November 2013 - James Peck

We are not the only "foreigners" here at Muhimbili National Hospital (MUHAS). There are 25 Chinese doctors from Shandong Province at MUHAS alone. They are here for 2 years and are then replaced by another 25 two years later. There are more than 50 Chinese physicians in the rest of Tanzania from the same Province.` One of the best anesthesiologist at MUHAS is a resident from New Zealand. There is a pediatric surgeon from Cuba. German physicians are her to do gastroenterology and babies.There is a number of German medical students.The head of the Emergency Medical Department is Teri Reynolds, MD,MS, PhD from UCSF Moffitt hospital. Today the ER was staffed by Dr. Allison Webber from UCSF with one of her residents and an ER Nurse (Tracy) from UCSF, Dr Ross was the other supervisor from Canada. There are ER docs from University of Chicago. There is a cardiologist from South Carolina.

Here is the schedule and the patients we are see in on the ward and in the clinic.  Jim and Mac

Schedule:

     Monday: Department of Surgery Meeting @ 0730 (Grand Rounds)
                    Operating Theatre @ 0830 +/-

     Tuesday: Morning Report by Interns on Admissions @0730
                     Clinic "Firm ONE" (Team 1) @ 0900 till 1300
                     Ward Rounds with Professor and Med.Students "Firm Two" @ 0900
                     Then Elective Surgery Scheduling @1300
                     Tumor Board @ 1400

    Wednesday: Master Thesis on occasion @ 0730
                         Operating Theatre @ 0830

     Thursday: Morning Report by Interns on Admissions @0730
                      Clinic Firm Two (Team 2) 0900 till 1300
                      Ward Rounds with Professor and Med.Students "Firm ONE" @ 0900
                      Then Elective Surgery Scheduling @1300

      Friday:  Morning Report @0730
                   Operating Theatre @0830

Ward rounds on Tuesday or Thursday: 

      Esophageal Carcinoma: 5 patients
      Obstructive Jaundice: 4 - most pancreatic CA
      Breast Cancer: 6
      Colon/Rectal/Anal cancer: 4
      Thyroid Cancer: 2
      Skin Cancer: 4
      Cutaneous apocrine carcinoma of scalp, Melanoma,Marjolin's ulcers
      Hepatoma: 3
      Lung Abscess: 2
      Mediastinal Tumor:2
      Sarcoma:  5
      Acalasia;, esophageal stricture: 2
      Splenomegaly: 1
      Chest tube/splenectomy for Trauma 2
      No hernias, no gallbladders.

Clinic on Tuesday/Thursday mornings:

      Thyroid disease - cancers and hyperthyroidism
      Diabetic gangrene
      GERDS
      Kaposi Sarcoma
      Fibrous histiocytoma,
      Post op care: amputations, SBOs, Breast Cancers
      Ganglion cysts
      Adrenal tumor - 6 cm
      Nipple discharge
      Skin cancers: albino
      Popliteal aneurysm

September 2013 - Laura Goodman

I traveled to Dar es Salaam for the month of September 2013 with UC Davis Surgery Professor Dr. James Holcroft. Muhimibili University of Health and Allied Sciences (MUHAS) was on summer vacation at that time, and my experience was not typical for a resident visiting MUHAS and Muhimbili National Hospital. There were no Tanzanian residents and no medical students during my time there. The normally scheduled educational conferences were on hold.

I rotated through Firm I and Firm II at the recommendation of Dr. Mchembe to see different cases (thoracic on Firm II) and work with different consultants and registrars. I went to the operating theatre for elective cases, which were scheduled three days per week, with an average of four cases per day.  When invited by the consultant surgeon, I scrubbed on the elective cases, of which the most common procedure was mastectomy for advanced breast cancer. Firm I completed 8 mastectomies in September, of 49 total cases.

I attended morning report each day, and I took call with the registrars, seeing consults with some, and simply attending the operations with others. The cases in which I was the most involved in happened on call – perforated peptic ulcer and sigmoid volvulus were the most common. Weekly major ward rounds were a part of my routine as well – and these included teaching of the interns and the visiting medical students from Germany (no Tanzanian students, because as mentioned, they were on vacation). I attended clinic weekly and saw disease states in this setting, for example, elephantiasis in a 25 year-old woman, which I have not seen in the US. I went to tumor board each week, and noted the very different practice of bringing each patient to the meeting while his or her case was being discussed. I visited the pediatric surgery wards in my last week. There are advanced pediatric surgery cases being completed at Muhimbili, for example, endo-rectal pull-through procedures for Hirschprung’s disease, in the absence of a pediatric surgeon. I was not able to observe any of these cases, but in the future would spend some time with the Pediatric Surgery Firm.

