I awakened our last morning in Tanzania having needed the rest after our ordeal in Tarangire and having driven back in the dark which is always an experience here. The roads can be treacherous at best and they are often without lines making the driving at night something to avoid if at all possible. Add to that the huge busses that ply the country between cities traveling at what sometimes seems like the speed of light when they are passing you along with the completely opposite huge trucks that travel uphill at a snail’s pace. Not a good combination on the road and add to that everything in between it makes for an exciting time. There are many accidents that occur mostly at night.

Pauline, FAME’s volunteer coordinator, had come with us to Tarangire as she’d never been there before, but she also needed to come to Arusha to go to the immigration office with me so we could have our resident permits stamped into our passports with the original documents she had. We had planned to go early in the morning, but as is often the case, Africa time struck again. Yusuf had insisted upon taking the vehicle to clean that morning and I had asked him to be back in 30 minutes so Pauline and I could leave. Two hours later he finally came back with the Land Cruiser, albeit very clean. Jess was taking a flight on Qatar Airlines that left much earlier and I needed to get her to the airport after the immigration office. She also wanted to make one last trip to the Maasai market.

Pauline and I dropped our passports off at the immigration office and were told to come back at 12:30 to pick them up. It was just out of principle that they couldn’t take care of them for us right away. We took care of the Maasai market and I dropped Jackie and Pauline off at the Blue Heron, a fantastic ex-pat hangout in Arusha that I hadn’t been to before. There was no need for them to take the long and hot, hour long drive each way to the airport. I got Jess there and turned right around and went back to the Blue Heron to pick them up. We were sitting in their wonderful courtyard when I suddenly realized that we hadn’t asked the immigration when they were closing that day and if they had, I’d be in big trouble since they had my passport. We rushed over to find them still open and picked up our freshly stamped passports.

We dropped Pauline off at the bus station where she was catching a “fast Noah” back to Karatu and we were off to meet some friends at the Arusha Coffee Lodge across town to drop something off for them. The traffic in Arusha is become ungodly these days as it is not only the center of business for Northern Tanzania, but is also now the capital of the newly formed East African Community. We made it to the Coffee Lodge in time for our meeting, but traveling back to finish packing took forever it seemed. We made it back to Leonard’s in time for quick showers and packing and were off to pick up Yusuf who was driving us to the airport. I let him drive this time as I had done enough driving in the last two days.

The drive from Arusha to the airport travels along the base of Mt. Meru and through many small villages, each with their own hustle and bustle of activity, people coming and going and doing business. No matter how many times I travel this route, I see something new each time and still marvel that I am in East Africa. I know that I’ll be returning in six months so it has lessened the blow of saying goodbye to everyone and to the country. Tanzania has become my second home and though I will miss it while I’m gone, it will always remain with me and the people there will always occupy a huge part of my heart. Our trip was another success for the patients we saw, the caregivers we worked with and the friends who touched our hearts. Jess and Jackie saw over 280 patients between the two of them, far more than they would ever hope to see had they been working in the US, and the diversity of diagnoses was also remarkable. They are both truly remarkable physicians and the experience they’ve had in Tanzania will only add to their already amazing skills and independence.

We had decided to leave Karatu and FAME at a very early hour to travel to Arusha via Tarangire National Park – it’s not actually on the way, but only about a 30 minute detour and one of the most beautiful parks in Tanzania with lots of elephants. It’s possible to spend a good part of the day at the park and still make it back to Arusha in the daylight which is always important consider the dangerous driving here after dark. The night sky just before dawn while loading the vehicle was a miracle of stars with the Milky Way being the centerpiece. It seemed there was more white than black in the sky. We were to pick up Sokoine and two others in town on our way out, but it turned out that the party had gone on much past our departure at 11pm. Many of the Tanzanians were dancing until dawn and only Sokoine was able to make it as the others were still sleeping. We left town with the sun just peaking over the horizon and a beautiful sunrise on our way to Tarangire.

(All animal photos for this post were taken by Jackie using my camera as I was doing the driving)

Tarangire is a unique park that is dominated by a river ecology. The animals all remain protected in the nearby hills during the night and then each morning travel slowly towards the life giving water of the river. The big cats, of course, sit and wait for the animals to move towards the river each day in hopes of catching some lunch. This is not the high season for Tarangire as it is very lush and green meaning that the animals can find tall grasses to eat without having to come all the way to the river and so they are more spread out and not concentrated at the river which is best for game viewing. It is still an amazing place at this time of year and there is lots to see. Tarangire is known for it’s amazing numbers of elephants and it didn’t let us down this time. There were hundreds of families of elephants usually made up of a dominant female along with her sisters and all of their babies. Males usually travel separately and alone, not in groups. There were so many babies which is always wonderful to see as the herds remain very healthy.

We traveled slowly along the river often encountering deep mud pits in search of more elusive game. It is always reassuring to see tire tracks on the opposite side of these pits with the knowledge that someone before you had made it across. Safari guides are very friendly and often share information when you pass on the trail and so I had received a tip that there was a pride of lions at the river crossing on the way to the Tarangire Sopa Lodge a number of kilometers ahead. We drove to the crossing and couldn’t find them on either side of the river, but then saw another vehicle parked a bit up river near some trees and made our way over. Two female lions were sitting in a tree and looking out over the river in search of prey. They eventually climbed down and then across the river. We could hear the male lion occasionally softly roaring across the river where they were heading. They eventually disappeared into the brush, undoubtedly getting out of the heat for a midday nap they were planning.

We crossed the river as well and decided to slowly make our way towards the Sopa Lodge as Sokoine had some friends working at the lodge and wanted to visit with them. The Lodge itself is a huge building that reminded me of the great old lodges out west in Yellowstone and Glacier. It had a grand dinning room with many tables all set in lodge style for the guests coming later for lunch and dinner. It was lunchtime for us so Sokoine walked us up to the staff area where his friends were and were invited to sit in their dining area which, though, far different from the opulence of the lodge, was equally comfortable and pleasant as we with the local Tanzanians who we felt totally at home with. We were treated to soft drinks to have with our sandwiches we had brought and watched as the guides and staff played pool and chatted. It was great.

