Saturday, March 16 – A wellness day at Gibb’s Farm and the Elephant Caves….

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We arrived Saturday morning for report and met with Dr. Anne to hear about how the patients had done overnight. Of course, we were all waiting to find out how our stroke patient from the day before had fared as we had placed her on palliative care and the expectation was that she wouldn’t last the night…hopefully. Anne reported that her breathing had become very shallow and that she remained unresponsive to any verbal stimuli. Again, there was absolutely no question by any of the care team as to what we were dealing with (an intracranial hemorrhage and increased intracranial pressure) and what the outcome of the case was going to be (that she would be left totally dependent on others with severe neurological deficits if she were to survive). Following report, several of us went into the ward to check on her and, as if having been waiting for our permission, she became apneic and shortly thereafter expired. Following her death, Daniel found that perhaps the most positive outcome from the entire process was when the patient’s sister asked him to check her blood pressure to make sure that didn’t also have hypertension.

Our lunch table at the Gibb’s

The little child with the thrombocytopenia and anemia who we had kept at FAME to see if their platelets would respond to steroids, was doing well, but their platelets came back that morning at only 4 thousand, down from 5, but it wasn’t entirely clear that the therapy had kicked in yet or not. Both Marin and Dan were incredibly helpful as pediatricians on this case as I would have had no idea of what to recommend in this situation. The plan ultimately was to keep the child over the weekend, continuing the steroids and then rechecking counts on Monday morning. If the platelet count continued to remain low, then the plan was to send the patient to KCMC for a bony marrow aspirate which was the next procedure to be done.  Dr. Jackie had already them about the possibility and there was no reason to send the child over the weekend as they wouldn’t be able to do the aspirate until Monday, regardless, and their specialist, who could evaluate the child, would also be there on Monday.

The Elephant Cave crew and their guide, Brown

Some “wild” animals on the trail to the elephant caves

Our plan for the day was to work the morning and see as many patients as possible with the idea that we would try to finish at around noontime. I had made reservations for the seven of us to enjoy the wonderful lunch buffet at Gibb’s Farm and every one was going to climb to the elephant caves that are a short hike from Gibb’s up the Ngorongoro Conservation Area, or NCA. As is usually the case, we had packed everything up and were ready to head to the house and go for lunch when a young girl arrived who had been struck by a piki piki. At the time, she had apparently been knocked to the ground, struck her head and was unconscious for two hours. She had also developed some bloody discharge from one of her ears that had stopped and now had classic post concussive symptoms that included headaches, dizziness, and tinnitus. She had been referred to us for evaluation and a CT scan. Jon took a thorough history and performed a neurologically examination that was normal including a look in her ear that revealed some dried blood in the canal, but the tympanic membrane looked just fine. Our CT scanner was not yet up, but we didn’t feel that she needed a scan regardless, and so treated her conservatively. Given that she was from the village of Oldeani, nearby the Rift Valley Children’s Village where we’d be next week, we just asked her to come see us there to make certain she was still doing well.

Daniel, Marin and Adys

A view down the valley near the waterfall

We were finally off to Gibb’s Farm for our lunch and it was an absolutely gorgeous day for us. They had reserved a table for us on the veranda overlooking the coffee plantations and with a view to the distant mountain ranges of the Lake Eyasi region many hours away. Lunch here is also an event, very similar to the dinners, but in a much more relaxed and informal manner. They have dozens of selections of local and ethnic cuisine that have all be prepared to perfection by the wonderful kitchen staff. Their cheeses are made on site and all of the produce is grown there at the farm. The dessert selection is also an amazing affair with numerous selections including fresh fruit. We all sat at our table in one of the most beautiful locations of the world enjoying some most wonderful dishes that one can imagine.

Elephant caves panorama

A view looking down from the caves

When lunch was finally over and everyone had had their fill (and then some), it was time to head to the trailhead for the elephant caves. Since this hike takes you into the Ngorongoro Conservation Area (read, wild animals), you have to first check in at the ranger station and hire a guard. The cost is $18 per person for the walk and well worth the experience. The “caves” are really impressions in the hillside where the elephants come to dig out minerals from the soil that they need for their nutrition. You can see elephants there on occasion, but for the most part, the elephants come there at night so you don’t run into them. You other animals on the hike, though, such as the ubiquitous baboon and lots of birds. There is a very nice waterfall on the hike as well that you can walk up to the edge of and is quite a drop. Since I had been on this walk several times before, I decided to drive them the short distance to the gate and then head back to Gibb’s where I could spend the entire rest of the afternoon waiting for them to return from their hike all the while sipping on a Moscow Mule. Even better yet, I am well-known to the staff aft Gibb’s Farm as either they, their spouses or children come to see us for their neurological care, so they take very good care of me. It is almost too relaxing sitting there on the lawn in the shade to do reading or work, so I am certain that there were a few short naps interspersed with my blogging of the day early. Gibb’s Farm has to be one of the most unique places in the world and being able to come  back here time and time again is truly special. Even more special, though, is bringing the residents and others who accompany me to this place of beauty to experience it for their first time and see their reactions.

The pool leading to the waterfall

The elephant caves

The trip to the elephant caves lasted until the evening and it was quite close to sunset with the others arrived back to meet me, still sitting in my same chair and typing away. I had promised them come nice cold drinks on their return and most everyone decided to enjoy the sunset with some refreshments. Everyone had also wanted to speak with the artists, one of who I had purchased several things from over the years. It was quite late by the time we ventured back to Turtle to begin our journey home to FAME. We had plans to head to Ngorongoro Crater the next morning, leaving at 6 am, and still needed to make our lunches for the game drive, so there was much to be done to prepare for the day. Jon, Daniel, Adys and Sheena have become real pros in making all of this happen and once again we had everything made and packed up in short order and now it was just a matter of getting to bed with thoughts of the crater on our minds as we slept and the vivid Malarone dreams assisting in the whole process.

Sunset from the Gibb’s terrace

Tinga tinga art for sale at Gibb’s Farm

Friday, March 15 – A very sad case of a stroke….

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Having had just a wonderful night with Daniel Tewa and his family, we were now ready for the end of the week. Our Saturday would be a half day of patients with a “Wellness Day” for the afternoon and then on Sunday, we had plans for a day game drive to Ngorongoro Crater, one of the premier game viewing sites in all of Africa. Since it will be March 17 the day we’re in the Crater and Phoebe, who is Irish, is coming with us, we will be bringing some beer along with us to celebrate at lunchtime. I will do my best to post the Ngorongoro Crater blog on Sunday night depending on how exhausted I am after driving and guiding all day. I was recently asked what my favorite thing to do here was, and I would have to say very honestly that it is taking people on safari and driving myself. I can easily remember how I felt when I first came here seeing the remarkable sights and visiting with these amazing people here. My greatest love is to introduce others to this wonderful country.

The neuro team enjoying the Lilac Cafe

At morning report, we ran through all of the patients in the ward, several of who were our pre-eclampsia/eclampsia women who, thankfully, were all doing well though needed some stricter blood pressure control as we were afraid that their PRES could easily return and they had been doing so well. Sheena’s patient who had been billed as a post-partum psychosis, but had no psychiatric history and seemed to respond well to blood pressure management and levetiracetam. She improved by the following morning, having gone from being completely uncooperative and constantly singing to being fully alert and cooperative. There seems to be a very significant incidence here of pre-eclampsia/eclampsia and it is not entirely clear why that is other than perhaps the much higher incidence of hypertension, even in young women.

Marin taking a photo of Jon discussing an outside CT with Dan

At the end of morning report, we were also able to pull up the X-ray of the young baby who had died last weekend so that Dan could review it in light of the initial concerns of some congenital heart issue. He felt that the X-ray was very abnormal and definitely suggestive of this. The baby had been initially fine, but then cried out several times, each time associated with desaturation of oxygen and turning a bit cyanotic. On the third cry, the baby died and they were unable to resuscitate it. The CXR had been done prior to all of that occurring and had a very large heart and wide mediastinum. Dan concurred that the baby most likely suffered from one of the congenital development cardiac issues such as transposition of the great vessels and that is not something that can dealt with here by any means.

Jon reviewing an outside CT scan with Dan

A baby had come in the day before and was presented today at report with severe anemia and thrombocytopenia who had been seen here last October with similar problems and had responded to steroids with the platelet count increasing from 5K to 85K the following day. It was unclear how much of a workup had been done at that time, but the baby hadn’t been seen in the interim so it was presumed that they were doing at least reasonably well. They now had a hemoglobin of 5 and platelets of 5K on admission. Given the fact that he hadn’t returned in the six months, that would make leukemia very, very unlikely, but an autoimmune thrombocytopenia was a possibility, but wouldn’t explain the anemia, so that would have to be from another process. After much discussion, the child was placed on IV steroids to see it he would respond again and will be monitored going forward.