Pros:

Extensive exposure to disease states not seen in the US, such as very advanced cancers, and surgical infectious diseases including typhoid (jejunal perforation) and tuberculosis (scrofula). I found that major ward rounds and clinic gave me the best exposure to the variety of disease states. There were a few cases seen on the wards that were discussed and scheduled for operations, which I was able to either see or participate in.

Teaching opportunities. I frequently rounded with the interns on the wards in the mornings and found that this was a good opportunity to teach and discuss post-operative management, but this was often at the expense of operative time, as rounds didn’t start until after morning report, when the elective operations started.

My experience was very useful for understanding a different training paradigm and different operative techniques. Some of the consultants are great teachers. The registrars and interns were very interested in exchanging experiences and ideas.

Areas for improvement:

The operative volume was not sufficient to allow residents to be involved in elective cases without bumping out an intern assistant, or an attending surgeon. It is very important to prioritize the education and practice of the local trainees, thus I was not willing to take a case if the intern (many of whom are interested in pursuing surgery) would then not be able to be involved. There are many more patients who require operations than operations that are completed. There was a Chinese visiting surgeon attached to Firm I from the day we arrived, completing a 1-2 year volunteer stint at Muhimbili. This further limited the opportunities to be involved in elective cases, but the case volume remained the same throughout the month.

Postoperative care was largely absent.  I struggled to cope with my lack of efficacy in taking care of patients post-operatively. Vital signs, labs, administration of IV fluids, and retrieving blood for transfusion became the responsibility of the intern (or the visiting resident) when required. This was very difficult for me to understand – but the nursing staff is very limited in number, and this plus lack of supplies (e.g. sphygmomanometers and normal saline) limits their practice. Additionally, ICU beds are in very limited supply and I found patients who required ICU level care could not be transferred.

The structure of the team, the schedule, and the conduct of post-operative care were somewhat opaque – having a resident assigned to the visitors for guiding them to operations and other Firm activities would solve this problem and help with integration into the team.

In the clinic, I was shadowing a consultant surgeon instead of seeing patients alone primarily for language reasons - I don’t speak much Kiswahili and no translators were available (nurses were too busy). I advise visiting residents in the future to either come with more language skills or find a resident/registrar to pair with for clinic. I did not see a registrar in clinic, and as mentioned, the residents were off on vacation during my month at Muhimbili.

I would suggest that visiting residents in the future do not go during the MUHAS vacation months so that residents and medical students are present. In 2013, the vacation months were August and September.

July 2013 - Week Four - Benjamin Howard

Dear colleagues and professors,

It's hard to believe that a month has gone by, but we've come to the end of our time here in Dar es Salaam. Like rotations back home, just when you're really getting the hang of things, time to move on...

Looking back, it's been an amazing mix of exhilaration, exhaustion, and, at times, exasperation.

The burden of surgical pathology here is staggering, and our time in the operating room has been phenomenal. Being able to "apprentice"

with Dr, Schecter, and to work closely with the residents and surgeons here, has been an incredible opportunity, and I've filled my notebook with pictures, operative notes, and observations. The relative autonomy of the on-call overnight operations (with backup from Dr.

Schecter) has been a bit like being in surgical training in "the good old days"... a remarkable experience, and one that made me glad for all my time in the OR last year with Dr. Harris!

Beyond the OR and the wards, the perspective I've gained as to the underlying challenges of "global surgery" cannot be overstated. From witnessing the depth of resource limitations to navigating the nuances of being a Western guest in a "developing" country, every day has been a lesson in disparity, culture, and humility.