After saying goodbye to everyone at the Sopa Lodge we loaded back into the Land Cruiser and it wasn’t long before everyone had fallen asleep other than Jackie and me, which was good since I was driving. We made our way slowly back on the opposite side of the river than we had come in on passing elephant family after family. Before everyone fell asleep, though, we did run across our two female lions again near the river crossing. One was up in a tree and underneath her was an entire family of elephants sitting in the shade and out of the sun. She didn’t look particularly comfortable with so many mortal enemies right underneath her, but she was definitely keeping her eye on several babies that were in the group of elephants. The elephants eventually moved on, much to the relief of the lion I am sure, and caused no further difficulties for her.

After leaving the river and traveling a short distance we ran across a lone bull elephant that appeared to be in musk. Unfortunately for us, he was in the middle of the road and didn’t seem to be all too happy that we were anywhere near him. As I approached him quite warily he wasn’t at all interested in moving off the road and continued walking in our direction. At one point, he looked like he was going to charge so I had the vehicle in reverse and ready for a quick escape. I started backing up very slowly and he proceeded to continue moving in our direction such that I had to keep backing up and be ready to fly if he did charge. At some point after a few minutes of this, he lost interest in our vehicle and veered off the road a little giving us the opportunity to zip around him and be on our way. Staring down a bull elephant is a nerve wracking experience.

I always keep our previous trips to the parks recorded on my iPad so I can return to certain high likelihood viewing areas. It also allows me to safely navigate through areas that are not well marked. Or at least that has been my experience on past trips to many parks. That was not to be the case today, unfortunately. Heading out of the park you have several options, some less direct than others, and I always like to maximize our viewing time so I decided to take one of the less direct routes out of the park this day. We traveled out to an area called the Little Serengeti Plain where I have often seen cheetah before (there were none today) and then turn to parallel the main road heading out of the park, but several kilometers to the west. Following the path on my GPS program we were clearly heading in the right direction. The path seemed to be getting bit less well defined as we traveled further and further into the grass. What I didn’t notice, though, was that the grass was getting taller and taller meaning that there was more moisture in front of us. We passed a huge herd of Cape Buffalo who kept close eyes on us and they eventually began to move to some more distant grasses. Our trail continued to be less and less defined and I eventually stopped to check things out. It appeared that there might have been another path next to us and I finally decided to move forward tentatively, but almost instantaneously our front tires dropped suddenly in the muck followed closely by our back tires as soon as I made an attempt to back up. It was very quickly apparent that we were hopelessly mired in the mud with no signs of civilization or another vehicle for many kilometers as I had traveled well off the beaten path. It was also clear that the road had likely been fine in the dry season when I had driven this road previously. Note to Mike – pay attention to the time of year in which you drove this route before. And, oh yes, pay attention to the grass as it gets taller and taller.

So, here we were, stranded in the middle of nowhere at the low season so we could be sure that no one would be passing this way for days and it was quickly approaching evening and then night. There was no way to walk out with the animals looking for dinner so we tried to jack up the vehicle. The hijack we had (a very tall jack for off-road vehicles) merely sank in the muck when you tried to use it so we pulled off the spare and used it as a base to set the jack on. Things were moving along though it was fairly clear that we weren’t going to be very successful in freeing ourselves as the wheels just spun free and we had no rocks nearby to put under them. What to do?

Had I mentioned that Leonard texted me earlier and told me he was on safari and taking a group to Tarangire that day? What is the likelihood of that happening, let alone the likelihood of our having a cell signal in the middle of nowhere, enough to text and call, but not enough for me to send my position to him. It turned out that he had just gotten to the gate entering the park and would call me back so I could describe how to get to where we were. There were storms in the area and it started to rain on us, but it was only a brief sun shower and did not continue for very long. OK, directions. Take the turnoff right before the lunch spot towards the little Serengeti and when you get to the far marker turn left. Drive along the trees for several kilometers and you’ll see a huge herd of Cape Buffalo. Just past the herd, you’ll see a small path to the left that heads in the direction of the main gate. Take that and we’re several more kilometers down that trail stuck in the muck. As amazing as it may sound, he came very close to finding us with those directions and it required only one more phone call and a small back track for him to see us in the distance with his binoculars. I can’t tell you how much relief I felt seeing him come up the trail in our direction. We hooked up a special strap (a snatch strap) that I had bought him a year ago and was in the vehicle and he was able to yank us out of the muck on the third try. I was in reverse and couldn’t see out the back well, but I kept driving for some time so as to be well clear of the muck until I heard Leonard honking to tell me to stop. What an adventure!! And what a story to tell your grandchildren. Leonard’s group in his vehicle also got a big kick out of it and I gave them money to buy drinks when they got to camp since I had delayed their arrival having to come out and rescue me.

We were behind Leonard traveling out of the area and back to the main road when we ran into our old friend, Mr. Bull Elephant. I pulled up along side Leonard and told him that the elephant was dangerous and that he had clearly not liked our presence previously. Leonard inched up towards to the elephant to drive around him on the road and was almost completely by him when the elephant decided to charge their vehicle. He gunned the engine and off they went. So here we sat with the bull elephant who just charged another vehicle and would probably like to do it again if given the chance. I waited for him to meander off the road a bit and behind a tree before I tried again to inch my way around him, but he was clearly keeping an eye on me. We waited for the right moment and gunned the engine, then drove by him as safely as we could. We were finally on our way out of the park, albeit a bit later than I had anticipated. We saw more lions on our way, but otherwise got to the gate in time as they close it at 7 pm and there’s not way to exit after that.

