March 2016 - William Schecter

Report on the Alliance for Global Clinical Training Rotation at the Department of Surgery, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania

William Schecter, MD
March 25, 2016

1.      Travel to Dar Es Salaam:  On this trip I traveled to Dar Es Salaam via Istanbul.  This is a very convenient flight from the West Coast.  I stayed in Istanbul for 2 days o rest.  There is a lot to see: the Blue Mosque, the Hagia Sophia, the Golden Horn, etc.  However, the most exciting thing for me is related to a tunnel built from the Gihon Spring through the Ophel Hill to the Shilo Pool in Jerusalem by King Hezekiah approximately 2600 years ago to ensure that Jerusalem would have a supply of fresh water within its walls.  This pool enabled Jerusalem to withstand the Assyrian siege led by Sennachareib.  The tunnel was actually discovered in 1880.  There were two teams of workmen working towards each other, one from the Shiloh Pool and the other from the Gihon Spring.  When they met, the workers recorded their success in graffiti written in Hebrew with an early Hebrew/Phoenician alphabet (Hebrew is now written with Aramaic letters).  In 1882, the wall of the tunnel containing the graffiti was removed and placed in the archeological museum in Istanbul.  As I have walked the 0.5 km through the tunnel, it was a thrill to see one of the earliest, if not the earliest, written Hebrew (although I am not enough of a scholar to read the Phoenician alphabet). 

2.      Life at MUHAS:  I was warmly greeted by all of our colleagues at MUHAS.  This is the 4th year of Alliance activity in MUHAS.  Our Tanzanian colleagues credit us with improving their surgical skill set.

3.      Memorandum of Understanding:  Shortly after my arrival, a ceremony was held with the Dean of the Medical School signing a Memorandum of Understanding between the Alliance and MUHAS.  We have been trying to make this happen for several years and finally our efforts are recognized officially by the Medical School.

4.      Resident Activity:  I was fortunate to be accompanied by a truly outstanding resident, Dr. Jahanara Graf, from the UCSF/East Bay Surgery Residency.  I met Jahanara at the PCSA meeting in Hawaii in mid February and 2 weeks later she joined me at MUHAS.  As you can guess, she has a real surgical personality, decided she wanted to come and made it happen in less than a week.  She has had a wonderful clinical experience but, like many of our residents, has also experienced the pain and frustration of working in a resource constrained environment.  She has told me that it has been a wonderful maturing experience. 

5.      Data Base for the MUHAS Department of Surgery:  Jahanara and I constructed an Excel based data base for the MUHAS Department of Surgery (they were not recording their cases), a death and complications protocol sheet and an Excel based data base for complications.  We also ran an American style Morbidity and Mortality Conference which was very well received.  Our Tanzanian colleagues say they will use the data base and begin weekly M&M conferences.   Jahanara hopes to turn this project into a peer reviewed publication.

6.      Case List:  This has been a very busy month with a fair number of complex advanced cases.  It is very gratifying to see the young surgical faculty and fellows operating with precision and self confidence, including dissection of major intrathoracic and abdominal vessels-something that was not happening here when I first arrived four years ago.  The volunteer surgical educators can take a lot of credit for making this happen.  I hope some of you who are kind enough to read this report will consider lending your expertise to this effort.  We are concentrating on training 6 young surgical faculty members (their residency is only 3 yearslong) so that they in turn can train their resident in the future.  Below please find a list of the cases I have taught in the past month:

Table1: Case list for William Schecter, March 2016

Diagnosis                                                               Procedure
Carcinoma of larynx                                              Cancelled
Rectal adenocarcinoma                                        Abdominoperineal resection
Chronic cholecystitis with                                    Open Cholecystectomy
perforated gallbladder
Left breast cancer                                                 Left modified radical mastectomyIncarcerated hernia                           Exploratory laparotomy, small bowel
with strangulated bowel                                       resection with primary anastomosis
Anal warts                                                             Excision of anal warts      
Hemorrhoids                                                                Hemorrhoidectomy
Small bowel obstruction with necrotic bowel     Exploratory laparotomy, small bowel
                                                                               resection, gastrostomy tube
Ulcerating right breast cancer                              Right toilet mastectomy with chest
                                                                               wall reconstruction
Right breast sarcoma                                            Simple mastectomy
Perforated duodenal ulcer                                    Exploratory laparotomy with graham
                                                                               patch repair
Achalasia                                                               Re-do Heller Myotomy
Left peri-rectal abscess                                        Incision and drainage
Rectal adenocarcinoma                                        Abdominoperineal resection
Hepatic cyst                                                          Subtotal cystectomy,
                                                                               cholecystectomy, damage control
Hepatic cyst                                                          Second look laparotomy, removal of
                                                                               packs, drain placement
Esophageal Cancer                                               Cancelled
Hydrops of gallbladder                                         Open Cholecystectomy
Left breast cancer                                                 Left modified radical mastectomy
Rectal cancer                                                        Exam under anesthesia and biopsy
Obstructive jaundice                                            Open Cholecystectomy
20x10cm open wound left flank                           Delayed primary closure
Question rectal mass (no mass found)                Exam under anesthesia
Esophageal Cancer                                               Ivor-Lewis Esophagectomy
Metastatic cancer                                                 En-bloc gastrectomy and transverse
                                                                              colectomy, small bowel resection,
                                                                              Roux-en-Y antecolic