As we were planning to work a shorter day tomorrow, this would be our last full day of clinic for Fien and of the week. We had anticipated a morning lecture at 7:30 am, though as we left the house to walk to campus, Leslie, who was outside exercising (yes, some of the volunteers do exercise on a regular basis), informed us that there was no lecture. We all reversed direction, quite thankful that we all now had an extra 30 minutes of down time, which I, of course, used for a quick cup of tea prior to starting our morning clinic. When we arrived at the education room in the admin building, where the education lecture and morning report take place on Thursdays, all the doctors were present and were having a session in Swahili that, regardless of the language, was clearly somewhat of a “gripe” session in which Dr. Gabriel was soliciting things that were being done right and those that weren’t. The session continued for another 10-15 minutes after we arrived and given that a small amount of it was in English, we got the gist of the conversation.

Things got busy even before our clinic started as there was a middle-aged patient who had come into the ED earlier with severe hyperglycemia in the setting of diabetes, but more concerning for us is that he was in status epilepticus, though had a history of seizures and who had not been taking his home medications, unfortunately. In reviewing his records, he had been seen before with similar issues and had actually had a CT scan, which had been commented on in the chart as showing some focal hypodensity, though the official read was unfortunately missing, and it would take some time to bring up his old study. In the ED, Fien was mostly working on the patient, who continued to have mostly focal status, though was not waking up between events. Dr. Amanda, along with an ER resident from Scotland who just happened to spending the day at FAME, worked to keep his respiratory status stable without intubating him as we have no ventilators to use on patients outside of surgical theater.

Compounding the issue, the only IV antiseizure medication we have is phenobarbital, which can only be used at real loading doses if you’re ready to intubate and ventilate the patient and that was not something we were intending to do. The patient received significant amounts of midazolam, a short-acting benzodiazepine, that, again, is an issue when it comes to breathing. Stuck between a rock and a hard place, with Dr. Amanda and Dr. Anna (our Scottish ED resident) maintaining constant jaw retraction to keep his airway open while we asked for an NG tube to be placed that would enable us to get some longer acting anti-seizure meds on board. With the NG tube now placed, we first gave him a levetiracetam load of 3 grams, which, if we had been in the US would have been immediately effective, but not so when giving it via the NG tube. To be honest, status epilepticus is a condition that is treated as an emergency, so I am very doubtful that there are guidelines anywhere referring to the use of an NG tube, though, as I have said often before, this is Africa.

By about this time, the CT scan done the prior year was finally made available for our review and was completely normal, which made me feel better as I was a concerned that the hypodensity someone had described last year could have been something more concerning, but at least that was not case. Waiting a full 30 minutes for the levetiracetam to work, which it hadn’t (he was continuing to have very brief focal seizures, but was not waking up in between), we then decided to give him a loading dose of sodium valproate through his NG tube. He eventually stopped seizing (thankfully), but given the amount of time he had been, he was not waking up. He was admitted to the ward with decent oxygenation, and, over the course of the day, seemed to become a bit less obtunded for us. Fien had an excellent lesson on how to manage status without IV antiseizure medications, something I’m not sure she had imagined doing previously.

At the same time as we were dealing with the seizing patient in the ED, Dennis was asked to see a young child in the ward with a bulging fontanelle and some developmental delay. Though he was pretty certain the child was going to have hydrocephalus, when they did an ultrasound of the head (possible with the open fontanelle), the ventricles looked normal, and it didn’t give us an explanation at all for the delay and the finding on exam. He also checked the baby’s thyroid as that was also on the differential (a simple blood test that is available at FAME) and it was essentially normal. With no good answer and an adequate ultrasound, he didn’t want to expose the baby to radiation from a CT if it wasn’t necessary so we recommended that they come back to see us in a few weeks when we would still be around.

Later in the day, we were asked to see a young Maasai boy who had been brought to FAME from the conservation area after having fallen over a cliff and had a serious head injury. The story was that two days earlier, the boy had been herding the family’s livestock when he slipped while standing on a rock at the edge of an overlook and fell approximately 50 feet, striking his face and head when he landed. The child had remained with his family for two days, but wasn’t getting better, so he was brought out of the conservation district by bus to FAME. In looking at the boy’s CT scan, he had very serious fractures of the right very much greater than the left orbits, right frontal skull fracture, and severe contusion of the right frontofrontal brain with some subarachnoid blood. He had no subdural or epidural hematoma, something that would have required immediate surgery, but his orbital fractures were something that would require an ENT specialist. He was not alert and his eyes were pretty much swollen shut. We recommended transfer to KCMC where he could be seen emergently and, thankfully, he was transferred before it got too late as ambulance transfers are very risky in the dark.

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It was a very busy morning which was great as it went quite quickly for us, and before we knew it, lunch had rolled around. Thursdays are pilau day, typically one of the favorites for everyone, that is except for the vegetarians in the group. The pilau, being rice cooked with meat and seasonings and accompanied most often by a cabbage slaw, is definitely delicious, though I am still totally partial to the lunch that is served for five out of seven lunches and that is the rice and beans with mchicha on the side and lots of pili pili. As I have mentioned numerous times in this blog, I think of this lunch often when I am home and miss it dearly the moment, I leave FAME.

Our evening activity tonight, which was rather impromptu, was an invitation for us all to attend Teddy’s son’s first birthday party. Teddy, the tailor who has taken such wonderful care of the residents over the last several years and has also now taken Dorthea in as an apprentice, had her first baby last year at this time. Not only was Allan born while we were here a year ago, but we have watched him grow and have enjoyed seeing him on each of our visits to her shop. Birthday celebrations, and especially the first, are huge events here in Tanzania, and a time for family and friends alike to gather and show respect. Being invited to such a celebration was an honor for us and something not to be missed. There were plenty of kids from the neighborhood in attendance, but more significantly, there were lots of adult. Allan, of course, will remember very little of the party, but his mother will, and it was a chance for us to congratulate her on such a handsome young man and to give a gift for his future.

Another tradition here, which I happen to love, is that birthday cake is cut into bite sized squares and then fed by birthday person with a toothpick to each of the attendees. Allen could not do this, of course, so it was left up to Teddy and everyone filed by to receive their piece of cake delivered directly into their mouth. I did this for my 60^th birthday at the Highview and remember everyone dance in line to file by for me to place a piece of my cake in their mouth with a toothpick, just like a mother bird feeding her chick in the nest. After our little piece of cake, we were all invited to partake in a lovely dinner that she had prepared for everyone. It was buffet style and Babu (meaning grandfather), or I, was invited to come up and get the very first plate of food for which I was obviously touched and incredibly honored. It was a lovely evening, and I am sure that it was something the residents will not soon forget.

I am going to take a lesson out of the playbook of Heather Cox Richardson, one of my favorite daily reads for US and world politics as well as historical references (her daily blog is a must), though rather than taking Sunday off, I’m going to pause today on writing much for the blog and, instead, share with you pictures of our daily life here in Karatu.

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Before I do that, though, I’ll tell you about a consult the residents did late last night after returning home from Teddy’s. There was a patient of approximately 50-years-old who had been either treated or admitted in Rhotia for a new headache of about seven days or so that was quite severe and hadn’t responded to standard analgesics. She came to FAME in evening and had been admitted to the ward for evaluation. Though her headache had migrainous features, she had really never had headaches this severe in the past and had never sought medical attention. Her examination was completely within normal limits and, most importantly, she had no focal findings nor evidence of meningismus (the resistance to flexion of the neck seen in patients with meningitis). In short, she had a very reassuring examination.