Dr. Caren, Dr. Julius, Dan and Frank discussing stroke case with patient’s husband

Just before noontime, we were urgently requested to come to the OPD to see a patient who had been brought in with an apparent stroke. Daniel accompanied Dr. Julius back to the OPD to see the patient and returned a few minutes later to report that she was a younger woman (51-years-old) who was not moving her right side, was not responsive and had systolic blood pressures over 200 mmHg.  She was being moved over the emergency bay so that we could care for her more appropriate. When she arrived here, she was already posturing her right side, her pupils were sluggishly reactive, and, most concerning, she was dropping her heart rate in the setting of severe hypertension with systolic pressures still well over 200, which is known as a Cushing’s response and occurs in the setting of high intracranial pressure and impending herniation of the brain.

Unfortunately, her symptoms had begun the day prior when she was shopping and developed right-sided weakness and aphasia. At some point, the family had taken her to a dispensary and she had been referred to come to FAME for a CT scan. Our CT scan has been down since last October due to the various problems, but was ready for operation once it was approved by the Tanzanian Atomic Energy Commission, which we were waiting for and had not yet happened. What ensued at that point was a very practical discussion of what should be done. Given her presentation, we were reasonably confident that we were dealing with a hemorrhage large enough to have caused her to begin to herniate. If we were to send her off to Arusha for a CT scan that would cost $200, it was very unlikely that there would be any intervention that could be performed. Even if some intervention could be performed, it could only be expected to possibly save her life, but to what purpose we were very confident that she would never be able to move her right side or speak and would be totally dependent on others for the rest of her life quite possibly with complete lack of awareness.

Frank discussing a case with Marin, Caren and Jon

We did discuss the situation with her family at length to explain to them the dire nature that she was in and that regardless of what we did, it was most likely that she was going to die and that the very best we could hope for in this situation was to save her life, but that she would be dependent on others for the rest of her life. We were limited in what to treat her with here as our IV antihypertensives are minimal and we were hoping that the family would agree with our plans to initiate palliative care. Anything that we did now would only prolong the inevitable. The family insisted in contacting her parents even though her husband and other family were here and, thankfully, after everyone was contacted, there was a very reasonable understanding on their part so that she was moved to the ward and placed on comfort care only. She was given a small amount of morphine to decrease any agitation she might have as a result of her oxygen hunger and she was made comfortable, waiting for the end to come.

Frank, Dan and Daniel discussing care for the stroke patient

Considering the circumstances, it was clearly the right thing to do, but regardless, it was tough for everyone considering her age and the fact that this very likely something that was preventable had she only been compliant on antihypertensive medications. Hemorrhagic stroke is much more prevalent here in Africa than it is elsewhere solely because of the higher incidence of hypertension in general, and untreated hypertension specifically.

We spent the evening at home, relaxing, and thinking of what we were going to have for dinner. We received our “bacon, no lettuce, and tomato” sandwiches on homemade bread, but I had been dreaming of making a bacon and tomato egg scramble with the ingredients after deconstructing the sandwiches. Jon was all in for the scramble as well so I whipped up some eggs and Adys joined us as well. We had borrowed a small, compact LCD projector that Phoebe had and watched the Lion King on the wall. I listened to most of it while cooking and typing, but it hasn’t changed. It’s a classic and everyone’s now exited to go find Pride Rock while we’re on safari. After Lion King we watched a very good climbing movie that Marin had on her computer called Free Solo about free climber Alex Honnold. For those of you who love extreme outdoor movies, it is an amazing documentary about an incredibly select group of climbers who do not use ropes and place their life at risk every moment on the mountain. It is also an excellent documentary from the perspective of what kind of person it takes to succeed in such an endeavor and the psychopathology (I’m using that word in a purely clinical perspective and not at all judgmental) that is necessary.

 

Thursday, March 14 – A visit with Daniel Tewa….

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Vic’s white board thesis on burn wound treatment

Vic Davis giving his lecture on burn treatment

For those of you who have read yesterday’s blog, there is no need for me to introduce Dr. Vic Davis. If you’re new to the blog, Vic is a trauma surgeon who has tremendous experience all over the world in war-torn torn areas and just happens to be here visiting FAME and Dr. Kelly on a short break from a stint in Dar es Salaam at Muhimbili University. Vic had offered to speak this morning for the education session on the management of burn wounds. Not something that we necessarily encounter on a daily basis in neurology, but something that is definitely worth relearning given the area that we’re in and the fact that we could certainly be asked to assist in managing these patients if the need arose. Vic had first completely filled out the white board with the points that he wanted to cover in his talk and did a wonderful job of getting to everything in the short time he had allotted this morning. It was again a complete pleasure to hear him speak from a place of absolute confidence and experience in the subject.

One of the more puzzling cases of the day didn’t involve anything neurologic, but it was a young 9-month-old child with a severe rash that had been seen previously at FAME and treated with topical steroids and antibiotics with continued worsening. It had been present for about six months and looked horrible. Both Dan and Marin (our pediatric peeps) were asked to take a look and weigh in with their thoughts. We did have some ideas, but in the end sent off photos to several resources in Philadelphia. I emailed the photos to Carrie Kovarik, who is at Penn and an expert in dermatology, dermatopathology and tropical medicine. Dan and Marin not only emailed the photos to their Jim Treat at CHOP, but also called (with the time difference, I think it was like 6 am!) to see if they could get additional information. The feedback we received suggested that this was “unusual/ fulminant acropustulosis of infancy,” that usually occurs on the hand and feet, but can also affect the face, nose and ears and can often be mistaken for scabies when it involves primarily the feet (trust me, all of this was from Carrie as this is not my shtick by any stretch). It should respond to high potency steroids and will often burn itself out over time.

We continued to see patients throughout the day, but having Dan here to not only staff the pediatric cases but also some of the adult cases, it has allowed me the freedom to spend some time at the Lilac Café this trip and that has been a real luxury for me. In the past, I’ve had Danielle Becker with me, though on one of those trips, she was focusing primarily on the epilepsy cases. Dan has adapted incredibly well to the style of practice here which is a real compliment given the unique nature of practicing medicine in East Africa and it has been wonderful to have him here working with us, and not just because of the freedom to take my Lilac Café forays.

Daniel Tewa explaining his Iraqw house

The sleeping platform for women and children

The Lilac Café was created when the new hospital opened several years ago as it became clear that there was a need to feed the inpatients and their families beyond what the FAME cantina could handle. It is a lovely place for us to meet and have coffee in the morning when things are slow and, today, I took the opportunity to spend some time here outside on the porch with a wonderful cappuccino. Susan and Frank also happened to be here at the same time discussing logistics for their upcoming fundraising trip in the US. I took the liberty of introducing them to the concept of AirBNB, something they have not tried in the past and something that I have been using extensively over the last several years. Two years ago, I spent a week in the Galapagos Islands in the town of Puerto Ayora on the Island of Santa Cruz, so it is clearly possible to find something just about anywhere in the world. For those of you who haven’t looked into it, I would strongly suggest giving it a try. I continued to enjoy the warm rays of the sun sitting out on the porch enjoying my cappuccino and remembering just how incredibly lucky I am to have this opportunity to come to FAME and share this experience with others.

Daniel explaining how an Iraqw family lived in their houses in the past

Two Iraqw warriors??

We had arranged to visit Daniel Tewa and his family tonight for dinner. As many of you know, I first met Daniel when I came to Tanzania with my children in 2009, and have visited with he and his family on every trip back to FAME since that time. Daniel is a remarkable man who is a self-taught historian of not only Tanzania, but also of the world and is far more knowledgeable about our own country than most Americans are by far. And though Daniel and I have become family over the years, it is really that fact that he has opened his home to those residents and others who have accompanied me on our visits without hesitating and has continually insisted that the honor is his and that he would not have it any other way. What began as simple visits by myself have now morphed into his entertaining our entire group for the evening which this time added up to seven of us including myself.

Marin and Sheena modeling Iraqw wedding skirts made by Elizabeth Tewa

In Daniel Tewa’s home

When we arrive, he has a table arranged for us outside among the trees in the middle of his beautiful farm with African coffee (coffee and milk boiled together) that is some amazingly delicious and is made with fresh milk from his cows. We sit and talk as he goes around the circle asking everyone where they are from and then telling us some fact about our city or state that we often don’t even know. We talk politics and given the fact that we don’t watch any television here or even keep up with the news, he usually tells us something that we weren’t even aware of. Tonight, he asked what we thought about Beto O’Rourke announcing that he was running of which none of us were even aware of at the time. After sitting for some time, we walked over to the underground Iraqw home that he built in 1994, and which is a replica of the type of house that he grew up in before they were outlawed by Julius Nyerere after the country’s independence and the need to bring all 126 tribes of Tanzania into villages together to create a country. The houses were underground so as to protect their cattle, sheep and goats from the Maasai during the night. The Iraqw and the Maasai were at odds with each other until a truce was finally signed in 1986.

