Thursday, September 26, 2019 – Our last day of neuro clinic….

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Surfing the hallway with one of Marissa’s little patients

It had now been nearly a month that we’d been away from home and three full weeks of seeing patient here at FAME. At had no indication by anyone’s mood or actions that they were homesick or tired of this place, but rather that it was becoming a second home as it has with me over the years. Today was our last day of neuro clinic, albeit unannounced, but we knew from the past that patients would come regardless and, besides, we had told several to come back today to see us in follow up or to have studies done. It was 18th clinic day, all told, and we were nearing 400 patient visits which is what our fall trips have been consistently running as opposed to the spring trips which are usually around 300 patients. I believe that had it not been for the extended coffee picking this month, we would have seen many more as that is the major employment in this area and, as I’ve mentioned before, the season is only around 40 days so that to miss the opportunity of making the equivalent of $2 USD for a day of picking can be extremely costly for most residents here. Whenever we’re driving down the road to town in the morning, coffee pickers are walking up the road towards the fields with their 5 gallon buckets in hand, ready for their work that will bring some shillings to their family and food on the table.

Group photo after our last patient for fall 2019

It was also everyone’s last morning report as the residents and Leah had already let me know that they would be sleeping in tomorrow rather than coming to report since we had no clinic. I had absolutely no issue as they had all earned that luxury given the days of hard work they had put in and the fact that we’d be getting up early on Saturday to leave for Arusha. Andrea had volunteered today to give the educational lecture on the different types of tremor and how to evaluate and treat them. Since she will be going into movement disorders, this is obviously her passion and it showed in her lecture which was complete, well-organized and well-received by the FAME clinicians. Also, as it was our last morning for the team to be at report, there were words of thanks by all the doctors, but especially by Dr. Anne, who had spent the month with us as she will be the FAME neurologist going forward, and Dr. Gabriel, FAME’s head doctor and someone who I have known now for many years. After the words of thanks came the mandatory claps, which are usually three, but this morning were six, the extra three as a sincere sign of appreciation. “Pasha, pasha, pasha, choma…” and then the six claps by everyone around the table.

The neuro team relaxing at the Lilac after our last clinic for sodas

Before this, though, Jacob, the overnight doctor, presented the ward and maternity cases to the group for any overnight changes. Our gentleman that Kyra had admitted with Wernicke encephalopathy had improved and was much less ataxic and less encephalopathic this morning after his supratherapeutic doses of thiamine which was great to see as we were worried about the oral thiamine replacement we had given him. As we had walked to report, we had noticed the FAME ambulance backed up the walkway near the ward which was a good sign as it meant that they were readying the patient with the meningioma for transport this morning to Arusha. Unfortunately, what we discovered from Jacob was that the patient had markedly improved overnight in regard to his encephalopathy (theoretically, a good thing) and that he was now refusing to be transferred to Arusha (a bad thing) after he found out the expense of surgery, despite the fact that his family was agreeable to him going and had already raised the money necessary to have him treated. Jacob had already. spent a great deal of time with him before rounds and the patient was adamant about not going and his family was now beginning to waffle.

An impromtu vote of confidence for Leah’s success as a neurologist (note – Leah’s eyes are shut)

The steroids would not continue to hold him for very long and his edema would eventually begin to reaccumulate and worsen and, if nothing were done for him, it was very likely that he would die due to complete obstruction of his ventricles and hydrocephalus. Mike went back after rounds to reassure me that the patient had capacity to make this decision as well as to make sure that his family was also well aware of the consequences. He was and they were, though they later indicated that they would likely drive themselves to Arusha rather than in the ambulance and were planning to see the neurosurgeon.  We made sure to make Dr. Rabiel, the neurosurgeon in Arusha, aware of the change in circumstances as Dr. Gabriel had called her yesterday afternoon and that we were hopeful that he would see her sooner rather than later as there was little question that he would be worsening in short order if nothing were done. If we had been at home, we would have made him sign something discharging him against medical advice, or AMA, but that would have been solely out of concern for medical legal reasons and of that we had little concern here.

Of the other interesting patients that we had for the day was the 91-year-old Maasai gentleman with the primarily proximal lower extremity weakness who we thought was mostly myelopathic, but without apparent sensory changes and normal ESR and ALT/AST (proxies for a CPK which we do not have here). He underwent his CT scan of the cervical and thoracic spine that were unremarkable as far as any destructive lesions anywhere, though I will admit that my abilities to look at CT scans of the spine in regard to the cord or other soft tissues aspects is a bit lacking since we rarely do them for obvious reasons as the MRI has become the gold standard for evaluating the spine. We remained at a loss for his diagnosis considering other possibilities such as spinal AVM or an inflammatory myelitis, both of which would be very difficult to diagnose with access only to a CT scanner. Unfortunately, we sent him home without a diagnosis, but will still be thinking about him with the idea of coming up with something.

Possible cysticercosis of the muscle

On a completely different note, though, we had a rather frustrating woman who came in with complaints that seemed mostly non-neurologic, but we decided to evaluate her none the less. She did have a swollen left lower leg that we really couldn’t ignore and sent her for an ultrasound, that was negative for a DVT, but Dr. Gabriel did note that she had some tenderness and pain to palpation and suggested that we get a plain film to rule out a fracture or other pathology despite her lack of trauma. We went ahead and ordered the plain X-ray of the foot, not something we normally do, only to notice that there some hyperdensities posteriorly that were in the soft tissue above the ankle. We had no idea what these were, but were surprised when Dr. Alex, our radiologist, read them as calcifications that could be suggestive of cysticercosis of the muscle.

A sagital view of our gentleman with progressive cerebellar ataxia

Now, this was a twist as we are totally aware that neurocysticercosis (pork tape worm cysts in the brain which are one of the most common causes of epilepsy worldwide) is present in this area (though it’s unclear if we’ve actually seen any to date), but in researching the possibility of cysticercosis of the muscle, it turns out that it is very rare and that if it is seen, patients should be screened for asymptomatic neurocysticercosis as this entity is so much more common than involvement of any other organ system. The following day, Dr. Gabriel did call the family explaining to them our concern and recommending a CT scan of the brain, but they elected not to do it and it was unclear if this was due to the cost or whether due to a local belief that X-rays take away years from someone’s life. Either way, it wasn’t going to be done which was unfortunate from an academic standpoint as it would have been very interesting to have answered that question.

Our favorite dinner spot

So, we had lots of commotion for the afternoon with all of these complex patients, but we did have something very much to look forward to as we had made dinner reservations at Gibb’s Farm for the six of us this night and it was a much anticipated event. We had actually finished everything up a bit earlier than anticipated, but most importantly, we had exceeded the previous number for patients for a trip by one, having had 405 patient visits for the month and still wondered what the number would have been were it not for the extended coffee picking season. We did have to run back to Teddy’s, now the all-time favorite FAME seamstress as there had been a few other things she was making for people that needed to be picked up. We decided to do this on our way to Gibb’s and, as expected, there can never be a short visit to Teddy when bringing along a female majority. I do apologize if there is something a bit sexist about that statement, but having visited her shop multiple times now on three separate trips, I believe I have the clear data to validate my observations if anyone wishes to challenge me.

Chicken dish at Gibb’s

Winning dessert at Gibb’s

We finished up at Teddy’s and then made our way up to Gibb’s for our dinner. None of the others had dinner there before, so I knew it was going to be a real treat for all of them tonight. We had arrived after sunset with plans to have some drinks before dinner, but they had a table all ready for us and since everyone was more than ready to eat, we decided instead to be seated and get drinks with our dinner. Visiting Gibb’s for me is always such a pleasure, not only for its wonderful setting and the scenery, but also for the fact that all of the waiters there, most of who have been there for years, know me and greet me with hearty handshake and hug. I have cared for a number of them or their families over the last ten years and they all know the work I have done at FAME and are appreciative of it. Visiting Gibb’s Farm is clearly one of the highlights of the residents’ visit to FAME and I always make sure that we make it here at least once for dinner and once for lunch during our month long stay. I am sure that one can find other lodges that may have some better attribute here or there, but when it comes down to the entire package, there is really no other that comes close to Gibb’s Farm.

