March 14, 2016 – A Very Successful FAME Neurology Clinic

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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.

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The crowded reception area on a Monday morning

The crowded reception area on a Monday morning

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.

Our Neurology waiting area outside the night office and ER

Our Neurology waiting area outside the night office and ER

Daniel translating for Jackie while she's examing a patient

Daniel translating for Jackie while she’s examing a patient

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.

Angel and Jackie taking a history

Angel and Jackie taking a history

Jackie doing what she loves most - evaluating a little baby

Jackie doing what she loves most – evaluating a little baby

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.

March 13, 2016 – Our Visit to Empakai Crater….

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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.

A rare sighting on the morning drive

A rare sighting on the morning drive (photos by Nick Patton)

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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.

Me and Sokoine in front of his cattle

Me and Sokoine in front of his cattle

Some of Sokoine's family members

Some of Sokoine’s family members

Some children of the boma

Some children of the boma

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.

Jess, Nick and Sokoine at his father's boma

Jess, Nick and Sokoine at his father’s boma

Filling her calabash with fresh milk

Filling her calabash with fresh milk

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.

A rare view of Kilimanjaro from a distance

A rare view of Kilimanjaro from a distance

Oldoinyo Lengai - The Mountain of God

Oldoinyo Lengai – The Mountain of God

Jess and Nick with Oldoinyo Lengai in the background

Jess and Nick with Oldoinyo Lengai in the background

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.

Empakai Crater and Lake from the rim

Empakai Crater and Lake from the rim

Along the trail descending into the crater

Along the trail descending into the crater

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.

Arriving to the lakeshore

Arriving to the lakeshore

A large and fresh lion paw print

A large and fresh lion paw print

Walking the Empakai lakeshore

Walking the Empakai lakeshore

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.

Exploring along the lakeshore

Exploring along the lakeshore

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.

A view of the crater hiking out

A view of the crater hiking out

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.

Jess negotiating for her bracelets with Sokoine's help

Jess negotiating for her bracelets with Sokoine’s help

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.

March 12, 2016 – Our Saturday FAME Clinic and Gibb’s Farm….

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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.

Jess examining one of her headache patients

Jess examining one of her headache patients

Jess teaching Daniel how to do the neurological examination

Jess teaching Daniel how to do the neurological examination

Seeing a young man from Shalom Orphanage with probable birth injury

Seeing a young man from Shalom Orphanage with probable birth injury

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.

Evaluating our Iraqw epilepsy patient with Renata translating and everyone else looking on

Evaluating our Iraqw epilepsy patient with Renata translating and everyone else looking on

Renata translating

Renata translating

Jackie examing and Renata translating

Jackie examing and Renata translating

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.

Charlie and his best friend after he had abdominal surgery for eating a rock

Charlie and his best friend recovering from abdominal surgery after eating a rock

March 11, 2016 – Our Friday Clinic at FAME….

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With our initial mobile clinics now over (we still have Rift Valley Children’s Village next week) we are finally able to focus on our work at FAME’s main campus with our advertised days for neurology clinic would begin today. Last week, we were able to spend two days seeing neuro patients in advance and I was very impressed with the number of follow up patients we were seeing which is always a good sign that patients are coming back to see us and are compliant with our therapies.

The morning didn’t exactly start off as planned, though, as FAME had planned for some time to have a workshop today and tomorrow that would include much of the medical staff and included our main interpreters, Sokoine and Angel. We had Dr. Anne to work with as she was assigned to the neuro team, but we were without an additional interpreter for us to run a second room. We already had patients piling up before we were even able to get started and after a bit of hectic negotiating, Susan found a wonderful translator for us from the Rift Valley Children’s Village. Daniel is an 18-year-old young man who has passed all of his national exams and is continuing on in secondary school with the hope of becoming a doctor one day. He arrived by mid morning and though initially quiet, quickly became an essential member of our team.

This always been an issue for us as we continue to rely on FAME’s manpower to staff our clinics and even though our working with a clinical officer or doctor benefits FAME, it is still removing someone from their rotation of work and given the already huge volume of patients they are seeing even without our clinics added on, it is difficult for them. My ultimate wish for our program is to obtain adequate funding to enable us to essentially pay a part of the salary for the clinicians who will work with us during our time here as well as follow patients in between our visits. That will be essential.

