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