I alluded last week to the frustrations of working in this setting, even beyond the expected problems of resource limitations. Perhaps a brief account of our day Monday would serve to illustrate the point

best:

We were scheduled to perform an exploratory laparotomy and possible resection/bypass of a presumed cholangiocarcinoma in a 77 year old woman with obstructive jaundice. Unfortunately, the anesthetist (I've only seen one or two M.D. anesthesiologists here) had difficulty with her airway, and on a second attempt at intubation the patient vomited and aspirated. We turned her and mask-ventilated for several minutes, but she quickly developed an upper airway obstruction, likely due to laryngeal edema and bleeding/aspiration. After trying to manage her conservatively with no significant improvement, and no available anesthesiologist, we soon found ourselves scrubbing not for a biliary case but for an emergent tracheotomy. In the end we got her tracheostomy tube in and got her to the ICU, but not before a maddening multi-hour series of delays and hiccups, from empty oxygen tanks to excessive paperwork to rough handling on transfer. Once in the ICU, she remained stable for the first day, though her kidneys began to shut down that night... unfortunately, nobody was informed until she had been anuric for 8 hours. Late on the second day she developed worsening pneumonia and respiratory failure, which we discovered only by making late evening rounds after an emergency case.

We spent a good deal of that night hand-ventilating her and trying to support her in any way possible, ruling out intervenable causes of her respiratory demise, but without rapid blood gases, portable chest x-rays, nebulizers, advanced ventilators, or effective respiratory therapy, our options were pretty limited. She arrested - "collapsed" - early the next morning.

One of many similar experiences, which underscores the fact that surgical quality does not begin and end with us, and that without competent, safe anesthesia and perioperative nursing, our efforts can be only so effective. (To that end, we've been lucky to be joined by U.S. colleagues from both anesthesia and nursing this month, as they assess the potential for a long-term partnership and presence here.)

Being in the thick of things in this environment also makes one think long and hard about the causes of endemic underdevelopment, and what the prospects for improvement might be. But that's probably a conversation for a different forum...

On a more positive note, this week we saw several of our patients taking big steps in the right direction: Our 21 year old woman with the perineal tear and pelvic fracture from a motorcycle crash, who had an ex lap and a diverting sigmoid colostomy, went home on crutches. I was stopped in the hallway by the 33 year old who had the stab wound with evisceration and underwent ex lap with closure of the jejunum, all smiles and back to get his sutures removed. Two of our young men with acute abdomens (the 25 year old with the history of childhood laparotomy and acute SBO requiring small bowel resection, and the 22 year old man with peritonitis from a pre-pyloric ulcer requiring ex lap and Graham patch) both came back to clinic, doing very well. Our gentleman from last week's case presentation, with the obstructive jaundice, went home with resolved symptoms and a decreasing bilirubin on post-op day 7 s/p open cholecystectomy, CBD exploration, and choledochoduodenostomy. And the woman who had the thyroid cancer invading her trachea went home with her tracheostomy and feeding gastrostomy, five weeks after her initial operation.

Here's a selected list of cases we were involved with this week:

- The above-mentioned tracheotomy, for a 77 year old woman with presumed cholangiocarcinoma and acute upper airway obstruction.

- A trauma exploratory laparotomy and splenectomy for a 38 year old woman status-post "motor traffic accident" with multiple rib fractures, an acute abdomen, and a positive FAST in the splenic view.

- A resection of an enormous (>20cm diameter) lipoma from the posterior neck in a 71 year old man.

- A modified radical mastectomy in a 51 year old woman with right breast carcinoma.

- A sigmoid colectomy in a 63 year old woman with recurrent diverticulitis.

- A colostomy takedown in a 63 year old man who had previous enterocutaneous fistulae and diverting loop colostomy.

- An EUA and diverting sigmoid colostomy in a 30 year old woman with advanced rectal cancer.

- A massive ventral hernia repair in a 46 year old woman who most of her small bowel and colon in her hernia sac (but no loss of domain!).

Thanks very much for your messages and support this past month - I look forward to seeing you all back home, ben

Benjamin Howard, MD, MPH
UCSF Department of Surgery

July 2013 - Week Three - Benjamin Howard

Dear Colleagues and Professors:

This marks three weeks here in Tanzania, and it's been another seven days of incredible experiences, fascinating cases, and sometimes difficult lessons in the realities of "global surgery."

Last Monday was "Morning Meeting," the equivalent of department-wide grand rounds, and since the residents had been busy preparing for exams, our hosts were gracious enough to offer me the opportunity to give the weekly "Case Presentation." I followed the format of our Red/Blue service case conferences, using the literature to answer a patient-specific question, which was an interesting exercise - especially since it came off as a bit different from their usual style, which emphasizes the subtle details of the history and exam.

