October 2014 - Week Three - Douglas Grey

Another very busy week and a pattern is emerging. There are both incredible highs and profound lows associated with a job whose mission is to attempt to help train others, improve outcomes for patients but without templates for accomplishing this. One confronts all sorts of difficult clinical problems that are desperate for many disparate reasons: late presentation of disease, lack of access to adequate screening programs, lack of resources necessary even of the diagnosis is made, lack of patient resources.
One of the typical "rock and hard place" situations is around antibiotics and chemotherapy. The patients are expected to pay for their required medication by purchasing them prior to admission. It is not uncommon for patients who walk to the operating theater (room) and hand the anesthesiologist their meds. As I mentioned previously, the hospital is surrounded with small pharmacies for this purpose. Likewise for chemotherapy, where it may be ordered for a certain disease- but the patients and families have to be able to afford these drugs, and worse, the pharmacies may run out of these intermittently. We actually had the discussion at Rounds this week of! "Should the doctors pay for meds or tests that are necessary, but the patient can't afford." Interesting to contemplate how these discussions would play in the  US.
We have had some positive stories. On Monday, we consulted on a case with a 35 year old woman with a cystic tumor in the pancreas, somewhat like Steve jobs suffered from. Dr. Craig Lubbock and I helped this surgeon with the decisions around exposure, resection, and pancreatic removal, something that the surgeon did not have much experience. The operation went smoothly, and the patient has thus far has had a smooth recovery. The surgeon was very grateful for the assistance and experience offered.
The volume of patients in dire straights remains daunting. One of the processes that becomes a routine is Thursday afternoon where the schedule for the subsequent two operative days is set. We generate a list of patients requiring scheduling, which includes many cases which one could only see in circumstances such as this. Upper extremity amputations for tumor, complicated intestinal surgery for infections, complex non-healing wounds where the diagnosis is unclear. Esophageal cancer is rampant and the treatment options become less varied as the diseases are generally more advanced.
One vexing problem is patients who receive a diagnosis and want to pursue traditional homeopathic treatment as an alternative. The patient will then disappear for 4-8 months. He/she will then reappear, with a longstanding diagnosis of a severe problem, be generally much more advanced or symptomatic, and much more high risk. It becomes much more difficult to treat and the system grinds on.
Another disease category that I was not expecting was domestic violence. Two cases that stood out were a 35 year old man stabbed by his  father (survived his diaphragm and liver injury) and a wife who was caned by her husband. This could probably happen anywhere, but seeing the victims and their injuries makes it more immediate.

On a lighter note, Tuesday was Julius Nyrere a Day, a national holiday. Our surgery resident, Jeff Crawford ran a half marathon in Dar.  I went out to cheer him on and was struck by two things. The first thrill was to see the leader group in the race. This was a group of 20 runners in the elite group- legs four feet long, four to five foot strides, and as graceful as anyone I have ever seen run. The second thrill was Jeff was the "lead white runner" of the entire race and finished there.

Last weekend Craig Lubbock and  I went to Mafia Island, an island off the coast south of Dar(like Zanzibar ). It is one of the largest marine sanctuaries in the world and relatively uninhibited. The reefs were extra worldly with hundreds of fish types and coral species. Even to a color blind snorkeler, this was impressive. There was an island across the bay, Chole Island (pronounced cha-lee) (pop 1000) with no power or consistent water supply, etc. it was a paradise with charming people, engaging children (I played "I Spy" on demand with some school girls as I had with my own children- something about, "I spy a lion" in that environment was cool). There was a hand made boatbuilding  yard, with no power tools, all wood hand hewn and unique, but it works. They make all the boats for the island. Fruit trees abound of every type. Baobob trees everywhere. Fruit bats  everywhere. Beyond fascinating.

Lastly a little Swahili. Greetings are varied and the most casual is "Jambo" (hello) or "Mambo Poe" (how's it going), to which you reply "Poe" (po-ah meaning cool)  and flash two thumbs up. Thus generally gets a big smile and they assume you know more than you do.