Suave and debonair

We finished dinner early enough for everyone to spend time in the gift shop with both Mike and Kyra finding wonderful bathrobes to purchase. Everyone had worn their new Tanzanian attire except for me and Mike, who had decided not to wear his infamous jumper to dinner, so he wore the bathrobe that he had purchased and I wore Kyra’s bathrobe for a group photo in front of the Gibb’s fireplace. It was a great ending to a wonderful evening.

Our group after dinner at Gibb’s

Night scene at Gibb’s

Wednesday, September 25, 2019 – A very busy afternoon…and then the Sparrow….

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Dr. Anne and Marissa evaluating a patient

Our morning report was very interesting today in that one of the patients who presented yesterday emergently to FAME was a young gentleman who had been attacked by a Cape buffalo. These events remind us that we’re definitely not in downtown Philadelphia as there is very little violent crime here other than the attacks by wild animals. Baboon or monkey bites have been relative common in the past given the total lack of fear these animals have at the Ngorongoro entrance gate and the picnic areas in Tarangire. At the gate, the baboons will very quickly enter any open window in a vehicle, target the lunch boxes or any food and be back out in a quick flash unless someone tries to stop them which they don’t appreciate and will quickly. provide a very nasty and dirty bite. Last year, a very unfortunate Maasai man from the NCA was brought in after being essentially eviscerated by an aggravated elephant and did not survive the night from his injuries. A Maasai women came in a few years ago with nasty hand wounds after tangling with a hyena who had successfully taken her infant from her hut and had to be referred to KCMC for more specific orthopedic repairs. Her infant was never found.

Another Denis creation

So, the gentleman who ran afoul of the Cape buffalo was actually a bit lucky in that what he had was a bit hemopneumothorax that needed to be drained, and though there was concern that he would need ICU level care (not available at FAME), a chest tube overnight seemed to stabilize him. There was concern for his mental status in the morning and we were asked to evaluate him from a neuro perspective. Mike went to see him in the ward and he was totally intact to the degree that I joked that he followed commands better than 90% of the patients that we were seeing in clinic. He was a lucky individual as Cape buffalos can be very, very dangerous in situations where they feel threatened and they unlike many animals as they will defend themselves. If you’ve ever seen the video of the Cape buffalo completely upending an adult lion, throwing it at least ten feet in the air in a tumbling fashion, and using its razor sharp horns, you can certainly understand the need to avoid them at all costs. There had been talk of transferring him, but he looked so good I the morning the decision was to keep him at FAME and to continue treating his injuries.

Someone assisting me with my blog

We had a patient come today who was following up from our clinic in Mang’ola last week and he had looked mostly cerebellar on examination. He was now encephalopathic and tremendously worse such that we were fairly confident his diagnosis was Wernicke encephalopathy, which often occurs in the setting of alcohol abuse and is the result of dietary deficiencies usually related to thiamine deficiency. If it is severe and irreversible and more associated with confabulation, we call it Korsikoff syndrome. In the US, patients with a history of alcohol abuse are immediately given what is called a “banana bag” intravenously that contains thiamine, magnesium and folate primarily  which effectively prevents the acute exacerbation of Wernicke that can occur when patients are given dextrose intravenously prior to correcting their vitamin deficiencies. We have no banana bag here nor IV thiamine for that matter, but we did have thiamine tables to send with the only proviso that we are unable to know for certain whether it’s being fully absorbed or not. Regardless, it was the only thing that we had and so it was five tablets every eight hours for several days to totally supplement and correct a presumed thiamine deficiency. Kyra had seen the patient in Mang’ola, so also evaluated the patient here and we all agreed that he should be admitted to make sure that he got his thiamine. With Dr. Anne’s assistance, this was taken care of and Kyra wrote the orders for him to receive thiamine as well as some other vitamins, none of which were quite as important as the former supplement, though.

Mike evaluating the ED patient in the ward

Mike evaluating the ED patient in the ward with the help of Dr. Jacob

In the midst of everything going on, a young patient with an IV was wheeled into our clinic space on a gurney by one of the nurses saying that he had been sent to us directly from the OPD to be evaluated for episodes of unresponsiveness. There was really nowhere to place him with all the patients sitting waiting to be seen, so he was wheeled into one of the unused rooms in the ward, but I insisted that there be a nurse with him as we had no one to spare that could monitor him. Though this hadn’t happened yet this visit, it is not all too uncommon for patients to brought to us in this fashion having come in unresponsive, many times after having “swooned” at school or work. I recall one time that a patient was delivered to us in this manner and after briefly examining the patient and getting the history, it was clear to me that it was not anything serious and that they would wake up eventually. We left the patient on the gurney nearby, monitoring them occasionally until, sure enough, they awakened and were back to their normal self-following what we refer to as PNEE, or a psychogenic non-epileptic episode. These are a form conversion disorder and are most commonly a response to underlaying stresses, though it takes a good deal of time and therapy to determine exactly what they are and how to best deal with them.

Mike evaluating the ED patient in the ward

For our patient, though, it was much simpler as after having taken an accurate history and examining him, it was quite clear that this was just a matter of several episodes of syncope in a patient who had been dehydrated. These are patients that we are often asked to evaluate at home to determine that they don’t have a neurological cause for their loss of consciousness, such as seizure, so it not at all that unreasonable to have us evaluate patients such as these, though typically it will be done in the ER if it is acute and they are not wheeled into our offices.

CT of patient with large right sphenoid meningioma

At the same time as the syncopal patient arrived in clinic, we had been called over to see a patient in the ER who had arrived unresponsive after having developed a severe headache, vomited and become less responsive the night before. Mike went over to see him right away (which is why we had no immediate person to evaluate the syncopal patient) and the patient was moving all extremities, but not following any commands and was very poorly responsive. We were most concerned about a subarachnoid hemorrhage and without any focality on his examination, this would have been suggestive of an aneurysmal bleed without significant parenchymal injury. We had another patient already in the scanner at the moment which had to be completed first, but he would be getting his study very soon and he was moved to the ward while he waited as it was clear he needed to be admitted.

CT of patient with large right sphenoid meningioma

He eventually had his study and it was not at all what any of us had expected. He had a very large, right sphenoid wing mass that was homogeneously enhancing and causing significant mass effect on his right lateral ventricle with right to left shift of the midline. There appeared to be some involvement of the cavernous sinus as well. The mass was most likely a meningioma and it was almost identical to the mass we had found in a gentleman two weeks prior, though that patient had a more gradual history over several years including complete loss of vision on the right secondary to optic nerve involvement. We were really unable to get any relevant history in our current patient given his severe encephalopathy. We spoke with his family at length regarding the fact that he had a potentially very treatable problem, but would need to be referred to the neurosurgeon in Arusha and transferred there the first thing in the morning as nighttime transfers are dangerous, risking the life of not on the patient, but also the lives of the support staff involved in the transfer. The family was agreeable so I proceeded to contact the neurosurgeon, as I had done several times already during this visit, to find out what the expectation would be for the amount of money they would need up front. We placed the patient on intravenous dexamethasone at the end of the day to help with some of his swelling and went back to finishing our work in the neuro clinic. We arranged for his transfer first thing in the morning by the FAME ambulance.

CT of our patient with progressive cerebellar ataxia

There are several important events that occur here in Karatu on Wednesdays. First, it’s meatloaf night for our dinner and Samwell cooks a very mean and moist meatloaf with some tanginess from a barbecue sauce that he uses and is probably homemade. It comes with a large side of mashed potatoes as well as green beans to add some color. I don’t know about the rest, but the meatloaf was clearly Mike’s and my favorite of the various dinners that we’re provided by the FAME kitchen five nights a week as part of room and board while volunteering here. In addition to these dinners (we have to fend for ourselves on the weekends), we’re also provided lunch every day which is perhaps my favorite food of all – five days a week it’s rice and beans with a local spinach made even more tasty by Samwell’s homemade pili pili, or hot sauce, that is made from the local hot peppers here which are very, very hot. This combination of food, the beans, rice, spinach and pili pili, may be my all-time favorite meal that I would choose if I were ever stranded on a deserted island. Tuesdays we have ugali, the East African staple that is a stiff porridge made from maize, and meat, while on Thursdays we have perhaps everyone else’s favorite, pilau, which is brown rice (cooked in meat stock) mixed with beef and then a coleslaw-like salad to go with it. Both of these, of course are made that much tastier by the addition of Samwell’s pili pili.

