Thursday, March 21 – A visit to Rift Valley Children’s Village…. 

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Note: Thanks to Katherine Kuhlmann, FAME’s Communications and Marketing Director, for sharing her photographs with me.

Dan and Adys presenting in the morning

Well, I must admit that everyone was just a bit slower getting started this morning after our night at The Golden Sparrow. Everyone had a great time, though, so it was well worth it and it was an excellent release for everyone. It was also Thursday, so it was another morning of teaching and Adys and Daniel had volunteered for this one to discuss altered mental status. As expected, even with the hurdle imposed the by Sparrow, they did an excellent job of discussing this topic which can often be very difficult for the non-neurologist. Correctly identifying a patient with an encephalopathy as opposed to an aphasia will completely change one’s differential and what evaluations and treatment are recommended for the patient. It is not always as straight forward as it may seem and the differences can sometimes be very subtle, even for a neurologist. Adys and Daniel covered the topic perfectly and alluded to a number of the specific features that we use to differentiate them.

Adys and Ann evaluating a patient

Compassionate care

After our talk, it was matter of getting everything together for our trip to RVCV. We were planning to take only one vehicle today as Chris and Michael, our interpreters are both from there and therefore would not require a ride in the morning. Still, this meant that we would have twelve people needing transportation there and back as both Katherine and Phoebe were also planning to come. My Land Rover has seating for nine passengers, but if we put four across the back instead of three and also used empty plastic soda crates between the second and third row of seats, we could reasonably and safely fit the additional passengers in for the 45 minute trip to the children’s village. We wouldn’t need lunch today as we are served a wonderful midday meal by the cooks here who also serve the other volunteers at the village.

Jon and Daniel acting out their exam

The drive to RVCV is as spectacular as just about anything we’ve seen here. Heading from Karatu in the direction of Ngorongoro gate, we leave the tarmac just before the final hill and begin to head in a westerly direction along a ridgetop that overlooks wonderfully fertile farmland in all directions. We drop down into several ravines, only to rise again on the other side of each when we finally come upon acres and acres of coffee bushes that surround the entire area including the village. For the full story of Rift Valley Children’s Village, you’ll have to go to their website, but it was founded by India Howell, who is originally from Boston, and fell in love with Tanzania while on safari here (sound familiar?) She worked for bit in the tourist industry, but quickly discovered all the needy children, some of who lived on the street and others whose families could no longer care for them. India partnered with a Tanzanian to develop the concept of a children’s village rather than an orphanage, where all the children are adopted and raised here as their home with no fear of having to leave until they are over 18, and even then, they have their own housing just outside the village. There are children from all ages here, all living in their own homes separated by age and gender, each house being run by separate house mothers who are from the outside village.

Marin and Dan conferring on a patient

Daniel and Jon present a patient to me

There is a primary school situated just beside the children’s village and this is where all of the children attend school every day. Early on, India realized that sending her children to a school where the other children were constantly sick due to the poor access to healthcare and the poor personal hygiene. She offered to partner with the local community to bring in more teachers that she would help pay for and also developed a regular clinic that would be staffed by FAME and would occur every other week and would see patients from a catchment area that included the surrounding villages along with the children’s village. When I started the neurology mobile clinics here, it was an obvious choice to also accompany the FAME doctors when they came, but about two years, it was decided that FAME would no longer have a regular clinic there in which case, we decided to continue with it as part of our mobile clinic week. It is now only a neurology clinic and any patients needing general medical care will be sent to FAME by vehicle.

Dan evaluating a young child with severe bilateral esophoria

Dan enjoying his exam

Who’s checking out who?

We see a wide array of patients here and much of them are obviously pediatric, but the bulk of the patients seen by us here are epilepsy patients for various reasons. Having Dan and Marin here was a huge plus for us this visit as was the fact that the clinic area had been extensively rearranged since last October. We now had four examination rooms that were all set up for us in advance along with a room that we could use as our pharmacy. All of the patients to be seen that day had already been organized into adult and pediatric cases and had also been fully triaged so that we were only seeing patients with neurological complaints.

Marin and Christopher evaluating one of our long term patients

Adys’s very first patient of the day was a young man with poorly controlled epilepsy accompanied by his mother. The episodes were primarily causing loss of consciousness and some abnormal behavior and we discussed the need to continue him on seizure medication because of the nature of his seizures, but after we were finished discussing his case, we heard a very loud commotion coming from the room only to find him on the floor trying to crawl into the corner of the room with a frightened expression on his face. The seizure lasted only a minute or so and I was able to get him situated on the floor so he wouldn’t injure himself nor would he injure me. As he settled down, I was finally able to help him up onto the bed in the room where he remained until he came around and his post-ictal lethargy had improved to some degree. This was a very classic focal seizure, probably of frontal or temporal origin and it was the same as those that he had been having at home which was very important regarding the diagnosis and the fact that seizures are, by definition, very stereotyped. His medication was adjusted to place him on a more therapeutic dose.