Daniel translating with our young girl with cerebellar problems

Daniel translating with our young girl with cerebellar problems

Following Daniel’s arrival, he began to see patients with Jackie and I sat in on the evaluations as Dr. Anne was working with Jess for the day. Being the pediatric neurologist here (and the only one in Tanzania at the time), Jackie’s was trying to see all the children that came. Our first patients was a delightful 11-year-old girl from the Karatu area who was accompanied by her mother who complained that her daughter was having difficulty walking and trouble with her eyes for the last five years or so and that these symptoms were getting worse. Sure enough, she had very definite nystagmus predominately to the right with some torsional component, dysmetria on finger to nose testing and ataxia on gait testing. She was also complaining of some headaches. It was quite clear that she would require a CT scan to rule out an intracranial (and likely posterior fossa) mass before we did anything else. When we discussed this with the mom (they are Iraqw from the Karatu area) she was quite clear that they could not afford a CT scan which would have to be done in Arusha at a cost of at least $200 and it would be for some time before our scanner will be up and running. Since Sokoine, Angel and William, the three individuals who would be the most knowledgeable as to whether we had any extra funds sitting somewhere, were all away at the training session, we would have to wait until next week to discuss her case further with them. We know, though, that it is highly unlikely that they will have it. Having our own CT scanner available in the future will obviously make these types of situations much more manageable. We’re just hopeful we can do something to help out this family before we leave.

Evaluating eye movement abnormalities

Evaluating eye movement abnormalities

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If anyone is interested in helping to fund the CT for this child, please let me know by email. You can go to the FAME website (www.fameafrica.org) and donate online. Just include the message “CT scan for young Neuro patient” and it will be directed appropriately. Thanks.

We continued to have great pediatric cases throughout the day for Jackie and she was the happiest pediatric neurologist in all of East Africa (as well as the only pediatric neurologist in all of East Africa). We had a cute young autistic child whose mother worked at Gibb’s Farm and had been doing all the right things for her up to date. There were some odd sensory integration therapies that mom was paying for, though, that we did not believe were helpful and thought they should discontinue as the cost was high for them. The mother had almost gone home as her daughter was so difficult to manage waiting for us, but luckily she stuck out the wait. I had to actually run after the young girl and practically tackle her outside our offices when we ready to see her. I carried her in as she was wiggling and writhing in my arms which was no small feat. Once in the office we were able to entertain her long enough for Jackie to do her evaluation. The mom needed to be seen as well, though, so their examinations were cut a bit short when the girl decided that enough was enough and it was time for her to leave. She had stuck it out long enough as had we, so we had no issue with her decision.

Our sweet little autistic child

Our sweet little autistic child

She saw a “floppy baby” (which is what I say I don’t evaluate as they can be very complicated) that she felt was very likely a genetic syndrome. The child has been receiving physical therapy as well as some questionable therapies that, again, we weren’t sure we’re benefiting the child and recommended stopping them. A young Massai boy came in with his older brother complaining of abnormal growths around his knees and elbows. What sounded like it might be our second case of neurofibromatosis turned out on examination to be symmetric bony overgrowth of those joints and what looked like a case of rickets. Unfortunately, we had already obtained a family history when we thought it was NF-1 and it turned out that his mother and another brother have the same problem. This threw a wrench into the diagnosis until Jackie, when doing some research while the patient was still around, found out that there is an autosomal dominant form of rickets that involves low phosphate. Unfortunately, that is one of the chemistries we can’t test at the present time. We did find vitamin D in the pharmacy and placed the child on that as it was the only thing we had here to offer.

Evaluating a floppy baby

Evaluating a floppy baby

Jackie and Daniel evaluating our your Maasai with rickets

Jackie and Daniel evaluating our your Maasai with rickets

One of last children of the day was a 15-month-old boy whose aunt had brought him in and had been seen by Verena, the long term pediatrician volunteer here at FAME, earlier in the day. He had been having fevers and was very lethargic, but all of his studies had been negative here as well as when he had been seen at several other locations. We just didn’t like the look of the patient and decided that he needed a lumbar puncture to make sure that he didn’t have a chronic meningitis. His fontanelle was still open which wasn’t normal, but it wasn’t bulging. Though would have loved to have had a CT scan first, it was impossible to send him to Arusha for one and we knew that we couldn’t really send him there for care either. We felt the likelihood of a contraindication was very low and didn’t fit with the fevers so we decided to proceed. The child was incredible strong and wasn’t happy once we positioned him and it was a struggle that went on for perhaps 20 minutes, but Jackie was persistent thankfully and we were able to get clear spinal fluid and an opening pressure that was high normal and likely somewhat elevated by his screaming. I had my arms wrapped around the baby holding him and towards the end of the procedure I had sweat dripping in my eyes which were burning horribly such that I had to squeeze them shut just to continue. It was one of those comical situations that we laughed about after all was well and all of us couldn’t wait to get home and shower. We sent the baby home as the aunt was actually breastfeeding her own baby and the other family member with them was pregnant and looked ready to deliver. We asked them to come back on Monday so we could check him out again.

