Reflections – Week 3

by Marcel

And so the third and final week of our visit has come to an end. It’s time to leave Bugando. Ricky will fly out to Europe today, and then on to Charlottesville, where they need him in the neuroangio suite. The rest of us will take a few days vacation in Zanzibar, to recover and reflect before heading back to the US.

This past week has been as busy as the others. The main difference has been the change in our surgeons. Gerald Mayaya (surgical resident) and Isidor Ngayomela (orthopedic surgeon) had been traveling to a spine meeting in Europe, but now came back – Gerald first, then Isidor. So, Ricky now worked with Gerald instead of with Emmanuel. Gerald had no experience in shunt placements, but as there were so many children to be treated, he had a quick learning curve, and by the time the Final Four were operated on this past Friday, he was able to do the cases by himself. Ricky didn’t scrub, and just watched and gave some advice. Similarly, on that day, Mr Mkama and Joel, the two neuro-anesthetists in training, did things by themselves. It was a nice feeling, on our last day operating, to stand back, to see the Tanzanian team work alone, and to see ourselves superfluous. Because making ourselves superfluous is what we really had come for.

The Tanzanian team places a VP shunt. Left Joel, right Gerald, working with an intern. In the back Mr Lema.

And along the way, quite a number of patients have been helped. The hydrocephalus ward has room for 32 patients (8 beds, with 4 children per bed), and we operated on about 25 of them. It will fill up quickly again, though. More fundamental approaches will be needed – folate supplementation for pregnant women, and meningococcal vaccination for the children – before the incidence of hydrocephalus will decline substantially. But at least we’ve been able to help some of the victims, and with Gerald able to perform the procedure now, we hope that the patients will no longer be waiting for months before operation.

You can learn a lot from unexpected events. We definitely were not planning on doing pediatric cases when we came to Bugando, but the CT and C-arm breakdowns pushed us there. What remarkable luck that there was a pediatric critical care nurse on our team! What we learned, though, is that there are real teaching benefits in doing simple cases at high volume. If the imaging equipment had worked, we would have done fewer, more complex and more diverse cases, intracranial tumors and complex spine – and we likely would not have left having trained someone to work independently. It’s only logical to leave the complex and challenging cases to visiting physicians, but it may not be the best teaching model. Doing a relatively straightforward procedure over and over again is a better way to teach someone. So maybe, on a next trip, we should focus on, say, doing single-level lumbar decompressions? It may not sound as exciting as saving someone with a brain tumor, but it may be a faster route to independence for the local surgical teams.

Postoperative care remains a big problem. The incidence of hypoxemia in the recovery room and the ICU is disturbingly high, and Natalia had to intervene with so many of our patients. Unless there’s a general consensus that all patients be appropriately monitored, and that hypotension and SaO2<90% are unacceptable events, neurosurgical patients may be at greater risk postoperatively than during operation. Part of the problem is lack of equipment (the PACU has only a single functional oximeter) and appropriate donations may be a way to approach that. But there is also a lack of training. The best way I can think of to address this, is to arrange for a small group of selected personnel to take care of these patients. Those people can then be trained to maintain appropriate standards. Similar to our Madaktari team working with a few surgeons and a few anesthetists, we may have to ask for a a few specific local ICU nurses to be assigned to our cases. So there’s much more work to be done…

But that will have to wait until the next trip! For the moment, I think we can be pretty happy with what has been done in a short amount of time. Haydom has its new ICU resuscitation protocol and some updates on critical care issues. Bugando has seen a lot of children helped, and some substantial training done.

We wish to thank everyone at Haydom and Bugando for making the trip a success. People have done so much to help us out. Examples are Emmanuel coming back from Dar es Salaam to operate with us for two weeks, and Bugando hospital arranging to modify their operating schedules to give us an operating room every single day.

We also thank our blog readers! It was really nice to check the stats on the site, and see how some days more than 100 people followed our work here.

This will be the last post of the series. Some material on earlier events may still be posted, and maybe some additional pictures added. If so, people with blog subscriptions will get an email, and we’ll link to Facebook.