Over and out
Sent from my iPad

October 2014 - Week Two - Douglas Grey

We began our first week of volunteer interaction in the Kisabila Annex, a 1950's style 30 seat classroom with antiquated furniture and ceiling fans. The staff surgeons all sit in the front of the room and the interns present, one at a time, all of the admissions of the night before. These are rotating internships and these folks are headed into other specialties and not necessarily interest in the complexities of surgery. Each admitted patient is presented in a British style system, very formally, with discussion of the nuances and vernacular of a traditional physical exam. The patients are generally VERY ill with advanced disease and oftentimes many attempts at treatment prior to their admission. The punch line to the presentation is always the "working diagnosis" and of much less importance, the treatment plan. As in the US medical schools, uncommon diseases, referred to as Zebras,  are much more common than horses in the presenters mind. The faculty get very agitated when the students do not do well with these - a particular peculiarity early in the training year- seems to be present in many teaching programs - learning by embarrassment.

Tumor Board was held on Tuesday afternoon in Sawa Haji Annex, a similar classroom to Kisabila. For this conference, the patient either walked or was wheeled in to the meeting. The clinical situation discussed, and a decision to treat or not was made. If the decision was to give Chemotherapy, then the family was given instruction to purchase the drugs for administration. It was not part of the discussion as what would happen if they could not afford it. Radiation Therapy was a similar situation, but if this was recommended, the cobalt machine had to be functioning for the course to be completed.

There are two main a General Servicesin Muhimbili National Hospital or MNH- Firm 1 and Firm 2. They have divided and often competing staff surgeons, they alternate days on call, and they share the patient responsibilities for the ward patients.
After morning report there is a surgical clinic that is in a large white building near the front entrance to MNH. There is a covered patio where the patients gather in the morning, as early as 7 am, waiting to be seen. With the colorful batik fabrics on the women - vibrant yellows, reds, greens - this is like a scene from a movie and is striking to the senses.  Craig Lubbock spent the day with Dr Makia, one of the senior female general surgeons, discussing complex cases, treatment alternative and respective philosophies. They are now friends and enjoy discussing differing philosophies of care. She seems to like the bigger, more complex surgical cases, but ends up getting referred lots of breast problems, including cancers-, partially because they are referred by her male colleagues- a source of frustration.

I tried to see some Pediatric Surgical cases ring done by a visiting British surgeon, Dr. Drake, but the pace of the cases in the Operating a Theater was slow, and unpredictable. Our team was able to deliver some surgical supplies to Janet, the Head a Nurse in the OR, and they were checked inas donations. We also delivered about thirty pairs of forceps and needle holders for teaching surgical skills to the residents.

Because Muhimbili is a very large referral hospital, with a broad age range and the patients are referred often late in the course of care, there is a lot of death. The families are heavily involved in the care of their family members who are patients, having to bring food, blankets, and purchase drugs such as antibiotics. There are about 20 pharmacies outside MNH for this purpose. Sprinkled amongst the pharmacies are the stores to purchase crosses and coffins - all too plentiful. Several times a day, there is the unforgettable wailing of a despondent mother with the death of a child. Today we saw six family members carryingout a loved one to the mosque on the grounds for the burial ritual.

Also MNH has a lot of maintenance issues. One of the more current problems is that the cobalt beam radiation machine is out of order. This prevents this patient population from getting the necessary care if radiation is an option. We saw a woman with a large Pancoast tumor (tumor in the top of the lung and under the clavicle) who was in severe pain, but unable to get treated other than narcotics. There is also a challenge at getting test results back. There is generally a week for pathology and several days for X-ray reports.

On the positive side, the OR personnel are incredibly honest and trusting.  The nurses all have their purses and belongings in a rack in the break room - no locks, no lockers , no guards - all trusting. The same goes for the men's locker room. We leave shoes coats, clothes there all day without concern.

