William Schecter - November 2018 Rotation

Report on the Alliance for Global Clinical Training Rotation

October 29 – November 16, 2018

Participants: William Schecter MD, President Alliance for Global Clinical Training, Ronit Bar Haim MD, Attending Surgeon, Western Galilee Medical Center, Nahariya, Israel, Jahanara Graf, MD, newly appointed Medical Director, Alliance for Global Clinical Training

Clinical Experience:  We were gratified by the excellent technical performance of several of our MUHAS/MNH colleagues who have been working with the Alliance for several years. The Tanzanian surgeons have performed 8 esophagogastrectomies independently this year without a death. This is a remarkable achievement considering that prior to 5 years ago no esophagectomy has been performed in anyone’s memory. There are now two appointed chief residents and ICU rounds are performed twice a day. There is a surgical resident assigned to the ICU who is a constant presence. The quality of the rounds is excellent and characterized by disciplined reporting of data and very thoughtful discussion of therapeutic goals and options. We scrubbed on a number of interesting cases at the request of our Tanzanian colleagues. A list of our cases appears below.

 Case List for Alliance Volunteers, November 2018

 Diagnosis                                                         Procedure

Adenocarcinoma of GE junction Ivor Lewis Esophagectomy

Fistula in ano EUA, placement of Seton

Rectal Cancer Low Anterior Resection

Rectal Cancer Low Anterior Resection

Choleilithiasis Cholecystecomy

Mesenteric  Tumor Small bowel resection

Cecal Tumor Right hemicolectomy

Ruptured Spleen Splenectomy

Recurrent Ventral Hernia Rives-Stoppa Ventral Herniorrhaphy

Left leg soft tissue mass Incisional biopsy

Intrabdominal  cystic mass Roux en Y cyst jejunostomy

Anorectal Cancer EUA, and biopsy

Right diabetcic foot Right below knee amputation

Carcinoma of the esophagus Left thoraco-abdominal esophagogastrectomy

Metastatic ovarian sarcoma Small bowel resection, excision of multiple tumors fromperitoneal cavity

Fistula in ano Anal fistulotomy

Rectal Cancer Low anterior resection

Giant Ventral Hernia Rives-Stoppa Ventral Herniorrhaphy

Anal Warts Excision of Anal Warts

Head and  Neck Tumor Gastrostomy and Tracheotomy

Sigmoid Vovulus Hartmann Procedure

Penetrating Abdominal Trauma Small  bowel resection

Incarerated Rectal Prolapse Altemeier Procedure

Small bowel obstruction Laparotomy lysis of adhesions

Goiter Hemithyroidectomy

Abdominal Trauma Laparotomy

Perforated Duodenal Ulcer Graham Patch

Right inguinal hernia Right inguinal herniorrhaphy

Paracolostomy hernia Relocation of colostomy 

Formal Teaching Activities

1.     We ran a two-day Abdominal Wall Reconstruction Course on November 1 and 2. The first day consisted of didactic lectures.  The morning of the second day was a cadaver lab in which the students had an opportunity to perform the procedures they had studied the day before. In the afternoon, there were breakout sessions in which students reviewed the material from the previous day and a half guided by instructors. Several days after the course, Dr. Schecter assisted our Tanzanian colleagues in a Rives-Stoppa submuscular ventral herniorrhaphy in a woman who had 3 previous failed ventral hernia repairs. We believe this is the first submuscular mesh ventral herniorrhaphy done at MUHAS/MNH.  Two weeks later, the Tanzanian team together with Drs. Schecter and Bar Haim performed a Rives-Stoppa repair of a giant ventra hernia. A calendar of the course appears below.

 MUHAS Abdominal Wall Reconstruction Course

 Day 1

1.       09:00-09:30 Anatomy of the Abdominal Wall

2.       09:30-10:00 History of Abdominal Wall Reconstruction

3.       10;00-10:30 Routine Laparotomy Closure: the Sundsvall Technique

10:30-10:45 Break

4.       10:45-11:15 Delayed Primary Closure of the Difficult Open Abdomen

5.       11:15-11:45 Separation of Parts Technique for Abdominal Closure

6.       11:45–12:15 On-lay Mesh Ventral Herniorrhaphy

12:15-13:15 Lunch

7.       13:15-13:45 Rationale for Posterior Component Separation

8.       13:45-14:30 Technique of Posterior Component Separation

9.       15:00-15:30 Laparoscopic Ventral Herniorrhaphy

10.    14:30-15:00 Unplanned Challenges during Abdominal Wall Reconstruction

 Day 2

1.      09:00-12:00  Anatomy Lab

2.     12:00-13:00 Lunch

3.     13:00-15:00 Breakout Sessions

a.     Review of Abdominal Wall Anatomy (30 minutes)

b.    Review History of Abdominal Wall Reconstruction (30 minutes)

c.     Review Techniques of Separation of Parts Technique, Bridge, On-lay Mesh and Rives-Stoppa Procedure

d.    Review Technical Details of Transversus Abdominis  Release (TAR)

