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