October 16, 2017 – A day in Qaru….

Standard

Sara and me prior to clinic starting in Qaru

Today we would begin our week of mobile clinics, traveling to villages in the more remote areas of Karatu district to provide neurological care, though most patients could make it to FAME if necessary. Glen was also leaving today, heading back to Botswana for some important meetings there regarding the Botswana-Penn Partnership and future goals for the program. His visit here had been productive and having the support of the Penn Center for Global Health has been essential for the continuation of our program and to determine future directions that will benefit FAME and possibly Penn.

Angel (second from left) triaging patients for us at the beginning of clinic

Whitley evaluating a patient with Emmanuel

It’s always a bit stressful for me when we start the week of mobile clinics as there are a number of logistics that need to be taken care of. Angel will be the point person for this visit, making certain that we have everything we need before we depart since we will always be an hour or more from home and there’s no running back to grab something forgotten. I have been traveling to Kambi ya Simba and Upper Kitete for 6-7 years to do a mobile clinic in those locations and we’ve recently added Qaru to our list of sites. The idea of our mobile clinics is to provide only neurological care to these communities as they have district health offices and clinical officers there who can provide general medical care. The villages are not remote enough that patients cannot get to FAME as we often have them come to get labs checked there after they’ve been on the medication for a month and to assess any possible adverse effects. Most of these patients, though, don’t realize that they have conditions that are treatable which is our main purpose here. There really is very little in neurology more gratifying than treating an epilepsy patient who has been seizing their entire life without ever ave been treated.

Neena and Dr. Anne evaluating a patient

Whitley evaluating an elderly patient with Sara working on her notes

The group we had today for mobile clinic included the three residents, me, Alex, one translator (Emmanuel), one clinician (Dr. Anne), Angel and Selena, our nurse who would be dispensing medications at clinic. We stopped at the tarmac at the end of the FAME road to buy things for lunch and get some bottled water and sodas for the day as we’d need something to drink. Our lunch consisted of lots of pastries – beef samosas, chapatti, vitumbua (fried rice cakes), and mandazi. Our course, most of us opted for the wazungu favorite drink of Fanta Passion. Once outfitted with our food and hydration, we embarked down the main road heading south of town in the direction of Qaru.

Sara and Emmanuel examining a happy little boy with epilepsy and delay

examining an elderly women with back pain and numbness

Qaru is about 45 minutes south of Karatu on the road to Endabash and we had first visited this site last March when it had been very productive with many good patients for us. The road is very good save for long stretches of washboard bumps that are mostly annoying, but can still produce back and next pain. We pass through several other villages that all look quite similar, but we eventually come to Qaru after passing right through it realizing our mistake only a moment later and turning around after we told our Tanzanian friends in the vehicle that we were just checking in on them to make sure they were paying attention.

examining an elderly women with back pain and numbness

examining an elderly women with back pain and numbness

Sara and Emmanuel examining an elderly women with back pain and numbness

The district health center at Qaru is a very nice facility and had room enough for us to run three exam rooms, but the patient load started out slow so we used only two exam rooms for patients. It was very clean and the building we were in was quite separate from the main clinic where the routine medical patients were being seen by their district clinical officer. Most of the patients had been there in the morning, but had gone home since we hadn’t yet arrived and so they slowly filtered back in throughout the day. The volume of patients at our mobile clinics can be quite variable and may depend on the season (e.g. harvest time) or perhaps just what has been going on recently in the village.

Sara examining the little girl with abnormal movements

Sara examining the little girl with abnormal movements

The most interesting patient we saw today was a young child that Sara evaluated. She was seven years old and had definite developmental delays, but she was extremely social and interacted well with us. She was completely unable to walk, though, and had abnormal movements that looked mostly like a combination of both chorea and ataxia. On her examination, she was very hypotonic and was actually unable to stand on her own because she was so floppy in combination with the ataxia and her movements. She would sit on the ground with her legs flexed at the knees and splayed outward, scooting herself along until she found something she could grab onto and try to pull herself up, most often unsuccessfully. She didn’t have convulsive seizures, but she did have interesting sudden tonic extensions of entire body that looked somewhat myoclonic in nature. She was a lovely young girl who with a problem that appeared to be either congenital or genetic, perhaps mitochondrial, and would be something quite unlikely to have any treatment per se, but it would be nice to identify her problem. She had three younger siblings, all of whom were normal neurologically and very loving parents.

Sara and Neena discussing our little girl with the abnormal movements and myoclonic seizures

Patients continued to straggle in throughout the day and we worked until 5pm since we didn’t want to turn away patients as we wouldn’t be coming back and we weren’t confident they would get to FAME if we had asked them to. I believe we saw perhaps 14 patients for the day – not a bad day, but we certainly would have preferred more. We continue to get the word out about our clinics and the Qaru clinic added last visit was somewhat in response to the District Medical Officer having asked if we could go elsewhere in addition to the Mbulumbulu region where we had been going for several years. Our neurology mobile program is one that has been based on bringing the awareness of neurological disease to these remote villages rather than trying to see as many patients as possible.

Selena (sitting furthest) running our pharmacy

A happy crew in the Land Cruiser

The drive home from Qaru had beautiful views of the region south of Karatu and off into the distance. The soft lighting of the evening was in sharp contrast to the strong equatorial sun from earlier in the day. We arrived home before 6pm and had planned to work most of the evening as Neena was doing her presentation on headache the following morning and this required our participation as headache patients. Tomorrow, following the presentation, we would be traveling to Rift Valley Children’s Village for another mobile clinic.

The driver’s view on the road home from Qaru

October 15, 2017 – Tarangire National Park…

Standard

It was Sunday again so in keeping with our tradition of “safari Sundays” while here on rotation, so we all awakened very early for a 5:30am departure from Karatu. The trip to Tarangire takes about 1:30 hours as we travel down the escarpment and through the village of Mto wa Mbu (Mosquito River) that lies at one end of Lake Manyara and traverse the valley towards Makuyuni where rather than turning left towards Arusha, we turn right in the direction of Babati. The north entrance to Tarangire National Park is on the way to Babati and just south of the shores of Lake Manyara.

