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.

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’ 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.

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.

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.

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.

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.

 

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

 

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.

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….

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.

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.

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.

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.

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.

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 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.

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).

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.

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.

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.

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.

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.

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.

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.

 

 

We had had such a wonderful safari the day before that I think everyone was still reliving thoughts of elephants and Cape buffalo, some of whom were chasing us. Most had gone to bed early, exhausted from the busy day of travel, and now we were ready for the week ahead that would bring us the bulk of the neurology patients for us to see as these were the days announced to the community and the far lying reaches of Karatu district. Alex had worked on most of the announcements and had traveled as far as Lostete, the village that sits far along the rift in the Mbulumbulu region at the very end of the road. We have plans to visit there in October, but now the road is not suitable so the patients from that village will travel to Upper Kitete, the village where we have held neurology clinic now for the last six years. Mobile clinic will begin next week, though, and for now, we are focused on the patients that have traveled here to FAME. Last week, we had seen patients who traveled from as far as Dar es Salaam to see us, a twelve-hour bus ride. I’m sure we’ll see many more that have come from similar distances or who have made more difficult journeys.

It had rained some overnight, so the volume of patients at the clinic at the start of the morning were much less than you typically see on a Monday morning, but from past experience, I knew that we’d see more patients come as the day went on. I had been introduced to someone in Arusha last week who had already called me this morning that he was on his way with two of his family members for us to see so I anticipated their arrival mid morning. There were no new consults in the ward from over the weekend, but we did have the little baby with meningitis to tend to as well as the young man who had come with severe back and neck pain who lumbar puncture had been benign, but had been on antibiotics for several days which clouded the picture. The baby was still quite sleepy which Susan felt could easily be from the phenobarbital so she had planned to lower the dose and, if he began to have more seizures, we would load him with either levetiracetam or phenytoin, both orally, of course, as there are no IV preparations here. The older boy with back pain was markedly better, but given that we could not rule out partially treated meningitis, it was decided to leave him on his antibiotics and continue to follow him.

One of Susanna’s early patients was a gentleman who had severe hoarseness and difficulty swallowing along with weight loss and we could find no neurological deficits otherwise, so were mostly concerned that he could have an occult malignancy causing his problem. We sent him back to Frank to discuss our findings and that we were recommending a scope of his throat and vocal cords, which was quickly set up to occur the very same morning. Things can happen a bit faster here as there is no bureaucracy to manage in any way and it is merely a matter of setting up the procedure room, finding a time that Dr. Gabriel is available and then it happens. By lunchtime, we had been told that his scope was normal, though we still had significant concerns for a malignancy so his evaluation would continue.

The friend from Arusha had soon arrived with his two family members and we began to evaluate them. One had had a stroke recently affecting his right side, but had recovered quite well albeit with continued deficits of mild weakness and dysarthria rather than any language dysfunction, making a subcortical infarct the likely scenario here. He was hypertensive, which was the likely mechanism of his stroke and we counseled him on getting his blood pressure well controlled along with his lipids. We sent him home with atorvastatin and aspirin, blood pressure and lipid parameters and made sure that he knew that he needed to find a primary doctor in Arusha to manage these things to prevent another stroke.

The other family member was someone who could be diagnosed just looking at him for a second, something known as an “augenblick diagnosis,” or “in the blink of an eye.” This is an expression that I learned many years ago while training and I try to pass on these historic pearls to the residents as often as possible as they are often very meaningful. To lose the history of our profession would be a tragic loss for it is this knowledge of how we got to where we are that helps us know why we are here. I have universally used the “augenblick diagnosis” expression in reference to patients with movement disorders, as the initial observation of the patient sitting in the waiting room can often be one of the most informative parts of your examination. Seeing a Parkinson’s disease patient sitting there with his masked facies and resting tremor tells you the diagnosis and your history and examination are often merely confirmatory. Seeing a progressive supranuclear palsy patient sitting in a chair with their neck extension as opposed to neck flexion of the Parkinson’s patient is also a differentiating observation that helps you even before the patient is brought to the exam room. These are pearls that the late Fred, or Fritz, Dreifuss, a giant in epilepsy, had instilled in me some thirty years ago at UVa while training and which I will never forget.

Sure enough, Susanna, being the resident that she is, had already noticed him sitting in our waiting area so was typed off to what she was looking for long before she even asked a question or laid a hand on him for the examination. This is something that we are trained to do as neurologists for it is often these initial observations as the patient is sitting in the waiting area or walking to the examination room that are the most telling. Unfortunately, back at home, we have often lost this opportunity to observe the patients as they are brought back to the examination room by a medical assistant. It is not a perfect world and not all progress is to the benefit of our patient care at times, which is sad. The gentleman had been gone to see the doctor in Arusha with complaints of feeling tired and they had done an MRI, telling him subsequently that he had had a stroke. Given that his blood pressure was over 200 systolic when we saw him, it would not be at all surprising that he had significant small vessel disease on his scan, but his presentation was certainly not that of a stroke. We told him that he definitely needed to get his blood pressure controlled, but we also prescribed him carbidopa/levodopa, or Sinemet, which is the single most effective medication for the symptoms of Parkinson’s disease, and that this would very likely make him feel much better. They were both quite thankful for our care and we sent them back on their way to Arusha, hopefully much for the better and certainly much more informed.

One of the more interesting patients that we have seen this trip was evaluated by Johannes, and was very apropos, and clearly had some trouble with his ambulation, swaying in all directions as he walked into our makeshift examination room in the hallway between the night doctor’s office and the emergency room. He was 35-years-old and his problems had begun in his twenties, but the most significant part of his history was that many of his family members had had the same problem and had died from it. This didn’t come out early in the history, though, as the notion that a disease can run in families is not something that comes to one’s mind here and the concept of genetics is a foreign topic that is quite difficult to explain. Indeed, he had multiple family members on his father’s side that had developed the disorder and had lived into their 60s by the sounds of it, many dying of traumatic injuries suffered by their unsteadiness.

