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 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