A banded mongoose

Tarangire is a park that is dominated by river ecology and during the dry season, all of the animals must travel daily down to the river for their water as the many other watering holes are all dry. Tarangire is also home to an incredible population of elephants who travel daily from the protection of the hills during the night down to the river during the morning hours and back in the evening. There are huge herds of elephants wherever you look with many, many babies confirming the health of these wonderful animals. In addition to the elephants, there are also tremendous herds of wildebeest, zebra, and impala primarily with a smattering of waterbuck, eland, and Coke’s hartebeest. There are also lots of giraffe with many babies. As for predators, there are lions, cheetah and an occasional leopard. And then there are the monkeys. Numerous baboon tribes roam throughout the park along with vervet and blue monkeys.

A vervet monkey at the main lunch spot

An impala at the water’s edge

We arrived to the park sometime after 7am as I had to get gas in Mto wa Mbu and they thought I had “four” instead of “full’ so had put in only 40,000 TSh worth of diesel fuel when I needed at least twice that. It took me some time to eventually speak with another attendant who’s English was quite good and he suggested that I they just finish off the fill, pay for it and then do the second fill which is how we handled it and all went quite seamlessly, though we had spent more time at the service station than I had anticipated.

Shockingly, this is not a blue monkey, but rather a vervet monkey

An elephant keeping a very close eye on us.

Once back on the road, the sun was slowly creeping up behind the mountains to announce the new day with a sky of orange predicting the impending sunrise. It was overcast as we reached Makuyuni, but the weather overall was amazing and there was still al cool breeze from the dawn as the sun had yet to warm things up and was still quite low in the sky. We made our way to the park entrance along a 7 km dirt road with many irregularly spaced speed bumps and washboards that are sufficient to loosen any precious dental fillings with ease. I will always remember the entrance to Tarangire as it was the very first park we entered in 2009 when I was here with Daniel and Anna and up until that point, we had not been on safari nor seen a wild animal. Though it only seems like yesterday, I have been on so many safaris since then that it also seems like the distant past at times. Regardless, each safari is different and I see something new each trip not to mention the pleasure of taking the residents on safari as well and for most of whom this is their first experience traveling to Africa so it is also their first experience on safari.

We were heading the river that runs through the park and dominates life here, especially in the dry season when it center of all activities considering it is the only water source as all others have completely dried up. As we were descending down to cross over the river, though, there were several vehicles stopped which is usually a good sign that there are cats around. Off to the side of the road and a short bit away were two cheetahs resting in the shade of a tree. Cheetahs are usually solitary animals, but will travel in pairs as two brothers or two sisters, but never mixed. They are such gorgeous and majestic creatures that I can never see too many of them. It was getting warm so they were in the shade and relaxing as much as possible at least until the sun begins to dip in the late afternoon. We’re on our way after a few minutes of viewing and several photos and looking forward to the remainder of the day and what else we might see.

Coming down to the river, there were huge herds of wildebeest and zebra all in constant movement making their way towards the river either in single or as a group. The river is their lifeline at this time of year for without it, life would cease and the herds would move elsewhere. We traveled along the south side of the river for a time, moving in and out of the brush and eventually crossing it at a narrowing. On the north side there we again ran across another group of cheetahs, two at least and possibly more, sitting in the shade of the trees with the heat of the day increasing. We were traveling towards the Silala Swamp, a very large area on the south end of the park where, during the wet season, there are many animals congregating in the large wet areas. As we crested the hill to view the wide expanse of the swamp and stop at the picnic area for lunch that looks out over the area, we saw hundreds of elephants stretched along the open area off into the distance. They were broken up into families, but this was a sight I had never seen here, so many elephants in one place and all mixed together. There were also zebra and wildebeest throughout, but the impressive sight really was the number of elephants.

Jackel on the prowl

Southern Ground Hornbill

We sat on a picnic bench and table for our lunch along with a very large group of adolescents from the US that were on a group safari and had also stopped for lunch. They were traveling in the large vehicles used for this purpose that are like troop carries with seats and lots of storage down below for tents, food and personal belongings. These groups normally stay at the public campsites rather than at the tented camps or lodges that are far more expensive.

While at lunch I had spoken with a safari guide, who was somewhat taken aback that I was actually driving and guiding our vehicle, and learned that there was a lion about two kilometers down the road along the edge of the swamp. We drove down to the edge of the swamp after lunch and just about where predicted there was a solitary female lion sitting under a tree. She appeared to be covered in mud (or blood?) so I suspect she had probably taken some prey in the wet mud not to far from where she was sitting. She got up a few times, but for the most part was quite content to be resting during the heat of the day.

We had also had word that there might be a leopard in the other direction along the swamp so we decided to drive that way and up into the hills eventually looping around in the vicinity of the Tarangire Sopa Lodge. There were several families of elephants wallowing in the mud quite close to the road and there was definitely some jockeying for position go on. There were lots of rumbling noises coming from the groups, a sound just like what the tyrannosaurus rex made in the movie, Jurassic Park. It is a low baritone sound that you can feel in your bones. That was fairly frequent along with other less frequent trumpeting sounds that were clearly some communication of displeasure or warning made as the families jostled amongst themselves vying for the best mud. We watched them for several minutes and eventually departed in quest of our leopard.

Cheetah

We drove slow and kept our eyes peeled hopeful that we would fine the third species of big cat for the day, but alas it was not to be. Leopard’s are certainly quite elusive and the most difficult of them to fine, but I thought we had a good chance given the reports we had heard. I have seen many leopards over the last years, but the others will have to wait for a sighting perhaps in the Central Serengeti where we’ll be this coming weekend.

