Having settled into the Raynes house yesterday evening, it was everyone’s first morning waking up in this paradise, save me of course. It was a beautiful morning with full sunshine quite early as the sun rose behind our house and cast long shadows towards the hills to our west. The sky was as sparkling clear as one could imagine and the songs of the many bird species fill the air with a lightness that is so very special here. There are no sounds of the city or civilization here other than the occasional vehicle or groups of children that come along the road from the coffee farms down the way. FAME sits six kilometers high out of town on a dirt road that is in decent condition as long as it hasn’t been raining much, but can become a bit of a slip and slide at times. It is literally beyond peaceful here and you have to pinch yourself almost every day to make sure you’re not either sleeping or in heaven. At least that’s how I feel about it here which must be pretty obvious as this will be my 18^th visit to FAME.

Everyone fared for themselves for breakfast (either eggs or cereal) and then readied themselves for the short walk to clinic and morning report at the start of the day. Morning report became a daily feature here once the hospital opened necessitating overnight coverage on the ward, and hence morning report where the overnight doctor gives everyone and update on the ward patients and any overnight admissions. Dr. Jacob, one of the newer clinical officers at FAME had been on overnight and went through the ward list of patients giving updates on each. There is always some discussion on many of the patients along the way and, at times, this can become quite vocal, but it is always for the purpose of educating and never degrading. Clinicians here come in three flavors; medical doctors, which is obvious, clinical officers, who are similar to an advanced practitioner or nurse practitioner, and assistant medical officers, who are somewhere in between the other two. FAME started with few MDs and mostly clinical officers, but now employs four MDs, five AMOs and five COs, all Tanzanian. All of the clinicians are generalists, though a number of them have extra training in certain areas that enable them to provide additional services to patients here at FAME.

During morning report, we listen intently for any patients that may need our services so that we can see then in the ward during the day providing our consultative services and often managing much of their care if they are primarily neurological in nature. This morning they presented an unfortunate case of a one-year-old child who had presented overnight with a prior history of cough who had been taken to an outside dispensary and given some treatment but sent home. The child hadn’t improved and the family decided to bring the child to FAME, though she had a prolonged respiratory arrest (perhaps up to two hours) prior to arriving and was resuscitated when she got here. The child had been intubated and was being bagged now (meaning someone sitting at the bedside constantly squeezing a bag to provide air to her lungs) as there are no pediatric ventilators here. She had also had a seizure in the morning and was given diazepam at the time. It was unclear what we were dealing with, though was most likely a primary respiratory process and not neurologic in nature, and given the history, we weren’t expecting much in the way of neurological function. With clinic starting for us and already having patients waiting, we decided that Jon would head over to the ward to see the baby and do an assessment while the others would begin seeing outpatients.

Our assessment of the little baby was not very encouraging, but we really hadn’t expected much more. She had no respiratory drive, and the only brainstem reflexes we could find were bilateral corneal reflexes. She had no response to pain, no oculocephalic responses and her pupils weren’t reactive. This was certainly consistent with a severe hypoxic injury as we knew had occurred and there was very little that we could see that was positive. Unfortunately, we were concerned that the diazepam she had received that morning could cloud her exam and we felt strongly that we should continue to watch the baby for approximately 24 hours. Later that day, she had recovered one pupillary response, but was otherwise unchanged and Jon went to have a “goals of care” discussion with the family, something that is always difficult when a child is involved and that much more complicated when dealing with the cultural considerations that must be considered. It was decided to continue watching the child overnight, but our expectations were grim regardless.

