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

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

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

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

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

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

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

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

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

Hopelessly stuck in the mud

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

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

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

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

Walking to work on Monday morning

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

Our two Land Rovers parked adjacent to the dispensary

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

A field adjacent to the dispensary

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

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

The Upper Kitete dispensary

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

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

Our mobile clinic contingent at the Overlook

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

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

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

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On the overlook at sunrise

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

The sunrise from the overlook

A Maasai boma looking south towards the Serengeti

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

A road well-traveled

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

Navigating the crater floor

A resting lion

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

Turtle with her crew on board

At the hippo pool

Lake Magadi full of flamingos

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

A male Thompson gazelle resting

A seldom seen flock of grey crowned cranes

A pair of Cape buffalo scratching each other

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

A mob scene at the rhinos

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

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

Rhinos up close and personal

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

A lilac breasted roller

A tawny eagle

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

Ngoitokitok Picnic Area

Ngoitokitok Picnic Area

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

A brewing downpour in the distance

The Lerai Forest

Saturday, March 16 – A wellness day at Gibb’s Farm and the Elephant Caves….

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We arrived Saturday morning for report and met with Dr. Anne to hear about how the patients had done overnight. Of course, we were all waiting to find out how our stroke patient from the day before had fared as we had placed her on palliative care and the expectation was that she wouldn’t last the night…hopefully. Anne reported that her breathing had become very shallow and that she remained unresponsive to any verbal stimuli. Again, there was absolutely no question by any of the care team as to what we were dealing with (an intracranial hemorrhage and increased intracranial pressure) and what the outcome of the case was going to be (that she would be left totally dependent on others with severe neurological deficits if she were to survive). Following report, several of us went into the ward to check on her and, as if having been waiting for our permission, she became apneic and shortly thereafter expired. Following her death, Daniel found that perhaps the most positive outcome from the entire process was when the patient’s sister asked him to check her blood pressure to make sure that didn’t also have hypertension.

Our lunch table at the Gibb’s

The little child with the thrombocytopenia and anemia who we had kept at FAME to see if their platelets would respond to steroids, was doing well, but their platelets came back that morning at only 4 thousand, down from 5, but it wasn’t entirely clear that the therapy had kicked in yet or not. Both Marin and Dan were incredibly helpful as pediatricians on this case as I would have had no idea of what to recommend in this situation. The plan ultimately was to keep the child over the weekend, continuing the steroids and then rechecking counts on Monday morning. If the platelet count continued to remain low, then the plan was to send the patient to KCMC for a bony marrow aspirate which was the next procedure to be done.  Dr. Jackie had already them about the possibility and there was no reason to send the child over the weekend as they wouldn’t be able to do the aspirate until Monday, regardless, and their specialist, who could evaluate the child, would also be there on Monday.

The Elephant Cave crew and their guide, Brown

Some “wild” animals on the trail to the elephant caves

Our plan for the day was to work the morning and see as many patients as possible with the idea that we would try to finish at around noontime. I had made reservations for the seven of us to enjoy the wonderful lunch buffet at Gibb’s Farm and every one was going to climb to the elephant caves that are a short hike from Gibb’s up the Ngorongoro Conservation Area, or NCA. As is usually the case, we had packed everything up and were ready to head to the house and go for lunch when a young girl arrived who had been struck by a piki piki. At the time, she had apparently been knocked to the ground, struck her head and was unconscious for two hours. She had also developed some bloody discharge from one of her ears that had stopped and now had classic post concussive symptoms that included headaches, dizziness, and tinnitus. She had been referred to us for evaluation and a CT scan. Jon took a thorough history and performed a neurologically examination that was normal including a look in her ear that revealed some dried blood in the canal, but the tympanic membrane looked just fine. Our CT scanner was not yet up, but we didn’t feel that she needed a scan regardless, and so treated her conservatively. Given that she was from the village of Oldeani, nearby the Rift Valley Children’s Village where we’d be next week, we just asked her to come see us there to make certain she was still doing well.

Daniel, Marin and Adys

A view down the valley near the waterfall

We were finally off to Gibb’s Farm for our lunch and it was an absolutely gorgeous day for us. They had reserved a table for us on the veranda overlooking the coffee plantations and with a view to the distant mountain ranges of the Lake Eyasi region many hours away. Lunch here is also an event, very similar to the dinners, but in a much more relaxed and informal manner. They have dozens of selections of local and ethnic cuisine that have all be prepared to perfection by the wonderful kitchen staff. Their cheeses are made on site and all of the produce is grown there at the farm. The dessert selection is also an amazing affair with numerous selections including fresh fruit. We all sat at our table in one of the most beautiful locations of the world enjoying some most wonderful dishes that one can imagine.

