Waking up to the sounds of Arusha, really Njiro, is always such a pleasant experience. The house is quiet here now as Nan, Chris and Jamie departed yesterday and the only others up are the two women here who help Pendo with Gabriella and the house as Pendo is pregnant with their fourth child. I can hear them working in the other parts of the house, washing the floors, which is done each and every morning, moving the furniture and being careful not to make too much noise. All around I can hear sweeping in the yards as every house has an askari that is working to clear off leaves and debris left by the night. The roosters are crowing, birds are singing and now gospel music is playing in the distance, soft and pleasing as the sounds here always are. The boys are still asleep as are Leonard and Pendo and I value the quiet time to sit outside on the porch and contemplate how remarkable Tanzania really is, with its extreme natural beauty and resilient population. I can hear children playing outside in the neighborhood now and they are the future of Tanzania and the reason why it is so important that we continue to return and work with them to allow this country to reach its full potential.
We were all recovered from our day in Tarangire and ready for more adventures in Arusha. The morning plan was for me to bring the residents to the Maasai Market here in town to buy gifts for home. The market is a conglomeration of probably 100 or so stalls that all have essentially the same items in them, each with its owner sitting outside “hawking” their wares as you wander down one of the aisles, trying to pull you inside with the chance that you may choose to buy from them. It’s a bit nerve wracking to say the least as you run the gauntlet trying to just take a glance inside for if you walk into their booth, you become trapped and have a sense of gilt if you don’t look at everything there, or worse yet, buy something from them.
I have brought every resident and fellow that has accompanied me to FAME to the Maasai Market to share in this experience and they all have had different reactions to the event. I think I can usually predict which ones will react which way, but it is still fun to watch for me as I’m usually not buying anything, or perhaps something very small and I know what I’m looking for so it isn’t a long search. They also know me there since I’ve come so many times with guests. As I walk down the aisles trying to keep track of everyone, I constantly hear “daktari” or “Dr. Mike” and greet each of them to be polite, and perhaps even take a peek into their kiosk as a gesture of friendliness. They have come to know by now that I am not buying anything, but they still show me things and I listen to them and look.
Of the three today, Nan was clearly the leader in covering the most ground, moving quickly through the kiosks and on to the next aisle if she didn’t find what she looking for or the price was too high for her. Jamie was in the middle, knowing exactly what she wanted and making it all the way down at least one of the aisles and on to another. I found Chris in perhaps the third booth down the first aisle where he found a vendor who was willing to work with him and spent all of his time there, finding all the things he needed to buy without ever having to move, and, more importantly, sparing him from having to run the gauntlet of vendors laying in wait for him if he had wondered outside into the aisle. Each was very happy with their purchases and, in the end, found what they wanted. Overpaying here often amounts to an extra dollar or two and they need it much more than we do so even if you didn’t get the rock bottom price, it went to a good cause at least. As a rule, though, the final price is typically half of what they initially quote you or thereabouts.
We finished with the Maasai Market and were on our way home so everyone would have time to pack, though basically it was all done beforehand with only the gifts to put into an empty roller duffel that was then placed inside another as we had far less coming home than we did a month ago on our way to FAME. Before home, though, we stopped at the market in the cinema complex near where we were staying. This shop is pretty unique and unlike any we had been in during our time here as they had everything we have back home and then some. It’s like a Trader Joe’s, Wegman’s and Whole Foods all under one roof only a fraction of the size of any one of them. Or at least that’s what it seems like after having spent a month in Karatu where there are no shops like this and finding a Diet Coke (Coca Light) is like striking gold and we’ve never seen an American candy bar there. That’s not to say it’s all bad, but it does tend to contribute to any homesickness that might just be creeping in along the way.
In short order, the three seasoned travelers were packed and ready to hit the road, about an hour drive to Kilimanjaro International Airport. I was planning to visit a friend’s father after dropping them off and somehow we had miscommunicated so that I thought his father was in Moshi, which is on the other side of the airport at the foot of Mt. Kilimanjaro. Given that, I had offered to pick him up on our way to the airport since he lives in Arusha and it wasn’t until we reached the airport that we realized the error. His father was actually in Arusha as well and there had been no need to drag him to the airport with us. We said our goodbyes to the tireless travelers and got a group photo of the four of us before they all disappeared into the airport to check in and get ready for their flights.
Daniel, my friend, was there to keep me company on the way back to Arusha. The main road, which is paved, has been undergoing major construction, so we have been using the Old Moshi Road, also known as the Nelson Mandela Road, given that the Nelson Mandela University of Agricultural Sciences is on it, which is paved for a short distance only and has the unique situation that there is also a stretch of paved road in the middle with unpaved road on both sides. I still can’t grasp how that came about, but be that as it may, it’s a short reprieve from the teeth rattling washboards we get here.
On our way home I got stopped at a traffic police checkpoint where the main thing that occurs is usually a shake down of some sort that entails a fine to be paid on the spot. I the past, no receipts were issued which means you had no idea where the money went, but with a somewhat more informed population now that Magufuli has said he was going to clean things up, we always ask for a receipt to make sure the money is being recorded. They told me my rear tire on the Land Cruiser was too worn despite having been stopped before with the same tire and nothing happening. Both Daniel and I got out of the vehicle and walked over to the police truck where two officers sat to explain what the fine meant and despite Daniel’s arguing with them and perhaps explaining who I was, it was to no avail and the fine was 15,000 TSh, or about $7.50. Not a large amount, but this has been the problem here. In the past, it was corruption among the traffic police and now that Magufuli has attempted to change the culture, it may be that the corruption has lessened (perhaps), but it is still misguided to fine drivers for such minor offenses when no one obeys the traffic laws and motorcycles (piky-piky) fail to stop at any intersections or traffic lights.