His speech was severely affected and was quite cerebellar in nature and that explained his difficulty with his ambulation. In fact, he was mostly all cerebellar on his examination with little else that could be brought out. Given his family history and the findings on examination, we were fairly certain that he had one of the spinocerebellar ataxias, a group of genetic disorders that are affectionately know as the “SCAs” to us are a seemingly ever expanding group with new discoveries being made on a regular basis. The apropos nature of Johannes’ caring for this patient is the fact that his father is someone who has spent his career studying these disorders (his mother, by the by, is also someone who has studied similar genetic disorders) and someone who has actually described at least one of them in connection with a large family in Cuba that was discovered. Finding a family here with one of these disorders was an exciting event, though unfortunately, we do not have access to any genetic testing or other methods of being more specific about which one he might have, not that we would have any treatment either here or in the US for it even if we could gather that information. It was still very exciting for Johannes to be able to email his father and then talk to him later on the phone about this patient. We don’t have the mechanism to get a specimen home currently, so we are unable to do any of the necessary genetic testing at the moment. I am hopeful that in the future we will eventually have the opportunity to more thoroughly evaluate these patients with some form of collaboration as providing genetic testing here will never likely be possible due the cost and lack of treatment, but would possibly further our knowledge of these disorders and be worth the investment in resources from that standpoint.

Mindy also saw a Parkinson’s disease patient today who had seen us previously and had been put on carbidopa/levodopa with excellent results, but had unfortunately run out of his medication for the last month and was unable to get here to refill it. He had very profound resting tremors and was quite bradykinetic, but both he and his family were adamant that the medication had benefited him significantly. This is such a common problem here regarding medications and the fact that we can really only give one or two months at a time for several reasons. First, we’re subsidizing the cost of the medications as our visits are 5000 TSh (Tanzanian shillings which currently are 2200 TSh per dollar so they are paying less than $2.50) and that covers the cost of seeing the doctor, any labs and their medications, typically for a month. On occasion, more than a month is given out, but not on a regular basis and we do this very judiciously. CT scans or x-rays are not covered under the 5000 TSh cost of the visit. When patients return they have to buy the medications so it is important to be certain that they can afford them for making an awesome diagnosis and starting medications only to have them stopped in month due to cost serves not purpose for anyone. If a patient is unable to afford the medications, we will involve our social worker, Angel, to speak with them and to decide what they might be able to afford and work something out with them.

Because of the slow start due to the overnight rains with patients coming later in the morning, our patient flow was shifted a bit into the afternoon. We ended up working a bit later into the evening than normal so didn’t finish up until probably 5:30pm this evening. By the way, most of the patients we see use Swahili time, which is a real thing and is based on 6am being considered zero time. So 7am is actually 1:00 and so on. 5:30pm would be 11:30 in the evening, or jioni. Signage here on stores and on our clinic indicate the time in both the western format as well as Swahili time. Thus we’re open from 2:00 until 10:30 Swahili time on normal days.

We walked back to the Raynes House after a full day of clinic looking forward to our dinners that would be there for us. It was a relaxing evening with catching up on some charts from Saturday and with today and my trying to catch up with this blog, at times an all-consuming vocation. We all slept very well this night.

 

 

(Photos courtesy of Susan, Susanna, Mindy and Johannes, and, of course, me)

I am always asked when I take guests on safari whether it is exhausting and I always give the very same reply. I can’t think of anywhere else on this planet that I’d rather be at that very moment and, though, it is incredibly tiring to drive for ten hours or more, starting and stopping, spotting game, and answering questions, it is perhaps the most exhilarating thing that I have been able to do in my life. As a child and young adult, I had always dreamed of being in Africa and to now have had the opportunity to be here providing care to our patients and taking some time to share the wonders of this country with those who accompany me, has been the ultimate realization of that dream.

We had had a wonderful dinner at Gibb’s last night as has always been the case and, thankfully, we were home at a reasonable hour that enabled us to make everything we needed for lunch while on safari at Lake Manyara. There are few services there, which are really like none as the Manyara Tree Lodge is open only to guests who are staying there and is very, very expensive. We have always packed our lunches and peanut butter and jelly sandwiches have always sufficed for the group as the main course. We’ve had hardboiled eggs, cheese slices, cut up mango, pineapple and other assorted goodies from our house to accompany the sandwiches, but the latter have always remained a staple, most likely given the ease of putting together the night before. Preparing for safari is really not a big deal, but you have to make sure that you have enough water for the day as there are not services available in the parks and it’s quite easy to become stranded if you have a mechanical breakdown or, worse yet, if you become hopelessly stuck in the mud in some remote corner of a park. It’s happened to us in the past and we’ve always been lucky enough to have been rescued.

Lake Manyara National Park is a wonderful place that is totally dominated by the very large lake that occupies more than half of the area of the park. As you are driving along the western shore of this body of water with the high cliffs of the Great Rift to your right heading south, it is very difficult to get lost or make a wrong turn there. I’m sure I’ve been on safari here more than a dozen times over the last eight years and it has always been a pleasant experience. This is the site of Ernest Hemingway’s exciting non-fiction novelette “The Green Hills of Africa,” where he is traveling with his wife and some other big game hunters competing to land the rhino with the longest horn. Outside of the fact that they were hunting these amazing creatures for the sport and their horns so that they are no longer there and are endangered in the remainder of Tanzania, it is a good story and a great read.

The best time to view wildlife here is early in the morning and in the late afternoon, so it is always the best to arrive to the park gate as soon as they open at 6:30am. The animals are most active at those times with the herds of elephants coming out of the foothills, where they have spent their nights, and traveling across the woodlands towards the much wetter lakeshore with it’s watering holes. Several years ago, the entrance to the park changed dramatically one night as a flash flood during a tremendous rainfall raged down from the hillside hurling huge boulders onto the small huts that housed the park office and bathrooms. Thankfully, no one was around at the time, but it essentially buried what used to be the entrance area under about six feet of rock and debris requiring that they fully renovate the gate area. The flood also completely took out the road making it impassable for several days and considering that this is the only road to the Serengeti and Ngorongoro Crater, it had a huge impact on the tourist industry as it stranded guests traveling to or from those areas on the wrong side of the huge ravine that was formed. Danielle Becker and I were still in Karatu working when this happened and luckily they were able to partially repair the road in time for us to leave. Driving across the temporary roadbed that had been put in place that morning to get to the other side was a bit eerie to say the least and watching the bus pass over in front of us gave me just partial confidence that it wasn’t going to wash away while we were crossing it.

We left our house a bit after 6am and drove through the dark of Karatu as we headed out of town on our way to Manyara. Once through the gate in Manyara, you pass through a very tropical forest with streams and occasional small waterfalls on either side of the road and troops of baboons sitting or standing in the center of the road, grooming themselves or playing. There were so many tiny baby baboons that were either clinging to their mothers or sitting very close by them so if any alarm sounded they could be back in their mother’s arms and safety in a flash. We also saw the two other types of monkeys resident to Manyara, the blue monkey and the vervet monkey, both highly sociable and also with lots of babies to watch this time of year. Occasionally, you will see a waterbuck or reedbuck in the forest, but we didn’t see any this time as we entered the larger portion of the park heading towards the hippo pool.

