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