2.     Dr. Ronit Bar Haim made daily ICU teaching rounds with the resident and attending staff

3.     Dr. Schecter was approached by the Gynecology Residents to give a course on ICU care. They had heard about the course from their resident colleagues in surgery.  Unfortunately, the request came close to the end of the rotation so Dr. Schecter held evening teaching sessions for the Gynecology residents on November 14 and 15 and will investigate whether the gynecologists would like courses given by Dr. Jahanara Graf and our Tanzanian surgical colleagues later this year and next year.

 Administrative Issues

1.     The newly constructed hospital (about 1 1/2 to 3 hours drive from MUHAS/MNH depending on traffic) had been administered by MUHAS.  3 weeks prior to our arrival, control of the hospital was transferred to MNH. So, the overwhelming concern about the new hospital on the part of MUHAS surgeons and Nursing Educators has now disappeared as they are no longer responsible for this hospital. MNH surgeons now staff the surgical service there for 1 week at a time. This change has major implications for the Alliance Nursing Initiative as the MUHAS Nursing Administration (Lillian and Dickson) no longer are interested in our nurse educators making the trek to the new hospital and have agreed to run all teaching activities at the MUHAS/MNH campus.

2.     Dr. Ali Mwanga has unfortunately left for a 4 year period to study liver transplantation in China. This is a big loss for the MNH teaching program and for the Alliance as Dr. Mwanga was our Alliance Tanzania Coordinator.

3.     Dr. Larry Akoko has stepped down as Chair of MUHAS Surgery and plans to do a year Fellowship in Thoracic Surgery in India. He has been replaced by Dr. Obadiah, a Urologist

4.     Dr. Jahanara Graf has assumed the position of Medical Director of the Alliance for Global Clinical Training. She is based at MUHAS/MNH. She began work on Friday November 9, 2018 and jumped right in with a full day in the OR. Her major project will be to implement a data base for the MUHAS Dept. of Surgery. She is consulting with Drs. Clifford Ko and Girma Tefera of the American College of Surgeons. We hope to do a Pilot Project on Firm I. If successful, the Data Base could serve as a model for many hospitals in Africa. This data base will be surgeon led and collect only clinically relevant data.

 Oncology Consortium

A group from a multi-institutional consortium focused on esophageal carcinoma arrived to train MUHAS surgeons in insertion of esophageal stents for palliation. Dr. Katherine Van Loon, the Director of the UCSF Global Oncology Program accompanied the group. There will be an internist, who is applying for an Oncology Fellowship, Geofrey Buckle, who will be intermittently present and coordinating research in esophageal cancer. Dr. Van Loon offered to make Dr. Graf a co-investigator on the study and she is considering this opportunity. The title of the project is “Management of Esophageal Cancer in East Africa: A Prospective Cohort Study of Treatment Strategies and Supportive Care”. Dr. Van Loon has met with Dr. Sosa, the Chair of Surgery at UCSF. There is a potential opportunity for the Alliance to collaborate with the Consortium, the UCSF Global Oncology and the UCSF Global Surgery programs. We will see how this plays out.

Nursing Initiative

Dr. Schecter met with Lillian and Dickson re: the Nursing Course. As previously reported, the course was enthusiastically received and will be given by the Tanzanians to their colleagues later this year. Dr. Schecter emphasized that our Nurse Educators do not wish to travel to the new hospital but as mentioned earlier, this is no longer an issue because MUHAS is no longer responsible for the hospital. Options for additional courses were discussed.

On October 15, Dr. Schecter met with Zuhara Mlupio, the Acting Director of MNH Nursing, together with Salome Buluba and Masunga Iseselo representing MUHAS nursing and Dr. Akoko. Zuhara was enthusiastic about the Alliance Nursing Education Initiative, perhaps because she took the course in September. She agreed to have the course taught at the MUHAS/MNH campus, have our nurse educators mentor their students on the wards and in the ICU and provide free housing for the nurse educators during their stay. We agreed that the subject of the next course should be ICU nursing.