We finally made our way back to Arusha and I parked my vehicle in a convenient location so that Daniel could drive his vehicle to his father’s house. His father lives in Mianzini, a suburb of Arusha and an area with many Maasai. His father has been unable to walk for a number of years which was believed to be connected to his history of prostate cancer, but they finally looked elsewhere, doing an MRI scan of the entire neuroaxis that demonstrated severe cervical compression at multiple levels. Without question, it would have been a surgical decompression had it been caught earlier, but the question now is whether it’s worth considering surgery or not. I’ll bring the CD containing the studies home with me and share them with a friend to get his opinion, but I’ve already discussed with them that I’m not sure it should be done.
His father’s story was pretty amazing in that he was an agronomist who was trained in Hungary in the 1960s just after independence, coming home as a graduate and working for the government for many years. In 1961, at the time of independence, there were just eleven Tanzanian graduates of any university so he was clearly one of the first to have been trained by the new government. Furthermore, Daniel told me that his grandfather had many, many wives and that his grandmother had died young during childbirth at a time in the colonial period when each boma was being forced to send at least one child to school. Since his mother wasn’t there to “protect” him from having to go to school, Daniel’s father was “sacrificed” and sent to school while the other children remained in the boma and cared for the livestock which had been what children did for generations. Because of this, his father received an education and was recognized as someone who had the potential to bring knowledge to his new country where little had existed before.
It is these remarkable stories that remind me of the resilience of the Tanzanian people, where they have come from and what they have the potential to accomplish in a country that is younger than I am. When I meet people like this I think of visiting the bomas and seeing such potential, but also the struggles that one must overcome. I see people like Daniel Tewa, who has managed to send all eleven of his children to college, Sokoine and his brother who is a veterinarian. When we were at the boma of my patient last Tuesday, there was a boy who looked to be perhaps 17 or 18, and spoke the most beautiful perfect English. When I asked him where he had gone to secondary school to speak so well he was taken aback and told me that he had only gone through primary school (grade 7) and indicated that his place was in the boma and on his land. This is certainly fine as well, but I couldn’t help but feel that he would never reach his full potential. Perhaps that is my problem, though, of having some expectation for him. He will be successful in whatever he decides to do and I hope that one day he will pass that on to his children.
We left Daniel’s father’s home to drive around Mianzini so I could see his home as well, later driving back into town to meet up with one of Daniel’s friends who is a general surgeon in Arusha. We discussed the status of medicine here and the hardships of diagnosis and treatment, considering along the way what we could possibly do to make things better. There have been changes, but they are very, very slow and without those such as Elibariki, the general surgeon, who is dedicated to making this a better place, it would probably not happen. Thankfully, there are many, such as all the doctors we work with at FAME, who are all there to make Tanzania a healthier nation.
I went back home after our meeting, perhaps with a greater understanding of what it will take for all of this to occur, and thankful that I have had the opportunity to work with and assist these amazing individuals who are the future of this incredible country. I am grateful to have been allowed to be a part of this.
(All photos are by Chris Perrone since I was occupied)
It’s still dark outside, but my alarm is telling me that it’s time to awaken as we are leaving bright and early this morning for a safari in Tarangire and then on to Arusha. We are leaving FAME and the spring 2017 neurology clinic has been completed and was another success. Thankfully, the remnants of our late night are a distant memory and I am no worse for the wear, ready to load our car with all our bags and begin our trek. Packing the vehicle on these mornings can be a chore as it is like a game of Tetris to fit in all of our bags and still make room for game viewing once the top is up. Abbey is coming with us this morning as well as she has decided to leave tomorrow from Kilimanjaro International Airport along with the others so she can see someone at home about her ankle which continues to bother her.
It’s still dark when I go outside to open the vehicle and turn the inside lights on so we can all see where things are going and to pack as judiciously as we can given the large duffels we travel with here and have to return home with us. Joyce and Terry are up and have brought Abbey’s bags as she’s still a bit hobbled and they hadn’t had a chance yet to say goodbye to those of us who stayed late at the Golden Sparrow. Nan’s overslept and appalled at herself, though there are no worries as we’re still ahead of schedule and, besides, it’s a rare indiscretion for her as she’s worked so hard during her time here. We’re loaded and packed, get our goodbye hugs from Joyce and Terry, who will be returning home in two weeks with the arrival of the rains, and we’re off. Despite the time, the skies are dark with thick clouds that still remain from the nighttime hours and will take several hours to burn off.
Traveling through Karatu it is a bustle with activity and children are walking to school everywhere. The fog is thick and for a time it’s difficult to see much into the distance as we travel along the tarmac. As the road crests in Rhotia and we begin our descent towards Lake Manyara and Mto wa Mbu we can see the effect of the sun on the clouds and sky and it looks as if the clouds will break soon in the direction we’re heading. We descent the rift into the valley and eventually pass the turnoff to the boma we visited on Tuesday, a nondescript turn off the tarmac where so many live in the bush, with their simple lives and their tradition. The Maasai are so unique and majestic. The clouds are lifting and the sun is now out as we roll into Makuyuni where we turn in the opposite direction of Arusha and head towards the entrance to Tarangire. We are now traveling on the opposite side of Lake Manyara, heading southwest on a very good highway that would lead us to Dodoma to the south, a major city with a university.