So, the question at hand was what to do about this patient’s headache and whether there were any concerns that she had a more ominous process that would potentially cause her immediate harm. In treating headache at home, we will often refer to what we call red flag symptoms or signs, which includes the history that we obtain. If one has these “red flags,” then we worry that the headache may be secondary to some other ongoing condition and the patient requires further evaluation, most commonly an imaging study (a CT scan in the emergency room or an MRI as an outpatient). New onset headache over the age of 50 is one of these red flags and this patient certainly fit the bill as she really had no prior history.

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Though these “rules” are certainly based in good clinical practice, they must be tempered for the environment where one is practicing, for the difference in resources makes this vastly clear. Ordering tests for what is a possibility, despite how remote that may be, is a phenomenon that exists only in countries of unlimited resources, if there are any of these that truly exist. In the United States, of course, where there are few restrictions for ordering tests, or at least few that cannot be circumvented, billions of dollars are spent ruling out conditions that may have only the very slightest chance of being present, or possibly no chance at all. It is clear that we cannot continue that course for our healthcare budget continues to grow astronomically and will be impossible to sustain for much longer.

Here, in Tanzania, with our limited resources, the question I had for my team when I came to the ward to staff the patient was much different. When they had finished presenting her case to me and we had finished discussing all the possibilities, my question was simple. “What do you think is most likely going on with this patient and what would you like to do to treat her?” In the end, we performed no tests nor any imaging. She had a headache and a totally normal examination. We gave her a large dose of IV steroids that we often use at home in the emergency department to break headaches, and the following morning she was headache free and was discharged home.

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It was the first day having the full crew on the second shift, though Fien would be leaving at the end of the week. FAME has initiated a more formal morning report that occurs on Monday, Wednesday, and Friday, and cases are presented by the overnight nurse on the ward as opposed to the doctors. The entire medical, nursing, and support staff show up for these rounds making it quite crowded in the conference room, but the rounds are very informative and there is a forum to discuss the patients, if necessary. In the past, when presented by the doctors, it was often, “they’re doing OK,” and that was the entirety of the assessment. The nurses are much more detail oriented and their presentations much more informative.

Being Tuesday, though, it was our education day and today’s lecture was being given by Dr. Leslie, our family medicine NP, who was going to talk about management of diabetes mellitus and other health management issues in these patients. It was a very helpful review for me since I haven’t really considered these things in many years and guidelines have certainly changed with the advent of new medications and our knowledge of co-morbid disorders such as the need to control blood pressure and lipids to reduce risk of heart attack and stroke.

Chronic disease states have always been an issue here from a cultural standpoint and health literacy is very poor as one would imagine. Taking a course of antibiotics for malaria or any other infection is well understood, and patients are certainly capable of taking medications for a short period of time in a curative fashion, that is, you take a medication for a specified time until the problem is gone and then you stop the medication. In our world of neurology, it is extremely common for patients with epilepsy to come in to see us for the first time and tell us that they were seen elsewhere, took the medication that was prescribed, which stopped the seizures, but then discontinued them when their prescription ran out and the seizures started back up again.

The two chronic medical conditions that come to mind first are high blood pressure (hypertension) and diabetes mellitus. These are conditions that are treated with chronic medications and lifestyle management and, even though patients can occasionally improve, and even go off medications with aggressive lifestyle changes, it is much more likely that they will need to be on chronic medications to control their condition and to reduce the likelihood of complications such as stroke and heart attack. Over the years, FAME has instituted chronic condition clinics for things like diabetes and hypertension that have been quite successful for the patients who have attended, but again, there is a constant battle with reinforcing the need to remain on medications and to continue following up in clinic. Looking at our data for one clinic here back in 2019, we did find in a small number of patients that were seen by us had a higher adherence rate to the anti-seizure medication than those started on medications elsewhere.

I introduced all the new doctors who were here to the medical staff at the end of morning report and Fien covered the rounds in the ward so that the others could start in clinic for the morning. The young boy who had a stroke at 4-years of age and whose sickle cell screen was positive returned to clinic this morning so that we could send off a blood sample to Arusha for electrophoresis, which is a more confirmatory test. Unfortunately, the test would cost 50,000 TSh (or $20), and that was not something they could afford as they barely had the bus fare to reach us today. Given the limited resources, I wanted to make sure first that they were treating sickle cell disease here at FAME as the likelihood that they could afford to go elsewhere was very small.

After discussing the issue with Elissa, our pediatric ID specialist who has worked at FAME for the last year and will be working here for another, she and Dr. Ken have been seeing these children and providing what was available medication-wise as well as counseling families. Given that there would be a purpose in spending the money for the test, we arranged to cover the cost of the test. Dennis also obtained a history that the patient had had a blood transfusion in the past, which clearly suggested that the boy would turn out to have Sickle Cell Disease rather than just the trait (i.e., heterozygous), and would be at risk in the future of having further complications of this condition. For those non-medical readers with an interest, Google sickle cell disease and malaria for an excellent discussion of why this condition (sickle cell) remains prevalent today among people of African descent.

Caroline’s first patient of the day was a rather doozy of a patient as it was an older gentleman who presented in a wheelchair due to what sounded like Pott’s disease (tuberculosis of the spine and myelopathy) many years ago who subsequently had what sounded like a stroke and also had progressive blindness. His differential was incredibly broad and included, among others, CNS TB, a cerebral vasculopathy, dissection, or one of another dozen or so conditions. As his Pott’s was very remote and his probable stroke had occurred several years ago, there was little reason to go looking for the underlying process as it would be very unlikely to affect his care going forward. Additionally, he did not appear sick, nor did he have any pulmonary symptoms to suggest that he had active TB (he had completed a course of TB therapy after his Pott’s disease presentation). We checked a bunch of lab work to see if he had anything else active that we could consider treating, but they were all normal giving us little in the way of clues and certainly nothing to treat actively. We did discuss whether to place him on aspirin (I don’t recall the outcome) but had little else to recommend.

At the end of the day, we had decided to go into town for everyone to purchase fabric, and then on to Teddy’s so that everyone could decide on what clothes to make, and she could take measurements. Shopping in town can be a bit of an experience as a group of Mzungu (strangers) walking through town are immediately noticed and prices seem to rise and are no longer as negotiable as they would have been, but having a Tanzanian with you who knows what things should sell for will typically prevent this from happening. In the past, Dr. Anne has always come with us, but with her new baby, we went without her several weeks ago and had found out later that they overpaid for much of the fabrics they had purchased.

Not wishing to make the same mistake twice, Dorcas was enlisted for her services, and Amos and Hussein also came for good measure. Not wishing to be involved in the shopping for fabrics, I sat in Myrtle making phone calls to friends and family, though I found myself playing Wordle and the NYT mini crossword puzzle while trying to occupy myself while they shopped. No matter, though, as I’m always very happy to also just sit and people watch, especially near the shops in Karatu, where I’m often spotted by residents who I have come to know over the years.

Once they had their fabric in hand, it was time to drive to Teddy’s for their fittings and selection of clothes to be made. It is always wonderful to visit her shop as she is always so very cheerful and it is wonderful to see Allan, her baby who is soon to be one-year old. Additionally, we were able to see Dorthea, who is someone I have cared for since 2011 for seizures secondary to a neonatal stroke and has a hemiparesis (Dorthea has given me permission to use her information and has been part of a video that was done for FAME to promote our neurology clinic). Dorthea has been apprenticing with Teddy now for the last six months and has come a long way in being able to work with the fabrics and sewing machines.

