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.




Benjamin Howard, MD, MPH
UCSF Department of Surgery