Thanks once again, from the whole Madaktari team!

Ricky, Natalia, Marcel and Diana in front of Theatre 4, where all operations were done

The Characters of Bugando Hospital, Mwanza

We have met and worked with many people while at Bugando and we thought that it would be fun to introduce them

Mr. Lema

Mr. Lema is in charge of equipment in the operating theaters.  Everything seems to be locked up and Lema can help you find anything from an arm board for the operating table, to the fiberoptic scope, to toilet paper for the restroom.  He is always very helpful and is willing to stay as long as he needs to for the patients.  He is a stickler about shoe covers and has often stopped us and asked us to go put covers on our shoes before we can enter the theater (we always seem to forget).  Most of the people in the OT change into tall white boots but we prefer the shoe covers.

Dr. Matasha

Dr. Matasha is the head of the anesthesia department and the only medically (MD) trained anesthesiologist.  He appears in his white coat early in the morning to teach the students in the nurse anesthetist program, then floats through the OTs in the afternoon.

Mr Mkama

Mr Mkama is one the anesthetist assigned to our Madaktari visit, to be trained in neurosurgery anesthesia.  When we arrive in the morning, Mr Mkama greets us with an enourmous smile and a jolly laugh.  He has the O.T. beautifully set up, everything is organized and ready to go.  Mr Mkama joined the German Red Cross to help establish refugee camps in Rwanda from 1999 – 2001.  Then in 2001 he went with the Tanzanian Red Cross to Congo during the Niragono volcanic explosion.  We have enjoyed working with him since he has such a wonderful demeanor and is so organized.

Joel Karugaba

Joel is the second anesthetist assigned to our visit.  Joel is younger than Mr Mkama and also greets us with a huge smile and is ready to help.  Joel is eager to learn new things and is always thinking.  One day, we noticed he picked up a blue piece of plastic laying around in the OT and he was using a scalpel to carve it.  When we asked him what he was creating, he told us it was a pediatric bougie.  How creative!

Mr Fortunate

Fortunate is one of the recovery nurses.  He is always busy extubating or moving the pulse oximeter or oxygen mask from one patient to the next.  When he is not running around the recovery room you can hear him joking with fellow coworkers and laughing in the Chai room. He wakes the kids (watoto) up with songs, and the adults by saying “Pole pole” (slowly).

Mr Magobe

Mr Magobe is the second nurse in the recovery room.  Mr. Magobe is the perfect complement to Mr. Fortunate since he is much taller and moves quietly around the room.  So while Mr Fortunate is running around, Mr Magobe is moving the suction machine quietly and slowly.  He has a distinctive way of wearing his OT cap, always with the strings untied hanging in the back.

Mr Mussai

Mr Mussai is an anesthetists that enjoys teaching me Swahili.  Each day he finds me in order to teach me a new word.

Vihar

Vihar is training to be a plastic surgeon.  He was our coffee connection while in Mwanza.  When we spoke of the coffee challenge, he took it upon himself to find a vendor in the market who sold real coffee, brought us samples and later helped us with our purchase in local price!

The Serengeti House

The Serengeti guesthouse has been our home for the past couple of weeks.

 

Gatekeeper/security

 

When we arrive there is a guard at the gate.  This guard is usually an older lady that greets us with a “karibu”, then slowly walks over to swing the gate open.  You can occasionally catch her standing outside our place, eating a piece of chicken with her hands and then tossing the bones into the garden.

Mrs Merina

Mrs. Merina is the head housekeeper.  She greets us each morning with a warm smile and asks us what we want for lunch, her reply always being “you want? no problem”.  Whatever we request is made and she treats us as if we are her own.  She has traveled to the market in search of wooden giraffes, safari animal napkin holders, and other souvenirs.

There are 4 houses in the complex, 2 are being used by visiting doctors, one by a hospital administrator and we are not sure who resides in the fourth house.  Our house has 3 bedrooms, one with its own bathroom and the other 2 bedrooms share the second bathroom.  This bathroom has been quite a challenge to adapt to since the shower has to be regulated by a scolding hot faucet, there is no hot water, or the water is out completely.