We are only heading a short distance, though, and leave the tarmac to travel along the seven kilometer road towards the entrance of the park to begin our game drive. At the gate as I begin to fill out the paperwork, the attendant tells that that is for the driver to complete and I promptly tell him that I am the driver. My comment is certainly made with some pride on my part and probably with some trepidation on theirs, but I take care of all the registration and fees as I have done so many times in the past as I have lost count of all the safaris I’ve driven now. The job can be exhausting, sitting in the driver’s seat for twelve or more hours, constantly scanning the horizon for that small clue that there’s a lion or cheetah in the brush or a leopard in the tree, starting and stopping the vehicle constantly to give everyone the very best view possible. This is what I love and look forward to sharing Tanzania with everyone who I bring each time I come.
We begin our drive into the park and the day is gorgeous. Bright sun, but not too hot and some high clouds to add some accent to any photos. I drive to spots where I have seen lions on previous trips and they are not to be found, but the day is young. We drive past the public campsites and off towards the river where the bridge appears to have been nearly washed away, but has repairs that make it passable and, in short order, we’re on the other side. The grass is very high and we see little wildlife for some time, but then the elephants begin to appear, numerous family units with many infants staying close to their mothers, both for safety and an occasional meal. Tarangire is known for its elephants and it did not disappoint today. We saw so many many families that were so close you could almost reach out and touch them. At one point later in the day, Nan was sleeping in the back and we were surrounded by a group of elephants so that when we woke her up, there was one staring through her window at her.
We traveled along the river and eventually made a crossing through rain swollen waters and I was quite thankful that we had fixed the four-wheel drive for this visit as it definitely came in handy on several occasions. I even had to shift it into four-wheel drive low on two occasions which converts the Land Cruiser into a tank that could probably climb a tree if it were requested to do so. Climbing out of a river bed onto the opposite steep shore was a common place to use it. We drove along looking for lions, but continued to strike out despite visiting areas where I had come across them in the past, such as down by the river crossing or along the embankment where we had seen a kill last October. We eventually decided to make our way down to the Silale picnic site that overlooks the Silale swamp and where we had lunch last October with Kelley and Laura. I was driving a faster pace heading to lunch (perhaps I was hungry) and at one point, Nan was again sleeping in the back seat as I drove through a rather large area of water such that she got hit with a pretty big splash through the open window much to her surprise.
We had the entire park to ourselves it seems and considering it is the end of the season, it was not surprising to find the picnic site completely empty with no vehicles in site in any direction for many miles around. We relaxed with our PB&J sandwiches and cut our sole candy bar into five sections to share. No luxury box lunch or picnic basket from the lodge like we had last October.
After lunch, which traveling back to the river, we came upon our sole lion of the trip, sitting on top of a termite mound directly in front of us. She was the same color as the mound so when I alerted the others, everyone replied “where?” To which I said “right in front of us” and there she sat literally in our path. She was probably an older lioness and had a radio collar on that is used for tracking the movement of animals in the park. Chris also later noticed that she was missing one canine, another clue to her age. We sat for some time just watching her until she finally got up, walked along side the road past our vehicle and then onto the road for a good ways. We followed her in reverse at first, then turned around to follow her, but she eventually left the road and wandered off into the thicker brush where we finally lost sight of her. Whether she was in the hunting mode or not, it didn’t seem like anything was going to happen in the near further so we left her there to her own devices.
We traveled back to the river and crossed at the most southern spot to do so and then drove up the other side of the river where we hadn’t yet been. There were elephants galore as we traveled through the beautiful landscape and we also spotted a small herd of Cape buffalo as we traveled. We crossed the river one again at the same spot we forded it earlier this morning and now drove back towards the main gate on the opposite side we had driven earlier. As we drove by the public campsite on the same road we were on earlier today we ran into a small family of elephants that seemed to notice us a bit more than those before. A rather small adolescent wasn’t very happy with us and charged, but seemed to stumble over a small rise and ended up on its front knees, quickly able to get right back up though agitated. Then one of the other smaller members gave us a loud trumpeting using as he was apparently displeased with us as well. We were quite shocked with the sudden display of emotion as they are typically much more nonchalant about our presence. No sooner had we gathered ourselves to move on, we received another loud trumpeting from a different elephant that was apparently equally unhappy with our intrusion. It was a very interesting behavior that I hadn’t experience before by a small family and, more so, by such adolescent members. Perhaps they were just misbehaving.
We were all quite beat after such a long day and pulling up to the gate to put the top down and get ready for the drive to Arusha, I think everyone other than me was anticipating a nice nap on the way. We traveled back to Makuyuni where we stopped for fuel and cold drinks and were then on our way. We pulled into the outskirts of Arusha just after 5pm and made our way to the Impala Hotel where we dropped off Abbey so she could fly home tomorrow along with Chris and Nan. Jamie would be leaving later in the day and heading to Johannesburg. We arrived to Leonard and Pendo’s house and emptied the vehicle of most of the luggage to be repacked before our flights. I would be spending two extra nights in Arusha with the Tembas and departing on Monday. We were all exhausted that night so everyone pretty much crashed after dinner and we slept quite well with thoughts of our time here in Tanzania.