I think the first time you leave the forest and enter the more open grasslands, it must be a real experience for everything suddenly appears before you with the lake in the background and groups of animals scattered about in front of you. As we approach the marshy wetlands heading towards the hippo pool, there were many different birds that were all gorgeous, some more spectacular than others. A goliath heron, an African spoonbill, a hamerkop, Egyptian geese, weavers, egrets, yellow storks, crowned cranes and more, all in one concentrated area and all singing and talking to each other was the most pleasant and relaxing sound. We drove around the marsh and to the elevated platform that lets you look out towards where the hippos congregate. On occasion, you may find one out of the water, still grazing from the night before, but none were in sight this morning.

There were several very large male Cape buffalo wading through the hip deep muck feeding that seemed to barely take notice as we drove closely by them. Fifty yards up the road or so, we stopped to watch some more of the waterfowl including the spoonbill that looked so very odd and prehistoric as it hunted for fish and seemed to be very successful. Suddenly, I heard several of my passengers screaming to drive forward, not an easy thing to comply with when the ignition is off, but somehow I instinctively fired up the engine, put it in gear and took off forward, only to look into my side view mirror and see a huge Cape buffalo charging at full speed towards us. As I drove a few more yards, the huge beast was suddenly beside us and I could see him running alongside our vehicle just outside the front passenger window. It was quite clear at that point, that he had had no intention of ever tangling with us, but was merely trying to get around us on a road that was surrounded by water on both sides requiring him to gallop at full-speed as he probably just wasn’t quite sure what to make of us. Had he been a bull elephant or a mother elephant defending her baby, it would have been an entirely different outcome, as they have been known to overturn vehicles on occasion. The Cape buffalo continued on his way, galloping at full speed across the grassland as we all couldn’t stop laughing over the entire experience that I think left some a bit shaken for suddenly having spotted the buffalo charging at full speed in our direction was certainly a scary site for anyone.

After we had all finally gathered ourselves up (some off the floor now suffering from PTCBS – post traumatic Cape buffalo syndrome) from the Cape buffalo episode, we continued on with our safari, traveling across the grasslands and back into the wooded regions looking for more game. Impala were everywhere, with their huge harems controlled by a single buck and the bachelor, or loser, herds made up of all those males who failed to win a harem. We later learned that the dominant male, after he is defeated by a challenger, would spend his time in a loser herd building back his strength so that he can compete once again for the harem. The dominant position is apparently a bit a revolving door so at least a number of males are successful in launching their genes into the next generation.

It was a beautiful day with a fair amount of cloud cover keeping the temperatures down, though there was still enough sun to keep things bright and it wasn’t long before I switched to my sunglasses. The route I usually take travels along the lakeshore alternating between the grasslands and wooded areas while we encountered more wildlife that included giraffes, more impala, wildebeest, Cape buffalo, warthogs and zebra. We even ran across a very small chameleon crossing the road that I almost didn’t see. He was doing this defensive maneuver in which he was stretched out completely and moving very slowly and deliberately (even exaggerated from what they normally do) so he seemed to be imitating a snake in some fashion. At least that’s what he thought he was doing. We all thought he looked like a chameleon doing some strange sort of dance. Once across the road, though, he scampered (as much as a chameleon can) quickly and disappeared into the brush having resumed his normal character.

We were on our way to Maji Moto (“hot water” in Swahili that is the site of hot springs feeding into the lake) to have lunch and to explore the new walkway that is like a boardwalk leading out onto the lake. Just as we were leaving the forested area, though, we ran across there adult elephants without any juveniles or babies. They were the first elephants most had seen in the wild so it was quite exciting and we watched them for a bit as they continued to feed on the grasses that at times were hidden underneath dead brush that they moved aside so dexterously with their huge trunks. It was still a ways to get to the hot springs so we left the elephants and continued our journey while it was still quite early in the morning. The parking at Maji Moto sits slightly elevated above the lake and from this vantage point you can see the thousands of pink flamingos that make Manyara their home during this time of year. There was a huge flock sitting just beyond the end of the boardwalk, but in the distance you could see a pink stripe of flamingos for the entirety of the opposite shore. The birds that were closest were making an incredible racket and were only overshadowed by the occasional honking of the hippos that were in a pool to our right at some distance. It took some time for me to convince the residents that those huge bumps in the pool that looked very much like smooth stones were actually hippos submerged during the middle of the day.

We left Maji Moto after eating our fine lunch of PB&Js and cheese. We had also brought along some of the leftover macaroni and cheese (and garlic) that served for some added nutrition. South of Maji Moto, there are some spots where I’ve encountered lion prides on more than once occasion, but I was unable to locate any of these felines in this area unfortunately. We continued driving along the lakeshore as the road began to peter out and we ended up pretty driving in the grass with only the sign of faint tire tracks for me to follow. We found small groups of wildebeest and Cape buffalo, but no predators. As we had reached the southernmost point that was really drivable, we decided to turn around and slowly head back towards the main entrance while still keeping our eyes out for wildlife. At one point, one of the other drivers had told me that there were some lions near the Bagayo River, so I decided that we should make that our destination for the time being.

I took a turnoff that we hadn’t been on following the river, but we saw not lions there. When I reached the lakeshore road, for some reason I decided to head away from the main gate rather than towards it, and within several minutes another tour group stopped along side of us and the guide told us that there several lion cubs in a tree 1.5 kilometers in the direction we were heading. We raced along trying to locate the spot and, sure enough, there were the cubs sitting on a tree branch with their mother nowhere to be found and probably off hunting somewhere. The two cubs were napping, but after a few moments, one of the got up and moved around on the branch. We had watched them for a bit, when Mindy spotted some elephants that were crossing the road in front of us. It’s the first time I’ve left lions in favor of elephants, but we drove ahead a short bit to see the big pachyderms and were thankful that we had. There was a watering hole on the other side of the road, which is where everyone was heading, and we had a wonderful show of the elephants drinking and showering themselves. They were also rolling in the mud to protect themselves from the hot sun.