Elephant caves panorama

A view looking down from the caves

When lunch was finally over and everyone had had their fill (and then some), it was time to head to the trailhead for the elephant caves. Since this hike takes you into the Ngorongoro Conservation Area (read, wild animals), you have to first check in at the ranger station and hire a guard. The cost is $18 per person for the walk and well worth the experience. The “caves” are really impressions in the hillside where the elephants come to dig out minerals from the soil that they need for their nutrition. You can see elephants there on occasion, but for the most part, the elephants come there at night so you don’t run into them. You other animals on the hike, though, such as the ubiquitous baboon and lots of birds. There is a very nice waterfall on the hike as well that you can walk up to the edge of and is quite a drop. Since I had been on this walk several times before, I decided to drive them the short distance to the gate and then head back to Gibb’s where I could spend the entire rest of the afternoon waiting for them to return from their hike all the while sipping on a Moscow Mule. Even better yet, I am well-known to the staff aft Gibb’s Farm as either they, their spouses or children come to see us for their neurological care, so they take very good care of me. It is almost too relaxing sitting there on the lawn in the shade to do reading or work, so I am certain that there were a few short naps interspersed with my blogging of the day early. Gibb’s Farm has to be one of the most unique places in the world and being able to come  back here time and time again is truly special. Even more special, though, is bringing the residents and others who accompany me to this place of beauty to experience it for their first time and see their reactions.

The pool leading to the waterfall

The elephant caves

The trip to the elephant caves lasted until the evening and it was quite close to sunset with the others arrived back to meet me, still sitting in my same chair and typing away. I had promised them come nice cold drinks on their return and most everyone decided to enjoy the sunset with some refreshments. Everyone had also wanted to speak with the artists, one of who I had purchased several things from over the years. It was quite late by the time we ventured back to Turtle to begin our journey home to FAME. We had plans to head to Ngorongoro Crater the next morning, leaving at 6 am, and still needed to make our lunches for the game drive, so there was much to be done to prepare for the day. Jon, Daniel, Adys and Sheena have become real pros in making all of this happen and once again we had everything made and packed up in short order and now it was just a matter of getting to bed with thoughts of the crater on our minds as we slept and the vivid Malarone dreams assisting in the whole process.

Sunset from the Gibb’s terrace

Tinga tinga art for sale at Gibb’s Farm

Friday, March 15 – A very sad case of a stroke….

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Having had just a wonderful night with Daniel Tewa and his family, we were now ready for the end of the week. Our Saturday would be a half day of patients with a “Wellness Day” for the afternoon and then on Sunday, we had plans for a day game drive to Ngorongoro Crater, one of the premier game viewing sites in all of Africa. Since it will be March 17 the day we’re in the Crater and Phoebe, who is Irish, is coming with us, we will be bringing some beer along with us to celebrate at lunchtime. I will do my best to post the Ngorongoro Crater blog on Sunday night depending on how exhausted I am after driving and guiding all day. I was recently asked what my favorite thing to do here was, and I would have to say very honestly that it is taking people on safari and driving myself. I can easily remember how I felt when I first came here seeing the remarkable sights and visiting with these amazing people here. My greatest love is to introduce others to this wonderful country.

The neuro team enjoying the Lilac Cafe

At morning report, we ran through all of the patients in the ward, several of who were our pre-eclampsia/eclampsia women who, thankfully, were all doing well though needed some stricter blood pressure control as we were afraid that their PRES could easily return and they had been doing so well. Sheena’s patient who had been billed as a post-partum psychosis, but had no psychiatric history and seemed to respond well to blood pressure management and levetiracetam. She improved by the following morning, having gone from being completely uncooperative and constantly singing to being fully alert and cooperative. There seems to be a very significant incidence here of pre-eclampsia/eclampsia and it is not entirely clear why that is other than perhaps the much higher incidence of hypertension, even in young women.