While everyone worked with Teddy deciding on what fabrics would be used for which pieces of clothing and getting measured, I sat in a chair on her porch out front of her home and worked on my computer. This is my normal position during a visit to Teddy’s as I have long given up on finding something that I would wear and not just sit in one of my drawers. It’s not that her creations aren’t amazing, but I’m just very particular about my clothing, not in any fashion sense as I am the furthest from being a clothes snob and typically where the same things over and over (I’m very conservative and don’t like change when it comes to clothes). My dress code here is the same pair of shoes every day to work, the same pants I’ve worn here for the last 10 years, and a selection of decade old Polo collared, knit shirts with horizontal strips and are short sleeved.

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By the time everyone had finished, it was now quite dark (remember, night near the equator falls very quickly) and time to go home. We loaded up in Myrtle (Turtle is still in Arusha getting repaired), but when I turned the ignition key, it just clicked as if there were something wrong with the battery or starter. We would have push start the vehicle and thankfully we were situated in such a way that it would be possible to get the car rolling one we got it turned in the direction we needed to travel. Everyone exited the vehicle other than me (I needed to steer and pop the clutch) and pitched in with pushing me around first and then in a straight line. In quick order, we had Myrtle purring and ready to drive home. As we were approaching our house and were just in front of Frank and Susan’s, the headlights illuminated two tiny, though full-grown, dik diks who were foraging alongside the fence line and on the FAME property. We sat watching them for what seemed like forever, though we eventually had to move forward to make it home. They scrambled into the shrubbery along the fence line and quickly vanished.

It was waking up in a completely new country as well as new continent for Dennis and Caroline, having just arrived in Tanzania yesterday and then traveling the three hours from Kilimanjaro International Airport to our home away from home, Karatu and FAME. Meanwhile, Kelly Boylan, who was attending a wedding in London that was a day later than she had originally thought, would be landing here early this morning, and then making the journey to Karatu to arrive by noontime. It would be Fien’s last week with us as she was overlapping the two groups, which worked out quite nicely as she was able to orient Dennis and Caroline on the electronic medical record last night and she could also attend morning report and make rounds with the ward team this morning since she already knew the routine here. Not that it was intentional, but it could not have been planned any better and I was quite thankful that she was here not only for that reason, but also for many others. She has been a significant part of the team and a huge help during her stay.

Having come here for so long (this is my 28^th trip to Tanzania and my 27^th visit to FAME over the last 15 years), the sheer beauty of this country is something that I have come to know very well, and though I have never taken it for granted, I have become accustomed to it. It’s difficult for me to imagine now, just how the residents feel when they arrive here for the very first time. The Ngorongoro Highlands where FAME sits is perhaps some of the most spectacularly scenic landscape that one could ever encounter and, when put together with all the other fantastic sights in this country, it makes for possibly one of the most beautiful countries in the world.

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With Fien covering morning report and rounds, I had planned for Dennis and Caroline to have a proper orientation to FAME given by Saidi, our amazing volunteer coordinator, which is the normal course of action. As Fien had started their EMR orientation last night, they finished on the fine points with the translators this morning and before I knew it, they were already seeing patients well before our scheduled start time of 11 am. That was fine as it meant that they could have their tour of FAME later after Kelly arrived (though this never really occurred until several days later) and could just begin the day in clinic. There were numerous epilepsy follow up patients coming in to be seen after six months since our last visit and several who had been started on medications three weeks ago and were just coming to check in with us.

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Dennis and Caroline were quite excited to have started so early seeing patient and it seemed like the morning had just begun when suddenly Kelly popped into clinic, having taken a private shuttle all the way from the airport. She had arrived early and made it out through immigration and customs quite quickly, so had a very early start. It wasn’t even noontime yet and we would be breaking for lunch quite soon. Though Kelly was totally psyched (for anyone who knows Kelly, that’s not hard to imagine) to begin seeing patients by herself, I wanted her to work with one of the others first so that she could get the hang of the EMR before starting out on her own. Though we had patients to be seen, there was no reason at all that she couldn’t begin seeing patient after lunch.

Meanwhile, while on rounds, Fien was asked to see a consult for a patient that had been having headaches for some time but was also having severe ear pain associated with them. On his examination, his left ear drum and canal did not look normal and he also had decreased hearing on that side. His neurologic examination was otherwise unremarkable. Given the focality of his symptoms and the abnormalities on examination, I agreed with Fien that the patient would require a CT scan of the brain, which was done, and demonstrated loss of aeration of the left mastoid and probably mastoiditis or other process involving the left mastoid bone. This was something that would have to be handled by an ENT specialist and, thankfully, the patient was financially able to go to KCMC, where they have several surgeons who would be capable of treating him.

The decision to transfer patients here is not solely based on medical need, which of course they must meet initially, but also on whether the patient, the family, or their community has the financial means to cover the cost of care at the accepting institution as the vast majority of patients here do not participate in the national healthcare insurance. There is a system that enables children with cancer to receive care for free, but even that can be very costly to the family as it often involves going to a larger medical center for treatment which means that the entire family may have to be uprooted to be close to the facility. There are, unfortunately, no easy answers to this type of dilemma, other than nationalized healthcare, but that is totally dependent on the wealth of the country, and Tanzania is in the bottom tenth in that category. In the end, patients and families much make these difficult decisions every day here, though I am sure there are very many families in the United States making similar decisions due to our lack of a nationalized health care system, or, at the very least, a two-tiered system that we should have had a long time ago (I’ll get off my soapbox now).

As it was the resident’s first day here, it was decided that we would have a quiet evening at home, and they all took the opportunity to get outside and have some fun with the frisbee. Our neighbors Pete and Amanda, along with their two children, Ollie and Astrid, were also out an about and the evening was absolutely gorgeous. Dennis had brought a drone with him and also took the opportunity to fly it around a bit and take photographs of the surrounding area. Its range is amazing, and I was incredibly impressed with the clarity of the photographs. Unfortunately, or perhaps for the better, drones are strictly forbidden in any of the national parks which I suppose is due to the risk to the animals for any harm should a drone come close to them.

Tomorrow morning, Leslie, a family medicine NP who is here volunteering for her second time, will be giving the morning lecture. It will be interesting to hear her take on things as she also speaks Swahili, having spent time here in the Peace Corps in the past where they had spent several months of intensive language training. Despite living in Washington, DC, and not speaking it regularly, she has retained a good amount and is able to speak it conversationally. I am incredibly jealous and also a bit ashamed given the amount of time I’ve spent here and being only able to speak short phrases and responses. I’ve never been good at languages, and it becomes more and more difficult as I age. Oh well.

Our changeover weekend, that is, one group of residents flying home (or to another destination if they have vacation scheduled) and the next group of residents flying in the very next day, is a product of the more robust scheduling that began a year ago to accommodate a greater number of residents in the program each year. The weekend, though, is pretty grueling in terms of the amount of driving that is necessary to deliver everyone where they are expected to be. Thankfully, driving long, open stretches of the vast Northern Tanzania landscape and the incomparable Great Rift Valley is something that I feel I had been destined to do all along. My childhood heroes were not the sports stars of the day like most other boys, but rather explorers and archeologists like Heinrich Schliemann, Mary and Louis Leakey, Jane Goodall, Jacques Cousteau, and others like them. My dreams did not involve a ball or a bat, or even a puck, but rather the dusty roads of Africa and a Land Rover, or a dive ship and a set of tanks.