Marin and one of her young patients

Adys and Dr. Annie presenting a patient to me

Marin saw a fascinating patient that became a real dilemma and something that we’re still working on. The baby was reported to be about 15 months old and had failure to thrive due to inability to take food adequately, having already been to a feeding program in Arusha, but failed to gain any weight there. The problem was that the baby examined more like a normal three-month-old from a cognitive and stature standpoint and just seemed to have a bit of diminished tone. No matter how hard she tried to clarify the history with the mom, the story remained the same which was completely perplexing. In the end, we referred the baby to FAME to obtain x-rays of her hands and long bones as well as an abdominal ultrasound to rule out some organomegaly consistent with some metabolic storage disease. The ultrasound turned out to be normal and the films will have to be read by someone at CHOP, which I will take care after my return.

Sheena and William evaluating a patient

Sheena catching up on her documentation

We always look very much forward to the lunches here as the house mothers cook amazing food. Today, it was fresh baked bread rolls with hamburgers, French fries, fresh salad and for dessert, chocolate oatmeal balls that were delicious. It was a wonderful meal that was well appreciated. After lunch, it was back to work to see the remainder of the patients and, eventually, a trip to the duka (store) run by Arturo and has a great selection of objects created by the Rift Valley Women’s Group. Everyone came back with a back of items and seemed quite happy with the selections they’d made. Sheena missed out on the group shopping spree and went over later and when she’d been gone for some time, we decided to call over to make sure she was still alive. She was, of course, and was also extremely happy with her purchases.

Daniel closing his charts so they don’t autoclose 😉

Phoebe and Dan during a break in the action

We left Rift Valley Children’s Village after a very successful and efficient day of seeing patients and a real sense of accomplishment. The cases that we’d seen were solid neurology and all of which we had something to offer, whether it was immediate treatment or at least some direction to head in regard to further investigations if appropriate. I took the more scenic drive home that turned out to be tremendously smoother than the primary road much to everyone’s joy as we were still loaded with the twelve occupants in Turtle and the less jostling meant happier passengers. This route does have a very, very steep downhill section driving to the bottom of a ravine and then a very, very steep uphill section coming out, but everyone held on tightly and Turtle took the hills like the pro that she is and in full Land Rover tradition.

Our clinic hallway

The waiting room at Rift Valley

We were scheduled to go to Susan and Frank’s house for the evening as this was the last night at FAME for both Dan and Marin for we are all heading to the Serengeti tomorrow, except for Daniel who decided to forgo the trip (despite just bit of FOMO) as he would be going there the following week with his fiancé after our time at FAME. Before going over to their house, though, we had to make what I thought would be a quick stop at the tailor’s shop to pick up all of the clothes that everyone (except me) had made from the wonder kitenge cloth ubiquitous here in Tanzania. It ended up being just a bit longer of stop than I had anticipated as there was a bit more shopping going on than I had been led to believe would occur, though I was finally able to rest everyone out of the shop and we were on our way. We had one more stop scheduled for next week, though, to pick up the additional orders made.

Daniel and Jon evaluating a patient with the assistance of Katie, the nurse at RVCV

Susan and Frank’s get together was a very nice affair as it always is at their home and we dined on wonderful local Camembert cheese from the Shangri La farm and both beef and vegetable samosas from the Lilac Café. Mixed with Safari beers, wine and Stoney Tangawizi, we were all quite happy and there was little need for the dinners that had been prepared for us that night, so we all saved our mac and cheese to eat the following day for lunch before our departure on safari.

Visiting the tailor’s shop at the end of the day

 

Wednesday, March 20 – It’s off to Kambi ya Simba and a night at the Sparrow….

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Evaluating a patient in 2011 with Dr. RIngo

Kambi ya Simba is another village in the Mbulumbulu region and about half the distance of Upper Kitete. When I had first come here in 2011, there was literally nothing to speak of in regard to their medical facilities with only a very small dispensary that wasn’t sufficient for us to work out of so we held our clinic in a small field in front of the church. Patients would sit on a bench made out of a log and wait their turn to be seen. Quite often, the patients waiting would slowly encroach upon my open air office out of their interest in what was going on and I’d have to repeatedly ask them to sit back on the bench so as to maintain some semblance of privacy. I would frequently remark to friends that I had the nicest office here that anyone could ever imagine.