A “daily wear” goat skin dress as opposed to the wedding skirts

In addition to Daniel’s Iraqw home, he also shared his methane gas collection system with the others which provides gas for cooking and lighting his home. It is a 10 cu. ft. collection tank that uses the waste from several cows to produce more than enough methane for his own use while also providing fertilizer for his fields from the byproducts of the process. It is an ingenious system that he has had for many years and that I had first seen in 2009. Later, we all walked to the nearby home of his eldest daughter, Isabella, where we were greeted as honored guests and served a wonderful dinner that was prepared specially for us. It has been this way for many years between us and there has been a relationship of mutual respect and gratitude. Though Daniel has continually reminded me of what I do for his community by bringing doctors here and providing care and that the honor is his, I constantly remind him of what he has done for us by sharing his home and family and teaching us about his culture. It is these relationships that we must treasure in life for they are the most genuine. There are no pretenses or expectations, only respect and love.

Wednesday, March 13 – Is there really such a thing as hump day in Tanzania?

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It is Wednesday and we’re half way through our week-long clinic here at FAME with the mobile clinics to look forward to next week. The low volume has been a bit frustrating as I’m sure you can imagine, but the cases have been interesting and it’s been good working with Caren as I haven’t really had a chance to work with her much in the past. As I’ve mentioned before, it is our main mission to teach the clinicians here at FAME and when we are working with interpreters rather than a clinician, it is a lost opportunity to teach. Though it is great for us to see more and more patients here, the real impact and capacity building occurs when you teach a man to fish. When it was just me alone here, that wasn’t a problem, but as the program has grown over the years, with FAME growing as well, it has created a situation where they are more and more strapped for manpower which makes it more and more difficult for FAME to free up other clinicians to work with us. There are several solutions to this problem, but in the end, it has to do with funding, which always seems to be the case, and the only resolution that I believe will give us some immediate solution going forward will be for us to have a designated clinician or two who will continue to provide neurological care to our patients.

The severely scoliatic and translucent spine of our osteogenesis imperfecta patient

Frank had posed a question to me last week regarding which specialist would be most appropriate to follow an adolescent with osteogenesis imperfecta. I had replied that it would be a pediatric endocrinologist and pediatric orthopedist most likely, which was later confirmed by his speaking with one of his resources in the US, but at least I knew that it wouldn’t be a neurologist, let alone an adult neurologist. As things go here, though, it usually turns out that we will end up seeing patients like this just to help out with whatever we can. So, this young girl with very serious osteogenesis imperfecta arrived to clinic today after having traveled down from Arusha. She was accompanied by someone from the international association who was working with her to navigate what exists of the health system here, and they came with many records and X-rays for us to look at to help with the evaluation. She did have some chronic pain symptoms that were certainly something we could help with, but beyond that, there was little from a neurologic standpoint for us to focus on. Regardless of that fact, both Marin and Dan did have some helpful thoughts about what could be done for her.  Her disease was quite advanced and plans to do anything for her would have to take into consideration the real risk of doing harm in the end. Merely transporting her would poise an incredible to her well-being. She will absolutely need to travel outside of the country for something to be considered and it’s not entirely clear what that might be.

Lower extremity/ankle films of our osteogenesis imperfecta patient

We also had another little infant come who was somewhat younger than our last with the similar problem of static encephalopathy and poor nutritional status. Once again, we contacted our sources in Arusha at one of the hospitals and were told that though they could see the child, the family would have to cover the cost of care. Though medical costs are most often very much less expensive here, they are typically going to be far outside of anyone’s or any family’s ability to pay. Patients will often go back to their communities to gain the funds necessary for some treatment which is the culture here. One of the lessons that are taught here is about unintended consequences and the fact that reaching into your pocket to help out, an act that we would consider the right thing to do, is not what one should do. It sends entirely the wrong message and rather than promoting self-reliance, it breeds continued dependence on others and is not sustainable in any sense. Though it is the ultimate intention to help others, without a plan and without first speaking with those who have been working in the area, it will most often lead to failure and heartache. There are many, many stories here of those wishing to help who have left in their wake millions of wasted dollars and nothing to show for it in the form of having made a positive change. Though this can be very frustrating, it is a lesson one must learn on Day 1. First and foremost, ask those you wish to help what is needed rather than giving them what you think they need. The latter tact will always end in animosity and lost friendship.

Knee films of our osteogenesis imperfecta patient

The weather here for the last week and a half has been nothing short of perfect. Outside of the first few days in Arusha and the heat, it has been just absolutely gorgeous – cool mornings and evenings, bright cloudless skies all day long except for a brief late afternoon rain shower, but we actually haven’t seen one of those in several days. The sun here is intense as we are just below the equator and it takes only moments in the direct sunlight to burn. We have no seasons here as we know them at home. Here, the seasons are known by their amount of moisture in relation to planting and harvesting. We are actually in the wetter season now where it is green and lush, there is less dust, and the planting is taking place readying for the rains of April and May. October when we have traditionally come, soon to be September this year and going forward, is much drier and dustier. Still, both seasons hold different benefits and both are lovely.

Daniel and Sheena working with Michael

As it is Wednesday, it is our Happy Day night. Again, this has been a tradition for several years for all the volunteers at the various sites in the area to mingle and share their “war stories.” It really is a time for everyone to unwind in the company of others of the same age and ilk. Everyone had decided to walk there tonight with the lovely evening, though I had to wait back at FAME as I was expecting to get Turtle back from the mechanic with its new emergency brake other small fixes. Soja, who is FAME’s mechanic, and has helped me with my vehicles for many years here in Karatu, brought Turtle back to me around 6 pm, which was perfect timing for me to drive him back to town and then meet Susan at the Lilac Café to chat. After my meeting, eating and catching up on some paperwork, I drove down to Happy Day with everyone sitting outside on the deck and lots of lively conversation already underway.

The new and much appreciated addition to the menu at Happy Day is ice cream!! There are no good sources of ice cream here and it is something that is sorely missed. If only we could get a Baskin Robbins or Rita’s (the latter a Philadelphia favorite source of water ice and custard) here in Tanzania, I would gladly promise to support them on a regular basis. For now, though, a cup of vanilla and strawberry ice cream at Happy Day will have to satisfy my sweet tooth.

A young child from the ward struggling with their walker

As I sat down next to Sheena and across from Ann, there was already an ongoing and incredibly interesting conversation that also included Drs. Vic and Kelly. Dr. Vic Davis is one of Kelly’s mentors from her surgical training and has been here visiting at FAME during a brief interlude from his more long-term work with the surgical department at Muhimbili University. Vic has been working for many years, it seems, in practically every remote corner of the world with the International Medical Corps, among others, providing emergency and heroic surgical services just behind the front lines of war-torn locations. We were all in awe of his stories, which he told in such a matter-of-fact fashion that if you didn’t know better you’d think he was just related a normal day at the office. These were not glorified junkets as they to such locations as Afghanistan, Yemen, Somalia, Rwanda and Sarajevo just to mention a few. These were not considered vacation sites, and certainly not during his tenure in these locations. I think everyone who was listening at that moment found themselves thoroughly entranced and it became quickly apparent that what Vic really needed was a ghost writer to help him put all of this into a book. I would be the first in line to buy a copy of his book as it would tell a story of an incredibly unassuming physician’s true dedication to humanity. It was a privilege to be sitting with Vic at Happy Day this evening.

Tuesday, March 12 – A ride in a bijaji….

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The group on a walk from yesterday

It was another education morning, but today we were off the hook. Ann Gilligan, the nurse practitioner working with Every Mother Counts and who has also been working here at FAME to educate the doctors and nurses on birthing position, was placed in the lecture slot. And rightly so as she is incredibly passionate not only about the subject matter, but also the need for education in this area. Without going into detail, as I would undoubtedly oversimplify the subject, it pertains to the fact that how babies are traditionally born is not the most natural, nor the safest, of positions for either the baby nor the mother. She gave a wonderful lecture that completely held my attention for it’s entirely which is saying something considering that not only am I a neurologist, but also long past having any more children of my own. Everything just made so much sense and in the short time she has been here at FAME (one week) she has been able to teach a number of the maternity nurses how to assess babies in this fashion and actually worked with a mother all day yesterday to help her towards what was an incredibly smooth and quick first delivery. Hopefully, Ann will be able to come back in the future to work more with the doctors and nurses as this has been so well accepted on its initial run through. Kudos to Ann.

Ann Gilligan giving her talk on birth positions with her algorithm on board

This was Dan and Marin’s first full day in clinic to see children and they were of such great help considering the number of children we see here. Children make up about 1/3 of our neurology patients here with the vast majority of them being either epilepsy cases or static encephalopathy and it is certainly great to have Dan and Marin available to see at least the latter cases, if not all. Marin evaluated a 2-year-old child with developmental delay who weighed only 6 kg and wasn’t not feeding very well at all because of her severe neurologic deficits and swallowing dysfunction secondary to oro-pharyngeal dysmotility. The child was repeated aspirating which was a huge issue and had gone from 10 kg a year ago when seen by us to her now 6 kg. There was very little that we had to offer the child from our perspective, but they were clearly in need of assistance with feeding and I had remembered that in the past we had looked into referring a child to Selian Hospital in Arusha as they had a program to help these patients. I spoke with Kitashu, our social worker, who subsequently contacted the social worker at Selian, who then spoke with the pediatrician there. After a short delay, we were able to confirm that they were willing to work with the family. Though it may have only been a small success, it was one that we were all more than willing to take for it is these small success that are often the most rewarding. It is one step at a time.

