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