Doug Grey - February 2017

I began my fourth medical mission trip to Dar es Salaam just before the New Years 2016. Having a number of home renovation projects finally finished, the travel was a welcome relief. The travel to Dar is made more easily with subsidized airlines (Emirates or Etihad) which are reasonably priced as well as a plane fleet that is in good shape. There is an overnight in Dubai that provides one night of combating jet lag on the way , with a convenient continuation flight to Tanzania.

I arrived in Dar the following day and met Dr Craig Lubbock, who is also retired Kaiser surgeon and had been on the trip in October 2014. The house in which we stay is the Kalenga House, a UCSF-sponsored house with rooms for 8, a common kitchen, and convenient proximity to the Muhimbili Hospital, the largest teaching hospital in Sub-Saharan Africa. It is a bit like being in something between a dormitory and a fraternity house. Cooking duty is shared, but there are those with culinary skills and then me.

The first weekend was dedicated to combating jet lag, getting the house provisioned for the month, and making initial contact with our Tanzanian colleagues with whom we will be working the next several weeks. There is a new Pediatric Surgery colleague, Dr. Henry Lau, a retired Johns Hopkins surgeon who is spending the year under the aegis of the US Peace Corps performing Peds Surgery at Muhimbili. He provides some consistency to the exchanges and efforts to pitch in assisting with the care at Muhimbili. He has taken a great interest in teaching the Tanzanian surgery residents basic surgical skills of knit tying, suturing, and some of the "craft" of surgery.  One of the hazards of spending a year in any one place is you inherently feel much more ownership for both the problems as well as responsibility for solutions. Inherent in any medical mission is "doing your best with what you are able in the allotted time..." .

There are advantages and disadvantages to almost any effort to help.

Our first day at the hospital (Monday) began early 6:45 am with a trek adjacent to the Baptist Chapel which finishes the morning service with a singing round by the parishioners snaking out of the chapel. The harmony was angelic and contrasted with the stillness of the hospital grounds. During the day, the hospital campus is over-run with humanity , but in the morning hours the corridors are empty and the gardens quiet.

We begin with rounds in the Intensive Care with the Chairman of Surgery, Dr. Ali Mwanga.  This is a six bed ICU with the sickest of the sick, most on ventilators, and either trauma cases or patients with surgical complications. It is evident that the Muhimbili staff dedication and commitment to getting these ill patients better is exemplary. Intensive Care Units are complex and getting some of the patient data is difficult to sort out in the bedside records. The patients can't be weighed every day which is an accurate proxy to fluid balance and some of the decisions are made with gestalt and not data, but this is not necessarily bad. The strain occurs in this limited resource environment, when all six beds are filled and a new case is contemplated. The safety net of an empty ICU bed isn't always available and patients can suffer with the lack of resources.

One of the systems improvement that has been introduced for the Surgery Department is a Morbidity and Mortality Conference, the standard forum for discussing complications due to  lapses in care or unavoidable circumstances. The Residents presented several cases where this ICU bed shortage had led to delays in necessary operations (in patients with worsening intraabdomininal infections). This was referred to as a "System Problem". Those bad outcomes due to bad judgement or bad decisions were called "negligence". The stark candor is both alarming and enlightening as now there has been a tangible increase in everyone's awareness (and responsibility) to improving care.

This level of frank discussion was impressive and has already led to good decisions and discussions from the younger surgeons.

One brief note about the improvement of the hospital grounds. The hospital campus four years ago was like an abandoned movie set. The hospital wards were concrete barracks. There would be areas of used medical equipment, almost like randomly occurring "equipment graveyards " of old white iron beds, stainless steel, broken furniture, etc. This happened in a society where almost nothing is ever thrown away, but rather re-utilized in a lower tech manner.

There hospital, through government jobs programs newly introduced by the Prime Minister, are now several different categories of workers that are improving the physical plant. There are security guards, both male and female, who  circulate on all the corridors outside and provide a feeling of safety. There are people assigned to raking leaves and picking up trash on all the  gardens and public spaces. There are construction projects throughout the campus with rich red soil being dug by hand in several different areas. Many of the gardens have been finished and are now like a public park. The plumeria trees are in bloom and the fragrance of jasmine, is pleasant.  One no longer gets the feeling of crumbling desperation that we has three years ago.

That feeling of thriving culture disappears when one enters the wards, where the patients are cared for. There would be 50 patients in a room otherwise designed for 30 patients. The walls which would usually house three beds in parallel, were now housing one bed, one patient on floor, then bed, floor, bed, floor and so on. There were also patients in the corridors. There is no patient privacy.