The toilet also works sporadically and has begun leaking, which has been temporarily fixed by the addition of a towel.  The hand washing faucet has a continuous leak and if we are not are not careful in closing it, precious water runs continuously.  Finally, the door once shut is impossible to open and has to be kicked opened which also alerts the rest of the household that the bathroom is available.  The rest of the house is wonderful, the rooms have nice windows overlooking the garden, and there is a nice living room and terrace that also overlooks the garden.  We eat our meals in the second house sharing these with the group of visiting doctors that reside in that house.  Breakfast is simple, usually consisting of peanut butter on toast and Africafe.  Lunch is waiting for us in the early afternoon and is always a delicious combination of rice, veggies, and fish or meat.  Merina cooks us dinner and leaves in the oven for us to warm up.

Marcel and the guard demonstrate how intruders are dealt with

Tuesday September 20 – ACDF

By Marcel

Two more anesthesia students arrived this morning! The grand total is now 7 – it’s beginning to look like a real group. It is still unclear why they can not all start at the same time, and certainly the late arrivals miss out on some basic material that has been covered these past weeks, but this is how the system works… A few more might “possibly” turn up this week. We’ll see. Most of the students also don’t have their textbook yet, largely because of financial reasons. This doesn’t help either.

But they enjoy the lectures. I now do a brief quiz (case-based) each morning, covering the main points we discussed the day before, and they are doing well. Also, they ask very good questions. Overall, I’m impressed with the group.

This morning we spoke about anesthesia systems, particularly vaporizers. Although Bugando has quite modern Ohmeda anesthesia machines, many of these trainees will later be working in district hospitals where much simpler (and more fail-safe) equipment is used. Specifically, they’ll be using draw-over anesthesia systems that don’t require oxygen, pressurized gases or electricity to function.  I explained the differences in construction and function, and later found out there is one of those systems in use at Bugando. Tomorrow morning we’ll bring it to the lecture room (i.e. the PACU) to show them.

Draw-over vaporizers: an Oxford miniature vaporizer (halothane) and an EMO vaporizer (ether) in series

While I was busy with all this, Diana and Ricky took care of a child for VP shunt placement. Then came the big case of the day: an anterior cervical decompression and fusion in an unfortunate patient with jumped facets at C5-C6 after a bicycle accident – he was mentioned in one of the previous posts. Ricky placed him in traction a few days ago and the dislocation was largely reduced. Now he could be fused, but it was going to be difficult for everyone. For Ricky, the main problem was not having access to intraoperative fluoro, only to a single flat plate, and that only after political maneuvering, since the “designated” ICU portable x-ray machine had to be brought to the OR. He also had to use a cage system that he was unfamiliar with. From our perspective, we had a patient with a highly unstable neck in traction to intubate. There is a single fiberoptic bronchoscope at Bugando, of an unusual model. It’s not clear that it ever has been used before. Justin Ford and I found it last year, but could not get it to work. This time, we managed to have it light up. We used it in a practice run on a patient yesterday, but found it very difficult to maneuver, and we abandoned it for direct laryngoscopy. But it simply had to work today! And it did. This was not an occasion to let one of our trainees (who have never held a fiberscope) try, so Diana used it. She did a flawless first-pass fiberoptic intubation, after anesthetic induction with thiopental and pancuronium (succinylcholine was contraindicated because of the patient’s paralysis).

The Bugando fiberoptic scope

Despite waiting for 45 minutes for an x-ray of miserable quality, Ricky localized the level, and he and Gerald (the surgery resident learning neurosurgery) then did a fast ACDF. We brought the patient to the ICU, where, before we could leave again, we were asked to help with another patient, who had just been extubated and was not able to maintain ventilation. The story was a little unclear – she underwent a thyroidectomy a week ago, complicated by bleeding, was intubated and extubated twice, and had quite a swollen neck. What was very clear was that she was not maintaining her airway at all. “We’re in trouble”, is how the intern in the unit put it. In a joint effort between him, Diana and me we reintubated her, using the second of the two bougies that we brought with us to Mwanza. We decided to take this bougie back to the OR to have it cleaned. It may help save a life during the next few days.