Sheena and Adys working together

Though we had seen a moderate number of patients for the day, including children to keep Dan and Marin happy, we were still able to finish early and everyone had made plans to go to town to the one of the seamstresses that Katherine has been using to make her clothes. As I had work to do and blogs to write, I opted to stay back at the house. Besides, the mechanic had picked up Turtle (my Land Rover) earlier in the morning to fix a few minor things that included the emergency brake that had stopped working on Sunday. Not entirely necessary as long as you park in the right place and remember to leave the vehicle in gear, but still something that’s nice to have when needed. As I wasn’t of any use to drive anywhere without a vehicle, it offered a good excuse to accompany them and, besides, they had Katherine with them. I was told that it took some time to get everyone measured for everything that was ordered and, to be honest, I can’t say that I was sorry that I missed it since shopping for clothes isn’t one of my favorite things, unless, of course, we’re talking about REI in which case I’ll be the first to sign up. After they had finished with their shopping, everyone rode bijaji’s home from town.

A bijaji at its finest

A bijaji is a three-wheeled vehicle that is like a combination motorcycle and small car. The driver rides up front and you can squish three into the back seat. They have a motorcycle engine in them so that they are grossly underpowered and it wasn’t until the last several years that they’ve appeared in Karatu. They were first in Mto wa Mbu for a number of years and slowly migrated up the hill just like swarm of bees. From another driver’s perspective, they are incredibly annoying as they drive on the side of the road most often, clogging up the flow of traffic and are usually in your way in the most inopportune times. They drive slow while at least the motorcycles, which are also annoying , drive at a greater speed and though they weave in and out of traffic, it isn’t necessary to watch out for them as they watch out for themselves. Leave it to say that I rued the day when the bijajis showed up in Karatu and they have in no way redeemed themselves over time.

A selfie in a bijaji – Katherine, Adys and Daniel

Having finished their “fittings” for their Tanzanian clothes, everyone decided to take the leap and ride the forementioned, infamous bijajis back up to FAME and, thankfully, everyone made it back in one piece. To honest, though, I have no issue with riding these vehicles as I am unaware of any significant risks, which is not to be said for the piki pikis, or motorcycles. Motorcycle taxis here are a huge business and probably transport the majority of passengers needed to get from point A to point B within Karatu and most cities and towns. At every small intersection you pass, there is always a cadre of piki pikis ready for hire, and, from what I understand as I have never ridden one, it is very, very inexpensive. On our last visit, Peter, the medical student who accompanied us and was living off-campus, used this mode of transportation on a daily basis and clearly survived to talk about it as he is alive and well in Philadelphia and without any PTSD from the experience.

A look back over the fields during our walk

After arriving back to the comfort of our houses here at FAME, it was time for a bit of rest and relaxation. That is until Kelly, Vic and Katherine came walking by our house on a walk and asking us if we wanted to accompany them. It was an absolutely gorgeous evening with the sun about to set in an hour or so and an offer we just couldn’t refuse. Within minutes, we were all out of the house heading down the trail to our back gate to join the others on a relaxing walk through the fields behind FAME. There are small roads and trails that travel everywhere here as villagers use them to walk to work, in town or the fields, every day and even those that cross the fields and are tilled on a regular basis, are quickly reformed within days after their disrupted. The trails crisscross everywhere and, if you don’t know where your going, it’s very easy to get lost, especially if you are in a depression or small valley where you can’t see the hills to get your bearings. Worse yet, when the sun sets it becomes even more problematic as darkness falls quite rapidly and it’s easy to become disoriented. On my first trip here, I had decided to take a long hike to a distant ridge in the west to watch the sunset, later realizing that I had no flashlight and there wasn’t much of a moon. I had to walk the near hour back in total darkness through old coffee fields, imagining at times that the bushes were wild animals which do roam the area, and thankfully arriving back to my house well-after sunset, only to receive a strict tongue-lashing from Joyce and Carolyn, who were my housemates at the time and were worried sick about me.

Our wonderful sunset

This walk was far more reasonable, though Sheena and I did take off on a fairly brisk pace ending up far ahead of the others who later texted that they were turning around and heading home as the sun was setting. Having spent more time here now, I knew that we still had plenty of light to make it home and, more importantly, I had a flashlight. We walked to the top of the hill where there is a neighborhood so we could watch the wonderful sunset off to the west and bask in the warm rays of the setting sun. We were actually not that far from FAME so there was no opportunity for a reenactment of my earlier lapse in judgement. We walked home at a pretty good clip, partially to make it back before dark, but also as Sheena has been considering climbing Kilimanjaro at the end of her time at FAME and wanted some extra training. We joined the others sitting out on Joyce’s veranda, though by this time the mosquitos were coming out and the bats were circling our heads. Those were both excellent reasons to retire to the comfort of our living room, which we did in short order, to enjoy our dinners. Chef Daniel offered to take our vegetable wraps apart and to stir fry the veggies while also making fried rice, which most of us felt was a marvelous idea. His creation was worthy of a culinary award and quickly devoured by all.

A colorful centipede

A colorful centipede with Sheena’s hand for comparison (notice how I used her hand rather than mine for this possibly poisonous beast)

Monday, March 11 – A full week of neuro clinic begins….

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I think just about everyone had a hard time getting up this morning after the exhausting day on safari yesterday so it seemed like a longer walk to morning report than normal. We arrived to the conference room for report to find now one there so left to find out what was going on for the morning. Bumping into Dr. Julius, we discovered that everyone was either attending the code going on currently in Ward 1 or was with the pre-eclamptic patient who presented with seizures in Ward 2. To say the least, it was going to be a very hectic day. We quickly discussed the other ward patients in morning report and then left to see what was in store for the day at the neuro clinic. Once again, there were far fewer patients there than I had expected and compared to what we have seen during past visits. Given that we have the same outreach team that brought in over 400 patients last October, it must be the time of the year and the fact that it is currently planting season here. Patients must decide whether they can neglect their fields to deal with their health and most often, their health will come in second place. It is essentially a matter of survival and without their crops, they have very little else.

Cappaccino at the Lilac

So, back to the busy start of the day. The ongoing code in Ward 1 turned out to be a young woman who had a history of about five days of gradually progressive confusion and lethargy, had presented to an outside dispensary where she had been treated and sent home. She had lost consciousness and was rushed to FAME the evening before. In the morning, unfortunately, she had had an arrest requiring her to be resuscitated and eventually intubated. She was now on one of the surgical ventilators in the PACU and without brainstem reflexes. Given the question of brain death, which is something that neurologists do routinely, it was just a matter of time before we were asked to see her. Daniel offered to do the evaluation and went over to the PACU to see her, and, as expected, found the patient to have no brainstem reflexes whatsoever.

Daneil working on a chart in the moring

Unfortunately, there were several factors that also played a role in the decision making. Patients here are usually not intubated even during a code as there are no long-term ventilators for use in most institutions. As you recall, the baby last week had been physically bagged all night as there was no pediatric ventilator available and the same situation existed for this patient in that there was no long-term ventilator available for her regardless of what anyone would have wanted. This is a basic problem all over Africa in that there are no facilities that can manage these patients requiring this care. I’d fight long and hard if we had a patient with Guillain-Barré syndrome come in needing ventilation given the knowledge that would be expected to recover fully. On the other hand, this patient, now without brainstem reflexes, meaning that she was unable to breath on her own, had an extremely poor prognosis even in the best of circumstances. Dr. Gabriel had spent a significant amount of time with the family to explain the gravity of the situation and prepare them for the fact that their family member was not going to survive. Her ventilator was eventually removed with the family understanding that would pass and that it was clear that she was brain dead, meaning that we had determined death by neurologic criteria rather than the more common cardiopulmonary criteria. Things don’t always go this smoothly with the decision making, of course. Her presentation, Daniel felt, may well have been that of meningitis given her encephalopathy for several days, and given that it hadn’t been fully treated until she arrived to FAME, her prognosis from the get go was incredibly poor.

Mid day at FAME

After dealing with this patient, we were peripherally involved with two patients who had also presented with pre-eclampsia, but were doing well as they had both delivered. In addition to this, there was also a woman who presented with abdominal pain and was eventually found to have a rupture ectopic pregnancy with a very large hemorrhage requiring her to take a trip to the operating theater to stabilize her. It was a very hectic morning for the FAME staff and since things were rather slow for us once again given the vagaries of the planting season here, we were happy out with some of the patients as best we could while staying in our comfort zone. No worries, though, I did not send any of my residents into the OR to assist. The closest thing we have to that here is Jon, soon to be a neuro critical care fellow, who is always more than happy to volunteer for any potential procedures and so far, has been incredibly helpful with the ultrasound machine here looking at hearts and optic nerves (for increased ICP). We haven’t provided him with any central lines yet, much to his dismay, but you never know.