Walking across the campus, I came across an extremely idealistic medical student who was going into Internal Medicine. She was proud that MUHAS was the most difficult medical school to gain entrance as well as the most difficult to stay enrolled and succeed. She was  optimistic and happy with her decision, which was not based on reimbursement potential, something that she thought motivated her fellow students. She was grateful to meet a happy retired surgeon who shared her same idealism.

Again on this trip, the engagement of random passers-by with solid eye contact is alarming at first, then very reassuring. "Mambo Poa" is the standard "How are you?" And their response can be many variations of "fine" ("Poa,poa", "Poa" , "Nzuri "). It certainly makes the walks more enjoyable.

Week #2 began in a different way.  There is a religious complex at Muhimbili consisting of a mosque on one side of the cross campus walkway, and two back-to -back chapels on the other (one Catholic, the other Baptist). I decided to visit the 6 am service at the Baptist chapel. The chapel is open air in the sense that equatorial Tanzania is temperate enough, there are permanent square cut-outs in the cinder walls that allow the signing or amplified preaching to be heard well away from the church. There were about 30 attendees, a preacher and a man on the keyboard. The roughly 40 minute service was punctuated by preaching (in Swahili, and I would not want to be on the receiving end of whatever he was preaching against), singing, and praying. The singing was to me, most remarkable: it was strong, in unassigned three to four part harmony, and absolutely uninhibited. It was what I had heard the week before. There were a few "low alto" women who were inspired. They could not have been more welcoming. Then on to Rounds.

The Patients family at Muhimbili. 
One of the the striking features in all the rounds of patients we have seen in this profoundly resource-constrained country, are the obvious lack of many basic elements that we associate (read as "take for granted") with good patient care. Many of these are startlingly absent at Muhimbili. These can be as basic as provision of food, bedclothes, liquids, and some basic elements of hygiene. There are a range of levels of service here-granted some wards are provisioned well. But the public wards are absolute bare bones. I mention this as an observation, not a criticism;  much, if not all, of the shortfall in provision of these basic human needs are provided by families. From kangas (colorful fabric coverings that provide coverage and privacy for the patients) to drinks, food, dressings, and transportation needs, all  are provided uniformly, unquestioning, and cheerfully by family members. I saw this time and again in the outpatient clinic, where an oft elderly family member would require wheelchair, assistance and assistance with the most basic needs, and there would be one or perhaps two attentive sons taking on this burden without hesitation. And this is in an environment with none of the aids for the disabled that are the law in the US, and which we take for granted. 

The most dramatic of these occurs with the seasonal cleaning of the wards, where all patients are evacuated into the streets, parking areas, and parks for several hours while the wards are scrubbed. It is disarming to see the entire ward census out under tents being tended to by some nurses in  a partnership with the family membership nothing were out of the ordinary. This couldn't occur without the family. 

Muhimbili recycling in the OR. Worldwide recycling is at a worldwide popularity and Tanzania takes this to a level unimaginable anywhere else. OR chairs have a variety of different looks, based on varying states of disrepair, causing one to question "What is a chair?"  Is it one without a back, how about a seat and back with no legs, how about just the seat resting on a stool? All of these are in use throughout the Operating Theatre. How about gowns? How much of the gown has to be lost before it is not usable? One tie, two ties, all the ties? These can be replaced with gauze strips (not designed for re-use) or plastic strips that have to be torn to be removed, then retied with the next use. Where does this stop?  But you have to cut a hole in the gown. How many holes are too many?

Hope and Change. 
One obvious issue that I have not addressed in prior blogs is how is the suggestion for change is received by the surgeons and is progress inevitable. We have experienced this directly with the two groups with whom we interact. Firm 1 is the group associated with MUHAS (Muhimbili University Hospital and Allied  Sciences) populated with motivated surgeons who are open to suggestions, who have added multiple operations to their repertoire the last few years and have adopted many of the patient care habits that Bill Schecter has been modeling through his five years of service. Firm 2 is comprised of the Muhimbili National Hospital  surgeons. There are many excellent surgeons , but a few of the older surgeons are somewhat rigid in their practice as well as uninterested in any suggestion of surgical alternatives for care. The issue of tiers of quality in surgical care is not new and peer pressure is probably the strongest motivator for change. In a truncated volunteer experience where time and cases are limited, it tends to be discouraging. 