Marin taking a photo of Jon discussing an outside CT with Dan

At the end of morning report, we were also able to pull up the X-ray of the young baby who had died last weekend so that Dan could review it in light of the initial concerns of some congenital heart issue. He felt that the X-ray was very abnormal and definitely suggestive of this. The baby had been initially fine, but then cried out several times, each time associated with desaturation of oxygen and turning a bit cyanotic. On the third cry, the baby died and they were unable to resuscitate it. The CXR had been done prior to all of that occurring and had a very large heart and wide mediastinum. Dan concurred that the baby most likely suffered from one of the congenital development cardiac issues such as transposition of the great vessels and that is not something that can dealt with here by any means.

Jon reviewing an outside CT scan with Dan

A baby had come in the day before and was presented today at report with severe anemia and thrombocytopenia who had been seen here last October with similar problems and had responded to steroids with the platelet count increasing from 5K to 85K the following day. It was unclear how much of a workup had been done at that time, but the baby hadn’t been seen in the interim so it was presumed that they were doing at least reasonably well. They now had a hemoglobin of 5 and platelets of 5K on admission. Given the fact that he hadn’t returned in the six months, that would make leukemia very, very unlikely, but an autoimmune thrombocytopenia was a possibility, but wouldn’t explain the anemia, so that would have to be from another process. After much discussion, the child was placed on IV steroids to see it he would respond again and will be monitored going forward.

Dr. Caren, Dr. Julius, Dan and Frank discussing stroke case with patient’s husband

Just before noontime, we were urgently requested to come to the OPD to see a patient who had been brought in with an apparent stroke. Daniel accompanied Dr. Julius back to the OPD to see the patient and returned a few minutes later to report that she was a younger woman (51-years-old) who was not moving her right side, was not responsive and had systolic blood pressures over 200 mmHg.  She was being moved over the emergency bay so that we could care for her more appropriate. When she arrived here, she was already posturing her right side, her pupils were sluggishly reactive, and, most concerning, she was dropping her heart rate in the setting of severe hypertension with systolic pressures still well over 200, which is known as a Cushing’s response and occurs in the setting of high intracranial pressure and impending herniation of the brain.

Unfortunately, her symptoms had begun the day prior when she was shopping and developed right-sided weakness and aphasia. At some point, the family had taken her to a dispensary and she had been referred to come to FAME for a CT scan. Our CT scan has been down since last October due to the various problems, but was ready for operation once it was approved by the Tanzanian Atomic Energy Commission, which we were waiting for and had not yet happened. What ensued at that point was a very practical discussion of what should be done. Given her presentation, we were reasonably confident that we were dealing with a hemorrhage large enough to have caused her to begin to herniate. If we were to send her off to Arusha for a CT scan that would cost $200, it was very unlikely that there would be any intervention that could be performed. Even if some intervention could be performed, it could only be expected to possibly save her life, but to what purpose we were very confident that she would never be able to move her right side or speak and would be totally dependent on others for the rest of her life quite possibly with complete lack of awareness.

Frank discussing a case with Marin, Caren and Jon

We did discuss the situation with her family at length to explain to them the dire nature that she was in and that regardless of what we did, it was most likely that she was going to die and that the very best we could hope for in this situation was to save her life, but that she would be dependent on others for the rest of her life. We were limited in what to treat her with here as our IV antihypertensives are minimal and we were hoping that the family would agree with our plans to initiate palliative care. Anything that we did now would only prolong the inevitable. The family insisted in contacting her parents even though her husband and other family were here and, thankfully, after everyone was contacted, there was a very reasonable understanding on their part so that she was moved to the ward and placed on comfort care only. She was given a small amount of morphine to decrease any agitation she might have as a result of her oxygen hunger and she was made comfortable, waiting for the end to come.

Frank, Dan and Daniel discussing care for the stroke patient

Considering the circumstances, it was clearly the right thing to do, but regardless, it was tough for everyone considering her age and the fact that this very likely something that was preventable had she only been compliant on antihypertensive medications. Hemorrhagic stroke is much more prevalent here in Africa than it is elsewhere solely because of the higher incidence of hypertension in general, and untreated hypertension specifically.

We spent the evening at home, relaxing, and thinking of what we were going to have for dinner. We received our “bacon, no lettuce, and tomato” sandwiches on homemade bread, but I had been dreaming of making a bacon and tomato egg scramble with the ingredients after deconstructing the sandwiches. Jon was all in for the scramble as well so I whipped up some eggs and Adys joined us as well. We had borrowed a small, compact LCD projector that Phoebe had and watched the Lion King on the wall. I listened to most of it while cooking and typing, but it hasn’t changed. It’s a classic and everyone’s now exited to go find Pride Rock while we’re on safari. After Lion King we watched a very good climbing movie that Marin had on her computer called Free Solo about free climber Alex Honnold. For those of you who love extreme outdoor movies, it is an amazing documentary about an incredibly select group of climbers who do not use ropes and place their life at risk every moment on the mountain. It is also an excellent documentary from the perspective of what kind of person it takes to succeed in such an endeavor and the psychopathology (I’m using that word in a purely clinical perspective and not at all judgmental) that is necessary.