Paula Gremley, Pastor Temba and Dr. Ringo discussing things with a patients mother in 2011

One of my favorite photos – evaluating a Trisomy 21 patient in 2011

Over time, though, Kambi ya Simba has acquired an ever increasing number of buildings here for medical care and my outside office has vanished and has now been replaced by a state of the art dispensary, wards, offices and other equipment that have now developed into a lovely facility. A few years ago, I had arrived for mobile clinic only days after the prime minister had been here with lots of fanfare including a small monument, plaque and flagpole in the center of the grounds. Pulling into Kambi ya Simba that time, I commented to everyone that I was just a bit surprised to what lengths they had gone to welcome us. As the commitment by the government has continued to improve the facilities here, our clinic has become that much closer to what we have at FAME, though we are still working as a mobile clinic meaning that we do not have access to labs or X-rays without sending patients back to FAME for those.

Kambi ya Simba dispensary. Note the not uncommon occurrence of pushing cars here

One of our clinic rooms at Kambi ya Simba

Adys, Jon and Dr. Caren evaluating a patient

With the shorter drive to Kambi ya Simba it means we get an earlier start with our patients. We weren’t sure how many patients would show up, but in the end, there were quite a few and there were some fascinating pediatric cases so that it was extra nice having Dan and Marin here to sort them out. One very interesting patient we saw was an infant that had reportedly been developing normally until about three months of age when, following their Tdap vaccinations, the child began to become very weak and floppy and their motor development screeched to a halt. The baby was now seven months old and have very reduced axial tone, but reasonable strength, normal reflexes, and seemed cognitively intact. It was a very puzzling story, but the mother was quite clear that the child had been fine before their vaccinations that also included a polio vaccination, raising the question of whether this could possibly have been an issue with the polio vaccine having reverted since it was a live attenuated oral vaccine and in very rare circumstances can cause cases of polio. After many emails, text messages and a phone call to one of the neuromuscular folks at CHOP, it was decided that this was very unlikely to be polio, but was rather more likely a progressive muscle disease and that without further testing it would be impossible to determine what it was. Furthermore, regardless of the diagnosis, it was exceedingly unlikely that it would be a treatable process. In the end, it was decided that we would try to get an echocardiogram on the baby to determine whether there was any involvement of the heart.

Sheena examining a patient with Daniel scribing

Dan and Marin discussing a baby

Dan and Marin continued to have very interesting patients throughout the day and any thought of leaving here early to try for the African Galleria was pointless. We continued to have two adult rooms and one pediatric room throughout the day which seemed to work very well with Marin seeing the children on her own and Dan staffing her along with some of the adult cases. Our lunch today turned out to be the boxed lunches again, even though I think all of us would have been much happier with the Tanzanian food we had eaten yesterday. We ate again in the vehicles which is usually the case so as to avoid eating our meals in front of the residents here. These are the smaller things you have to think about here that wouldn’t even enter your mind at home.

Marin consulting on a patient with Chris translating

Dan and Marin discussing a pediatric case

It was a steady day of patients that kept everyone quite busy and though we had hoped once again to make another attempt at getting to the African Galleria, it was not to be as our window of opportunity closed quickly. Having learned the hard way with all of the dust we ingested on the first day, the two vehicles were now driving separately and it was much better experience for everyone. We arrived back to FAME in time to relax for the evening and catch another of the beautiful sunsets here as we had plans to go to Happy Day after dinner and then to The Golden Sparrow for some dancing. The Golden Sparrow is a restaurant and dance club that opened about two years ago and is the reincarnation of Carnivore, which was the previous iteration of this establishment. Carnivore was a dirt floored restaurant that served only roasted chicken, chips (fries), and fried plantains as well as lots of beer and wine. They also had a very small bar with a smaller dance floor that could accommodate only a handful of people. A night at Carnivore for dinner and dancing had been a regular highlight of our trips in the past.

Sheena taking a quick break from seeing patients

Kambi ya Simba dispensary. Note the not uncommon occurrence of pushing cars here

Two years ago, the owner of Carnivore closed its doors or, more accurately, it’s gate, and opened The Golden Sparrow. The Sparrow is a much more upscale version of Carnivore, and, to be honest, has much less of the charm and character than the original. There is a huge outdoor area for eating that does serve the same delicious roast chicken that was served at Carnivore along with a much larger menu than the original. There’s also an outdoor bar that serves whatever drink one could imagine. What really differentiates the Sparrow from Carnivore, though, is the dance club. It’s a very large and very dark room with tables and chairs and, most impressively, a disc jockey playing songs and taking requests. There are many locals here and far few fewer ex-pats, but everyone is enjoying themselves just the same and this has now been one of the social highlights of our trips here. Tonight, it was our entire neuro crew plus Katherine, and absent Dan, who claimed to be tired and not up to it, though I have no independent confirmation of this claim. We all had a wonderful night of dancing and had set a midnight curfew (which I had later regretted as it should have been a more conservative 11 pm considering we had a 7:30 am talk in the morning to deliver). Tomorrow we would also be heading to Rift Valley Children’s Village.