As we watched, more and more elephants kept coming from the brush until there were probably nearly thirty elephants all in a small area surrounding the watering hole and simply enjoying themselves. There were babies and adolescents in addition to all of the adults and they could care less that we were sitting watching them for the entire time. We popped back briefly to see the lions, but they had moved off the branch and were now nowhere to be found. I would imagine that their mother had shown up, perhaps with a kill or they had heard her calling them someplace else. We went back to watch more of the elephants and when we finally drove away we continued to find family after family likely making their way back to the safety of the hills. Our drive back to the main gate was otherwise uneventful, though we continued to spot more wildlife as we drove. We departed the park after 4pm, having arrive there before 7am, so that we had nearly nine hours driving in the part which a long time for a game drive.

We stopped by our friends gallery on our way home, but they were about to close and he wasn’t there, so we made our way back to Karatu with plans to go to Happy Day for dinner as we had very little in the house to make. It takes forever to get your food there, but the pizzas were delicious as was the chicken curry. The beers were also quite refreshing, I will admit. It was off to the Raynes House and sleep as our big neurology clinic would be starting tomorrow morning and we definitely needed some rest after such a long day on safari. It was an incredible day of animal viewing, the best I have ever seen there as far as elephants go, and everyone had had a great time. It was the first safari for everyone other than Mindy, who had been to South Africa before, and I believe they all had an unforgettable day. That is why these trips are never exhausting for me and I am always in awe that I have had the privilege to bring these experiences to each of them. What more could one ask for.

It was our last day of “unadvertised” clinic as we would be starting our full on FAME neurology clinic next week, one that is announced to the entire Karatu District with personal visits that are made by FAME to churches, local villages within the district, and the local markets. Fliers are also posted around the community announcing the neurology specialty clinic and attempting to communicate what type of disorders we will evaluate, but despite these attempts to triage patients in advance, we still see very many musculoskeletal pain patients that slip through our screening process. Theoretically, this wouldn’t be an issue if we had the capacity to see the patients, which we often do, but it is a problem financially as we are subsidizing the cost of these neurology visits that are for neurology patients and not for the general pubic as that would not be sustainable for us. It is already tenuous just trying to fund the neurology patient visits without adding in all the non-neurology MSK (musculoskeletal) patients who would overwhelm us in very short order.

The clinic today was surprisingly slow at the start and, though it picked up later in the morning, we were still able to finish a bit early, which was good as we had plans for dinner at Gibb’s Farm tonight and that entails arriving there early to take advantage of their fantastic grounds and amazing views prior to sunset. There were several interesting patients today and one of the more interesting ones was a young woman who had a history very suggestive of schizophrenia, but also epilepsy, and the two disorders seemed to have very little to do with each other, but were both very convincing from her history to the degree that we weren’t comfortable even considering discontinuing her anticonvulsant treatment. She wasn’t on anything currently for her behavior so we provided a prescription for olanzapine, a very reasonable atypical antipsychotic medication that would work very well for her and is one that is reasonably priced here.

Susan and Susanna evaluated a young 19-month-old girl whose mother had accompanied a friend to clinic and hadn’t actually planned to see us, but thought she would since she was there and we were all very glad that she had. The little child did not have any neurological disorder, but she did have an incredibly severe case of malnourishment, weighing only 5kg with a normal head circumference. The mother reported that she had been eating normally and had a good appetite, but given that she was well under three standard deviations below on the weight-to-height charts, it was quite clear that she had a very serious problem.

We had asked Dr. Jackie to come help with a decision of what we would be doing for the young child and both she and Susan were in agreement that should be admitted to determine why she was so malnourished and also to begin consideration of a refeeding program once she had undergone some testing. It was clear that her mother was caring for her, but not how she had become so malnourished. When Jackie and Susan spoke to the mother and informed her of their desire to admit the child, she indicated that it would not be possible, as she had come from a long distance with others and had to return home to take care of her other children. The gravity of the situation and the degree of malnutrition was made clear to along with the potential risks to the child of not coming into the hospital, but mom was adamant that it would not be possible to bring the child in, so we ended up doing all the lab work planned as an outpatient and had them wait for the results of those tests before they would leave for home.

I did have some vague recollection of the refeeding syndrome, but Susan reminded me of the seriousness of this condition that occurs when giving protein-rich feedings that can cause numerous electrolyte abnormalities, cardiac arrhythmias and other potentially life threatening complications. It was important, therefore, that we didn’t just send the child home with these feedings and find out later that she had succumbed to one of these complications. The child’s labs returned essentially normal, but this didn’t give us much of an answer as to why she was having the problem with her ability to grow. To give you some idea as to the degree of malnutrition and growth retardation, the little 2-month-old boy on the ward we are treating for meningitis weights some 10 kg, or double the weight of this 19-month-old patient.

As I mentioned, patients were filtering in rather slowly over the day and so when Angel and someone else pointed out a wonderful chameleon climbing in the tree outside of clinic, I quickly grabbed a ladder and climbed up high to catch the beautiful creature before it could escape. For those of you who are not familiar with these old world chameleons as opposed to the new world anoles that live in Florida, Mexico and further south, there is really no comparison at all. The true chameleons are just the sweetest lizards that wouldn’t hurt a flea, though love to hunt bigger insects such as crickets and beetles. Their feet are like clamps with tiny little nails that they use for their climbing in trees and their eyes move independently of each other so they can be looking in two directions at any one time. They are simply an amazing feat of nature. When I was young and we owned a pet shop, we used to have chameleons as pets and actually successful bred some of them much to the dismay of my father who never quite understood our fascination with reptiles. I had later instilled that love in my children, and especially my daughter, Anna, who had a series of bearded dragons growing up.

This had to be the healthiest chameleon I had ever seen and when I grabbed him out of the tree, he hissed and opened his mouth in a threatening manner as if he were going to bite me when that is never their intention. It is merely a bluff. Mindy fell in love with it immediately and couldn’t hold him (or her) enough, having it climb all over her while trying her best to keep it on her arms in front of her rather than her shoulders and head. Johannes held him as well and they were both quite adamant that we bring him back to the Raynes House and release it the general vicinity in one of our trees. I got a cardboard box and was big enough for him, but couldn’t climb out, and Mindy brought him back to the house. Later, when I arrived home after the others, I found them all out on the veranda holding Doug, as he was now called, and letting him climb on them. As we had planned to head up to Gibb’s Farm for the evening, they would have to let him go shortly in the bushes near the house where he would hopefully do just fine, catching as many flies and bugs as his little heart desires as that will limit the number of those creatures that wish to share the house with us as this is a continual battle.