On Thursday, the Big Ward Rounds takes place. This is a review of 50 patients with one to two attending surgeons, several medical students, and a couple of residents. The patients are all very sick with diseases that we seldom see in the US- massive breast cancers, liver tumors, soft tissue tumors, or infectious diseases, diabetic gangrene. Dispositionsare reached and surgery scheduled, if appropriate. After rounds, we meet all the patients for the next two scheduled OR days, generally Friday and the following Monday. This will be each day with two rooms and two to four cases per day. All patients are asked to come in to be considered and there are more patients for surgery than dolts available. For those patients who are not able to be scheduled, there is great disappointment- some have come in for weeks in a row. The residents and registrars do not like this part of the job - this is life in a resource-constrained environment.
Lastly, becauseMNH us a large medical complex, I sought to finda map of the complex. I was led around by very affable employees who when they heard of the request for a map, would scratch their heads in puzzlement. None in engineering , information, safety, and patient services. I finally realized that their culture is not a map-based system of geography,  but "description-based" locations (trees, roads, buses, and other landmarks are relevant ) and maps are not helpful to them. Who knew?

Cheers. Doug

October 2014 - Week One - Douglas Grey

Hi Bill and Sonia. I wanted to carry on the tradition of capturing the senses of the experience at Muhimbili National Hospital as part of the AGCT Volunteer effort. Craig Lubbock and I left San Francisco last Monday, traveling through Dubai on way to Dar es Salaam. Air Emirates is a good airlines but a rather chaotic trip with rowdy passengers. Arrived at Dubai at 7 pm and to hotel in Jameriah district (hotel like ship) along beach. Hotels are beautiful and many employees. We went up the worlds tallest building- up to 124 floor and still only 2/3 the way to the top. Dubai to Dar is an easy flight that gets in at 3:30 pm so easy transport to Kalenga a House. It is empty this time of year, with only Hamid, an Egyptian Anesthesiologist here. Jeff Crawford, a fourth year resident from University of Oregon came on Saturday.
First weekend setting up the house for our stay including stocking the kitchen, getting Tanzanian schillings, and getting the phones to work. We learned several things, not necessarily in any order. First, there are roughly three tiers if grocery stores, depending on what you want. The one down Kalenga is fine for most of what one needs to do basics. We bought coffee maker for kitchen and coffee for breakfast now enjoyable. The next tier is downtown in VIVA building, across from Serena Hotel. Has better quality but limited inventory.  Most complete is Village Market on Haile Selassie Blvd on peninsula. Expensive but have fresh produce and extensive inventory.
Schillings are easy to come by and ATMs are everywhere but occasionally they run out of schillings. Changing $100 bills us also good, but can take time. Exchange rate is 1675:1.
The phones are all working now and we discovered two things: SIM chips that are unused for several months cannot be reactivated; and using minutes (in a plan) instead of schillings is more cost effective.
We have had very discussions with the two MUHAS surgeons who have been AGCT supporters for residents: Ali Mwanga and Larry Okoko, absolutely wonderful people. They put on a multidisciplinary meeting yesterday about two issues: blood transfusion resources, and case cancellations. They had two residents who had used these themes for their research, and will be presenting these at COSECA in a few months. They wanted a "low energy" [read unemotional] discussion to improve their programs. There are many obstacles to the delivery of care, but they led the discussion masterfully.
Today we had morning report, met many of the surgeons and residents. There were fifteen patients presented, the residents were grilled, and done patient care decisions made. The staff is committed to excellent care and it came through. We learned much of the practice of surgery in a resource-constrained environment.
We brought lots of surgical supplies for teaching surgical skills and hope to put on labs for residents beginning next week.
Tomorrow is idle. There is one OR that needs a cardiac monitor to function and there is still no end to this. I am looking on eBay and working with the Biomed engineer to try to identify one .

In finishing, it is a privilege to be here. Yes it it inconvenient and challenging, but the people make it worthwhile.

Cheers. Doug

March 2014 - Week Four - Rebecca Maine

Well, my four weeks at Muhimbili are, incredibly, already over.   I must again express my appreciation to the surgical service there that extended this opportunity to learn with and from them, and to the folks in the US who worked to put it together.  It was an incredible growth and learning experience.

