March 24, 2017 – Rift Valley Children’s Village and our last day of mobile clinic….

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It was Friday and our final mobile clinic of the Spring 2017 trip to FAME. I’ve written so many times about Rift Valley Children’s Village, but it’s very difficult to say too much about this amazing place. RVCV is not an orphanage, but rather a home to approximately 100 children of all ages were have been orphaned or unable to be cared for by their family and have been adopted by Mama India and her business parter, Peter. They grow up at RVCV which is their home and they go to school at the primary school that is next door. Eventually, they have the opportunity to go to collage and most do.

Tanzanian market weaver male weaving a new nest

The reason that FAME is in Karatu is that Frank and Susan met India when they first came here with the idea of opening up a facility and India convinced them that Karatu would be the perfect place and that would also allow them to provide care for her children and the surrounding community which she would subsidize as she realized that her children would be healthier if the local community were healthy. FAME continued to provide these regular medical clinics at RVCV until very recently and now patients are sent to FAME as it is about a 45 minute drive to the Children’s Village from FAME. We have been tagging along with the FAME clinic over the past, but today we would be going by ourselves, though we would have a clinical officer with us to help with medical decisions other than neurology.

Nan and Sokoine evaluating a young woman with cognitive delay

Nan examining her patient

The drive to RVCV is absolutely spectacular (as are all of our drives anywhere around here) as you leave the tarmac just below the Ngorongoro Gate and travel along a slight ridge in between fields of green that go on forever. There is no sign indicating that the road leads to our destination, though there is one for the Crater Forest Camp nearby along with a sign stating “rough road,” typically ominous here considering that other than the tarmac, all the roads are rough. There are several lodges visible along the way just before we begin descending into several valleys and eventually climb up into a coffee plantation that we travel through a short distance until we reach the primary school and, behind it, Rift Valley Children’s Village where we’ll spend our day. There are always patients waiting for us sitting in front of the offices, though today, since we are here by ourselves rather than with the FAME general medicine clinic, they are all for us. There have been times when it’s been a bit overwhelming, though today are list is manageable. We unpack the medications and supplies from the vehicle and immediately get to work creating a list and getting rooms set up.

Chris and Angel evaluating a patient

Jamie evaluating a young woman with epilepsy

Considering one room has a bunch of stuffed animals, that will be Nan’s as she has been seeing children whenever possible. I should have mentioned previously, that for all of our mobile clinics, we keep separate records from FAME as it’s impossible for us to know who will be coming so we don’t have access to the FAME charts. Even when we have some form of an EMR at FAME, there is no cell service at Upper Kitete and the bandwidth on the cells is not great. We keep notebooks of all of our mobile clinics with past records so when patients return we can find their previous clinic notes. Not ideal, but it works 90% percent of the time or more. RVCV, on the other hand, keeps meticulous charts for all their children in addition to the patients who come from the town, so it is very easy for us to find our notes, though we still make copies of all our handwritten notes that we bring back with us and keep them in a binding the same as the other clinics.

Nan evaluating another pediatric patient

RVCV also has a wonderful nurse, Gretchen, who has been there now for 18 months and is quite familiar with all of the patients including those from the local village next door, especially the children. She is able to fill us in on lots of back information that is not always readily available in the chart nor do the patients always offer it to us considering it is often very sensitive, dealing with all types of abuse. As such, we are often doing a fair amount of counseling here and, unfortunately, much with children who are quite commonly the victims of this abuse. Some of the stories are quite gut wrenching and, though there are authorities to deal with these instances, it is not always the most simple or effective. There is a social worker at RVCV who we are able to discuss these cases with and pass on the information we gather to her, but it still leaves us with a feeling of sadness often in not being able to rescue everyone, similar to how we feel with many medical cases that are not able to be treated here for lack of resources or otherwise.

Chris evaluating a patient with epilepsy with Angel’s help

Patricia counseling a patient on how to take his medications

Nan is in heaven considering the number of children we see at the this clinic and she wastes no time in getting started. We saw a number of epilepsy patients during the day and it so difficult at time as patients rarely know what they are taking, or how much or how often, when we ask them and we have to bring out tablets to confirm with them what they are taking. We were last here in October and many patients, as is commonly the case, have stopped they medication in the interim because they were “finished,” meaning that despite our constant education, most often in triplicate, they didn’t understand that they had to continue the medication for it to continue working as we are not “curing” their problem, but rather treating it.

