Dear Bill. I will be continuing the tradition of capturing the experiences of the Alliance for Global Clinical Training (AGCT) in this blog after the first clinical week. The trip has been a bit more chaotic and started to be challenging three days before my plane left SFO. I received word that our usual housing across the street from the Muhimbili National Hospital (MNH), the Kalenga House, would be unavailable and I had to seek alternative housing arrangements. Our colleagues found a hotel about 2 km from the hospital gate and on a major thoroughfare near the Indian Ocean. The place didn't have rave reviews on Tripadvisor but I thought this was something I could cope with when I arrived. I was traveling with one suitcase of medical supplies that you had requested and more about that later.
With a bit of uncertainty on logistics, I took the same route through Dubai (overnight) and then on to Dar. I picked up the Needlestick meds and the phone from Kalenga and went to the proposed hotel. It was a scene from the Blues Brothers in the lobby with about ten people there and an argument over non-functioning wifi...that sealed the decision not to stay. I had done enough research to identify a hotel about 200 yards away and fortunately they had a room. Despite being a higher rate, it was a welcome place to land that could be used short term for volunteers in a pinch as a backup.
Staying so far from the hospital, despite the reasonable accommodations, was not ideal. Problems: you have to take everything you need for the day as you cannot go back and forth to Kalenga for anything. This means carrying a back pack all day. I initially had security questions, but one comes to realize that this is about the most honest country in the world based on a few observations: the staff routine leave their belongings in the locker room unattended; the nurses have the "mountain of purses" in the common break room; I once left my cell phone in the locker room and it was back in my hand before I knew it was gone.
For clinical activity, I was assigned to Firm 2, and two young surgeons, Dr. Ramadhani and Dr. Moses, who desire to be further trained in thoracic surgery. They are outstanding young General Surgeons who are forming a team around learning Thoracic procedures. They are smart, dedicated, good doctors, and get the most out of a resource-constrained environment.
The first patient I was asked to evaluate was a 36 year old female who had been in a roll-over motor vehicle accident. She had both lungs collapsed and blood around her heart. These were treated and she still was not improving. We examined her and made a presumptive diagnosis of diaphragmatic rupture. Trying to get a CAT scan was difficult because the patient could not afford the $60 cost, to be paid up front. We offered to help her with this cost with her, but she would not accept this gesture. She finally got her son to help her.
This scan confirmed the diagnosis and her diaphragm was repaired through the chest, an operation that is uncommon but also fairly successful. She began to recover immediately.
I went by the hospital sewing room, a place that I had visited in the past. They machine sew all the gowns used in the operating theatre and had developed a habit of making "bell-bottom " cuffs for the arm sleeves, an annoyance that makes sterile gloving almost impossible. The now (at least) make straight seams which is great progress. We are hoping for some progress towards a cuff, but they will need some trial material- an easy problem to solve.
Finally, walking the hospital corridors is an experience difficult to describe. Muhimbili is a large, public hospital, with every type of clinic. They take care of the uninsured as well as the political elite. The disabled are often independent in their travel and one is struck by the determination, focus, and fierce independence that they display. Even bed ridden patients are transported through long, outdoor hospital corridors, probably by family members, to secure their care. It is a privilege to be here.
Doug
March 2016 - William Schecter
Report on the Alliance for Global Clinical Training Rotation at the Department of Surgery, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
William Schecter, MD
March 25, 2016
1. Travel to Dar Es Salaam: On this trip I traveled to Dar Es Salaam via Istanbul. This is a very convenient flight from the West Coast. I stayed in Istanbul for 2 days o rest. There is a lot to see: the Blue Mosque, the Hagia Sophia, the Golden Horn, etc. However, the most exciting thing for me is related to a tunnel built from the Gihon Spring through the Ophel Hill to the Shilo Pool in Jerusalem by King Hezekiah approximately 2600 years ago to ensure that Jerusalem would have a supply of fresh water within its walls. This pool enabled Jerusalem to withstand the Assyrian siege led by Sennachareib. The tunnel was actually discovered in 1880. There were two teams of workmen working towards each other, one from the Shiloh Pool and the other from the Gihon Spring. When they met, the workers recorded their success in graffiti written in Hebrew with an early Hebrew/Phoenician alphabet (Hebrew is now written with Aramaic letters). In 1882, the wall of the tunnel containing the graffiti was removed and placed in the archeological museum in Istanbul. As I have walked the 0.5 km through the tunnel, it was a thrill to see one of the earliest, if not the earliest, written Hebrew (although I am not enough of a scholar to read the Phoenician alphabet).
2. Life at MUHAS: I was warmly greeted by all of our colleagues at MUHAS. This is the 4th year of Alliance activity in MUHAS. Our Tanzanian colleagues credit us with improving their surgical skill set.
