Monday, March 19, 2018 – Day one of mobile clinic at Kambi ya Simba….


Our Land Rover with Angel speaking to some of the local residents

Today is the first day of our week-long neurology mobile clinic, where we travel to four local villages in the Karatu District that are more remote and usually require anywhere from an hour to an hour and a half travel by safari vehicle from Karatu. I first began providing this service in 2011, with the help of Paula Gremley, an expat who had lived in Tanzania for a number of years providing help with social services for neurologically impaired children through her own NGO, and Amir Bakari Mwinjuma, her Tanzanian partner in the project. Paula and Amir were the first to take me to the villages of the Mbulumbulu region of the Upper Rift and I have been coming back ever since to provide neurological services to this rather remote corner of Karatu District that was settled exclusively by the Iraqw in the years past. Paula accompanied for a few years, but traveled back to the US for personal reasons several years ago. With FAME’s continued support, though, I have been able to continue these clinics each time I am here (barring political or weather events that prohibit our travel here) and bringing residents to these amazingly beautiful parts of Tanzania is always a highlight of their visit here.

Susanna and Mindy evaluating a patient with Emanuel

Patricia manning our pharmacy

The clinics vary in size, often depending on the weather or the time of year (i.e. harvest time), but there are always some patients who come to see us, many of them returning every six months. It is not our mission to provide general medical care in these locations, as they do have dispensaries where there are typically clinical officers to provide that care and our purpose is to exclusively see those patients with neurological illness only. This can be challenging and requires a bit of triage, though we have angel to do that for us this year. It is always tough to tell at times whether someone has a neurological problem until you have evaluated them so we often see patients with osteoarthrosis (run of the mill arthritis) or what they refer to here as “GBM,” which means, “generalized body malaise,” but has an entirely different meaning in our world as it refers to glioblastoma multiforme, or one of the most aggressive primary brain tumors that has a very poor prognosis even with treatment. When I kept seeing this written in the charts of patients here, I wondered to myself why there was such a high incidence of this malignant brain tumor here. Thankfully, I was in error.

Susan and Johannes evaluating a patient with Dr. Jackie

The first clinic of the week was to be in Kambi ya Simba, or lion camp, that is a small village it the Mbulumbulu region and just shy of an hour away. The roads to the Mbulumbulu region can be very treacherous in the rains and I’ve managed in the past to get my vehicle hopelessly mired in the mud, having to be rescued by Ema, one of our FAME drivers and quite to often my hero here when I seem to find myself in trouble on the road. Roads here become skating rinks in the rain as the “Karatu clay,” the orange or ochre clay that coats everything on the roadside in the dry season when it is dust and everything underfoot and under tire when it is wet, becomes a slippery, sloppy mess. Add to that that deep drainage ditches on the side of the road that are formed by the quick downpours that occur here, and you have a sure bet to spends hours trying to extricate yourself should you happen to slide off the driving surface. These days, during the month of March, I have a driver from FAME take us to Mbulumbulu, and the other sites if possible, since they are much more experienced at driving here than I am.

Mindy and Susanna evaluating a patient with Dr. Jackie

As I mentioned, the road to Kambi ya Simba is close to an hour from Karatu, and by the time we get our lunches, waters and anything else for the day, it always seems like we arrive between 10:30 and 11am for our clinic. Just shy of the dispensary where we are seeing patients, a huge panel truck that we are following up the hill became stuck, delaying us for several minutes while it was being dug out, though we eventually were able to drive around it with only minor trepidation. As we pulled up to the dispensary here, I barely recognized it as there is so much construction going on. The first two years I came here, I saw patients in the field by the church using a desk and chairs to sit on under the open sky. Then we began using the labor ward and over the last two years have used a new building they had constructed. Now there are nearly a dozen buildings where there used to be none and we’re given our own building, though they did have to carry desks and chairs for us to use to see patients.

Johannes and Susan seeing a patient with Emanuel

The truck we had driven around was actually heading here to deliver construction supplies to the jobsite and arrived shortly after we began to see patients. Previously, we had seen numerous epilepsy patients here, but none of them seemed to return which is always a bit worrisome considered the now more realized issue of SUDEP, or sudden unexplained death in epilepsy, in patients with epilepsy that is more prevalent in patients who are poorly controlled with their seizures. The patients today turned out to mostly be those with arthritic pains or “GBM” and neurological disorders were few and far between, unfortunately. We were not overwhelmed with patients, but since we started late, it took a while for us to finish causing us to arrive home a bit later than anticipated. I think we were all a bit overwhelmed from our experience yesterday, and so were all pretty much exhausted as we headed home so decided to have our dinner and then a relaxing evening at home.

Susan and Mindy evaluating a patient with Emanuel

Sunday, March 18, 2018 – A trip to the boma, and, thankfully, back again…


Johannes and Mindy very sad to have had to experience the Sopa Lodge. Susanna is obviously enjoying it.

Ngorongoro Crater from the lookout

For our trip to Empakai Crater and Ngorongoro Conservation Area, I had decided to see whether Sokoine could possibly accompany us and perhaps we could arrange a visit to his father’s boma where he had grown up. He has been living in Arusha for the last several months, but had agreed to travel here and meet us in Karatu where we would buy some gifts to bring for his father as that is the appropriate gesture when visiting a boma socially. Their boma sits in a gorgeous valley that is beyond the big crater (Ngorongoro) and is among a number of surrounding Maasai villages that are so numerous there. I have been to his father’s boma on two prior occasions and there is always something new that I see for the first time so I never refuse an offer to go back. The residents were also all very excited about the prospect of visiting a boma so we left town that morning with lots of excitement and enthusiasm as we’d not only get to visit the boma, but also hike into Empakai Crater, which is truly a unique experience as the scenery is so unique and it’s rare that you are able to hike through a forest teaming with animals. No worries, though, for we do have a Maasai guide with us who carries with him a spear that can be used if needed, How he would ever protect a group, though, with a single spear against a charging lion is a little beyond me, but hey, we’re in Africa and that is how things are done here.

On our way to the boma

Being greeted to the boma

Since we weren’t leaving at the crack of dawn, there was plenty of time to make sandwiches for lunch along with some other snacks that we’d bring such as cutup pineapple, sliced cheese and, of course, some Coke Zeros. We also packed extra sandwiches for Sokoine and Philipo, our guide, who would protect us while hiking into Empakai. After meeting up with Sokoine in town and picking up all the supplies we’d bring to his father as gifts, we departed for the Ngorongoro Conservation Area gate that was about 20 minutes out of town to the west. Getting through this gate has always been a huge source of stress for me, as the requirements seem to continuously change every time I get there. Over the last several years, they have required that you deposit money into one of the national banks here and that would remain I that account until it’s used. You would take the receipt of deposit up to the gate and, as long as you had the correct amount of money deposited, they would grant you access to the NCA. You couldn’t use cash at any of the gates, as much of it would disappear. Thankfully, over the last year, they have now allowed the use of credit cards at the gate, so it has become a much simpler process.