Yes, we even enjoyed a bit of Konyagi, The Spirit of the Nation

The second event that occurs on Wednesdays is our Happy Day night. Happy Day is a long-standing local pub that also has small bungalows where many of the long term volunteers at FAME have lived in the past, including Peter Schwab, the medical student who worked with us last October and is now a neurology resident at Penn. Happy Day (note the “Day” and not “Days” so as not to be confused with that popular sitcom) has been an institution here in Karatu since my very first trip, but has changed its ambience since taken over by new management. What used to be uncomfortable picnic benches on the outside deck are now very comfortable outdoor sofas and pillows, lots of them. It has been a tradition for years that all the ex-pats working in Karatu and surrounding areas come to Happy Day on Wednesday night to socialize and share stories. Frequent attendees include much of the staff from the School for Field Studies in Rhotia, which is quite close and is field school where college students come for study abroad programs. The mix of individuals depends on who is in town and who is around and is different every Wednesday night.

Andrea and Marissa enjoying themselves

The third event on Wednesdays is much less of a sure thing and really depends on how much energy everyone has and what we have planned for the following day. If everyone is up to it, and that is not always the case, we will all make our way over to the other local hotspot which is the Golden Sparrow. “The Sparrow” hasn’t been around forever, but was the creation of the owner of the previous dance club which was called “Carnivore,” and was a little hole in the wall place that served the most scrumptious, though also the scrawniest, barbecued chicken and chips along with drinks. Seating for dinner was mostly outside on a dirt floor where they cooked the chicken whole on a huge grill and then literally whacked it into pieces with a huge cleaver before bringing it to your table to eat while dancing occurred inside on a tiny little dance floor that was nestled amidst the bar tables and stools.

The gang at the Sparrow

Carnivore is no more and the owner, Martha, created a true dance club that would rival anything in a larger town and includes a DJ, disco lights and televisions around the dance floor. I will have to admit that in the past, there has been dancing on the tables though I will not mention any names (Mindy, Susan, Susannah, Whitley and Neena, I believe), but the tables have been changed and it’s no longer possible to do so. There is a very large outside seating area for dinners where they still serve their delicious chicken, but the most fun occurs inside on the dance floor. This night, we all loaded into Turtle and drove over to the Sparrow to let off some steam as we had working very hard for the month and were looking forward to our final day of clinic the next day, though no one really wanted to leave. Yes, there was dancing tonight, but none on the tables and we left before midnight to make sure that we’d all be in OK shape for the following day. It wa an incredibly enjoyable time, but not something that can happen every Wednesday night, that’s for sure.

Tuesday, September 24, 2019 – Babies, babies everywhere….

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One of FAME’s main missions from the very beginning has been child and maternal health, though it wasn’t until the fall of 2014 that they opened for routine deliveries here. The reason I remember that date is that Doug Smith was here as the CHOP rotator and was the attending physician for that very first planned delivery here. Since that time, the number of deliveries at FAME has continued to grow as has their reproductive health clinic volume. Considering that woman pay a fee to deliver at FAME as opposed to the government hospital where it’s free, that is a very strong statement in favor of the community’s trust in the care they receive here. The cost at FAME for their antenatal care is very little and the delivery itself is 80,000 TSh, or about $36. At the government hospital, though the delivery is free, the patient must bring their own supplies even down to the sutures if they happened to need a C-section.

Walking past the maternity ward towards clinic in the morning

With the growth of deliveries at FAME, though, there has been a growing need for neonatal care both for babies born here, as well as those who are brought or sent here following birth elsewhere for the exceptional care that is received. During our neurology months, the pediatric neurology residents have also provided pediatric and neonatal care as those who have come are also board eligible pediatricians in addition to child neurologists in training. Hypoxic-Ischemic Encephalopathy (HIE) injury is one that unfortunately occurs all to commonly in Africa for many reasons and having pediatricians, and especially those well versed in this primarily neurological condition, can be extremely important and it is the first hours after birth that can often make the biggest difference in regard to reducing their overall brain injury.

Kyra’s lecture

Though this wasn’t necessarily the purpose of their time here, the residents from CHOP (Children’s Hospital of Philadelphia), recognized as one of the best pediatric hospitals in the world, if not the best, have contributed greatly to this mission of FAME in an exclusively positive manner, and it has been my privilege to have brought them here. They are the most amazing clinicians who, in addition to loving neurology (very dear to my heart), are truly dedicated to children as are all pediatricians. They have always been huge part of this program from its inception given the number of children and adolescents that we see here during our stay.

My first ride in a boda boda

It was Kyra’s turn to give a talk this morning and considering that she’s going into cognitive neurology, it was appropriate for her to talk about evaluating cognition and the various disorders of cognition that we see along with their treatment, or unfortunately, for the most part, their lack of treatment. Regardless, it’s a very important part of the neurologic examination and we have many patients who see us complaining of memory loss, though quite a few of those have primarily issues with focus and attention rather than true memory loss. It is always important to screen for mood disorders or anxiety in those situations as these are very treatable problems that can be treated either with SSRI medications or counseling, though the latter is not readily available here. Perhaps, someday that will change, but for now we’re left with prescribing medications.

Somewhat skeptical in the boda boda

At morning report, the most striking revelation that was discussed was the fact that there were nine, yes NINE, deliveries yesterday, six being spontaneous vaginal deliveries and three being C-sections. That’s an incredible feat when you consider the size of FAME and that we only have a twenty-five bed maternity ward that was now completely full. All the mothers and babies were doing well, another amazing feat in of itself considering the overall higher rate of birth related difficulties in Africa in general along with the fact that not all of the women had received their antenatal care at FAME, but rather came in labor and were appropriately attended to. Hopefully, as the word continues to spread regarding the quality care received at FAME, the deliveries will continue to increase, though that will also require a greater number of doctors, nurses and maternity space over time. As with anything else, this will also require a greater amount of successful fundraising and donors willing to consider supporting these vital services to the Karatu community and beyond.

At the brick quarry

We had another busy day in clinic, but one thing that stood out, actually, was a visit we had from the wife of our patient with the epidural abscess or mass from the week prior and that Ray had initially seen. We had spoken with the patient and his son about the fact that we needed him to see the neurosurgeon in Arusha to probably undergo surgery, but his wife called this morning to ask if she could come speak with us to get more information. Andrea, who had seen him yesterday, agreed to speak with her and we had asked Kitashu to help with the discussion while I sat in to assist if needed. Kitashu, who I have now worked with for about two years, has to be one of the most compassionate individuals I have ever known and his demeanor is so immediately calming regardless of the situation, that I cannot imagine anyone better at speaking with families in these sensitive situations.

The brick quarry

We explained to the wife why he needed to see the neurosurgeon and very soon as time was of the essence in situations like these. She explained that they didn’t have all the money necessary for the surgery and that he didn’t have the government insurance (which most people don’t have) that would have covered the major cost of the surgery. It is always so difficult to sit there, knowing that the amount of money we were discussing was not that significant to us, but could ultimately be life changing to this family, yet we are unable to step forward to help in these situations as it would not be appropriate if we can’t do it for everyone. One of the biggest lessons you must learn here is that what sometimes seems like the right thing to do, isn’t, and you must resist reaching into your pocket as those actions are not sustainable nor do they solve anything but for one individual. These are very hard lessons, and sitting in a room explaining to a spouse why her husband needs surgery that they may not be able to afford to possibly prevent him from being a paraplegic, isn’t an easy task by anyone’s standards. Yet Andrea was stellar in this most difficult and delicate of situations that required a tremendous amount of empathy and strength of character.

Walking through Tloma village near the lodges

At some point during the day, I needed to bring Turtle down to the mechanic as the driver’s door was still out of commission and entering through the passenger side or climbing through the driver’s window, though possible, was not an ideal situation for someone with a history of both back and neck surgery. At the right moment, I told everyone that I’d be gone for 30 minutes and I zipped down to the tarmac to have the vehicle looked at, originally thinking that they could fix it quickly, but realizing once I was there that was highly unlikely. I left Turtle at the shop and decided to take a bijaji back to FAME as that would be the least expensive option short of taking a boda boda (motorcycle taxi) back which I didn’t even consider given the number of accidents I’ve seen here on them and not wanting to end up in the ED at FAME. So, I hailed a bijaji, never having ridden one before, and began my short ride back to FAME in style. Well, if climbing into Turtle wasn’t a good idea for me given my past orthopedic issues, then riding in a bijaji definitely wasn’t a good idea either. These three-wheeled motorcycles with a body have absolutely no suspension or shock absorbers and you feel every bump, which, had it been on the tarmac, wouldn’t have been a problem, but on the horribly rutted FAME road it was quite uncomfortable and something I will not experience again. Suddenly, I now realized that taking placing my life in danger on a boda boda may have actually been the smarter option here. I made it safely and didn’t suffer any new injuries that would have been difficult to explain to the others if I had.

