October 2012- Week One - William Schecter

Arrival

We (my wife Gisela and I) arrived by way of New York and London to Dar es Salaam.  I think it is preferable to stop for 12-24 hours in Europe to rest so that recovery from jet lag is shortened and you can begin the clinical rotation in better physical shape after arrival.  We arrived on a Friday morning.  There is a direct flight from London to Dar es Salaam which takes about 9-10 hours.  We were met by a driver from the Muhumbili University of Health Associated Sciences (MUHAS) and taken directly to the Kalenga House on Kalenga Road.

Accommodations

We arranged our transport and our accommodation at the Kalenga House through MUHAS which has a formal relationship with UCSF.  Dr. Terry Reynolds, who is the Director of the Emergency Medicine Residency Program at MUHAS and resident in Dar es Salaam for most of last year, was very helpful in supplying this information.

The Kalenga House is a relatively new two story building with multiple rooms (small for two people), some of which contain private bathroom facilities and showers.  All rooms have air conditioning (essential in Dar es Salaam—particularly at this time of year).

Initial Arrangements

We met Dr. Jessica Beard, our first UCSF Surgical Resident on rotation with me, at the Kalenga House.  Jessica is doing research projects in Tanzania this year and is fluent in KiSwahili.  She has been here for two months and has spent extensive time in East Africa previously.  She was most helpful in getting us organized the first day.  The key issues are:

1.   Cell phone Service:  You MUST have a cell phone to function in Africa.  We immediately went to the Vodafone Store and bought cell phones for approximately $20.00.  I also bought approximately $40.00 in minutes.  Once you have a cell phone, you can function as your colleagues can (and will) reach you when they need you.

2.  Internet Access:  There is Wifi at the Kalenga House but at the present time it is HIGHLY unreliable.  Thebest thing to do is buy a modem for your computer.   You can also insert a Tanzanian SIM card in your IPAD but I elected not to do this as I didn’t wamt anyone fiddling with my IPAD (rightly or wrongly).  Jessica advised us to go to the Zantelcellular company as their modem apparently is more reliable than

Vodafone.  The modem cost about $40.00 and a similar fee for 5 gigabytes for one month of usage.  This has been very reliable and the Internet Access relatively rapid.  Perhaps we should have used Zantel for the cell phone as well.  In any case, the process was relatively painless and within 2 hours we had cell phone and Internet Access.

3.   Groceries:  You will need to purchase groceries.  The best grocery store is Shopper’s, an inexpensive cab ride from the Kalenga House.  The kitchen in the Kalenga House is well equipped.  If you are challenged in the kitchen (as I am—Gisela is near Arusha at the National TB Hospital for a week of work but will return today), there are plenty of Indian Restaurants which serve good food for dinner.

4.  Recovery from the Trip:  We spent most of the weekend resting and sleeping.  We took Melatonin in the evenings and slept through the night.  It was the easiest recovery from jet lag that I had ever had.

5.  Cash:  Barclay’s Bank ATM’s are a cab ride away and offer cash with your Debit Card at no cost for the transaction.  There is an ATM within the hospital grounds that charges for the transaction

Department of Surgery Schedule

There are two surgery firms: 1 and 2.  Firm 1’s focus is gastrointestinal disease and Firm 2’s focus is thoracic surgery.  In practice they both do the same cases.  Most of the “thoracic” work is chest tube insertion although they did a right thoracotomy to remove a giant fatty tumor arising from the mediastinum and occupying most of the pleural space—hopefully a giant lipoma although the histology is not yet back).  Jessica and I elected to join Firm 1 and are functioning more or less as regular members of the Firm.  The academic and clinical schedule for Firm 1 is listed below.  The schedule for Firm 2 is the same except that they have a different operating and clinic schedule.

Monday

07:30-09:00           Department Wide Meeting and Morbidity and Mortality Conference
09:00-pm               Ward Rounds and Elective Surgery

Tuesday

07:30-09:00           Resident Presentation (similar to our “Schecter Conference”)
09:00-pm               Clinic

Wednesday

08:00-09:00          Ward Rounds
09:00-pm               Elective Surgery

Thursday

07:30-09:00           Resident Presentation Conference
09:00-11:00            Grand Rounds—this is a major teaching rounds at the bedside with students presenting the cases and being grilled by the faculty.  Everyone is dressed in white coats and standing at attention.  All business work is conducted in English but social discussions occur in KiSwahili--this is the way bedside teaching used to be. 

Friday

08:00-09:00          Ward Rounds
09:00-pm              Elective Surgery

Personnel:

In my next report I will submit a detailed list of the Department of Surgery personnel with contact information.  As a brief overview, the Surgery Department is divided between the University surgeons and the Muhumbili National Hospital Surgeons.  They all work together but as you can imagine, there are the usual political intrigues that are present in every University Department (of course we don’t have any of those problems at UCSF!). There are several young faculty members.  Residency here is only 2 years.  They are highly intelligent and highly motivated.  Their enthusiasm for learning is both uplifting and infectious.  They have an excellent fund of knowledge but their surgical repertoire and technique are limited.  I showed up on Monday morning and immediately after the morning meeting they asked me to demonstrate a thyroidectomy in a patients with a large vascular goiter due to Graves Disease.  I was amused as I thought they were pitching me (the new guy from San Francisco) a challenging case to see what kind of trouble I got into).  Jessica spoke to them in KiSwahili afterwards and apparently no, they just wanted to see how to do a thyroidectomy.  It was the first time that they had seen the recurrent laryngeal nerve.  They usually just cut through the thyroid and not expose the nerve

(which is not a bad way to do it given the circumstances as they say they have few complications).  Immediately after the thyroid, a young surgeon from Firm 2 asked if I would help him do a modified radical mastectomy.  I helped his resident do and en-bloc mastectomy and axillary dissection removing all the nodes in a fascial envelope.  They had never seen anything like this before and had never seen the intercostobrachial, long thoracic and thoracodorsal nerves in a clean axillary bed.  All of their patients present late with bulky nodal disease in the axilla.  I suspect they berry pick a couple of the biggest nodes in the axilla and go home as they were very concerned about dissecting out the axillary vein.  At any rate, they were very appreciative and have since asked me to help with another modified radical mastectomy.