Ady, Jon and Marin at Happy Day

Most of the gang at Happy Day

Tuesday, March 19 – Day two at Upper Kitete….

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Our mobile clinic week was now underway and we were returning to Upper Kitete today for our second clinic day there. We had had another site selected, but things had fallen through as far as scheduling was concerned and there really wasn’t enough time to find a new location given the amount of planning and announcements that have to take place for this. Up the road from Upper Kitete is the village of Lostete, which is the last village on the plateau and the end of the road literally, though we were hopeful that patients from that village would come visit us just down the road. Also, the road to Lostete is very often a horrific mess once the rains begin to fall and then it’s a very iffy proposition to make it up there. So, we’ve settled this year on making advance announcements there that we’ll be in Upper Kitete for a second day with the hope that patients will come there to be seen.

Marin delivering her talk on Hypoxic-Ishcemic encephalopathy to a very interested bodyd

Tuesday mornings are education day and we’ve been asked to give lectures for all the days that we’re here save for the two previously given by Ann and Vic. With our pediatric neurologists here, it certainly made sense to have them give some of the talks and today’s was going to be on hypoxic-ischemic encephalopathy, or HIE, which is something seen at birth and not infrequently seen here. Marin filled the whiteboard with lots of information regarding the causes of HIE, both maternal and fetal, how to evaluate the children and, then, what to do for them. In the United States, it is now standard to immediately begin cooling the children which improves their prognosis as it reduces the amount of injury to the brain. What is really most important, though, as emphasized by both Dan and Marin, is that the child is not allowed to be too warm, such as a fever. It isn’t necessarily the most important to have expensive cooling beds or blankets, but rather to aggressively treat fevers and to not cover the baby or use the incubators warming system as readily. Allowing the baby to remain cool and treating any fever will probably capture a significant amount of the benefit seen with cooling such as they do at home. It was a great talk and very, very relevant considering the number of babies now being born at FAME along with those who are brought here immediately after birth. Even a small benefit and improvement in prognosis of these children will be immensely helpful to their quality of life and that of their family who must care for them for many years.

Yesterday, we had followed the other vehicle and had essentially eaten their dust for the entire drive to Upper Kitete, or an hour and a half. Since I’ve driven this route now for several years and know it well, there was really no reason in regard to directions, but there is some security in knowing that if we had any mechanical problems along the way, there would be a seasoned driver/mechanic there to help. Last October, we had just such a problem with Turtle and were without a driver when our alternator died leaving us about an hour out of Karatu essentially dead in the water. Thankfully, we had some semblance of a cell signal and were able to call Soja, who is FAME’s mechanic, to come rescue us with a new alternator and install it just as darkness was falling. There is no AAA here and for readers of my blog, you are well aware of some of the sticky situations that we’ve gotten into in the past, some due to mechanical failures and some due to pilot error (getting stuck in the mud in Tarangire several years ago).

FAME doctors focused on Marin’s talk while a Maasai woman does her laundry outside.

So today, we took off well ahead of the FAME Land Rover as that way if we did have a breakdown, they’d find us easily and, perhaps more importantly, we wouldn’t have to suffer the clouds of dust that we did yesterday and which left the right hand side of my face with enough dirt on it to pot a plant. The drive went smoothly enough without incident and was tremendously more pleasant, though with each passing car, everyone still had to quickly slide their windows closed so as to avoid filling the car with pounds of dirt. Needless to say, the necessity of taking a shower as soon as we arrived back home was a given, even if it was typically cold as the kuni boilers (a wood fired hot water heater that is used here) are only fired in the morning and by the end of the day, the hot water and fire have been exhausted.

We arrived to Upper Kitete a bit earlier than yesterday as we were hoping to get to the African Galleria this afternoon to do some shopping. It also turned out that our patient volume today was fairly light making us even more hopeful of the possibility of our shopping spree. For lunch yesterday, Angel had purchased lunch boxes for everyone from one of the local restaurants. Lunch boxes are a staple here with everything revolving around the safari business as they are carried with you into the parks to sites that are good for lunch – i.e. no dangerous animals roaming around or those that are designated picnic sites. At certain places, you have to eat in your vehicle, such as Ngorongoro Crater, where the kites drop out of the sky to steal your food right out of your hand and in front of you face. Today, we decided to pick up a more traditional Tanzanian travel lunch that included a number of primarily deep fried items such as beef samosas, vitumbua ( a fried rice cake),  egg chops (a battered and deep-fried hard-boiled egg), sambusa (deep-fried, battered vegetable bites) and donati (yes, just as you might have imagined, donuts). All of this with a side of bananas and for drinks, various Coca-Cola products including Fanta passion and Stoney Tangawizi (both of my favorites). On our last visit, we discovered that they had actually released a sugar-free version of the latter called Stoney Zero, but I will have to admit (after many trials) that the sugar-free version is not nearly as tasty as the regular.