On arriving at the gate this time, though, we were immediately confronted by a government official wanting to see all of the paperwork for our vehicle to make sure the appropriate taxes had been paid (which they thankfully were). Once inside the gate office, we were again confronted by another official asking us the very same questions. Finally at the window to purchase our entrance fees, the agent wanted to know which safari company we were traveling with and where our booking confirmations were. I took forever to convince him that I was the driver as he was somehow under the impression that Sokoine was our driver/guide and that we were trying to avoid paying additional fees. Once that was all straightened out, they let us on our way and we were finally through the gate heading up to the crater rim. The long winding road up to the crater rim is like driving through a primordial forest as the drop-offs are severe and the trees, many of which are quite large, are incredibly tall as they reach for a share of sunlight from the bottom of the gorges that accompany us as we make our way. Every form of vine imaginable are hanging from the trees as we travel up and up towards the rim which has an elevation of over 7500 feet. As we approach the top, the assent road immediately takes you to the overlook, with an incredible panoramic view of this amazing geologic feature.

Sokoine’s father

Ngorongoro Crater is actually a massive caldera formed by an ancient volcano and is ten miles in diameter and 2000 feet deep. The walls of the crater are quite steep and there are only three access roads into it – a descent road on the far opposite side, an assent road half way around to our left and a two-way road half way around to our right. At the bottom of the crater there is a very large lake near the center and a smaller lake where most groups have lunch. Roads crisscross the bottom of the crater and from above, everything looks so close, but having been inside many times, it is a vast openness filled with animals that have no need to migrate as everything is here for them. The crater is also home to the largest collection of black rhinos in the world as they are an endangered species. Every type of animal is here other than the giraffe, as the steep walls are too difficult for them to navigate, and the Nile crocodile, as there is no flowing river here. It is truly a magnificent wonder and as you descent into it you feel as though you are entering another world.

This crater wasn’t our destination today, though, as we were traveling to Empakai Crater, which is smaller, but equally gorgeous and is unique as you hike down into it rather than drive. It is north of Ngorongoro and is one of three large caldera that are the remnants of a vast volcanic range of mountains that also includes Kilimanjaro far to the east. The drive around the rim has to be one of the most scenic roads in the world as you have the crater constantly on one side and you are looking out towards Karatu on the side we are on or the Serengeti on the far side. You travel up and down the undulations of the rim, always with the chance of spotting animals along the way. Two years ago, we had a leopard jump out into the road in front of us and then slowly wander alongside our vehicle in full view. This drive is an amazing experience in itself.

Once we were driving along the rim road this morning, though, we ran into a bit of a problem with our vehicle. A constant squeaking that we had heard earlier, much like one of the many squeaks you hear on a twenty-year-old Land Cruiser, began to get louder and then we developed a loud clunking noise underneath the vehicle that was a bit more worrisome. The clunk eventually turned to a loud vibration that would develop when we hit potholes that are essentially constant on these had packed mud roads. I could get the vibration to stop briefly by slowing to a stop, but it would quickly occur again and we were eventually driving at a snails pace to keep it from being constant. I had gotten out twice to see what the problem was, but thought it was in the suspension and hadn’t seen anything. On the third look, though, I spotted the problem, and it wasn’t good. The cross bearing on the rear drive shaft just behind the transfer case had come apart and it didn’t look like it would make it much further if something wasn’t done.

Sharing compliments with Sokoine’s father

Becoming stranded on the crater rim wasn’t something I looked forward to as it has happened once before to me. Our choice was for us to turn around and hope that we could make it to the gate without breaking down or possibly limp another five or so kilometers to the Sopa Lodge and hope that they had someone there on a Sunday morning who could even look at the vehicle, and then the question would be whether they could even fix it. Either possibility seemed quite unlikely, but Sokoine, who studied tourist management before and had worked at several of the Sopa Lodges made a few phone calls and the prospect of having something done seemed to become a bit more encouraging. So we limped ahead towards the Sopa Lodge, driving about 30 kph maximum and, amazingly, made it to the Lodge with the vehicle still making forward progress, albeit at a fraction of my normal speed.

The mechanics had gone home for the day, but the manager made a few calls on his radio and we were instructed to drive back towards the staff housing where the “garage,” which was essentially a very small workshop with a compressor and a pit in the ground for the mechanics to stand in while they worked on the car. As we had pulled into the lodge, we had also discovered that we had a flat rear tire that also had to be repaired, but I eventually drove into the workshop on top of the pit and the mechanic got under the car to announce that, indeed, it was our driveshaft, but that he could fix the problem. The solution turned out to be taking the entire rear driveshaft out and then engaging the four-wheel drive that would essentially give us only front wheel drive since there was now no drive shaft in the rear. The remedy would allow us to drive, but having only front wheel drive in a massive stretch Land Cruiser wasn’t something I looked forward to, especially on these roads, some of which were quick muddy and rain soaked. Getting into any situation that would require four-wheel drive to extricate ourselves just wasn’t an option any longer, but that isn’t always up to the driver, unfortunately.

Handing out candies…

While the vehicle was being fixed, the others enjoyed the amenities of the Sopa Lodge, which arguably has the absolute best view of Ngorongoro Crater, and when it began to rain a bit, they sat inside the “Crater View Bar” which they had all to their own and had a picnic lunch. We were on our way after about two hours and, though, we had to abandon our plans to go to Empakai Crater as it was too far and remote to risk another breakdown, and we didn’t have enough time left to do it as the park gate closes at 6pm. Instead, we decided to just to go Sokoine’s father’s boma and visit his family. The short distance of six or so kilometers was a bit muddy, but we were able to navigate it safely and arrived to the small trail of a road that would take us to the boma. I drove a short distance and didn’t like what I saw ahead of us as the last thing I wanted to do was to get stuck in the mud here after all we’d been through. We unloaded the gifts we had brought and made our way the remaining short distance to the huts that were a short ways down the road.