 

Thursday, March 14 – A visit with Daniel Tewa….

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Vic’s white board thesis on burn wound treatment

Vic Davis giving his lecture on burn treatment

For those of you who have read yesterday’s blog, there is no need for me to introduce Dr. Vic Davis. If you’re new to the blog, Vic is a trauma surgeon who has tremendous experience all over the world in war-torn torn areas and just happens to be here visiting FAME and Dr. Kelly on a short break from a stint in Dar es Salaam at Muhimbili University. Vic had offered to speak this morning for the education session on the management of burn wounds. Not something that we necessarily encounter on a daily basis in neurology, but something that is definitely worth relearning given the area that we’re in and the fact that we could certainly be asked to assist in managing these patients if the need arose. Vic had first completely filled out the white board with the points that he wanted to cover in his talk and did a wonderful job of getting to everything in the short time he had allotted this morning. It was again a complete pleasure to hear him speak from a place of absolute confidence and experience in the subject.

One of the more puzzling cases of the day didn’t involve anything neurologic, but it was a young 9-month-old child with a severe rash that had been seen previously at FAME and treated with topical steroids and antibiotics with continued worsening. It had been present for about six months and looked horrible. Both Dan and Marin (our pediatric peeps) were asked to take a look and weigh in with their thoughts. We did have some ideas, but in the end sent off photos to several resources in Philadelphia. I emailed the photos to Carrie Kovarik, who is at Penn and an expert in dermatology, dermatopathology and tropical medicine. Dan and Marin not only emailed the photos to their Jim Treat at CHOP, but also called (with the time difference, I think it was like 6 am!) to see if they could get additional information. The feedback we received suggested that this was “unusual/ fulminant acropustulosis of infancy,” that usually occurs on the hand and feet, but can also affect the face, nose and ears and can often be mistaken for scabies when it involves primarily the feet (trust me, all of this was from Carrie as this is not my shtick by any stretch). It should respond to high potency steroids and will often burn itself out over time.

We continued to see patients throughout the day, but having Dan here to not only staff the pediatric cases but also some of the adult cases, it has allowed me the freedom to spend some time at the Lilac Café this trip and that has been a real luxury for me. In the past, I’ve had Danielle Becker with me, though on one of those trips, she was focusing primarily on the epilepsy cases. Dan has adapted incredibly well to the style of practice here which is a real compliment given the unique nature of practicing medicine in East Africa and it has been wonderful to have him here working with us, and not just because of the freedom to take my Lilac Café forays.

Daniel Tewa explaining his Iraqw house

The sleeping platform for women and children

The Lilac Café was created when the new hospital opened several years ago as it became clear that there was a need to feed the inpatients and their families beyond what the FAME cantina could handle. It is a lovely place for us to meet and have coffee in the morning when things are slow and, today, I took the opportunity to spend some time here outside on the porch with a wonderful cappuccino. Susan and Frank also happened to be here at the same time discussing logistics for their upcoming fundraising trip in the US. I took the liberty of introducing them to the concept of AirBNB, something they have not tried in the past and something that I have been using extensively over the last several years. Two years ago, I spent a week in the Galapagos Islands in the town of Puerto Ayora on the Island of Santa Cruz, so it is clearly possible to find something just about anywhere in the world. For those of you who haven’t looked into it, I would strongly suggest giving it a try. I continued to enjoy the warm rays of the sun sitting out on the porch enjoying my cappuccino and remembering just how incredibly lucky I am to have this opportunity to come to FAME and share this experience with others.

Daniel explaining how an Iraqw family lived in their houses in the past

Two Iraqw warriors??

We had arranged to visit Daniel Tewa and his family tonight for dinner. As many of you know, I first met Daniel when I came to Tanzania with my children in 2009, and have visited with he and his family on every trip back to FAME since that time. Daniel is a remarkable man who is a self-taught historian of not only Tanzania, but also of the world and is far more knowledgeable about our own country than most Americans are by far. And though Daniel and I have become family over the years, it is really that fact that he has opened his home to those residents and others who have accompanied me on our visits without hesitating and has continually insisted that the honor is his and that he would not have it any other way. What began as simple visits by myself have now morphed into his entertaining our entire group for the evening which this time added up to seven of us including myself.