The patient flow was not overwhelming or the day, allowing us to finish up shortly after lunch and begin to pack up our things. As we were doing so, of course, a piki piki drove up with three men on it and as they dismounted it became readily apparent that the man sandwiched in between was actually unconscious and had to be carried to the grassy area in front of the dispensary. There are few things that get our attention more than an unconscious patient, so everyone quickly went over to assess the patient who was breathing just fine and had a good pulse, so that was quite reassuring. When it was eventually learned that he was merely inebriated, we were all a bit relieved as he was a very young patient and had that not been the case, the differential would have been quite large and nothing that we would have been able to handle here so he would have had to come back to FAME with us. We departed Upper Kitete that afternoon with the drunk patient having been carried into the nurse’s office with the plan to manage him there and quite confident that they could handle the situation on their own.

Hopelessly stuck in the mud

The plan was to take an alternate route to the tarmac as we were planning to go to the African Galleria just outside the village of Manyara. This road takes off about half-way home and used the be the road we used for every trip to Upper Kitete, but the other road we now use was found to be quicker and more reliable. Immediately after starting down this road, it became readily apparent that this had been a wise decision as the road was in horrible shape and this was without any rain. Had it been raining, this would have been an incredible mess for certain and would have brought back memories, actually nightmares, of the time my Land Rover slid off the horribly muddy and slick road into the muck, hopelessly miring us in a sea of slimy mud that even the local farmer refused to help us for fear of getting his tractor stuck. It took the help of another vehicle from FAME, lifting and digging out each wheel at a time and then supporting them with rocks. The other vehicle couldn’t even get close for fear of becoming stuck itself, so it eventually pulled from afar and we were freed after several hours. Not one of my finer moments driving in Africa as the clinic we were heading to had to be cancelled. It was very disappointing for everyone.

Meanwhile, we were finally able to navigate this bouncy road and make it to Manyara and the gallery, only to learn that it had closed for the afternoon as all the employees were attending the funeral of a prior employee. How disappointed everyone was after having left Upper Kitete early only to find the shop closed, but it was clearly for a good cause as funerals here are a very big affair as they a time for all those to show respect to the departed and to the family. As we drove home from the gallery, we came upon many, many cars parked on the roadside at one spot with markers in the road warning drivers to slow down. There were many hundreds of people there and this was clearly the funeral that had closed the gallery. The funeral typically goes on for three days and is a huge and important affair with the host family arranging to feed all of the guests during that time.

Monday, March 18 – A drive to Upper Kitete and the Overlook…. 

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It was the beginning of our mobile clinic week and I think everyone was very much looking forward to heading out into the bush to explore more of the Tanzania they had now come to know. Adys, Jon, Sheena and Daniel had been here now for a full two weeks, while Marin and Dan had now been here for a week. Everyone was half way through their visit here and it’s always sad to reach that milestone. We had had a wonderful safari to Ngorongoro Crater yesterday with a wonderful sighting of two rhinos for a long stretch of time and very close, so everyone was still on a bit of a high from that standpoint.

Walking to work on Monday morning

Our neurology mobile clinics were an offshoot of the larger mobile clinic that FAME used to do when I first came in the Lake Eyasi region where we would take the bus, a few Land Rovers, about 25 doctors, nurses, and other workers, as well as a ton of medical supplies and would spend a full week in the bush running clinics for the Datogo and the Hadzabe. These clinics were funded by a grant that lasted three years, but early on, Paula Gremley and her business partner, Amiri Mwinjuma, who worked in the area mostly helping disabled patients, suggested that I accompany them to the Mbulumbulu region of Karatu to provide neurological care to two villages there. This was in 2011, and I have continued to visit both Upper Kitete and Kambi ya Simba twice annually since that time. The Mbulumbulu region sits on a plateau bordered by the mountains of the highlands on one side and the escarpment of the rift valley on the other until in the distance, these two borders meet as the mountains descend directly to the valley floor below.

Our two Land Rovers parked adjacent to the dispensary

This region was settled by the Iraqw and the fields here are incredibly lush and fertile with maize and other crops growing and being harvested. The soil is a gorgeous red-orange and motely tilled either planted or readied for crops. Most of the work here is done by hand or with teams of oxen and the fields are full of workers. It’s an incredibly different and tranquil world here and life is dictated not by the hands of a clock, but rather by the seasons and the angle of the sun. Life is changing here, though, even in the short time that I have been coming as at Kambi ya Simba there is now a beautiful dispensary and multiple buildings for all aspects of healthcare there. In 2011, I was in a field under the midday sun with a desk and chairs for my office and a waiting room that consisted of a log on which my patients sat. Upper Kitete, though, remains much the same as it was in 2011 when I started, save for a small building next door to the dispensary that we used on one occasion but haven’t since. Oh yes, there are new outhouses at Upper Kitete and a flushable, though squatty, toilet at Upper Kitete.