Baby elephant nursing

Traveling back towards the main gate we spotted many more animals and even another cheetah back on the main road. It was a long day for us having entered the park before 7:30am and not reaching the gate to exit until perhaps 3:30pm. That’s quite a long safari and I think everyone, including me, was quite tired from the day. We grabbed some cold Fantas before hitting the tarmac and were then on our way home. A quick stop at our friend’s art gallery to buy more presents for home and we were back to FAME in no time. We were all quite dusty and tired from the day, but thankfully Alex, our intrepid volunteer coordinator, had offered to make us dinner after our safari. We had homemade tortillas, corn salsa, grilled peppers and grilled meat. Glen made a cucumber and salsa appetizer to go along and we were all quite happy with a well-cooked meal at home.

Whitley in her National Geographic photographer pose

Tomorrow we will begin our mobile clinic week so will miss the lunches here at FAME. We begin at Qaru, south of Karatu, then Rift Valley Children’s Village on Tuesday, Kambi ya Simba on Wednesday and ending with Upper Kitete on Thursday. We’ll organize everything in the morning and be ready to hit the road by hopefully 9am or so.

October 14, 2017 – Julius Nyerere Day….

Standard

Saturdays are typically very slow as I have mentioned in the past, but today was very, very quiet it seemed as we showed up in our neuro clinic following morning report. It was unclear why, until we were told that it was actually a national holiday, Julius Nyerere Day, and workers all over stayed at home rather than go into work. Nyerere was the first president of Tanzania, their George Washington. He was an amazing man who had been educated in Uganda then England and in 1961, became the countries prime minister, and later after the formation of the United Republic of Tanzania when Tanganyika and Zanzibar united, became the first president. They had very few resources at the time including other qualified college graduates that could help, but they persevered and eventually brought a country consisting of 120 unique tribes, each with their own language and living in their own villages, together for the benefit of all and a means of creating an infrastructure to best serve the country. He is simply known here as “teacher.”

The combination of a Saturday and Julius Nyerere Day, though, decimated our clinic volume and after a very slow start, the clinic remained slow as we moved on towards lunchtime. Sara saw a young woman, actually adolescent, who we had treated in the past for seizures, but had run out of medication and was no longer having seizures, but was now complaining of headaches that were very likely migrainous in nature. It was great that she was no longer having any seizures and we were perfectly comfortable now treating her headaches that would be a much easier proposition. We did make sure that her mother realized, though, that she was not totally out of the woods and to make sure to come back should she have seizures again. Unfortunately, we do not have topiramate (Topamax) here which would be the perfect drug to use in this situation to give us extra insurance as far as covering both the headaches and the seizures.

Whitley evaluating a patient with Emmanuel

Whitley’s highlight of the day was doing a consult on a patient in the ward who had been admitted yesterday with recent onset of psychosis. The patient had remained quite psychotic overnight and the story was much more concerning for a rapidly progressive dementia than anything else. Two daughters were present, but neither of them had been living with her so were not totally aware of the recent history. Whitley had a bit of a handful examining her (the patient was spitting on her caregivers including Whitley), but eventually had gotten enough information to begin a workup. All of her routine dementia labs (RPR, HIV, TSH) were negative or normal so it was decided that she would probably benefit from a lumbar puncture to help direct our future recommendations. An autoimmune encephalitis was certainly in the differential, but trying to evaluate that here would only be less difficult than trying to treat it if that were indeed the diagnosis. None of the therapies other than steroids would really be available here so our inability to confirm such a diagnosis would only be disappointing from an academic purpose.

Neena examining a patient with Baraka’s assisting

Neena saw a patient with primary insomnia as well as another patient with carpal tunnel syndrome and Whitley had a patient with back pain and “numbness,” a common complaint that we see here that isn’t often the more typical neuropathy symptoms that we see back at home. This is usually numbness involving an entire limb or one side of the body in the absence of findings on examination and most often in a patient without much else medically or too young to consider a vascular etiology (i.e. stroke).

We all went to lunch (my favorite, rice and beans) and discussed what we’d do with the afternoon since we had no more patients for the day. Neena decided to stay at the Lilac Café (excellent internet) to work on her presentation for Tuesday morning while the rest of us went downtown to get phone cards to recharge our internet and also to walk around town a little bit. Glen ended up buying ingredients to make a nice cucumber and salsa for dinner tomorrow night and I purchased a shovel for the Land Cruiser that I wish we had had last March when we were stuck down in the Southern Serengeti deep in the mud with numerous other vehicles and it took us half the day to get ourselves out.

Sara evaluating a seizure patient with Emmanuel

For dinner, we had made plans to go to the Plantation Lodge, another of the great traditional lodges here in Tanzania. We made it there around sunset and it was again an absolutely gorgeous evening so we all sat on the outside patio to have drinks. They had provided a table full of appetizers for us so when Neena, Whitley and Sara disappeared, it didn’t take a detective to figure out where they had gone for the moment. They eventually made it back to our table so we all ordered drinks, including my Moscow Mule, and relaxed in the amazing glow of sunset and the sounds of the Ngorongoro Highlands quite close reminding us that we were all definitely in paradise. There was no rush to get to our table for dinner as we were only one of two parties there that night, the other being the owner of the lodge with some of her guests from Germany. Dinner was a delicious meal with tasty beef filets as the main course along with vegetables while dessert was an ice cream creation that we all quickly devoured.

We arrived home much later than we normally do for a dinner which was significant as we were all getting up quite early to head to Tarangire National Park for a safari. The park opens at 6:30am and is about an hour and a half away so we all decided on leaving at 5:30am in the dark so we’d have an early start on the animals. So it was off to bed for everyone with a very early awakening and the hope that we’d have hot water that early in the morning. Our water heaters are wood burning “kuni” boilers that the askari (Maasai watchman/guards) fire up morning early, but we weren’t sure just how early that meant.