Adys relaxing at the Raynes house

We had a number of children to evaluate this morning, which was fine as they were all relatively straight forward, but it was a bit frustrating as Dan and Marin, our pediatric neurology team, would be arriving around noontime today. One of the children we did see was a little baby with a question of developmental delay as the mother was concerned he wasn’t walking at 12 months since her other children had walked at 9 months. The walking issue was of no concern to us since they were still well within the range, but there were other much subtler signs that were present that did raise some level of concern. It still wasn’t 100%, though, and neither myself nor Adys felt that we say one way or the other. Hence the need to have a full pediatric person with us here as it has always been my contention that I am comfortable evaluating children, but admittedly feel less confident when it comes to floppy babies or early development.

A frisbee game in paradise

Thankfully, Dan and Marin arrived around noontime as expected and were both prepared to see patients that afternoon, though we only had a few. They had been traveling for several days to get here, making a small detour in Dar es Salaam, but eventually arriving safe and sound into Kilimanjaro International Airport. After having spent the night at the KIA lodge, they were awake and on the road early to join us here for two weeks and the bulk of our clinic. Dan is a pediatric neurologist from Children’s Hospital of Philadelphia, who graciously offered to accompany us for this visit as we didn’t have a pediatric neurology resident along to help with the children. Marin is primarily a pediatric inpatient neurology nurse practitioner, who I am told pretty much runs the ICU service at CHOP, and has been incredibly enthusiastic about the possibility of accompanying us here and has finally made it happen.

Fabric shopping in town

Given the rather slow nature of the day, we took the opportunity to run to town for some fabrics as everyone was interested in having some clothes made by one of the shops in town. The fabrics here are incredibly colorful and beautiful and there are many, many shops downtown that offer a wonderful selection of patterns and then it is merely a matter of trying to describe to one of the tailors what it is that you would like to have made. That can often be an issue, though, since most of the women at the shops do not speak English and it’s always just a bit nerve wracking hoping that they understood everything you were trying to convey. Today was only a fabric buying trip and that would not be difficult. Phoebe accompanied us all downtown and in very short order, there was agreement on which fabrics were being purchased. Going to the dressmaker or tailor would wait for another day. I had told Kitashu to call me if any patients came in for us to see while we were away and he called at just after 4 pm to let me know that someone had arrived.

A view during a walk…

Adys agreed to see the patient with Dr. Carin and it turned out to be a woman with what appeared to be some cognitive impairment when they took the history and she was initially thinking about a neurodegenerative process. The more that Adys got into the history, though, it seemed that the confusion was episodic which wouldn’t necessarily be consistent with a diagnosis such as this. After further questions and the recognition that the patient had underlying diabetes mellitis, it was decided to check a blood sugar. Thank goodness they did as her random blood glucose was 18 (!) meaning that she was severely hypoglycemic and at great risk of suffering injury if it weren’t corrected immediately. We whisked her to the emergency bay to get an IV started and gave her fluids and D50 and within moments she began to perk up. Though she had improved with the D50, I believe it was decided that she would come in the hospital overnight to make sure that she was stable. It was disaster averted and just reinforces the fact that you have to look at the basics first before you begin to consider other things. Had that patient had to wait much longer for us it could have been a very serious problem. The old adage, “if you hear hoofbeats, don’t think of zebras,” doesn’t necessary translate in this part of the world given the number of zebra we see here every day, but it still conveys the necessary concerns of thinking of the basics first.

Sunday, March 10 – It’s off to Lake Manyara and everyone’s first safari….other than Disney’s Animal Kingdom, of course….

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A selfie of the crew

If it’s Sunday, it must be safari. Sorry, it’s a movie reference for those of you old enough to recall the movie, “If It’s Tuesday, This Must Be Belgium,” a 1969 comedy about a group of tourists traveling through Europe. As has been a tradition since my first coming here, I have always reserved Sundays for going on safari, or as they say here, a game drive. Safari in Kiswahili merely refers to a journey and actually has nothing to do with traveling to a park to view animals. The parks in Northern Tanzania are some of the most amazing parks in all of Africa with the Serengeti and Ngorongoro Crater being at the very top. Tarangire, a wonderful park and home to the elephants here is very large and great to visit, but there has been an overabundance of tsetse flies there of recent, and for anyone who has experienced these heat seeking missiles disguised as an insect knows, their bites are very painful and swell to a nice welt in short order. The fact that they do carry trypanosomiasis (sleeping sickness) as well is much less of a concern here as we haven’t had any cases of this here in forever. The other close park for us in Lake Manyara, a much smaller park that is often overlooked and on far fewer itineraries than the others, though would be our destination for today.

Two olive baboons

Lake Manyara sits on the floor of the Great Rift Valley and is well over 50 km long, with the national park nestled between the rift to the west and lake to the east. The lake itself is very shallow and quite alkaline, but not as much as nearby Lake Natron that serves as a major breeding ground for the lesser and greater flamingos that reside in Northern Tanzania. Lake Manyara is also home to the flamingos that, when in flight, can be seen as huge clouds that will appear and disappear as suddenly as it takes the flock to change direction in unison during midflight. Lake Manyara also used to be the home of the Black Rhino who was hunted to extinction in the last decades, but not before Ernest Hemmingway found the time to travel there with his wife and others to bag the rhino with the largest horn. His adventures there were documented in his non-fiction novel, “The Green Hills of Africa,” and is well worth reading, as are all of Hemingway’s novels.

A Cape buffalo wading in the muck

A black heron

We packed the Land Rover with all of our supplies for the day that included cameras, binoculars, water, food, and first aid supplies. It was dark on awakening and the stars once again blanketed the sky as though they were our escorts on this trip. The five of us and Ann Gilligan piled into the vehicle after some light breakfast and made our way down the FAME road towards the junction with the tarmac and Karatu proper, which was still in night mode with the coming dawn. It was overcast, but we knew the clouds would be lifting soon enough and we all hoped for a wonderful day at the park. The entrance is only about 30 minutes away and is all downhill traveling from the Ngorongoro Highlands making our way to Mto wa Mbu, where the entrance to the park sits. There are hundreds, if not thousands, of giant white storks nesting in the trees at the entrance of the park, each of them launching themselves into free flight on a regular interval in search of whatever branches and debris they can find to construct their nests. From a distance, they appear as stark white flowers on the tops of the enormous trees and it is only on closer inspection that one realizes the full size of these gorgeous creatures.

Grey-crowned crane

Entering the park is merely a matter of registering our vehicle for the day and paying the fee for each of us. I used to have a resident’s permit here that allowed me to get into these parks for half price, but the permit became too expensive to make it worth my while so that now I travel with a business instead. Regardless, the fee is quite reasonable for what we’ll see and the cost for each of us is less than $60 USD. As you drive into the park, the first section is a thick forest with streams running through it and across the road. Looking through the brush you can occasionally see a solitary reedbuck or vervet monkeys in the trees, but today it is the baboon troops that are the most abundant. They love to sit in the middle of the road playing and grooming themselves and conveniently move for us only when they’re certain that we’d like to proceed. The baboons here are incredibly healthy with many, many cute babies to show for it, jumping off of branches onto each other and riding on their mother’s backs or, for the really tiny babies, hanging onto their mother’s bellies. We encounter troop after troop of the baboons as we travel through the forest and, thankfully, everyone finally has their fill so that I don’t have to stop for each cute baby seen and we can move onto other animals and out of the forest.

Giraffes by the lake side

Our next stop after entering the park is the hippo pool and viewing platform. This is a spot where you can get out of your vehicle (as long as there no close hippos or cape buffalo) and walk up onto a viewing platform that normally has an incredible view across the marsh towards a large pool where you often see hippos that appear as large rocks in the water until they roll over or rear up in a minor confrontation. On our way, we did spot a hippo that was still out of the water returning from an overnight foraging expedition. Hippos spend most of the daytime in the water socializing and go out to feed only at night and may travel several miles to find food before returning to their pool. Hippos are the most dangerous animal in Africa, accounting for more deaths than any other and it is often encountering a hippo out of the water that is the problem or coming to close to a baby with the mother around. Underestimating the ferocity and speed of one of these animals can certainly be the last fatal mistake that you make and I now understand why Leonard would always check around the car in all directions before we got out when mother nature called if we were anywhere near a hippo pool.