Nan being Nan evaluating a pediatric patient with Sokoine’s help

One of the benefits we look most forward to at RVCV more than the other mobile clinics is lunch. This is extra important for Nan, who is always thinking about food and where will the next meal be served. When traveling to Empakai last Sunday, we all secretly place odds on when she would first mention lunch in the morning, but she fooled us all by lasting until 11am before asking about food. She was more than happy to discover that today we would be eating a delicious home made lunch in the volunteer dining room where the “mamas” always make an incredible meal for us. Today it was broccoli soup, salad, and cheesy pasta along with fresh fruit, including everyone’s favorite, mango. Lunch is always served at 12:30 so we didn’t have to worry about when to take a break.

Jamie providing a psychiatric assessment to Dr. Mike and Elmo

After lunch, we visited the gift shop while waiting for our Tanzanian counterparts, who eat a more traditional lunch along with the staff here, to come back ready for our afternoon session. Having three rooms seeing patients allowed us to plow through the patients rather quickly and we were done shortly after 3pm, which was good because some of the younger boys were kicking a soccer ball around nearby and I know Jamie had been mentioning wanting to play soccer here for sometime, but it was readily apparent that Chris was also more than ready to play. Even Nan pitched in guarding the goal for a bit and it was great to watch the three of them running around with the children who were all so happy here at the village. It is a place of miracles and you can’t but help know that everyone of these kids was rescued from a harsher life had it not been for the India and Peter, The Tanzanian Children’s Fund and Rift Valley Children’s Village. Saying goodbye and leaving this magical place to head home is always tough. I know that I’ll be back as I have so many times, but for residents, this is likely their only chance to experience this place.

Chris playing soccer with the RVCV kids

Jamie trying to steal the ball

Fancy footwork

Nan playing goalie

Chris playing defense

The weather today has been lovely and the drive home was so peaceful after having seen our patients, played soccer (the residents, not me, of course) and had a great lunch (Nan is very happy!). We arrived back to Karatu, our home for the last three weeks, early enough for Jamie to pick up the skirt she had made and then do some shopping as we’ll be heading into the bush tomorrow on safari. Yusef, our guide for this safari to Lake Ndutu in the Southern Serengeti, had called and was waiting up at FAME for me to give him the Land Cruiser so he could check it out before heading off to such a remote location. Nan and Abbey immediately went to the maternity and pediatric ward where they promptly assisted in finding a delivery going on so when we walked in a few minutes later, we found Nan holding a newborn and beaming from ear to ear.

Nan with a precious new baby

Meanwhile, I received a text from Frank shortly before getting back to FAME informing me that somehow, Dr. Lisso had told them about a patient still “waiting” for us despite the fact that we didn’t have clinic. It was a huge imposition after having nine days of clinic here, finishing five mobile clinics and preparing for four more clinics at FAME that we had to see a non-urgent patient after hours. After briefly venting (a single text) to Frank (who was also pretty frustrated by the event) Jamie and I saw the patient, who actually turned out to have psychosis and had just been treated at the local hospital days earlier, receiving some injectable medication that they didn’t know the name of and didn’t have their discharge papers from the hospital with them. Argh!!! We just kept repeating “TIA” (This is Africa) and explained to the patient, who, by the way, was doing better after the injection that we really couldn’t treat him as he had very likely been given a long acting medication that we didn’t know the name of, and, besides, it was helping him. They were happy with the visit, though we were a bit perplexed as to why they had come, not to mention being still bend out of shape as to why we had to see this patient at 6pm on a Friday evening.

Jamie’s birthday cake – it was delicious!

We eventually got home to eat our dinners, albeit a bit late, and got down to the work of preparing our lunches for the safari tomorrow as we wouldn’t be getting to our camp until dinner time. It was also Jamie’s birthday (sworn to secrecy on how many) and we had ordered a birthday cake from the Lilac Cafe which was running late, so Denis from the Lilac brought it to us during dinner. I had the desired effect either way as Jamie was quite surprised and we all sang happy birthday to her on Joyce’s veranda where we were eating. Later, I worked on my blogs while the Chris, Jamie and Nan made sandwiches, arguing about important things like the “appropriate” amount of peanut butter in a PB&J or PB and Nutella, the latter everyone’s favorite but mine preferring to stick instead with the more basic version of this American classic. Nan cut up a pineapple to eat with lunch and we each went off to pack for overnight in the Serengeti. We each slept with dreams of the wildlife we’d see the following day and the adventures we’d experience, having to awaken quite early for a 6am departure to head through the Ngorongoro Gate when it opened.