 We hit a little bit of a quiet period in our call cycle, which Dr. Schecter jokingly attributed to having already operated on all the peritonitis in Dar.  So there were fewer late night cases with the residents, but still plenty of interesting opportunities to learn with the team during the elective cases.   We did a sigmoidectomy this week.  It’s interesting that the epidemiology of sigmoid volvulus in Africa are quite different than those in the US. It is fairly common here, and happens in much younger, healthier patients.  This was actually a topic of discussion at the COSECSA (College of Surgeons of East, Central and Southern Africa) in Zimbabwe in December.  There was a presentation on a anatomic study in fetuses looking at colonic development in the African population and noting longer colons further out of the pelvis.  However, these difference in volvulus incidence don’t seem to persist after emigration to the west, so diet and lifestyle are likely factors.  The patient we treated was in his early twenties with a history of intermittent constipation and an impressive CT scan.  The differences in epidemiology of different surgical conditions between different places are very interesting, and deserve more study to ensure adequate capacity to detect and treat them.  To me this is just one of the cases that highlights the need to support the growing field of academic global surgery.

The last case that I participated in was a common bile duct exploration for a woman with choledocholithiasis.  We started with an open chole and then proceeded to the duct exploration.  Passing the instruments through the common duct we were not able to clear it, but instead felt a somewhat mobile mass at the ampulla through the duodenal wall.  We were concerned it was a tumor, but were relieved to find that after the duodenotomy it was just a large, impacted stone that we removed with a sphincterotomy.   We then did an open sphincteroplasty, a procedure I had not yet seen in the US.  As I plan to continue to work in places where ERCP will not be available, it’s great to have had the opportunity to learn how to do this procedure.

 I finished my month with a mix of emotions.  I will in many ways be happy to return to the well-equipped hospitals of the US, where clinicians do not lose patients for lack of antibiotics or oxygen delivery.  But, I will miss working with clinicians who show strength in fighting against these types of limitations, many of whom are also eager to expand the care they can offer their patients.  I don’t know when it will be, but I look forward to returning to Muhibili to see my new see how things have changed.

Looking forward to seeing everyone when I get back to San Francisco in June.

Rebecca

 

Rebecca Maine, MD, MPH
Paul Farmer Global Surgery Research Fellow
Program in Global Surgery and Social Change, Harvard Medical School
Boston Children's Hospital
PGY5 UCSF General Surgery Residency

 

March 2014 - Week Three - Rebecca Maine

Hello again from Tanzania-

Only one more week for my time here at Muhimbili, the month has been flying by.  I am very appreciative of the hospitality I have received from residents, faculty and nurses in most of the hospital, and especially appreciative of their patience as I struggle to communicate.  Swahili is not an easy language, and, unfortunately, I have not learned much beyond some basics general surgery words, like scalpel, suture, pain, vomiting, and drinking. 

 This week I was again able to participate in several interesting cases and procedures.  The most interesting case was the resection of a large thyroid tumor.  The patient had received external beam radiation, leaving him with a large, infected neck mass, which bled intermittently.  He spent most of the last year in and out of the hospital.  The tumor was large and the surrounding skin tissue was damaged after radiation, so the team here was focusing on wound care and symptom management.  After a CT Angiogram confirmed the tumor was not involving the carotids (not a complete contra-indication, but definitely something that would have made the case more difficult), the patient was scheduled for an excision with reconstruction using a pectoralis major flap – thanks to some advice Dr. Schecter got from Dr. Hansen at UCSF.   The case took 8.5 hours, many of them struggling against a fairly vascular tumor.  But, in the end we were able to resect the tumor (with the internal jugular) safely.  The rotation of the pectoralis flap went smoothly, with a healthy looking skin flap, and good coverage of the carotid and the neck defect.  The ICU nurses, unfamiliar with this type of flap, cared for the patient well.  Though tired, I appreciated the late night calls to check on bleeding and “the tube coming out”.  The later problem ended up being one of translation, the patient did not self-extubate, the tube just came out a bit.  We were glad to see that all we need to do was secure the tube, not do an emergency trach next to the flap late at night. Fortunately, the next morning he had a good cuff leak and we extubated him without a problem.  He is doing quite well, with a good looking flap, breathing well and eating.  We are hopeful that after recovering from the procedure he will finally be able to get on with his life.