We began our 1+ hour trip back to Arusha with the sun setting behind us and a very treacherous road in front of us. It seemed like forever, but we finally arrived to Arusha and took Sokoine back to his in-law’s house where his wife and son were staying. We met all of her family and were given chai and banana stew in true Tanzanian fashion as you always feed a guest. We had dinner waiting for us at Leonard’s house as Pendo always makes sure we are fed, so we had a spoonful of the stew which is fine as someone else will always eat our leftovers. We arrived to Leonard’s and Pendo was already well aware of my trials and tribulations as Leonard had called her. We were all covered with mud and dirt, but dinner was delicious and I can’t recall having ever felt quite as relieved as I was that night to have made it home.

Our Friday at Rift Valley had been busy enough for us to return on Saturday as there were still additional patients for us to see and since we’re only there every six months it was very important to go back. We had lots of errands to do later that day as it was our last full day in Karatu and we’d be leaving early the next morning for Tarangire National Park and a safari on our way to Arusha. What was originally a dozen patients in the morning continued to grow and after lunch I finally had to close the list otherwise we could have spent the night and still not seen everyone. Daniel was working with us again and he was wearing the scrub top made from Tanzanian cloth that we had given him as a present the day before. We had also given him a nice reflex hammer with the hope he’d get the message that we’d all love to see him pursue neurology in the future. He will make a great doctor one day and an even better neurologist and you can be sure that we will follow his progress and try to help in any way we can to make things happen for him.

This day we also had Renata again with us. While eating dinner at her grandparent’s house last week, I had invited her to come to Rift Valley with us if she were free. She showed up bright and early to FAME with her mother and was dressed in a beautiful outfit ready to work with us. It’s certainly far to early to know whether she will be a good enough student, but she has the aptitude and if the desire is still there, I have no doubt that she will be able to do what she wishes.

 

I think we ended up seeing about twenty patients that day with a two day total at Rift Valley being 47 patients. The clinic there is always very successful and due much in part to the continued support of Mama India and her philosophy that her children’s health is very much dependent on the health of the community surrounding them. And it has been the case that this has been successful not only in the physical health of the community, but has also been readily apparent in the educational successes at school where healthier children do so much better. This small microcosm of Oldeani and the surrounding areas is an excellent analogy to the current philosophy of global health and the fact that there are no more physical borders to disease and illness. Our health is directly dependent on the health of our neighbors whether they be next door or residing on the same planet as us. Building walls and isolating ourselves will not protect us so that even beyond our altruistic desires (which should be enough in and of itself), it still behoves us to reach out and better mankind for our own sakes.

We said our goodbyes to Rift Valley Children’s Village, Daniel and Mama India late that afternoon, but in enough time to get back to Karatu for some errands. Jess and Jackie had decided to have new dresses and skirts made for them at the fabric store in town where I have taken many volunteers before. The tailors are amazing and I’m sorry I didn’t get photos of them at work, but will do so in the future. They all work sitting out in front of the fabric stores using old pedal driven sewing machines and taking quick measurements before entering them in the their notebooks that are all tabbed with small cut swatches of the particular fabric for that specific piece of clothing. It is an amazing operation to watch and to see just how precise and wonderful their final product is when you consider what they are working with. These are truly hand tailored clothes that would be nearly impossible or too expensive to obtain here, yet here they are an incredible bargain. Labor costs are negligible here. As you may recall, it cost me a little over $200 to have a clutch replaced a year ago on my Land Rover that meant dropping the drive train and the better part of a day of labor, not to mention parts. That price would have covered 2-1/2 hours of labor here and not parts.

We ran a few more errands and then dropped Renata off at her grandfather’s house where her mother, aunt and grandmother were all out working with the livestock when we arrived. It was great to see them all and sad to say our goodbyes, but we’ve been able to have wonderful visits with them this trip. Though I will be back again in six months, it is unlikely for most of the resident volunteers to return so it is truly a goodbye for them.

Brad’s party at the Highview Lodge was an amazing event that night as it was held outdoors around their lovely pool with a buffet dinner and drinks and, eventually, some amazing dancing. There were well over 100 guests there and dinner was delicious. There was an orange punch with Konyagi in it for starters and Brad was handing out drink coupons to everyone it seemed like all night. They had a DJ playing music and when the dancing started the real party began. Everyone danced all night and I’m quite sure it will shock those who know me that it even I was included. You really didn’t dance with anyone specific, though, you just danced. You danced with your friends, some who you knew and some who you barely knew. You danced with the amazing star filled southern sky, with the amazing Ngorongoro Highlands, the Great Rift Valley and Mother Africa. It was a night to put away all your worries and concerns and to just be present. This is Africa.

I have written many times about the Rift Valley Children’s Village in Oldeani, about 45 minutes from FAME. It is not an orphanage, but rather a home for about 100 children through the age of 18 who have come to live there for various reasons. Some are orphans and others were brought there because their families could no longer care for them. It is an amazing facility and anyone who visits there cannot help but feel the peace and security that these children know despite the noise and commotion that may exist at times. India Howell, or Mama India as she is known locally, has created a masterpiece at RVCV that is unlike any I have known and her formula of love and care not only for her children, but also for those living in the surrounding area, has created a unique opportunity to improve the quality of life for all those involved. It has been our privilege while working at FAME to provide a two day neurology clinic in conjunction with the regular twice monthly FAME general clinic.

Our typical day to attend the RVCV clinic begins with morning report followed by preparing the necessary medications and supplies we will need in addition to that brought for the regular FAME clinic. We try to leave before 9am to begin our clinic as early as possible, but it never fails that something holds us up and this day was no different from the rest. Dr. Isaac had a patient that we had seen before who had contacted him about seeing us and he had told them to come in. He was a young boy who had been previously diagnosed with basilar migraines characterized by classic migraines and episodes of confusion along with loss of consciousness. He had been place on topiramate, a medication we bring from the US due to it’s expense and lack of availability here, which had worked previously, but had been out of the medication for well over six months and his headaches had returned. Restarting his medication was pretty simple, but we had to go over his history again which took some time.