March 23, 2017 – Day two of our clinic at Qaru…

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The team rounding on a patient with severe burns – Dr. Elle managing

 

I completely forgot to mention that the night before, we had a ward consultation regarding a gentleman who had presented after the sudden onset of right-sided weakness and inability to speak or comprehend. Chris had gone to see him after we had returned from clinic and was happy to report that they had assessed him correctly after his lecture Tuesday morning which was very reassuring. He appeared to have a complete left MCA territory infarction on examination with a global aphasia, right visual field cut and right arm and face weakness with some sparing of his leg. He was also in atrial fibrillation which we had discussed at length at the lecture in regard to the fact that you should wait about two weeks before anticoagulating a patient due to the risk of hemorrhage. It was great for Chris to use as a teaching case, though not so great for the patient. He was a bit agitated when he was admitted, likely due to his global aphasia. So on morning report, we discussed his case and what his continued management would be going forward.

Chris examining his stroke patient with the team. Dr. Gabriel, Dr. Msuya and Siana looking on

Chris examining his stroke patient

Rounding on a pediatric patient with Nan discussing the case with Dr. Gabriel, Dr. Msuya, Siana and Dr. Brad

Nan, of course, was busy with her pediatric cases before and during rounds which she has been doing a great job with. This morning, the very tiny Maasai baby, whose name is Frank, had decent labs so he will go home today with his family. They live quite far and it will still be touch and go with him. The family agreed to come back next week to see us before we leave and we hope to reinforce the education that was given before he left when they return. He’s so small and without his mother, it will be touch and go. His family, though, was very motivated and seemed to want to provide excellent care for him.

Chris and Angel evaluating a patient

We picked up Sokoine in town as he was buying our food for lunch so we could get an earlier start. Stopping at the grocery store with everyone getting out of the vehicle and choosing what they would like to eat can be a bit cumbersome and time consuming to say the least. We’re often delayed in town for 45 minutes picking everyone up and shopping for each days lunch. I had tried lunch boxes (which are what is used when you’re traveling on game drives so are quite commonly sold here) before, but it didn’t go over well with the Tanzanians as it wasn’t what they were used to eating. Since then, we’ve typically bought the various pastries that are all full of carbohydrates and typically fried so they are the furthest from a healthy diet that you can imagine. Everyone seems happy with these, though, so that has been our practice for the last several years. At least having Sokoine buy everything in advance will save us time, if not calories, carbs and saturated fats.

Jamie evaluating her patient with epilepsy

Jamie examining her patient with epilepsy along with Dr. Mary. Moments later, the patient had a seizure

Discussing treatment options after the patient was back to his baseline

Clinic today was a bit interesting, considering Jamie’s first patient, which I had decided to sit in on today, wanted to demonstrate for us what his seizures looked like. This was a 21 year-old gentleman who was accompanied by his mother and spoke mainly Iraqw which is quite unusually for a young man. His mother described episodes that were fairly classic for seizures and, specifically, frontal lobe seizures that were reasonably frequent. As Jamie was examining him, he suddenly leaned forward and spit on the ground, then stood up with a very blank stare and was clearly having a seizure. We eased him onto the bed where she was examining him and his eyes were fixed to the right and he was not responding. This lasted only briefly and then he began trying to get up and was still quite confused. We put his coat under his head and he curled up for several minutes before he was finally able to speak and comprehend. He didn’t generalize, though his mother clearly described generalized convulsions in the past and this seizure was clearly a partial complex seizure without generalization and was quite consistent with a left frontal focus for his seizure. He had been put on phenobarbital sometime in the past, but the dose wasn’t clear and it hadn’t helped him at all. His mother had eventually stopped the medication due to it’s ineffectiveness and he just continued having seizures on a regular basis. How amazing it will be to possibly finally control his seizures after all these years. His mother was so appreciative and grateful that we were at least giving her son some hope that she was close to tears and couldn’t thank us enough even though we hadn’t even done anything yet.

Nan examining an adult

Nan happily keeping busy seeing patients.

Patricia in our “pharmacy”

Patricia talking with a patient in the “pharmacy”

Nan’s final patients of the day were also quite interesting. It was a mother and daughter who both suffered with epilepsy, though it wasn’t quite clear that it was genetic. Mom’s seizures hadn’t begun until her 30’s and her daughter’s seizure began at age 4 and she was now 7. The description of mom’s seizures by her husband, which very much embarrassed her, looked primarily generalized, but the description of the daughter’s seizures were less clear. While Nan was taking their histories, I gave the daughter my cellphone to play with for a bit and when I left with it after a while, she apparently burst out in tears so I had to give it her again. She was quite cute and thankfully seemed to be cognitively normal despite having had untreated seizures for several years which is so often not the case here. It was a struggle for us to decide what medication to use for each of them as we don’t have the full complement of medications to use that we have at home and some of the medications we have here are often in short supply and sometimes too expensive for the patients. We eventually came up with a plan that seemed reasonable, but it will require that they be followed up at FAME to make certain that they’re each doing well.