So, after many years of having the fullest and most rewarding life with absolutely no regrets, I have now returned to those childhood dreams that were always somehow lurking in the far reaches of my imagination. At this moment in my life, I could think of little more that I would love to be doing than to be driving a Land Rover here in East Africa, shuttling my residents to and from the airport with all that goes with it including the constant stops by the traffic police, the incredibly slow trucks, and the dust and the heat. I am happy for every last bit of it and then some as I feel like the luckiest man alive, not only for what I have here in Africa, but also what I have at home and those I love.

Not having to leave until mid-morning allowed the residents a chance to sleep in for the first time since having arrived. I would be driving everyone to Arusha, where Whitney would be meeting up with her fiancé at the Mt. Meru Hotel for the start of their two-week adventure in Tanzania (hasn’t she already had one?) and the three others would be flying to Zanzibar after I dropped them off at the airport. Fien would be spending the weekend alone (I’m jealous) here in Karatu to work on a research project and plugging away at some statistics she needed to get done.

Our trip was pretty basic and leaving FAME, the weather was absolutely gorgeous for the two-hour drive to Arusha. We had left a little later than planned, though, and by the time we got to the Mt. Meru to drop off Whitney, we were in just a bit of a time crunch to get to airport. The girls had wanted to order a snack, though as in Africa, everything takes nearly 10 times longer than it should, and they ended up only getting my sandwich and giving up on the vegetable samosas they had ordered. LJ was the one who had wanted something, though, and since I had ordered a chicken salad sandwich, she couldn’t eat any of that. Thankfully, there were French fries that were perfectly acceptable for her to eat.

We were now behind schedule to get them to the airport for their flight and it seemed we encountered every slow truck possible along the way. As we drove up to the departure entrance to the airport, which is tiny by the way, there was a huge crowd waiting to get in and even though it wasn’t for their flight, it certainly posed a problem. Since we had arrived just in the nick of time for their flight, they were somehow able to get in and to the ticketing counter. In the end, they made their flight, but I do think they would have preferred a little more buffer of time than they had. I turned around and drove back to Arusha after buying a Stoney Tangawizi (an ultra-gingery ginger ale) before departing the airport parking lot. Shortly after I arrived at Leonard and Pendo’s home, I received a message that they had arrived in Zanzibar safely and I could relax.

I spent the night at Leonard and Pendo’s home, which is so much quieter these days as all their children are now in the same boarding school in Nairobi, coming home only during school breaks. I miss them quite a bit and it’s been some time since I’ve seen them, but hopefully soon.

The next group of residents would be arriving first thing in the morning, and I would have to leave for them around 6 am to get to the airport in time. Dennis and Caroline would be coming in the morning, while Kelly would be arriving the following morning, coming from a wedding in England, and would be taking a private shuttle to FAME to arrive before lunch. It was a lovely drive to the airport early in the morning with little traffic and cool enough for me to put on a light fleece. I got to the airport with plenty of time to spare, found a nice parking spot in the shade and walked over to the little outside café to order a coffee and chapati. I was early enough to sit on the curb and do some reading prior to their arrival, though they came out with the earlier groups mostly because we always purchase our visas in advance.

We packed the car and I drove to the parking office to pay for parking and to get my token. After checking my mirrors, which were clear as I always use my mirrors whether in my car or Land Rover, to back out of my spot, I began to reverse, but very quickly heard a honk and a crash, only to discover that a van was behind me, and I had struck only his headlight but had broken the lens. I was certain that he wasn’t there as I began backing up which meant that he must have been moving and struck me, but I wasn’t very optimistic that anyone else was going to see it that way. After he put me on the phone with his boss, the owner of the car, and reassuring him that I would make good on my promise to pay for a new headlight, as I didn’t want his driver to have any issues, we exchanged numbers, and we were on our way back to Arusha. I was not interested in involving the police, nor were they, and it seemed we would get things taken care of eventually. Things happen differently here in Africa.

Our first destination was to Leonard and Pendo’s house to eat some food and regroup. Myrtle also needed a quick repair as the bonnet (hood) release on the inside of the vehicle had come loose and there was no way to check any of the fluids, etc., which is certainly necessary when planning a several hour excursion where there is a rare service station and nothing like AAA to come to the rescue. Pendo had thought that there were four residents rather than the two present (Kelly would be coming tomorrow and we had an adult spot open this trip) so the amount of food that was being placed on the table for us bordered on obscene. Pancakes, fruit, sausage, hash browns with onions, cardamom and lemon grass tea, fresh mango juice, toast, and eggs. Hospitality is definitely not a problem in the Temba household.

Waiting for the fundi (mechanic) to come to the house to fix Myrtle, we all took food coma naps on their couches as I think we all needed them. The fundi arrived eventually and needed to take the car to the shop to fix the problem as well as buy a new cable, but it was done in a little over an hour and we able to get on the road to Karatu around 2 pm, meaning that we’d get to FAME sometime around 4 pm. We made a quick stop at the Galleria and were soon back at home in Karatu and FAME. Sunday dinners are not prepared for us, so we all decided to head into to town to the Lilac Café and other than the standard 1+ wait for our food, we had a delicious meal that everyone was quite happy with. Tomorrow, we would be starting our second 3-week rotation and Kelly would be arriving around noontime. For me, though, it would be Groundhog Day all over again.

As the first group of residents would be leaving FAME tomorrow for their continued adventures, this was their last day in clinic, and we had scheduled it for a half day to see any final patients that needed our attention. As you might imagine, though, making plans and sticking to them are two completely different things and there’s Africa. It was LJ’s day to make rounds after morning report and it turned out to be a very interesting day for her on the ward. It was also an interesting day in clinic with a wide selection of patients.

I had mentioned that Whitney had initially seen a young 4-year-old boy at the Children’s Village who had suffered a stroke earlier in the year and we had asked them to bring him to FAME to have labs done. He had reportedly been evaluated and worked up at KCMC, though without having the specific records, we decided to send whatever we could think of and what would be available at FAME for, though we have an extensive array of labs, many are missing as we are either unable to do them here or they would be done so infrequently that it would be too expensive to keep the reagents on hand. Regardless, we had sent one test that was very important, but did not come back until this morning and was positive – a sickle cell screen! We were surprised that it had not been done at KCMC, and, though we’re not entirely sure that it wasn’t, having a positive screen was very suspicious and would need to be followed up with electrophoresis to confirm that the child did indeed have sickle cell disease. If that turned out to be the case, he would need specialized care that is only partially available at FAME.

While on rounds with the ward team, LJ had heard a case presented of a gentleman who had come in the day prior with nausea and vomiting and had been diagnosed with gastritis for which he was currently receiving care. There was something about the case, though, that bothered LJ and watching the patient, she thought he looked somewhat ataxic. Not wanting to rock the boat, she mentioned that perhaps she could see the patient in consultation, and though she initially received a bit of push back, she received approval and once rounds were completed, she returned to evaluate the patient fully.