Mindy learning how to build a hut

As we entered the boma, we were first greeted by children which is always the case and then by other members of Sokoine’s family. His father has five wives, four of whom live it he boma as Sokoine’s mother is living some distance away near Oldupai Gorge where he father used to travel occasionally, but no longer can given his age (he is 86 now) and arthritis. His father, four of his wives, most of his sons and some of their families (including grandchildren too numerous to count) all live in this enclave of mud and dung huts that is referred to as a boma. Small corrals for the animals at night are located in the center of the boma to protect them at night against the lions and hyenas, thought they still lose animals to these predators on a regular basis, there having been a hyena attack the night before with the lose of two donkeys and injury to a third.

We made our way through the boma to find Sokoine’s father and eventually did find him sitting beside his youngest wife’s hut with lots of grandchildren surrounding him. He is a small and aged man, but one can clearly see his profound character and prominence when you sit with him and talk. Wealth in the Maasai world is based on cattle and children and he has many of each. We gave him his gifts, which were promptly stored inside his hut, and then we roamed through the boma enjoying the many children who were thrilled to have the hard candies that Sokoine had brought with us for this exact reason. A few of the older boys were fascinated by my camera so I put the strap around one of their necks and showed them where the shutter was. He promptly took lots of photos as I had the shutter still on continuous mode, but that’s OK as we’re in the digital age and I knew that I could just delete the photos later. Several of the boys wanted to try the camera so I patiently showed each one how to use it and allowed them to play with it.

Sokoine and his father’s first wife


There is some grass between the huts where were wandered, but the majority of the ground is covered in reasonable fresh cow manure and most of the children run barefoot through it with little concern while we watch every step trying to collect as little of it on our shoes as possible. I’ve been here twice before and I always enjoy just watching the residents interact with the children and women here for most of the men are out with the cattle during the daytime. Eventually, we all went to have a seat with Sokoine’s father inside his youngest wife’s hut. There was an outer area inside the hut that we first sat in a all shared a drink of the Konyagi, a strong gin that is made in the country and is very cheap, that we had brought as a gift for him as Sokoine made sure we know that true friends do not visit a boma without this gift in addition to the other many supplies we had brought like cooking oil, beans, sugar and such. I sat next to his father who recognized me from my previous visits and we exchanged complements with each other. After this, Sokoine took the others further inside the hut to see the living area where there are beds, room for some animals and a fire to burn for warmth. It is a very simple existence with absolutely no amenities. They bath outside using well water, milk the cows in the morning for their drink and occasionally slaughter a goat for their meat. The normal sustenance is ugali, which is the still porridge that is made from maize and is eaten either with vegetables or meat.

After their tour of the hut, we all again sat with his father and everyone got to ask lots of question, though Mindy was by far the most curious, having many excellent questions about their culture and religion, and, thankfully, stayed away from any of the more difficult questions such as women’s education and female circumcision, that is still practiced in the bomas even though it has been outlawed by the government. These questions would not have been appropriate to ask in this setting for certain, though they are huge issues that must eventually be tackled by the Maasai.

As we had to get back to the gate by 6pm, we eventually had to say our goodbyes to everyone at the boma, though the children all followed us back to our vehicle, still waving as we backed out of the small trail we were on and onto the main road back to the crater rim. We still were not home free as the road was quite slippery in some places so there was still the challenge of making it back around the rim and down to the gate in time. We eventually came to one incredibly slippery uphill section that I tried twice to get up and finally had everyone get out of the car to make my third attempt a bit lighter. Just before I got underway, a safari vehicle came down and the driver offered to take it up the hill for us. He did so successfully, and even though my machismo may have suffered a tad, I was just happy that the vehicle was now on the other side so we could be on our way.

I drove like a banshee for the remainder of the distance and, even with that, we made it to the gate with just ten minutes to spare as they close the gate at 6pm sharp and you have to pay for an additional day to get out, something that none of us would have been very happy about. We all felt the sense of having survived something meaningful, though, as we were all nearly stranded in the crater on several occasions and, given the remoteness of this area, that is a feat certainly worthy of a great accomplishment. We all cheered as we passed through the gate with minutes to spare, still with forward progress in our hobbled Land Cruiser, the little engine that could. We went into town directly to a local restaurant for some nyamachoma, or, literally, burnt meat, which is their version of barbecued beef or goat. We had a mixture of both, along with some chips, or French fries, and some beers and were all totally satisfied with our wonderful day, despite the challenges that may have made it all that much more satisfying to each of us. It was really an incredible day all around.

Saturday, March 17, 2018 – St. Patrick’s Day in East Africa


A Maasai family member washing clothes in the morning

Susan catching up on charts

Today is our last day of the big neuro clinic at FAME, which is the one that we announce to the town of Karatu and surrounding communities with the hope that we can have most of the neuro cases come in during these six days. Next week we’ll begin our neuro mobile clinic, traveling to the more outlying villages where FAME may still be accessible to patients by taking the local dala dala (mini bus taxis) or larger buses, but patients don’t often realize that they have a treatable neurological problem so that I look at these mobile clinics as something to educate these remote communities of what we do. As I have mentioned before, the clinic has been lighter than normal with the early rains, though we’ve still had some very interesting cases and it’s given the residents a chance to catch up on their Swahili and Iraqw.

Mindy and Dr. Julius examining a patient

Mindy and Dr. Julius examining a patient

Once again, I knew that a friend from Arusha was coming today and bringing several patients with him so that was a plus. We had lots of peds today for Susan and she was quite happy about that aspect of the clinic. Two young boys who were brothers were seeing her this morning and were quite interesting as the younger brother had very clear febrile seizures with a very normal developmental history and examination. The older brother, though, had epilepsy that from a seizure semiology standpoint was very much localization-related as the seizures had clear focality with head turning and he had been on carbamazepine that was working quite well for him. The significance of all of that is that we would have expected the two to have a more common primary generalized epilepsy if this were indeed a genetic epilepsy, but the fact that that the older brother had focality to seizures and that he had responded to carbamazepine, a drug that morning makes primary generalized epilepsy worse and which is avoided typically avoided in these patients.

Susan and Baraka evaluating a patient

Susanna teaching Dr. Julius how to test for reflexes

This is the place where an EEG would be invaluable in both children, as it would have easily answered the question for us on the spot. Unfortunately, the EEG we have here is no longer operational, though hopefully this is something we will once again have available here in the future. Had the younger brother not had a sibling with epilepsy we would have merely diagnosed him with simple febrile convulsions and that would have been that. But with the older brother’s diagnosis, it would certainly increase his risk of developing epilepsy in the future, but not to the degree that would lead us to treat him at this point. We did suggest that he could get an EEG at Kilimanjaro Christian Medical Center in Moshi, which is the only center in Northern Tanzania with those services, or possibly Nairobi, though it wasn’t entirely necessary at this time. At the end of the visit, I had mentioned that they could contact me through my friend in Arusha who had brought them, but it turned out that they had actually come on their own as their father comes to FAME for his medical care and had been here on Wednesday and had seen our notices of the neuro clinic, so had decided to bring his two sons to see us today. We were so happy that they had come, though, as the younger brother may have been put on medication prematurely had he been seen elsewhere.