A klipspringer

Unfortunately, the grasses were so tall that you really couldn’t even see the pool or the hippos from the platform, but it was gorgeous just the same and Cape buffalo foraging nearby made it more than worth our while to have traveled out here. On our way out from the viewing area we did see an African Fish Eagle sitting atop a tree eyeing the pond for some prey while a black heron walked along frequently spreading it’s wings outward to form an “umbrella” that shades the water and allows it to hunt for small fish and insects. It would take several steps, then spread its wings for another few steps and the process would repeat itself over and over again, all the while hunting and eating. There were herds of wildebeest, Cape buffalo, and zebra and many, many groups of impala, both harems with their single male and its dozens of females, as well as the bachelor herds, made up of up to dozens of males that continually challenge other males for their harem. Impala are the dominant antelope in the woodland areas while it is the Thompson gazelle and Grant’s gazelle that are in the open plains of the Serengeti. We finally ran across some giraffe, or twiga, at first a few solitary ones and then more in groups as you commonly see them. They are incredibly graceful animals who always look as if they’re running in slow motion, but can pick up speed so very quickly as to be deceiving.

Nice tusks

It was everyone’s very first safari which I though was very cool as they were getting some great game viewing, though we still hadn’t seen any elephants. That was to change shortly, for as we turned one corner we ran into what we thought was going to be a small group of elephants, but that very quickly became a huge family of dozens of elephants including may young ones, some much less than six months as they couldn’t quite reach their mother’s stomachs. The elephants were all moving in one direction in a very slow manner, stopping every so often to eat some grass or strip the leaves from some branch of a bush or a tree. They are incredibly majestic and magnificent animals, meandering down from the safety of the hills in the morning to seek food and water during the day before heading back up to the safety of the hills for the night. They have little to fear here as there are no poachers nearby, though occasionally a pride of lions may decide to go after one of their babies when times are tough.

Our lunch spot with the boardwalk in the background

We watched this family of elephants for a very long time as they mostly tolerated us slowing moving our vehicle forward to stay in the middle of the group. As we left, though, one of the larger females took some offense to our being there and took just a bit of an aggressive stance, though it was little more than that in the end and she let us pass by on our way without incident. It was just a bit further until we reached Maji Moto, which means “hot springs” in Kiswahili and marks the spot where there is a picnic area and everyone is able to get out and walk around. It was 11 am as we reached Maji Moto and we had only been in the park for 4 hours now, but had already seen so much. It was time for an early lunch after everyone had a chance to walk out onto the new boardwalk that reaches out into the lake. Adjacent to this there was a group of hippos floating along, again looking like a group of huge smooth rocks until one of them decides to bellow loudly or open its giant mouth widely to display its massive canines. We had a relaxing lunch on the picnic tables once everyone came back from their stroll to the end of the boardwalk, with everyone sharing the peanut butter and jelly sandwiches lovingly made by Jon the night before and the hard boiled eggs. There were also protein bars and mango slices to share.

After lunch, we decided to head further into the park as we were still hoping to see some of the lions that live in the park. I had seen them on a regular basis during previous excursions, but in the last two years or so, they have been much more difficult to find so that whenever I query another guide along the road as we pass, it seems that no one has seen them. Though all lions climb trees to sleep, it seems the lions here are much more prone to spend the day lounging in the branches here to get out of the heat of the day. It’s no hotter here, though, than it is in the Serengeti, so that isn’t really an answer as to why that’s the case in this park. It is some learned behavior that these lions have passed down from generation to generation and I’m not sure it’s known why other than some theories.

A nursing baby

Much to everyone’s dismay, we didn’t locate any lions and, in the afternoon, most everyone save Sheena decided to take a little snooze which meant that my driving must not have been that bad as it allowed them to catch some shuteye on four wheel drive roads. Right before we reached Maji Moto on our way back, I spotted two Klipspringers just feet from our vehicle on the side of the road and they just sat there posing for us without ever moving. Klipspringers are a very small mountain antelope that is about the size of a Thompson gazelle, though much stockier with downward pointed hoofs designed for jumping from rock to rock. They are probably one of the most docile of antelopes as they always seem to just sit and pose for us. The dik dik, which we did not see today, is smaller and much more skittish, scurrying into the underbrush as you drive past them. The drive out of the park was much less eventful than the morning which was fine as I think everyone was quite exhausted and I had been driving since 6 am straight through save lunch. It is very tiring driving on a game drive, but something that I absolutely love to do and always hate to give up the assignment to someone else.

As a child, I had always dreamed of going to Africa and had always looked to the Leakey’s and Jane Goodall as my heroes unlike other kids. If someone had told me that someday I would be here as a significant part of life, bringing others to experience what I truly love, I never would have believed them. Driving a safari vehicle here and actually guiding safaris is like icing on the cake.

Saturday, March 9 – A slow clinic and time for relaxation at Gibb’s

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OK, I will now admit to everyone that in the past years, I have purposely neglected to tell everyone that it was birthday on March 9th. It’s not because of a sense of martyrdom or anything like that, only that I’ve never made a big deal of it my entire life and as I get older, it just seems to be that much less important. I have also managed to spoil surprise birthday parties in the past mostly because of my need to always know what is going on (very much to a fault). When I was 13, my mother managed to plan a surprise birthday party for me at Disneyland during a school trip, nonchalantly saying that she and my brother were planning to go the same day and wouldn’t it be nice to meet for lunch. Of course, she had planned a party for me, having brought a bunch of my friends along and having ordered a big cake for me at one of the restaurants along Main Street. I was having a blast with my friends on the rides and just decided that I would meet my mom and brother later in the afternoon. She was not very happy with me.

Adys and Jon working with Michael, our interpreter

For my thirtieth birthday, Kim had planned a big party with all my friends from medical school with the theme of “over the hill.” It was a surprise party and everyone was to wear black as if attending a funeral and the cake was decorated in black and white with a tombstone and “R.I.P.” gracing the top. Knowing my past history, she simply said, “OK, I’m planning a surprise party for you so don’t ask any questions of anyone and make sure you’re available that night.” I understood my marching orders and was able to attend a wonderful get together of all of my school friends who were all dressed in black, and even more wonderful, I have managed to outlive my R.I.P. cake and have enjoyed many more birthdays following. I have now been coming to FAME almost every March since I started (I came one April and found the heavy rains and getting my Land Rover stuck axle deep in the mud were not conducive to our work here) and, as such, spend my birthdays here. Three years ago, Pauline, a prior volunteer coordinator, Jess Weinstein and Jackie Herold, both residents working here with me at the time, planned a surprise party for my 60th birthday at the Highview Hotel close to FAME with about fifty guests that was a truly amazing get together with dancing and celebration long into the night. Perhaps this should have been a message to me to reconsider my prior approach to this issue.

Daniel working with Christopher evaluating a patient

For this trip, though, I had decided that I would just spill the beans to the others and simply let them know the day of my birthday. We had already made plans to go out to dinner at Gibb’s Farm that night as it is one of my favorite places to eat here and I knew that everyone was looking forward to a relaxing night out and enjoying ourselves. The clinic again began on a very slow pace, similar to what we had seen the day before and most of our patient had been finished by lunchtime (usually around 1-2 pm) so it was decided that we’d head back to the house to relax and asked them to call us if anyone else showed up for the day. I think it was around 3 pm before we finally left for home and having discovered that my internet was out for the week, I was going to run into town for some airtime vouchers which is the way that you load money or airtime onto your phone here to purchase internet bundles. We also needed some extra groceries for our trip to Manyara National Park as we were bringing our own lunch – peanut butter and jam sandwiches, hardboiled eggs, chips and lots of water. You should never travel anywhere here without a sufficient stock of water in case of an emergency or just a plain breakdown, which is not too unusual here if you have read my blogs in the past. Daniel, Jon and I went into town to buy the groceries and airtime vouchers while Sheena and Adys remained behind at home to relax.

Vegetation at Gibb’s. The bathroom with a view is at the top of the photo and looks out to the gardens below

The gardens at Gibb’s

Though we had intended to make our lunch before heading out to dinner, by the time we got back home, it was too late for that plan so we relaxed a bit as well and then got ready for our nice dinner and drinks at Gibb’s Farm. It’s always important to get there before well before sunset as the views of the surrounding topography from the veranda are just incredible and like no others. In addition to the five of us, we had invited Ann Gilligan another volunteer at FAME, and anyone else who also wanted to go with us. Ann was the only one that took us up on the offer, which was not surprising as the other everyone else were long term and unable to go that often due the expense. Ann is a nurse practitioner specializing in birth positioning and working here at FAME for a few weeks to see if it would be a good fit for her to come back on a more regular basis. She has been working with Every Mother Counts, a US non-profit that has worked with FAME in the past and had a group working in Arusha this month. Ann decided to check it out here and I suspect that she will become a regular here in the future like most of us have over the year.