As we walked to our last day of clinic here at FAME we were all a bit sad that the month had gone by so quickly and it was last time that we’d leave our house with the excitement of a new day of seeing patients. There was a soft drizzle, though we knew it wasn’t something that would last and it was likely to be another beautiful day here with the sun shinning. Each of us had different emotions that morning. For Chris and Nan, it would not be likely that they would return, at least for a very long time if at all. For Jamie, she would be flying to South Africa to meet up with her boyfriend for two weeks of vacation there and in Namibia. Her reality would be delayed by two weeks before she, along with Chris and Nan, re-entered the world of Philadelphia, HUP, CHOP, Presby and whatever rotations they have left in their residencies. For me, it’s different. Each time I leave, it’s merely “baadaye,” which means “later” in Kiswahili as I know that I’ll return six months with another group of eager residents. Another group who will get to experience what all those in the past have, now along with Chris, Nan and Jamie, which is a reaffirmation of the practice of medicine for most, but to all has been a truly rewarding time intertwining medicine, cultural awareness, nature, teamwork and, perhaps most of all, friendship. That I have been able to, at least in some part, assist them with this adventure, has been gratifying, to say the least, and in a more personal way has been life defining for me. But, hey, we still have a full day of clinic to get through.
Morning report was held in the same small night office with all the doctors and clinical officers “smooshed” together, some sitting, some standing, but all happy to be here in this remarkable place. Dr. Lisso made a point of recognizing that it was our last day at FAME and thanked us for all for the work we’ve done while we were able to say a few words about how much we’ve enjoyed our time here. Then it was off to rounds which we spent a little more time on today just to make sure there weren’t any loose ends on our part. We rounded on the little three year-old boy whose been here the entire month with horrible burns over his entire back and legs after having backed into a fire on which sat a pot of boiling food. He’s so much better than when we first arrived and though we haven’t had to care for him, we’ve watched as he has been wheeled daily to and from the OPD where the procedure room is so his wounds could be dressed and redressed.
We rounded on the woman who had suffered second and third degree burns over 60% of her body from ignited kerosene in a somewhat mysterious manner that really never mattered to those caring for her. She has amazingly improved, despite her odds, with the thoughtful care of Dr. Elle, a surgical resident from North Dakota who departed yesterday, but reinforced with everyone here how to continue her wound care. We also rounded on the 16 year-old girl with the likely osteosarcoma of the knee who would be sent home to die with only palliative care after her case was discussed with the oncologist at Muhimbili Hospital. Neither the family nor the patient had been told yet of the decision as the plans were to have a family discussion later in the morning. How sad it is to know that she would not have encountered the same issues that did in receiving care early on and would have had at least the possibility of surviving this cancer rather than what we know will be a certain death.
At clinic, we had a number of follow up patients which is always good as you never know that they will show up as requested considering the difficulty many of them have in getting here which includes the equivalent of one or two USD bus fare. Jamie’s patient with HIV and the brain lesion came today as requested as we had wanted to evaluate him after 10 days of therapy to see whether he was responding to the toxoplasmosis therapy we had him on. Unfortunately, his examination was unchanged which was the least helpful option for us. Had he gotten worse or better we would have know whether the therapy was working or not and would have been able to make a decision to continue his medication or not. We lobbied with Frank that a CT scan would be helpful in making some sort of decision as it might offer additional information (improved or worsened), but alas, it was also unchanged to our eyes. We left it that he would remain on the medicine which he had been already and we would have the scans read in the US by someone to make sure that we weren’t missing anything subtle and would then make a final decision. If it’s not toxo, then the next candidate is lymphoma which, without a biopsy, would be very hard to treat and the other possibilities, crytococcosis or TB would also be tough without special labs and/or biopsy, neither of which was a option here.
During the midst of our clinic, we also had a debriefing for our neuro team that consisted of me, Alex (who is the new project manager), Sokoine, Angel, William and Dr. Brad. Susan was not feeling well and couldn’t make it and Frank was home caring for her. The meeting lasted an hour and was very productive, identifying the things that worked well this trip and those that hadn’t as well as future directions and development for the neuro project. I had been very hectic this trip due to a doctor shortage at FAME as one doctor had given late notice and several were on their annual holiday so that we didn’t have the maximum exposure with the medical staff for the teaching that we have done in the past. This was an aberration and something that we will work on preventing in the future. The good thing is that we know have a list of things to work on in the short term as well as long range. When I returned to the “neuro wing” (the night office, ER and small outer office) everyone was working just fine in my absence and no significant difficulties had been encountered.
Perhaps the best of our follow ups today was the little Maasai baby, Frank, who returned with his caregiver (recall that his mother died shortly after childbirth) and had actually gained some weight. He had been feeding well on formula which was verified during his visit today as well as the technique that his “mom” was using to mix it. Nan was the happiest to see him, of course, but everyone involved was very pleased considering that it was a very likely possibility that he wouldn’t make it to today’s visit. He labs looked great and he looked better as well. At the end of the day, though, when we were finished evaluating him, it turned out that the last car had left to where they live (several hours away) and they didn’t have money to stay in town so Angel was meeting with them to figure something out. Little Frank was a success story so far, but he has a long way to go to be completely out of the woods and will need his formula for good bit longer. Just mixing it with clean water isn’t something that’s guaranteed so it remains to be seen how this will play out. This is just one of so many cases here like this and we always have to remind ourselves of this. But Frank was the one we were involved in caring for, so somehow, for us, he’s different.