3. Memorandum of Understanding: Shortly after my arrival, a ceremony was held with the Dean of the Medical School signing a Memorandum of Understanding between the Alliance and MUHAS. We have been trying to make this happen for several years and finally our efforts are recognized officially by the Medical School.
4. Resident Activity: I was fortunate to be accompanied by a truly outstanding resident, Dr. Jahanara Graf, from the UCSF/East Bay Surgery Residency. I met Jahanara at the PCSA meeting in Hawaii in mid February and 2 weeks later she joined me at MUHAS. As you can guess, she has a real surgical personality, decided she wanted to come and made it happen in less than a week. She has had a wonderful clinical experience but, like many of our residents, has also experienced the pain and frustration of working in a resource constrained environment. She has told me that it has been a wonderful maturing experience.
5. Data Base for the MUHAS Department of Surgery: Jahanara and I constructed an Excel based data base for the MUHAS Department of Surgery (they were not recording their cases), a death and complications protocol sheet and an Excel based data base for complications. We also ran an American style Morbidity and Mortality Conference which was very well received. Our Tanzanian colleagues say they will use the data base and begin weekly M&M conferences. Jahanara hopes to turn this project into a peer reviewed publication.
6. Case List: This has been a very busy month with a fair number of complex advanced cases. It is very gratifying to see the young surgical faculty and fellows operating with precision and self confidence, including dissection of major intrathoracic and abdominal vessels-something that was not happening here when I first arrived four years ago. The volunteer surgical educators can take a lot of credit for making this happen. I hope some of you who are kind enough to read this report will consider lending your expertise to this effort. We are concentrating on training 6 young surgical faculty members (their residency is only 3 yearslong) so that they in turn can train their resident in the future. Below please find a list of the cases I have taught in the past month:
Table1: Case list for William Schecter, March 2016
Diagnosis Procedure
Carcinoma of larynx Cancelled
Rectal adenocarcinoma Abdominoperineal resection
Chronic cholecystitis with Open Cholecystectomy
perforated gallbladder
Left breast cancer Left modified radical mastectomyIncarcerated hernia Exploratory laparotomy, small bowel
with strangulated bowel resection with primary anastomosis
Anal warts Excision of anal warts
Hemorrhoids Hemorrhoidectomy
Small bowel obstruction with necrotic bowel Exploratory laparotomy, small bowel
resection, gastrostomy tube
Ulcerating right breast cancer Right toilet mastectomy with chest
wall reconstruction
Right breast sarcoma Simple mastectomy
Perforated duodenal ulcer Exploratory laparotomy with graham
patch repair
Achalasia Re-do Heller Myotomy
Left peri-rectal abscess Incision and drainage
Rectal adenocarcinoma Abdominoperineal resection
Hepatic cyst Subtotal cystectomy,
cholecystectomy, damage control
laparotomy
Hepatic cyst Second look laparotomy, removal of
packs, drain placement
Esophageal Cancer Cancelled
Hydrops of gallbladder Open Cholecystectomy
Left breast cancer Left modified radical mastectomy
Rectal cancer Exam under anesthesia and biopsy
Obstructive jaundice Open Cholecystectomy
20x10cm open wound left flank Delayed primary closure
Question rectal mass (no mass found) Exam under anesthesia
Esophageal Cancer Ivor-Lewis Esophagectomy
Metastatic cancer En-bloc gastrectomy and transverse
colectomy, small bowel resection,
Roux-en-Y antecolic
gastrojejunostomy
November 2016 - William Schecter
Report on the Alliance for Global Clinical Training Rotation at the Department of Surgery, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
William Schecter, MD
December 1, 2016
I arrived in Dar Es Salaam on Saturday morning October 28, 2016 on a flight from London. I had attended the ACS meeting in Washington D.C., visited my daughter in NYC and spent 2 days in London prior to flying to Tanzania. The transition to the new time zone was relatively easy and I highly recommend staying a few days in Europe, Turkey or Dubai and arriving on a Friday or Saturday so you can sleep off the jet lag prior to starting work on Monday. Of course, I am retired and not everyone has the time to do this.
My Israeli resident, Dr. Ron Pery, arrived on Sunday. On Monday October 31 we attended the Dept. meeting and heard about a preventable death in a young man with a ruptured spleen who had a competent splenectomy but was sent to the ward under resuscitated and died in shock. This unfortunately is a common occurrence and as you shall see, we are taking steps to correct this problem.