October 13, 2017 – Day 4 of neurology clinic and our very first resident wellness day….

Standard

It was once again a picture perfect morning here in East Africa. A slight chill was in the air walking to clinic this morning as the nights are becoming cooler and refreshing. We all arrive to morning report with all of the doctors working this day along with the night doctor finishing their shift and getting ready for some sleep. Dr. Ivan has been on night duty for the week so has given us report each morning not only on the patients already on the ward, but also on the new patients who came in overnight. We always listen intently to each case for any neurological issues, as we will provide consults on those patients. A woman did come in with what sounded like new onset psychosis and would be someone for us to see, but she needed to have most of her medical workup first to see if there was an obvious cause of her symptoms before we would get involved.

Whitley evaluating her Parkinson’s patient

We were working only a half day today as I had scheduled the afternoon for a resident wellness day. I believe this is a new requirement for all ACGME accredited programs and provides that residents receive a certain amount of time during training which can be used for personal enrichment and “wellness.” As these days will typically be given during elective rotations and they are currently on an elective with me, it made sense to place two half-days aside for this purpose. Today would be the first resident wellness day, or really half-day, in Tanzania. Since it would be impossible to see the same number of patients we’d been seeing in a half-day, I asked Angel to only schedule 16 patients for us to see this morning which meant 5+ patients per resident if we had our three rooms running and seemed more than realistic.

Whitley questioning her Parkinosn’s patient

sWhitley’s day included her favorite type of patient, Parkinson’s disease, since she is planning to go into a movement disorder fellowship and this is her main area of interest. The patient and family reported that he had been on carbidopa-levodopa previously and they thought that it had helped, but that the effect of the medication was wearing off prior to the next dose. Carbidopa-levodopa is a combination medication that comes in several ratios of the two medications. At home we typically use the 25/100 combination for reasons that I won’t bore you with other than to say that we like to achieve a minimum of 75 mg total daily dose of the carbidopa to avoid side effects from the levodopa. Using at least three of the 25/100 tablets at home is the perfect combination for us, but for some reason the only strength we can get here are the 25/250 tablets which are typically used for the more advanced patient with the larger dose of levodopa (250 mg). This creates a bit of an issue when starting this medication, as it is impossible for us to get enough carbidopa in the patient when initiating therapy.

Dr. Anne and Sara questioning a patient

Whitley’s patient had been on the medication in the past and they felt it had worked as he was very clearly quite symptomatic and would certainly benefit from it. Since the main issue really is the tolerability and not effectiveness with the dosing we have here, we’ve found that most patients will do well and the complaints are pretty minimal (mostly nausea). Whitley started him on ½ tablet four times a day as he was often up rather late and would need this to get him through the day. Most patients are up at sunrise (6am year round since we’re on the equator and there’s no need for daylight savings time) so he would take his first dose at 6am and then at regular times following that. Since we’ll still be here at FAME the week after next and the patient lives quite close we decided to have him come back to see us before we leave so we could see how he was doing on the medication.

Doing a good examination

Sara’s last patient of the day was a young girl that we have seen over the last year and has been quite a diagnostic dilemma for us. She is sixteen and began having events that were quite suspicious for seizures with a very normal developmental history. She was injuring herself falling during the seizures, but some of the events were also quite odd and concerning for psychogenic episodes or conversion. In addition, she seemed to be having subtle cognitive issues at first, but it was hard to tell and there was some concern that this may also be more of a psychogenic issue. She had been in school, which is how she first came to us through the expat operating the school, but over time she has worsened and was no longer able to stay in school so is now at home with her family. As is often the case, I believe there were also concerns about her home life that further complicated issues.

Dr. Anne and Sara questioning a patientd

She has been on multiple medications over the last year, none of which completely controlled her seizures. We even resorted to valproic acid, a medication that can cause severe birth defects so is never used in woman of child bearing age, but we did so after the family finally consented to giving her Depo-Provera, a long acting birth control injection lasting three months. That was done at our last visit here in March, but in the interim it was noted that her seizures had worsened, or at least were no better, and so she had been switched back to levetiracetam, This medication had possibly helped in the past, but the supply was limited which is why we switched her to valproic acid last visit. Levetiracetam is now available in the country, though it is very expensive compared to other antiepileptic medications and therefore difficult to use for that reason.

Neena and Emanuel evaluating their patient

Sara went through a thorough history of her seizures as well as her cognitive issues and also did as comprehensive examination as she could given her cognitive issues that are now clearly worse raising concern for some metabolic or genetic disorder and it is also now quite apparent that we are not dealing with any facet of conversion, but rather a degenerative condition that will likely not end well. What that is, though, is really not an easy question given her constellation of symptoms and seizure types. Lennox-Gastaut syndrome would be an easy solution, but she did not really fit this for various reasons. Sara decided to do some research to come up a better differential diagnosis list, which was certainly beyond my capabilities, and in the meantime, increase her levetiracetam to 1500 mg twice daily. The family did not have concerns with the cost of the medication making things a bit easier on that end. The list of diagnoses that Sara came up with later, and which I was absolutely no help with, were Lafora disease, Niemann Pick type C, Gaucher type III, Sialosis , and Hallervorden-Spatz. Please don’t expect an academic discussion from me on these diagnoses as that is exactly why I’m an adult neurologist. As with the other patients, we asked that they come back to see us before we leave so that we can assess how things were going with the medication as well as after we’ve had some time to think about her case.

Neena and Emanuel evaluating their patient

The residents had multiple options of what to do on their very first wellness day that ranged from relaxing at home and catching up on work to going to town to do some shopping to visiting one of the lodges for an afternoon at the pool (Whitley hadn’t brought her bathing suit though could just use shorts and a tank top). The final decision of what we would do, though, was clearly dictated by our stomachs as Gibbs Farm has a wonderful buffet lunch that I hadn’t gone to since 2009 when I was originally here on safari with the kids. Since then, they have completely remodeled the resort and the kitchen. We were running just a little late given Sara’s final, quite complicated patient of the morning, but we arrived to Gibbs in plenty of time for lunch.