Chris’ last case of the day was a young 18 year-old Maasai woman who was accompanied by her husband and brother-in-law and had been having seizures for several years and were best described as generalized, but with a significant myoclonic component. The decision was to begin lamotrigine which is always a bit of a challenge due to it’s complicated titration schedule that is not always the easiest to communicate to someone. Chris did an excellent job of having them repeat the directions back to Sokoine to make sure they understood them. As an interesting note, the family of this patient had also been attending FAME as their younger children all have rickets and are receiving vitamin D supplementation. The video of the young girl is a classic example of a rickets “waddle.”
Soja had called just as we were finished with our patients which was perfect timing so I had Alex drive me down the hill to pick up the vehicle. He had fixed the four-wheel driver that required a new relay under the dash, fixed the emergency brake and welded a new brace for the pop top. He had also put in a new headlamp as the one before had water that filled it half-way up. The total for parts and labor came out to be 230,000 TSh, which is a littler over $100!! I don’t think you could drive a car into a service center in the US for less than that just for them to take a look at it.
I was back in a flash and sat with Chris as he finished logging the last of our spring 2017 patients into our database. It hadn’t been our biggest clinic here, but we ended up seeing at least 226 patients during our visit at FAME as well as the four different mobile clinic sites. There were plans to go out to dinner tonight with the possibility of dancing afterwards, but we were leaving early in the morning so had to do our packing first. We had plenty of time to get the packing done, though Nan managed to fall asleep prior to dinner despite our upbeat packing music playing on the bluetooth speaker I had brought along for just an occasion. It was to be a night at The Golden Sparrow which had taken the place of Carnivore, a dive restaurant and pub that served only grilled chicken, chips and drinks. The owner, Martha, had built the Golden Sparrow, then closed Carnivore with the intention of capturing the old clients plus some new. The Golden Sparrow was a far cry from Carnivore 2.0 which was easily recognized the minute you entered this outdoor cafe as the floors were not dirt and uneven and the chairs and tables were level, a fact that was much appreciated after a beer or two so you didn’t feel like you were listing long before you felt the beer.
The Golden Sparrow certainly did not disappoint this night as it served for our final get together that included Sokoine and Angel along with several other volunteers from FAME. It takes quite a long time once your dinner is ordered, but when the roasted chicken finally arrived, it was the same delicious dish that had been served at Carnivore and which we had longed for. After dinner, several of us went into the lounge where there was a DJ taking requests and a small dance floor. This was also a significant upgrade from the tight quarters of Carnivore and we took full advantage of the situation by putting the dance floor to good use despite the fact that we had lost half of our group who were calling it a night and heading home. We had set a limit to how late we’d stay out and each of us stuck to this witching hour of 11pm as we had planned to leave on safari by 6:30 the following morning and still had to make our lunch and finish last minute packing. Jamie, Abbey and myself, who had taken advantage of the lounge got home to find that Chris and Nan had actually taken care of making our PB&J sandwiches (Jamie was heartbroken that there was no Nutella left, of course) that we’d eat on safari the following day as well as extra sandwiches for the flights home since both Nan and Chris both complained that there no snacks on the flight to Doha. We were safe in bed by around midnight and looking forward to the following day.
Our stay here is winding down and it doesn’t seem like it’s been nearly a month here, time flies by so very fast. Today was the day I would be getting our Land Cruiser down to Soja, a good friend of FAME and someone who has done work on the vehicle for me in the past when we’ve had things to fix, which is unfortunately quite often here as they are usually about twenty years old and have several hundred thousand kilometers of very rough roads behind them. This time it was our four-wheel drive that was the problem and which had contributed to our almost being stranded and left for lion prey in the Southern Serengeti. I had planned to run the vehicle down to him, but he had miraculously shown up at FAME late morning to work on one of their Land Rovers so I didn’t have to leave the residents for a brief time as I had planned and prepped them for. I think they were disappointed at not being able to have worked on their own, even if was only going to be for a few minutes. With no transportation for the late afternoon after clinic, we would have to remain on campus which isn’t necessarily a bad thing every once in a while.
We had morning report and then rounds, the latter of which I skipped to get things set up for us. Nan came out to let me know that there were two critically ill patients in the ward that needed blood transfusions and that Jamie was a match (O+) for one of them so was going to give a unit of whole blood which meant that she’d be out of commission for at least pat one the morning. He blood donation went fine and she even scored a free Fanta out of it, but it was orange and we really only crave the Fanta Passion which is the very best. More importantly, it was Wednesday, which is mandazi day as I’ve mentioned before, so we made sure that we all accompanied her there early so that she (read we) would get some mindazi and chai masalla before the crowd hit. We were all successful in our task and, most importantly, Jamie, who actually did feel a bit weak-kneed after her blood donation.