Later in the morning we went with Dr. Akoko, the Dept Chair,to a ‘hydrocele camp”. This took place in a rural clinic about an hour’s drive from the hospital. There was a big room with 5 examining tables. Patients would walk into the room wrapped in a sheet and lie down on a table. The groin and scrotum were prepped and draped and a hydrocelectomy performed under local anesthesia with a spermatic cord block. 5 patients in one room with little or no privacy, 4-5 instruments and an electrocautery. By the end of the day, Ron could independently do the case with skill. We did 28 cases that day-reportedly a “light’ day. There are apparently about 3000 untreated cases of hydroceles due to filariasis in Dar Es Salaam alone. You can imagine how many there are in the entire country of 57 million people.
On Wed Nov 2 we did a Nissen fundoplication for free reflux. There is very good endoscopy here (done by both surgeons and gastroenterologists) but no esophageal manometry. When I first showed them how do a Nissen several years ago, I emphasized that they have to select the cases very carefully and they have adhered to that caution as far as I can tell. I was very impressed by their operative technique and the patient was discharged several days after surgery swallowing well with no symptoms of reflux.
On Saturday Nov 5 I helped one of the younger surgeons treat a patient with gastric outlet obstruction due to peptic ulcer disease. The stomach was gigantic and the patient had been vomiting for months. We did a truncal vagotomy and Jaboulay gastroduodenostomy. These cases are rare now in the US but I have helped them do several like this in the past couple of years. The patient was discharged and has had no further problems with gastric outlet obstruction.
Anorectal surgery has improved dramatically since Doug brought an anorectal set (courtesy of MEDSHARE) last year and I showed them how to use it. We did a few cases of very complex fistulas in ano including one supralevator fistula who is now improving significantly.
On Nov 7 we took off a giant sarcoma of the back. I keep re-emphasizing the need to remove tumors in a fascial envelope and I believe they have now adopted this principle. However, they were very reluctant to skin graft a perfectly clean wound bed, preferring to allow it to granulate (and waste several weeks of hospitalization). However you have to pick your battles and I decided not to go to the mat. They have since decided to follow my advice in the future and graft clean beds as we have had several subsequent successes.
On Nov 7 we had an interesting case, a lady with a mega esophagus and a large epiphrenic pulsion diverticulum due to either untreated achalasia or esophageal spasm for more than 20 years. She has been regurgitating her food constantly. They did a great job mobilizing the esophagus but asked for help with the diverticulum which went high up in the mediastinum and stuck to adjacent structures. It was a battle to get it out through the abdomen. I almost opened the chest but with a little more persistence was successful. After resecting the huge diverticulum, we did a Heller myotomy and Dor fundoplication. She is now home swallowing normally.
I supervised the Morbidity and Mortality Conference the following Monday and spent about 2 hours with the presenting Tanzanian resident on Sunday night. There were two terrible cases, another ruptured spleen in an 18 year old and a septic abdomen due to a 2 day old stab wound to the small intestine treated conservatively at a peripheral hospital. Both patients were sent to the ward in shock from the recovery room. Although operative technique has improved dramatically, there is very little understanding of pre and post-operative care. So three weeks ago we ran the first “MUHAS TRAUMA COURSE” which is a modification I designed of the ATLS Course. This was a suggestion of Dr. Ben Paz who was an Alliance volunteer in July. This was a “train the trainers” course. Two weeks ago, the instructors I trained the previous week ran their own course for the residents while I observed and critiqued the performance of the instructors. They did a fantastic job and the course got rave reviews from the residents. The plan is for the faculty to give the course several times a year and we have already received requests from the other surgery departments, nursing and the surgery department at the Kilimanjaro Christian Medical Center in Moshi (an hour’s flight from Dar) to attend the course.
I plan to make a new one day MUHAS PERIOPERATIVE CARE COURSE and hope to have it completed by the time I return in March so that I can again “train the trainers”. I think it is much better for our Tanzanian colleagues to take ownership of the course and give it multiple times a year to various constituencies rather than for the visitors to give the course (which happens often) but then nothing changes.
On Nov 14 we did a huge squamous cell carcinoma of the hand. Their plan was to amputate the hand but instead we were able to resect the tumor and preserve four fingers. I was trying to save the thumb as well but unfortunately near the end of the resection discovered that the tumor was invading the base of the first metacarpal bone so the thumb had to go with the specimen. We covered the defect with a large distally based radial artery forearm flap. The patient got a 100% take of the graft covering the donor defect and the flap is fine and he has full range of motion of his fingers.
