November 2023

November in Dar Es Salaam

My return visit was wonderful as expected. I flew in this time to Zanzibar, where the visa and immigration lines were fairly disorganized, but the airport is small and manageable. I had no trouble getting through customs with the two surgical instrument sets and two Butterfly ultrasound machines to be donated - I was momentarily paused when the luggage was being Xrayed and asked if I was a doctor, then passed through without further questioning. I stayed at the Seyyida Hotel (lovely!) and was able to take a little walk around Stonetown. Some of the nearby sites included Forodhani Park with many food vendors and a gathering of young men singing and jumping/diving off the sea wall into the bay. The following morning, Sunday, I visited Mnazi Moja Hospital, where along with a couple of the Zanzibari surgeons we conducted a brief screening of six dialysis patients for potential arteriovenous fistula. One instrument set and Butterfly ultrasound were left to be used by Mnazi Moja’s fledgling dialysis access program. Then one of the Mnazi Moja surgeons, Dr. Rukia Msoma, and I took a walk to get gelato before catching the last ferry of the day to Dar Es Salaam. Going through customs again in Dar, I was finally asked to actually open the suitcase to show the remaining set of instruments and ultrasound but otherwise had no difficulties.

On Monday, I brought the second set of instruments and Butterfly ultrasound to Amana Hospital, where we conducted another screening in the dialysis unit. Recall that this was the hospital where we had done our last AV fistula “camp” in April to finish the training for the inaugural MUHAS surgeons. Our surgeon learners this trip was the Amana surgeon, Dr. Gilbert Kwesi, who had hosted us in April, and Dr. Rukia from Zanzibar. Three MUHAS surgeons also attended - Drs. Akoko, Fransia and Nashivai. Out of 15 patients screened, 14 were deemed candidates for surgery. We then went back to MUHAS, where we had an informal loupes “ceremony” for Drs. Gilbert, Rukia and Nashivai to receive their new loupes, donated by Designs for Vision. We then went through several practice arteriovenous anastomoses using a chicken neck model.

Over the next five days (Tues-Sat), a total of 16 arteriovenous fistula operations were performed, including three patients who had been screened in Zanzibar. Each patient’s veins were reevaluated on the table prior to prepping using the Butterfly ultrasound. The first two days were primarily me and the two surgeon learners doing the cases together, while the last three days were the Tanzanians (including Dr. Akoko from the first trip) working through the cases supporting each other with me looking over their shoulders and chiming in periodically. Fortunately, we had the two instrument sets from MUHAS and the new instrument set I brought with me to donate to Amana; this allowed us to do 3-4 cases a day without having to wait for instrument reprocessing between each case.

After the last two cases on Saturday, Drs. Akoko, Gilbert, Rukia and I had a wonderful rooftop dinner at the Holiday Inn in the center of Dar Es Salaam. Dr. Leila Nassib, an intern at Amana who helped scrub several of the cases during the week, was also able to attend, along with Dr. Akoko and Rukia's families. The weather was actually quite pleasant and cooperated by not raining on us. The view was amazing looking out over the city and surrounding bay waters.

This trip I tried to have more of a local experience. I stayed at a hotel in the Kariakoo district, a busy working part of town, located between MUHAS and Amana. I used the Bolt app (like Uber/Lyft) to call for bajaji (tuk tuk) rides to and from the hospital each day. I wasn’t quite brave enough to do a boda (motorcycle) ride, although I told myself it was because of the bag of supplies I carried. I even bought vitumbua off the street, and they were delicious! I did learn that bajaji and bodas are not allowed into the airport property, so I had to walk from the gas station at the corner of the intersection to turn into the airport (fortunately not that far to the terminal and my suitcase has wheels). I am looking forward to another visit to Tanzania soon!

April 2023

April in Dar Es Salaam

Karibu!