Our lethargic baby falling asleep standing up prior to his lumbar puncture

Our lethargic baby falling asleep standing up prior to his lumbar puncture

We had planned to go out and eat at Carnivore that night, so it was a much needed excursion, both mentally and physically, to relax with good company along with the very best grilled chicken I have ever tasted, fries, and, of course, a cold beer. It had been a trying day for all. We have clinic again tomorrow and we all were looking forward to it.

March 10, 2016 – The Clinic That Wasn’t….

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We had decided in advance that if it had rained all night we would cancel our final mobile clinic at Upper Kitete as the drive had been so treacherous the day prior. We all had lots of busy work to complete and a free day at FAME to catch up would have been well used by each of us. It had rained some last evening during my birthday party, but overnight it cleared and the roads would be no problem so it was decided that the mobile clinic was on for the day.

Thursday mornings there are nursing educational lectures and Jackie had decided to speak about the bedside assessment and treatment of seizures. This would be an excellent talk for the nurses who are most often the first line for assessing events such as seizures and are also the ones to initiate treatment so it is very necessary that they have these skills. Everyone was very engrossed in the topic which was readily apparent in the questions that were asked during and following the session.

Jackie teaching the nurses about bedside recognition of seizrures.

Jackie teaching the nurses about bedside recognition of seizrures.

We arrived to Upper Kitete by late morning and were immediately confronted by the obvious lack of patients waiting for us. In the past we would arrive to large groups of patients milling around the building and we would be ready for a busy day at the clinic. It’s difficult to tell what the reason is for this change in volume and whether it has to do with missing the clinic last October due to the election or whether it could be related to the rains that have been falling. Sokoine has visited this area on numerous occasions to announce our clinic and that has been sufficient in the past. We had talked about doing only one day each at Kambi ya Simba and Upper Kitete while also scouting out sites for additional neurology clinics and I think it is probably the right time for that. I will likely try to get away for an afternoon next week so we can visit additional sites.

We waited for an over an hour to see if patients would show, but to no avail so decided to head to the overlook for a picnic lunch. As the villages we go to have very limited services such as a market or restaurant to get lunch, we have been stopping on our way out of town to buy an assortment of Tanzanian “take-out.” This includes delicious beef samosas, mandazi (something like a donut or muffin) and vitumbua (I’m not sure if that’s the correct spelling, but they are a deep fried, sweet rice cake). And, of course, the always necessary Fanta drinks. Fanta passion is my favorite here, but there is also Stoney Tangawiezi, which is a very strong ginger ale. We sat at the overlook having lunch for a bit, but then realized there were very dark and ominous clouds looming in the distance and in the direction of our travel. We quickly packed everything up, jumped in the Land Cruiser and began to head back to the main road, glancing back briefly as we passed the clinic to assure ourselves there weren’t any patients waiting for us and were on our way. Shortly after leaving Upper Kitete, though, we ran into a massive rain storm with tons of runoff already flooding the countryside. The runoff was flooding large sections of road and the drainage ditches were all full. As we came to Kambi ya Simba, which is about halfway back to Karatu, though, the rain suddenly stopped as we passed through the storm and the roads were clear. It was as if someone had just turned off the faucet. The rest of the drive back to Karatu was uneventful and we arrived at FAME unscathed from our brush with the flooding.