Last weekend we did an Ivor Lewis esophagogastrectomy with a Roux en Y esophagojejunostomy in the chest. Unfortunately he developed a chest wall hematoma so we had to take him back 2 days later to evacuate it. However he otherwise has done well and has been discharged home. The next day Sunday Nov 20 we did an obstructive jaundice case which was billed as a cholangiocarcinoma. We opened the gall bladder-no stones. There was extensive portal lymphadenopathy. There was a palpable mass at the ampulla region. It certainly looked like a cancer but I smelled a rat. We did a common duct exploration and out popped two stones. We opened the duodenum and did a sphincteroplasty to totally exclude a tumor and then did a choledochoduodenostomy (rightly or wrongly) because the common duct was so dilated. He has done well and has been discharged. The following day we did an abdominoperineal resection for a large rectal cancer. He has done well but has been discharged home. That night I got sick and over the next two days passed what seemed like an 80 pound kidney stone!! After suffering all night, my Tanzanian friends insisted that I go to the ER for hydration and analgesia (they were of course correct—doctors are the worst patients, especially when treating themselves). It was a tough two days but I was then able to resume exercising and saw a couple of very complex patients in consultation.
Ron returned to Israel after his one month rotation. I stayed another week as I have to teach a course in Israel in mid December. We are planning a big operative week next week. We’ll if it actually happens
On November 26 we did a Whipple for a patient with a mass in the head of the pancreas. Unfortunately he did not survive and in retrospect it was an error in judgment to do such a big operation on an elderly patient. We all felt terrible and did our best to rescue him without success.
On November 28 we did an en bloc right nephrectomy, resection of a giant adrenal tumor and resection of a lateral segment of the right lobe of the liver through a right thoracoabdominal incision. The incision gave us spectacular exposure. As the tumor was up underneath the liver, I asked Dr. Henry Lau to assist. Henry is a Hopkins pediatric liver transplant surgeon who is here for a year with the Peace Corps working in Pediatric Surgery. He is a great surgeon and an expert liver surgeon and was very helpful with the dissection of the tumor off the retrohepatic cava. Today is POD # 3 and he is extubated and eating without any complications so far. The next day we did a palliative wide local excision of a giant sarcoma of the thigh that was about to ulcerate. The tumor invaded the right femoral vein. It was a battle to dissect the femoral artery off of the tumor and we had to repair a little hole in the right superficial femoral artery. We had to sacrifice the gracilis muscle so I had to swing a tensor fascia lata myocutaneous flap over to cover the exposed femoral vessels. The flap is doing fine and the right foot is warm and well perfused. He’ll need radiation therapy for local control but unfortunately will undoubtedly soon develop metastases.
I leave for Israel tomorrow evening. This letter is obviously written primarily for our surgical friends and volunteers and is filled with surgical jargon and operative details. However, I hope it may be of some interest to our non-clinical friends who read it. It is difficult to convey the sense of privilege, challenge, the elation, frustration and occasional profound disappointment that are part and parcel of surgical practice in Tanzania. I take particular pride in the dedication and skill of our Tanzanian colleagues who assure me that the efforts of the Alliance volunteers over the past 5 years have not only changed the skill set but also the attitude and dedication of the MUHAS surgeons.
Table1: Case list for William Schecter, November 2016
Diagnosis Procedure
GERD, Hiatal hernia open Nissen funduplication
Polytrauma, splenic rupture exploratory laparotomy, splenectomy
Peritonitis exploratory laparotomy, lysis of adhesions, multiple biopsies of peritoneal lesions
Cholelithiasis Laparoscopic cholecystectomy
Gastric outlet obs. Due to chronic peptic ulcer trunchal vagotomy+gastrodouadenostomy
Complex perianal fistulas fistulectomy+Drainage of left supralevator abscess
Fistula in ano fistulotomy
Giant back mass (sarcoma?) Wide local excision
Peritonitis exploratory lspsrotomy, left oophorectomy
Epiphrenic diverticulum, achalasia diverticulectomy+Heller myotomy+Dor funduplication
Anal fissure Lateral sphincterotomy
Hydrocele Bilateral hydrocelectomy
Thumb SCC WLE+distal radial flap+skin graft
Peritonitis due to perforated rectal cancer laparotomy, double barrel colostomy, washing and drainage
Right IDC simple mastectomy+ level 2 axillary dissection
Intra abdominal tumor Mini laparotomy+biopsy
Acute colon pseudobstruction Transverse loop colostomy
Multinudular goiter Hemithyroidectomy
Distal esophgeal cancer Ivor lewis esophagectomy+gastrectomy
Obstructive jaundice Open cholecystectomy, bile duct exploration, sphincterotomy+ sphincteroplasty+choledochoduoadenostomy
Rectal carcinoma APR
Distal esophgeal cancer Wound exploration
Obstructive jaundice Whipple
Giant adrenal tumor Right thoracoabdominal incision, en bloc excision of right kidney and adrenal and lateral segment of right lobe of liver
Right supralevator fistula in ano Excision of fistula tract
Sarcoma Right thigh Excision wide local of mass, repair of RSFA, Right TFL Flap