February 2016 - Douglas Grey

Dear Bill. I will be continuing  the tradition of capturing the experiences of the Alliance for Global Clinical Training (AGCT) in this blog after the first clinical week. The trip has been a bit more chaotic and started to be challenging three days before my plane left SFO. I received word that our usual housing across the street from the Muhimbili National Hospital (MNH), the Kalenga House,  would be unavailable and I had to seek alternative housing arrangements. Our colleagues found a hotel about 2 km from the hospital gate and on a major thoroughfare near the Indian Ocean. The place didn't have rave reviews on Tripadvisor but I thought this was something I could cope with when I arrived. I was traveling with one suitcase of medical supplies that you had requested and more about that later.
With a bit of uncertainty on logistics, I took the same route through Dubai (overnight) and then on to Dar. I picked up the Needlestick meds and the phone from Kalenga and went to the proposed hotel. It was a scene from the Blues Brothers in the lobby with about ten people there and an argument over non-functioning wifi...that sealed the decision not to stay. I had done enough research to identify a hotel about 200 yards away and fortunately they had a room. Despite being a higher rate, it was a welcome place to land that could be used short term for volunteers in a pinch as a backup.
Staying so far from the hospital, despite the reasonable accommodations, was not ideal. Problems: you have to take everything you need for the day as you cannot go back and forth to Kalenga for anything. This means carrying a back pack all day. I initially had security questions, but one comes to realize that this is about the most honest country in the world based on a few observations: the staff routine leave their belongings in the locker room unattended; the nurses have the "mountain of purses" in the common break room; I once left my cell phone in the locker room and it was back in my hand before I knew it was gone.

For clinical activity, I was assigned to Firm 2, and two young surgeons, Dr. Ramadhani and Dr. Moses,  who desire to be further trained in thoracic surgery. They are outstanding young General Surgeons who are forming a team around learning Thoracic procedures. They are smart, dedicated, good doctors, and get the most out of a resource-constrained environment.

The first patient I was asked to evaluate was a 36 year old female who had been in a roll-over motor vehicle accident. She had both lungs collapsed and blood around her heart. These were treated and she still was not improving. We examined her and made a presumptive diagnosis of diaphragmatic rupture. Trying to get a CAT scan was difficult because the patient could not afford the $60 cost, to be paid up front. We offered to help her with this cost with her, but she would not accept this gesture. She finally got her son to help her.
This scan confirmed the diagnosis and her diaphragm was repaired through the chest, an operation that is uncommon but also fairly successful. She began to recover immediately.

I went by the hospital sewing room, a place that I had visited in the past. They machine sew all the gowns used in the operating theatre and had developed a habit of making "bell-bottom " cuffs for the arm sleeves, an annoyance that makes sterile gloving almost impossible. The now (at least) make straight seams which is great progress. We are hoping for some progress towards a cuff, but they will need some trial material- an easy problem to solve.

Finally, walking the hospital corridors is an experience difficult to describe. Muhimbili is a large, public hospital, with every type of clinic. They take care of the uninsured as well as the political elite. The disabled are often independent in their travel and one is struck by the determination, focus, and fierce independence that they display. Even bed ridden patients are transported through long, outdoor hospital corridors, probably by family members, to secure their care. It is a privilege to be here.