Whether you are a global surgery veteran or a first-timer, there’s nothing like taking your first deep breath and look around in a new country. The smells, sounds, colors and sensations form the backbone of your experience and should be savored from those initial moments. When I travel to other countries, I love getting to know the people, their foods and customs, music and values. In that regard, Tanzania does not disappoint. Every person I encountered smiled and greeted me politely and warmly. While I am clearly a foreigner (by my face, clothing and speech), at no time was I ever made to feel unwelcome or uncomfortable. I stayed at the Protea by Marriott Hotel Courtyard, which was a short drive from MUHAS (Kalenga House being remodeled I believe). The hotel is also a quick walk along Barack Obama Drive to the Indian Ocean. Arnold, the weekday bellman, was friendly, helpful and checked in with me frequently to make sure I had all I needed.

I arrived having done surgical trips to other low-middle income countries, so there was little preamble in getting to work. I got a brief tour of the sprawling MUHAS/MNH grounds, including the new laparoscopy skills room off of the anatomy lab. Dr. Larry Akoko’s office is much like the offices I have seen of others who are the creators and builders of new programs – models and supplies in every corner, shelves crowded with books, students and visitors coming and going constantly (Dr. Akoko seems to know EVERYone there), and the ubiquitous electric water kettle and tea supplies accorded valuable and readily accessible counter space. I had brought with me six pairs of loupes donated by AGCT and Loupes Around the World for the six surgeons who had started the dialysis surgery didactic training. We had a little “loupes ceremony” for the recipients, all of whom were deeply grateful and excited.

We then travelled 20 minutes or so to the Amana Regional Referral Hospital. They have a very clean and modern ED/ICU (funded by Abbott), as well as several bright, open and clean patient wards. There are three reasonably sized operating rooms.

Of course, the main objective of our visit there was their dialysis unit. In Tanzania, dialysis units are based at the regional and national hospitals and also at privately run units. The regional hospitals are staffed by physicians and surgeons, who may work at more than one hospital to make a living. The primary surgical specialties available at Amana are gynecology, general surgery and urology.

We were accompanied through the dialysis unit by a nephrologist and a couple of the interested Amana surgeons. Using the donated Butterfly portable ultrasound unit, we evaluated all of the patients who were there to receive dialysis.

Of the 13 patients who came for dialysis that day, only one had had a prior attempt at dialysis access and had a tunneled catheter in place instead. We scheduled 11 of the 13 patients for arteriovenous fistula creation; the remaining two were felt to have inadequate veins and referred for tunneled dialysis catheter placement.

Over the following four days, we were able to operate on 10 of the 11 patients, and 8 of those 10 had successful AV fistula creation (the two failed cases had poor quality vein intraoperatively - one of those had already been anticipated by preoperative vein imaging to be a marginal candidate).

In total, I participated in or observed six brachiocephalic, two single-stage basilic transposition, and two radiocephalic fistulae operations. The 11th patient had a functioning fistula created the subsequent week by the Tanzanian surgeons operating completely solo.

On my last day, I went to the Mwenge Carver’s market (and probably spent more than reasonable on souvenirs), then to a BBQ at Dr. Akoko’s house. What a wonderful and endearing way to end the trip being invited into someone’s home and made to feel a part of the family!

In terms of travel logistics, the food in Tanzania was savory – a mixture of Indian, Middle Eastern, Asian and African influences and spices, along with the unexpected central mainstay of hot tea! Some particularly memorable local dishes were: ugali (thick maize porridge/dough), vitumbua (rice donut), ndizi (plantain), mbuzi (goat), mtori (banana) soup and chipsi mayai (egg-potato omelette). The music is upbeat in a distinctly different tone and rhythm compared to the Latin-Caribbean influences we mostly hear at home in the US. The traffic, not surprisingly for densely populated areas, requires a little bit of faith in your driver’s knowledge of driving rules and etiquette, not to mention navigating around (or sometimes through) jarring potholes. It rained intermittently while I was there, which made for even more complicated traffic jams. Nonetheless, Uber and local ride-hailing services (like Bolt) were readily available and worked reliably. I did take malaria prophylaxis (Malarone) and used mosquito repellant daily, and I was only bitten on the one day when I decided to eat dinner outside on a patio during a rainstorm.

Asante sana!