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


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