What she found was that in addition to his nausea and vomiting, the patient complained of headache with no prior history of such, and on his examination, she found that he was indeed ataxic and had nystagmus. She was adamant that the patient needed a CT scan as she was concerned about a cerebellar process. His CT scan was obtained shortly thereafter and revealed a moderate right-sided cerebellar hemorrhage with mass effect. Posterior fossa processes like hemorrhage or infarct, or any space occupying lesion for that matter, can look good one moment and trying the die the next because there is very little room there and a very small increase in the size of a lesion can cause a huge increase in pressure. It was decided that the patient would be transferred to KCMC for neurosurgical management if he were to worsen and required an emergent decompression which could not be done at FAME. Had it not been for intuition on rounds, it is very likely that the patient would have worsened and quite possibly have died. These are the subtleties of neurology that are the most difficult to teach.

While managing her patient with the cerebellar hemorrhage, LJ became involved in another patient who presented unresponsive and was hemiplegic. I believe the story was that he had been found down at home and the initial concern was for a stroke, though on examination there was concern that he was having continuous seizure activity and was in status epilepticus. After receiving a benzodiazepine to break his seizure, she also asked that he be given a levetiracetam loading dose and, though we only have this at tablets, we have used it successfully many times in the past by putting it down an NG tube and it is absorbed rather quickly. Meanwhile, she was assisting with getting him a CT scan in the midst of everything else going on, and it was unremarkable. This doesn’t necessarily rule out an acute infarct, but it does rule out a hemorrhage or other mass lesion that may have been causing his hemiparesis. [Follow up: I had lost track of this patient, but reached out to LJ to see if she knew anything and she sent a message to Dr. Omary, who replied, “Actually I discharged him a day before yesterday (Sunday), he is improving very well. No more seizures reported since admission, blood pressure normalized without medications, paralysis improved as well. Will see him after 14 days. You have done a very good job, LJ.” I’m not certain there is higher praise than that.]

Meanwhile, in the clinic there was a patient who presented with complaints of a mild tremor that turned out to be primarily resting, and she had some other features on her examination that suggested she had very early Parkinson’s disease. Since the medications we use for PD are only symptomatic in nature, and her tremor was dysfunctional for her in any way, we decided not to initiate any medications and have her follow up with us in six months. If her tremor became worse for any reason, she was advised to come back earlier at which point Dr. Anne could see her and we could start medications, if appropriate.

Another gentleman came back to clinic to see us who had been admitted to the hospital six months ago while we were here and had presented then with seizures and an abnormal CT scan of the brain that looked like a possible cerebritis. Looking back at the old CT scan, it was a really difficult call to make back them, but he had been doing well since his hospitalization and had recovered completely. We had kept him on his anti-seizure medication over the six months, but he had no recurrent seizures in the interim since having seen us last visit. As one of the main questions was whether he needed to remain on his medication or not, we decided to do a repeat CT scan of the brain as if there were no remaining structural injury, we would discontinue the medication. His repeat CT scan was completely normal meaning that we could safely take him off the medication and it would be unlikely that he would seize again, though certainly not 100% I’ll have to admit that seeing complete resolution of the abnormalities on his prior CT was a bit surprising, though not shocking, and was very reassuring as to the prior prognosis that we had given him.

With the very busy morning we were having, I wasn’t sure there was going to be time to go to the African Galleria for the afternoon as we were really pushing our window of opportunity. Thankfully, though, things quieted down quickly by around 2pm and those of us interested in having a light lunch at the canteen could do so, while others ran home to have a snack before we headed off down the road. We were planning on an early dinner at the Galleria so that we could then come back up and go to Green Park, where a number of people from FAME were meeting as it was Judith’s last day of work here. We don’t have much in the way of snacks here at the house, though there is Nutella, and I think that sufficed just fine, especially for LJ, who seemed to have an addiction to the stuff. I gathered up the troops, loaded them into Myrtle, and we were off down the road in the direction of Rhotia and Manyara.

The African Galleria, which is owned by my friends, Nish and Punit, brothers who grew up in Mombasa and then moved to Tanzania over a decade ago. The African Galleria wasn’t here when I first came through Karatu in 2009, but within a few years it became the largest shop for souvenirs and art in the region, as well as amazing gemstones of the best quality including lots of Tanzanite. The Ol Mesara restaurant at the Galleria was opened in March 2019, with the unfortunate timing of being just in time for the pandemic as the tourist industry pretty much collapsed for almost two years. Thankfully, though, they weathered the storm, and the restaurant has become one of my go-to spots with the residents as the food is just out of this world and the setting in a large open-air, covered space is just delightful. The dishes are traditional East Africa but done in a gourmet manner and everything is served family style. Though every single dish is scrumptious, my particular favorites are the pumpkin soup, cheese samosas (to die for), and the grilled paneer and beet skewers. Everything served there is just incredible.

The residents did some shopping first, and then we all met for a light dinner and drinks. My favorite, the Dawa, a traditional Kenyan drink that is made at Ol Mesara with local gin, honey, sectioned lime, tonic, and a wooden stick to muddle the ingredients. By the way, “Dawa” in Swahili means medicine and the drink certainly cures whatever might ail you.

After dinner, we hit the road again and it was back to Karatu and Green Park, an outdoor club that serves nyama choma (barbecue), chips, and chips mayai, the latter being essentially a frittata made with French fries and eggs (mayai). Of course, they also serve drinks, and the local beers seem to be the favorites. All our translators were there, so it was a nice going away party for us, as well as for several other volunteers who had been working here. Pete and Amanda were there with their children, Ollie and Astrid, who, of course, were the hit of the party it seemed. Ollie crashed early, though, and many were happy to cradle him in their lap while sleeping including Whitney, for what else would you expect from a pediatric neurologist.

Our day began with a surgical lecture on intestinal obstruction given by Judith, who is volunteering here at FAME, but whose last day will be tomorrow as she has taken a job at KCMC. To be honest, I haven’t thought about intestinal obstruction in a long time, though it never hurts to have a refresher on a subject that may come in handy sometime. Morning report began immediately after our lecture and then clinic after that.

Whitney began the day seeing a young 4-year-old boy back in clinic who had a stroke earlier this year based on his history. For some reason, we had seen him last week at Rift Valley Children’s Village even though the child lived in Karatu, and it wasn’t clear exactly why that was given the fact that the Children’s Village was 45 minutes away. Regardless, the child needed to be sent for laboratory tests (which could only be done here at FAME) as part of his work up for stroke, which isn’t the most normal thing for a 4-year-old to have. We sent off a slew of tests, some of which would come back today and others that would not.

Shortly after, Jenna and Fien were seeing a young woman who came in to see us and who was just over two months pregnant, and it was reported that she had developed rather sudden onset of a head shaking tremor. Though she had significant social stressors making it very possible this was a functional movement disorder (FMD), I was just not ready to blow it off completely and when she was asked to suppress the movement, even though it lessened, you could still see some of the muscle contractions. There is a movement disorder that is associated with pregnancy called chorea gravidarum, though luckily it is most often a self-limiting process unless associated with anti-phospholipid antibodies or rheumatic fever. We couldn’t check for the former and she had nothing clinically to indicate the latter. I sent a video off to some of our colleagues who are movement specialists and will wait to hear from them.

Lastly, Fien had a very interesting patient who was HIV positive but had been off and on their anti-retroviral medications over the last two years and was now complaining of right-sided symptoms that were progressive. On examination, she was found to have a mild right hemiparesis and when we looked back at her HIV record from the government clinic (which patients carry with them), we found that her most recent CD4 count, essentially telling us how well her immune system was working, indicated that her count was lower than it should be meaning that she was at risk for opportunistic diseases associated with HIV. With that information, the possibility of her having a neoplasm or an infection in the brain causing her focal symptoms became a significant concern.