Chris started his morning with a continuation of his psychiatric practice here at FAME, seeing a young man in his early twenties who had lost his ability to speak after having been verbally abused by his father and then lived on the street for several years unbeknownst to his family. He could understand perfectly well and could also write, but just wouldn’t speak. His neurological examination was completely normal and it was clear that he had selective mutism on a psychiatric basis, but the question was what was his diagnosis which would determine his treatment. We didn’t feel he was schizophrenic as he had never had any agitation or hallucinations the best we could tell and he was clearly very depressed, so it was more than likely that this was PTSD and depression that would respond best to an SSRI antidepressant medication. He was place on fluoxetine (Prozac) and will hopefully improve once it begins to work.
Once Jamie was feeling back to herself, she was able to see one of her follow up patients, a young girl who with epilepsy who was still having episodes despite being on several medications and also seemed to be having cognitive issues on the medications. We had placed her on valproic acid, despite our typical concerns about not using it in women of child-bearing age due to a serious risk of serious fetal malformations, as nothing else had worked. She was clearly better when she saw us this time, both cognitively and in regard to her seizures as she had had none in the two weeks since we had started her on the medication. She’s a tough case and it still isn’t 100% clear as to what is going on, but she seemed to be better and will follow up again in one month.
Frank came by our clinic at around 3pm in the afternoon to show us a picture of a young 16 year-old who had just showed up with a massive enlargement of her right knee that had been present for approximately nine months. It was extremely firm and didn’t look very good as it was most likely a tumor, and probably osteosarcoma. She was admitted to the ward as she was in extreme pain and when Chris examined her, it was also clear that she had no function of her lower leg likely on the basis of either nerve compression or frank destruction from what was very likely cancer. Abbey Owens, the pediatric nurse practitioner who has been here for two weeks and had done pediatric oncology previously, suggested obtaining a chest X-ray to see whether there were any metastatic lesions as this would be a very bad sign.
Unfortunately, it was positive for lesions, most likely metastatic, and after Frank contacted the pediatric oncologist in Dar es Salaam he heard back that there was nothing they had to offer her due to the extent of disease. This would mean palliative care for a 16 year-old who had just walked into the OPD. We later found out, though, that she had been taken to at least two clinics previously, both of whom had recommended that she go to KCMC in Moshi, but that the family had not taken her because of the cost. Had she gone earlier, perhaps she would have been able to at least have received some treatment or perhaps had the leg amputated to possibly have saved her life, though in the end, none of these would have been certainties or have made a difference. The following day, the care team along with the social worker would have a conversation with the family and the patient to convey the news to them that there was no treatment at this point and she would be going home to die.
Clinic finished early for once which meant that we could have run to town for errands of gone somewhere, but we had no vehicle as it was still with Soja and we wouldn’t be getting it back until the follow day…hopefully. We went back to the house early as everyone had work to catch up on (for me, this blog) and there were plans for a movie night. After dinner, Jamie and Nan settled in on the couch with some popcorn and watched “Taxi Driver,” the second title of their Robert DeNiro film fest after having watched “Deer Hunter” last week. They are truly gluttons for punishment. Chris watched the movie off and on while I sat at the table and listened to it while posting blogs. “You lookin’ at Me?” I got such a kick out of hearing this classic line again.
We had one day of clinic left and one night after tonight of staying in our wonderful house here, The Raynes House, that is so comfortable and warm and was made possible by the generosity of the Raynes Family, who knew how important the work is that we do here and how important FAME is to the people of Northern Tanzania. It is with the support of many that we are able to provide this care.
Our day began early as it was Tuesday which is education day. Today, Nan was speaking about neonatal sepsis as it has been a topic of discussion since her arrival and was an area that certainly needed further clarification. The real issue here was when to proceed to an LP and how that would change management as our resources are far more limited than they are at home. We have no cultures here, either blood or CSF, though they are coming in September, and are critical when managing these patients. In the US, any baby less than 28 days presenting with fever has an LP done as part of their work up. That has not been the practice here and the issue really becomes how long of an antibiotic course these children receive and what are the doses, either sepsis or meningitis coverage.
Somehow, Nan managed to find studies from various Tanzanian institutions that covered this topic perfectly and they were tremendously relevant considering where they were from. It had already been decided that it was not only impractical and resource consuming to do spinal taps on every neonate with a fever, but without cultures, there was also a significant question as to the information they would yield in this particular situation. She delivered an impressive lecture that provided an immense amount of relevant information with which to develop a protocol for FAME to use that would be appropriate for care in a resource limited country, though with a progressive attitude to continue improving the care here at FAME which is always the purpose of these exercises. There are always many questions that follow our lectures and this morning was no exception. Hopefully, the outcome will be that Nan will help to develop a practical and realistic protocol for neonatal sepsis and meningitis.
After her lecture (we did morning report beforehand due to a brief windows vs. Mac snafu) everyone began rounding in the ward while I went off to find Sokoine so we could get started on seeing patients that were already arriving for us. Chris rounded on his stroke patient with the team (the 90 year-old gentleman with a large left MCA territory infarction by clinical signs who was now nearly a week out) as he was still on the ward and hadn’t been eating well so had a feeding tube placed. After that, I was able to get Jamie and Chris started with patients and then went over to Ward 2 (maternity) looking for Nan as we had a third translator this morning to run three rooms seeing neurology patients.