Finding some friends during our walk

We finished early enough today to consider taking a nice walk for both exercise and exploration after clinic. It was a beautiful afternoon/evening as the temperature was very mild even though the sun was out and strong. I took Kyra, Andrea, Leah and Marissa for a walk down through the brick quarry that is adjacent to FAME across the road and then up the opposite side of the valley to the road that leads to Tloma village, one of the main Iraqw communities nearby and where Gibb’s Farm sits just above. The brick quarry is very interesting as this is where they dig the clay to form the bricks, dry them and then stack them into tall oven-like structures that are hollow inside where they stack wood to eventually ignite and fire the bricks to finish the process. How this all works as far as who owns the quarry or the bricks once they are made, I’m not sure, but they are eventually purchased and made into structures that are often left incomplete and may take years to finish. There is a long explanation for this behavior, but essentially it has to do with community and the fact that if you have money in your pocket, or in the bank, and someone you know is in need then it is considered an obligation to help them. Therefore, if you have your money tied up in bricks and half built buildings, you can’t give it to someone who may be in need and you won’t be effectively shunned for not sharing.

We walked through the brick quarry where there many men working at all phases of making bricks and eventually walked all the way to the Tloma village past several nice lodges and eventually intersected the Gibb’s road where we turned to walk uphill towards one of the shops where ebony and acacia woodcarvings are made in the Makonde style of southern Tanzania. These beautiful works of art and there are carvings of most animals, bowls and the “tree of life,” which is a tradition carving typically of people stacked on top of each other, but hollow inside and well-polished. We didn’t end up buying anything, but the owner of the shop remember me from a number of years ago as I had purchased a very large tree of life carving that is now in my office at Penn.

A Makonde tree of life

We walked back along the road through the Tloma community where we encountered many children, some young and some school age walking home from school in their uniforms. The greetings were nearly unanimous with a frequent “jambo” and a wave to us. The lighting was wonderful as the sun was low in the sky and would be setting very soon. We reached home just before sunset and were all happy to be back in our comfortable house to enjoy our dinners and a later movie. I had suggested “The Eagle Huntress,” a delightful documentary about the Mongolian practice of eagle hunting a young girl who is determined to become the first female to compete in the previously all-male competition to be the best eagle hunter in the region. For anyone interested in determination, wildlife, gender barriers and gorgeous cinemaphotography, this is the movie for you.

Arriving back at FAME

 

Monday, September 23, 2019 – It’s back to work at FAME…

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Everyone had a wonderful time over the weekend in the Serengeti, and how could they not have. We slept in tents for two nights under the beautiful stars and though our camping was as far from roughing it as one can get, it was still in the traditional style of game drives of the past with the sounds of wildlife throughout the night (much to Andrea and Marissa’s dismay). It is the only way to really experience the Serengeti short of camping on your own, but I’ll leave that to the tremendously more adventurous of which I can think of only one who has come with me so far, and that would be John Best. John had decided to climb Kilimanjaro after his time here at FAME and, if I’m not mistaken, chose to carry his own gear rather than the typical fashion of having more porters than clients which is how I did it back in 2015. Spending two nights in the Serengeti gave everyone a very good taste of what a magical place this is, where the animals are really secondary to the scenery itself, and where the term “endless plain” is an understatement. There is no other place like it on Earth.

The doors to our clinic

Meanwhile, everyone was exhausted from the weekend trip and dragging getting out of bed Monday morning for clinic. There were no major neurologic issues that had occurred over the weekend so that we had no patients that were in the wards needing a neurological evaluation on our return. At morning report, though, we did discuss two burn patients that were in the wards, one a young boy with very serious burns on over 60% of his body and requiring skin grafting that was actually going very well, but taking a long time due the fact that they were having to wait for the donor sites to heal before harvesting again. The child has been here since we had arrived weeks ago and will probably be hear much longer. There is also a woman on the ward service with severe burns who has been here for over a month, though I am not entirely certain of how she got them.

A typical Tanzanian cooking scene

Burn injuries are a tremendous issue here for many reasons, though the primary one has to do with the manner of cooking in the typical Tanzanian household, which is over an open flame utilizing either charcoal stoves or propane burners that sit in the middle of the kitchen. These are all very easy for small children to fall into while playing, for older adults with an unsteady gait to navigate around or for patients with epilepsy to fall into while having a seizure. We have seen so many of our epilepsy patients over the years that have been injured in this manner and many patients who come to see us for the first time with uncontrolled seizures have been horribly disfigured and disabled by these injuries in the past. We have seen children who have fallen into boiling pots of porridge or women who have spilled the contents of their cooking upon themselves. The burn injuries don’t necessarily have to involve epilepsy, though, as neither of the two patients in the ward have seizures. There were merely injuries caused by cooking over open flames in tight quarters where accidents are bound to happen.

Cooking over an open flame

Last week, while we were off in Mang’ola, Dr. Ray had seen a patient before heading home that raised concern for a spinal cord injury – the patient presented with three weeks of difficulty walking and urinary retention and had an examination that clearly localized to the cord below the cervical spine, but was unclear whether it was thoracic or lumbar as he was not overtly myelopathic. He was admitted and underwent a CT scan that demonstrated what were preliminarily read as degenerative changes at the T6-T7 level. We had been away at Mang’ola on both days having left early in the morning so the patient had been discharged home as there was little to do immediately, but the final read came back with concern for an epidural process at that level and compression of the cord. This is not something that is easily seen on a CT scan and is where the MRI really shines, though it was still extremely concerning for an abscess or possibly TB given his presentation. We had him come back today to discuss what needed to be done and that was to send him to Arusha to the neurosurgeon. I contacted the surgeon and the cost of the surgery and hardware necessary would be 4.8 million shillings, or something a bit over $2000 USD. The family went home with that information and the hope that it might be able to be raised by them so he could be treated.

One of Denis’s paintings

Marissa’s paintings

Another interesting patient that was seen by Andrea today was a patient with progressively frequent attacks of vertigo who also had tinnitus and possibly some sensorineural hearing loss. They had seen the ENT docs in Arusha and had been recommended to have a CT scan of the temporal bones, but hadn’t done so yet. His exam was normal other than the hearing loss and we were concerned about the possibility of either Meniere’s disease or a mass in the cerebellopontine angle on the ipsilateral side. The other thought, and why the ENTs had wanted a CT scan of the temporal bone had to do with the possibility of dehiscence of the semicircular canal causing his vertigo, so we asked that the temporal bones also be imaged with the CT of the head. The study was negative for both the mass and the dehiscence, so we were left only with the possibility of Meniere’s disease and recommended that he go back to see the ENT docs in Arusha with his CT scan disc that they could now look at for any abnormalities.

Dinner Monday night

Dinner, take 2

We finished out the day of patients and went back home to rest, still exhausted from the weekend travels. The movie of the night was the original Lion King which made tremendous more sense now that they had all been to the Serengeti and to Pride Rock. There were lots of references that were now made clear as well as many of the names and Swahili words and phrases used in the movie. It was an early evening for everyone and there was an early educational lecture in the morning that Kyra was going to give on how to evaluate patients for cognitive impairment.

Sunset

The Lion King

Sunday, September 22, 2019 – A pre-dawn game drive in the Serengeti….

