I went out hunting one morning with two young boys (I am not even sure they were teenagers) and watched them shoot small birds from the trees with their ancient weapons. Larger game has been scarce for them for several years now, but they continue to practice their primitive way of subsistence as they have for so many centuries. How much longer can they exist in this manner is unclear at the moment.

So it was on this backdrop that we left our friends home in Arusha this morning to travel across this timeless land to our ultimate destination – FAME Medical. On our drive, though, we ran across a small group of giraffe and zebra close the roadside and positioned just perfectly for Christyn and Payal to photograph them. As neither of them has been on safari before, I am certain that this moment was quite impactful for each of them. This wasn’t a zoo, nor, for that matter, was it a park. We were merely driving along the tarmac of the major highway here and ran across the animals likely in transit, but they had little concern for our presence. I know I’ve mentioned this before, but in Tanzania, parks are located where the animals congregate and have no fences. Animals roam freely through the county hence our encounter today traveling from point A to point B. I told them that now we didn’t need to go on safari since they had seen everything, but somehow I don’t think they bought that.

Arriving to FAME I immediately noticed a new building and later discovered that it’s the new administration building! When I began here in 2010 we had the outpatient clinic and the hospital foundation had been laid. There were two volunteer houses and Frank and Susan rented a house in town. Now, in addition to the outpatient clinic we have the laboratory building, the hospital building, the OR and ER building, another volunteer house, four houses for Tanzanian staff, the Lilac Cafe, and now the administration building. Also, Frank and Susan are now living on the grounds in their own home. We have labor and delivery up and running. The concept here has been amazingly successful.

But among all of the new buildings and new faces, there remain quite a few old ones. The clinical officers I first began to work with are still here, as are reception staff and nurses. The staff has grown out of necessity, but so many have remained. There is an energy and a passion here that remains undeniable and continues to be fueled by those who experience it, both as patients and as caregivers. It is for this reason and these attributes that I have continued to return each year and will continue to do so for as long as I can continue to contribute to this incredible cause.

Tomorrow we travel to the Rift Valley Children’s Village to provide a neurology clinic there and I know that we are all three very much looking forward to that visit.

Photo courtesy of Dr. Payal

Photo courtesy of Dr. Payal

Arriving in Arusha

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Well, we’ve been in Tanzania now for close to 24 hours and it seems like I never left. It has become so familiar to me here in Arusha and Northern Tanzania that we always start without ever having missed a beat from the last visit. The stars were aligned for several reasons; Our flights were very uneventful (even with my jinx on Newark to Amsterdam flight) and on the flight to Kilimanjaro we each had an extra seat next to us to spread out. We were practically the first ones through immigration and amazingly our six massive duffels were some of the first ones out. Our ride met us outside of customs and we were on our way to Leonard’s home and a very late dinner on our arrival. Pendo is always the most generous host no matter how late we arrive.

I awoke early to see the boys off for school. Lennox is now 8 years-old and Lee is almost 5. They are now in the same school which is across town back in Sakina, a suburb of Arusha where the Tembas used to live, but they are now in Njiro which is all the way across town. Sound confusing? Well, it is. Gabrielle is the new addition to the family and is now a bit over a month old and very cute. She’s got two big brothers to look after her.

Our first business of the day (that is after breakfast) was to see a young boy who is currently 5 years-old and was born with arthrogryposis. Even though we haven’t made it to FAME yet, we’ve been put to work here in Arusha seeing patients. Junior (the name he prefers to use) is the only child of a friend of the Tembas and they had asked for our help. It’s always difficult to tell whether a family’s understanding, or lack thereof, is due to what they’ve been told or what they’ve heard. Junior was born with a genetic disorder that may have been inherited from one or both of his parents and they needed to be told that there was approximately a 25% chance that they could have another child with the same disorder. In addition, he needed to continue with his physical therapy which is perhaps the most important thing for him to continue with reasonable function. He is an extremely bright young boy who otherwise is unable to use his arms and, to some degree, his legs. Watching Junior play Temple of Doom on his mother’s phone, though, made it very clear that this young boy was going to defeat all the odds against him as his mother will be his tireless advocate. We will continue to follow him going forward and I very much look forward to watching him succeed

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Junior, Christyn and Payal

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Now, that’s a very happy child neurologist!