Mindy and Julius evaluating a patient

Mindy and Baraka evaluating a patient

When we did finally get to see the patients my friend had brought from Arusha, one was a young four-year-old child who had spina bifida, a neural tube defect that can be of varying severity and most often is an incidental finding, but can also, in much less common cases, involve the lower portion of the spinal cord leaving a patient with severe neurological deficits. This young girl, unfortunately, had the less common, more severe form of spina bifida, causing her to have a flaccid paralysis of her legs as well as complete loss of bowel and bladder function and had had surgery on her back just after birth. In addition, she had had hydrocephalus at birth requiring a ventriculoperitoneal shunt so most likely had another condition called an Arnold-Chiari Type II that is very commonly found in association with the more severe forms of spina bifida. She was clearly delayed developmentally in addition to her other neurological deficits, but was very interactive with good speech.

Susanna checking someone’s gait

Dr. Frank and Johannes discussing a case

In addition to the life altering neurological deficits that she had, the other very sad issue was that her parents came here with the hope that we would have some type of treatment for their daughter. When Susan asked what their expectations were and they replied that they hoped that something could be done to help their daughter eventually walk and be independent, Susan’s heart dropped as she had to tell them that she would never walk, but could someday hope to use a wheelchair and still have some independence, perhaps. Though you can never be entirely certain as to what patients and families have been told in the past as people often hear what they want to hear, her parents were quite clear with us that they had never been told this before so I am sure that it was quite devastating for them to have heard this in no uncertain terms. Susan waited some time for them to digest the news that she had given them and then allowed them to ask as many questions as they had. There is absolutely no difference culturally in this part of the job and we could have easily have been at home delivering the same devastating news to parents with the very same reaction. This is not an easy part of the job, but is a very satisfying one when you are able to spend time and deliver the news with empathy and grace.

Our neurology waiting room

Mindy and Julius with a patient

Meanwhile, Johannes was in the ward for much of the morning with a difficult patient that we had been asked to see for symptoms that were more concerning for a psychogenic illness, though after seeing him it was not so black and white. The young man had been having episodes that had been very anxiety provoking for him, but were felt to very possibly be cardiogenic in nature and related to either drops in blood pressure or alterations in his heart rate with the episodes. There is a disorder known as postural orthostatic tachycardia syndrome, or POTS, that is often the bane of neurologists, as it is unclear from our standpoint that it even exists, yet is so very often diagnosed and patients are labeled with this. Johannes felt very strongly, though, that this young man had some condition that affecting his blood pressure and pulse that were causing his episodes and that they were not purely psychogenic in nature. It was very helpful as this had been a significant management problem previously for this patient and now at least they would have something to focus on as far as treatment options going forward. These are quite often very difficult situations to figure out and there is often much that is lost in translation with the language barrier when trying to make these distinctions that are so important as they greatly affect the management of these patients. We do see quite a bit of psychogenic illness here, easily as much if not more than at home, and it can very often be quite challenging.

The heavy rains just outside our exam rooms

The heavy rains just outside our exam rooms

Susan had plenty of children today to fill her schedule and at one point, realized that she was behind in her charts and needed to do some catching up so it is clear that some things don’t change whether you’re on electronic records or not. During the middle of the day we had a tremendous thunderstorm with lots of lightening and thunder that seemed to be right on top of us dumping buckets of rain with bright flashes of light followed by their thundering booms that shook everything and could be felt throughout your entire body. For at least half an hour, it seemed like the heavens had let loose with all they had to give at the moment. As quickly as it began, though, it ended and the mud and puddles quickly dried as if nothing had happened and the world was right again. Blue skies and sun eventually appeared and we were quickly back in paradise.

Susan and Baraka evaluating a young child

Susan’s pediatric patient

We are prepared dinner here at FAME during the weekdays, but on weekends, we are left to fend for ourselves. The weekday dinners are quite delicious and healthy, for the most part, except for perhaps the mac and cheese that is a bit more westernized and unhealthy, but is still quite tasty. We had discussed celebrating St. Patrick’s Day here (yes, I had worn green and changed my name to O’Rubenstein for the day), but both Mindy and Susanna were both feeling a bit under the weather and we had plans to go to Empakai Crater tomorrow, so instead, we all went out to Happy Day for dinner, where we did find others, but certainly not a celebration by any standards. Happy Day has quite reasonably priced, mostly western food that includes delicious Pizzas, Tanzanian style. Not much tomato sauce and toppings that are a bit different, but all in all quite tasty and something that certainly hits the spot when one is craving it. Mindy and Johannes had burgers that were apparently very good. Susanna had stayed home for the evening as she wanted to get some sleep before our trip tomorrow, but she didn’t miss any celebration as there was only one other group of volunteers there and certainly no festivities to speak of. I think we were all a bit tired after the week of seeing patients so we chose to head home instead and relax for the rest of the evening. We weren’t leaving at the crack of dawn so that meant that at least we’d have an extra hour or so of sleep.

Johannes and Emanuel evaluating a patient

Johannes and Emanuel evaluating a patient




Friday, March 16, 2018 – An interesting stroke syndrome and a slippery walk…


Our patient arriving by vehicle

We were on the home stretch for our weeklong neurology clinic at FAME and, to date, it had been a rather slower than usual clinic. It’s always hard to predict what the volume of this clinic will be beforehand as it can be affected by so many variables. I know that Alex and Angel had gotten the word out to the Karatu community at large as well as to all of the mobile clinic sites, but even with the excellent outreach team we have working in advance of our visit, the other factors involved are well out of our control, such as the weather, harvest time and, at other times, politics. In October 2015, we were unable to do our mobile clinic due to the national elections and many patients were fearful to travel to clinic out of concern for their safety. Most recently, though, we are having more rains than we’ve had in the past during this month which is the main reason for the lighter than normal clinic volume. The orange-colored clay of Karatu turns to pure muck during the rains and makes travel often very difficult, if not impossible. During the heavy rains yesterday, I was very surprised to see the patients that came, but was very happy they did.