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Sunrise on the Serengeti

The rain of yesterday evening was a very brief event and the night was once again breezy and cool in the tent, perfect for sleeping under the cozy comforters, but making it all the more difficult to get up early in the morning. We were going for a pre-dawn game drive today at 6 AM, meaning that Mike and I were up again early and having coffee at the main tent by 5:30. It was cool outside, but so delightful that a light second layer did the trick for most of us. The camp staff were up and had some munchies to eat, though I was still full from dinner the night before. Sunrise on the Serengeti is a miraculous event that is truly difficult to describe. Once you’ve experienced it, though, the opening scene of The Lion King becomes that much more relevant as corny as that may sound. From the orange glow of the horizon to the east, it is clear what is happening and when the sphere of the sun begins to rise and meet the sky, there is an intensity that continues to build with the songs of the birds and the movement of the animals now that the day is upon them.

An early morning stretch

We left camp shortly after 6 AM and in the distance you could see four balloons from the two companies slowly rising after their lift-off and continuing downwind for the short, one-hour flight before landing and then enjoying a wonderful breakfast on the open plain. I had the good fortune to have been invited on a flight back in 2014, with Danielle Becker, as one of the pilots is a good friend and they happened to have had open spots in the gondola that day. Danielle and I shared a compartment in the giant basket that held 16 guests in eight small cubicles and the pilot in the center space. You are picked up at 4:30 AM and driven to the launch site where you receive instructions on what to do during takeoff and landing and what to do in an emergency. You lift off well before sunrise so that you are well in the air before it becomes light and you are then watching sunrise from a position that is well above the clouds and, given that the balloons fly in tandem, you have perfect views of the other gondola and its guests. It seems like you’re up forever, but the entire trip lasts only a bit more than an hour and then it’s time for the landing, a rather exciting event that’s over before you know it. We toasted the successful flight with champagne in the long tradition of ballooning and then sat down with all the other guests to enjoy an incredible breakfast before heading back to meet our guide at the visitor’s center.

A lilac-breasted roller in a tree

There are now two ballooning companies that fly here in Seronera, so there were four balloons in the air this morning, rising and falling with the thermals, as well as the hot air supplied by the burner on board. We watched the sun slowly rise to the horizon and then above as it illuminated the bush in the soft glow of the golden hour before the temperatures rise. With the rising sun we continued our trek past the lion pride we had seen the day before, still drawing a crowd of vehicles, and towards the river where we had seen our lion kill the day before. Near one of the crossings, there was another large pride of lions that we stopped to watch for a bit, but they eventually wandered into some tall grass where they could no longer be seen.

Balloon flight

Two balloons over the Serengeti

We soon left the river area and were heading off to the southwest in the direction of the where we had seen the young leopard hidden and her mother nearby so I knew that Dodo wanted to go back to see if we could find the leopards again and, this time, possibly a better view of the two. Driving up to the kopje where we had seen the young one yesterday, we were alone which wasn’t a good sign considering the crowd that a leopard will draw if it’s visible. With no leopard in sight, we soon left the kopje and drove over to where we had seen the mother at the base of the tree yesterday. She wasn’t there, but we received word that the two leopards were a short distance away and not far from the kopje where we had seen the cub. We reversed course and were quickly there with several other vehicles and as we pulled up, there in front of us was the mother leopard and her cub strolling in the tall grass heading in the direction of the kopje that we had visited earlier. The two were absolutely gorgeous, with their bright coats of open spots and sturdy tails.

A Marabou stork

An Agoma Lizard

The mother would slowly walk along while her cub would run ahead and then lay down in front briefly rest while mom caught up to it. Leopards are most often seen in a tree or up on the rocks from distance and rarely close up. They are solitary except for a mother and her offspring. I had seen only one leopard cub before, but it was from a far distance and in a tree, much different than what we now had before us. We sat and watched as they continued to move off towards the kopje and then we chose to drive back over to the rock where they were heading, though unfortunately, the word had gotten out by now and there probably dozens of vehicles already waiting for their arrival there. It was so crowded that it became very difficult once again to see anything, and so we stayed for an only a brief while, but were more than pleased with the time we had to watch them crossing the field. Leopards are so incredibly impressive to see when they are out of the trees and it was a rare sighting for us. Everyone in the vehicle was tickled that we were so lucky to have had that opportunity.

A mother leopard and it’s cub

On the move

From a distance

We left the kopje with just enough time to make it back to camp for breakfast and were glad we did as we were all starving. Our breakfast was as delicious as the day before, though I think everyone ordered a Spanish omelette today other than Dodo and Andrea, who ordered over easy and scrambled, respectively. We again had fruit, cereal, yogurt, muffins, and. Fresh squeezed juices. After our meal, we picked our food for our picnic lunches that we’d probably eat at Naabi gate on our way crossing back into the NCA heading home. We packed our bags and settled our bar bill for the two days we were in camp and headed out to Turtle to pack everything up. Our plan now was to head towards the Maasai Kopjes on our way out of the park with the intention of hitting Naabi Gate around 1 PM so we could get to Kitashu’s boma round 3 PM and visit.

Mom

baby

A closer shot of mom

Before leaving Seronera, though, we did have to add fuel to Turtle as we were still running on the original tank from Friday when we had left from Karatu. The fuel station there was of course run by TANAPA, the government park administration, which meant that I would again have to deal with the same bureaucracy as I did at the Serengeti gate and that had almost been a nightmare. The attendant at the station informed us that the machine for taking credit cards was down that morning and they were not allowed to take cash which had been instituted a few years ago to curtail corruption. There was one other option, though, and that was to use the M-pesa, which is the system here where you can put money on your phone and then pay for things with it. I guess it would be similar to ApplePay, only it works on debit system rather than credit. There was a small shop nearby in the worker’s compound where we could put the money on my phone so we traveled there to make the transaction.

A resting male

Two sisters

It was actually interesting to visit this area (I have in similar places before when traveling with Sokoine) as this is where all the Tanzanians who work at the lodges and shops live with their families during the year. It is a little village in itself with restaurants and stores for supplies and there were plenty of people waiting for the many buses that come through here. Dodo and I walked to several shops and finally found the right one where the man pointed to a woman sitting out front who would take care of it for us. I gave her my phone number and she confirmed the name with me whereupon I gave her 100,000 TSh to put on my phone. This is a huge amount of money for people here and it obviously spoke to the safety of these areas that you don’t have to worry about being robbed by anyone. We traveled back to the fuel station to take of things, but the adventure wasn’t over there. No one had asked me if I had ever used the M-pesa system before, which I hadn’t, and when I punched in the numbers to access the money, it asked me for a PIN. Having never used it, though, meant that I didn’t have a PIN. We worked on it for some time, continuing to dial the numbers and getting the wrong menu on the phone, until I finally tried putting in a PIN which seemed to get us closer to where we needed to be. I did have to call Airtel (the company my phone was using) once, to have them help me, and somehow, we got it to work. We put in the code for the fuel station and paid for 95,000 TSh worth of fuel, or about 40 liters, and we were finally off with about ¾ of a tank which was more than enough to get us home.

Cape buffalo with red-billed Ox-peckers

Close-up of a Cape Buffalo

The rest of our game drive in the Serengeti was a bit of a blur, but we continued to see more and more lions as we drove, to the point where the response was, “oh, just another lion.” It is truly amazing the number of lions the Serengeti supports and we were only exploring the central portion of the park. The drive back to Naabi Gate took about an hour or so, and thankfully, we had all the necessary paperwork to exit the Serengeti and to enter the NCA on our way home. We had our lunches at the gate where there were more vehicles and people than I had ever seen there and it was difficult to even find a table to sit at. We were on our way again in short order, though, and traveling back on what has to be one of the very worst washboard roads I have ever been on. To make matters worse, every so often, there are short stretches of very soft dirt that has to be taken slowly to avoid driving off the road or tipping. Thankfully, Dodo is a great driver, so we sped along the road quite safely and managed to maintain a good pace as we were trying to get to Kitashu’s boma by around 3 PM.

Handing out candies to the children

Mike in the dance line

Andrea and Leah with the women

I had to make one short stop at the Olduvai gate, which is just a short distance off the main road, to drop something off with a friend who was waiting there for us. When we pulled up, we discovered that the driver’s door wouldn’t open as the latch had loosened with the bumping from the rough road, so Dodo ended up having to climb out of the window. He worked on it briefly, but it wasn’t cooperative would have to be fixed later. Between the fuel station fiasco and Olduvai Gorge stop, we were a bit behind schedule, so ended up getting to Kitashu’s about 45 minutes late which was a shame as we had really wanted to spend some time there.