A field adjacent to the dispensary

It’s always a chore to get out of FAME on time for these clinics as somehow patients show up for us to see and that was the case this morning as they as Onealy, our radiology technician had contacted me on Saturday afternoon that the CT scanner was finally running and they had scanned a patient of ours who clinically had a thoracic myelopathy (spinal cord injury). Since we were at Gibb’s Farm in the afternoon on Saturday, I told him to have the patient return on Monday and we would also look at the scan, so I guess in some way, the patient there on Monday was partly my fault. In any event, her scan was normal meaning that we didn’t have a clear explanation as to what was causing her myelopathy. In going through the same exercise that we do here repeatedly, it was not merely a matter of sending her off for an MRI scan, as we would have to find something that we could treat here and that is a very “if” in East Africa. Rather than sending her for an MRI scan that would be very costly for her, we elected to do a lumbar puncture as this information would help us immensely. Sehewa, who is an amazing anesthetist here at FAME agreed to do the procedure for us and we gave him the labs we needed and asked him to contact me once they came back. What we hadn’t realized, though, was that we were heading to Upper Kitete for the day, where there is no cell service whatsoever. I finally received the information once we were heading home and conveyed our instructions to Sehewa later in the day and he contacted the patient.

Usually, we take one vehicle with us on mobile clinic, but since we had such a large contingent of neurologists (four adult neurology residents and two pediatric neurologists plus me) it meant that we would have to drive two vehicles. After finishing with our myelopathy patient and a pediatric patient that Marin saw as someone handed her the chart, we were finally on our way into the Mbulumbulu district. I drove our vehicle, which was perfectly fine since it wasn’t raining and the roads were clear, albeit a bit dusty. We didn’t arrive in Upper Kitete until almost 11 am which was certainly much later than we had intended, but we were perfectly fine working as late as necessary.

The Upper Kitete dispensary

Our turnout was a bit lighter than normal due once again to the planting season and the fact that most people were out in their fields rather than coming to see us. We had two rooms to work in, which was fine, and there were babies coming for their well-baby visits needing to be weighed, which is always such an enjoyable event. Each baby has their very own personalized harness that their mother has sewn for them and they are then attached to a “meat scale” where they swing in the breeze while their mother checks their weight. Some of the babies are completely unfazed, while others will scream bloody murder, but the most part, it all goes well and no one is worse for the wear.

One patient today is a young adolescent girl whose mother reports that she had not been to school in a number of months and has lost a tremendous amount of weight due to nausea and vomiting. Not really a neurological problem, but worrisome just the same, so we decided to bring her back to FAME with us to check her blood work and have her seen by one of the general folks. It took some doing, but we finally convinced her mother that it would be the best for her. We loaded them in the other Land Rover as ours was full and started our trip home at the end of the day. Leaving town, though, I remembered that I had wanted to show everyone the “Overlook,” which is this amazing view from on top of the escarpment down to the valley below. Our patient and her mother decided to wait at their home briefly while we drove the short distance to the incredibly scenic sight and then returned to town to pick them up. Paula had first taken me to this place in 2011, and since then I have brought every group here so that they could also enjoy it.

Our mobile clinic contingent at the Overlook

The drive home was uneventful except for the fact that the young girl had become very nauseated and was vomiting in the other vehicle. Thankfully, Sheena had brought enough Zofran with her to supply an army and quickly came to the rescue, running the medicine over to her. All seemed well, until we had arrived in Karatu and while the other car stopped to let out some of the FAME people, the girl and her mom also got out and were apparently planning to hop on a piki piki (motorcycle) to head back home for some reason which was never entirely explained to us. They were convinced to get back in and we eventually made it back to FAME where Marin escorted the young girl to the ward to be admitted and evaluated.

We spent a relaxing evening at home taking care of busy work and devouring our dinner of roasted chicken, mashed potatoes and vegetables and prepared for the next day’s mobile clinic which was going to be back out to Upper Kitete. We had taken care of the Overlook today and tomorrow we were hoping to stop by the African Galleria on our way home so that everyone could look at gifts to bring home.

Sunday, March 17 – St. Patrick’s Day in the Crater with the rhinos….