…and being loaded onto a stretcher

At the start of clinic today, the stroke patient we had seen previously had come back to have her INR (a measure of how thin her blood was from the warfarin she was taking) checked and was booked into our clinic again even though we hadn’t planned to necessarily see her back. It was good that we did, though, as she had been put on a medication to treat her stiffness and it was working rather well so that we could adjust the dose upwards and she would get yet greater benefit. This is often such a problem here as many medications are meant to be titrated to effect or they have to be started slowly so a patient can adjust to any potential side effects. Trying to do this in the absence of a neurologist here isn’t ideal and is something that I am hopeful to address in the near future by possibly training practitioners who can care for our patients in our absence and following through with our recommendations. So often, we see patients back after six months and nothing had been done in the interim. Hopefully we can help to change this going forward.

Johannes, Susan and Baraka evaluating a patient

Johannes’ favorite patient of the day was a gentleman who came in after a stroke, but it was a very unique syndrome that Dr. Price, Penn’s residency director, loves to focus on because of it’s importance when trying to localize lesions. The gentleman had severe right facial weakness of sudden onset that was quite atypical for a Bell’s palsy, or facial nerve palsy, that is so commonly seen. The other unique feature of his examination was that he had abnormal eye movements, and, specifically, a sixth nerve palsy on the same side. This is caused by a brainstem stroke that hits the sixth nerve nucleus and the facial nerve fibers and they travel around the sixth nucleus. The gentleman had actually had an MRI done and there was a lesion in just the right location, but it hadn’t been read as such, and, so for us, it was a great case. It had actually occurred only a month or so ago, so we were able to institute so secondary prevention therapy that might help him in the long run. He was a very nice man and it was a pleasure to not only have helped to treat him, but also to be able to explain to him definitely what had happened and what his prognosis was. Of course, even though he spoke good English, it was still challenging and took much longer even with that. Thankfully, we weren’t tremendously pressed for time today.

Baraka with his two language students

Mindy and Susanna continued on their quest to not only master the neurologic examination in Swahili, but also in Iraqw, as they are neck and neck with the Maasai in regard to the patients we see here. We really don’t have a full-time Maasai translator to teach them Maa, so they will have to be satisfied with those two languages for now. Given that, though, they have become extremely proficient in Swahili and Iraqw and they continue to amaze me. Susan and Johannes have also picked more than is usual for the residents on this trip, but the other two have excelled.

Mindy teaching Dr. Julius how to do occipital nerve blocks

The rest of the day was filled with our normal smattering of developmental delay, headache, epilepsy, and back pain, and Mindy was even able to do occipital nerve blocks on a patient with occipital neuralgia and show Dr. Julius how they are done. This is a technique that we use often at home to manage our headache patients who have a significant posterior component to their headache or more classic occipital neuralgia and it is often very helpful in relieving their symptoms. We have had the supplies here to do these and over the last four years have found them equally helpful here as they are at home.

Mindy seeing a patient with Dr. Julius’ help and Susan scribing

Susanna evaluating a patient

With the light patient volume, we were able to get home at a decent time and though I was still behind in my blogs, I offered to show Susanna and Mindy where we normally do our walks from the house here. There is a gate at the bottom of the slope behind our house that lets you out onto the road traveling around FAME and takes you further from town and finally out to the fields behind our compound. It was quite muddy and there was no way we were possibly going to take the normal circuit, but there is a part of it that would be possible even with the mud. So we began walking and eventually climbed the hill to where Caroline, the development coordinator and someone who’s been here as long as I have, lives. From her property, you can also see the new private school she has built, and so we continued our walk in the direction of the school. It was a gorgeous evening to be out walking despite the muddy roads, or at least I thought so until I took a misstep and slipped, almost catching myself, but alas, didn’t, coating my hands and pants in the sticky goo that is the Karatu clay. Thankfully, no injuries other than my pride, and we continued the walk back home with one of us a bit more distressed in the furniture or fabric sense of the word.

Johannes conferring with one of his patients one last time before they leave

Mindy examining a patient with Dr. Julius’ help while Susan scribes

Everyone was happy to remain home this night, though Susanna and I made a quick run into town to the exchange bureau where we get TShillings for dollars, only to find our normal exchange closed and were directed to another down the block that I hadn’t know about before. I had had to replace the battery on the Land Cruiser and needed to pay the mechanic in the morning when he brought the car back to us.

Johannes evaluating a patient with Baraka’s help


Thursday, March 15, 2018 – Dinner with Daniel Tewa and his family…


It had begun to rain in the early morning hours well before 5am as basically everyone had heard it in his or her slumber. It remained heavy and relentless well through the morning hours so the walk to clinic was a wet and muddy one that required full rain gear and mud boots and, despite this, kept only half of the water and dirt out it seems. When it rains like this, it is difficult for most patients to make it to clinic as the roads become very treacherous and walking, the main mode of transportation for patients we see here isn’t feasible. Thursday mornings are now reserved for the Tanzanian doctors to give a lecture on a specific topic and this morning, Dr. Badyana was speaking about the surgical treatment of appendicitis. We had all been out late and some of us later than others, but Susanna, Susan and Mindy were determined to make his lecture on time, which they did, and Johannes and I were much slower to move so straggled in a bit later. Having to make a lecture at 7:30am requires a very dedicated and concerted effort, neither of which Johannes nor I had that morning.

Susan and Baraka taking a history

I knew that we had at least one patient who a friend had referred from Loliondo, a district that is accessible primarily by the Lake Natron road and is north of here near the Kenyan border. It is a very remote area with few resources and I have visited there once before a few years ago. It is very dusty and dry, but absolutely gorgeous in that very rugged sense and totally worth visiting if you were ever to have a chance. The Lake Natron road travels through some valleys and by the foot of Ol Doinyo Lengai, or the Mountain of God, and is a sacred mountain to the Maasai. It also erupted in the not too distant past, so still has Lava flows that drape over the top of the mountain and radiate downward from the cone traveling to the base of the mountain. There are places on the road where you are driving over crazy rock formations, often with very little shoulder to them so there is little room for error. It is not exactly rock hopping, but it comes very close and is certainly not for the faint hearted.

Susanna examining a patient with Emmauel

We had some very interesting and diverse patients this day, most of which were quite determined considering the long rains of the morning and the difficulty in getting here. Susanna and Johannes evaluated a young woman who was having episodes of loss of consciousness that had previously been diagnosed as seizures, but clearly were not. The episodes also raised concern for PNEE, or paroxysmal non-epileptic events, that used to be referred to as pseudoseizures and a type of conversion disorder and usually not malingering as was often thought to be the case in the past. These events are obviously not treated with anti-epileptic drugs, but there is one caveat; a significant percentage of patients with PNEE also have underlying epilepsy that complicates the issue of diagnosis. At home, we’re often admitting these patients to the epilepsy monitoring unit, or EMU, which is an inpatient unit where the patients remain on continuous EEG monitoring with the hope of capturing an event. It goes without saying that there is nothing similar to an EMU here or probably anywhere in East Africa. Having had the EEG machine here back in 2015 was such an amazing resource, but, alas, it is no longer operational and has yet to be replaced. In the end, though, this young woman’s events were also concerning for syncope, or loss of consciousness that is related to perfusion of the brain due to a drop in blood flow, so we decided to get both an EKG and echocardiogram on her to rule out this possibility, both of which were normal.