I had forgotten to mention that the night before, on our way to the Kudu lodge, as Mindy stepped out the door to put her shoes on that were just sitting outside, she let out the cry as there was a considerably large spider sitting at the toe of her sandal that turned out to be a rather small tarantula, but a tarantula just the same. Her reaction was already perhaps one of the highlights of my trip here.

Tonight, though, we were heading to Gibb’s Farm for dinner and, as I mentioned, it’s always important to get there with plenty of time to enjoy the scenery before sunset. We drove my standard back route which is a series of small trails that eventually intersects the Gibb’s Farm road and winds its way up through the center of Tloma, which the small village nearby Gibb’s that is one of the Iraqw cultural centers and from where a number of our patients come that we see at FAME. Once at Gibb’s, I had the residents explore the vegetable gardens that occupy a large plot of land that slopes sharply down from the parking area and reception where they grow most of the food that is served in the restaurant and is just such a pleasant place to visit. At the bottom of the very large garden is a massive and majestic tree where they have talks in the evening around a fire pit for the guests. While the residents were in the garden, I went and found a nice place on the veranda to sit as it has one of the most spectacular views of any lodge in Africa, looking east towards Lake Eyasi. Tonight it was particularly cloudy such that the sunset wasn’t the best, but no matter, the view was still awesome and, more importantly, the drinks were delicious and were a great prelude to the dinner to come. I had ordered my Moscow Mule and sipped on it while waiting for residents as many of the waiters who know me from past visits came by to say hello. As everyone else arrived, they ordered their drinks and we took some photos to remind us of this magical place that has to be one of the most truly serene locations on this planet. The positive energy that exudes from there can be felt and it is no wonder that it has special healing powers for there is a sense of wellness that permeates through the premises. One cannot help but look forward to visits here.

 

 

The residents now had one full day of clinic under their belts and they were already working on their Swahili for their exams and, it seemed, had much of it down. Today was my birthday and I celebrated it much as I have for the last five years, here in Africa with my second family. Ever since childhood, birthday celebrations have never been a very big thing to me for some reason, so being over in Africa was a perfect way to just avoid anyone paying any attention to the day and I was able to just go about my business. I will have to admit, though, that the event they put on for my sixtieth birthday two years ago was a pretty cool event and I’ll always be thankful to Jess, Jackie and Paulina who managed to pull that one off, I’m sure with the help of others here. It seems to have become a more common knowledge now among some of the residents so it is now more difficult for me to remain incognito and avoid any celebration. So for breakfast today, where I am usually eating granola or cornflakes (the latter is now the standard since the granola in Arusha seems to have doubled in price since our last trip and I’ll to smuggle it in on future trips apparently) for breakfast, Susan offered to make me a delicious meal of toast, a friend egg and avocado. I added the tomato for some extra color and Susanna added the freshly pressed delicious Ngorongoro coffee that is the standard here, though I’ve most converted to tea these days.

It was off again to morning rounds at 8am to hear about the patients in the ward and any new neurologic cases or others that might benefit from our help and expertise. The young Maasai boy was still in the makeshift ICU on the ventilator and had shown now signs of improvement and, in fact, had worsened in some respect with low blood pressures issues overnight, making any attempts to lessen his dependence on the vent successfully unrealistic. Given the appearance of his CT scan the day before and his worsening condition, we met briefly with Frank and all agreed that regardless of whether he would survive or not, he had suffered a devastating neurological injury and would never regain consciousness.

Susan, with the help of Sangoma, our new receptionist who is Maasai, went in to speak with the father and uncle about removing then ventilator and endotracheal tube, in which case we were fairly certain that he wouldn’t be able to breath and would probably pass away quickly, but, of course, you never really know and have to caution families that it is difficult to be certain of that fact. Thankfully, the young boy succumbed quickly once the ventilator was removed as the burden to the family had he kept breathing would have been immense and is something that must always be considered so much more acutely here given the lack of resources and social support. It is one thing for an individual to have a disability that they must overcome, but when someone is so neurologically impaired that they cannot care for themselves in any way, you have now burdened the family and the community. Providing “life saving” efforts here may not always be what they seem and the outcome can be financially and socially catastrophic to a family and community where there are no social safety nets to provide the support that we so take for granted at home. This is one of the big lessons here that is perhaps not encountered daily, but when it is, we have to make certain that we are making decisions that are appropriately sensitive to the social structure in which we are practicing.

Susan not only had to deal with this young Maasai boy, but also with the little two-month-old on the ward also with meningitis and seizures. The lumbar puncture from the evening before had been clear, but this had been after several days of antibiotics and was mainly done to be certain the baby didn’t have herpes or something else we weren’t treating. He (I think I was incorrect yesterday in referring to him as a “she”) was still not very awake, but he was still having intermittent seizures despite being on a very good dose of phenobarbital, which also didn’t help with his level of consciousness, as it is very sedating. He was no worse clinically, so we decided to stay the course and continue monitoring him.

Clinic was again fairly busy at the start, with lots of patients waiting to see us after rounds even though this was still one of our unadvertised days. There was also a large family that had driving from Arusha with several family members that had neurological issues, one of who was in a wheelchair with a very clear neuromuscular disorder. Since this is what Susan is planning to do for a career, she was very excited to examine this family that based on what we were being told, would very likely have one of the genetic neuromuscular disorders that we all love to see as they are often those classic disorders that we are taught in medical school and, so often, never get to see or at least not frequently.

The first boy was 19-years-old and in a wheelchair with very severe and devastating deficits causing him to have contractures throughout and very little strength. The history was that he had a brother who had died of the same thing at 18 years of age, so we were fairly certain that we were dealing with Duchenne’s muscular dystrophy, the most common of this group of disorders that most of us in the US are family with through the Muscular Dystrophy Association and their telethons that have been so successful in raising money for research and support. Interesting, when my family first moved to California so many years ago in the early 1960s, my father had worked for the MDA in fundraising for several years and as a young child, it was my brother’s and my luck that we got to bring the MDA Poster Child to Disneyland for several years. I have fond memories of pushing their wheelchair through Disneyland, though on many occasions, they were pushing the chair with my brother or me in it, all while wearing their braces that enabled them to walk.