 This case and several others over the past three weeks highlighted the broad skill set needed for a global surgeon.   I have seen this too in Rwanda where the general surgeons and GPs do a broader range of procedures - c-sections, fracture fixations, basic urology, etc.  At Muhimbili there are a fair number of specialist– an interesting side note the poly-trauma is not managed on the general surgery service, but instead goes to the orthopedics/neurosurgery hospital.  But the skills a physician needs here include excellent physical diagnostic skills (emphasized repeatedly in morning report), IV placements- (cut-downs, central line and peripheral IVs have all been needed), intubation, reconstructive flaps(we did a sartorius flap and a pectoralis flap this week), excellent therapeutics knowledge (no pharmacists rounds with the team in the morning), excellent radiology skills to interpret studies and ultrasound skills, among others.  I keep a running list of all the areas I can improve to be more effective doing this work in my future career.   

 Another thing that has been very interesting to see is the amount of time the residents put into their training and education.  Many of them are in the mid to late 30s, or even late 40s, because they have worked as general practitioners in other hospitals for a few years before specializing.  They have families and small children.  Yet when they are on call they often have to stay for two or three days straight (sometime five days!), because you cannot leave on call until after you have completed all of the emergency cases you have admitted.  This is true even if the case is postponed because there is no blood or anesthesia refuses.  While the ACGME might not approve, I think it creates a great continuity of experience.   In addition, on weekends, most of the surgical team come to the hospital to participate in rounds.  This is in addition to spending several hours on the weekend studying and working on their research requirements.  There is a clear drive to work hard and take care of their patients, despite the limits placed on them by the system where they work.  

 I am looking forward to the last week on service, trying to make the most of this opportunity.  

Rebecca Maine, MD, MPH
Paul Farmer Global Surgery Research Fellow
Program in Global Surgery and Social Change, Harvard Medical School
Boston Children's Hospital
PGY5 UCSF General Surgery Residency

March 2014 - Week Two - Rebecca Maine

Rebecca Maine Week 2

It’s hard to believe how quickly my time here is going.  I feel like in 4 weeks I will only begin to learn about the challenges that the physicians here face in trying to provide care for their patients, especially the sickest patients. 

Unfortunately, we had many more complications in this past week.  Including the loss of two young, new mothers from post-partum abdominal sepsis.  In both cases after laparotomy they reminded septic.  However, intubation was not an option with limited numbers of vents.  When the physicians wanted to broaden antibiotic coverage to meropenem, they chose partial treatment (daily instead TID dosing) because of the high cost of the medications to the family.  In fact, I was told by a medicine colleague that meropenem resistance is on the rise here, as this partial dosing practice due to cost is not uncommon.  One of these patient became very hypotensive, and we wanted to give fluids rapidly.  However, central lines are too expensive for many patients and are not available in the hospital, so not that helpful in an emergency. 

 As one patient started to code, there was nothing we could do, as no ACLS drugs were available, in fact, oxygen was not even available in the block at that time, despite it being the “mini-ICU”.  Both patients might have benefitted from full ICU care, more availability of appropriate antibiotics and perhaps the ability to return to the theater more quickly to have a second look and further washout.  But all of these things that I have taken for granted in the hospitals at home are not easily done here.