Mike jumping with Kitashu

One of Kitashu’s brothers jumping very high

Mike doing his best and succeeding

His boma is in the NCA on the Endulen Road which is very near the Crater Lodge. His entire extended family lives there in very traditional fashion with all of their livestock that grazes over the nearby hills when there is enough vegetation. On occasion, though, they will have to travel far with their animals to find adequate grazing, sometimes all the way to Ol Doinyo Lengai, the active volcano on the. Lake Natron road that is sacred to the Maasai as the Mountain of God.

The women’s dance line

Mike with some of the children who wanted a photo with him

There were many, many children at the boma, but we learned that there were many from other bomas who had come when they had heard that we would be visiting. There are “cultural bomas” throughout the NCA where safari companies bring their guests and pay them to put on dances (we had done this on our original trip here), but this visit was very different as we were guests of the boma due to our relationship with Kitashu. We had brought some small gifts with us – rice, sugar, soap, tea leaves and candies for the children – to show our thanks for having us. The woman of the boma immediately brought Leah, Andrea, Kyra and Marissa into a nearby hut to have them dress in traditional clothing and jewelry as we would be doing a dance with them and Mike also dressed in shukas and jewelry for the festivity.

Washing our hands prior to eating goat

Kitashu and Dodo slicing goat

We all walked to another area where the men and women demonstrated their dance and song with everyone participating (except Dodo and me). Mike hadn’t been feeling well prior to this, but managed to be a good sport and do some of the jumping that the Maasai men are famous for, though I suspect he could have gotten much higher had he been in full form. After the dancing, we went and walked around behind one of the animal enclosures to eat some roasted goat that Kitashu has prepared for us. The Maasai men never eat in front of the women of their village as it is believed that it is bad luck for the women to watch and that the men will become sick if they do. It was on skewers that it had been cooked on and after we all washed our hands, Kitashu proceeded to slice off chunks of tasty goat meat and pass them around to each of us in turn. The goat was cooked perfectly for us and was incredibly juicy and tender. I have eaten at a number of goat roasts in the past, and I will have to say that the meat is at tender and tasty as pretty much anything I have ever eaten before.

 

A scene from Kitashu’s boma

A scene from Kitashu’s boma

Once we had our fill and had again washed our hands, it was time to depart the boma so we would make it through the gate by 6 PM or else spend the night in the crater which wasn’t something we were planning. We ended up make it through the gate with literally minutes to spare and, for the first time in several days, breathed a sigh of relief with the smooth surface of the tarmac and the absence of the continual chatter and bouncing of the washboard roads we had been driving on since entering the NCA on Friday. It had been a wonderful adventure in the Serengeti and now it was back to our primary mission here, seeing neurology patients at FAME and working with the doctors here.

Saturday, September 21, 2019 – Waking up in the Serengeti….

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All loaded and ready to go

There can really be little dispute that the Serengeti is one of the most spectacular locations on the planet Earth and a sight that should not be missed if humanly possible. The word “Serengeti” comes from the Maasai word “siringet” which means “the land that goes on forever,” and it is an accurate assessment of the landscape here for it is truly an endless plain. Everyone’s introduction to the park last evening was only a small sampling of enormity of this place and we would be spending our second day in only a very small portion of this enormous park that embodies the true essence of Africa. The Serengeti contains the majority of the greatest land migration of wildebeest that travel in a circular fashion throughout the year in search of grass, stretching from the Southern Serengeti, thought the Central and then crossing the Mara River in the Northern where they calf in the Maasai Mara of Southern Kenya only to travel back into the Serengeti to complete their migration. The Southern Serengeti is the place to be in the wet season for all of the herds are there feeding on the luscious grasslands. The crossing of the Mara occurs in early September in most years, but it really depends on the weather.

A large family of giraffe

So, the second day of our trip began waking up in our tents that are more like a small house. The tented camps here can be semi-permanent or seasonal and typically consist of anywhere from 10-20 tents that are divided on either side of a central tent that contains areas for lounging, a bar and a dining area where there are tables set up for all the guests and are available for three meals a day, though most eat only two or even one meal in camp with the rest of them being eaten on the game drives and prepared by the kitchen. Overnight we had heard the sounds of hyenas and, in the morning, the lions, all of which sounded like they were only feet from our tents. We had decided to have breakfast at 7 am given the long and tiring drive the day before, though Mike and I were up early to have coffee and watch the sunrise. Everyone gathered on time for our breakfast which consisted of various fruits, cereal, yogurt, muffins and fresh juices. At the table, the staff took our orders for eggs however we desired them cooked along with bacon, sausage and toast. It was an incredibly filling meal that was easily going to last us the better part of the day, yet it was now time to pack our lunch for the road as we would be out game viewing for the entire day and not returning to camp until dinnertime.

More hippo viewing along the river

A young hippo out of water

The hippo pool

Leaving in the morning for a game drive is always so exciting for you never know what the day will hold. Dodo had decided to take us by the hippo pool for the early morning since some would be out of the water and we may be able to see a few crocs in the area. There is a very nice viewing area nearby where you can get out of the car without fear of being attacked by the hippos as the edge of the pool is steep enough to prevent it. There is a wooden rail at the viewing area that is meant to keep guests from getting too close to the pool, but of course there are always those who don’t seem to understand the significance, and possible danger, of these situations, thinking perhaps that this is a zoo. While I stood taking my photos of the hippos, there were those who just had to have those selfies as close as possible, putting themselves, and perhaps others in danger.

Leah, Kyra and Mike at the hippo pool

Mike and Kyra at the hippo pool

A vulture overhead

A vulture overhead

We left the hippo pool to drive along a wooded river area looking for leopards, though what we found were tsetse flies and lots of them. These flies are rather infamous in East Africa for carrying trypanosomiasis, or sleeping sickness, but luckily there are only very rare cases of this in Tanzania, and none in this region. They aren’t harmless, though, as they have a terrible bite and feed on the blood of their victims. They are incredibly slow, but are like heat seeking missiles when they find your vehicle, flying alongside at whatever speed your traveling until the enter through the top or the windows looking for a meal. It’s almost impossible to feel them when they land on you, that is until you realize that they have bitten you. Their bite is significantly more painful than a mosquito and can create a welt much more uncomfortable and long lasting. Thankfully, that is all they leave and there is no worry here for sleeping sickness.

An adult hippo out of water

As we came closer to one of the main roads, we noticed in the distance that there were a number of vehicles concentrated in one area and that can only mean one thing in this region – a large cat. As we drove closer we could see a very large pride of lions lounging in the grass and under a large tree. Lions sleep most of the day except when they are hunting and that is only done by a few females at a time. The males, a great number of females and many younger lions will all be lying in the shade for most of the day, resting and readying themselves for their larger nighttime hunts. We watched the lions for only a little while as they didn’t appear to be interested in doing much else other than sleeping.

A herd of Cape buffalo

As we drove around the river areas we saw plenty of wildlife that included small herds of zebra, lots and lots of birds, baboons, elephants, giraffes and just about everything in between. We were still trying to make a sighting of a cheetah or a leopard and, at one point, we did run across two cheetah, but they were lying under a tree a fair distance away and, although you could certainly see them with the binoculars, they didn’t appear to be planning to hunt anytime soon. We were near the park visitors center where there is a picnic area, but we weren’t quite ready for lunch, so decided instead to head further out and find another picnic area in which to eat our lunches. We head out along another line of trees where there are often leopards, but not were to be found today in this area so we continued on. Once again, we could see a number of vehicles next to a kopjes far off in the distance and, as we approached, it was quite clear that there was something to see here. It was a leopard that was resting well-hidden behind some bushes and under a large rock, resting in the shade. It was barely visible and you certainly could not take a photo with all the bushes around it. We queued up behind several other vehicles, each taking its turn to pull up alongside the leopard. There wasn’t much to see at this time.

A southern ground hornbill

We moved on to the picnic area where tables were at a premium as we were still in the high season here. There was also one of the large participatory camping vehicles there that usually have around twenty guests so this also occupied several tables to accommodate everyone on the tour. These companies usually provide tours that can be a month or more in length and travel through several countries in a large half truck, half bus-like vehicle where all the travelers are up high in a compartment that usually is open on the sides, with lower bins that pull out to provide all of their camping and cooking equipment. They set up their own tents and everyone shares I the cooking. I had looked into this for our trip back in 2009, but there wasn’t enough cost savings to justify it for me and even though I love camping and the outdoors, I just couldn’t see sitting in such a large vehicle for such a long time. In the end, had I chosen that style of trip, I wouldn’t have found fame and would certainly would not have been on my 20th trip back to Tanzania at this point in my life.