Patient Privacy. 
Patient privacy is paramount and sacred in the United States. There is a semblance of some privacy in Muhimbili, but the very public nature of "ward medicine" make this difficult. Exams are considered private for all ages and both sexes. This is not an easy task in public wards that are over crowded, but small mobile privacy screens that roll up and down between beds can afford this for patients, at least to the degree that they will accept exams that are essential. The outpatient clinic is different with shared exam rooms by two senior doctors each with a desk but separated by only a few feet. So simultaneously , there are two patients, each with family, each giving an oral history. There is a shared exam table with a small privacy screen and a small sink, has to be enough to get the necessary exams done. The exam is concluded, and the patient leaving is asked to call out the next patient's name to the throng outside. The waiting room is an inside courtyard with dozens of benches along the walls lining the courtyard.  The next patient moves into the room and the process continues. 

In years past, Muhimbili had been "paper based" in their record keeping but have now moved to computerized records. This would seemingly be great progress for a country in the pursuit of improving care. The infrastructure has not kept up, however, and the computers lose power every ten to 15 minutes. They have to be rebooted, and the record keeping takes twice as long. No one complains. 

Washing Cement. 
Last blog, I referred to the campus maintenance legion who does their work all day. When we are walking to rounds at 6:45 am, the hospital is getting scrubbed. The dirt paths, dirt parking areas and the public spaces have already been raked to clean the leaves and overnight debris as well as trash. There must be a mile of concrete walkways that are actively being washed, mopped, swept every morning. Dust blows all day so this is an endless task, but their commitment to this effort has paid off with maintenance of a clean space is easier than achieving that first clean transformation. The hospital corridors are protected in the same way. Yes, it might be cosmetic, but their seemed to be a real sense of pride of the end result. The patients and their families are the ultimate beneficiaries. They have done the same with the campus gardens, but they are, unfortunately, cordoned off with barbed wire and are off limits for sitting. Too clean to use....

What's in a name? 
When we arrived at Muhimbili in October 2014, we were perplexed about how they decide what to call us or refer to their own colleagues. They called Bill Schecter "Prof" as a sign of respect. They referred to me as "Dr. Grey" and called Craig Lubbock " Dr. Craig" - no explanation, no reason for this difference. During this trip, it became evident that there was this inconsistency even within their own ranks.  They would refer to each other by either the use of their first, middle, or last name only, about a third of each, and  not refer to any as " Doctor". Today the explanation. Their society chooses to take the simplest name - either the  first name, middle, or the last name - and that becomes their name to all employees and patients.  "Bosco " is the name of reference of John Bosco Ngendahayo ; "Kitembo" is the reference name of Kitembo Salum. They take the easiest name of the three and that becomes the reference name for all. Makes sense. Mystery solved. 

Things have gone well the first three weeks at Muhimbili National Hospital in the Upanga District of Dar es Salaam. We have been working for three weeks and participated, assisted, or performed many operations. There have been the range of reactions to this experience from highs to lows, depending on the circumstances and the outcome, sometimes both in the same day. 
First a point of clarification of how we got here. The retired Chief of Surgery of San Francisco General Hospital, Bill Schecter , began this program with the premise of having a cadre of surgeons spend a month at a time, helping with operations, making rounds, giving advice, and overall providing examples of how surgery is practiced in the US. The adage, "You can't solve a problem that someone doesn't know he has" comes into play. Bill visited many facilities in Africa and Muhimbili had interesting cases, some interested staff, and a pre-existing relationship with University of California, San Francisco. The Dean at UCSF had spent time in Dar and had actually helped sponsor a donated building to the medical center. So here we are and we have provided about 20 months over the last four years for MNH. 

Change is Hard...
One of the challenges, frustrations, and satisfactions of a volunteer is you can give advice but they don't have to take it. One quick example: bronchoscopy or looking down the airways into the lungs. This is performed on awake patients, after proper anesthesia. I observed/assisted two different surgeons do this. Their standard anesthesia is spraying the mouth, nose and airways with novocaine-like substance to numb the threat and windpipe. Their technique for accomplishing this is somewhat like waterboarding, where the patient is flooded with anesthetic, temporarily can't breathe, and experiences something like drowning. It is difficult to watch. This is easily avoided by administering  the anesthetic with the patient sitting; the patient controls when and how much anesthetic you use. The first surgeon kept doing the "drowning" technique, over and over, despite suggestions, despite the patients' discomfort. No change with any suggestion. The second surgeon heard the rationale for sitting the patient, performed it once under observation , and then never had the patients lie down again. What determined the difference of adaption  to change was not clear to me, but progress is often not linear. 