Unloading the radiology equipment

Unloading the radiology equipment

FAME was having some exciting times after we arrived in that the X-ray equipment that had been donated by GE had arrived after a day delay. This was a huge event as it has been in the planning stage now for probably over a year and the radiology building has been finished for some time. The technical aspects of this project have been overwhelming, but Nancy Allard, FAME’s ICU nurse/architect, has been overseeing things and has been doing an amazing job. The big news for the neuro team, of course, is that the radiology suite is going to include a new 16-slice CT scanner! Up until now, we have had to send all of our CT scans to Arusha, which is 2-1/2 hours away and that’s if the patient can afford the $200+ for the study. Having the ability to do our own CT scans will be revolutionary for us, but with that comes the issue of doing a CT scan just because it’s there and over utilizing the scanner. That all still needs to get worked out and I am planning to make up some algorithms that will help when deciding who needs a CT scan when there are neurological indications.

Pulling the one ton + CT scan out of the truck

Pulling the one ton + CT scan out of the truck

The CT scanner on the flatbed

The CT scanner on the flatbed

Lowering the CT scan

Lowering the CT scan

The CT scanner after still wrapped

The CT scanner after still wrapped

Our first look at the CT scanner

Our first look at the CT scanner

Moving the CT into the radiology suite

Moving the CT into the radiology suite

Positioning the CT scanner

Positioning the CT scanner

In any event, all of the radiology equipment showed up in a large box truck that included the CT scan weighing in at over a ton and everything was boxed with “no tilt” and “no impact” warning labels that would register “red” if any of the pieces were mishandled. They were all meant to be unloaded with a forklift, but there wasn’t one in working order anywhere in Karatu, so they finally found a small crane to use. With some amazing maneuvering and a bit of “Tetris” work, they were able to unload everything, including the CT scanner, and just in time as it began to rain a bit and they needed to get everything inside or undercover so as not to damage the electronics. Finally, everything was moved to its respective resting place and the work of the GE engineers could begin in earnest. One big problem will be the energy requirement for the equipment to operate – though FAME is now attached to “the grid” and has moved on from relying solely on solar power to function, the current generator here is not capable of powering the radiology equipment here during the very frequent power outages that have been plaguing the country. And that’s just one of the many logistical problems that needs to be solved prior to the radiology suite being fully operational. I believe it will only be a matter of time for all of these issues to get worked out and hopefully for our next trip in October we will have access to our own CT scanner that will be just shy of a miracle considering all the hurdles that have been overcome to get to where things are today.

March 9, 2016 – A Birthday To Remember….

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Rather than the light rains of the night before, it rained heavily all night such that we knew the drive would be very treacherous. Given that the roads would be questionable, I had Ema drive again and was very quickly justified in doing so as we were slipping and sliding our way to Upper Kitete. Driving an extended Land Cruiser which is more a less a tank along a slippery, rain soaked mud road with drainage ditches usually run on one if not both sides can be a bit nerve wracking to say the least. The good news was that the road past Kambi ya Simba has been recently improved and has a layer of ground up brick or cinder to improve traction. The improvement worked as planned and allowed us to finish our trek to the tiny village of Upper Kitete sitting on the high escarpment above the Rift Valley, but further to the north.

Jackie, Pauline and Jess en route to Upper Kitete on slippery roads

Jackie, Pauline and Jess en route to Upper Kitete on slippery roads

Where Kambi ya Simba has a very nice clinic or dispensary now, Upper Kitete is somewhat the opposite. There is a small government building that serves as the dispensary and there is a clinical officer and a nurse working there to provide the routine baby care primarily. We work in one office, which is where the nurse does medical work, and a second room that serves as the labor and delivery room with two beds in it. The office is also shared with a colony of bats that live in the attic and can often be heard through a large opening in the ceiling during the day. Their smell is clearly present, though, as there is the strong odor of bat urine in this room and, to a lesser degree, the the labor and delivery room next to it. I had been concerned for some time that I was exposing everyone to rabies by working in these rooms, but have since found out that African bats do not carry it like their North American counterparts do. At least that’s what Frank has told us and I’m pretty certain he wouldn’t joke about such a serious subject.

Jess and Pauline meeting baby Jessica

Jess and Pauline meeting baby Jessica

Often at Upper Kitete, our visit coincides with the well baby visits and it is always so reassuring to see all the beautiful and healthy babies here with their mothers getting weighed and checking in. Today, there were only a few of them coming for visits and Jess ran into one baby named Jessica and was so thrilled to have found someone here with her name. Each baby being weighed usually has it’s own little harness to attach to the scale hanging from the ceiling. It is a very cute process to observe and some of the babies are so calm and could not care less while other babies exercise their lungs until well after being taken down from the scale.