 It is hard for the residents and specialists here who must fight against these limitations constantly.  Last week we did a damage control laparotomy for a patient very ill from a perforated transverse colon tumor.  (One of 3 emergency laparotomies we did that call!) After resection, we left the bowel in discontinuity with the plan to return the next day to look again and do the formal anastomosis.  While the team knew about the idea of damage control, it is not an approach that is used here often.  One reason is that the very sick trauma patients that we often give these laparotomies to, are not making it to the hospital for care in Tanzania.  However, the delayed presentation of many patients means their peritonitis is fairly severe, making it an option to consider. It became obvious the next afternoon, however, that the OR space and anesthesia availability is another factor that limits the number of damage control surgeries.  The surgical residents spent 2.5 hours begging and cajoling to get the patient back into the theater the next day.   There is a protocol for how emergency surgeries are booked (airway, ectopics, pediatrics, ruptured viscera – all come first).  As we were talking with anesthesia – even though we had added the patient to the add-on board at 8am- 2 visceral injuries were booked.  The resident, however, was able to convince the team to get the patient to the OR. The case went well and the patient is recovering, slowly in the ICU.  Until things change in terms of access to OR time, it’s hard to think that damage control operations will be widely practiced here.

 

In addition to the emergency laparotomies I have had the opportunity to see a variety of very interesting cases.  This week the team performed gastrectomies, colectomies and cystjejunostomies (all for probable malignancies), all potentially palliative.  The cystjejunostomy was very interesting as it was diagnosed by imaging pre-operatively as a post-traumatic pancreatic pseudocyst.  However, as it was explored and drained intra-operatively we become very concerned that it was malignant.   Unfortunately the lesion was unresectable. The woman had been having pain from the large cystic lesion and it had been opened, so we did a drainage procedure and sent biopsies.  We did a finger amputation, giving me the chance to learn about radial, medians and ulnar blocks.  On call there were 5 emergency laparotomies (for duodenal perforation, gastric perforation, transverse colon perforation, post-septic abortion peritonitis and post partum peritonitis).  Observing and participating in the theater continues to be a great learning opportunity and I feel lucky to get to participate in the care of these patients, even with all of the challenges.

More updates next week. 

Rebecca

Rebecca Maine, MD, MPH
Paul Farmer Global Surgery Research Fellow
Program in Global Surgery and Social Change, Harvard Medical School
Boston Children's Hospital
PGY5 UCSF General Surgery Residency

March 2014 - Week One - Rebecca Maine

Greetings from Dar Es Salaam –

 It’s hard to believe that the first week of my month rotating at MUHAS is already done.  It has been wonderful to be welcomed to learn with the surgical team here.  The surgical specialists (attendings), residents and registrars (basically general practitioners employed by the surgical team) were excited to have Dr. Schecter, “The Professor”, return, and many speak fondly on the previous residents who visited. 

 The opportunities to learn are tremendous.  Here there is a different spectrum of illness. For example, we did a splenectomy this week on a child with tropical splenomegaly whose liver and spleen were so large that he looked like his abdomen was full of ascites (it wasn’t).   There are a tremendous number of patients who are presented on rounds with obstructing esophageal lesions.  Late cancer is common, often receiving palliative or no resections, or just open biopsy at the time of operation.   

 What I have really started to learn about is the surgical system, though there is still much to learn.  The system differences are apparent in everything from the structure and emphasis in the medical education, the nursing training, the provider to patient ratios and the availability of resources.

I must note that I was actually surprised by the number of resources available at Muhimbili.  The surprise comes from my experience this year working in Rwanda, where many diagnostic tests (Doppler ultrasound, endoscopy, even basic electrolytes!) are often not available even at the major referral center.  The facilities exist at Muhimibili for many of these tests, however the speed that they can be accessed and their affordability for patients means that for many patients they are effectively not available.  Working in this situation forces you to relay on physical exam and knowledge of physiology.  During morning report each day, the specialists really emphasize the role of physical diagnosis and good history for understanding the patients’ situation. These few diagnostics and the limited time available for nurses to care for individual patients given their tremendous workload, make watching the patients closely an important part of each day.   The experiences have shown me clearly some of my strengths and some of my weaknesses in clinical comfort and knowledge, which I think is an excellent preparation for returning to full time clinical residency in June.

 I have noted that some things appear to be universal in medical education: first trainees everywhere often grasp for more obscure diagnoses from text books when asked about differentials – i.e. Plummer Vinson before esophageal stricture.  As the specialist on major ward rounds – a 5 hour marathon done once a week – was reminding the medical students to focus on common things first, I wondered if in East Africa the common phrase in medical education about hearing hoofbeats had to be turned around to “Think Zebras, not Horses.”