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On the overlook at sunrise

Ngorongoro Crater is truly one of the wonders of the world. Its name is actually a misnomer as it is really not a crater, but a caldera formed by the collapse of a massive volcano some 2.5 million years ago. In fact, it is the largest dry caldera in the world, measuring  10-12 miles in diameter and two thousand feet deep, with a large lake in the middle and thousands upon thousands of animals that remain in the crater year-round and are not part of the Great Migration. Most every animal that is in the Serengeti can be found in the crater other than the Nile crocodile (there are no flowing rivers in the crater to sustain them) and the giraffe, as the crater walls are far too steep for its access. One animal that the crater has and is known for, though, is the endangered black rhino that was near extinction not long ago and thanks to the dedicated conservation efforts of many in Tanzania, it has been increasing in numbers. The rhinos in the crater are all monitored at every moment so that the rangers know were each one is at any given time which has led to an increase in their numbers. There are also black rhinos in the Serengeti, but the populations are quite separate. The rhinos have very poor eyesight and, therefore, depend primarily on their hearing for defense which means that they are rarely out when it is windy in the crater. When I first came to the crater, I did not see a rhino and it took me several other trips there until I had finally spotted one. I have seen many since, but never very close, at least not in the crater. Going into the crater today, in addition to seeing big cats, we were looking for rhinos.

The sunrise from the overlook

A Maasai boma looking south towards the Serengeti

The gate entering the Ngorongoro Conservation Area from Karata is about 16 km west of Karatu on the hardtop or tarmac. Here is where the last paved road heading west across the Serengeti ends until you reach Lake Victoria. The gate is an imposing structure and opens at 6:30 am, which is the earliest that you can check into the NCA. Trucks and buses traveling to Lake Victoria take the same road that we are taking, though today we will be heading into the crater and not the Serengeti. We had planned to leave at 6 am and made it pretty it on the road pretty close to that. I have had major delays in the past getting through the gate as it is heavily dependent on having all the correct paperwork and sometimes that can be a problem. I had come up to the gate several days ago just to get things taken care of and am glad that I did as everything went quite smoothly this morning. We were through the gate in probably 15 minutes or less and on our way into the NCA and eventually down into the crater. As we traveled through the gate, it reminded everyone of Jurassic Park which is actually not a bad comparison given the size of each which is quite large.

A road well-traveled

The road winds slowly up to the crater rim through what is literally a primordial forest with trees reaching to the sky from the bottom of the deep ravines or valleys that lay on one side of the road as we hug the mountainside on the other. It was an amazingly beautiful day with not a cloud in the sky and the normal clouds that sit on the crater rim early in the morning on most occasions are not present. As we reach the rim, the massive expanse of the caldera exposes itself for the first time and we stand on the overlook with the most incredible view one could ever imagine. Every detail of the crater lies in front of us. In the foreground of the crater, there are tiny bodies of water or small lakes from which extend small channels in various directions that immediately remind each of us of neurons with their numerous dendrites and axons. Leave it to nerdy neurologists to make that association. It was quite cold standing on the overlook and everyone was incredibly excited to get into the crater, so we began our drive to the opposite side of the rim where we would find the one-way descent road and make our way down to the floor.

Navigating the crater floor

A resting lion

As we travel around the crater, there are constantly views to the floor at various places, as well as tremendous views of the surrounding countryside which is all the conservation area and the home to very many Maasai living in their bomas. The purpose of the conservation area is that it is multiuse. The Maasai who live here graze their cattle throughout the area, often alongside herds of zebra and wildebeest. There are also Cape buffalo and elephant who trample their gardens or small plots of crops. Lions will also attack their cattle at night which is why the livestock are brought into the middle of the boma at night to protect them. As we reach the southern edge of the crater rim nearing the descent road, the view south looks towards the Southern Serengeti and Olduvai Gorge stretching far into the distance. There is a valley in front of us that contains numerous bomas and is lush and green at this time of year. A shallow lake occupies the center of the valley where the herds of livestock and wildlife mingle among themselves throughout the day.

Turtle with her crew on board

At the hippo pool

Lake Magadi full of flamingos

We’ve finally reached the top of the descent road where we stop to check in with our paperwork. The views from this spot are equally impressive as those from the overlook so prior to loading back into the vehicle, everyone has a chance to take photos. Most importantly, we finally raise the top on Turtle so we’re in full safari mode now and it only increases the excitement that’s been building, more so given the fact that no one on board, save me, has been to the crater before so it will all be new to them. The descent road is wickedly steep, rocky, narrow, and, thankfully, one way. Leaving the Land Rover in first gear to stay off the brake is best and it is a long way down to the floor. The candelabra trees, a unique succulent here rise up alongside the roadway as we descent. We get our first good glimpse of the wildlife as we approach the bottom, but when Marin first spotted what she thought was a “dead lion,” (no worries, it was only sleeping as most lions do throughout the day) it became clear to everyone that we were going to see much more than just antelope here. There was a total of five male lions here, two adults and three youngsters, the latter with shorter manes. They were all sleeping, but one of the older males stood up at one point to move into the shade where he promptly plopped down alongside one of the other males. That was about as much activity as we witnessed from this group of lions today.