So in summary, we have been very well received by the students, residents and faculty and as far as I can tell there is no interpersonal tension or resentment caused by my presence.  In fact, they have solicited my advice on many cases and followed it every time (hopefully for the patient’s benefit).   On the other hand, I have modified my practice to a certain extent to make sure that both my operations and my advice did not violate their “comfort zone”.  They know much more about their patients’ response to surgery and their diseases than I do right now.  I am teaching basic surgical principles but following their lead otherwise.

Pre and Post Operative Care:

Our residents are not coming here to learn pre and post operative care.   Residents and future faculty will have to be screened to make sure that they can emotionally tolerate the level of care and the interaction with patients that they will find here.   If you are unwilling or unable to practice African Surgery, you will be very unhappy and likely create animosity that will endanger the sustainability of this effort should the Department decide to proceed after this trial effort.  You will find patients lying around for many hours (or perhaps even a day or more) with peritonitis, intubated patients transported from the ICU breathing spontaneously through an endotracheal tube connected to the atmosphere with no oxygen, patients admitted to the surgery service in the ICU with a pH of 7.22 breathing at 50 times per minute without informing the surgeons.  I discovered such a patient last night at 22:00 while visiting one of my patients there.  You also have to be comfortable making clinical decisions including the decision to operate with little or no imaging (the CT scanner is broken) and almost no laboratory work.  When there is lab work, it is often more than 24 hours old. There is one other point.  You will meet many of your elective patients in the OR.  They have been evaluated by someone else.  You will probably be asked to assist a resident or demonstratethe operation yourself.  Of course this is not the way we practice surgery nor do we want our residents to practice this way.  However, I do a careful personal evaluation of the patient (briefly) and have proceeded—so far without any problems.  If you have a real problem in the operating room, the “system” will probably not be able to rescue you as there is limited blood, most of the anesthetists are not physicians,  and the ICU capability is limited.  The nurses are diligent, hard working but do not have the education, training or skills of our ICU nurses.  I mention all of this not to criticize this institution which is doing outstanding work but to emphasize that the people we recruit to this program (should you wish to continue it) must have the flexibility, the cultural sensitivity and the emotional stability to work in this environment.  Our surgeons also must be comfortable doing a wide variety of cases as you will see with the case list I will present below.

Operative Case List(Cases scrubbed by Drs. Schecter and/or Dr. Beard )

Diagnosis                                                                    Operation
Graves Disease                                                            Subtotal thyroidectomy
Direct LIH                                                                    McVay LIH repai
Ca R breast                                                                 Right MRM
Recurrent dermato- Fibrosarcoma rt neck               Wide local excision and neckdissection
Cholelithiasis                                                              Open cholecystectomy
Ca R breast                                                                 Right MRM
Chronic appendicitis                                                  Appendectomy
Blunt perforation of 4th duodenum                          closure of 4 day old perforation, peritoneal
                                                                                    toilet, open abdomen followed by
                                                                                    repeat washout and definitive closure 24
                                                                                    hours later
Ruptured spleen                                                         splenectomy
Perforated jejunum due to TB                                    small bowel resection
Gangrene of leg                                                          Guilloutine above knee amputation
Soft tissue tumor abdominal wall                               wide local excision

There is only limited availability of mesh for herniorrhaphy.  As you can see, I did a McVay repair for an elderly man with a direct inguinal hernia (I haven’t done one of these for 20 years as I consider it an obsolete operation and prefer mesh).  However, it was the perfect solution in this situation and it was the first time that Jessica has seen a Cooper’s ligament repair (or the first time that my Tanzanian colleagues had seen one for that matter).  They asked me to demonstrate a herniorrhaphy and I helped their resident with Jessica assisting.  They do a Bassini repair, which is ok for an indirect hernia but probably not ideal for a complex direct hernia.

Clinic

My job in clinic was to listen to medical student presentations and make decisions with them on these patients.  I worked with a Tanzanian resident.  Jessica worked with the Head of Firm 1 in another room and saw an equally interesting group of patients.  Breast cancer here is a huge problem and all of the patients I have seen so far have presented with either advanced or far advanced disease.  Below is a list of the patients I personally saw in clinic on Tuesday with the medical students:

1. Stage 2 breast cancer, 2. Inflammatory breast cancer, 3. Kaposi Sarcoma of leg in HIV + man, 4. Large soft tissue tumor of upper arm, 5.  Bulky rectal carcinoma (missed during a previous hospitalization 2 months ago)

Initial Impressions

So far the experience is working out better than I had anticipated.  My reception here has been warm and kind.  Jessica is a known entity in the Department, speaks fluent KiSwahili and I visited last year and met most of the people when I negotiated the arrangement.  I am sure these factors eased the transition.  If I ever decide to make a major time commitment to Tanzania, I would go to school for a couple of months to learn KiSwahili.  The doctors speak excellent English but very few patients speak English, most of the nurses speak only rudimentary English (and why should they, KiSwahili is their language), and the people on the street speak almost no English.  I will send another report on our progress next week.