Lunchtime in the shade at the car

We were finished with patients and decided to have our lunch under the same tree, but try as I may, I couldn’t track down another chameleon and was very disappointed over that. After lunch, we discovered that we had more patients who had showed up in our brief absence, and since it was our last day at Qaru, it was only appropriate that we see them despite the fact that it was getting late.

Nan evluating a mother and daughter epilepsy case

Playing games on my cellphone

Happy with my cellphone

We traveled back to Karatu, arriving back to FAME sometime after 5pm and decided to relax for the evening. We were planning to go on Safari for the weekend and needed to do some shopping, but that would wait until tomorrow after work. So, for tonight, it was dinner and work and then to bed. Tomorrow we would be heading off to Rift Valley Children’s Village for our last day of mobile clinic and then next week we will be back at FAME for neuro clinic again.

Abbey’s new boot

March 22, 2017 – Our first visit to Qaru in the Endabash area….

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Today we were continuing our week of mobile clinics and after servicing the Mbulumbulu area to our northwest, we were now going to travel to the Endabash area and village of Qaru which is to the northeast. We had been looking for another site to have a mobile clinic and the district medical officer here had been supportive of it after having seen what we had been doing at Kambi ya Simba and Upper Kitete. We eventually settled on the village of Qaru, who were delighted to have us come to their dispensary and care for their residents. So it was set that we would spend two days in Qaru for our visit visit and see what came of it without knowing the volume of patients we were going to see, only that they were happy to have us there.

A typical wheelchair

Glen Gaulton, who had been visiting with us since last Thursday evening, was planning to leave this morning as he was departing from Kilimanjaro International Airport this afternoon. Glen and I met with Susan and Frank yesterday morning to discuss future plans for our involvement with Penn as far as neurology was concerned as well as other services that might work for both FAME and Penn. The big topic of conversation for us, though, was the laptop ban for carry on luggage from primarily Muslim countries that had been recently announced. Thankfully for Glen, it would not affect him as it wasn’t going to be enforced until several days from now, but for the rest of us flying through Doha, Qatar, it would mean that we won’t be able to bring our laptops, tablets, cameras or any other piece of electronic equipment larger than our cell phone with us on the flight. Yikes! Each of us had been planning to do work on our devices on the long flights home and will no longer be able to do that. It will mean that we have to read a book or watch non-stop movies on the 7-8 hour flight from Kili to Doha and the 13 hour flight from Doha to Philadelphia. Jamie will be heading to Namibia after we finish at FAME and she will have an even longer flight to Doha. I did read somewhere that Emirates (who is also affected by the ban) is planning to allow people to bring devices on the inbound flights to Dubai connecting to the US and then would pack anything there in locked cases for no charge. It is said that the ban was based on specific intel, but there is also a suggestion that this is an economic retaliation against middle east airlines that receive government subsidies and can therefore offer lower fares which the US airlines can’t compete with. Regardless of the reasons for the bans, it is going to pose a significant hardship for all of us, not to mention the fact that I am going to have to check all of my camera equipment and hope that it will arrive at home with me and not disappear. The fact that all of these electronic devices will now be stored in checked luggage surely won’t go unnoticed by unscrupulous baggage handlers along the way. The consequences of this ban in the long run remain to be seen, but for our flights home it will be a real hassle.

Angel screening patients wating to be seein

Sokoine screening patients

The drive to Qaru leaves from the tarmac immediately opposite of the FAME road and travels northeast through a somewhat different landscape than that of Mbulumbulu, but it is equally breathtaking with long vistas of green fields among low rolling hills and occasional kopjies (Dutch for “little heads” and referring to the large boulders poking above the ground, often the home of many animals in more remote places like the Serengeti) scattered across the countryside. This is an equally poor area of Tanzania where small villages along the road are made up of a few shacks that account for not only the homes of the inhabitants, but also the small places of business. We finally reached Qaru after perhaps 45 minutes to an hour and drove through town to reach the dispensary. They had a wonderful dispensary with two wings, a male and a female, along with a central office that were all for us to use during our visit there. The nurses were so happy to have us there that they directed moving desks to each of the wards along with extra chairs and, in very short order, we were set up for three lovely offices in which each resident could see patients along with their interpreters.