Next was visit to a patient I follow here with a chronic neurologic disorder that is currently well controlled and despite living in the inhospitable environment of Northern Tanzania while also taking immunosuppresive agents has managed to remain out of trouble from an infection perspective. They live in a lovely home with a lovely view of Mt. Meru and it is always a pleasure to visit.

Vanessa, Payal and Christyn

Vanessa, Payal and Christyn

Following a brief visit to the Airtel store to secure SIM cards for Payal and Christyn to use in their phones and a data plan so I can keep up with my blogs, we returned home through all of the hustle and bustle of downtown Arusha during rush hour. I took a walk with the boys and then Pendo’s friend arrived during the evening with her 12 year-old daughter who has a static encephalopathy and seizures. Amazingly, they had taken her to Dar es Salaam and obtained an MRI scan – for what clinical reason I just can’t imagine other than a desire to know as it wouldn’t change immediate management. In any event, the MRI showed that she had had an insult to the right hemisphere that was very extensive and certainly explained her exam findings. We’ve made some recommendations with more to come after we consult with our epileptologists back in Philadelphia.

Tanzanian neuroradiology reading room

Tanzanian neuroradiology reading room

imageTomorrow we leave for Karatu in the late morning after I wake up early to say good bye to the boys. ┬áStay tuned for more updates. I was luckily able to stay away to post this tonight as Pendo has been feeding us far too well. Considering I have very little sleep on either flight here and little sleep last night, I’m definitely ready to crash.

Lala salama..

Amsterdam and beyond…..

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For some odd reason I always think I’ll get some sleep on the flight over the Atlantic, but arriving in Amsterdam I’m never fully rested. It’s no wonder since they feed you a bit over an hour into your flight and then again a bit over an hour before you land and considering it’s only a six plus hour flight you’ve got only several hours in between. An hour to toss and turn and finally get comfortable, fall asleep and then it’s time to wake up. Next time I’ll just work or read or watch movies straight through and skip fooling myself! Perhaps I’ll get some rest on the next flight to Kilimanjaro.

Last September, Danielle and I had a bit of excitement on the flight having “rescued” a poor women who had syncopized in front from of the lavatory – no, it wasn’t out of necessity as neither of us were on our way to use it at the time. No events this flight though I probably just jinxed myself considering we have a tad over an hour remaining in our flight. Oh well, perhaps something more to write about.

Not much layover in Amsterdam so I’ll try to upload this on the fly. They have so-so free Wi-Fi at the airport depending upon which gate you’re flying out of whether it wants to work or not. That’s perhaps the one thing you find you miss the most when in Africa – connectivity. They actually have a wonderful cell network – when it’s working – as there are no landlines anywhere in Northern Tanzania. Most people there carry at least two cell phones to assure that you have one connecting to the network where you happen to be at the moment. Somehow I’ve always picked the one that isn’t. There are a number of cell “dead zones,” though, where we’ll be traveling, and being out of touch for an entire day at a village while providing medical care can be a bit unnerving. Considering many things we often see aren’t your everyday maladies, the lack of easy access to the internet can be a hardship.

And perhaps that’s just a metaphor for the real issue we face here practicing medicine – the lack of technology. And why this experience can be so eye-opening for those who have never practiced neurology without an MRI, or a CT scan, or even an x-ray for that matter. You must trust your instincts when sending someone several hours away for a study that may cost a month’s income or even a year’s or may just be entirely out of reach for some. Bringing technology where it doesn’t exist currently will solve only part of the dilemma. Bringing the knowledge of how and when to use that technology is the real key and that’s just what we’ll be doing for the next several weeks. Working with the doctors and nurses here to pass on the knowledge, that is so powerful, of when and where to use that technology that we take for granted every day of our lives.

My tenth visit to FAME

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All packed and ready to go. I have three full 50 lbs. roller duffels filled with medical supplies for FAME and expect Christyn and Payal to arrive here shortly for our final packing organization (have to max out those duffels to bring supplies!).

Christyn Edmundson is a senior adult neurology resident at Penn who has done a fair amount of global health work already and will now get to experience Tanzania and FAME.

Payal Patel is a senior child neurology resident at CHOP (Children’s Hospital of Philadelphia) who has also been involved with global health in the past.

We leave Newark Airport on our way to Amsterdam tonight at 6:30 p.m.

Thanks for viewing my blog and I hope you enjoy our adventures in Tanzania.