We began a discussion with her about the need to obtain a CT scan of the brain, but as is often the case, she did not have the necessary funds to cover even a portion of the cost. Patients are usually asked to at least contribute something towards the cost of the scan, though reported that she was unable even to do that. There was still some hope, though, that she might be able to raise some of the money from her village or family and would pursue that option.

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Typically, on our ride home from the Serengeti, we always stop to visit Kitashu in his boma on the crater rim, but unfortunately, we were running so late last Sunday that we were unable to make a real visit out of it. When there’s time, all the residents are taken into the some of the huts and then dressed in traditional Maasai clothing and jewelry after which they participate in dancing and singing with his family. There are many “cultural bomas” throughout the region and in the Ngorongoro Conservation Area where safari companies will bring their guests to see what a Maasai boma is, have an opportunity to dance, and to buy some Maasai beadwork and other crafts. The companies pay the Maasai for these visits and there is no relationship to any of the Maasai in the boma per se.

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Visiting Kitashu’s boma is quite different for we are invited to visit and are treated like honored guests by his family. I always bring gifts for his mother or wife that consist of staples such as tea, honey, rice, cooking oil, soap, and other essentials while we are often treated to a traditional goat roast by the boma. Kitashu is always very proud to have us visit his family and when this couldn’t happen last Sunday, it was very disappointing, and I felt bad about letting them down as they often prepare in advance for our visit. We were still able to give the kids their pipi, Swahili for candy, but we didn’t have time for the dancing with his family. As it was, we got to the gate late and could have easily been refused passage which would have meant an unplanned night in the crater which is not as cool as it sounds as it would have meant not only finding a place to spend the night (Kitashu offered for us to go back to his boma and sleep there), but also having to pay for an additional day in the crater. Basically, it would not have been a good thing.

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Instead, Kitashu has invited us to his brother’s boma on the other side of Mto wa Mbu in the Lake Manyara area. To be honest, I wasn’t certain what to expect, but on arrival discovered that his brother’s boma was one of the many cultural bomas in the area and that his brother and his extended family, who were only meters off the main road, had guests coming to visit throughout the day. On our arrival, there were several safari vehicles already there and their clients were already participating in the dancing and singing. After being introduced to Kitashu’s family, we were brought into the boma and each of the girls were taken into a separate hut to be dressed. It was clear that they were doing something extra for us as the other guests weren’t dressed nearly so thoroughly or with the jewelry that was placed on them.

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Everyone was eventually taken out in front of the boma at which point, the men and women organized and then began to dance. There were other tourists present when they were dancing and having seen this many times before at Kitashu’s boma, it was the same as what everyone had done in the past, except for the fact that we in a hot and dusty place with vehicles zooming by in the very close distance. Regardless, the dancing went on for about 15 minutes or so, often alternating between the men and the women, and, at other times, in unison. After the end of the dancing, we all went back in the boma, and they brought us to a larger hut where all the pre-school age children were going to school.

The girls had bought colored pencils and paper to give to the children, but first they had some songs to sing to show us what they were learning. There was a chalkboard on which their lessons were written, but they could all sing them from their memory. Afterwards, the pencils and gifts were handed out to the children and later, after we had moved on for our tour, I spotted several of the children running around with the paper or with some of the other items that were given to them.

Our last stop was to be a large ring of tables that had been set up to display all the women’s handicrafts and it turned out that Kitasuhu’s mother was living in this boma as living on the crater rim, where she was before, had been too cold for her arthritis. Kind of like moving to Palm Springs or Phoenix, where the weather is far drier and more suitable for elderly patients with health issues. His mother was also incredibly sweet and gave us each a small gift, which for me was a lovely beaded leather keychain, so I immediately turned around and purchased another one from her for Jill.

Though I would have preferred having everyone dancing and singing with Kitashu’s immediately family in his boma in the conservation area, doing that wasn’t possible at this point and visiting here was certainly a good taste of what their dancing is like. The Maasai are a very culturally distinct group living in Tanzania and Kenya predominantly, having traveled here from the north some 200 years ago and who now occupy much of the arid lands of Northern Tanzania. Bomas within the conservation area, though, have much more in the way of good grazing lands for their cattle, of which there are many. Without going into details, I will say that there are huge political factors ongoing at the present time that have to do with the Maasai in the conservation area and concern for overcrowding, many of which remain unresolved. Over the coming years, there are very likely to be many changes and the hope is that in the long run it will be better for all.

It’s hard for me to know just how the residents feel during their last week here given the fact that I know that I will be returning soon enough. Three weeks, or even a month for that matter, is only enough time to get a small sampling of what it is like here. Though I encourage everyone to come back to FAME in the future, that is much easier said than done given the busy lives with families and academic careers. Therefore, given the low likelihood of their return, they must be having very mixed emotions during this final week of their stay, so I wanted to make sure that we got all our activities in for them. Yesterday was our visit to Phillipo and his family for our coffee tour and then to Athumani. Today, we were planning to visit Teddy again to pick up everyone’s clothes that they had made. Tomorrow would be a visit to Kitashu’s brother’s boma on the other side of Mto wa Mbu (we weren’t able to get back to Kitashu’s home as that would have cost us $60 each to re-enter the Conservation Area and that was prohibitive). On Friday, we were planning to visit the Galleria for dinner and shopping. For those of you old enough to remember, I often feel like the social director from Love Boat, the mediocre romantic comedy series that aired from 1977 through 1986, several years longer than it probably should have.

Last night while visiting Phillipo and his family, we met two optometrists by happenstance, and I had invited them to stop by FAME this morning for a tour before they were heading out of town. They were taking a few days to sightsee, but the real purpose of their visit was to develop some type of collaboration between Cardiff University in Wales and Muhimbili University in Dar es Salaam. Though I can recall the name of the Tanzanian, Godluck, I apologize for forgetting the name of the British member of the pair. Regardless, they were both very impressed with FAME and it was very helpful for them to hear the story of how our neurology program has worked as it gave them many ideas of how to begin to create their collaboration here in Tanzania. Additionally, I am hopeful to put them touch with Sehewa, our amazing nurse anesthetist here at FAME who also does all the eyecare and refractions for our patients, though is present at Stanford University for some anesthesia training. Lastly, while they were here, I discovered that the African Galleria has entertained sponsoring some type of eye care program in the area which might be a great way for Muhimbili and FAME to collaborate in the future. This is how things happen here, by coincidence (or, as Father Bill from Carron used to say, “there are no coincidences, just God-incidents”), though there clearly must be some master plan as they happen far too often.

We were quite slow throughout the morning as the weather had been a bit cool with some spots of rain which always makes things slow in clinic as it was not just neurology who was slow, but the entire clinic. One good thing was that our cute little girl we had seen previously with ataxia and nystagmus and whose CT brain was unremarkable came back in significantly improved. Though we absolutely wanted to consider a diagnosis of either acute cerebellitis or acute cerebellar ataxia in childhood, both self-limiting and benign process, but there some atypical features that made us concerned that something else could be responsible. Seeing her today, though, was incredibly reassuring as she was almost completely back to normal and had only some subtle nystagmus still on examination. We were so thankful that she had improved for she otherwise normal and a delightful child.