Chris seeing a patient in Qaru with Particia’s help

Nan evaluating a seizure patient with Sokoine

Jamie and Dr. Mary evaluating a patient

The patients were already there waiting for us as we arrived and the residents each jumped right in to see them so we were off and running quite early. One of the most important parts of these clinics is the pre-screening of patients before they are seen since we are there to see patients with neurological disease and not those with arthritic or orthopedic issues. Our role is not to do general medicine when we are there as they have clinical officers at the dispensaries for that and since we are charging only a small fee that doesn’t come close to covering the cost of the visit and medications, we cannot subsidize anything but neurology. Early during the clinic, Nan came out of her office at one point with a bit of a frustrated look saying that she couldn’t evaluate her 37 year-old patient who was complaining of chest pain. Clearly, that would not be considered a neurological problem on the face of it, but after reassuring her that it was unlikely that the patient had an acute cardiac condition, I sent her back into the room to ask a few more questions and after a some further assessment she not only found that that woman didn’t have a cardiac condition, but very likely had a neurological complaint that she could actually treat. Alls well that ends well.

Chris examining a patient with Angel’s help

Patricia and our pharmacy at Qaru

Jamie saw a woman with a clear psychosis who has been under the care of the government psychiatric nurse and receiving long acting antipsychotic medications, but we were unaware of the actual medication she was on and both she and her husband were asking if we had anything other medications to suggest as she had been having side effects. A call to the government dispensary to gather information didn’t go as planned as they were apparently unaware that we were in the area and wouldn’t provide us with any information. In the end, the patient was directed back to the dispensary since we were unable to treat her without knowing what she had been treated with previously and what she was currently receiving.

Jamie and Mary evaluating a patient

Chris examining a patient with Sokoine’s help

Lunchtime came and we put shukas down on the grass in the shade of a tree next to some boulders where our care was parked. This was a small kopjies and the trees were growing out of the rocks with their roots exposed. It was a lovely spot and while looking for lizards, I found a beautiful chameleon that was colored an amazing green and black at the moment. He threatened me with open jaws that were merely for show and puffed out his throat to make him look bigger. In the end, though, he settled down and we were able to handle him gently so that everyone got a chance to have him walk on their arm and marvel at his independently moving eyes, each moving in a 360° circle separately. Everyone other than Angel thought he was so cute as she went screaming around the car and wouldn’t return until he had been released back to the bushes near where we found him. As soon as we let him go, he immediately turn to color green that exactly matched the bushes as camouflage in the manner we’d expect of any respectable chameleon.

A nice close up of Mr. Chameleon

Jamie holding our chameleon

Taking photos of the chameleon

We had a few more patients after lunch and were able to get back to town in time to stop by the fabric store we had visited before and Jamie picked out some fabric for a skirt they were going to make for her. At the same time, I saw a Thomson Safari vehicle parked just up the road from where we were and decided to see who was driving it. When I asked whose vehicle it was, a familiar looking gentleman stepped forward and I realized it was Mohamed, who had picked me and my kids up at the Manyara Airport in 2009 after we had returned from the Norther Serengeti while on our original safari. I’m not sure if I’d seen him since then, but we clearly remembered each other so we sat and shared a drink to catch up on things. What a very small world this can be. I showed him pictures of my kids from our safari as well as where they are now and he was so happy to see them as well as knowing that I’ve been coming back every since to help out at FAME. It reminded me of my first visit to FAME that was the result of volunteering for a few days in Karatu, and what FAME was at the time. From a simple outpatient ward then to the complex of patient care facilities that it is today, we have grown together over the last seven years.

March 21, 2017 – Upper Kitete…..

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It rained pretty heavily overnight and once again we were heading out to Mbulumbulu for our mobile clinic, today visiting Upper Kitete, which is our furthest clinic and about an hour and a half drive along the rift. From Upper Kitete there is an overlook that we often visit that sits 2000 feet above the Great Rift Valley with a view down to Lake Manyara that is just spectacular when the weather is clear as it goes on forever. Today, though, I am more worried about the roads since we’re heading back towards Kambi ya Simba and beyond where it doesn’t take much rain to make it treacherous.

Chris doing his chalk talk on stroke

Thankfully, we’ve been able to recruit George Mila, a long time employee of FAME and someone who has helped me out in the past when I’ve needed it. George will drive us to Upper Kitete so if the roads are bad or if rains while we’re out there, we’ll be sure to make it home or at least we’ll have someone with more know how who can help us out of a bind. With Glen traveling with us today that will make ten for a Land Cruiser that only seats eight. We normally use the refrigerator in the back for an extra seat, which we did today as well, but to seat ten, I am sitting on a soft drink crate with a cushion, wedged between the third row that will serve as my seat for the drive today. It was remarkably comfortable, despite the bumpy road and long drive, though I’m not sure I’d recommend it to anyone if they had a choice.