Jackie had also been asked to see a young patient on the ward who had been developmentally normal until age 5 or so and then had rapidly lost milestones and general function. She clearly had a neurodegenerative condition, but it was not until she obtained the history of the hand waving or flapping that had been present early on that it became clear that the young girl had Rett syndrome, a somewhat rare genetic disorder. Another fascinating patient for Jackie to see and to add to her list of interesting pathology she has seen while here.

We finally broke away from FAME about an hour late which delayed starting our clinic at RVCV until close to 11am. The drive to RVCV is incredibly beautiful and runs through some of the most luscious and fertile farmland in Ngorongoro Highlands and as you approach the village you begin to travel through a large coffee plantation so typical of the region. As we drove through the gate of RVCV and approached the administrative offices where we see patients we could first see all the patients waiting for the FAME general and neurology clinics. We had a large number of patients to get through so we worked in two rooms with Daniel helping again to round out our interpreters for the day. He was again incredibly capable in that capacity and Jess had him so proficient in asking the headache questions that she could finish her previous note while he was asking his questions for the next patient and when she was ready he would summarize the history for her. Daniel, who just passed his exams to continue on in school is very interested in going into medicine so it will be very exciting to watch his progress towards that goal and I am looking forward to it.

We always look forward to lunch at RVCV as it is some of the best food we eat during our entire stay in Tanzania. There is always fresh fruit and the cookies or cake for desert are always a hit. We continued to work after lunch until late in the afternoon and I decided to take a route home that was even lovelier than the one we took in the morning. It is impossible, though, to catch the grandeur of these highlands in a photograph so suffice it to say that you are breathless for the entire drive both there and back and as we approach Karatu we are continually reminded how fortunate we are to have the opportunity to visit and work in a region such as this not only for the beauty of the land, but also of its people.

We arrive back at FAME to eat some dinner and then head out to a gathering of expats and volunteers at a local pub where we all relaxed and shared stories of our various experiences in Tanzania. It is clear that everyone here has quickly fallen in love with this country. We had much of the world and job types covered by the volunteers at the table. Some have experience in other countries, but the story is always the same and it is that Tanzania is where they chose to come because of its people.

I woke with the anticipation of a big day ahead for a number of reasons. It was our last clinic day for FAME and I knew that we still had many patients to see. We had no room for error as the two following days we were scheduled to be at the Rift Valley Children’s Village. There was also a surprise party at lunch for Brad Snyder, the totally awesome nurse practitioner who has been at FAME for over a year after having spent time in Rwanda prior to that, and would be leaving FAME at the end of this month. The big event for me, though, was that we were breaking ground for our volunteer home, the Raynes House, sometime this morning.

The day began with Jackie giving her seizure recognition lecture to the nurses again as not everyone had been able to hear it the first time. There were far fewer nurses, though, as I think many of them had wanted to hear it the first time and so it was a much quieter crowd as often happens with the very polite Tanzanians who tend to ask fewer questions when not fully engaged. It is always a struggle to get your lecture just right for the group attending. The prior week, there were plenty of questions. This time far less.

We had planned to meet for our groundbreaking at 8:30 am right after morning report, but one of the FAME staff members had come in with a problem that required my assessment so we were a bit delayed. We also had to see our Guillian-Barre patient on the ward and made the decision to discharge her as she had been stable for 48 hours with no progression. Only half an hour late, we all gathered at the site for our new volunteer house – many of the workman as well as much of the staff and volunteers – along with the FAME tractor pulling a blade to take the first swipes at leveling the grade to accept the new foundation. Before the tractor began it’s work, we took a few photographs that included more traditional shots of us with shovels.

It was a really incredible moment for me as it was a dream come true and was all made possible by the generosity of Stephen Raynes and his family who have followed my work at FAME from the beginning and have shared my vision for what can be accomplished with compassion and good intentions. The house will not only allow the expansion of our neurology program, but also open the door for other specialties from Penn to begin exploring the development of similar programs.

Jackie and Jess began their morning patients for our last clinic at FAME. I think Jackie had at least one additional infantile spasm patient that day, having seen several spread out over the previous clinic days. Typically a very devastating syndrome with a very poor prognosis, the best that can be hoped for is some control of their seizures that is most often incomplete. I’ve diagnosed several cases in the past and have also diagnosed a number of Lennox-Gastaut patients, a syndrome that can develop from infantile spasms. Though there are no cures for these conditions, there can be therapies that improve quality of life and it is those that we seek to provide for these children and adolescents.

We continued to work through the morning becoming more and more hungry for the special lunch planned for the day that was apparently taking more time than the typical rice and beans that we get most every day. Don’t get me wrong, though, as our normal lunch of rice and beans, along with “mchicha,” the spinach-like vegetable grown in the FAME gardens, is something that we all enjoy, perhaps as much as any lunch we have ever eaten. This was a special lunch that was being served and would have to outdo our favorite rice and beans, as we were celebrating Brad’s service to FAME and his leaving for the US and pursuing further education there. He has been an inspiration to all and a good friend to everyone. In addition to his clinical responsibilities and his role as director of nursing education, he has led frequent evening yoga sessions for the volunteers and anyone who wishes to join him, and has begun to practice acupuncture, an art far more complicated than something I’d ever take on. Brad has had the energy to accomplish all of this and still more and I know will be sorely missed at FAME. The lunch was amazing with huge portions of chicken, salad, fruit and more, but it was the wonderful ginger cake that made it special as he fed each of us a piece with a toothpick in the traditional fashion that I had down with my birthday cake.

