March 16, 2016 – And a somewhat more sane clinic today….

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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.

Jess demonstrating her exam for the patient

Jess demonstrating her exam for the patient

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.

Jackie evaluating a young woman with seizures and delay

Jackie evaluating a young woman with seizures and delay

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.

Jess and Daniel evaluating a Maasai woman with headache

Jess and Daniel evaluating a Maasai woman with headache

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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.

Jackie evaluating a young Maasai boy with seizures and developmental delay

Jackie evaluating a young Maasai boy with seizures and developmental delay

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.

One of Jess' stroke patients

One of Jess’ stroke patients

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.

March 15, 2016 – An Even More Successful Clinic….

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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.

Jackie giving her lecture on how to evaluate a floppy baby with Jess demonstrating

Jackie giving her lecture on how to evaluate a floppy baby with Jess demonstrating

 

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.

Daniel and Jackie taking a history

Daniel and Jackie taking a history

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.

A follow up patient previously seen by Payal with a syndrome of corneal opacification and developmental delay

A follow up patient previously seen by Payal with a syndrome of corneal opacification and developmental delay

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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.

Daniel and Jackie evaluating a patient

Daniel and Jackie evaluating a patient

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.

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