Susan drew a pedigree out for this young man and it quickly became apparent to us that the other members of the family that were to see us weren’t close enough members of the family to have the same disorder, and, in fact, one them didn’t even have a neuromuscular disorder, but something entirely different. The second member of the family was a young child who had had some probable hypoxic event early in life and was severely impaired neurologically with constant movements very likely from basal ganglia involvement, visual impairment and was cognitively devastated. He had been seen by someone previously and had been scanned, but the family hadn’t brought the films with them. They had been told his brain was “shrunken” so we were pretty certain that he must have had some significant atrophy from his hypoxic event that he had suffered. There was nothing progressive about his illness and it was a monophasic event that, unfortunately, wasn’t going to improve over time. We provided the necessary instructions for exercises and other things they should do going forward to provide him care, but in reality, they had already been providing this care to him.

The third patient in the family happened to be a 35-year-old gentleman who clearly had a progressive neuromuscular disorder, but it was obviously not connected to his distant relative with Duchenne’s as these patients typically die in their late teens or early 20’s. Also, his onset by history was eight years ago, meaning that he was even late for Becker’s muscular dystrophy, a milder form than Duchenne’s that has a later onset, but typically not in someone’s late 20’s. Also, his distribution of weakness involved the more proximal musculature so, though clearly he had a muscular dystrophy, it was most likely to a limb girdle dystrophy, which a very large and heterogeneous group of these disorders that can only really be distinguished with genetic testing. We explained to his family that if they wished to do genetic testing, it wouldn’t be possibly here, but they could certainly consider traveling to Nairobi or India, as they seemed to have the means to do so. The first patient with Duchenne’s did have an unaffected brother with children so we were able to reassure him that his children would have nothing to worry about going forward as far as possibly having the disease as it is an x-linked condition and men cannot be carriers.

Evaluating these patients here is done by history and physical only as we are unable to get even the most basic of labs such as a CPK, or muscle enzymes. Genetic testing is far outside of what we could ever hope to consider for several reasons. First, the costs for these tests are still exceedingly costly even in the US and, secondly, they do not lead to treatment options or would they change the life of these patients. They would, perhaps, help with being able to advise families in regard to family planning, but doing them for the sake of knowing a diagnosis alone is not valid here.

Another patient who we saw today was a very unfortunate case of a young woman, 30-years-old, with a history of mitral valve disease and who was status-post valve replacement several years ago who had been on anticoagulation with warfarin to prevent embolic events since her surgery. Three years ago, she had apparently decided not to take her warfarin in favor of prayers to prevent a stroke and was unsuccessful in her efforts as she suffered what appeared to be multiple embolic strokes several weeks ago and was admitted here at FAME. We looked at her CT scan from her admission and she had what appeared to be a hyperdense right MCA and some edema, but also had a hypodensity in the left pons that was very convincing and explained the bilateral deficits that she had on exam. She was fully aware, could converse and follow commands, but mostly just moaned on a fairly constant basis. She was perhaps more spastic on the left, but she had contractures in all four extremities unfortunately and this was not a good sign considering her stroke was only last month. She had also had several seizures consistent with her cortical deficits and had been started on carbamazepine several weeks ago. The addition of carbamazepine was a bit of a problem now that she was back on her warfarin the former medication is an enzyme inducer and will cause the protime to be less than therapeutic when added. Her protime turned out to be double what it should be, though, so we had to instruct her parents to hold her warfarin for several days and then restart it with another check in one week. It was so unfortunate that after have gone the extra distance to even get the valve replacement, a tremendously costly endeavor and one that I am sure bankrupted her family, she ultimately made the decision to choose a non-medical remedy that, in the end, failed rather miserably. I guess we’ll never know, though, as she could have had a stroke had she even remained on the warfarin, but I’d like to think that the reasons we do the things we do are that they are successful and are to benefit the patient in the end.

It wasn’t an overly busy day, but busy enough and we finished with patients around 4:30pm or so, time enough to get home in time to do some work and watch the sunset once again. Dinner tonight was essentially garlic with some macaroni and cheese and a side of sliced carrots and beans. Very tasty and, thankfully, everyone shared in the dinner so there were no hard feelings for anyone having garlic breath later that evening. We had tried at the last minute to get a birthday cake made, but it was too late to ask the Lilac Café to make it (it takes a minimum of an hour to get a pizza made at the café so who knows how long a birthday cake with a last minute notice would take) and our other choice was Alex, who is an exceptionally good cook, but was recuperating from some unknown illness that he had contracted while running a 5K in Moshi and which had drained all of his energy for the week apparently. For all those Alex fans reading this blog, there are no worries, for he would soon recover completely after sleeping continuously over the weekend.

After dinner, I had been talked into going out for drinks with the group and, though Alex would not be accompanying us, I contacted our friend Nish, who owns the large art gallery nearby, who was already at the Kudu lodge with friends so we all decided to head in that direction. Unfortunately, as we all loaded into the Land Cruiser, I turned the ignition key only to discover that the battery was dead (I checked the following morning and the battery was dry so needed battery fluid, something we don’t have to deal with in the US). We eventually called a cab with four of piling into the back seat of a small sedan, Susan in the front to avoid motion sickness, and we were off to celebrate. The Kudu lodge is a very fancy gated lodge on the edge of Karatu where I had never been before, but it was a very nice place for a birthday shot of tequila, courtesy of Nish, and a margarita, courtesy of the residents, while they ordered a bottle of a South African Syrah that I sampled and was actually quite good. All in all, it was a birthday that was just my speed – no hoopla or big celebration, just being with friends and relaxing. We were to be back in clinic the following morning so it was home not too late to bed with dreams of another exciting day at FAME tomorrow.

There is always an air of excitement and anticipation for everyone after waking up on the first day of clinic here, both for me, as well as the residents. Despite this being my sixteenth trip to FAME (and seventeenth to Tanzania), each visit brings such new and varied experiences that there is always that feeling in my chest as we walk along the short trail by the other volunteer houses and approach the hospital and the outpatient ward. Just remembering everyone’s name given the six-month absence would be enough by itself to instill a bit of anxiety in anyone (There are over 100 employees here at FAME and I know the names of at least half of them which is pretty darn good for me). There is always a short delay, of course, as I approach someone for their name to pop into my head. For each of the residents, I can only imagine what feelings they must have as they are first walking to clinic. They have all been briefed by me and their fellow residents who have come before, but there is still no way that one can fully anticipate what their first impressions and emotions will be. Walking down the corridor between the hospital and the surgery suites brings you to the courtyard (that used to be the parking lot) with its lovely landscaping and total openness that suddenly reminds you (if you haven’t figured it out already) that you are in rural East Africa. The weaver birds in the trees, with their constant songs trying desperately to attract their mate, and the gorgeous flowers make you acutely aware that you are not at home.