Our plan had been to go to Teddy’s this evening to pick all the clothes she had made for the residents (neither Fien nor I were included), but first we needed to find a stationary shop as the residents wanted to buy some educational gifts for the younger children, we would be visiting tomorrow at the boma. Originally, they were considering colored chalk and coloring books, neither of which were available here in Karatu, though they did find some colored pencils and a ream of plain white paper on which they proceeded to draw some figures for the children to color. I thought they were quite ingenious in the who process.

We were on the main road in the center of town which is not my normal starting point for driving to Teddy’s, though I gave it go trying to make it to her place from there. I ended up driving a giant circle around her house, but it was an interesting tour of the outskirts of Karatu and places that we usually don’t get to see. We ended up looping back onto the Endabash Road on the other side of Kudu Lodge from the main tarmac, making it incredibly easy for to now find my way.

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Visiting Teddy’s home is always a pleasure and not just because she greets us every time with a big plate for of candy, though that is part of it, at least for me. Everything that she had been commissioned to do for the residents was now finished, so it was just a matter of trying everything on and making any alterations that were necessary. Of course, being Teddy, she did everything while we waited and perfect on the first try. Everyone had something made for themselves other than me as I have in the past and don’t wear them, and Fien for pretty much the same reason. Most of the residents, though, will wear their clothes to work at times and absolutely love Teddy’s work. I guess it’s to each his own.

We were back home a bit later than normal, but our dinners were waiting for us as usual. Tonight was a ground meat concoction with mashed potatoes and a vegetable. Something like a shepherd’s pie that is one of the favorites, especially when we mix in hot sauce, at least for some of us. Tomorrow we were planning to work a short day and going to Kitashu’s brother’s boma in the late afternoon.

[Note: As these blogs are written several days after the fact, I wanted to make sure that Caroline’s family was aware that both she and Dennis arrived safely on Sunday morning and are now at FAME ready for their adventure. Kelly has already landed and is on her way here now, October 9]

It was Whitney’s day to shine as she was not only giving the morning educational lecture on neonatal seizures, but she also seemed to have the bulk of patients for the day as there were many children. If there was a child that one of the others saw, chances are that Whitney had some involvement in the case in some manner. Her lecture was quite helpful, and she used cases to present the topic which always seems to work the best here and has the most participation by the FAME staff which is what we’re really trying to achieve.

 There was also good news on our new FAME emergency room that is being built as they began taking down the corrugated sheets of aluminum that had been hiding their progress until now. I believe I had mentioned previously that we have needed a larger, full equipped emergency department here at FAME and were finally able to break ground with the committed funding last year and the pandemic seemingly behind us. We see a great many emergency patients here at FAME, but it should be noted that these patients are routinely brought to in private vehicles, so the initial triage of the patient does not occur in the field as it does in the US and other countries who have the infrastructure to support emergency medical services. Here, there are no emergency services that are provided prior to the assessment that occurs at the hospital. Here in Tanzania, there is no 911 to call, no rescue squad to attend to an accident, or a seizure for that matter. If a patient requires medical care, emergent or otherwise, they are brought to the hospital, and not by any medical personnel.

In addition to the new ED, FAME now also has a fully equipped ambulance, thanks to a gift from several of our board members, that will be able to transport patients the several hours who need more complex care than we can offer here. Patients that come to my mind are the neurosurgical cases that require the expertise of a fully trained specialist and an operating room and nurses outfitted for such cases. With our current surgical staff here, now doing emergency burr holes for acute subdural hematomas is entirely possible, and have been done, so providing care to those patients has been made possible following the visit of Sean Grady and Kerry Vaughn who brought two manual drills for such purposes along with the training of the doctors and nurses on how to do the procedures. These patients are often unable to make the trip to KCMC in Moshi due to the urgency of their condition or to the fact that, even though these are life-threatening conditions, there is still a cost issue at the other end that can be dealt with much more easily here. These are the sad realities of a lack of a national health care system coupled with a lack of a safety net for care such as the EMTALA laws that we have in the US for providing emergency care.

As I mentioned, it was a particularly busy morning of pediatric patients for Whitney and one in particularly was a bit puzzling for us. She had seen a baby with a bulging, and somewhat pulsatile, fontanelle (the opening on the top of a baby’s head that closes as the skull develops usually after the first year of life) that was concerning for the possibility of hydrocephalus. With the child’s age, it was necessary for us to do a CT of the brain, which the child wasn’t the most cooperative with, but we were able to see enough to know that they didn’t have this condition. That was a bit perplexing as it meant that there was something else causing the fontanelle to bulge and raised concern about some vascular anomaly that would require us to give the child IV contrast for the scan. This meant bringing the baby back, which was not a cost issue, but more of a logistical issue as they would need to be sedated and the baby was breastfeeding and will need to hold off eating for several hours per their protocol here at FAME. Somewhat comically, while sitting in the CT scanner to look at the non-contrasted scan immediately after it was finished and recognizing that there was no hydrocephalus, I asked about sedating the child and said, “I wonder if the child has eaten recently,” only to turn around and see mom breastfeeding the child in a chair directly behind me in the CT control room. I promptly replied to my own question, “never mind.”

After the onslaught of children in the morning, it had slowed down enough in the afternoon for us to consider a trip to visit Phillipo, who I have been bringing the residents to over the last several years. We had first visited him on a fluke as we had taken a hike from the brick quarry up to the wood carvers in Tloma Village on the Gibb’s Farm Road. While there, Mbuga, the wood carver asked if we wanted to visit his friend next door who had a small coffee farm. Phillipo and his wife, Fausta, run a small, family coffee farm of approximately five acres, hand picking and processing all the coffee themselves on the grounds of their small home. Not only have a I found their coffee to some of the very best in the area, but they also demonstrate how everything is done and I have never been there when they weren’t roasting their small batches of coffee, ready to package. They have become a required stop for my visiting groups and the friendship has grown as I visit him at least four times a year now. His daughter, Eliza, is also one of my favorites as I always find her so happy and willing to help her parents. They have an older son, whose name I don’t recall at the moment, but I believe he may now be away at school.

The raw coffee berries are put into a special hand processer where the shells are taken off and discarded for composting and used for fertilizer later. The beans are then soaked and placed on drying racks and, when ready, are pounded to break off the outer shells. Then they are winnowed, my favorite as I collect winnowing trays made by the California Indians, which means to separate the chaff from the beans, which are then ready for roasting. Roasting the beans is again done by hand over hot coals for about 45 minutes, constantly rotating the drum containing the beans as they will burn if it stops for any length of time. Once the beans are done, the drum is lifted, very carefully, over to a cooling bin where they sit on top of a screen mesh and then stirred and rocked to allow for an even cooling and to prevent any scorching. Once cool, the beans are ready to be packed into 500-gram plastic bags that are hand sealed with heat by holding the seam against the box used for roasting and containing the hot coals. Incredibly efficient and simple.

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As this is a family affair, Fausta works on the treadle sewing machine sewing the colorful cloth bags in which the coffee is placed with Eliza helping in pinch. In addition to selling their coffee and demonstrating how it is made, they also make sure that everyone has had a chance to sample the coffee, serving a small cup of rich, French pressed coffee that is absolutely delicious and, even more, given the fact that the beans were just roasted. Along with his coffee plants, Phillipo also keeps many bee hives distributed around his home where the bees who pollinate the coffee bushes are living and producing honey, another byproduct of the production process. The bees are small, stingless bees and their honey has a remarkable floral taste to it which we also get to sample. Wajiha loved the honey so much that she purchased two small jars of it to bring back home for herself.