Chris demonstrating how to do the NIH Stroke Scale using Jamie as his “patient”

Tuesday mornings are for education, so before our drive to Upper Kitete, Chris delivered a lecture on stroke for the doctors that he had been requested to give. Chris is a master educator and provided an interactive chalk talk on a propped up white board using markers to run through the vascular anatomy of the brain, the NIH Strok Scale, and finally treatment rationale. Chris did an excellent job and though the participation of the Tanzanian doctors wasn’t brisk at first, they eventually chimed in with some of the answers. Jamie served as Chris’ “patient” to demonstrate the NIHSS and how to rapidly assess a patient to determine the size of their stroke. There were many excellent questions after he was finished with his talk that clearly demonstrated not only how important this subject is, but also how much they had gained from the presentation that Chris had given. We have always given these talks since I’ve been coming here and now the residents give them as they are all incredibly educators which is one of their key roles back home for the medical students and they provide the same here for all the medical officers and nurses.

The Upper Kitete Dispensary. Rain water collection container and our parked vehicle

The drive to Upper Kitete was quite uneventful as to any incidents, though the beauty of this region would compare to any in the world. The fields are lush and green as far as the eye can see and we pass tractors and workers along the way going to and coming from their daily labors. It’s quiet and serene here that belies the difficulties of life here, given the remoteness and occasional struggles to make do. It is a much simpler life for certain. Upper Kitete is the second to the last village on the road we’re traveling that ends as the mountains meet the escarpment and it is no longer possible to travel further by vehicle.

Chris seeing a patient with Angel’s help

Nan evaluating a patient with Sokoine’s help

The dispensary at Upper Kitete is a bit more primitive than that of Kambi ya Simba. The two rooms we usually use are cramped and not ideal, but we’ve always made do. The one office has a square hole in the ceiling where there is a large colony of bats that can often be heard and there is always the aroma of bat urine, but I have never seen one fly out during the day so I am comfortable that everyone is safe. The other room we use is the labor and delivery room where there are two beds and a very small amount of space between them. As long as there are no patients in labor, we’re safe to use the room. Today, we were also given the dispensary’s clinical officer’s office to use which actually had a nice desk and bed in it on which to examine patients. Everyone got to work and Jamie drew the short straw meaning she would see patients in the “bat room,” though it took just a tad of convincing that she needn’t worry about the little creatures. Nan worked in the L&D room and Chris ended up in the office as this came available later and he was in the right place at the right time.

A young patient waiting to be seen

Nan and Angel evaluating a patient with hip pain

We had a smattering of the usual patients with headaches, neuropathy and seizures with none that stood out remarkably, though Chris’ last patient was one that took a bit more in the way of thought. He was a young boy of 5 whose grandmother was raising him and gave us a history of “drop attacks” that began at one year of age and had continued. When we hear the term “drop attacks” we usually think immediately of Lennox-Gastaut syndrome which is a devastating epileptic encephalopathy where children loose milestones and suffer injuries due to the multiple seizure types. We were also given a history that the child may have had spasms when younger, another worrisome feature suggesting infantile spasms. But he looked way too good to have either of these conditions and, in fact, his examination demonstrated normal cognition which went along with what his grandmother was telling us.

Our young child with seizures. Glen Gaulton, Sokoine and Dispensary Clinical Officer looking on

Glen Gaulton and Sokoine with patient

Getting a high five from our young patient once he’s more awake

He appeared initially to be a bit sedated which wasn’t surprising as he was on 90 mg of phenobarbital, but he later awakened to fully participate in his evaluation which was also very encouraging. We wanted to convert him to valproic acid, but before doing so, he needed to get labs to make sure there were no metabolic issues that can be seen in certain children and which would be a problem if we put him on this medication. In the end, we convinced them to come to FAME next week to have the lab work done at which point we’d decide whether to switch him to valproic acid or not.

Chris evaluating a patient with Sokoine’s help

At the end of the clinic day, the clouds were rolling in from the valley below and we could hear thunder in the distance. We packed up and hit the road, skipping the overlook as the weather was closing in fast on us. It began to rain and did so most of the way back to the tarmac. We had wanted to stop at a friend’s shop in the village of Manyara so took a different road back and made it there just in time before they closed. I had wanted to get some wall hangings and items for the new house and was successful in doing so, while the others were looking for gifts to bring home with them. We eventually got back on the road and made it to Karatu in time to watch the sunset with dinner. Glen made us a great tomato, cucumber, onion salad to go with our cheesy pasta that Samweli made us for dinner. We relaxed for the rest of the evening with Jamie, Nan and Glen watching Lost in Translation on Nan’s laptop. It was a good day at Upper Kitete and we made it back safely. Tomorrow would be a new clinic location at the village of Qaru in the Endabash area of the Karatu district. Glen would also be leaving tomorrow morning and it has been great having him here to see what we have been doing at FAME.

March 20, 2017 – Kambi ya Simba….