Just before sunset, while Ricky was still seeing some clinic patients with Emmanuel, the rest of the group climbed to the top of the hospital to view the sunset. Magnificent! For some reason, the sky is so beautiful here around that time of day. Great views of the lake, and lots and lots of large birds wheeling around. It was very spectacular.

Sunset over Lake Victoria, seen from the 9th floor of Bugando Hospital

We then made a brief visit to the hydrocephalus ward, to see some of our patients – and to find out that there’s still a lot of work to be done. One child has “sundowning” eyes to such an extent that you can’t see any of the iris at all. We plan to do another 4 cases tomorrow. Good practice for Gerald, who has not done many shunts yet.

Child with severe hydrocephalus

Coming back to the house, we found we had forgotten our keys, and were locked out. Luckily, Ricky had meanwhile come home and could let us in. Otherwise, it would have been a real problem, since no one else but Ms. Merina has a key to the place.

Fish dinner! A request from Diana, and Ms. Merina quickly obliged. It was excellent. Some coffee afterwards. Not a bad way to end an successful day.

Monday in Bugando Hospital Mwanza – our third week begins

by Natalia

Ricky operating with Gerald, a surgery resident learning neuro procedures

After a quiet weekend with much needed rest and delicious Indian meals, we were back in the OR first thing in the morning. This Monday proved to be less busy than last Monday, our three patients had checked in, OR 4 was set up with the proper equipment and we started our first case before 9am! The morning started with the usual review of cases by Dr. Matasha and the anesthesia students, followed by Marcel’s lecture. The group of students remains at 5, they enjoy and benefit from Marcel’s morning lectures and the time they spend in the OR with Diana.

Ricky and Emmanuel are now placing VP shunts at great speed and the OR runs smoothly with everyone in their respective spots. So today, we had 2 more children with hydrocephalus having VP shunts placed and one lumbar decompression.

This is how we position the children for VP shunts

The PACU is still hectic, at least once a day we find a patient with low O2 sats, without oxygen. Since there is only one pulse oximeter (with limits set to adult parameters so that it is constantly alarming) and one tank of oxygen, and one person who switches the equiment between patients without haste or speed. Marcel and I help out and elicit a sense of speed when patients desat but this only lasts while we are present. One of the patients that we helped out with was a young boy that had suffered a “bite to his lip from an unknown animal”.

Child suffering from bite from "unknown animal "

Since the OR ran smoothly we were done in time for a late lunch at the Serengeti house. Ricky joined us after a quick visit to the outpatient clinic. One of the surgeons has found us local coffee that we can brew and this morning gave us instructions on how it is brewed locally. Since we are laccking a coffee perculator or brewing system we decided to try making the coffee using the Turkish method of pouring boiling water over the grounds in each cup, letting it steep and drinking it after the grounds settle to the botttom. We were delighted by the result, our first cup of real Tanzanian coffee!!

I woke up with the beginnings of a cold so I decided to rest while the others went out for an afternoon excursion through the neighboring village.

After asking Ms Merina for more vegetables (because Ricky is vegetarian), we were greeted by a dinner of only vegetables. Ricky and I were excited but Marccel and Diana had been looking forward to a dish containing some meat. The joys of communication! Seems so much is lost in translation!

September 17/18 (Yes, the weekend!)

By Diana

After a long week, we were all looking forward to the weekend.  No planning. Just relaxing.  On Saturday morning, we made our way down to the hospital ICU where several of our patients were.  One of them was a child with hydrocephalus, whom we had decided not to place a VP shunt in because he had open wounds on his head (the size of this child’s head was impressive, the biggest one we had all seen thus far).  Instead, Ricky chose to place an external ventricular drain (EVD) and to close his wounds, treat him with antibiotics and then reevaluate for a VP shunt placement in a few days.  Since the ICU is not familiar with how to manage an EVD, our team had to make sure we educated the nurses on how to care for the patient.  Natalia spent a lot of time explaining and demonstrating to the ICU nurses how to care for the drain.  We were happy to note on Saturday AM that they had done a nice job in taking care of the patient.  We also checked on a patient who had a bike accident, now with a high cervical spine injury leaving him quadriplegic with a very unstable spine.  Ricky placed weights on him in order to try to reduce the dislocation so we could possibly operate on him in the upcoming days.