This was an unannounced day for clinic meaning that we had not made an effort to let the community know that we were here, but rather we would see patients who had been called to come in and were either follow up patients we had seen previously or were those patients who had been recommended to see us when we arrived. There were a fair number of patients already waiting for us and I had wanted this to be a slow day so that everyone would have the time to get their feet under them and learn the system here. Though the documentation in the chart is universal, writing prescriptions, requesting labs and radiology and just about everything else is very much different than what we do in the States. It doesn’t take long, though, for everyone to get up to speed and we were through our morning patients in no time. We were working with Dr. Anne who I have worked with for a number of years now and a fantastic clinician. She was an amazing clinical officer and is now an even more amazing assistant medical officer. At least half of the patients today seemed to be children which was unfortunate given the fact that we’ll have two pediatric neurologists here with us beginning on Monday. Later in the day, I was over in the OPD where they were checking in a very small infant who had obvious developmental delay and seemed to have an episode while in triage that raised concern for a seizure. Dr. Ken asked if we could see the child, and when I learned that they were from Karatu, I immediately suggested that they return next week to see to one of the peds folks.

We had planned to head downtown to pick up sim cards for the residents immediately after clinic, but of course, nothing works to plan. We were asked to see a woman who had just arrived this afternoon with a history of having given birth one week prior and had eclampsia with high blood pressure. She had been discharged home and the day prior to presenting here had developed a headache, then intermittent right sided weakness and finally confusion. Her blood pressures were moderately elevated and she was completely encephalopathic on examination, being unable to follow all but a single verbal command. She had roving eye movements and did not seem to track or blink to threat. She was moving all of her extremities, but seemed to move the right side less easily. Though FAME has had a CT scan for the last several years, it has been out of commission since our last visit here and is awaiting the blessing of the atomic development commission in Tanzania so that it can be switched on and used to scan patients.

Without the CT scanner, though, it meant going through a laundry-list of diagnoses and not beginning any treatment that might be harmful for any one of the top diagnoses. The main concern would have been whether or not we felt that she might have a hemorrhage given her headache, but the leading diagnoses were PRES, or posterior reversible encephalopathy syndrome, or RCVS, or reversible cerebral vasoconstriction syndrome. A third diagnosis, that being venous sinus thrombosis was also a consideration, but her presentation wasn’t as classic for that entity making it less likely. All of these entities are more commonly seen in the setting of pregnancy or being post-partum, but PRES remained our leading diagnosis and, luckily, treating her blood pressure (normalizing it) was the most important treatment at hand. For venous sinus thrombosis, the treatment would have been placing her on anticoagulation, but without having a CT scan to rule out hemorrhage, that was entirely not an option. We ordered magnesium and blood pressure control and hoped for the best.

Despite our emergent patient at the end of the day, we were still able to make it to town to purchase the sim cards and at long last, the residents were now back in touch with the rest of the world through their phones and all was in balance again. There was plenty of daylight remaining for us to do some shopping in the vegetable markets here and we managed to pick up everything we needed for some good guacamole other than the cilantro, though I’m not sure how hard we really searched. It was back to home for dinner, which tonight was comprised of a delicious meatloaf and mashed potatoes. It was Wednesday night which is the evening that all of the volunteers in Karatu get together at Happy Day pub and so I drove everyone down to enjoy the warm company of others from many countries who have come to this part of the world for one reason or another, but everyone with an interest in helping others less fortunate. It’s a wonderful feeling to be part of such a club.

Despite the heavy rain and thunderstorm, I think everyone slept like logs needing to catch on their sleep deprivation and recharge their batteries. It’s amazing what a good night’s sleep under mosquito netting can do for you. We had arranged for all of us to travel together for a visit to James’ auntie where we finally be able to evaluate her tremor and to determine exactly what we were dealing with. The morning had been clear, but it began to pour as we left the house for our short drive to James’ home where we all scrambled onto the porch so as not be soaked. Our patient was waiting for us in the house and we all sat in the living room to commence with our evaluation. I had forgotten that Adys is planning to go into movement disorders and should have turned everything over to her from the get go, but I proceeded to obtain a thorough history from regarding the tremor and any other associated symptoms that she not have realized was significant. Other than her tremor, though, she had little in the way of other symptoms that we look for when dealing with Parkinson’s disease and its associated disorders.