The case was a 31 year old man with recent history of right upper quadrant pain followed a few weeks later by the development of obstructive jaundice. Based on the history, labs, and imaging, the etiology seemed to be related to benign calculi. I reviewed the pertinent data, our general approach to such a patient, the sensitivity of the studies involved, the historical shift in treatment that occurred with the widespread availability of ERCP and its mortality/morbidity compared with open CBD exploration, the more advanced laparoscopic techniques - even got to show Dr. Carter's video of lap CBD exploration (as seen on youtube!). In the end, given our resource limitations in this setting (no ERCP or advanced laparoscopy, and T-tubes and cholangiography hard to come by), and after consulting with Dr. Schecter, I advocated for an open cholecystectomy with (open) common bile duct exploration, and possible biliary-enteric anastomosis. After some good (and a few tough!) questions, and after some consideration, the senior attending surgeons agreed, and we booked the case the following day... What a difference the lack of interventional endoscopy makes! All went well, and the patient is recovering (with decreasingly yellow sclerae) on the ward.

 

As for the wards, well, they look almost like those iconic images of crowded early-twentieth century American hospitals, the patients lined up in cots within arm's reach of each other - at times, on cots on the floor. The white mosquito nets are draped overhead during the day, and tucked tightly over each patient from sunset to sunrise. The windows are open to the outdoor breeze, which is nice on the upper floors, but not so nice when it gets hot - right now it's the coolest time of year, which means pushing 90, with 90% humidity. Last Wednesday the wards were being "fumigated," which meant that all patients spent the day outdoors under tents and trees. Once I got over the sight of the "outdoor hospital," I must admit that I was impressed with the nurses'

strategic skill in orchestrating the movement and care of so many displaced patients.

Though vital signs are recorded regularly on the wards, labs can take days to be resulted, and non-urgent radiology studies usually take several days to be completed. With the paucity of available data, morning rounds become rather empiric - instead of focusing on a magnesium level or a chest x-ray, one must take a more global view based on the information at hand - general appearance, heart rate, chest auscultation, a careful abdominal exam, post-op progression or regression, overnight symptoms and their sequence - I'd like to think that Sir Zachary Cope would approve. The ability to intervene is also limited - medications may be unavailable, there's no such thing as parenteral nutrition, and patients usually get their food from home.

Needless to say, from the wards to the operating "theatre," practicing in such an environment requires extraordinary patience, flexibility, and a willingness to adapt one's clinical judgment to often less-than-ideal information and resources.

Here's a selection of some of the cases we've been involved with this week:

- Exploratory laparotomy, sigmoid colectomy in a 53 year old man with sigmoid volvulus, with classic x-ray findings and clinical exam (the sigmoid colon was clearly outlined on his abdominal wall, 15 cm in

diameter.)

- Modified radical mastectomy in a 36 year old woman with left breast ductal carcinoma.

- Open cholecystectomy with common bile duct exploration and choledochoduodenostomy in a 31 year old man with recent cholecystitis and persistent obstructive jaundice.

- Feeding gastrostomy in a 60 year old woman with esophageal cancer invading the trachea, T-E fistula who had resection with tracheotomy three weeks prior.

- Exam under anesthesia for a 56 year old woman with an exophytic rectal tumor who had reported prior APR; in actuality had just had diverting colostomy. (We are planning possible APR this week.)

- Another modified radical mastectomy in a 68 year old woman with locally advanced breast cancer, with peau d'orange.

- Exploratory laparotomy in a 46 year old man with gastric cancer, with equivocal CT findings; determined to be unresectable intraoperatively, with gross invasion of the transverse mesocolon, satellite lesions through the duodenum.

- Abdominal perineal resection in a 41 year old woman with distal rectal cancer, who had attempted treatment with herbal remedies for the past two years.

- Omental resection, McVay repair in a 70 year old woman with incarcerated left femoral hernia.

- Open tracheotomy in a 77 year old woman who had traumatic intubation and upper airway obstruction in the OR.

 Hope all's well back home; if you'd like to get in touch, please use my gmail account, benjaminhoward@gmail.com.

Kwaheri,

ben

Benjamin Howard, MD, MPH
UCSF Department of Surgery

July 2013 - Week Two - Benjamin Howard

Dear Colleagues and Professors:

Wanted to check in again to let you know how things are going here in Dar es Salaam. It's been two weeks, and though some of the routines of the surgical service here are becoming familiar, I find myself amazed each day by the vast differences in surgical practice on "the other side" of the world.