Mother and baby

Marissa’s fav – a baby nursing.

After lunch, we drove through an area that should have been ideal for cheetah as the grass was tall and there was plenty of small game for them to hunt, but they were nowhere to be found. We drove a big loop so ended up driving back by the rocks with the leopard, though it hadn’t moved and was still nearly invisible behind the bushes and under the rock. As we drove off and were a few hundred meters away from the Kopje, Dodo spotted a shape laying under a distant tree. With the binoculars you could clearly see another leopard resting there. As leopards are purely solitary animals, this was the mother of the one we had seen under the rock and she had stored her cub away while she had gone hunting. She was really too distant for any good photos, but it was great to know that there was a healthy mother and cub nearby.

Staying out of the sun

We continued our drive with the intention of finding a closer cheetah to view, but it just wasn’t to be this day. We were moving pretty fast alongside one of the many rivers that course through this area when I suddenly spotted the dark backs of two lion ears off in the distance amid the green bushes of the riverside. Dodo was able to eventually stop the vehicle and reverse and, sure enough, it was a lioness on her haunches and she was clearly scanning the opposite riverbank for distant prey. We decided to watch her for a while and in five or ten minutes, two other lions slowly came into the picture from our right. When they were finally together, they moved off as a hunting party traveling as a unit with one walking in front and constantly checking for prey. At one point, two of them climbed onto a small hillock which was rather odd as they were very visible from there, but we later determined that the group contained a mother with her adolescent daughter and son and it was the two less experienced animals that had exposed themselves.

The first lion we spotted

On the prowl

There was a small herd of zebra on the opposite side of the river that were aware of the lions and moved a good distance away, but we knew that there were a number of other animals still at a watering hole far off to the left which was where this trio of lions was heading. At this point, we were the only vehicle watching these lions as they slowly moved through the tall grass, now in an incredibly stealth fashion, and seemingly more determined with every minute. Dodo continued to move our vehicle for the best possible view while the lions slowly moved in the direction of the watering hole, still completely undetected by the animals at the watering hole. On several occasions, the lions were so concealed in the tall grass that we had difficulty spotting them even though we knew they were there right in front of us. We had now watched the lions maneuvering for an attack for probably 20 or minutes, but we were quite sure that our patience was going to pay off in the end.

A very hungry mother

The youngsters scounting out

Finally, the attack was on as the mother lion sprung from the grass to the other side of the river where there was a small beach and all the zebra in the pool began to scatter in all directions. I’m not really certain that her children contributed at all other than to perhaps block the passage of some escaping animals, but in this case, all it took was the one determined lioness to make the kill. When she leapt to the other bank which was a huge distance, she seemed to collapse with the impact, but very quickly righted herself and was immediately on the run again with a zebra in her sights. In a cloud of dust, she caught the zebra and very quickly had its throat in her jaws to suffocate and kill the animal prior to eating it. The zebra struggled for several minutes, kicking up more clouds of dust, but eventually succumbed to the more powerful attacker and lay still. The two adolescents strolled over to their mother still latched on to her prey and began to eat the zebra. Hopefully the two had learned something from their mother’s example, but at the moment, they seemed more interested in devouring the kill.

Just after the kill with the zebra still kicking

Just prior to the kill, another vehicle had pulled up on the opposite side of the river having either spotted us watching or possibly the lions, but either way, we were now sharing our lions with someone else. Once the kill was completed, though, Dodo very quickly drove us to the other side where the view of the lions with the zebra was a bit closer and we would be able to watch their behavior feeding together. On a previous kill that I had seen with four female lions all of similar age, there had been a tremendous amount of jostling for position, snarling and general poor behavior between them with lots of growls and roars. These lions today, though, were much more civil to each other, if not to the zebra, as it was a mother and her offspring. Each lion alternated between sitting and standing as they began to feed and there were absolutely no harsh words that could be seen spoken between them. We continued to watch for some time until finally, one at a time, they walked away from the kill having filled their stomachs to the brim. It seemed as though the young male was the last to leave the carcass and I was surprised that there were no vultures yet on the scene as they are typically incredibly efficient in this process, but the African vultures rely entirely on their keen eyesight and not their sense of smell as do the American vultures, such as the turkey vulture.

We eventually left the lions, who were now in their post-prandial stupors resting comfortable nearby their kill, and continued on our game drive hoping to see cheetahs if we could find them. As we drove near the small airport we saw a few vehicles looking at something, but as we approached they began pulling away. They informed us that a cheetah had been walking across the road which we had just missed by a matter of minutes. It was surprising that we were have so much difficulty finding them as they are usually very easy to spot and fairly numerous, but the Serengeti has been extremely dry and the grasses rather short for the most part which is not conducive to cheetahs hunting. They’re around, but just not readily apparent in the regions we’ve been scouring.

It wasn’t exceptionally late, but between our exhaustion from being out all day and our excitement of the kill we had witnessed, everyone was ready to begin heading back to camp. As we were driving back and were only a short distance from camp, we came to a culvert under the road and, out of the corner of my eye, I spotted a tail and then a spotted body just to the side of the road in the grass. I yelled “leopard,” and then “cheetah,” not having been totally sure of what I had seen, but when we backed up to see, it was gone, but Dodo felt very strongly that it had been a leopard as one was living in this area and may well have been hiding in the culvert. We backed up to see if it would come out again, but there was the steady traffic of safari vehicles traveling in both directions, heading to their respective camps at the end of the day and it was very unlikely that the leopard would surface. We eventually gave up and made our way the very short distance to camp. Shortly after we arrived back to camp, it began to rain, so it was excellent timing for us having missed the need to put down the top while on the road and it was so relaxing for Mike and I to be sitting under the edge of the main tent drinking our Safari beers and listening to the softness of the rain as it fell and struck the tent. We had an excellent day on the trail, having seen a lion kill following a long hunt, an event that is not always seen when coming to the Serengeti regardless of effort.

Dodo and I sharing coffee in the morning

We had another lovely dinner and everyone, except for me as I was blogging, hit the sack early as we were going to leave on a pre-dawn game drive at 6 AM the following morning.

 

A very young elephant (?a week old) teething on a tree limb

Tiny baby

Friday, September 20, 2019 – A half-day of clinic and then off to the Serengeti….

Standard

The resident rotation to Tanzania not only includes an amazing amount of neurology given the number of patients seen here and the diversity of the neurologic disorders, but it also includes exposure to this countries rich cultural heritage, as well as its equally impressive wildlife. We’ve already visited two parks for day drives, Lake Manyara first followed by Ngorongoro Crater, which we did both on Sundays as we have traditionally not worked those days making it perfectly reasonable to spend them either at the parks close by or spending them doing something outdoors (such as our hikes down into Empakai Crater that we’ve done in the past. To get to the Serengeti from Karatu, though, it requires a minimum of two nights given the distance as that allows for a full day of game viewing in between the long drive on the other two days. But before I get to the Serengeti, we have a half day clinic that we have to tend to.

Crossing into the Serengeti

It was the end of our mobile clinic week and we have traditionally done a half-day clinic so that we could leave sometime after noon to arrive to our camp in the Serengeti before dark as driving in the park after sunset is very much frowned upon and actually against the law. Unfortunately, while we were away, many patients were told to return on Friday to see us as I’m not certain that everyone knew that we’d only be there in the morning despite my having supplied a schedule specifically to avoid any conflicts. Thankfully, though, the turnout was still manageable with some strict discipline by everyone along with some strong encouragement on my part. Kitashu had been at his brother’s wedding the weekend before near Loliondo, a predominantly Maasai region far north on the Kenyan border, and had told several people there to come see us on Friday for their neurological issues. Mike ended up taking care of the entire group that comprised four patients, but since they were all family members they really could be split up due to the language and history taking necessary.