As I had mentioned previously, Parkinson’s disease is a diagnosis that is often made on observation and only confirmed with the examination. Everyone gave their thoughts based solely on their observation and then I turned over the neurological examination to Adys after asking who wanted to take the honors and her colleagues immediately deferring to her. The tremor was predominately resting and only slightly noticeable when using her arms or maintaining posture. It was very asymmetric and predominantly right sided. It activated significantly with any distraction and with gait while she also had diminished arm swing on the right. Afterwards, we discussed her case, putting together all of the aspects of her history and her examination and decided that she most likely had tremor dominant Parkinson’s disease, a subset of these patients with a typically better prognosis for disabling rigidity and gait dysfunction as well as dementia. Explaining something like this can be rather daunting, but she was a very insightful woman who was clearly absorbing much of what we had to tell her. She had read much on the diagnosis of Parkinson’s disease and was clearly scared once we had started the process of evaluating her, but in the end, after explaining everything to here, she was a bit reassured by what we had to tell her. It would require a few medication trials going forward, but I was fairly confident that we would eventually find something that would work for her. We departed their home with lots of sincere thanks and gratitude for having come to see her and the possibility of visiting her in Tanga prior to some of leaving for home. She was the lovely woman and I am hopeful that we will be able to make something like this happen.

The rain had mostly stopped by the time we left for home and when we arrived, it was thankfully no longer storming so that we all remained dry prior to our departure for Karatu. We had lots to load and having had to do so in the rain would have been perfectly demoralizing. We were finally on the road sometime after noon and I had decided that we would stop in Makyuni for fuel as we made our way towards to the Great Rift Valley and up into the Ngorongoro Highlands. It is normally a gorgeous drive, but this time of year, everything is incredibly plush and green. We refueled in Makyuni and picked up snacks for the completion of our drive. We were now going to be crossing the Great Rift Valley and on through the town of Mto wa Mbu, or Mosquito River, before climbing up the steep escarpment towards the Ngorongoro Highlands and Karatu. The scenery traveling along the valley floor by the mouth of Lake Manyara is pretty spectacular, but I have never felt it really prepares you for what you will see once on top of the rift and into the beautiful highlands where the most amazing coffee grows in the incredibly rich soil here along with the many other crops that are grown locally here.

We rise up and up until we are finally in the village of Rhotia where we begin the descent into the Rhotia Valley below with the village of Karatu off in the distance to the west. Even in the wet season, Karatu seems dusty in the distance which continually gives it that frontier look, as it is the last outpost before departing for the Serengeti and parts beyond. The tarmac ends some 15 kilometers beyond the town as you travel through the Ngorongoro Gate and into the NCA, or Ngorongoro Conservation Area. Beyond that is the crater and then you descend into Serengeti while passing by Oldupai Gorge, where Louis and Mary Leakey built their careers by finding oldest man here (Mary) and creating a dynasty (Louis) that included Jane Goodall and her incredible groundbreaking work with the chimpanzees of the Gombe. This area is so rich in the history of not only humankind, but also of the earth as it was millions of years ago. Ngorongoro Crater is a caldera created by the collapse of an enormous volcano three million years ago and represents the largest dry caldera in the world, and is its own ecosystem where the animals have no need to migrate. We are in a region that is rich in both geological and evolutionary history.

We finally arrived to FAME late in the afternoon as the clinics were closing and the residents finally had the opportunity to see where they would be spending the next month of their training. We would begin our clinic in the morning, though it would unannounced and hopefully somewhat less crowded than our clinics normally are. Our new volunteer coordinator, Phoebe, as Alex is now in Kenya as executive director of another NGO, had anticipated our arrival and we had our dinners waiting for us once we had unloaded the car. Perhaps equally important, she had also supplied our house with a case of Safari beer which was very much appreciated after the long and hot drive that we had had coming here today. We eventually all sat on the veranda eating our dinners, with the warm glow of the sunset in front of us along with our cold beers. There are few things in life that can equal these moments or the friends we share them with. It is these moments that will shape our lives forever and I am forever grateful that I have been able to share them with others.