Before I could reach Nan, though, Siana, the head nurse here, walked up to me with her phone to show me a photo that was of an anencephalic baby. When I asked her when the picture was taken she told me that she had just taken it in the labor room as the baby had just been born and was alive and crying. An anencephalic baby is one whose cranium and other parts of it’s skull and face have not formed properly nor has their cerebral hemispheres, but they do typically have an intact brainstem so are able to breath. I asked Siana to grab Nan from rounds and the two of us made a bee line for the labor room where we found one of the nurses attending to the mother and another nurse attending to the baby in the incubator.
The baby was severely malformed and didn’t have a complete face nor cranium so that the majority of it’s brain was not enclosed. Worse yet, the baby was struggling to breath and would intermittently cry. It had a very rapid pulse and was clearly very cyanosis, though we had difficulty getting an accurate oxygen level as we had to measure it from the limbs which were not reliable. Nan took immediate charge of the situation, attempting to make the baby comfortable knowing that it didn’t have very long to live. She got an oxygen line even though there was no where to hook it up to on the baby, so we just allowed it to blow in her face in an attempt to help her breathing and make it less labored. Dr. Brad was in as well and assessing whether the mother wished to hold her dying baby or after it had passed as we would have to wrap the baby in something to make her more presentable to her mother. There was some confusion by the nursing staff as to whether the mother wanted to see her, but it was unclear if they had actually discussed it with the mother or whether they had made the decision for her.
After a bit, we were concerned regarding the babies labored breathing and didn’t want it to suffer any more than it already had, so we were all in agreement that we give it a small amount of morphine to ease her breathing and pain. The baby remained alive for perhaps an hour after that, slowly fading, but with a clear drive to remain alive as that is a very strong desire regardless of one’s situation. The baby finally passed quietly and the family was comforted. It was nothing the mother did to cause this to happen and it would be unlikely for it to happen again to them. It was a tragic end to her pregnancy and she had no warning prior to going into early labor and delivering the baby prematurely. But with the tragedy, we were hopefully able to offer a bit of comfort to the portents and the baby, however short its life was.
We had excellent patients today including several epilepsy patients and a four year-old child that Chris evaluated with clear developmental delay and who had seizures previously, but was no longer having them. We brought Nan in to help with the child, but there didn’t appear to be any regression of milestones so it was very likely another story of perinatal injury or anoxia. It was decided not to treat the child with antiepileptics as she wasn’t losing milestones nor having clinical episodes.
While Chris was seeing his patients today, Dr. Jackie slipped into the room to inform him that his patient who had suffered a stroke last week had died. Even though the patient was 90, it was still a bit of a shock as we had seen him that morning and there were no clinical changes. Chris finished with his outpatient and went over to the ward to find out what had happened and learned that family had been in the room with the patient and had just thought he was sleeping. By the time anyone realized anything, the patient had fixed and dilated pupils and there was no point in trying to resuscitate him here. Chris was rather surprised that there had been no code status on the patient, though I explained to him that coding patients here can be very tricky as we don’t have an ICU or a mechanism to support patients for any length of time on a ventilator. Performing CPR for a witnessed arrest is one thing as they have a reasonable chance of recovering quickly, but trying this on someone who has been down for sometime with the likelihood of having suffered significant neurologic injury and would require long term recover is another matter altogether. Regardless of what this patient’s outcome was going to be, it’s never easy to have someone you’ve been caring for pass away so suddenly.
We had planned to visit a long-term patient of mine and her husband at the boma after work today and were able to finish a bit early to get on our way. Elias is a Maasai who met over four years ago when he brought his wife to me for seizures and she had never been treated before. We eventually transitioned her to lamotrigine (not an easy trick with someone living far away in a boma) and she has not only been seizure-free now for several years, but has also had several children without incident. The last two visits, he had expressed an interest in having me come to his boma for a goat roast to show his gratitude to us, but we have always run out of time to do this. I had told Sokoine last visit that I wanted to made sure this happened during our time here this month.
So today was the day for our goat feast and we loaded everyone up in the Land Cruiser to visit their boma. We picked up a few gifts to bring as Sokoine says that you never visit a boma without something to give so we brought a bag of rice, a case of water and a case of soft drinks. The boma was on the other side of Mto wa Mbu and Lake Manyara which was about a 45 minute drive for us to reach the turn off. Alais met us there along with one of his neighbors who led us to the boma driving a motorcycle in front of us while Alais jumped in our vehicle. The drive was longer than I had anticipated and traveled along a thin trail the majority of the time and at times was more a cross country jaunt. We eventually reached his boma, an enclosed or six or so mud and dung huts. We drove our vehicle through the opening in the brush fence that enclosed the boma and when we arrived, all the children and wives came out to great us.
They brought small stools and five-gallon buckets out for each of us to sit on. In addition to Chris, Jamie and Nan, we had also brought Sokoine and Angel along with Abbey so we had a large group of us. We sat around in the boma and presented them with their gifts before eventually taking a short walk to where they were roasting the goat for our dinner. Thankfully, they had already butchered the goat which was just fine with Jamie as she is a vegetarian and even though she hadn’t planned to eat, it was still nice not having to watch the poor goat before being cooked. It was being cooked on small stakes leaning over a fire and as we waited for the meat to finish, they were piling all of the organs in a bowl of water to boil as they waste nothing that is potentially edible. Even the head is roasted and eventually striped of all it’s meat.