Seeing patients together in the labor and delivery room

Seeing patients together in the labor and delivery room

Anne examining a patient with the help of Jess and Jackie

Anne examining a patient with the help of Jess and Jackie

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Anne performing the Jendrasik maneuver while examine her patient

Our patients today at Upper Kitete were mainly headache patients and we didn’t have the normal number of patients we have seen here. We also didn’t have many of the return patients we had seen a year ago with epilepsy which is a bit concerning and I was hopeful they might come the following day or possibly have been coming to FAME to get their refills of medications which we’ll find out next week during our big clinic there. This has been the difficulty with following patients here in that we can make the diagnoses and treat the patients initially, but if they don’t follow up to refill their medications, all goes for naught. Jess and Jackie worked together after lunch as we had so few patients, but at least there were a some.

Jess and Jackie conquering the mountain at the overlook

Jess and Jackie conquering the mountain at the overlook

The gang at the overlook with the Great Rift Valley in the background

The gang at the overlook with the Great Rift Valley in the background

We finished quite early and decided to make a run to the overlook which is our favorite spot at Upper Kitete. It overlooks the entire Rift Valley from Lake Manyara on one side and far up the Lake Natron road on the other. There is so much history in this valley from pre-historic times to the present and there are many ancient cultures that lived here and long ago vanished. It is such a relaxing place for me as we watch the large birds of prey soaring on endless up drafts in search of prey. There are small dots of white on the valley floor 2000 feet below that are herds of cattle and goats as the Maasai graze their livestock and I can only imagine the huge herds of wild animals that use the roam this land. Some of them are still present as I have seen zebra, giraffe and some wildebeest along this valley when I have driven up to Lake Natron in the past, but we can’t spot them today from these heights. There are homes along the rift with perhaps one of the best views on this planet, but it is unclear is that is really appreciated here as it would be in the west. Prime real estate here has to do much more with fertile land for planting and away from any flooding. As we sit here on the edge of the world I think we are the luckiest people on the earth at this moment.

We left for home after the overlook and the road had dried significantly, but not completely. It was early so we were all looking forward to spending some downtime in the afternoon at FAME. I have spent my last three birthdays here in Africa and I had been very successful at maintaining a low profile with very few people realizing it. This year was not to be the case. When we arrived back to FAME I was told that I should be ready to go somewhere at 6:30pm so I obviously presumed that our little group was going somewhere for dinner to celebrate my birthday. That was not to be the case. As we arrived at the Highview Lodge nearby there was already a large number of friends including Pam, our previous volunteer coordinator form several years ago who I had not seen for some time. Frank and Susan, of course, Joyce, Verena, along with many of the staff from FAME. In the end, I think there were perhaps 30 people assembled and we sat outside having drinks at a very long table watching an amazing light show in the Ngorongoro Highlands with a lightening storm approaching.

The entire gang at dinner

The entire gang at dinner

After some time we went inside for dinner and all sat at a very long table and more people continued to show up as the evening went on. Dinner was a delicious buffet and I should have taken the hint when Jess continued to pass on desert. Suddenly, all the lights went out and we heard the entire kitchen staff singing and as they came through the dining area they were all dancing behind a birthday cake one of them was carrying over their head. It at first seemed like they not have known which table was celebrating, but it became quite clear that they were first dancing to every table before they set the cake down. They finally made it to our table and stopped in front of me but continued to sing and dance for some time before they put the cake down. It went on forever it seemed. I finally blew out the candles while they continued to sing and went on for some time more before they finally retired to the kitchen. It was quiet for only a brief time, though, and we heard them singing again and out they came, dancing through the tables and back in front of me. By this time I had begun to cut the cake and pass out pieces when Pam told me that it is tradition for me to feed each one of the dancers a small piece of cake with a toothpick. I cut up a bunch of small, bite-sized pieces of cake and proceeded to feed each one of them a piece of cake as they continued to sing and dance.

Me, Jess and Nick

Me, Jess and Nick

Enjoying the entertainment

Enjoying the entertainment

My birthday cake

My birthday cake

Unwrapping my birthday present

Unwrapping my birthday present

Denis and me with my portrait

Denis and me with my portrait

Feeding the staff their pieces of cake

Feeding the staff their pieces of cake

Besides the party, I also received a wonderful gift of a portrait painted by Denis who is one of the workers at the Lilac Cafe, the small cafe here at FAME. He does amazing work that is displayed and for sale in the cafe, but the portrait is really over the top. Most of his work is Tinga style, but this is real life and very accurate. It will have a place in my office or my apartment as soon as I’m home.