It has been inordinately hot here for some time and though the big rains have not yet started, it had decided to pour overnight. The air was clear and cool this morning and I had finally caught up with sleep deficit well-earned on the flights over. The mornings here are cool and delightful with a soft breeze, the roosters crowing (not beginning at sunrise, though, as one would imagine, but well before) and the sounds of the surrounding community slowly coming to life. I had set up a meeting this morning at 10 am with some friends for coffee and would then make my way back to the airport to pick up the residents who were all arriving together later this afternoon. We would all be staying with Leonard and Pendo tonight, a tradition that began many years ago with my initial trips and then somehow morphing into having one, then two and now four residents all staying here in their small house. I have offered numerous times to find other arrangements for this large group, but they will have none of it, insisting that they are honored to have us here as their guests and that it is the least they can do for us. It is so special for all of us to have this opportunity. I am part of the Temba family here and have watched their children grow over the last ten years, but for the residents it is a rare opportunity to spend time in a Tanzanian home and to have a glimpse of the life here which is far different than ours at home.

I have mentioned Africa-time so often in my blogs, but it is such an important concept to grasp, for not doing so will only lead to tremendous frustration and angst in one’s day. Life is at a much slower pace here and you must adapt to that fact and plan for it every day. Trying to get out of the house for a meeting can be a lesson real lesson in frustration. If only I had a transporter like the Enterprise that would enable me to suddenly be where I need to be leaving only a split second prior. Now that would be cool. I ended up leaving the house at 9:45 am for a 10 am meeting that was on the other side of an incredibly busy Arusha bustling with traffic. I had to drop Leonard off someplace first on the way and actually made it through town very quickly only to find myself thwarted by a huge “diversion,” or detour, on the other side of the airport where the new bypass is crossing the main road. This is a muddy trail with traffic traveling in both directions and everyone trying their very best to miss the huge muddy pools that are created not by the rain, but by the water trucks constantly wetting it down to avoid dust. I’m not sure which is worse. I eventually made it to my destination some 20 minutes late with my friends totally understanding knowing full well what it had taken to get there.

I made it home just in time to rest a few minutes and then leave for the airport to pick up the residents who would be arriving in a few hours. I had hoped to get there early before their flight landed, but again was waiting for someone to drop off something off for me prior to my  trek to the airport. I once again ended up leaving behind schedule and ended up getting there moments before they landed, but all was well since the trip was uneventful for them. I had asked Jon, though, to bring a duffel over for me that I ended up having to pay customs on which is another story entirely. I was less concerned with having to pay the customs than I was with the amount of time it had taken to get through everything (over an hour) which meant that the others had to sit around waiting for me until I completed the process. The final step was going to the new mobile bank outside to deposit money into the customs account, then go back in and wait for the transaction to show up on their system at which time they would give me my paperwork. It was a major hassle that I cannot recommend to anyone and well worth avoiding at all costs.

Once clear of our delay at customs, we were finally able to get onto the road and make our way back to Arusha. Everyone had made it safely and that’s what really counts. They were all incredibly exhausted as they had spent the prior evening at the Souq Waqif in Doha and gotten up early to catch their flight to Kilimanjaro. It was the beginning of an incredible journey for them and I was so happy to have everyone here together. They are all each such amazingly capable individuals and there has never been a need for me to worry, but they are still my responsibility and having them travel half way around the world is something that I take very seriously.

We arrived back to the Temba’s home where we all be staying tonight and enjoyed an amazing dinner that Pendo had been working on. We relaxed after dinner, but it wasn’t long before everyone looked as though they were going to pass out. Daniel and Adys lasted the longest, but it was only a matter of time before they to found it impossible to remain awake. I continued to work on my blog into the wee hours and eventually made my way to bed. It rained and thundered most of that night, but we all slept deeply with thoughts of arriving to FAME the following day.