After lunch, Jackie had a young girl seen with an odd complaint for us which was that her voice was very quiet and difficult to hear. It turned out that she had had a benign papilloma removed from her throat at Kilimanjaro Christian Medical Center in the fall and had been told that she should improve, but clearly wasn’t as her voice was indeed very difficult to hear and was a soft whisper at best. We had little to suggest other than returning to the ENT at KCMC who performed the surgery and seeing if he had any other suggestions.

Our afternoon clinic continued despite our post-lunch lethargy from such a huge meal and the patients kept rolling in. Siana had sent me a request earlier to see two of her friends at the end of day as they hadn’t gotten there early enough to get a number to be seen that day and considering it was Siana, I couldn’t say no. Somehow the message didn’t get to everyone, though, and when I turned around, Jess and Jackie were in the ward seeing an interesting Maasai women with a very complicated history and we’re having Sokoine translate for them. I had suddenly lost everyone working with me, and had no way of seeing these two patients without a translator, so Siana sat in with us and I proceeded to see the two woman myself while the Maasai woman was being evaluated. Not the best situation as neither of the women had anything close to being urgent and it was quite late. I finally finished with them and joined everyone in the ward with the complicated patient who was quite young and we believe probably had a small stroke sometime in the past, but her history kept changing and her exam was difficult. We eventually decided that she needed an echocardiogram and wanted her on aspirin, but we have no capabilities to pursue laboratory studies to look for hypercoagulable conditions. In the end, the family decided they didn’t want to pursue the CT scan and her echocardiogram was negative, so she was referred to the government rehab facility at Monduli, where she can get physical therapy and her family can get instruction.

We all finished very late indeed and we were all quite tired that evening as we returned to our houses for the night. Sometimes the exhaustion can be overwhelming and our brains a bit fried after days like this, but the beauty of Karatu and Tanzania with the gorgeous sunsets and the green hills in the distant light make it all worthwhile and we look forward to another day as our heads sink into our pillow. This is what we come for, and what I seek each and every time I return. And it is the excitement and wonder I see in the residents I bring and the Tanzanians that work with them that increases my satisfaction exponentially.

Our Wednesday began with morning report where we learned that one of our patients had passed away the night before. She was a lovely 92-year-old Bebe who was of European descent and had lived her entire life in Tanzania. We were initially asked to see her for the benign diagnosis of restless legs syndrome and had discovered that she also had diabetes and neuropathy, but neither of those were necessarily a significant problem for her. She was discharged with her family earlier in the week and had returned after only a day with severe abdominal pain. Her ultrasound looked like it was her gall bladder, but she slowly decompensated through the night and passed away quietly and comfortably. Her family returned the following day to retrieve her and though the loss was great, all were comforted by the grace of her life and her restful end. Jess and Jackie had been the ones to evaluate her and were both touched by her.

Our GBS patient was also a topic of discussion at morning report and I had wanted another set of eyes on her before we decided further management decisions. I had asked both Jess and Jackie to evaluate her and to give me their thoughts regarding her case as she didn’t have the most cooperative exam and the diagnosis was a pure clinical one. They both agreed with my diagnosis, which is always reassuring in this setting, and we decided it would be best to keep her for another night to make sure was stable and not progressing. Developing respiratory failure anywhere in Africa is a bit of a challenge to one’s survival, but doing so in the bush would not have been wise on an entirely different level.

Overall, our morning seemed to be slightly slower than the previous two days, though we had a number of patients who had been left over that were coming back to be seen. Jess had several interesting stroke patients, including one man who had suffered a hypertensive subcortical hemorrhage and returned with his CT scans, and who also had a rhythmic movement of his thumb that either represented tremor or EPC (epilepsia partialis continua). The concern was that the movement persisted in his sleep which would go more along with EPC and if this was the case, he needed to be on an anticonvulsant. Though his hemorrhage was primarily subcortical and shouldn’t cause him to have seizures, the scan was several years old and so we decided to place him on an empiric trial of an anticonvulsant to see if the movement would stop. An EEG would have been reasonable to get in this case, but our machine is unfortunately still down with technical problems.

We continued to keep Jackie happy with a good number of pediatric cases and, of course, a smattering of adult cases for her. She had several good cases, one of a very cachectic young women who had seizures for her entire life that hadn’t been treated and looked to have some either infectious or metabolic cause, but alas none was found despite numerous labs. Another Masaai boy had a history consistent with Lennox-Gaustaut syndrome, an unfortunate diagnosis with multiple seizure types and progressive functional decline. Interestingly, Jackie had also seen a number of cases of infantile spasms here and though it’s not a rare condition in the US, it seems we see it more often here perhaps secondary to serious childhood infections or trauma.

We had been doing rather well keeping on schedule for our morning session and didn’t have a tremendous number of charts for the afternoon. As soon as we got back to the office, though, we had a patient wheeled in who had apparently collapsed. We see quite a bit of what is best termed “swooning” here and which is most often seen in adolescent and young women. There is certainly nothing sexist in that observation and I believe those numbers would hold true back home as well. This was a young woman who was unresponsive in a wheelchair and had to be lifted onto the ER gurney where she very quickly began to respond to Jackie who was evaluating her. She complained of a rapid heart rate and had apparently had these episodes before as her mother reported that they had been told she had an abnormal echocardiogram in the past. We checked her BP and as we stood her up to check her pressure, she promptly “swooned” again, with normal BP, or course, and awakened as we laid her back on the gurney. It was quite clear that her episodes weren’t real, but we were stuck with where to put her until she was stable as we needed to get on seeing patients. So we put her in a ward bed for observation. What happened next was actually quite predictable. Within 15 or 20 minutes, someone came running from the ward to tell us that she was having a seizure. Jackie and I both knew what was going on and quickly walked to the ward, not because either of us was worried about the patient, but rather we wanted to make sure we both saw what she was doing. Sure enough, she was having a very classic non-epileptic event, or what we used to call a pseudo seizure. This is an event that is an event that is often part of a conversion disorder and is subconscious, or can be factitious in nature. Either way, though, it does not require any medication and after more thorough questioning regarding a possible recent traumatic event or underlying stress that may be causing it, the patient is told this is often the bodies repose to stress and she was discharged to home to the care of her mother.