 First week by the numbers:
5 days with the team on the service
4 morning reports
1 major ward rounds
1.5 nights on call. – Including 3 laparotomies.
Scrubbed on 9 major cases – laparotomies, ventral hernia repair, amputation.

Thank you, 

Rebecca

Rebecca Maine, MD, MPH
Paul Farmer Global Surgery Research Fellow
Program in Global Surgery and Social Change
Boston Children's Hospital
PGY5 UCSF General Surgery Residency

March 2014 - William Schecter

Dear Friends:

I have just finished a month rotation at the Muhumbili University of Health Allied Sciences (MUHAS) with UCSF Resident Dr. Rebecca Maine.  I am pleased to submit a very positive report on this experience

Administrative Issues:

As many of you know, we have established a non-profit corporation entitled the Alliance for Global Clinical Training (AGCT) to provide Surgical, Anesthesia and Nursing Education at MUHAS (and perhaps other places in the future depending upon how things develop).  Paul Hofmann and Doug Grey (AGCT Board members) joined me for a week this month and negotiated a Memorandum of Understanding between MUHAS and AGCT.  As of this writing, the MOU has not been signed but we are optimistic that it will take place soon (Swahili time!)  Shannon Macfarlan, an SFGH ICU nurse and AGCT nursing coordinator joined us also for a week and had productive discussions with nursing administration and did some excellent teaching as well.  There are intensivists and anesthesiologists from the Karolinska Institute in Sweden who have been giving courses here for several years.  I had dinner with them last night and we will continue our discussions to see if we can create synergy between our two programs (which would help us advance the anesthesia education component of AGCT

Clinical Rotation:

I think that most of you have received Rebecca’s blogs.  We have had a fabulous clinical month and you can see the cases we scrubbed on below.  Not captured in these lists are the myriad of consultations on the ward, the ED, the ICU and the Clinics.  Rebecca was very aggressive and I think has the record for the most cases of any resident so far (not that we’re competitive!).   We have had some great saves but also have witnessed some heart breaking losses (including two brand new young mothers who died of peritonitis).  I am trying to encourage more use of the ICU, mechanical ventilation after difficult emergency laparotomy in the middle of the night, and second look laparotomy.  However, it is an uphill battle and as I have said before, this is at least a 20 year project and we have to manage our expectations (a difficult thing to do in the face of so many potentially preventable deaths).

Cases of William Schecter

Diagnosis                                                                 Operation
Gastric outlet obstruction, PUD                              Finney pyloroplasty
Tropical Splenomegaly                                            Splenectomy
Gastric Cancer                                                         Gastrectomy
Ventral Hernia                                                          Ventral Herniorrhaphy
Perforated DU                                                          Graham Patch
Perforated Transverse Colon Ca                             Damage Control Extended Right
hemicolectomy                                                        Same Second Look, ileotransverse colon
                                                                                 anastomosis   
Cystic lesion of pancreas                                        Roux en y cyst jejunostomy
Carcinoma right colon                                             Right hemicolectomy
Fibrosarcoma of groin                                             Wide local excision, Sartorius flap
Recurrent ulcerating thyroid                                   Classic radical neck dissection with
- cancer in an irradiated neck                                  - pectoralis major myocutaneous flap
GERD                                                                        Nissen fundoplication
Gastric outlet obstruction due to                            Roux en Y gastrojejunostomy
unresectable gastric ca

The above list does not capture the many cases that I observed and advised, sometimes having a significant impact on the conduct of the operation and its educational as well as clinical outcome.