It seems as if I had just left, though it’s been a solid five months home. I guess that’s a good thing as it must mean that I have the proper balance between these two vastly different, though somehow similar, parts of my life as it exists today. Flying over here has now become virtually routine for me which is pretty impressive considering the sixteen hour layover in Doha that we now have thanks to a schedule change likely the result of a smart marketing executive trying to expose travelers to this country. I had already made the decision not to let anyone fly through Nairobi again as our last visit was a real nightmare with a luggage debacle that was not very much fun. We all had to spend the night at the Nairobi airport which leaves much to be desired, but I do understand that they are updating their services which I’m sure will be a major plus for those that travel I the future. For now, though, we’ll just steer clear of the place. The luggage debacle, for those that don’t recall, occurred because the flight from Nairobi to Kilimanjaro was on a significantly smaller plane that didn’t seem to be able to accommodate all of our luggage. I arrived without either of my duffels and Lindsay arrived without her duffel of personal gear. John’s duffel containing items for FAME showed up long after our arrival to FAME necessitating that it be sent by bus from Arusha and thankfully arrived.

As usual, I had planned to depart on Friday, with the residents following me a day later so that I would have time to get situated here before picking them up. I awakened on Friday morning in Philadelphia to a fairly good snowfall and an accumulation on the ground. It brought back memories of my flight last year that was delayed by six hours due to a massive Nor’easter that had dumped boatloads of snow and gale force winds onto the city as I was preparing to depart for the airport. The Uber price to the airport had suddenly risen by a factor of five, but since I had no choice needing to get to my flight, I bit the bullet and ordered a vehicle to pick me up. Upon entering the car, a gust of wind caught the door and literally ripped it off of its hinges. We were able to close it somehow and make our way to the airport with the driver insisting on opening it up for me on our arrival with some trepidation. I made it to my flight with plenty of time to spare, only to have my flight delayed by six hours leaving us the only passengers in the international terminal as the airport closed (including the American Express Centurion Club) early in the face of the massive flight cancellations. I didn’t get to visit Doha that trip given the flight delay, but was very much looking forward to visiting the city this time around.

With the sixteen hour layover, which seems like an inordinate amount of time, Qatar Airways has graciously (recall that smart marketing executive) offered to have passengers spend the night in the city at one of the hotels there for free, or to upgrade to a five star hotel for a mere $23. It’s basically a little mini vacation on our way here and the residents loved it a year ago, sending me photos, perhaps to rub it in just a bit considering the flight troubles that I had experienced. So, I was obviously very much looking forward to this brief exploration of a Middle Eastern, something that I hadn’t been able to do previously. There is much to see in Doha, which will be holding the World Cup soon, but my main interest was in seeing the Souq Waqif, a traditional marketplace in Doha that is at least 100 years old and was restored to its more authentic current state in the last two decades. I arrived to my hotel, just across the street from the Souq, just before sunset and refreshed myself with a nice shower after my 12+ hour flight, airport time and taxi ride. I arrived to the marketplace in the dark only to find myself in the midst of wonderful maze of appropriately lit alleyways, all branching off from a larger main passage way and then themselves branching again and again. Thankfully, there are small green lit signs indicating how to get back to the main thoroughfare for anyone who might become a bit anxious or lost amongst the wonderful shops that are all organized into different sections. There are the perfume shops, the fabric shops, the tailor shops (for everything Arabic), cookware shops, food shops, and just about any other specialized item that one may possibly need. The shops selling the more touristy items are all on the main drag as are most the many, many restaurants and hookah bars.

Finding a restaurant was no small task as there were so many of them and I finally took the plunge after identifying one where there enough locals to make me feel comfortable. I had a meal of way too much chicken and turmeric rice, chick peas and some curry- pasta dish that was also quite delicious. Later, while continuing to explore, I found what looked like a truly amazing restaurant with tons of locals and some tourists and sent the location to the residents on my phone like any good chief resident would do. They found it the following evening and found that it lived up to the hype I gave it so it will be certain that you’ll know where to find me during my fall visit here on my way to FAME. While exploring the various passage ways, I heard an incredible squawking very close by and followed the sound, quickly arriving to one of the alleys, or actually several of the alleys, where the pet shops were. Birds greatly outnumbered any other type of animal there and the bird shops had cages full of African Grey parrots along with just about any other rare parrot that you could image coming from Africa and then some. I also found fish shops, with many of the same fish I used to keep, and small rodents like hamsters. There was even a cage full of sugar gliders, which the shopkeeper was seemed very impressed that I recognized, but given my long history with animals of all types, it wasn’t much of a stretch. I left the marketplace at around 10 pm while it was still going strong, but I was still quite exhausted and considering I had spent another three hours there walking around, I was quite ready to seek the horizontal position and to close my eyes. The marketplace had not disappointed in any way and I’m looking forward to going back again in the near future.