We ended up finishing our clinic at a decent time which was good since we had planned to visit with Daniel Tewa and his family again that night. It was a great ending to a very interesting day. Daniel filled us in on all of the world news we had been missing since being away and again amazed each of us with his understanding of world politics that seemed far beyond that of any one of us. When he mentioned the name of the French foreign minister, Pauline was more than impressed as was I considering I couldn’t even recall the name of the President of France at the moment. Daniel’s family was as gracious as ever and it was so good to see them again and spend time in their home. It was another gorgeous night in East Africa with a sky full of sparkling stars so vastly different from those at home reminding us how fortunate each of us is to be in such an exotic land.

Tuesday morning began with another lecture to the medical staff, this time given by Jackie on the evaluation of the floppy baby. I will tell you that I have always seen children as part of my practice, but I draw the line when it comes to floppy babies. Mostly because it is a very complicated science that involves a myriad of disorders that are often very rare and requires one to revisit his biochemistry to remember all the various metabolic and genetic disorders that can afflict an infant. And that doesn’t even include all the neuromuscular and neurodegenerative disorders that exist. I’ll leave this to the pediatric neurologist any day and am glad that Jackie chose to tackle this topic as I certainly wasn’t going to do it.

 

Reception was again a mass of patients, many of whom were our neurology patients who had been told to return today along with patients who had only come this day to see us and were unaware of the volume. I decided to increase the number of patients we could see as Jess and Jackie were now veteran Tanzanian neurologists prepared to tackle anything that came their way.

It was really a jumble of patients and hard to recall who we saw that day, though several were follow up patients from prior years. Jackie saw a young girl with a clear syndrome who Payal had seen last March and Jess evaluated a young girl who I first saw four or five years ago with epilepsy and a spastic hemiparesis who sees us every six months and continues to do remarkable well.

We ended up seeing our full quota of patients this and then some as I was pulled to the other side of the clinic (we were seeing patients in the night office and emergency room close to the wards) to see a few patients that included a patient who appeared to have suffered a small stroke that had occurred weeks prior and didn’t need to be admitted. There was no need for a CT scan and I referred him to the rehab center for some physical therapy.

The other was a young woman of 16 or 17 who had come from the Mbulumbulu region where she is attending a boarding school and reports that she had developed numbness and tingling in her legs 3-4 days prior to coming and then had developed weakness in her legs the day prior. She had a very odd affect and wasn’t fully cooperative with the examination so I could confirm the amount of effort she was giving on motor testing, but she was completely areflexic for me which was quite alarming for Guillian-Barre syndrome or acute inflammatory demyelinating polyneuropathy. There is really no treatment here other than support which is often necessary if the patient develops respiratory distress or swallowing difficulties. I didn’t feel comfortable sending her home to the Mbulumbulu district in case she progressed and developed respiratory problems, so we elected to admit her to the ward to observe her overnight.

In the end, Jess saw 18 patients and Jackie 16, which was a record for our clinic here and with the two I saw, our grand total for the day was 36 patients! And there were still more that were sent home to return for tomorrow’s clinic which is really amazing.

After such an amazing day at Empakai Crater on Sunday, I think we were all prepared to get back to work on Monday morning. Mondays are typically the busiest day at the clinic and the volume then drops throughout the week. We had several patients we were expecting to see that we had told to return – a Maasai woman with a large plexiform neurofibroma on her scalp, the young boy who had the lumbar puncture on Saturday and the mother of our patient with the cerebellar problems as she had no phone for us to contact them. None of these patients showed, but instead we were swamped from the get go and it was quite clear after a short time that we were going to need some tight control on the numbers as well as triaging patients to make certain they had real neurological problems.

Sokoine and Angel had done an excellent job announcing to the community of Karatu and the surrounding districts that we would be in full swing this week for our neurology clinic and immediately after morning report we began to see patients. Reception was keeping track of the numbers and within a bit more than an hour we were at 30 neurology patients and more were still coming. I told Sokoine that we could see 32 patients for the day which meant 16 each for Jess and Jackie barring any emergency patients that needed to be seen. By the end of the day, I believe they had a list of approximately 28 patients that were sent home to come the following day. The rest would wait until they were called, often spending the entire day waiting to see us. Young Daniel from Rift Valley Children’s Village had decided to spend this week with us after his experience last Friday and Saturday, and we also had Dr. Isaac and Angel working with us so all was well.

Jackie had her fair share of pediatric cases, many of whom were developmentally delayed which is unfortunately much of what we see on the pediatric side here. She was also able to see a number of epilepsy cases, some of which were follow up patients doing well on their medications. Jess’ population of adult patients were unfortunately heavily weighted on the headache end of the spectrum. Patients coming in mentioning “kichwa” (headache) were the norm and it became a running joke that we could almost write the amitriptyline prescription before the patient entered the exam room. This was, of course, a gross oversimplification of the work we’re doing here, but there did seem to be an inordinate amount of headaches on Monday and I give Jess a huge amount of credit for fully evaluating each and every patient when it did seem they were leaving with the same medication each time.

I had mentioned that several patients who we had expected to return today did not. One of those included the little girl who we had seen last Friday with cerebellar findings and who needs to have a CT scan. We were successful in raising money for her scan, but are now in the process of trying to find her as her mother couldn’t even afford a cell phone so we had no way to contact them. We had asked mom to return today, but she didn’t. We will hopefully be able to track her down so she can get scanned before we leave. This is often the problem here in Tanzania in that time and people’s schedules move at a much different pace here and are driven by very different values, often far more real, than ours. Whether someone can afford a cell phone, or a ride on a “piki piki” (motorcycle cab), or the 5000 TSh ($2.50) to see us may dictate whether they come to clinic to be seen or not. I’ve mentioned before that if patients can’t afford to pay for their visit with us we will still see them, but of course we can’t advertise that or it would become the norm. We can only help those who make it here to see us and we think often of those who do not come, but should. We are seeing so many patients, yet I am sure that number is far exceeded by those who never make it here. We can only hope that number will become less and less over time.