As we have done for the last several years, our clinic will be held in the emergency room area and specifically in the doctor’s night office, the emergency room itself, and the hallway in between where there’s a small alcove that is large enough for a desk, exam table and several chairs. This has worked well as it provides us with a separate outside waiting area from the main clinic so that our patients are lost in the mass of humanity waiting to be seen by the FAME doctors on a daily basis. They are currently seeing over 100 general patients per day and during the height of our neurology clinic we will usually see around 30 patients per day, so the waiting areas can become pretty crowded during the day. Most patients come first thing in the morning and, depending on how busy we are, may have to wait most of the day to be seen by us. Angel, who is now our coordinator for the clinic, has even arranged for our patients to have their vital signs done here in our section so there is less of a chance of someone sitting in the wrong place as that usually doesn’t get discovered until the end of the day since no one speaks up here and they are used to waiting for services. This is very much different than back home.

The emergency room was being used for a procedure this morning so we could only use the two other “rooms” to see patients, but we also had a few ward patients to be seen, both of whom were children, so Susan broke away to take care of that while the others go started working on the growing stack of patient charts. Baraka and Emmanuel were interpreting for us this visit, which they’ve done in the past, and we would eventually have a doctor to work with us after the procedure was finished. Doctors here practice general medicine for the most part, meaning medicine, ob/gyn, surgery, pediatrics, etc., so it happened that the doctor working with us for the day was performing the endoscopy procedure that was also occupying the emergency room. That worked out fine, since we had the two other interpreters, but there is always a sense of loss opportunity when we’re working without one of the doctors as we lose that chance to educate.

Susan went off to see the young Maasai boy in the makeshift ICU as we were quite concerned about him. He was perhaps subtly improved, but only in regard to perhaps some minimal withdrawal to pain in his lower extremities, still with no heart rate variation with pain. Susan decided to opt for a trial of weaning from the vent and after a short period of time, the young boy had proven that he still had at least some respiratory drive meaning that at least some of his brainstem was still functioning. Unfortunately, this only mean that he wasn’t “brain dead,” a term we use to indicate that someone has suffered a permanent and irreversible injury of their brain with complete loss of all functions of the brain and brainstem and can be declare dead by neurological criteria. The presence of withdrawal of his lower extremities, which is sometimes tough to differentiate from “triple flexion,” which is a spinal reflex and not inconsistent with brain death, would have also meant that he was not brain dead, but was less definitive for us than the breathing was, of course, so now we had to make some decisions. Without going into all of the details, that would undoubtedly bore anyone without a strong interest in critical care medicine, we decided to obtain another CT scan after lunch to see what changes had occurred and may help us with the decisions that were necessary to make.

The CT scan ultimately demonstrated significant worsening of what appeared to be a progressive suppurative meningitis, meaning that his brain was covered with pus, despite being on numerous antibiotics along with acyclovir. His brain was also more swollen such that performing a lumbar puncture now could be very dangerous. We discussed his case at length with everyone involved and decided to continue watching him overnight and make decisions tomorrow of whether to withdraw care or not depending on his examination.

Susan also saw a little 2-month-old baby who had come in with presumed meningitis and was having focal seizures. The baby had ben given diazepam (Valium) at the time of its last seizure so the examination was not entirely informative as Susan was worried that the baby could have been lethargic and unarousable due to the medication and not the meningitis itself. Given the focal seizures, I was also concerned about herpes encephalitis and the baby wasn’t on acyclovir. We discussed further with Dr. Jackie and it was decided to do a lumbar puncture on the child to see if we could further characterize the meningitis any better. She had been on several days of antibiotics, though, so it was uncertain how helpful the LP would be in the end. We had little else to offer treatment-wise, though, so we went ahead and performed the procedure that showed few cells, but was not hemorrhagic. We started the baby on acyclovir (for herpes) regardless, along with continuing her other antibiotics and asked not to treat the seizures with any benzos in the future so we could get a good exam on the child. Hopefully, she will come around over the next several days.

Despite the clinic being “unadvertised,” for the next several days, meaning that it wasn’t broadcast to the community here, we had plenty of interesting patients that came, some new and any follow up patients. One of the more interesting of the day was a seven-year-old girl with a myelomenigocele, or a failure of development of the bony spine typically at the bottom of the lumbar region that often involves various structures of the nervous system, meaning either the cord, the cauda equina (spinal nerves after the cord ends) or a combination of both. Most often, these children undergo surgery within days of their birth, but this child had never been operated on and still had the large and soft myelomeningocele sack at the bottom of her spine, obviously not open otherwise she would have developed a fatal infection shortly after birth. The problem here was, that though she had preserved function in her lower extremities, often completely lost in this syndrome, she was now developing bowel and bladder symptoms that were clearly due to the fact that her spinal cord was tethered, or essentially being stretched as she grew taller and the cord moved upward with growth. This was going to cause a progressive problem for her and she would need surgery to prevent this from getting worse over time. Also associated with myelomenigocele is a condition called Arnold-Chiari Type II, far different from the more common, and often asymptomatic, Arnold-Chiari Type I. Patients with Chiari Type II develop hydrocephalus due to a brainstem deformity and aquaductal stenosis so are most often shunted early in life. This child clearly had frontal bossing consistent with some history of hydrocephalus, but it had apparently arrested, as she no longer had any clinical signs of such. We ended up referring the family to Haydom Hospital, which is a medical center several hours away and apparently has a visiting team of neurosurgeons there on occasion. There was certainly very little that we could do from our standpoint.

Another interesting patient for the day was a young woman with hyperhidrosis that primarily involved her hands and was very impressive. She had sweat dripping from both hands and moments after it off, it returned. She had been seen her previously by Frank and he had referred her to us to see if there was anything that could be done from our standpoint, perhaps. This is often treated with Botox back home that is injected into the wrists, but that’s very out of the question here. We wracked our heads to think of something else to try and eventually came up with using trihexyphenydil, an older anticholinergic medication that might work by helping dry her up and decrease sweating. We gave her a prescription for it and we will see her back in several weeks before we leave to see if it’s effective.

Our last interesting patient today was a young woman with narcolepsy and cataplexy that had very classic symptoms of both and was disabling for her such that it was going to worth treating her for the condition. The classic medication used for the narcolepsy component (the inability to control sleep onset such that they fall asleep frequently throughout the day) are the stimulant drugs like Ritalin, though there are newer medications out such as modafinil, which works much like the stimulants, but without some of the same concerns or side effects.