Once ready, they would take one of the various cuts and place it on a taller stake that allowed them slice chunks of meat off as we ate them. The first pieces were all a bit chewy and it was hard to tell what was meat and what was gristle, but it was tasty just the same. As time went on, though, the slices of meat became leaner and leaner and were pretty much irresistible, at least to my palate. The others were not quite as enthusiastic as I was and, because of this, they seemed to continue handing me the chunks of meat to eat, which was perfectly fine with me. It became a bit of a joke after a while as I kept saying “last piece” and they kept handing me more which I didn’t want to turn down so as not to offend anyone. Eventually, though, I had to step aside or I would have burst.
The scenery was amazing with nearby Lake Manyara shimmering in the setting sun and the lush vegetation of this area after the recent rains. As we walked back to the boma with the long shadows of the dimming light, it was never more apparent to me both the differences and the similarities of our cultures. Beauty and joy seem to transcend all as we give our thanks for the courtesy they have shown us here tonight in their home, in their land and in their world.
We were all exhausted after our incredible adventure over the weekend and went to bed earlier than normal I think. At about midnight, though, we had a tremendous thunder storm come through the area that lasted the entire night and into the wee hours of the morning. I think after our ordeal at Ndutu, we were all a bit gun shy and skittish of the heavy rains given what the roads become in very short order here, but the weather let up a bit in the morning long enough for us to walk to the clinic and then later in the morning the skies became clear with bright sunshine.
On the mornings where it’s rained all night, clinic is usually slow first thing, but today we had a number of patients already waiting for us. What we discovered, though, was that many of the patients had come from Arusha this morning, having driven the tarmac which is much more dependable than the dirt roads most patient use to get here from the nearby communities. Though Arusha and its surroundings is a city of probably a million people, there are no neurologists there and only one in all of Northern Tanzania at Kilimanjaro Christian Medical Center in nearby Moshi, and she is primarily dealing with hospital patients there so I’m not sure what type of outpatient practice she has. The patients that came this morning from Arusha were primarily of Indian descent as there is a very large Indian population in Tanzania who have been here for many generations after having arrived here in the 19th century as traders on the coast and in Zanzibar.
Patients seen today included a general smattering of the usual complaints including headache, back pain, extremity numbness and the such. One woman who saw Chris, though, brought an MRI with her that revealed an extra-axial mass of the right sphenoid wing compressing the right anteromedial temporal lobe. She was complaining of a right sided headache and the MRI had been taken at Muhimbili Hospital in 2015, though she reported having had a repeat MRI done within the last several months, also at Muhimbili, and that she had given a disc with the study to Frank.
Chris’ exam was very concerning as she now had right sided ptosis and impaired vision on the right that we felt was referable to the lesion we saw. Frank was out so we had the patient wait until he returned and reviewed the study on his computer. The report of the repeat scan did not describe the lesion nor did it suggest that they compared it to the original study and after looking at the scan we felt the lesion was still there and was responsible for her headaches and the change in her examination. We suggested that she return to Muhimbili, which is in Dar es Salaam and a day’s bus ride away, and we gave her a letter from us indicating that we felt she still had a problem and should see either the ENT who she had seen before or the neurosurgeon (of which there is only one in the country). As she had been seen numerous times there before we were certain that she had the means to make it there which is so often the limiting factor here as most everything has to be paid for and most often patients just don’t have the ability to do that.
Since this is our last week here, I had promised Daniel Tewa that we would stop by his home to visit with him before we left. We had agreed on today and it was also agreed in advance that he would not provide us with dinner, something that he loves to do because he feels that it’s an honor, but also something that I am sure is expensive for him and very time consuming. We went after work and probably arrived at his place around 5:30pm or so. The chairs and table were set up outside as they always are among the eucalyptus trees in front of his home. This is where he entertains groups of safari goers from the different countries, educating them about the history of Tanzania and the Iraqw people. His wife, Elizabeth, brought us delicious African coffee which is boiled with milk and really, really amazing, even if you’re someone who normally drinks your coffee black.
As we began to discuss politics (always entertaining with Daniel), Elizabeth began to bring out additional plates containing sandwiches of cucumber, tomato and beef that were incredibly tasty and despite our objections considering his promise not to feed us dinner, he argued that they were merely snacks and couldn’t be considered dinner. When the plates of fresh fruit and avocado arrived, though, I think his argument was quickly falling apart which was of no concern to him as he continued to insist that we eat. I had asked him for some coffee beans to take back with me and insisted that I pay him for them as he usually gives me several, but I had asked for a few more for friends this time. It took some doing, but I was eventually able to give him some money for the coffee and I don’t think that he was offended. In addition to saying goodbye to Daniel and Elizabeth, we were also able to see his granddaughter, Renata, once again before we left and I look forward to seeing her again in October. I have seen her grow from a six year-old happy to eat her grandfather’s leftovers (an honor) to a now thirteen year-old doing great in school and a pleasure to have work with us at times. Her aunt, Bernadetta, had also worked with me at FAME several years ago before going off to college, so the family has been very close since coming here.
We came home from Daniel’s not quite hungry for dinner so stored all of our dinners (roasted chicken and potatoes) in a Tuppeware container for another night, though we’re running very short on remaining nights here. We have three more days of clinic and three more nights as we are planning to head to Tarangire National Park on Friday before arriving to Arusha later that evening. The residents will spend the night there and fly out on Saturday while I will be flying out on Monday. It always seems to go so fast when we’re here, but we’ve gotten so much in.