Giraffe on the backside of Ngorongoro

In addition, the gentleman who we had seen previously with the large meningioma had returned to go over the results of his scan. This was a bit complicated given that he was going to require surgery so we contacted the neurosurgeon in Arusha (the only one outside of Dar in the country) to find out how much such a surgery would cost. He would also need to have an MRI done prior to surgery which would be an additional cost. Kitashu helped with giving him all of the information not only because the patient was Maasai, but also due to issues with cost and whether he would be able to consider it. Thankfully, the patient indicated that he was going to go home and sell some livestock along with other family members to have his surgery. I speaking with the neurosurgeon, we discovered that the older gentleman who we had seen with the large chronic subdural hematoma had not followed through with seeing the neurosurgeon which was very disappointing given the fact that he will not have any chance of recovery and will very like succumb to it in the end.

The largest herd I’ve seen of Grant’s gazelle

We finished the morning with about 15 patients or so and were finished by around 12:30 PM. There were still some labs to check and Dr. Annie would take care of giving those patients their results while we were on our way to the Serengeti. Somehow, one of the patients that Marissa and Andrea had seen in the morning and was depressed, so they had given the patient fluoxetine (Prozac), turned out to be pregnant (how Annie discovered this after the initial visit I’m not entirely sure) and this prompted a vigorous WhatsApp discussion while we were en route regarding what we could do for the woman. Unfortunately, not of these medications are safe in pregnancy and certainly not to start a medication unless there were extenuating circumstances. In the end, the decision was that she really couldn’t be started on a new medication and it would have to wait until after her pregnancy and possibly even breast feeding due to the selection of medications that we have here.

Marissa’s favorite sight – a nursing baby. These are Coke’s hartebeest

For our trip to the Serengeti, as in all the trips we’ve taken there in the past, I find a guide to drive us as I’m not comfortable navigating the vastness of this park and its extreme remoteness. Having a breakdown in the Serengeti can be a disaster for many reasons, not that having a breakdown anywhere in Tanzania isn’t a major problem given the fact that there is no AAA here to come help. For this trip, I had asked a someone I had met recently to drive us as I had an immediate feeling that he was very knowledgeable, experienced and dependable. His name is Samwell Bariye Dodo and after taking care of the particulars, he had agreed to come to Karatu to pick up the vehicle in the morning, fuel it up and have it cleaned as well as check it out to make sure that it was worthy of the trip. He had taken care of all of that and met us at our house to load our bags and get under way.

Hyena and gazelle

We would be driving to the Central Serengeti where we had booked two nights at the Thorntree camp just north of the Seronera, which is where the small airport servicing the Central Serengeti. The Serengeti is an incredibly large park that is divided into the Southern, Central and Northern sections, as well as the Western Corridor that is a strip jutting out to the west and follows the Grumeti River. The Western Corridor is the least visited region of the park. The Northern Serengeti runs to the Kenyan border where it extends north and becomes the Maasai Mara, which is the name of the game park in Kenya containing this contiguous area. The Central Serengeti’s geography is dominated by the famous Kopjes that are small, rocky hills jutting up from the flat plains that go on forever.

Just to give you a perspective on how close we were

Before our trip, it was necessary for me to go the NMB bank in town to pay for our transit across the Ngorongoro Conservation Area. The road to the Serengeti is the very same road we travel to the get to the crater and, in fact, you drive around the crater rim road all the way to the opposite side of the crater where the descent road is before continuing on rather than down into the crater. Everything went smoothly at the crater gate and we were soon on our way past all the sites we had seen the weekend before. The visibility was tremendously better than it had been previously given that it was now afternoon. As you leave the rim road and begin your descent down to the plains below, the immensity of the region suddenly becomes apparent and this is just a small sample of what we’d be seeing one we reached the park. You drive past Olduvai (or the proper spelling of Oldupai as I like to use) Gorge, the single most famous anthropologic site in the world and the home to the discovery of oldest man many years ago by Mary Leaky. Unfortunately, we wouldn’t be visiting this site today, but I have been there many times before and it is a simply magical place that clearly deserves its place in history.

Joined by the other hyena

Carrying it’s prey away

From the Olduvai region, you travel along until you reach the road to Lake Ndutu which is the place to be in the rainy season as all of the wildebeest herds are there with their new calves having been delivered on the way down from Kenya during the great migration. At this point, you enter Serengeti National Park, though the entrance gate is still another 20 minutes or so at Naabi Hill. Both Dodo and I went in to take care of the entrance payment, though in typical the typical bureaucratic fashion here, there was an issue that arose. I had been sent two quotes for the NCA transits (there and back) that I had paid for at NMB, but every time in the past, I had paid for the Serengeti quote with my credit card. Apparently, in the time since March, they had changed the procedure and were no longer allowing payment at the gate for any guided vehicle, only self-drive vehicles, meaning that I was supposed to have paid at the bank in advance. The only other option was for me to obtain the log in information for the company who booked the quote and then to make payment on the website with my credit card. It sounded very arcane, though I know they had their reasons for it. What should have been a several minute transaction ended up taking us about an hour with multiple back and forth phone calls to get the necessary information. Everyone remained very calm and we eventually got all the information to load into the computer, though the first credit card I tried didn’t work due to security  reasons, my good old Wells Fargo debit card came through and we were good to go.

Elephants at dusk

baby elephant at duck

We were now about an hour behind schedule which was a bit disappointing for me as up until then I had managed to keep everything moving on schedule, and we still had a long way to get to our camp and do some game viewing on our way. You are not supposed to be driving after 6 PM in the park, or at the very least sunset, but since we were on our way to our camp and had been held up at the gate, I was pretty sure that no one would be hassling us about that. It was a gorgeous sunset that took quite a long time to happen as there were multiple layers of clouds in the distance. The sky began to change to every shade of orange imaginable and we had to stop Dodo multiple times for everyone to take photos.

Baby elephant

Sunset on the Serengeti

At one point as we were driving, a hyena suddenly appeared on our left, darted across the road and grabbed a dead Thompson gazelle that was off to our right. We’re not sure how the gazelle had died as we didn’t see any other predators in the vicinity (hyenas will often chase off cheetah and even a single lion), but sure enough, the gazelle was dead when the hyena reached it. It began tearing immediately at the abdomen of the gazelle and began to devour the animal in very short order. A second hyena came up to feed, but kept its eyes on us as we were only several meters away and it was spoked by our presence. We were so close that we could easily hear the bone crunching by the hyenas who have the most powerful jaws of all the animals here and, even more so, we were close enough to smell the gazelle’s abdominal contents once it had been opened up. It was not very pleasant making me think that the gazelle may have been dead for at least a short while before the hyenas came upon it. As we were on our way to camp for dinner and truly looking forward to it, we all wished to keep our appetites, so eventually drove off prior to the arrival of any vultures to finish off the carcass.

Our lion admiring the sunset

The sun continued to set in the most spectacular fashion and as we rounded a marshy area where you will often see lions, we came upon a large pride, all of who were lying comfortably in the final rays of sunshine except for one female that was sitting on her haunches, facing off to the west, and clearly looked as though she were admiring the beautiful sunset. It was a glorious sight with the orange glow of the setting sun, the lions, the green of the marsh in the foreground and the endless plains in the distance. We were all in awe of the moment and now one wanted to leave this spot. Both Dodo and I knew, though, that with the setting sun, it would soon become pitch black and we still have at least 30 minutes to camp. We left this magical sight of the lion admiring the sunset and continued our trek north towards camp.

Lion admiring sunset

Dodo knew the Serengeti like his second home so there were no wrong turns and he knew exactly where camp was for us. As we arrived, we were given cool wash clothes and fresh melon juice to wash down our dusty throats. We were in plenty of time for dinner and even had enough time for Mike and I to go to our tents to shower. We sat around our large table finally able to relax from the long drive here and very happy that we make it through safely. It was time now to enjoy a cold Safari beer for Mike and me and wine for everyone else. Dinner was a delicious affair of probably ten dishes that were brought to the table by the camp staff for each of us to serve ourselves. The homemade soup was amazing as it always is and every other dish was equally cooked to perfection. We retired to our tents, all exhausted form the day, and prepared for a very restful night. Some of us were a bit more concerned about the animals surrounding our camp, though I reassured everyone that the animals have no interest in coming into camp. The fact, though, that Andrea asked the camp staff four times what the emergency whistle was for and why it was there may give you some indication of was going to sleep more soundly that night and who wasn’t.

A happy man and his Safari