One major difference is trauma. As we all know (especially after recent events at SFO), the coordinated pre-hospital trauma system in San Francisco gets patients to the General pretty quickly - we often get the page as the patient is rolling in the door... Not so in Dar es Salaam. At first, I wondered why we saw relatively little critical trauma on call nights, especially given the burden of vehicular injuries in the city. What I'm coming to understand is that most critically injured patients don't make it off the street. If they survive long enough to be transported (usually by a family member) to the ED, they have essentially passed a sort of stress test. The unstable "Room One traumas" that we rush to manage at SFGH rarely get to the hospital here. When a trauma patient does arrive, the surgical team does not "run" the traumas, and is only called once the ED determines that surgical consultation is merited. As such, the last two trauma laparotomies that we had were hemodynamically stable, and by the time we were booking the case it had been at least two hours since the actual time of injury. Makes one truly appreciate not only the surgeon, but the integration of systems and institutions that allow for the "saves" of severely injured patients in San Francisco.

Oh, and there are essentially no CT scans for trauma, which tends to broaden the indications for exploratory laparotomy.

Another big difference is overnight call - I suppose the best description is "old school." Residents are in-house alone (without an

attending) overnight, and they operate very independently, making most decisions and performing most cases by themselves, with the intern assisting. They are thus more than happy to have another pair of hands around. On call nights, we trade off on who will be the "surgeon" for each case. Needless to say it's been an incredible operative experience - and of course, I have the privilege of being able to consult Dr. Schecter at any hour for questions or operative guidance.

Here's a selected list of some of the cases Dr. Schecter and I have been involved with this week:

- Open feeding gastrostomy in a 39 year old woman with esophageal cancer who developed an iatrogenic tracheoesophageal fistula after rigid esophagoscopy performed the previous month.

- Urgent Bassini repair of an incarcerated inguinal hernia in a 35 year old man; you only get mesh if you pay for it.

- Mesh repair of a recurrent inguinal hernia in a 61 year old man (who could pay for his mesh).

- Exploratory laparotomy for trauma in a 21 year old woman sustaining multiple injuries, including T7/8 spinal fracture with gross dislocation and paralysis, who presented with hypotension, decreased hematocrit, and an initial positive FAST.

- Excision of a 30cm soft tissue mass in the left posterior thigh of a

60 year old man; mass was adherent to the sciatic nerve.

- Takedown and resection of prolapsed ascending loop colostomy, conversion to end sigmoid colostomy in a 47 year old man with advanced metastatic rectal cancer, previously treated with chemotherapy.

- Exploratory laparotomy, repair of jejunal perforation, closure of abdominal wall stab wound in a 33 year old man who presented with a left flank stabbing through which approximately 50 cm of small bowel had eviscerated.

- Total thyroidectomy in a 26 year old woman with long-standing refractory toxic goiter.

- Rigid esophagoscopy and biopsy of distal esophageal mass in a 60 year old man with dysphagia, barium swallow showing obstructive mass.

- Exam under anesthesia with biopsy of recurrent anal warts in a 13 year old boy with HIV who had prior resection of a Buschke-Lowenstein tumor with diverting colostomy; planned anoplasty was deferred given the finding of warts just under the closed perianal skin.

And for a quick survey of inpatient pathology, here's a list of the patients we recently rounded on in the male ward, some admitted within the past 24 hours, others longer-term ward residents...

- 35 year old man post-op day 12 s/p repair of ileal perforation, likely due to typhoid.

- 65 year old man with leprosy (yes, leprosy), leonine facies, and no digits, with distal lower extremity osteomyelitis.

- 23 year old man transferred for "peptic ulcer," though diagnosed on rounds to have TB pericarditis and congestive hepatomegaly.

- 53 year old man 7 years s/p right hemicolectomy for colon cancer, with fever, pain and leukocytosis, awaiting CT scan.

- 60 year old man post-op day 5 for AKA for diabetes-related gangrene.

- 70 year old man with obstructive jaundice from pancreatic head mass.

- 60 year old man with jaundice and ascites related to hepatocellular carcinoma.

- 61 year old man with exacerbation of chronic scrotal swelling, associated with abdominal pain, awaiting imaging.

- 31 year old man with acute cholecystitis and obstructive jaundice, awaiting cholecystectomy with common bile duct exploration (no ERCP here).

- 75 year old man with approx 10cm breast mass, grossly positive axillary lymph nodes.

- 57 year old man with fixed left gluteal tumor, likely squamous cell carcinoma.

- 70 year old man with hematemesis and wasting, found to have advanced gastric cancer.