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This will be our week of mobile clinics for the neurology team and there is always a bit of stress associated with making certain that everything we need has been loaded in the vehicle as we can’t come back for anything once we’re out. When I first arrived in 2010, FAME had been running a big mobile clinic to the Lake Eyasi region one week every month since they hadn’t opened their hospital and the clinic visits were at a low enough volume that it was still doable to split the clinical team and make things work. In 2011, Paula Gremley, who had been working with FAME at the time on the mobile clinics to Lake Eyasi, suggested that she and I travel to several villages in the Mbulumbulu region of the Karatu District where we would see only neurology cases specifically as each of the villages have their own small government dispensaries so we weren’t looking to do general medical care there. Paula, who ran her own non-profit at the time, was interested in providing neurological care to patients in the region and so it worked out perfectly with my trips to FAME and an interest in developing a neurological presence here.

Paula, unfortunately, left to return to the US shortly after our “mini mobile clinics” (in deference to the large mobile clinic to Eyasi) began, but it was a concept that I had felt strongly about as did Susan and Frank here at FAME. When the funding for the Eyasi trips had ended (They were funded by Malaria No More, a Dutch based non-profit), the Neurology Mobile Clinics became the main functioning remote clinic for FAME other than the Rift Valley Children’s Village (RVCV) biweekly clinic that was run at RVCV to care for the patients there as well as the adjoining local village. Since 2012, we have been running a series of mobile clinics in two villages in the Mbulumbulu region as well as at the RVCV accompanying the FAME general clinic there.

Nan examining a patient with Dr. Mary’s assistance

The Mbulumbulu region is a remarkably gorgeous area that follows along on the high side of the rift and forms a triangle bordering the Rift Valley and escarpment to the southeast and the Ngorongoro Conservation Area to the northwest until it reaches it’s apex about half way to Empakai Crater. This region is populated mainly by the Iraqw and is blessed with extremely fertile soil so that it is heavily farmed with many varieties of crops. Driving through this area one is continually reminded of the main occupation here which is farming as there are always people in the fields working, and certainly now as we are nearing harvest time before the big rains of April and May. The road is generally good, though once it is raining it can become quite treacherous and I have learned that the hard way in the past having gotten my Land Rover, a virtual tank of a vehicle, stuck axle deep in the mud after running off the road during the heavy rains of April.

For this year’s mobile clinics, we have chosen to visit two of the original villages in the Mbulumbulu region, Kambi ya Simba and Upper Kitete, though we’ll do only one day in each where we have done two days in each in the past. Kambi ya Simba is the closest of the two villages, about 45 minutes away, while Upper Kitete is almost exactly twice the distance, or about 90 minutes away. For this year, we will be going to another village in a different region, Qaru, in the Endabash region, and spending two days there. Sokoine and Alex had been meeting with villages in this region and chose Qaru over the others for several reasons. We will then finish off the week at Rift Valley Children’s Village on Friday.

Chris examining lower extremity strength with Dr. Mary’s assistance

We had told our patient with HIV and the abnormal CT scan with presumed toxoplasmosis to come at around 8 am on Monday, and sure enough, there he was, having traveled several hours by bus to see us so we could explain his medications to him. Jamie met with him and went over the protocol which wasn’t simple and then explained it to the nurses as well so they could reinforce it with him. He will be coming back to see us next week as well so that we can assess whether he’s had any clinical improvement and after further discussion with everyone, we’ll very likely do a repeat CT scan to gauge if there’s been any improvement in the edema we saw on the first scan, indicating that the medication is working for him. We will have further decisions to make regarding whether we continue him on this course of therapy or not and we’ll cross that bridge later when we’re there and have some more data.

I typically have someone drive us out to the mobile clinics, especially this time of year when a heavy rain can come down without notice and turn the roads into a slip and slide in no time at all. This morning, there was no one available to drive, which meant that I would do all the driving and would also keep my fingers crossed that it didn’t start raining while we were out there. Again, the preparation for these clinics is crucial due to the number of meds we bring, medical tools, and, of course, our lunch which has to be enough for all of us and something that everyone can eat. After filling our fuel tank on the Land Cruiser, we drove a bit further through town to pick up lunch. I sent Nan and Jamie along to make sure what was being acquired would be to their approval as some of the lunch items can be a bit bizarre at times. We ended up with samosas, vitumbua (sp? Fried rice cakes that are delicious, but dripping with grease), donut-like pastries that aren’t very sweet, bananas, and avocados. We also had a huge selection of drinks and addition to the water we bring and which you don’t travel anywhere here without considering any safari (journey) can be an adventure you may get stuck in the bush for hours in the hot sun or torrential downpours as they change that quickly.