Farrah and Shannon will communicate with Lillian, Dickson and Zuhara re: the plan for next year’s course.

Data Base and M&M Conference Pilot Project

Drs. Schecter and Graf met with Dr. Obadiah, the new Chair of the MUHAS Dept of Surgery and Dr. Akoko. Unfortunately, we missed a meeting with Dr. Ibrahim Mkona, the Chief of the MNH Dept of Surgery but we have spoken informally with both him and Dr. Shamshama, the Head of Firm I. The plan is to institute a data base of all Firm I surgical cases prospectively and institute a weekly M&M Conference as a pilot project. If successful, the concept will be extended to the entire Department. Drs. Akoko and Obadiah agreed to supply one person to manage the data base. The Kitembo will be assigned to coordinate with Jahanara and run the M&M conference.

Drs. Schecter and Graf had a conference call with the American College of Surgeons staff. They agree to allow the MUHAS/MNH Department of Surgery to have access to the American College of Surgeons’ Surgeon Specific Registry as a platform for our data base. We will strongly consider this option and make the decision within the week.

William Schecter - March 2018 Rotation

Report on the Alliance for Global Clinical Training Rotation

March, 2018 Rotation

March 21, 2018

Participants: Bill Schecter (President, the Alliance), Madian Yahya (Attending Surgeon, Danbury Medical Center, Connecticut), Alon Wachtel (Resident Surgeon, Kaplan Medical Center, Israel)

Clinical Experience:  We had a very busy month with challenging cases. Madian completed his training in June, 2017. He is an excellent surgeon with good judgment and technical skill. His family is originally from Tanzania and he plans to volunteer with the Alliance for 1-2 months per year. He is an enthusiastic hard-working surgeon and an excellent teacher. Alon Wachtel is a fourth-year surgery resident in Israel. He has an impressive military background and brings this discipline and commitment to his work as a surgeon. He developed excellent relations with his Tanzanian peers and was very enthusiastic about his learning and teaching experience. Both Madian and Alon served as instructors in the breakout sessions during the Myocutaneous Flap Course that we gave.

We started off the rotation with an obstructive jaundice due to choledocholithiasis case at the new Muhimbili Academic Medical Center which is about an hour and a half drive from Muhimbili National Hospital. It is a spanking new beautiful hospital built by the Koreans. There are very few hospitalized patients so far and they are just getting cranked up. We had to bring common duct instruments from MNH as they don’t yet have them at the new hospital. Madian scrubbed on another common duct and a couple of days ago we did a difficult intrahepatic cholecystectomy, resection of what was probably a cholangiocarcinoma (no frozen sections available) and hepaticojejunostomy.  So far, she is doing beautifully. In addition we did two large sarcomas requiring a myocutaneous flap and a muscle flap for closure. We did a total of 36 cases. Our case list appears below.