Everyone getting into the action

A young child that Susan say this morning had a very interesting combination of developmental delay and epilepsy that fit the phenotype of GEFS+, or generalized epilepsy with febrile seizures plus, that is a genetic disorder and requires specific medications to be avoided, that are unfortunately nearly every medication we have available here and are the medications that are the least expensive. Perhaps the most common medication we are using in the US currently, levetiracetam, is the most expensive anti-epileptic here and is nearly impossible to use due to that fact. The reason it is used some commonly at home is because of its versatility in the seizure types it can treat along with the low likelihood for interactions and side effects. The least expensive medications here are the older AEDs that are being used less and less in the US. Phenobarbital, which is still the first line AED listed by the WHO, has many, many side effects, especially for developing children and is really something we try to get most patients off of when we see them. It is also known to make patients with generalized epilepsy worse rather than better so that is another significant issue. In the short time that we were doing EEGs here, we found a great number of patients with primary generalized epilepsy in whom you would not want to start phenobarbital.

Susanna checking a patient’s postural stability

There was a family who came from a great distance to be seen today by Frank in the general clinic and he had asked us to evaluate an older woman among them who he noticed a tremor in. The woman clearly had a significant resting tremor that was not disabling and Susanna also found some subtle abnormalities of tone suggestive of possible Parkinson’s disease. The findings were subtle, though, and we didn’t feel that she required carbidopa/levodopa as this medication provides only symptomatic relief and primarily related to rigidity or increased tone, which she really didn’t have. The woman also had an abnormal gait that turned out to be from a monoparesis, which was the result of childhood poliomyelitis affecting only leg. None of the residents had actually ever seen a patient with a dramatic monoparesis and wasting of a limb as the result of polio.

Johannes and Baraka evaluating a patient

One of the families seen today had a young boy with severe autism and developmental delay, but also with episodes that bore some concern for epileptic events. They really hadn’t found any good support systems for their child as they do not live close to other relatives and schools for this type of problem were far too costly and would be prohibitive. Later, we were given the name and number of a women living in Moshi, near Mt. Kilimanjaro, and who could possibly help them significantly or at least know someplace that they could go to for that type of rehab that might be closer to home for them.

Mindy and Susanna evaluating a patient with Baraka’s help

With the long rains of the morning, the patient volume was only moderate and we were able to finish up clinic a bit early, which was good as we had plans to visit Daniel Tewa and his family tonight for dinner. I’ve written about Daniel so many times on this blog that I don’t want to bore those of you who have read about him before, but our visits with him are so significant that I can’t help but expound on it for those who are new to the blog. I fist met Daniel Tewa when I was here in 2009 with my children and we had asked to do a bit of volunteering as a part of our safari. We spent that time in Karatu (which is when I was introduced to FAME and Dr. Frank, and, as they say, the rest is history) working at the Ayalabe Primary School helping to repaint the school buildings. Daniel, being an elder in the village, had been asked by Thomson Safari to be a liaison for us, so we spent three days with him working on the school. There was an immediate friendship created and when I came back the following year to work at FAME, I had contacted Daniel to reconnect and it was almost as if I had never been gone.

Daniel helping Susanna model an Iraqw wedding skirt

He invited me for dinner that trip, and I have gone to his home to have dinner with his family ever since, and now bring my residents to meet them. It is a wonderful friendship that we have and Daniel has been so gracious to open his home to us as this is an amazing experience for the residents who accompany me making this not only a medical mission, but also a cultural experience so we get to know more about the people we’re seeing every day to who we are providing treatment. That is such a very important part of global health as you much have some understanding of the people here and their lives to be able to provide them care. Though the basic principles of medicine may be the same wherever you are, your ability to apply them and to provide patients with the information they require to make those important necessary decisions relies heavily on that understanding.

Dinner at Isabella’s

We sat out in front of Daniel’s house as I had nine years ago when we first met and drank the wonderful African coffee they serve here, in which the coffee is boiled with fresh whole milk. It is mostly milk, but it is rich and tasty for even those not used to drinking coffee. We also had avocados from their garden that we sliced in half and ate with a spoon as they do here. All of this while discussing everything from politics, both US and Tanzanian, to the intricacies of the Iraqw culture and their history. It was dark, but we managed to spend time in Daniel’s authentic Iraqw house that he built on his property back in the 1990s as a reminder of the type of home in which he grew up. It is underground, which was for protection against the Maasai whom they were always battling with, and provided shelter to an entire family along with all of their animals so they would not be stolen in the night. The Maasai and the Iraqw signed a treaty finally in 1986 ending their conflicts that were quite real prior to that.

Susan and Baraka evaluating a young patient

When it was time for dinner, we all walked down the road to his daughter, Isabella’s home where we would eat as the group has become larger than can be served in the small living room of Daniel’s Bantu home. It was a wonderful dinner that was served to us by Isabella and two of Daniel’s neighbors who had come to meet us. Daniel has always reminded us of what a true honor it is for his family to serve us in this way, and I have always reminded him of how grateful we are to his family for providing us this friendship. Everyone there, whether American or Tanzanian, was truly moved by the experience and I knew there would be a lasting impression on everyone. We drove home through Karatu, which is always a challenge at night without streetlights and with every headlamp misaligned and seemingly pointing right into your eyes, as the faint shapes of people, and sometimes animals, are dodging in front of you to cross the street. Up the bumpy and muddy road to FAME and we are home, everyone happy to have had the wonderful experience of dinner with Daniel Tewa and his family.


Wednesday, March 14, 2018 – A day of wellness and so much more…


I had designated today as a wellness day for the residents. Now you might just ask yourself, “isn’t everyday in Tanzania a wellness day?” and you would be entirely correct in your assumption, lending yourself to the expected follow up question that would be, “why would anyone need a wellness day in Tanzania?” In fact, these were exactly my responses to Ray Price when he asked me to schedule these days for the residents here on rotation, but it actually turns out that the GME (graduate medical education) office had asked all residency programs to schedule these days into the resident’s schedules and who am I to buck the establishment when it means accompanying the residents on their half day off.