As you may have gathered by now, Sundays have been reserved for exploring this beautiful country and today was no different than others. We usually go on a wildlife safari to one of the nearby parks, but today we decided to visit Empakai Crater which is in the Ngorongoro Conservation Area and is unique in that you hike into the crater on foot. Though Ngorongoro Crater is the best known of the volcanic calderas in the conservation area and rightly so for it’s amazing diversity of wildlife and its beauty, Empakai Crater is an equally stunning, though smaller caldera whose bottom is almost completely occupied by a lake. It is totally undeveloped and except for the road that ends at the crater and a few primitive campsites, it is a feature that is undisturbed and has not changed at all from when it was first formed.

The trip to Empakai begins by driving up to the big crater (Ngorongoro) and then around it’s rim in the opposite direction than if you were traveling to the Serengeti. If you think you have to drive down into the crater to see wildlife, you’d be mistaken. Shortly after we began our drive around the rim, I spotted a leopard that jumped from the road and into the grass along side it. Amazingly, the leopard didn’t run and just sat there for several moments as if posing for us. He then moved along the vehicle and back into the road where he lumbered off and out of sight. I started up the car and around the next curve were two rangers walking in the road with rifles. We stopped and told them that there was a Chui (leopard) just ahead and in the road as we didn’t want anyone to be surprised or any accidental consequences.

Our trip to Empakai was suggested by Sokoine who had grown up in the conservation area and knew how much we all liked to hike. Unfortunately, Jackie didn’t feel well the morning of our trip so she remained back at FAME and we were all disappointed as we knew it was something that she had really been looking forward to. In addition to myself and Sokoine, were Nick and Jess, Pauline, Angel and Patricia. We were planning to pick up a guide along the way for our hike into the crater which is required. I hadn’t realized just how close it was that Sokoine’s family lived so when we suggested that we stop by his boma it was an easy visit. We turned off the main road onto a small trail just wide enough for the Land Cruiser and proceeded to his boma that was only a few hundred meters off the main road. He had grown up here and left when he was 14 to go away to boarding school, but it was his father’s boma and everyone there were family for him. His father had five wives, though his mother had moved away from the boma to live with two of his brothers several years ago.

It was so incredibly touching to see how each of his younger family members came up to him to be greeted which is done by placing his hand on their head as they gently bow. It was clearly a sign of respect given to one’s elder. We finally made our way to where his father was and greeted him with hand shakes and kind words. I stood next to Sokoine as he and his father caught up with each other speaking Maa and the respect they had for each other was so heartwarming. The children were all watching us as it was clear that our visit was a big event in the boma. We walked around among the small huts and numerous cattle that they were walking loose through the boma. Sokoine showed us his 30 odd head of cattle that were a small number compared to the 400 plus that his father owns. It was a wonderful visit to to a friend’s home and something I’m sure none of us will forget. And I know that it made Sokoine very proud to have us there.

We were soon on our way again and stopped to pick up our guide, Philipo, who lived in a boma very close to Sokoine’s. He spoke perfect English and was very knowledgeable about the crater and the wildlife in the area. The landscape as we traveled to the crater was indescribable. We traveled by another smaller crater and then down into a depression filled with wildlife living together with herds of cattle, goats and sheep that the Maasai grave through this region as part of the multi-use mandate of the conservation area. Many, many Maasai boma were high on the hillsides overlooking the road as we drove along and not until we approached the crater did the landscape begin to change.

The weather was also beautiful this day and as we drove higher to the crater rim, it suddenly dawned on me that I could see forever and there in front of us was an almost never seen view of the top of Mt. Kilimanjaro, snow fields and all. Not only that, but Mt. Meru was also fully visible and as we turned a corner, there was Oldoinyo Lengai sitting right in front of us in all its glory. Oldoinyo Lengai means Mountain of God in KiMaa and it is a sacred mountain to the Maasai as well as an active volcano that last erupted in 2008.

We drove a bit further and parked near the beginning of the trail that descends to the bottom of the crater. We were the only visitors to Empakai this day and there was a Maasai family that approached us to buy their jewelry as we arrived. We began our descent into the crater which was a spectacular hike of about 45 minutes through overgrown canopies to trees and vines and tall brush that included stinging nettles to be avoided. The trees were almost primordial as they reached towards the sky and well clear of the lower vegetation we were hiking through. It was very warm and humid along the trail, but as we exited at the bottom of the crater and onto the lake shore it was bright and refreshing. It was like being in another world and reminded me of all the class B movies about traveling back to the time of dinosaurs. Our guide had spotted a bushbuck that we soon spotted running into the thick undergrowth at the edge of the forest.

As we strolled along the lakeshore we spotted countless footprints of game animals, mostly Cape buffalo and other antelope, but then saw numerous paw prints of lions some of which were quite large and fresh. The lions come out of the forest and down to the lake in the evening in hope of ambushing prey and they are likely quite successful at it considering the number of prints we saw on both sides of the food chain.

Sokoine and I hiked along the shore towards a group of flamingo while the rest of our party decided to relax amid an outcropping of rocks that likely represented tufa similar to that at Mono Lake in California considering that Lake Empakai is also a soda lake. We came to a rise that looked like a perfect location for lions to scout from and approached it slowly until we were sure that no lions were present. We sat on the rise that offered a perfect view of the entire lake while behind us a boisterous group of baboons were in the trees making their presence known. We eventually walked back to the rest of the group for lunch on the rocks as we watched the baboons slowly come out of the trees and into the tall grass.