Table 1 Case List for Alliance Volunteers, March 2018

Diagnosis                                                                      Procedure
DM septic Left foot                                                   Guilloutine LAKA
Common duct obstruction                                       Cholecystectomy CDE, Choledochoduodnostomy
Gastric Cancer                                                            Subtotal Gastrectomy with BII reconstruction
s                                                                                    Laparotomy
Unresectable pancreatic cancer                                Cholecystojejunostomy
Unresectable pancreatic cancer                                Cholecystojejunostomy
Squamous CellCarcinoma                                          Left BKA
Septic Abdomen                                                          2nd look laparotomy and abdominal wash out
 Chronic Cholecystitis                                                Lap Cholecystectomy
obstructive jaundice dt pancreatic cancer               Cholecystojejunostomy
esophageal SCC                                                          Aborted esophagectomy
obstructive jaundice dt pancreatic cancer               Cholecystojejunostomy
rt colloid goiter                                                           hemithyroidectomy
advanced rectal carcinoma with mets                      loop sigmoid colostomy
advanced breast cancer                                              modified radical mastectomy
Choledocholithiasis with obstructive jaundice       Cholecystectomy, CBDE, 
stab wounds                                                                 exploratory laparotomy
Gastric Cancer                                                             aborted gastrectomy dt carcinomatosis feeding gastrostomy
Choledocholithiasis with obstructive jaundice       Cholecystectomy, CBDE, Choldochoduodenostomy
suspected sarcoma                                                      groin biopsy
lt leg SCC                                                                     above knee amputation
Resection of Sarcoma lt flank and abdomen           excision of lt flank and abdomen sarcoma, rectus femoris flap and skin grafting
rt peritonitis                                                                resection of small bowel with anastomosis segmental ischemia of small bowel
choledecholithiasis                                                     cholecystectomy RY hepaticojejunostomy dt suspected cholangiocarcinoma with liver mets
Perforated gastric Ulcer (3rd Portion)                           exploratory laparotomy  omentopexy
Attempted suicide multiple abdominal stab wounds  Ex lap Repair of liver laceration
Colloid, suspicion of folicular ca. Goiter                      Right Thyroid Lobectomy
Pancreatic Pseudocyst                                                     Cystduodenostomy
obstructive jaundice dt pancreatic cancer                    Cholecystojejunostomy
Epigastric Hernia                                                             Epigastric Hernia Repair
Pelvic Retroperitoneal Sarcoma extending to groin    Excision of sarcoma and sartorious muscle Flap
Ventral Hernia                                                                  Ventral Herniorrhaphy
Septic Abdomen due to Perforated Uterus                   Hysterectomy and Peritoneal toilet
Incarcerated Inguinal Hernia with ischemic bowel     Small bowel resection and right inguinal herniorrhaphy
Tumor Ascending Colon                                                 Right hemicolectomy
Goiter                                                                                Left thyroid lobectomy
Goiter                                                                                Left thyroid lobectomy
 

Formal Teaching Activities

  1. We ran the MUHAS Myocutaneous Flap Course over a two-day period including an entire morning in the dissection lab. All the students had the opportunity to perform almost all of the flaps taught in the didactic portion of the course. The next day we had an en-bloc resection of the side of the chest wall and lower abdomen including the iliac crest and two ribs for a recurrent dermatofibrosarcoma. We covered the bone with a rectus femoris myocutaneous flap (one of the flaps taught in the course). It was a great learning experience as the residents and fellows had a chance to perform the operation the day previously in the lab. Fortunately, the patient is doing well and we hope we have solved the local control problem of the sarcoma. Time will tell.
  2. Madian and Alon made formal rounds with the residents and fellows each morning. They are continuing to make ICU rounds in the morning and in general the ICU care has improved dramatically although we still have a long way to go.

Administrative Issues

1.       I met with the Director of the Muhimbili Orthopedic Institute (MOI) and Dr. Mwanga re: creation of a unified Trauma Service as suggested by Prof. Elhanan Bar-On of Israel.  Drs. Mwanga and Akoko are very supportive of this suggestion.   The Director of MOI also expressed interest but confirmed the significant administrative obstacles.  Dr. Akoko suggested that an e-mail conversation between Prof. Bar-On, the Director of MOI and Drs. Akoko and Mwanga begin in preparation for Prof. Bar-On’s visit to MOI/MNH.

2.       I spoke with Dr. Akoko re: a position for Dr. Jahanara Graf, a previous Alliance resident, who will move to Dar Es Salaam in October after taking the Surgery Board exams.  He has agreed to offer her a position but cannot guarantee funding. Dr. Graf and Dr. Akoko will begin corresponding about the details.

3.       I sent Ms. Lillian Mselle, the Assistant Director of Nursing the following e-mail:

Saturday March 17, 2018

 Dear Lillian:

 I am sorry that our busy schedules precluded a meeting last week. As I mentioned in my last e-mail, I am writing to give you some background on the reason I requested the meeting to give you time to think about the proposal. Hopefully, we can get together in the coming week prior to my departure early Friday morning, or at least have a telephone conversation.

 I am the President of the Alliance for Global Clinical Training. The Alliance has had a collaborative relationship with the MUHAS/MNH Department of Surgery for the past 6 years based on an MOU signed both parties. We believe this relationship has resulted in an improved surgical education for students, registrars and residents and an addition of 14 surgical procedures to the skill set of MUHAS/MNH surgeons as documented in the attached documents. In addition, the Alliance, working collaboratively with our MUHAS/MNH colleagues, has introduced four multi-day courses (Trauma/Acute Care Surgery, Peri-operative Care, Surgical Critical Care and Myocutaneous Flaps).   We have “trained the trainers” and now our MUHAS/MNH colleagues are giving these courses on a regular basis to their trainees and other departments.  The plan is to expand the educational program to other hospitals in the region.  You can get more information about the Alliance by visiting our website at www.agct.info.