Johannes and Mindy outside clinic

But first, we had plans for clinic in the morning and would finish by lunchtime so that we could make it to Gibb’s Farm for their fabulous buffet lunch. Now mind you, I had absolutely nothing to do with the fact that the residents chose to spend their wellness day at Gibb’s Farm having a wonderful lunch, but anyone who knows me has already realized that if I did have any say in the matter, this would have been it. OK, back to clinic….

Angel, our fearless leader

Mindy’s favorite patient of the morning was gentleman who had eight different complaints and was not very happy when she tried to narrow them down to those that were the most important and were neurologic, which of course is what we are supposed to be doing here. We certainly encounter this issue in the US when we’re seeing patients and it can be very similar here at times. Our job is to try to get the patient to focus on the issues that are most bothersome to them or the ones that we feel are the most likely to do them harm. Fortunately, Mindy’s patient had no life-threatening issues, but unfortunately, he did have quite a few that were bothering him. We ended up treating him for neuropathy as he was a diabetic with poorly controlled blood sugar along with headaches, so amitriptyline, our most commonly prescribed medication here, would work well for him as it would treat several of his problems quite well.

Johannes and Mindy chatting with Dr. Julius

Drs. Ivan and Asanga chatting with Jacob

We were able to wrap up the morning clinic with little time to spare to begin our trek up to Gibb’s, when I discovered that there was a patient who had traveled from Arusha and who would need to see us for an assessment. Since it was getting just a bit late and I didn’t want the resident to miss out, I told them to go ahead with one of the FAME drivers and I would meet them there. It ended up though that the patient had nothing acute neurologically and had actually suffered trauma several years ago so there was very little I had to offer. I gave my recommendations to Frank, who was also planning to see the patient and I arrived back at the house just as the FAME driver was pulling up. It was a pretty comical scene, but I asked him to wait to make sure our car started, but he understand me and drove off just as I was trying to start the Land Cruiser, which, of course, didn’t start. We were eventually able to get someone over to jump the car and as we were finally getting under way, very much later than I had planned, it began to rain on us.

Susan on the ward discussing her patient with Drs. Badyana and Mbogo

I typically take a very nice short cut to get to Gibb’s and, since we were running late, decided to do so today as well. As soon as I got up on top of the slight ridge it rides upon, the road suddenly became mush so that it was a pure slip and slide trying to stay on the road and required that I drive mostly in second gear and, at times, first gear just to keep from having to hit the brakes which would mean a definite off road excursion in the pure muck. It probably took us twice as long to get to Gibb’s as I had to take some different routes to keep from getting stuck and drive so much slower than normal. The drive seemed like an eternity and when we finally reached Gibb’s I took a very deep breath and let out a huge sigh of relief.

Johannes and Dr. Julius examining a patient

Once there, the blue skies opened up and it was once again gorgeous, so much so that we were able to eat out on the veranda looking out over the valley and once of my favorite places on earth. The lunch buffet at Gibb’s is a wonderful feast of mostly local dishes and all grown on their farm there. There were cheeses, breads, a ginger carrot soup, quiches, many salads, samosas, grilled chicken and so much more. And then there was desert. We all just relaxed in the shade of the umbrella over our table and enjoyed the good food, good company and unbelievable scenery.

Susan and Susanna evaluating a patient with Baraka’s help

We had plenty of time after lunch for another adventure, so it was decided that I would drive everyone down to a friend’s gallery in the town of Manyara where everyone could buy gifts for family and friends. There are so many amazing crafts here from the local tribes with beautiful jewelry and carvings that are probably the nicest. We were in no rush so everyone had plenty of time to spend shopping to his or her heart’s desire, although the shop was closing up around 5pm, so there was a bit of a deadline, I guess.

Johannes evaluating a patient with Dr. Julius’ help

Once finished with the shopping (of which there was plenty), we headed home in time for dinner as we had plans later that night to meet all the other volunteers in town at Happy Day, the local pub where everyone meets on here on Wednesday nights. Everyone enjoyed the night out as we later moved on to the Golden Sparrow, which is the new club in town that was opened by the owners of Carnivore. Carnivore, a place of lots past memories, was a fine joint that served only grilled chicken, chips (French fries) and fried plantains. The Golden Sparrow has all the same food, but also a separate dance club, which was our destination that evening. It was quite crowded for a Wednesday night, but everyone seemed to be watching a soccer match and had less concern with dancing, though we well made up for any lack of enthusiasm by the locals. We all made it home safely that night and with a 7:30am lecture on management of acute appendicitis, it wasn’t going to be a long night of sleep.

Enjoy the sights and sounds of our precious weavers here at FAME


Tuesday, March 13, 2018 – And a few more neurology patients….


Tuesday mornings at 7:30am have traditionally been reserved for volunteers at FAME to give a lecture on a topic that would be useful for the doctors here to help with their practice. We have obviously repeated many of the topics, as there are only so many general neurology topics for us to cover for the practitioners here. Remember, most doctors here have never worked with a neurologist, often even in medical school. In all of Northern Tanzania, there is one neurologist currently at Kilimanjaro Christian Medical Center in Moshi, and up until several years ago, the neurologist there was not fulltime. Never having worked with a neurologist, or ever having seen a neurologist perform a neurological examination would be a huge disadvantage in caring for these patients as our specialty is so driven by the history and physical examination rather than testing. I so enjoy teaching the neurological examination to medical students and residents and can still remember all of my mentors as I was training. I cannot imagine not having received that wonderful and empowering knowledge of the physical examination from these superlative teachers and then having tried to go on and do what I do today. Having had to learn it form a textbook or even from a non-neurologist would not have been the same and I’m not sure I would have chosen neurology as a career had it not been for that long line of mentors that began in medical school and continue even into the present.

Absolutely an Academy Award best actor nomination worthy performance

Susanna and Susan chose to speak about epilepsy this morning, and though we have given lectures on this topic several times before, it is always presented in a slightly different manner and always contains new information for the doctors here. They can never learn enough about this topic that is so prevalent here in Sub-Saharan Africa, likely due to the frequency of childhood illnesses and trauma that are also so prevalent and increase the risk of developing epilepsy over ones lifetime. That being said, when Daniel Becker brought her EEG machine here in 2015, we found many patients with primary generalized epilepsy that is more commonly genetic in nature rather than symptomatic. Their lecture this morning was organized around taking a seizure history and what information is important to ask when evaluating a seizure patient. To do this, Susanna gave an academy award worthy performance of a patient having a focal seizure progressing into a secondarily generalized seizure and then the two of them launched into a discussion of what the doctors had observed and what questions they would ask of a family member who had possibly observed the event. It was really a very helpful discussion and, though it usually hard to get the full participation of the often doctors here (it is also quite early as these talks commence at 7:30am), I thought they did a wonderful job of garnering their attention so there were many great observations and questions. Or perhaps it was just the shock of having seen Susanna have a full-blown seizure right in front of them that early in the morning. Regardless, the lecture was well received which is usually determined by how long Dr. Msuya allows the questions to go on after the lecture which has usually gone over the allotted time cutting into our morning discussions of the ward patients (sit down rounds).