- 33 year old man s/p ex lap and repair of jejunal perf, left flank stab wound with evisceration.

- 61 year old man with right upper quadrant pain, jaundice, and a history of alcohol abuse, awaiting imaging.

- 48 year old man s/p resection of prolapsed ascending loop colostomy, now with end sigmoid colostomy.

- 62 year old man who was readmitted with wound dehiscence following a laparotomy for bowel obstruction.

- 58 year old man with diabetic foot ulcer.

- 72 year old man with left orbital malignant tumor.

- 60 year old man with esophageal cancer, awaiting EGD.

- 70 year old man with esophageal cancer and tracheoesophageal fistula, awaiting possible feeding gastrostomy.

As you can see, a broad mix of the familiar and the (much) less-familiar.

Kwaheri,

ben

 

Benjamin Howard, MD, MPH
UCSF Department of Surgery

July 2013 - Week One - Benjamin Howard

Dear colleagues and professors,

“Habari” from Dar es Salaam, Tanzania; as some of you know, I am spending the month of July here with Dr. Schecter, working with the Department of Surgery at Muhimbili University National Hospital. I’ve been here one week now, and wanted to give a quick update.

First, I must acknowledge those who have come before me – Jessica Beard, Evelyn Shue, and Lawrence Oresanya have all spent time on service here at Muhimbili, and they prepared me very well for my time in Africa. They are also remembered fondly by much of the hospital staff!

Since last Monday, Dr. Schecter and I have scrubbed in a number of cases, elective and emergent, a selected list of which may give a taste of the general pathology seen in what was once called “tropical surgery”:

- Exploratory laparotomy and Graham patch repair of a perforated prepyloric ulcer in a 22 year old man with diffuse peritonitis and sub-diaphragmatic free air.

- Gastrojejunostomy and cholecystojejunostomy for palliation in a 38 year old woman with pancreatic cancer, obstructive jaundice, and gastric outlet obstruction.

- Ex lap and diverting sigmoid colostomy on a 21 year old girl struck by a motorcycle with a pelvic fracture and a massive tear in her perineum.

- Modified radical mastectomy on a 43 year old woman with locally advanced breast cancer. (we’ve actually been involved in at least four similar cases – let’s just say the Z11 trial would be difficult to conduct here!)

- Ex lap, hysterectomy with resection of a 40cm mass (!) arising from the uterus in a 36 year old woman with a 3 year history of “enlarging abdomen.”

- Takeback laparotomy, resection of the transverse colon, diverting ileostomy on a 66 year old woman one-week post-repair of gastric perforation, found to have multiple colonic perforations and feculent peritonitis.

- Thyroidectomy and excisional biopsy of clavicular lesion in a 50 year old woman with likely metastatic follicular thyroid cancer, primary lesion 10cm.

- Appendicectomy (that’s how they say it) on a 50 year old man, found to have a 20cm long, 2cm diameter appendix (pathology pending).

- Partial gastrectomy with Billroth II reconstruction for palliation in a 71 year old man with metastatic gastric cancer and persistent bleeding from the primary tumor.

- Open Heller myotomy with Dor fundoplication in a 16 year old girl with achalasia.

- Ex lap, lysis of adhesions, small bowel resection in a 25 year old man with small bowel obstruction and history of laparotomy as a small child.

Needless to say, the differences between surgery here and in San Francisco are vast. Even though it’s a national referral center, the resource limitations are staggering. In the OR, we wear cloth gowns, use a lot of 0-vicryl, hand-sew all anastomoses, and continually battle for effective electrocautery. On the wards, and even in the ICU, the basics we take for granted are just not there. Lab results come back the next day, maybe. The wards are shared, open air, with rows of closely-placed beds and respective mosquito nets over each patient.

Perhaps equally remarkable are the similarities; the attending surgeons, residents, and staff here are dedicated and caring, they do a great job running overwhelmingly busy services, and they have a outstanding ability to adapt to often less-than-optimal conditions. I’ve been taking call with the residents, and the entire department has made me feel very welcome; they have taught me a great deal already. The operating room – I mean theatre – runs basically the same as it does at home. And of course, even in a place where everything else is so foreign, the inside of the abdomen is reliably familiar – an odd comfort!

If you’d like to get in touch with me while I’m here, please use my gmail account, benjaminhoward@gmail.com, as UCSF email is somehow not compatible with my current internet connection.

Tutaonana,

Ben
Benjamin Howard, MD, MPH
UCSF Department of Surgery