We arrived at Kambi ya Simba without incident and found no patients waiting there for us, but it was around 11 am and Sokoine informed us that many people here were still finishing their morning chores so would likely begin showing after noontime. Sure enough, a few patients began to show, but not the volume that we had hoped for. There were a few children for Nan, one of whom was a very cute little two year-old child whose mom brought her in because she wasn’t able to run and play like the other children. It was clear that she had a mild right hemiparesis on her exam that had been present since birth so in the end she was another child with mild CP, though she was functioning very well cognitively with only mild delays. Nan felt she would do very well long term and she instructed mom on some simple exercises she could do that would help with her physical issues. Mom had also described two episodes of seizure in her life so Nan decided to treat her for these as it would be difficult to tell if she were having additional seizures and, if she were having more, they would also negatively impact her development that was already delayed. We stressed the need for her to follow up at FAME for refills of her medication and to see us back in October to re-evaluate her when we’re back.

Nan evaluating our little patient with CP and seizures with Angel’s help

The other patients were a smattering of typical complaints here – headache, neuropathy, back pain – but at the end of the day before our departure we were asked to see a 17 year-old schoolgirl who had been brought in with a severe headache and was in their small ward there. It turned out that her headache was only a minor problem and the more significant issue was the recurrent episodes of prolonged unresponsiveness she was having which would last up to 11 (!) hours and without any clinic story suggestive of seizure. What she had was a conversion disorder (psychogenic) and further investigation by Nan and Jamie it was discovered that she had significant traumatic issues in the past that were contributing to this and was also clinically depressed. After we discussed the case further, it was decided to place her on fluoxetine (Prozac) as she would clearly benefit from a course of antidepressants. Unfortunately, what she really needs is counseling and psychotherapy, but these really don’t exist here in any reliable fashion so we would have to rely on the medications and letting the clinical officer there know what our thoughts and recommendations were so they wouldn’t treat her with anything else for these episodes.

Psychiatric disease is very prevalent here as it is elsewhere, but often presents very differently than it does back home due to cultural variations. Prolonged episodes of unresponsiveness lasting hours and hours is quite common which we don’t see quite as much at home. I have my suspicions as to why that is, but I’ll not bore anyone here with my hypothesis at this time. “Swooning” is quite common as I have seen many a patient brought in by their co-workers from the fields or from their schoolmates from school where they were basically not responding, are carried in, and miraculously wake up within a short time of being here and are back to their normal selves immediately. An unresponsive patient obviously creates lots of excitement and angst among the family and medical staff, which is perhaps the point, but is something that we have dealt with fairly frequently and is most often readily clear to us.

Our lovely child with CP and seizures

We departed Kambi ya Simba seeing perhaps fewer patients than we had hoped, but it still serves a purpose to visit these villages so they are aware of the neurologic disorders we can treat here. For the little girl with CP and developmental delay it will make a huge difference in her life having seen us at age 2 as opposed to at age 10 after she’s developed contractures or has been seizing intermittently for 10 years. Hopefully, we were able to also help the school girl with her depression, but that’s a tougher problem. We arrived home after dropping all of the FAME employees off in town and Nan went to the peds ward to check on her patients here. After relaxing for a short bit, we met up with Alex as we had plans for dinner at the Manor Lodge which is a lovely resort that sits high up on one of the hills overlooking FAME and town. The drive there is through the Shangi-La plantation (coffee) which is massive and then through a short easement that cuts through the Conservation Area where you can occasionally spot some wildlife.

You then cross the gate into the lodge grounds were you enter another world of closely kept lawns and landscaping with gorgeous white washed cottages interspersed looking out over the coffee plantations that adjoin the grounds. The Manor House is a large lodge building with fireplaces and sitting chairs and perhaps the finest dining room in all of Tanzania. I had thought there was lots of silverware at Gibb’s Farm, but there was at least an extra setting here for an additional course so they had them beat. We sat outside on the veranda looking out across the rows of coffee plants in the distance with the hills dropping off to Karatu even further in the distance. Nan was enjoying the grounds taking more photos of flowers and eventually joined us as we relaxed under the clear sky to watch the stars begin to surface as there was no moon. The soft hues of the sunset faded away slowly to an amazing gradient of blues that began at the horizon and darkened to the night sky above.

We eventually moved inside to our dinner table where we enjoyed luxurious service and food to match. Glen selected a few nice wines to go along with dinner and it was a marvelous time with good friends and colleagues as we all share now in our love of Africa and of serving the people here where it makes such a difference. I know that I will be back as will Glen, and I’m hopeful that Chris, Nan and Jamie will consider it in the future, whether it be here at FAME or elsewhere, whether it be Africa or at home, it it is all the same. The lessons learned here will last a lifetime as will the memories, and they will carry it all with them for as long as they live. That is the beauty of it all.