Marin and Sheena modeling Iraqw wedding skirts made by Elizabeth Tewa

In Daniel Tewa’s home

When we arrive, he has a table arranged for us outside among the trees in the middle of his beautiful farm with African coffee (coffee and milk boiled together) that is some amazingly delicious and is made with fresh milk from his cows. We sit and talk as he goes around the circle asking everyone where they are from and then telling us some fact about our city or state that we often don’t even know. We talk politics and given the fact that we don’t watch any television here or even keep up with the news, he usually tells us something that we weren’t even aware of. Tonight, he asked what we thought about Beto O’Rourke announcing that he was running of which none of us were even aware of at the time. After sitting for some time, we walked over to the underground Iraqw home that he built in 1994, and which is a replica of the type of house that he grew up in before they were outlawed by Julius Nyerere after the country’s independence and the need to bring all 126 tribes of Tanzania into villages together to create a country. The houses were underground so as to protect their cattle, sheep and goats from the Maasai during the night. The Iraqw and the Maasai were at odds with each other until a truce was finally signed in 1986.

A “daily wear” goat skin dress as opposed to the wedding skirts

In addition to Daniel’s Iraqw home, he also shared his methane gas collection system with the others which provides gas for cooking and lighting his home. It is a 10 cu. ft. collection tank that uses the waste from several cows to produce more than enough methane for his own use while also providing fertilizer for his fields from the byproducts of the process. It is an ingenious system that he has had for many years and that I had first seen in 2009. Later, we all walked to the nearby home of his eldest daughter, Isabella, where we were greeted as honored guests and served a wonderful dinner that was prepared specially for us. It has been this way for many years between us and there has been a relationship of mutual respect and gratitude. Though Daniel has continually reminded me of what I do for his community by bringing doctors here and providing care and that the honor is his, I constantly remind him of what he has done for us by sharing his home and family and teaching us about his culture. It is these relationships that we must treasure in life for they are the most genuine. There are no pretenses or expectations, only respect and love.

Wednesday, March 13 – Is there really such a thing as hump day in Tanzania?

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It is Wednesday and we’re half way through our week-long clinic here at FAME with the mobile clinics to look forward to next week. The low volume has been a bit frustrating as I’m sure you can imagine, but the cases have been interesting and it’s been good working with Caren as I haven’t really had a chance to work with her much in the past. As I’ve mentioned before, it is our main mission to teach the clinicians here at FAME and when we are working with interpreters rather than a clinician, it is a lost opportunity to teach. Though it is great for us to see more and more patients here, the real impact and capacity building occurs when you teach a man to fish. When it was just me alone here, that wasn’t a problem, but as the program has grown over the years, with FAME growing as well, it has created a situation where they are more and more strapped for manpower which makes it more and more difficult for FAME to free up other clinicians to work with us. There are several solutions to this problem, but in the end, it has to do with funding, which always seems to be the case, and the only resolution that I believe will give us some immediate solution going forward will be for us to have a designated clinician or two who will continue to provide neurological care to our patients.

The severely scoliatic and translucent spine of our osteogenesis imperfecta patient

Frank had posed a question to me last week regarding which specialist would be most appropriate to follow an adolescent with osteogenesis imperfecta. I had replied that it would be a pediatric endocrinologist and pediatric orthopedist most likely, which was later confirmed by his speaking with one of his resources in the US, but at least I knew that it wouldn’t be a neurologist, let alone an adult neurologist. As things go here, though, it usually turns out that we will end up seeing patients like this just to help out with whatever we can. So, this young girl with very serious osteogenesis imperfecta arrived to clinic today after having traveled down from Arusha. She was accompanied by someone from the international association who was working with her to navigate what exists of the health system here, and they came with many records and X-rays for us to look at to help with the evaluation. She did have some chronic pain symptoms that were certainly something we could help with, but beyond that, there was little from a neurologic standpoint for us to focus on. Regardless of that fact, both Marin and Dan did have some helpful thoughts about what could be done for her.  Her disease was quite advanced and plans to do anything for her would have to take into consideration the real risk of doing harm in the end. Merely transporting her would poise an incredible to her well-being. She will absolutely need to travel outside of the country for something to be considered and it’s not entirely clear what that might be.