Susan and Susanna giving their epilepsy lecture

Patients this morning this morning were quite varied and one of Susan’s first was a young three-year-old child with developmental delay, macrocephaly and seizures. The child clearly had frontal bossing (meaning their forehead was quite pronounced and bulging forward that is seen in children with hydrocephalus and increased intracranial pressure) and, perhaps even more significantly, had what appeared to be bilateral sixth nerve palsies, meaning that his eyes both inward leaning due to the loss of the lateral rectus muscles supplied by the sixth nerve. The significance of the sixth nerve palsy is that it is the nerve that has the longest intracranial path and is frequently stretched or injured in patients with increased intracranial pressure. The baby looked very good, but we definitely had concerns that they might still have active hydrocephalus that might benefit from a shunt. This is the one neurosurgical procedure that is easily available here and so, if present, we would definitely want to know about it as we could intervene.

Susanna and Susan giving their epilepsy lecture

Radiology (and other procedures) are not covered in our “all-inclusive” price for the neurology evaluation (5000 TSh or less than $2.50) which includes blood tests and medications for a month, so having a discussion about obtaining a CT scan that costs just shy of $100 USD can be very difficult. FAME does not turn away patients who cannot pay, but they do charge for services as to open an entirely free clinic here would be unsustainable as you would soon be taking care of the entire population of Northern Tanzania, and perhaps further away, as everyone would flock from every corner of the country to come. There is a very delicate balancing act here between maintaining some status of fee for service, although that is not even sustainable without significant outside support, and making sure we provide treatment for those in need. Thankfully, we have Angel here, who can help sort things out in these situations. We presented the options to the family and our recommendation that the child undergo a CT scan of the head to look for hydrocephalus. There were very open to the idea and understood our concerns, so we proceeded to get the baby ready for the CT scan, which is not a small undertaking in a toddler. They are no quieter than an infant and are less manageable as they are much stronger. We sedated the child after an IV was finally place and put them on the CT table, but as they went to inject the contrast after the plain scan was done, the IV was found to not be working and we were only able to complete the non-con study.

Johannes and Baraka evaluating a patient

The child didn’t have overwhelming hydrocephalus, but the scan was also not normal. There was asymmetry of the ventricles that were larger than they should be and this seemed to be more consistent with arrested hydrocephalus, though, the sixth nerve palsies still worried us. Susan sent images from the CT scan to the US for one of the neurosurgeons at CHOP to review and would hopefully get back to us with some guidance shortly.

Caught in the act… as Baraka and Emmanuel look on

Sometime after lunch, Frank came over to tell me about a patient who had come with her family from ten hours away and who had been seen yesterday with complaints of left arm pain. He had injected her, but her pain continued and she had come back to take care of some other medical issues. He brought her over and asked in typical Frank fashion if he could consult with me on a “neuro-orthopedic” case. After I heard the story, I took my normal course of action, which is to deny any and all accountability, for his patient or the “non-neurological” problem she would very likely be suffering from. As she walked over in my direction, I immediately noticed that she had a very distinct and unquestionable drooping of her left eyelid. For a neurologist, this is a very, very bad combination of symptoms, perhaps second only to the patient coming in complaining of twitching in all of their muscles and who happens to be a “really nice person,” as they will usually have amyotrophic lateral sclerosis (ALS) or Lou Gehrig’s Disease, a terminal condition from which patients usually die within several years. This patient, though, had a combination of findings that makes us immediately concerned for a tumor, usually lung cancer, in the apex of the lung that erodes into the brachial plexus, or network of nerves supplying the arm, and the sympathetic nerve supply going to the eye and causing a Horner’s syndrome.

Johannes and Baraka evaluating a patient

As soon as I walked in the room with Susanna and Mindy and said they were going to see patient with arm pain and a drooping eyelid, they both immediately knew what to be concerned about. The woman had had the symptoms for about a year or slightly less and both the arm pain and the drooping eyelid had begun at approximately the same time, making us even more concerned than we had been before. She had no weakness or other physical findings other than some swelling of the left arm and she had apparently had some surgery in the left axilla about five or so years ago, which was a bit of a confounding piece of information, but didn’t lessen our overall concern very much. The way to diagnosis this problem is, of course, a CT scan of the chest, which will reveal a mass in the apex of the left lung and typically bony erosion into the chest wall as well. When we discussed our concern with the patient and her family member also present, they had very little hesitation whatsoever in what was necessary to do, so we prepared to do the CT scan in very short order. I looked at the scan myself and couldn’t really see much of anything, but I will be the first to admit that CT scans of the chest are absolutely not my forte and not even close, for that matter. We would have to wait for the radiologist back home and who is reading FAME’s CT scans to look at the films and get back to us and this would be some time due to the time difference.

Mindy and Emmanuel examining a patient

We eventually received word that the there was no mass in the left lung apex, but he did see some questionable inflammation in the left axilla and this, unfortunately, could merely have been residual from her prior surgery. I’m really not certain we were able to get an answer on this one, which was very frustrating to all of us, and especially Dr. Frank, who keep asking me “well, what’s next?” I didn’t really have a very good answer for him and, as usual, he was less than thrilled with this fact and, somewhat jokingly, probably wonders what good we are at times. All joking aside, though, we are often limited in our ability to explain everything, and that includes being in the US, where we can do a multi million-dollar workup and still not have the answer. Here, it is much more common as we do not do things just to find an answer, but rather to benefit the patient, meaning, that if doing a test won’t change your management or the management necessary is not available in this country or not accessible to the patient, then we elect not to waste valuable resources for either ourselves or the patient.

Susan and Baraka evaluating a patient

We finished a bit earlier today and elected to head home to get work down in our wonderful home with it’s veranda looking over the beautiful hillsides in the far distance. Everything is green and plush right now with the changing over to the wet season soon to come in April and May. Tomorrow is a resident wellness day meaning we will work just in the morning and have plans for lunch at Gibb’s farm mid afternoon. That is something that can definitely be dreamed about as I’m sure each of us did that night, heightened to some degree by the effect of the Mallarone each of us is taking that gives you very lucid dreams.