Dr. Gaulton sharing his photos with a patient

To say that the lunch was spectacular would be an understatement. There were so many things to choose from including at least half a dozen different types of salads, cold meats, cooked meats, chicken stew, quiche, incredible soup and more. We all got a plate full of food and relaxed at our table admiring one of the most lovely views in all of Karatu as we all counted our blessings that we were here to enjoy this. I don’t think I would surprise anyone to tell you that we each went back to the buffet for seconds before later checking out the deserts, which were equally scrumptious. We were all silently thanking Ray Price for insisting that I schedule this wellness day for the residents, Glen and I most of all since we were merely chaperoning and, to the best of my knowledge, there was no mandate for a faculty wellness day!

Lunch on the veranda at Gibbs Farm, one of the loveliest places on earth

Glen and I had decided to remain at Gibbs for the afternoon while the residents were going to hike to the Elephant Caves, a moderately strenuous hike that is in the Ngorongoro Conservation Area starting from behind the Gibbs property and going uphill to a location where the elephants mine for necessary minerals in the hills forming “caves.” It’s a gorgeous hike that I’ve done before and given the fact that I’ve been having some trouble with my left knee (a torn meniscus from a bicycle fall while training for the MS bike ride and diagnosed the week before I left) I decided not to take any chances. The path travels through the forest on the side of the crater rim and traverses several creeks and waterfalls. Glen had some work to finish on a grant and I on my blogs, so the two of us had to tough it out by sitting on the lawn in front of the veranda in very comfortable lawn chairs being served iced tea the whole while. As they say, it was rough, but someone had to do it.

Neena, Whitley and Sara were back just before 6pm (sunset), but I knew they were safe as you are accompanied on the hike by a ranger from the NCA for the mere fact that you’re walking through an area teaming with wildlife – elephants, Cape buffalo and an occasional leopard. When they returned, we all decided to have a drink as the sun set in the distance and enjoy the tranquility of Gibbs Farm, perhaps one of the most beautiful places on earth. I again worked on my quest to sample Moscow Mules and can report that the ones served at Gibbs are truly delicious and should not be missed.

We all finally loaded up into our vehicle to head home and relax for the remainder of the evening. Dinner had been brought to our house and even though we were all still somewhat full from that amazing lunch, everyone but Neena managed to take care of our dinners, spaghetti and meat sauce. I was quite a memorable day and for the first designated resident wellness day, quite a success. We have one other half-day designed just before we leave and I think you already know the answer as to where we will be spending it.

 

 

 

 

October 12 – Day four of our FAME Neurology Clinic…

Standard

An older Iraqw woman complaining of memory loss

At morning report today, we discussed the little newborn who we had tried to do the LP on but were unsuccessful and who was receiving antibiotics for presumed meningitis. The baby had improved substantially following the institution of antibiotics and we still had a significant concern that we were indeed treating a CNS infection that would necessitate the baby receiving a full course or 21 days of antibiotics, but the family wanted to take the baby home now due to how we’ll the little baby was doing. We felt that would be the wrong choice and that we had to convince the family to stay in the hospital until the course was finished which would cost them additional money for the continued stay and treatment. They were finally successful in making a case a full treatment course with the family, thankfully, so they will be here with us for a few more weeks.

Patients on Thursday morning

Patients on Thursday morning

Patients on Thursday morning

Arriving to our neurology space after morning report, we were again encountered by a mob of patients waiting to be registered for our clinic. Once again, the numbers were not going down at all and we had a large group of patients waiting to see us today. I have limited each day to somewhere between 30-35 patients, otherwise the days become quite unwieldy for us. Chai time is from 10-11am and all the Tanzanian workers, including our interpreters and doctors working with us expect to go up for Chai that essentially shuts us down during that time. Lunch is at 1:30-2pm usually and everyone goes up to eat with us going typically on the later side. The patients today were all great neurology cases today except for a two, I believe. The first had a painful rash and the second had something else that was non-neurological. These patients were sent back over to the regular OPD (Outpatient Department) to be seen by the general FAME doctors.

Sara getting a history on the muscular dystrophy patient

Sara examining the young boy with muscular dystrophy

The case of the day was a young boy that Sara was seeing for weakness. The child was quite thin, though many Maasai are, but he was now having difficulty walking. He was here with his sister, but it turned out he was adopted from another family, as is often the case here, so we didn’t have a good family history for him. They had come to see us from Loliondo, a region far north by the Kenyan border and a seven-hour bus ride from here. I have been up this region to visit before and it is very, very remote, primarily Maasai, and has a small hospital in Wasso that is run by some priest/doctors, but is quite overcrowded, understaffed and undersupplied. I was totally overwhelmed as I toured the hospital with the only Tanzanian doctor there for around one hundred patients and had been asked to look at a young woman who had had an episode of asphyxia during childbirth and was now unresponsive, but still breathing. It was a very depressing case with little to be done either diagnostically or therapeutically other than to wait and see what she recovered, if anything. It is also a very poor region, further complicating providing medical care there.

Facial features of our muscular dystrophy patient

Pseudohypertrophy of the calves

This young Maasai boy of approximately 9 years of age had come with his adopted sister due to weakness and difficulty walking that he had had over the last year or slightly longer. The problem was progressive and we were both immediately thinking of a muscular dystrophy, probably Duchenne’s, which would be the most likely to see. He had a very hatchet-shaped face with what looked like some facial atrophy and also some atrophy around his temples quite possibly. His shoulder and humeral muscle bulk was quite atrophic and there was also some possible scapular winging. The most impressive finding, though, was his large and rubbery-feeling calves clearly suggesting pseudohypertrophy. He had definite weakness primarily of his shoulder and hip girdle and was strong distally in the upper and lower extremities.

