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.