I had arranged for the same taxi driver to pick me up at 6:30 am to give us enough time to get to the airport, and received a text from him right around then that he couldn’t make it, but had sent another driver to get me and all was well. We made it there in plenty of time so that I was able to some window shopping at the many upscale stores in the newly renovated Doha airport before making my way to my gate among the seemingly hundreds of other gates at this massive airport. The flight to Kilimanjaro was thankfully shorter than the one to Doha, but still longer than a typical transcontinental North American flight and, with no entertainment whatsoever onboard, it gave me plenty of time to catch up on some necessary work that needed completing.

I sat up front in economy so was into the terminal very quickly and able to get my business visa form filled out and processed much ahead of the other travelers. I grabbed my bags and whisked through customs only to find that Leonard and Pendo had been waiting in their car a bit longer, thinking that I would be delayed, as is usually the case, at some point along the process. Within minutes, though, we were skirting along the tarmac heading back to their home in Njiro, where I would be reunited with Gabby, now four, and Gabriel, now almost two. Their other two children, Lennox and Lee, had unfortunately left that morning to head back to boarding school in Nairobi.

It was an uneventful evening for the most part, but Leonard had wanted me to stop by and visit the family of a good friend who had recently lost his father. Funerals here are huge affairs that will usually last 3-5 days with the immediate family hosting all the extended family and friends and feeding everyone continuously for the several days. I had been to Leonard’s mother’s funeral a number of years ago that was held at the plot of land where they had lived when he was young and was high up on the slopes of Mt. Kilimanjaro. The local villagers all met to discuss who would now be in charge of the family, including the grown children, now that she was gone. I felt so privileged to have been invited to this incredible ceremony and touched by the wonderful sense of family and friendship that existed there.

As we arrived at the family’s home so that I could give my sympathies to his friend’s father’s wife and family, I was brought around the back of the house where huge pots were stacked on the ground in front of the kitchen building that had been used to feed the upwards of 1000 guests over the last several days. As I met his auntie, I immediately noticed her shaking hand, for that’s what we neurologists do all the time. We notice those things that others may not, simply because it’s what we do for a living. I am constantly telling the residents that we miss much of our exam these days by having our patients roomed for us and not greeting them in the waiting room to walk them back. Observation is very much of neurology, and there are many diagnoses that can be initially considered by merely watching someone get up out of chair or walk back into your exam room. Our history and examination are there to confirm things for us, but to miss this first observational period is a real crime and a victim of those practices that serve to make us more efficient and revenue neutral, but often at the expense of what medicine was meant to be.

I quietly and privately asked his auntie how long she had had the tremor and she said it had been there for several years, but was worsening over time. I hadn’t wanted to intrude, but she was clearly interested in speaking with me about it and didn’t mind doing so in front of her family. They were all astonished when they asked me what kind of a doctor I was and I simply replied, “that kind of doctor.” We all chatted for some time, Leonard’s friend, his mom, his auntie and several other family members as I was trying to figure out just how I was going to examine her which would be necessary to confirm her diagnosis. I had suspected that this may very well be Parkinson’s disease, but it would take further questioning and an examination to confirm things. It turned out that she lives on the coast in the district of Tanga, a six hour drive in the opposite direction from FAME, so I offered to come back with the residents to see her on Tuesday morning prior to our departure for FAME.

It always seems that these thing occur for a reason and I was clearly brought here tonight for a purpose that no one had realized in advance. Planning is important, but one must always have the ability to be flexible and to make things work even if that wasn’t part of your initial plan. I think we all had smiles on our faces that evening, realizing that our meeting was not one of happenstance, but rather one of a higher meaning. The residents would be arriving tomorrow and I would be picking them up in the late afternoon. It was the start of another month of global neurology and it had already begun for me a few days early.