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It was well after sunset when we were finished at Phillipo’s and the residents were interested in stopping back by the woodcarver’s shop next door as well as Athumani, the painter, who also shares space with the woodcarver. I have purchased several pieces from Athumani in the past as he has a very distinctive style and creates his canvas using scraps of colorful cloth which he then paints on top of and incorporates into his design for the work. Something I had only found out recently about Athumani, is that he has also been extremely active in teaching art to children who are on the street or of lesser means in the hope of giving them not only skills with art and discipline, but also learning how to have dreams and to pursue them. Once I find out such things about a person, they earn a special place in my heart, and it is difficult not to see them in a much different light. Everyone here is in survival mode given the amount of poverty and just how difficult it is to provide for yourself and your family, but when people then go out of their way to provide opportunity for others, it places them on an entirely different level in my mind.

Two of the residents proceeded to purchase paintings from Athumani. They will take these home, have them re-stretched and framed, and then placed on their walls so they will always remember their time here at FAME and in Tanzania, though I don’t think they’ll necessarily need the paintings to remind them. They will always carry this memory with them and refer to it often, as I have done. It is impossible to have spent time here and for it not to have changed you for the better.

I think we were all recovering from our three days in the Serengeti and needed a break from all the excitement. It had been a wonderful trip on all accounts, and even considering the fact that we had one breakdown, another need for a repair, and Turtle was on its last leg as we pulled up to the house in Karatu, we had seen everything that we wanted, there were no catastrophes, and we spent two nights in the luxurious Dancing Duma tented camp which was quite unexpected. I hadn’t mentioned in yesterday’s post that Turtle’s engine sounded horrible as we were ascending to the crater rim and Kitashu’s boma. I knew that it would get us home, but it clearly needed repairs and was a bit disconcerting as we had just put a “new” rebuilt engine in it prior to my return. One of the cylinders was losing compression, though knowing what the problem was did not help the situation as we had nothing to fix it here. Thankfully, we had Myrtle, the other Land Rover sitting at FAME and, with no outings or game drives this week, it was perfect timing to get it back to Arusha for repairs. Vitalis had taken the bus from Arusha to get to us on Thursday, so it was a simple matter of having him bring it back with him.

There were several patients over the weekend who had been admitted to the hospital and needed our input, so I went to morning report to hear about any updates that we could assist with. As I walked back to the OPD (outpatient department) and to our outdoor neurology clinic, I noticed that there were a good number of young children walking around with abnormal gaits (something a neurologist always notices) and wondered if they were for us, though quickly realized that it was the week that the Plaster House Kids were coming to be seen by the orthopedist and have surgeries.

The Plaster House (www.theplasterhouse.org) is a wonderful organization that was founded in 2006 to provide surgical care and rehabilitation to children with disabilities throughout Northern Tanzania. Their model was to create an incredible outreach program to identify children with primarily orthopedic disabilities who could potentially be treated surgically, bring them in for a full evaluation and, if appropriate, provide them with surgery, post-operative care and then a complete course of rehabilitation so that all their medical care will be taken care of prior to their return home. They have been located primarily in Arusha but have recently decided to open a house in Karatu for children to receive their care and have identified FAME as their surgical partner where the children could undergo the surgery that was necessary. This partnership was obviously incredibly exciting, though did require that FAME could accommodate the additional surgeries which has not been an issue for us.

The orthopedic surgeon is now on staff at FAME to provide surgery to these children and all of that will usually occur in a given week, typically once a month. Children stay here at FAME for their first pre-op night but will then go to the Plaster House in Karatu for their continued care and rehabilitation. I’ll hopefully take a tour of their house in Karatu in the next few weeks as Pete, who is now volunteering here at FAME, is quite connected given that his sister, Sara, founded Plaster House nearly 20 years ago. Pete, a pediatrician, and his wife, Amanda, an ER doctor, are both volunteering at FAME for the year with support through an Australian foundation (yes, they are both Australian). Pete and Amanda, along with their two children, Oliver, and Astrid, joined us in the Crater in their own vehicle a week or so ago.

With the Plaster House now doing much more than just orthopedic cases and providing plastic surgery for children in need, the name has been changed to Kafika House to represent just more fully what it is that they do. Though I have not been directly involved with their work in the past, I have known about them since I’ve been coming here. They are another amazing organization who have changed so many lives here similar to FAME.

There were not a tremendous number of interesting cases for the day, though one that took up a considerable amount of time for us was a 20-year-old psychotic man who we had seen in the past and had placed on olanzapine (the primary antipsychotic medication we use here) a year or so ago, which had helped, but he unfortunately had stopped it and though had been doing OK in the interim, was now coming in acutely psychotic and difficult for us to manage in our neurology space. It was very likely that he had a primary psychiatric diagnosis and most likely schizophrenia, though there was also a question as to whether there was some contribution, at least in part, of drugs and alcohol. Regardless, we could not manage him, and it wasn’t long before we brought him over to the emergency room (the old one with only two beds as the new one is not open yet) to received more appropriate IM medications that would work more quickly.

I had learned some time ago from Frank that the best combination we have here is 10 mg of haloperidol mixed with 4 mg of lorazepam (simply known as 10-4) given intramuscularly so that it’s rapid action. I have used this combination here on a number of occasions and it has worked very well. You might be asking what a neurologist is doing treating primary psychiatric disease, and it would be perfectly reasonable for you to ask such a question. The simple answer is that there equally few psychiatrists here as there are neurologists. Frank puts it another way when he says, “you’re the closest thing we have here to a psychiatrist.” I have heard this so many times that I’m almost starting to believe it, though I’m very cautious about doing anything that I’m not entirely comfortable with and I counsel my residents to think the same way. There’s never an issue with trying to help, but you should never leave your comfort zone, nor should anyone ever expect you to do so.

Given the patient’s agitation, it was imperative that he receive his medication parentally, i.e., by injection, rather than by mouth as we really wanted him calmed down rather quickly. There was some discussion in the ED as to whether we had injectable haloperidol or not, though I know that we’ve had it in the past because I had brought a supply at some point and, regardless, we should never be without it given its effectiveness in just such a situation. He was given some IV midazolam, which is a very short acting benzodiazepine, to calm him down until we figured out the haloperidol situation, but the midazolam, though short acting, is pretty potent and the last thing wanted was for it to suppress his respiration in which case someone would be bagging him for a bit as we do not have ventilators to use in such situations.

Thankfully, after asking around (mainly a quick phone call to our pharmacist), the haloperidol injectable was located, ordered, and drawn up into a syringe for the patient. After it was given, the patient quickly calmed down and was more manageable, finally allowing us to have him admitted so we could keep a close watch on after his injection and while getting his oral medications back on board. The following morning, he was much calmer, though not so easily redirectable and tended to want to wander around the hospital. He was back on his outpatient antipsychotic, olanzapine, and we felt that he was OK to discharge at that point.

With the excitement, and the exhaustion, of the weekend, it was decided to spend the evening in. The residents all took the opportunity to watch the original Lion King with my LCD projector and make some popcorn. Not at all surprisingly, none of them had previously realized just how realistic the setting for the Lion King actually was and how much Swahili was used in the dialog and song lyrics. If you’d never been to the Serengeti before, how would they have known? Next up is Out of Africa, but that will have to wait for our return to the US and a post rotation gathering.