Whitley teaching the neurological examination to Dr. Anne

Given our lack of ability to further evaluate with lab studies such as a CPK or to do an EMG, we were really limited to our clinical history and examination in this case, but our thoughts really were that though he most likely had Duchenne’s muscular dystrophy, we could rule out other forms with the present data and that we would want to see him again in six months. We put him on a low dose of prednisone which can help muscular dystrophy patients remain ambulatory for a longer period of time but would not likely change his overall prognosis. When we pressed the older sister for any additional family history, there didn’t appear to be any other family members who had similar problems.

Whitley and Dr. Anne discussing a patient

Whitley had an interesting patient in the morning today as well. This was a gentleman who I had seen 5 years ago and had given a history of a gradual onset of weakness in the lower extremities and difficulty urinating. I had requested lumbar spine films to rule out a mass lesion or similar, but he had apparently not gone to get the X-ray and was now back to see if there was anything that we had to offer. On exam, he definitely had a spastic paraplegia and a T10 sensory level that was consistent with my examination back in 2012. He also had urinary problems, having to usually manually compress his bladder in order for him to urinate. We sent him for the lumbar X-ray that I had originally ordered in the past and it was normal other than some osteophytes that were not what we had been looking for. Whitley got a much better history of the onset of his weakness that seemed to have been more sudden in onset or at least over a period of days suggesting that it was much more likely vascular in etiology than anything else and was certainly not compressive from any type of bony problem having now looked at his plain films. He was given some baclofen for his spasticity, but told that we unfortunately had very little else to offer him.

Aziza learning the neurological examination

Aziza learning the neurological examination

During our visit with the young dystrophy patient, while grabbing my camera off the table to take a photo of his calves, the camera strap somehow caught on the table causing it to pull out of my hand and promptly crash to the floor with the sound of broken glass. Luckily, it appeared that I had only shattered the lens filter and not the lens itself or the camera, but it was definitely out of commission for the time being. The filter that has a metal bezel and threads was heavily dented from the impact and completely unable to be screwed off no matter how hard we tried. I was later able to remove all of the glass from the filter, but with the bezel remaining on the lens, I could not attach another filter to protect the lens so would have to go sans filter, which I have never done before for fear of damaging irreparably the outer element of an expensive lens though this is what most professional photographers do. Not earning a living from my lenses, though, I have never been able to justify ruining a lens and buying another should that happen.

Dr. Anne and Whitley evaluating a patient

Sara examining a patient

We finished up the day with some time to spare as tonight we were heading to dinner at the Manor Lodge that sits high up on the ridge overlooking FAME and borders the Ngorongoro Conservation Area. Shangri La coffee plantation, one of the largest in this area occupies the slopes and ridge top of the Ngorongoro Highlands so that you drive through the coffee plantation to get to the lodge, also driving through a bit of the conservation area along an easement where you can see some animals occasionally. The main building at the Manor Lodge was an old German home that has been built up to be one of the premier high end safari lodges in the area with cottages that are quite spectacular and expensive. We have come though just for dinner that we get at a reduced rate due to our work at FAME, as most lodges in the area do for us.

My poor lens and cracked filter – the lens survived, the filter did not

The Manor Lodge has been designed to replicate the wine region of South Africa with its ornate English-style buildings that are quite beautiful. The views are great and they also have horses to ride here along with a pool, so many volunteers will come here to relax from time to time. As we sat out on the veranda watching the beautiful sunset with our special drinks (I’ve become accustomed to a Moscow Mule given my love of ginger and have embarked on a survey of Moscow Mules at all the lodges here) while we were also served some appetizers to whet our appetites.

Panorama of the grounds at Manor Lodge

We were called to dinner and sat at a table containing more silverware than I’m used to even at the fanciest of restaurants stateside while we were all served a five-course meal accompanied by first a white and then a red wine from South Africa. The food was, of course, delicious and we had a wonderful, relaxing and enjoyable dinner after a tough day of patients.

We eventually all piled into the Land Cruiser to drive back through the easement (no animals seen), through Shangri La Coffee Plantation and eventually back to Karatu and FAME, where we all settled into the Raynes House for the rest of the evening before climbing under our mosquito nets to enjoy the cool night air of the Ngorongoro Highlands while we slept. Tomorrow we were working in the morning, but would be free in the afternoon having scheduled our very first resident “wellness day” for that afternoon. We were still coming up with plans of what to do.

The four of us enjoying Manor Lodge

October 11, 2017 – And the beat goes on….

Standard

Our crowd of patients to be seen on Wednesday morning

Certainly by Wednesday, we had expected things to be a bit more sane as far as the patient numbers, but that was not what we found to be the case as the onslaught continued. In the past, our volume had always dropped off as the week went on and had become more manageable every day so that by the end of the week we fully able to handle all the patients without having to limit the number of patients we could see. Today, being hump day, it was as busy as ever and we were still making a list of the patients that came as we could only see 30 in the day while the others were sent home to return the following day. Obviously, our hope was that the numbers would decline a bit and we’d catch up by Saturday, our last day of the week here before starting mobile clinic all of next week. There were more people today than each of the previous two days, though.

Our crowd of patients to be seen on Wednesday morning

We again ran three rooms so we could actually get everyone seen and the patients were a smattering of the typical patients for us without any particular skew. We had patients with memory loss, back pain, numbness, developmental delay, headaches, and, of course, seizures. We had Dr. Ken with us again along with Baraka and Emanuel, both of whom were planning to spend the entire week with us. It was another very long day of patients with us seeing a few over thirty or approximately ten per resident which is a good number considering most of the patients were new to us and even the follow up patients are often complicated because of the difficulty getting a complete history and the fact that medications are often stopped or changed without good documentation as patients may be see elsewhere in between our visits.