Pre-hospital Treatment
One of the more disturbing aspects of the month was seeing patients who had either minor problems that had been neglected, or worse, minor problems who had horrific solutions recommended by a local relative or doctor. The worst I saw was a 46 year old diabetic man who had injured his left knee. I don't exactly know the magnitude or specifics of his injury, but the solution was to pour scalding hot water on his entire leg. Not only did this not help his leg, he developed third degree burns on his thighs. He sought no care. By the time he came to the Emergency Room, he had a gangrenous leg and gas in his muscle up to the thigh. An emergency amputation at the hip was performed and he died in about six hours. No therapy is better than some ill advised treatments. 

Know Thy Patient. 
One of the differences between approaches to patient managements is that we have been surprised how busy/overworked the surgeons are. This frantic pace tends to preclude them from doing all the necessary evaluations pre-operatively.  They might not have all the information necessary to completely manage a patient's problem. One example of this was a woman with bowel troubles who was evaluated with a CT scan of her abdomen. It was abnormal and she was scheduled for abdominal exploration. When she was wheeled in the room and the blankets removed, she was noted to have a left thigh mass the size of a volleyball. 

The surgeons were surprised. Apparently no one had examined the patient before. This was eventually taken care of but it was an odd sequence of events. 

The Scrubs and Gowns...
The surgical scrubs at Muhimbili are an experience. There is a sewing room where all the scrubs  are hand sewn. Ordinarily, surgical scrubs come in a few sizes, are made of cotton, and have pockets for storage.  They are extremely easy to put on. The sewing room has received some very durable new material that is more like tent canvas. It is hot. It is undersized do that removing them may involve the Jaws of Life. They have a loop of cordon that is difficult to tie. They may fall down if the cordon knot loosens while walking. The pockets may have holes in them so that they are a decoy pocket. But the older versions are thinner, cooler and do the trick. We ended up wearing a shirt that we had brought and washing at home every day. 

Surgical gowns are typically fitted to put on easily, have tapered sleeves and gathered wrists for ease of gloving, and are impervious to blood. The MNH surgical gowns have evolved into a different experience. They are of varying age, some new, some old, and are porous cotton fabric. Surgeons wear plastic "butcher's apron" underneath to prevent blood strike through (penetration). They are taped in the back to keep them closed. The sleeves are straight and have no wrist gathering. Donning gloves with these are a challenge, as nurses and surgeons glove themselves. Maintaining sterile technique is tricky, but thankfully absolute sterility here has not been the necessity, such as was the case during the  Ebola epidemic. The infection rate is extremely low so what is done seems to work. 

Disposables in the OR...
One curious  aspect of the conduct of operations is the virtual total absence of expensive disposables during surgery. Things such as drains, catheters, sterile covers for cautery, etc. are all absent. These are replaced with lower budget common items. The disposable glove, in addition to being a glove, can be used as a drain, a bovie cover, a collection container, a specimen bag for laparoscopy, a bag for generating positive airway pressure during convalescence. There are probably many more uses. The disposable Anesthesia in a typical hospital closet can be massive, but here it is a few drawers of IVs, a few buckets of IV solution, and some intubation equipment and medications. They have learned to do without. 

An actual conversation.....
Unfortunately, one of he visiting surgical interns had a low risk needlestick during what might have been an HIV exposed patient. We inquired if the hospital had a "Post-Exposure Prophyllaxis" or PEP protocol for such an occurrence. (The Intern had inquired and was not able to get information). 
Me: "Do you have a PEP protocol?"
Him: "Yes,  we do."
Me: " It would be nice to have it on the wall in the Operating Theatre ". 
Him: " I think it is here or there."
Me: "I don't see it here."
Him" So it must be there!"
Me: "Yes, I think so."

There is a new vendor between our front gate and the hospital entrance: a farm to table vegetable and fruit vendor. He had a metal display rack, and had beautiful Roma tomatoes, cucumbers, onions, lettuce, cilantro, pineapples, mangoes, and two types of  avocados. We have made a fantastic salad from his array of offerings that would make any Four Seasons Hotel chef proud. All for about 4000 Tanzanian shillings or two dollars. A game changer for a mid-day break from the hospital. 

It has been a privilege to work this month at Muhimbili National Hospital.