Dancing with the staff

Dancing with the staff

Dancing with the staff

Dancing with the staff

Dancing the Charanga

Dancing the Charanga

Apparently, the fun wasn’t over yet as they next urged me to come dance with them. Anyone who knows me well is quite aware of what it takes to get me to dance, but I wasn’t about to disappoint anyone, so I got out from behind the table and began to dance Charanga style with them. When I showed Leonard the photos later he began to laugh so hard he couldn’t stop and when he finally did, he said he was pretty impressed. As I said, I didn’t want to disappoint anyone and certainly didn’t want to give anyone the impression I was a lightweight. It was a totally amazing night and a birthday I will never forget. It was so great to have so many people come out for my party and a real statement as to the family that FAME is here. Everyone is here because the want to be and everyone is here because of the good that comes from FAME. I couldn’t imagine anywhere I would have rather been that night.

Day Two in Kambi ya Simba

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The lightening and thunder began well in advanceb and the rain started around bedtime, but it was a light rain that fell slowly throughout the night. It was enough of a rain, though, that I decided to have Ema drive for me as the roads can become very treacherous here this time of year and there is no automobile club to come to the rescue. Four years ago my Land Rover slid off the road on the way to clinic and that memory remains fresh in my brain. Much of life here revolves around the weather – travel is clearly dependent on whether the roads are passable and volume at our clinics will depend on whether patients can get there by walking or vehicle. Planting and harvesting are also times that will cause our clinic volume to be low.

On Tuesdays we have a doctors lecture and it was decided that Jess would do a lecture on dizziness, which is always a frustrating subject for neurologists. It is not that the dizzy patient is complicated, but rather that there is really no specific definition for “dizzy” so the group of patients is very heterogeneous. There are patients that are lightheaded, weak, vertiginous (spinning), or fuzzy headed. The first job is to determine what they are complaining about. Jess covered primarily the neurologic causes of vertigo and how to break them down into central (brain) or peripheral (inner ear and nerve) causes. She did an excellent job for the doctors and gave them a good algorithm to cover the dizzy patient.

Jess lecturing on the dizzy patient

Jess lecturing on the dizzy patient

After her lecture was morning report and then we left for mobile clinic. The drive to Kambi ya Simba for our second day of clinic there was uneventful, but the rains likely have kept some patients away. We ended up seeing only about seven or eight patients that day which is far lower than our average that we have seen there in the past. It’s always a bit of a dilemma as to whether it is worth our while to travel that distance for so few patients, but we never know how many will show and the patients that are seen are often returns. By traveling to the villages, though, people become aware of what FAME has to offer and it is certainly possible for them to get there if needed.

Our first patient of the day was a woman who first described two episodes of prolonged loss of consciousness, but it was readily apparent that she was depressed and the episodes weren’t seizures. She had actually had the episodes for some time and had been depressed. Her care was a bit tricky for a number reasons and in the end we placed her on fluoxetine, which is available here, but with the proviso that she come to FAME in two weeks to check in and make sure she was doing well.

A worried mother with granddaughter on her back and daughter sitting next to her

A worried mother with granddaughter on her back and daughter sitting next to her

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Our other patients were afflicted with the more common disorders including one gentleman who had had a stroke in the distant pass and had been placed on aspirin in the past, but was no longer taking it as he had run of the supply given to him. His blood pressure was also very high and he wasn’t on any antihypertensive medications. We placed him on the aspirin, but asked him to come to FAME for further testing of his cholesterol and kidney function before starting him on any medications. We don’t have access to these tests in the field here. Both Jess and Jackie stayed busy seeing the patients with Dr. Anne and Sokoine, but we finished early and left for home.

A patient waiting for clinic

A patient waiting for clinic

Arriving back to Karatu during the afternoon is always a treat as it gives us time to explore the town a bit. Both Jess and Jackie had been interested in having a dress made from their lovely conga cloth here so after dropping everyone else off in town, I took them to the tailors shop that I have gone for the last several years. Nick and I walked to the vegetable market while Anne helped the girls describe what dress and skirt styles they wanted. They found some wonderful cloth to use for the clothing and their dresses will be very inexpensive and custom made.

It was home early for dinner and we all spent time chatting before an early bedtime after a long day and tiring day.