Whitley and Baraka evaluating a patient

Sara and Emanuel examining a patient with seizures

Patients often stop medications because of cost or because “they are done,” meaning that the prescription has been completed and rather than refilling the medication, they just stop them. If you’re treating something symptomatically like headache, that’s not a problem. But if you’re treating something like epilepsy, that is a major issue as their seizures will just begin again and then it’s difficult to get a good history of how the medication was working. Having to start again from scratch can be very frustrating and very often it’s the reason patients are tried and retried on the same medication several times. We are often running to the pharmacy to get samples of the various AEDs to show to the patient to confirm what they had been or are currently taking,

Whitley and Baraka evaluating a patient

Sara and Emanuel examining a young girl with seizures

Neena did create a spreadsheet of all the neuro medications we use and what their costs were as that is often an issue. Though we cover the cost of medications as they are included in the visit cost when patients come to see us, they must pay for the medications separately when they return for refills. The AEDs are the most important for us as they are taken indefinitely and the costs add up. Levetiracetam (Keppra), is an anticonvulsant we’ve brought here in the past as it was never available here, and though it is now, it’s also quite expensive. The single pill cost is 1500 TSh (Tanzanian shillings) and patients will typically be taking from 2-4 pills a day meaning 3000-6000 TSh/day or $1.30 to $2.60 per day at the current conversion rate. Over $30/month for a single medication can be devastating for a family in a region where the average annual income is well below $500 and less for many families. Phenobarbital, the cheapest of the AEDs, is just not a great drug for anyone over 2 years of age and it’s very difficult for us to prescribe it to anyone knowing that there are better and safer medications, though they come at a cost.

A young boy with milestone delays and seizures

Wednesday nights has turned into expat night at Happy Days since we had been here last, mostly under the direction of Alex, our volunteer coordinator, who seems to have organized the affair. At our visit last week there had to have been at least twenty-five, mostly younger, primarily volunteers there, all from different regions of the world, who are living in Karatu or the surrounding environs providing assistance with education, microfinance and health (us). It is a great community here and having a weekly gathering is a great idea for everyone to meet and I am sure keeps those who are here long-term from getting homesick during their months of work.

Whitley evaluating a women with “numbness,” a frequent complaint here

Neena evaluating a patient with complaints of memory loss

Unfortunately, I think we all needed to have an evening off to catch up on work and other things so we decided to stay home for this week’s affair. Neena, Whitley and Sara decided to take a walk down the main road towards town and since they had forgotten to supply Glen with dinner tonight, I met him at the Lilac Café for dinner so he wouldn’t have to eat alone. The Lilac was set up to supply food for the patients in the wards as well as their families and also serves as a nice alternative for us to have a meal or sit and have a delicious cappuccino (read Glen) in the middle of East Africa. Glen and I had some wonderful Pizza and Stoney Tangawezi (their strong ginger ale) that is worth the wait as it

Sara and Emanuel evaluating a patient

typically takes about 40 minutes to get a meal here. They have internet that works sometimes with tables outside and the evening was lovely.

Sara evaluating a 9-year-old with perinatal injury and seizures

We all arrived home at around the same time and sat down to catching up on emails, work and reading this evening. It was another great day here, but I think everyone was quite tired from the day.

A gentleman we saw complaining of memory loss

October 10, 2017 – Day two of our FAME Neuro clinic and still growing….

Standard

Tuesdays are the day for educational talks and every time we’re here, the residents will give talks that the doctors have an interest hearing. Dr. Msuya is the educational coordinator and one of the topics he requested this trip was the pediatric neurology examination which was great since we had Sara along with us to do the honors on this one. The talk is done before morning report at 7:30am and usually attended by all of the clinical officers, assistant medical officers (AMOs) and the MDs. Occasionally, there are also some of the more advanced nurses that come to the lectures which is great, but we’ve also done these talks at various times for the nurses as well.

Sara giving her lecture on the pediatric neurologic examination

After the talk, we had morning report and learned of an inpatient consult for a young baby with what sounded like infantile spasms, an epileptic disorder that is most often treated with medications other than the typical AEDs. Sara broke off to see the consult after report while Neena and Whitley accompanied me to the front area where we hold our neuro clinics only to encounter a large mob of patients far larger than what we had yesterday. It appeared that word of our clinic had spread much further and faster than we had anticipated and we were now seeing increasing numbers of patients from the day prior which had really never happened to us before.

Our mob of patients on Tuesday morning

Whitley discussing things with Emanuel, Baraka and a patient

A close conference obtaining a patient’s history

In addition, to the regular patients coming to see us for neurology evaluations, we had a host of young boys in wheelchairs lined up to see us that had been brought by Ståle, the Norwegian gentleman I’ve spoken about before who runs an orphanage in Mto wa Mbu and is incredibly generous. He runs his non-profit with personal funds and donations that are fairly meager considering all of the amazing work he does with these children. He is the one who took in Bahati, the young girl that ended up having a very treatable skin condition when all had suspected a more permanent and likely fatal condition. Her family had abandoned her long ago so that was not an option for to return to them after she had been treated successfully. She’s now a very bright and lovely young girl with the world ahead of her. The other children that Ståle has brought today, unfortunately, do not have quite the same bright future as they are primarily a group of neuromuscular boys that are slowly loosing there ability to ambulate so have all been brought with their wheelchairs today.

Ståle’s group of young men. The Maasai boy on the left is the one Neena admitted today

The younger of the two Duchenne’s brothers with Neena, Baraka and Ståle

Two are brothers that I’ve been following for several years. The younger brother has recently lost his ability to walk while the older brother hasn’t walked in several years. Their personalities couldn’t have been more different as the older brother was very angry and uninterested in anything that we might have to offer , which isn’t very much and so not surprising, while the younger brother has been noticeably less affected by the whole process to this point. They have Duchenne’s muscular dystrophy most likely, though we are unable to check any tests here including a simple CPK blood test, let alone an EMG or a genetic test. The boys have been on steroids before, but as they are no longer ambulating it is less likely to be helpful at this point and having them on steroids in East Africa with all its unknowns isn’t exactly appealing if there is no real benefit.