Cases of Rebecca Maine

Incarcerated Umbilical hernia - Richters                   Hernia repair
SCC of breast                                                             Wide local excision
Pending - Probably lymphoma                                  Cervical lymph node biopsy
Ileal perforation after myomectomy                          Exploratorty laparotomy, bowel repair
Jejunal perforation after motorcycle crash               Exploratorty laparotomy, bowel repair
Tropical splenomegaly                                               Splenectomy
Gastric cancer                                                             En bloc gastrectomy and transverse
                                                                                     colectomy
Ventral hernia - lateral s/p appendectomy                Hernia repair with mesh
Diabetic Foot                                                              Right AKA
Gastric Cancer                                                            Gastrectomy with retrocolic
                                                                                    gastrojejunostomy
Perfored duodenal ulcer                                            Exploratory laparotomy, bowel repair
Synovitis of 3rd digit- pyogenic, diabetes                Disarticulation of the 3rd metacarpal
right inguinal hernia, uncicumcised                           Inguinal hernia repair, circumcision.
Perforated hepatic flexure tumor                              Exploratory laparotomy - Right colectomy -
                                                                                    Damage control
Perforated hepatic flexure tumor                              Second look operation with bowel
                                                                                    anastamosis
Perforated gastric ulcer                                             Exploratory laparotomy, stomach repair
Post-partum peritonitis with perforated appendix   Exploratory laparotomy - appendectomy
Cystic pancreatic tumor                                             Cystjejunostomy
Peritonitis post septic abortion                                  Exploratory laparotomy, washout, drainage
Fibrosarcoma of the left groin                                    Wide local excision - groin dissection
Necrotizing Facitistis 2/2 Diabetic foot                     AKA - Right
EC fistula of the appendix                                          Fistula repair, appendectomy, hernia repair
Ileal perforation - peritonitis                                      Exploratory laparomty, ileal repair,
                                                                                     appendecomy
Large thyroid tumor                                                    Neck Dissection with pectoralis major flap
                                                                                     reconstruction
Reflux                                                                           Nissen fundoplication

Are we having an impact?

We are trying to develop metrics (besides the number of months we have covered and the cases we have done) to assess the impact of the program but we have a long way to go.  However, I am only scrubbing when they need me.  The rest of the time I am advising.  This is the first month that the attendings are actually taking their residents (and ours) through some of the cases (actually a lot of them).  When I first got here 1 1/2 years ago, the residents weren’t doing anything during the day except holding hooks.  One of the young attendings I have been working with has become a very thoughtful compassionate and ethical surgeon.  He is now independently doing common ducts, Heller myotomies with Dor fundoplications and laparoscopic cholecystectomies (47 at last count).  He will soon be ready to do Nissens independently.  None of these operations were being done before we started the program and the patients were just sent home (sadly that still happens to a lot of patients with potentially treatable disease but we are working on it).  As you can see from the list above, I have started to introduce the concepts of reconstructive surgery with the Sartorius and Pec Major myocutaneous flap (thanks to Scott Hansen who advised me to cover the neck with a pec major myocutaneous flap.  It worked great.  My initial plan was a deltopectoral flap but this was a safer and better option.   Also thanks to our friend Steve Mathes, who died unfortunately well before his time.  Steve did the research in the 1970’s which made the operation possible).

What’s next for the AGCT?

We have completed a 6 month pilot project sponsored and encouraged by the Pacific Coast Surgical Association.  Thanks to former PCSA Presidents Jim Holcroft and Jim Peck for volunteering to do one month rotations with their residents and thanks to the 5 UCSF residents, and one resident each from UC Davis and OHSU for doing such a wonderful job working with our Tanzanian colleagues.  Also thanks to Nancy Ascher, Diana Farmer and John Hunter for their strong support of the program. 

Our plan is to cover 10 months next year and I think there is an excellent chance we will achieve this goal.  Once the AGCT achieves non-profit status (which hopefully will be later this year) we can begin fund raising efforts to ease the financial burden on our resident volunteers and nursing educators.  We plan to be at MUHAS for at least 20 years as we estimate that this is a long term process and commitment.  Although we hope to have both individual and grant support for the effort, the program must be able to continue (as it has until now) independent of the vagaries of the funding cycle.  We hope to avoid the fate of many grant dependent programs that disappear the day after funding stops—and therefore have no long term impact.  Many thanks for your support of AGCT.

Bill Schecter