October 2012 - Week Three - William Schecter

Lawrence Oresanya arrived on Sunday, November 4, and will begin his rotation next week after Jessica Beard rotates off the Service.  Last week we became more integrated into the service and both Jessica and Eveline worked on emergency and elective cases.  We are seeing a lot of regular general surgery cases presenting with far advanced disease and fewer “tropical diseases” than I anticipated. 

Academic Program

We are attending all the Department meetings and the Resident Teaching Conferences.  The quality of the conferences varies but in general is quite high.  In addition, both Jessica and Eveline are preparing case conferences for our own small group based on interesting cases that we have seen.  I have also given a case conference to our residents and anticipate giving additional ones.  Our days are quite long and so we are not having as many conferences as I anticipated (which is good in the sense that we are all very engaged clinically).

Security

A word about security:  The Kalenga House where we are staying was originally built by UCSF for the XXXXX Program.  This program has now ended and the Kalenga House has been turned over to the Muhimbili University.  It is located within a walled compound and has a full time security guard (as do most establishments of this type in Africa in my experience).   The door of the building within the compound is also kept locked most of the time unless one of the residents is in the common room.  Valuables are safe within the rooms (which are also kept locked).   It is a short walk from the Kalenga House to the gate of the Muhimbili National Hospital/Muhimbili University of Health Associated Sciences complex which is also a guarded walled compound.  Walking in this area during the daytime is safe.  There are few lights in Dar Es Salaam compared to most cities in the west.  Women should not walk alone at night.

Midpoint Evaluation

This is the fourth week of our eight-week experimental program.  I have scheduled a meeting for a midpoint formal evaluation with the Chair of Surgery and his faculty as well as our residents to take place on Thursday, November 9, 2012.  Informal discussions indicate that Muhimbili residents and faculty are pleased with our presence.  We have talked about ways of better integrating our residents into the call schedule (which has obvious challenges because fluency in Kiswahili is very important.  However, this is a solvable problem and I anticipate a satisfactory resolution after Thursday based on the initial discussions.   I have the feeling that everyone wants to make this work and there is a lot of good will and a minimum of politics (as best I can tell with my rudimentary Kiswahili!)

Challenges for the UCSF Residents and Faculty

1.      The Kalenga House:  The great advantage of the Kalenga House is the proximity to the hospital and the security.  However, communal living is not for everyone and some future faculty members here for an extended stay may wish to live in an apartment.  I will investigate this option.  The most attractive places are near the beaches but the traffic in Dar Es Salaam is horrendous and traveling 3-5 kms at rush hour can sometimes take an hour or more.  There are some apartment buildings near the hospital and I will also check these out.

2.      Integrating into the Service:  As in any new environment, learning how to make things work is a challenge, especially if you don’t speak the local language.  However, our Tanzanian colleagues at every level have looked out for us and done their best to ease the transition.

3.      The greatest challenge, particularly for the residents, is dealing emotionally with the level of pre- and postoperative care which of course is quite different than in the United States.  Laboratory data is often non-existent and when available is usually at least 24 hours old.  In essence, the patients are on automatic pilot.  Concepts of ventilation and oxygenation are quite different than our own standards. Nutritional support is not available.  Almost all food is supplied by the family.  If the family doesn’t bring food, the patient doesn’t eat unless very special arrangements are made.  This has been hard for the residents.  On the other hand, these patients are incredibly resilient and have survived experiences which surprised me.

 

Case List

Diagnosis                                                        Operation
Goiter                                                              Right thyroid lobectomy
Carcinoma left breast                                     Left modified radical mastectomy
Tumor of back                                                 Wide local excision
Wound dehiscence                                          Laparotomy, drainage of abscess, open abdomen
Cecal diverticulitis                                           Cecectomy                
Incisional hernia                                               Ventral herniorrhaphy                                         Carcinoma left breast                                      Left modified radical mastectomy
Open abdomen                                                Peritoneal toilet and abdominal closure
Perforated GU                                                 Graham patch
Incarcerated inguinal hernia                           Bassini repair and hydrocelectomy and
                                                                         hydrocele                            
Blunt small bowel injury                                 Small bowel resection
Sigmoid volvulus                                            Hartmann Resection
Sigmoid volvulus                                          Sigmoidectomy and primary anastomosis
Pancreatic injury                                            Exploratory laparotomy
Airway obstruction                                        Tracheostomy

Overall Impression

Last week was an excellent week.  If our progress continues at this rate, I believe the rotation will be very successful.