A lily pond at Gibb’s

Sunset at Gibb’s

Gibb’s Farm, for those who haven’t read my blog before, is an old coffee plantation that used to run as a small village of worker that made everything in house and became a lodge a number of years ago. It was sold several years ago to new owners who have managed to keep the absolute same ambience and feel of the original plantation and have turned it into one of the top destination resorts around. It is not that it is incredibly posh, but rather it is still very Tanzanian, albeit a bit on the pre-colonial side of things. It remains a working farm and most everything is grown there that is served on the table. Sitting on the veranda sipping my Moscow Mule is like taking a time machine back in time 100 years or more. It is beyond relaxing and one can feel the stress of everyday life simply melt from your body with each minute that you’re there. The management of Gibb’s graciously allows us to have dinner there even though we’re not guests of the lodge because of what we are doing here. Many of the staff at Gibb’s or their family are also patients of ours and have known many of them for many years.

Ann and the Penn Neuro group relaxing on the veranda at Gibb’s Farm

Gibb’s also serves as a studio for a number of local artists who use it as their base of operations and paint local scenery and classic views of the region. The lodge itself is decorated with their art, all of which is for sale, and well worth the cost when you are on a trip here. Our dinner was a delicious four course meal with multiple entrée and appetizer choices, all of which are farm to table fresh and very unique recipes. The house bottle of wine matched perfectly and was a welcome addition to the various dishes that were ordered. One cannot go wrong here with anything you order and it is a true pleasure to experience a meal such as this anywhere in the world and even more so here in Tanzania.

Cutting my birthday cake after dinner

After dinner was finished, I heard the waiters banging a drum and beginning to sing “Jambo, Jambo Bwana…,” which is a song of celebration they usually sing here for many things and in this case, it preceded singing “Happy Birthday” to me. The other two tables eating at the time also same to me and it was all great fun and quite a way for me to remember my birthday here in Tanzania with my friends.

We drove home by the short cut that I always use for Gibb’s and can be a bit intimidating for those who are not familiar with the roads in Tanzania and the darkness of the night here. I have driven these roads now for a number of years and feel comfortable on these in most situations, but will admit that in the heavy rains and previously mentioned slip and slide conditions, it can become a nightmare to even the most accomplished drivers. Four-wheel drive is great, but when none of the wheels have any traction, there is very little once can do.

Once safely home, it was time for us to get the lunches for tomorrow made. I worked a bit first on my camera equipment, getting batteries charged and making certain that I had everything needed for the trip to Manyara the following day. When I drive, I obviously am unable to shoot photos, so usually hand over my cameras to the others to take photos. It is a great opportunity for the residents to have the experience of shooting a big DSLR camera with a long safari lens that is perfect for wonderful wildlife shots. The others began to work on the lunches with Jon taking over most of the duties for the peanut butter and jelly sandwiches in a factory-like fashion and Daniel initially working on Ziploc bags of water for the cooler. I think Adys and Sheena were both sharing duties on the hard boiled eggs. The house was filled with music and dance while they were working and it was a real sight. The entire process took less than an hour so that everyone could get to sleep as we were planning to leave bright and early at 6 am so as to get to the park when the gates opened. Everyone’s dreams certainly contained visions of wildlife that night and we were all hyped for tomorrow, even me, having been on dozens and dozens of safaris by this time. There is just something about taking people on their first safari to see the wildlife here that is so exhilarating.

Friday, March 8 – Our FAME Neurology Clinics Begin for Real….

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Our clinic today was to be the first of the announced clinics here at FAME for this trip, meaning that the community was given a schedule of the days that we would be seeing patients and it was announced in the churches and public events, as well as fliers being placed around town the adjacent communities. This is accomplished by our outreach team at FAME which is currently made up of Angel and Kitashu, both of whom are social workers at FAME in their normal day jobs, but handle this task for us and have done so over the last few years. In addition to the announcements that are made in Karatu and its environs, they also travel out to the villages where we will be holding mobile clinics and the nearby villages for the specific dates that we’ll be visiting them. It is mostly a very successful process and FAME also has other programs that are similarly announced, such as cervical cancer screening, with all the programs benefiting from the lessons learned as these announcements are being made. There is also sweet spot as to their timing so as not to make them too early or too late in which case they become much less effective.

Following morning report, I must admit that it’s always a bit anxiety provoking as I walk down the walkway between the hospital and the operating theater and first look upon our neurology clinic “waiting room.” It can be a mob scene, especially on the first day of one of these clinics, but for some reason, today was not such a day and the crowd appeared to be quite manageable. When we have far more patients than I know we can see comfortably in one day, we will begin to hand out numbers for the following day and ask patients to return in the morning. We do have to sort through those patients who have traveled far, though, as it’s difficult to ask someone who lives seven hours away to come back in the morning. Surprisingly, though, patients can usually find a friend or family member in town who they can stay with and come back in the morning.  It is a different culture altogether here in this regard as one is considered to be related as long as you come from the same village and, as long as your related, then it is perfectly appropriate to expect things such as a meal or a place to stay for the night.

The “Neuro Crew” – Anne, Sheena, Daniel, Adys, Jon and Me

So, our first full announced clinic did not turn out to be quite as crazy as they normally are, but then that clinic is typically reserved for the first Monday that we’re here and that is the second week. The lower than normal volume may have been related to that or it may have been related to other factors such as the time of year and whether it is planting or harvest time. Whatever the reason, I was actually a bit relieved given the prospect of having some semblance of sanity for the day. It was also a blessing given the fact that I agreed to give up our ER bay (one of “clinic” rooms) to Dr. Gabriel for a few hours this morning so that he could endoscope a patient. That meant that we’d be down to two stations for seeing patients until he was finished with his procedure. In the end, we actually used the room while the patient was recovering behind some curtains as we did need to get started using it.

Sheena evaluating a patient

The day was made of the usual suspects – headaches, anxiety, and GBM. The later abbreviation, which strikes fear in the heart of any knowing neurologist, definitely threw me off here when I first ran into it. Thankfully, it does not stand for glioblastoma multiforme, a highly malignant brain tumor with a very prognosis and short life expectancy, but rather generalized body malaise, or someone complaining of basically total body pain and very likely without a unifying diagnosis. Not a patient that excites us at all as this is rarely secondary to a neurological condition meaning that it’s not something I want to be treating here to begin with. One of my long-term patients who I have been seeing since 2011 did return with her mother (also a patient of ours) today for follow up. She has been on anticonvulsant medications, doing well for many years, and it has been a pleasure to watch her grow up while under my care. Overall, the day was rather nondescript from a patient perspective and other than an inpatient consult that Adys did later in the afternoon, it was pretty much bread and butter neurology; that is, the usual suspects mentioned at the beginning of the paragraph.

Adys’ patient had undergone a procedure with spinal block a week or so ago and had developed a severe headache that was worse when he stood up. This was particularly concerning for a post LP headache, or low pressure headache and which we would treat with a blood patch, where a small amount of the patient’s own blood is placed into the epidural space and essentially patches the leak that is presumably the cause of the problem. Unfortunate for us and the patient, though, was the fact that the person who performs these blood patches was not around. The other option was to give the patient caffeine sodium benzoate intravenously, but the only IV caffeine that was available here were 5 mg vials of caffeine citrate and, though I could find a reference on how to convert the two forms of caffeine, I didn’t feel comfortable injecting something into a patient’s vein only to find out that it would cause some unexplained condition considering that we weren’t treating a lethal condition to begin with even if it was bothering him so severely. So, in the end, we chose to give the patient a high dose of IV dexamethasone, a corticosteroid, that could possibly decrease the inflammation and potentially reduce his headache. I did seem to actually work as later he reported that his headache was improved, but it was decided to keep him in the ward overnight to continue him on IV fluids and just to make certain that he was actually getting better.

Daniel and Adys charting on the veranda. We enter all the patients into our database to keep track of things

I certainly can’t leave out the fact that today was also International Women’s Day 2019. The theme as noted by the UN for this year was, “Think Equal, Build Smart, Innovate for Change.” Here in East Africa this is so very apparent as education for so many years has been reserved only for men as it is in so many other parts of the world and efforts to change this have been ongoing, but are still so necessary. There are many non-profit groups that have been trying to change this by offering scholarships to young girls so that they can continue in school and these should be supported wholeheartedly for it is often through these programs that change will occur as we’ve seen in so many other areas. My good friend, Barbara Poole, has been active in this arena for many years, as she has been in the US, and has had programs here in Tanzania just to focus on this need. She has had programs that have taught women to organize into groups to better market their trade and also programs to sponsor girls in secondary school where they are very underrepresented and it is very expensive for families to send their children to these schools that are only partially supported by the government. It is through these initiatives that society will eventually achieve equality for women and I celebrate all those who are working for this cause. Today at FAME, Katherine, our communications director, spent the day visiting all the women working here to allow them to express their gratitude for this movement and the need for continued vigilance until there is full equality.