Otherwise, we saw our normal smattering of epilepsy and headache patients, many as follow ups and some new patients, all coming to get their medications and to have us determine what labs they may need based on the specific medication they were taking. Angel had called about 20 patients to come see us today and we ended up having 15 show, or at least we saw 15 patients from the pool she had called in addition to others that just happened to pick the right day to have come to FAME.

We all walked home after a successful first day of clinic, all the residents finding the day to have been quite satisfactory and exciting to them. Seeing patients here is much different than at home and not only because of the allure of being in a remote part of Africa and the fact that we’re using translators. I believe that it has to do with the lack of technology available and the fact that we are making decisions without having scans or other sophisticated testing available so that it is just the patients and ourselves. That’s not to say that there shouldn’t be more equity as far as technology and resources are concerned, but more so that practicing here requires you to think a bit more, perhaps, about what you want to do with a patient and how you’re going to do it.

We drove to town to get some airtime to reload the phone the residents were going to use as an Internet hotspot and a case of Coke Zeros. There are still some things that we just can’t live without, but that’s fine. We’re here and that’s what really counts.

We had originally planned to leave Arusha late morning to arrive in Karatu by lunchtime. It’s always nice to arrive with half a day to get oriented for the residents and for me to make my rounds greeting everyone once again as I return home. Leonard was flying in from the Serengeti, though, and wouldn’t be arriving until noontime so we decided to stick around town a bit later than usual so I could introduce the others to him and for Susan to meet the person who had helped plan her short safari for after we were finished at FAME. Besides, I had to get the rear door of the Land Cruiser fixed before we left town on our way to Karatu, as it would be tremendously more difficult to get the work done there. Everyone, save Johannes, was up quite early as the girls had apparently awakened at 3:30 am and were up talking all night, and I had decided to get up early to work on my blog which is a labor of love. Johannes was quite happy to snooze away, and rightly so, as it was going to be a very slow morning as we were planning to have breakfast before heading out for the day. Breakfast is usually a fairly big affair here, I’m sure mostly related to my visiting, and this morning was no different. We had huge bowls of cut fresh fruit that included pineapple, mangos and watermelon along with sweet bananas from Kilimanjaro, scramble eggs, toast and pancakes, all of which more than satisfied our hunger that morning and could have been our only meal of the day.

After breakfast, we went out to meet Jones to take the car to someone who would fix the back door. I left the others along main road in Arusha so they could walk around a bit of the town while I drove with Jones to find the repair shop where they were going to get the back door open and, hopefully, provide the necessary repairs so that it would open. The “shop” was down a back street and consisted of a group of men standing along the side of the road working on various and a sundry types of vehicles in every state of disrepair, but each vehicle with the expectation that they would have their lives extended at least for a few extra years. We waited for one of the fundi (or specialists) to be free and come by to take at look at the back door. I was very thankful that it didn’t just pop open to make me feel foolish, but it didn’t, and the fundi had to get into the back seats of the Land Cruiser, that are separated from the boot by bars like those in police car, and reach through to unscrew a plate at the door latch and then reach inside to release the door. If there had been luggage back there like there was in October when I drove everyone to the airport, it would never have been possible. Once open with the door latch exposed, he cleaned out all of the dirt that had collected and lubricated the hell out of the mechanism so that it would last us for some time…hopefully.

Having the back door finally open and fixed, I dropped Jones off at the nearest corner (again, to disappear into the foot traffic on the street) and went to pick up the others who had been wandering around downtown Arusha. Leonard was arriving and was at the Arusha Coffee Lodge and I wasn’t sure whether he needed a ride home or not. As usual, the communications were a bit faulty and Pendo told me to go ahead to the Lodge to pick him up, but when I got there after traveling all the way across town at the height of traffic, we found out that he still needed to have lunch with some safari guests and wouldn’t need a ride home regardless. These events I believe are somehow connected to Africa Time and it’s due to the style of communication here which is very laid back and mostly on a “need to know” basis, so extraneous information that may cause someone to worry is not shared unless it is necessary. We drove back across town to pick up our luggage and say goodbye to Pendo, then drove all the way back to the Coffee Lodge to say goodbye to Leonard and take care of some last minute business.

So, having originally planned to be in Karatu by lunchtime, and then by 5pm, we ended up finally arriving here as the sun was setting sometime around 6:30pm. We drove straight to the Raynes House, found Alex for our keys and began to move our things in and get settled. Thankfully, there were dinners for all of us as we were all starving having had our last meal at breakfast and just made the long drive here. We were all quite happy to be here finally, probably most of all the residents who were probably anxious to finally see that FAME really existed and they would indeed have someplace to spend the next month. I guess having found out otherwise and being stranded in Northern Tanzania wouldn’t be the worst thing to happen to someone, as this really is a paradise when it comes down to it. Now, though, it was a paradise with an amazing medical center ready and waiting for the new neurology team to begin their work.

We were planning to go out to Happy Day, our local pub as Wednesday nights are the night for all the volunteers in town to meet, for a beer after dinner, but first, there was a patient for us to see who had apparently come in a day or so before and was apparently in the ICU. The only problem, though, is that FAME does not have an ICU, or at least they had never had one before and I was completely unaware that there had been any changes in my absence. The reason there are no ICUs here, is that there are no ventilators here other than those used for surgery and there is really no way to have a patient on chronic ventilation should they end up needing that. This is really a distinction in many African countries regarding initiating this type of care, as you cannot sustain it. This was an eleven-year-old Maasai boy who had complained of headache for several days, then began having seizures at home where he remained for two days before he was brought to the FAME. He was given diazepam that stopped his seizures, but shortly after stopped breathing and was put on a ventilator. That had been done the day before as had a CT scan that was concerning for meningitis. He hadn’t been tapped yet, but was on the proper antibiotics and acyclovir to cover for herpes meningitis, but hadn’t perked up. In fact, he was very much devastated as he had fixed and dilated pupils, no oculocephalic responses, no gag and no response to pain. I spoke with his father to tell him that we were very concerned that he had suffered a major brain injury and very likely would not improve or survive, but we would re-evaluate him the following morning. It was not a very uplifting first experience for everyone, and especially not for Susan, who bore the brunt of the care for this child on her shoulders as there was little I could do to help her with things other than to agree with her assessments. We would evaluate the child again in the morning so we felt that going out for that beer after this experience would actually be quite therapeutic for us all.