 Drs. Akoko, Mwanga and the Alliance faculty realize that Surgery is a collaborative discipline.  We cannot expect to achieve sustainable improvement in outcomes without close collaboration with our colleagues in Nursing and Anesthesia. Re: Nursing—in the past we have had two Nursing exploratory visits, one accompanied by a Senior Hospital Administrator. We met with the nursing leadership and worked with rank and file nurses in the ward, ICU and theatre.With the exception of Kalenga in the ICU and Zawadi in the theatre, the reception to these efforts was polite but unenthusiastic. After discussions with Drs. Akoko and Mwanga, as well as the Board of Directors of the Alliance, we have decided to try once more to initiate a collaborative relationship in Nursing Education similar to the arrangement we have with our Surgical colleagues. To that end we have recruited Ms. Farrah Kashfipour, a senior nurse educator with vast experience in nursing education in low and middle-income countries, to our Board of Directors. In addition, Ms. Shannon MacFarlan, a highly experience ICU nurse who has made several visits to MUHAS/MNH and has close relationships with several MUHAS/MNH nursing leaders, remains enthusiastic about the possibility of developing a collaborative educational nursing relationship. Farrah is willing to fly to Dar Es Salaam, probably as early as the end of May for exploratory meetings.

I want to emphasize that our program is purely voluntary and not based on grants.  We have a long-term commitment to MUHAS/MNH which is independent of grant funding.  That means that we will not disappear the moment funding ends.  However, we never promise more than we can deliver.  There are significant barriers to recruitment of nurse volunteers for a sustainable long term educational program similar to the one we have in surgery.  The reasons include limited discretionary funds for most nurses due to salary structure, limited discretionary leave policies for most hospitals given the nursing employment structure, and family obligations for many nurses.  However, our Board believes that these barriers can be overcome.

The reason I wanted to meet with you is to ascertain whether or not the Nursing Administration in both MUHAS and MNH would be open to a collaborative relationship with the Alliance.  If not, I certainly understand. However, we don’t want to send Farrah on a long trip with no chance of success.  If you would be open to such a relationship, we would love to explore the possibilities with you recognizing that these discussions would be provisional and that you might decide not to pursue the matter further. Alternatively, we might find that despite our best efforts, recruitment of a sufficient number volunteer nurse educators might not be feasible. On a positive note, Shannon Macfarlan, our Alliance nurse with hands on experience at MUHAS, thinks that recruitment of nurses will not be a problem if we can solve the financial and leave barriers that exist. Dr. Paul Hofmann, our Board member with extensive Hospital Administration experience, believes that these obstacles are not insurmountable.

I hope that after reading this letter, visiting our website and perhaps discussions with Drs. Akoko and Mwanga, you and your colleagues will be open to further discussions. If so, I would be delighted to meet with you either in person or by telephone to answer any further questions you may have prior to my departure Friday morning.

 With kind personal regards, I am

Respectfully yours,

 William Schecter, MD

President,

Alliance for Global Clinical Training

I received the following reply:

Dear William

 I am very positive about this collaboration and the idea of having close collaboration with nursing as well. I have understood that this collaboration is clinical skills capacity building and I believe it will benefit not only the staff at the University hospital but also nurse faculty who most of them are young and inexperienced.

 I will be very happy to meet with you before you leave on Friday. How about Tomorrow (Wednesday) or Thursday (22nd) at 8am? I will have to leave MUHAS at 9 am for external examination at Hurbert Kairuki Memorial University.

I met with Lillian this morning (March 21) as well as Mr. Dickson Mkoka, Head of Clinical Nursing Department at MUHAS (e-mail: mkokamalinga@yahoo.co.uk; Mobile: +255718694495).  They reiterated that they were very positive about collaborating with the Alliance to improve nursing education and nursing care.  They are looking forward to meeting Farrah and Shannon

I sent a note to Farrah so that she can communicate directly with Lillian re: their educational needs and the details of her visit.  If this works out, it remains for Paul to find a creative solution to the administrative barriers to nurse recruitment in the US and for Shannon to organize recruitment efforts.

This concludes my report on what I believe was a very productive visit.

William Schecter, MD

President, the Alliance for Global Clinical Training

Professor of Clinical Surgery, Emeritus

University of California, San Francisco