Now for full disclosure. A beer on the veranda in the equatorial sun makes the work much less painful

Since we were actually able to get back to the house at a decent time, I decided to work on the guacamole that I had bought the ingredients for a few days before. The avocadoes here are quite large and were just perfect so Sheena and I worked on concocting a Tanzanian version of the traditional Mexican dish that contained onion, garlic, lime juice, salt and pepper in addition to the main ingredient. We had it with chapati and chips of all sorts other than potatoes. There were casaba chips, plantain chips and sweet potato chips that when perfect with the dish. Dinner that night was a version of a BLT with the lettuce, so essentially a BT, that was on very thick homemade bread that was just a bit much for the sandwich. I tried putting on some of the guacamole and cheese, but even then, it was difficult to eat due to its dryness so I ended up just eating the parts of the sandwich separately and it was all fine.

 

Later that evening, we had the most magnificent display of lightning and occasional thunder. The entire sky was lit up continuously to our east with cloud to cloud lightening that would occasionally result in an intense bolt of lightning shooting across the sky looking like a mad scientist was preparing to create another Frankenstein. It was just another awesome display of nature here that reminds us of the uniqueness of this part of the globe.

 

 

Thursday, March 7 – They’re old hats now….

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Having survived the first day of clinic, albeit a bit slower since it was unannounced, was certainly a positive sign and the residents should absolutely have felt a keen sense of accomplishment over that fact. Being thrown into a completely different process as back home, without the necessary hoops that we have to jump through in regard to our documentation gives one a sense of freedom, but it is also new for each of them who have not had to write notes in some time now that the electronic medical record has virtually taken over the medical world. All that those of us used to hold sacred, most of all, our patient interactions have changed now that the computer keyboard has entered the picture and sits in between the doctor and their patient. It is a sad reality in the end.

Another gorgeous morning in paradise

Medicine here is as it should be. It is without the clutter of the electronic medical records, insurance verifications or HMO referrals. We don’t have the millions of dollars’ worth of tests to order, and even if we did, there wouldn’t be anywhere to send the patients for treatment. What we have here is our clinical acumen, some basic laboratory tests and the patients. They come to see us as there are no other accessible neurologists in Northern Tanzania that come on a regular basis and certainly no others in the Karatu district or for hours in any direction. Last visit, we saw over 400 neurology patients in the short time that we were here and the numbers have steadily grown over the years as have the numbers of patients seen annually here at FAME. Dr. Anne, who we are working with for much of this trip and who has worked with me for several years now, has such a tremendously better understanding of neurology than do nearly all other clinicians in the region and, if all goes well, I am hopeful that we will continue with her education so that in addition to seeing the other patients she sees, she will also care for our neurology patients in between our visits along with those new patients that come in to be seen. This will create a more sustainable neurology presence here in Tanzania and begin to build on the work that we’ve completed so far.

Our garden at the Raynes House

FAME has a very significant focus on education here for both the nurses and the doctors. It is one of the major foundations of their mission here in Northern Tanzania. Not only to do they sponsor nurses, clinical officers, assistant medical officers and doctors for continuing education, but they also have two weekly educational sessions that are provided either by the FAME doctors or by the visiting volunteers. Over the years, we have provided countless lectures on various aspects of neurology that have been given by every resident who has accompanied me. I did these in the beginning, but have felt that it should really be the residents providing these talks as part of their educational process once they began to come with me on a regular basis. It has worked out incredibly well and we have typically asked the FAME staff to tell us what they would like to hear about. Wednesday evening, Dr. Gabriel had asked if it would be possible for us to provide a talk the following morning which was a bit of concern considering that we were heading over to Happy Day in the late evening and I wasn’t sure if the residents had any canned talks to give to the doctors here in such short order. Jon volunteered and I actually suggested that we discuss the pre-eclamptic woman from yesterday in somewhat of a “professor rounds” format that I felt would be useful for the other doctors to see how we approached these types of cases. Jon did an excellent job presenting the case with the help of the others commenting along the way and though it was a bit tough at times to get the others to participate, I think that everyone got the picture of what we do with these cases in regard to a differential diagnosis, evaluations, and management. Again, she was a very complex case that provided an excellent opportunity for lively discussion.

Professor Jon running JAR report

Our clinic today was about the same size as yesterday and considering that it was still unannounced, I was happy to see that we had a fair number of patients coming. Of the interesting cases of the day, Jon saw a young boy who had had what sounded like a psychotic break as an adolescent, where he suddenly began hallucinating (thinking his classmates were a pack of hyenas) and then began running away from home and biting people that tried to stop him. Over a few years, he had become non-verbal, was no longer ambulating and then several months ago began having episodes of extremity shaking that were arrhythmic so didn’t sound like seizures necessarily, but would also have eye fluttering. When Jon saw him, none of the episodes of arrhythmic activity were seen, but he did seem to have some eye fluttering. His case was very difficult to sort out and the boy was completely non-functional in his current state. We all went down the various list of disorders that we felt were likely, less likely and completely unlikely.

Professor Jon running through our thought process on the woman with PRES

We were initially discussing entities such as non-convulsive status epilepticus, an epileptic encephalopathy or possibly something psychiatric in nature, but considering we were from Penn, we couldn’t leave out the possibility of an autoimmune encephalitis. Just to clarify this, a the autoimmune encephalidites, of which a fairly famous one, namely NMDA receptor encephalitis, are a group of disorders that can present in very many flavors and much of the early work in this was done at Penn, where we continue to see patients transferred to our institution on a regular basis to be evaluated for these disorders. Often enough, though, patients who come in will be found to have some either specific or more generalized autoantibodies that may full well be the problem at hand and in need of treatment. Other than steroids, though, we have little else that we could try here to treat anyone with this disorder.

Considering diagnoses that we could possibly treat here, it was decided to give the child a benzodiazepine challenge to see if he was possibly in non-convulsive status or ictal stupor. This is a diagnostic procedure where we give a valium-like medication to a patient who is encephalopathic, which would in normal patient or someone not seizing, cause them to become sleepier, but in a patient,  who is actually having ongoing seizures, it will cause them to paradoxically wake up. In the correct clinical setting, this is an incredibly impressive maneuver and one that will usually cause medical students to immediately consider neurology as their career. A patient who is otherwise unresponsive will suddenly awaken in a very “Lazarus-like” moment that will certainly produce lots of oohs and ahhs from those observing. We gave the young boy a 2 mg IM injection of lorazepam (we didn’t have IV access in the child) and set him aside in the emergency room, under observation of course, and otherwise went about our work seeing other patients. Jon went back to assess the child on several occasions and he did appear more alert and the eye fluttering that he had observed earlier did appear to have resolved. Not quite a Lazarus moment, but it was enough for us to consider the option of placing the child on valproic acid (Depakote) and having him come back to see us in a week. We loaded him orally on the medication and asked them to return at the end of next week to reassess the child. It’s a long-shot, but that’s often the very best we can do here. Had we had access to an EEG machine, things would have been entirely different as we could have immediately known whether the child was in status or not. We would have to work with the next best thing, though, by loading the child on a very good anti-convulsant medication and see him back in short order.

We had not made it to the ward all day, though we knew from rounds that the woman we believed to have PRES had been doing better overnight as we had been told that by the morning she was awake and appropriate and moving all of her extremities. We went back to evaluate her late in the day and, indeed as billed, she was quite alert and fully oriented. Her vision was fine as well, but she still had asymmetric weakness with a left upper extremity drift and some facial asymmetry. Her blood pressures had been just in the range that we had requested and she had continued to receive magnesium overnight so her reflexes remained suppressed. With everything we say, we were still leaning much more towards PRES, but with her continued deficits it was very likely that she had suffered some ischemic injuries along the way. Our CT scan was still down and we debated whether there was still a need to image her or not as she had improved, and given the very low likelihood of venous sinus thrombosis, which would have required anticoagulation, we didn’t feel that it was necessary at the moment. If she continued to improve, we were quite comfortable with our diagnosis and would continue to treat her at PRES.

Daniel and Adys evaluating a patient with Dr. Anne

Unfortunately, the young infant who had suffered the hypoxic brain injury did not fare as well which had been entirely expected. When Jon had had the goals of care discussion previously, and into the evening, the family had indicated that they were still interested in pursuing treatment, possibly being transferred to another hospital, but thankfully our message had gotten through and it had been decided to withdraw care from the child who was extremely unlikely to have survived, let alone had any semblance of a life with any quality. The child died peacefully during the day with medications to make her more comfortable and everyone felt that the right thing had been done. Making a difference isn’t just about saving lives, but it is about preventing suffering and helping patients and families through that process.

We all went back to the house with a sense of accomplishment from the day, in the patients that we helped and those others that we had worked with here at FAME. It was a quite evening that ended with an amazing display of celestial brilliance as we all wondered outside to gaze at the heavens. It was a completely clear night that offered a glimpse of what we rarely can see in North America except in a few places and even more unique that we’re in the southern hemisphere. As our eyes became even more adjusted, it was readily apparent that there almost more stars than there was darkness here. As you looked at any particular constellation, you would immediately begin to see that there are stars beyond that until you realized the huge immensity of our universe. And, at the same it becomes readily apparent that we are just a small dot in someone else’s night sky and you quickly realize how tiny our significance is in the grand scheme of things and that we are not at the center of the universe.