A male Thompson gazelle resting

A seldom seen flock of grey crowned cranes

A pair of Cape buffalo scratching each other

Once down on the crater floor, your perspective of the topography completely changes as it is now a flat plain that you are sitting on surrounded completely by 2000 foot high cliffs in all directions. There are relatively easy landmarks by which to navigate and definite highlights such as the hippo pool, Ngoitokitok Picnic Area, the Lerai Forest, the Munge River and Lake Magadi. We initially drove around the periphery spotting many jackals and hyena along the way, but eventually made our way to the hippo pool where there were plenty of hippos cooling in the waters there. In the past, I’ve seen several serval cats here, but not today. As we made our way around in the direction of the picnic area where we planned to have lunch, we spotted two large black rhinos which everyone had hoped to see today. They were a fair distance away initially, but were moving laterally from us in the direction of one of the roads that they would eventually need to cross. We waited long enough to snaps hundreds more photos, but at the right moment, I began to move the vehicle in the direction of where they were heading.

A mob scene at the rhinos

Initially, there were probably half a dozen vehicles watching the two rhino, but as word got out on the two-way radios, over a dozen cars began to accumulate at the site so I hung towards the back of the pack so as not to interfere with the animals. The rhino are very skittish which became evident as they looked as though they wanted to cross the road, but their pathway was blocked by the many vehicles so they just continued to walk parallel with the road and eventually just changed direction. At one point, they were interacting with a small group of Cape buffalo, forcing the buffalo, a pretty feared animal in its own right, to the side with ease. The rhinos finally crossed the road in front of us, despite all the vehicles there, and made their way to a more secluded spot behind a bluff so that they couldn’t be seen as well by everyone. By this time, I think that everyone in our vehicle had had their fill of rhinos, at least for the moment, and were very interested in getting to the lunch site.

How do you move a Cape buffalo? With a rhino, of course

Rhinos up close and personal

The Ngoitokitok Picnic Area in the crater has to be one of the most beautiful sites in the world to sit an eat one’s lunch. Beside the fact that you’re sitting inside a massive caldera that is millions of years old with 2000 foot cliffs reaching up all around you, there is a lake with hippos floating in it and more birds than you would ever hope to count. Everyone is free to walk about here, though I have seen lions visiting this spot in the past. The most impressive birds here are the black kites that patrol the region from high above and have the remarkable eyesight typical for a bird of prey. They can spot a sandwich in someone’s hand from far above and then drop in a remarkable feet of acrobatics, divebombing the unsuspecting person and stealing their food just as they are about to put it into their mouth. And all of this without ever touching their victim and without any warning whatsoever. Since my first visit here, I was taught about the kites and the need to stay in your vehicle to eat or else suffer the consequences. There is usually one group who have either decided to disobey their guide or their guide had decided in advance not to tell them. Who knows? But for those of us watching, it can be a pretty crazy show and well worth the cost of admission. We did keep an eye on the kites throughout lunch as they were checking out every vehicle that had stopped for a meal. There are lots of weaver birds circulating here as well, and they’re brave enough to come into our vehicle, but do far less damage than a giant kite would do with its enormous wingspan. While on the crater rim having lunch one time, I hadn’t thought that the kites were there, but one located my piece of chicken that was inches from my mouth and promptly swooped in to grab it without having even grazed me in the process. That was a bit startling, to say the least, and had quickly gotten the attention of not only me, but also everyone else sitting in our little circle.

A lilac breasted roller

A tawny eagle

As we left the picnic area we decided to head towards the Munge River area looking for any cats, but unfortunately, did not see any today. Driving along the river, we did run onto large groups of Cape buffalo, who always look a little bit disturbed by our intrusion, to the degree that at times they look as they would love to charge the vehicle, but thankfully haven’t. We drove along the opposite side of the river for a long way, ending up sitting on the top of a large hill that has a great vantage point to see the entire crater floor. There had been clouds gathering and small ran showers in local areas that forced us to close the tops on the Land Rover on one occasion, but only temporarily. It was getting late and we had planned to pick up Kitashu at the junction of the road to Endulen around 4:30 pm.

Ngoitokitok Picnic Area

Ngoitokitok Picnic Area

Driving up the one-way, paved ascent road, winding up and up on continuous switchbacks, there are constant vistas of the crater, each one more beautiful than the next. A short backtrack to the junction and we met Kistashu, who piled into the vehicle and we were off on our way back home to Karatu. You must check out of the NCA by 6:30 pm, which is when the gate is locked and, without an official document, you end up having to spend the night there which can be a bit of an issue without having first arranged some form of accommodations. Sleeping in your vehicle can be a bit of a struggle while sleeping on the ground outside can be just a bit too dangerous. We made it to the gate with plenty of time to spare, unlike a few times in the past, checked in with the rangers and we were shortly on our way having had a wonderful day we had in the crater, one that everyone would certainly remember for years to come, and headed off to Karatu and Happy Day pub for dinner.

A brewing downpour in the distance

The Lerai Forest