Neena examining the younger brother with Duchenne’s

The older Duchenne’s brother with Neena, Baraka and Ståle.

Neena also go to see a young man who I had first seen several years ago with Payal Patel and who we thought had most likely had polio in the past, but on today’s examination he seems to be progressing which would mean his diagnosis isn’t really as secure as we had thought. It will mean watching him more closely, but there is still really nothing to offer him other than supportive care. We don’t have the tests here to make the definite or at least likely diagnosis which is going to have to be good enough in this situation.

Neena evaluating a young boy with a neuromuscular disorder

Neena’s final neuromuscular child is one who I know rather well, having diagnosed him with either Duchenne’s or Becker’s muscular dystrophy several years ago when I had arrived one trip and he had been kept over in the ward for me to see. They had told me that he had bilateral lower extremity weakness, but when I had examined him it was clear to me that he had a myopathy and most likely a muscular dystrophy. I remember so clearly speaking with his mother who had remained so stoic and emotionless as I told her the prognosis for her son who at the time had only recently been affected. Shortly after our conversation, though, I found her silently sobbing in the room next door, grieving over her son who would never grow up to be a Maasai warrior in the tradition of their people. It was rare to see a Maasai express this type of emotion, though it was also so natural and expected. I don’t recall that it seemed she felt in any way uncomfortable or that she had tried to hide her outpouring at that moment. What I do know, though, is that I had a much better understanding of the struggles of the people here and that it was an honor for me to have been allowed to share in that moment with her.

Neena and Baraka examining a patient

Sara and Dr. Ken examining a patient

Now here in clinic, several years later, her son was clearly struggling and thankfully they had someone like Neena caring for them. He was totally wasted now with almost no muscle on his body and unable to care for himself. He was breathing rapidly and clearly had an aspiration pneumonia that could likely be the complication that would end his life. Recognizing what he needed, Neena organized his admission to the ward just to hydrate him and give him some antibiotics to cover the likely infection he had along with some medications to make him breath easier. This wasn’t something done to extend his life, but rather to make him more comfortable in what must obviously be a terrible existence in the little time he has left. It was heartbreaking to see him, but also reaffirming in being able to provide the small amount of comfort to him that she did. It is always a struggle to decide whether to put someone in the hospital like this as they may not make it out, but she made the right choice as it was clearly beneficial for him as he was able to leave two days later in a relatively better condition.

Dr. Ken evaluating our young girl who is post-ictal

Sara’s introduction to clinic this day would be with a young girl having a seizure on the bench right outside our clinic door. She was carried in poorly responsive and post-ictal to the examination table and laid there slowly regaining consciousness as Sara gathered her history from her mother. Dr. Ken worked with us again today and he was assisting her in examining the patient who needed some adjustment to her anticonvulsant regimen. We were again working with three clinical teams given the volume of patients and so had a makeshift examination room in the hallway between the night office and the emergency room. Seeing patients in this setting reminds me often of the clinics I did in Southwest Virginia during my residency when we would see patients in whatever facility we could find. It would often be a school or a community building where we’d use the laundry room or whatever space was available to do what we needed to do. I have such fond memories of these incredible of these incredible teaching experiences when I would spend the three days with such legends as Fritz Dreifuss, who was perhaps the greatest mentor of them all, and there were many.

A young child with seizures and question of autism spectrum disorder

A young child with seizures and question of autism spectrum disorder

We had scheduled dinner tonight with Daniel Tewa and his family and I am always so excited to bring my residents to meet him. He is such an amazing individual that it is always an experience to go to his home and hear the stories of Tanzania before there was ever a country with its name. We sat outside his home among the eucalyptus trees in the center of his farm discussing world politics, US politics, geography and the history of this country that was created with so little and is still a work in progress. When we think that we’re nearing our 250th anniversary and there are just beyond their 50th, it all becomes so much clearer. There were only 21 college graduates in the country when it gained it’s independence in 1961, only 11 of whom were African. To successfully develop a country with such limited resources to start, it is not surprising that it has far to go. Daniel showed everyone his underground Iraqw house that he built in 1992 as they had been banned since 1974 to bring everyone into the villages to build an infrastructure in the country at the expense of their culture. The house is now a historic structure that many students from all over come to study and experience. The Iraqw and the Maasai were also constantly at war with each other until 1986 when a treaty was finally signed to end the feud over cattle, but Daniel still has the weapons in spears, shields and clubs that were used to defend themselves in the not too distant times. They are used now only for demonstration purposes.

Sara and Neena

Preparing to throw their spears

Throwing spears

Daniel showed off his talent at throwing a spear and next let Glen have a go at it. Daniel’s spear went clear to the road and a young woman walking by kindly pitched it back in our direction. Glen’s throw went only as far as where the woman threw the other back which was about halfway. Next up were Neena, Whitley and Sara, who all decided to take a shot in unison. I’ll leave it up to your imagination as to how far their throws went and which threw the furthest.

Neena and Sara wearing Iraqw wedding skirts with Daniel

Whitley, Daniel and Sara

We walked up the dirt road to Isabella’s home, Daniel’s oldest of twelve children, for dinner and were greeted by Renata, Daniel’s granddaughter who I have known since 2010 and is now 13-years-old. She loves science and I am hopeful that she want to consider medicine as she goes forward. She has helped us several times at FAME interpreting and I think she’ll have a real knack for it. They are one of my families here in Tanzania, families that also include the Tembas in Arusha and FAME here in Karatu. They are among the reasons I continue to come back year after year. They and the residents I bring to share in the joy of meeting, caring for and teaching such lovely people who populate this wonderful country.