It was eventually time for us to depart the lakeside and make our way out of the crater. The hike was on the same trail we came down, but it seemed much easier to hike up than down as the footing was more secure. It was hot and steaming and I was soaked in sweat in very short order on the way up. Angel and Patricia, who had asked to come along with us for the hike were not prepared as it was fairly strenuous ascending and we had many stops for them to catch their breath. Finally, as we were quite near the rim of the crater, Angel sat down and seemed to nearly pass out from exhaustion. Neither she nor Patricia had brought a lunch and I don’t think either had eaten very much so perhaps they had both run out of energy. Either way, she eventually recovered and continued on the trail to the road on the rim and the completion of our hike.

The Maasai family was still waiting for us hoping to sell some of their jewelry and Jess decided to oblige them by looking at their bracelets which were a bit overpriced, but considering their struggle, it wasn’t an issue. Jess was quickly surrounded by several of the women and children hoping to sell one of their bracelets to her and she eventually made a decision that made at least a few of them happy.

We departed Empakai for the long and somewhat treacherous drive home back along the big crater rim which is often wide enough for only one vehicle despite the frequent traffic of safari vehicles and residents of the conservation area heading in both directions. A short stop at the Ngorongoro Crater overlook and we were back to the gate and the tarmac and heading for home. We did have one additional encounter with wildlife as a very large baboon decided to jump on the hood of the Land Cruiser while I was taking care of paperwork at the park exit. The baboon had then jumped into a tree and intentionally urinated right next to our car so I was warned as I came back to avoid standing under him for too long. That clearly would have ruined a most beautiful day.

Young Daniel arrived early on Saturday morning from Rift Valley Children’s Village ready for another day of work with us. He was really a breath of fresh air and it wasn’t difficult for all of us to relate to that period of our lives when we had all considered medicine. It had come very late for me, well into my graduate work, but it was much the same when one becomes passionate about medicine and begins the process of choosing it as a career. Whether Daniel continues that course or not, it is still exciting for all of us to spend time showing him how rewarding it is and why each of has choose this path. Here in Tanzania it is difficult as schooling is government funded which means you don’t necessarily get to decide what you will study, but rather it is decided for you by others and how well you do on testing. There is always the private route, but that is very costly and depends on whether you have a sponsor. Daniel may have a better chance coming from Rift Valley as Mama India will undoubtedly be looking out for him as he pursues his studies.

I ran out in the morning as I had to go to the bank to put money in for a trip we had planned the following day to Empakai Crater. The Ngorongoro Conservation Area gate doesn’t accept cash as much of it was diverted in the past so you have to first go to the bank to put it in escrow, then to the NCAA office where they stamp your receipt to acknowledge that the money has been deposited and then you’re good to go. It didn’t take long and I arrived back a bit after 9am as Jess and Jackie had already gotten started. Anne was working with Jackie today and Jess had Daniel interpreting for her. I can sum up Jess’ patients for the day by merely telling you that by the end of the day, Daniel knew everything there was to know about headaches and amitriptyline. He became proficient in not only asking our headache questions of patients for their history, but also in telling them about the side effects of amitriptyline, the most common medication we use here for chronic headaches. I think Jess may have had one patient complaining of memory loss, but it wasn’t dementia and they also had headaches.

After a few adult patients, one who did truly have early dementia, Jackie and Anne had some good pediatric neurology cases. Shortly after the day started, I had a visitor arrive who was Daniel Tewa’s granddaughter, Renata. I have known Renata since she was 7 years old and she is an incredibly bright and capable young woman. She is now 13 and has been talking about medicine for a year or two and I have offered in the past for her to spend the day here at FAME with me to see what we do. I initially had her spend time with me bouncing between offices sitting in with both Jess and Jackie while they were seeing patients. Late afternoon, though, we had a young epilepsy patient come with her grandmother who only spoke Iraqw. I walked into the room just as the bebe was walking out to find an interpreter for her among the other patients when I realized that Renata not only spoke Iraqw, but was also fluent in English and Swahili. I asked her if she felt comfortable translating for us and her eyes lit up in a split second. To say that Renata shined as an interpreter would be an incredible understatement. She was superb and the visit proceeded with her help as she spoke all three languages brilliantly and seamlessly not only translating questions from Jackie, but also from Anne in Swahili to make sure that we didn’t miss anything. The young girl had been doing well with her epilepsy and hadn’t had a seizure in two years so it was decided to give her a trial off medication and if she had another seizure, we would obtain an EEG and start her back on a better long term and broad spectrum anticonvulsant as she was on carbamazepine currently. Renata explained everything to her grandmother in a fashion that was so impressive. After we were all finished, you could see how very proud she was and I knew it would make her grandfather incredibly proud. I called him later to have her picked up and I told him what she had done and how impressed we were with her. I know that he was bursting with pride on the other end of the phone.

That night we had made reservations to go to Gibb’s Farm for dinner which is always one of the highlights of our visit here. It is a gorgeous resort that I have spoken of many times in the past and is a favorite of many a volunteer I have brought with me. We had drinks on the veranda before dinner looking out at the spectacular view into the distance as the sun was setting and listening to the beautiful sounds of the African landscape. It is easy to fall in love with Africa and the wonderful people here. I was greeted with hugs by all the workers at Gibb’s, many who have family members I have treated over the years and some who have questions about family members they would like me to see. Defay, who is one of the waiters, came to me about his brother and described about as classic a resting tremor as you could and when I asked a few additional questions, it was clear he had Parkinson’s disease. I told him to bring him to us and we have medications that could help with his symptoms. I am hopeful that we will see him this week as he does live far away. Relaxing at dinner was a special treat for us and I think we all left for the evening with a further appreciation for why this country is so special and unique and why we are so happy to help them in any way we can.