Lower extremity/ankle films of our osteogenesis imperfecta patient

We also had another little infant come who was somewhat younger than our last with the similar problem of static encephalopathy and poor nutritional status. Once again, we contacted our sources in Arusha at one of the hospitals and were told that though they could see the child, the family would have to cover the cost of care. Though medical costs are most often very much less expensive here, they are typically going to be far outside of anyone’s or any family’s ability to pay. Patients will often go back to their communities to gain the funds necessary for some treatment which is the culture here. One of the lessons that are taught here is about unintended consequences and the fact that reaching into your pocket to help out, an act that we would consider the right thing to do, is not what one should do. It sends entirely the wrong message and rather than promoting self-reliance, it breeds continued dependence on others and is not sustainable in any sense. Though it is the ultimate intention to help others, without a plan and without first speaking with those who have been working in the area, it will most often lead to failure and heartache. There are many, many stories here of those wishing to help who have left in their wake millions of wasted dollars and nothing to show for it in the form of having made a positive change. Though this can be very frustrating, it is a lesson one must learn on Day 1. First and foremost, ask those you wish to help what is needed rather than giving them what you think they need. The latter tact will always end in animosity and lost friendship.

Knee films of our osteogenesis imperfecta patient

The weather here for the last week and a half has been nothing short of perfect. Outside of the first few days in Arusha and the heat, it has been just absolutely gorgeous – cool mornings and evenings, bright cloudless skies all day long except for a brief late afternoon rain shower, but we actually haven’t seen one of those in several days. The sun here is intense as we are just below the equator and it takes only moments in the direct sunlight to burn. We have no seasons here as we know them at home. Here, the seasons are known by their amount of moisture in relation to planting and harvesting. We are actually in the wetter season now where it is green and lush, there is less dust, and the planting is taking place readying for the rains of April and May. October when we have traditionally come, soon to be September this year and going forward, is much drier and dustier. Still, both seasons hold different benefits and both are lovely.

Daniel and Sheena working with Michael

As it is Wednesday, it is our Happy Day night. Again, this has been a tradition for several years for all the volunteers at the various sites in the area to mingle and share their “war stories.” It really is a time for everyone to unwind in the company of others of the same age and ilk. Everyone had decided to walk there tonight with the lovely evening, though I had to wait back at FAME as I was expecting to get Turtle back from the mechanic with its new emergency brake other small fixes. Soja, who is FAME’s mechanic, and has helped me with my vehicles for many years here in Karatu, brought Turtle back to me around 6 pm, which was perfect timing for me to drive him back to town and then meet Susan at the Lilac Café to chat. After my meeting, eating and catching up on some paperwork, I drove down to Happy Day with everyone sitting outside on the deck and lots of lively conversation already underway.

The new and much appreciated addition to the menu at Happy Day is ice cream!! There are no good sources of ice cream here and it is something that is sorely missed. If only we could get a Baskin Robbins or Rita’s (the latter a Philadelphia favorite source of water ice and custard) here in Tanzania, I would gladly promise to support them on a regular basis. For now, though, a cup of vanilla and strawberry ice cream at Happy Day will have to satisfy my sweet tooth.

A young child from the ward struggling with their walker

As I sat down next to Sheena and across from Ann, there was already an ongoing and incredibly interesting conversation that also included Drs. Vic and Kelly. Dr. Vic Davis is one of Kelly’s mentors from her surgical training and has been here visiting at FAME during a brief interlude from his more long-term work with the surgical department at Muhimbili University. Vic has been working for many years, it seems, in practically every remote corner of the world with the International Medical Corps, among others, providing emergency and heroic surgical services just behind the front lines of war-torn locations. We were all in awe of his stories, which he told in such a matter-of-fact fashion that if you didn’t know better you’d think he was just related a normal day at the office. These were not glorified junkets as they to such locations as Afghanistan, Yemen, Somalia, Rwanda and Sarajevo just to mention a few. These were not considered vacation sites, and certainly not during his tenure in these locations. I think everyone who was listening at that moment found themselves thoroughly entranced and it became quickly apparent that what Vic really needed was a ghost writer to help him put all of this into a book. I would be the first in line to buy a copy of his book as it would tell a story of an incredibly unassuming physician’s true dedication to humanity. It was a privilege to be sitting with Vic at Happy Day this evening.