Diana with the hydrocephalus child (preop)

Intubation

After finishing in the ICU, we returned home.  We decided to make another trip to the market to buy additional fabric, since we had the tailor coming to our house later that night.  Natalia and myself found some beautiful red fabric that we decided to buy.  After bargaining we were able to bring it down from 18,000 shillings to 17 (shopkeepers in the market are not willing to bargain much).  Still we were happy with our purchase.

Natalia and Diana in the Market, with Ana (the anesthesia student) who accompanied them

Random woman laying among clothes in her street shop as we walked in the market

Lots of fresh fruits

After buying a few more things, the four of us headed to the Faculty Club, a local restaurant very close to our house, popular with hospital employees.  From the terrace we had a beautiful view of Lake Victoria, as we enjoyed some Coca Cola and mango juice.  Around 6:30 pm we headed back home just in time to meet our tailor.  We had already looked online and picked out a couple of designs for dresses that we liked.  After showing them to the tailor, we got measured and then hoped that we did not confuse him too much (since he basically drew all the designs that we wanted on a piece of paper).  He told us he would return on Wednesday with some of the finished products.

Around 8 pm we decided to go for a nice dinner to Diner’s.  We had heard praises of this restaurant all week long from some of the other resdients so we decided to try it out.  We were joined by some of the medicine and pediatric resdients from Cornell.  Well, Diner did not disappoint.  We all ordered Indian food and it was delicious.  After dinner we decided to go in search of a good cup of coffee.  Ricky and Natalia had spotted a place called “The Coffee Shop” on our drive, so we decided to walk and check it out.  The weather outside was nice, a slight drizzle that felt great on the skin.  When we got there we were all disappointed to learn that all they had to offer us was Africafe.  The same instant coffee we have at home.  Oh well, at least the meal was incredible.  We called our cab driver and headed home.

Not much took place Sunday morning, except for a quick trip to the hospital to see our patients.  In the evening, Natalia and myself decided to go for a walk down our street.  We walked down a nice road towards the lake. As we continued, there were many twists and turns leading us down dirt roads.  Around us were tons of small shops, people everywhere going about their daily work.  Children followed us as we walked down, smiling and singing.  Vibrant colors were all around us.  After about an hour, we headed back home.  All four of us then headed to one of the local resorts, Malaika.  After a walk on the beach, we were just in time to watch the sunset.  It turned out to be one of the most spectacular sunsets I’ve ever seen.  We watched the sun from the top floor of the restaurant, as we enjoyed some more indian food.  Ricky spotted an Espresso machine and with much hope we decided to order a shot each.  Once again we were disappointed when we took our first sip.  The espresso turned out to be Africafe!  The search for good coffee goes on!

Ahh, the Sunset

The beach at Malaika

Reflections – Week 2

By Marcel

One week of operating at Mwanza behind us. Although the patient population has turned out quite different from what we expected, I think we’re doing well.

The CT scanner and C-arm are still broken, and despite efforts to loan a C-arm from another hospital, it is starting to look unlikely that we’ll have one available for our second week. The result: no intracranial tumors, and no instrumented spine procedures. Instead, we’re working our way through a whole ward full of hydrocephalus children, and we’re making steady progress. They are operated on in simple chronological order, by admission date. We’ve completed the July and August admissions, and are now working on September. About 15 shunts were done last week, as well as a couple of myelomeningocele closures and a few back decompressions. Not a bad count, due in large part that we have had an operating room available to us every single day of the week.

Although Emmanuel does shunt placements by himself, it’s useful for him to do it together with Ricky these weeks, as there are lots of details and alternatives to be discussed. As an example, some of the children with really large heads have pressure sores on their scalp, increasing their infection risk. When one such patient appeared in the OR this week, it was decided, after a long discussion between Emmanuel and Ricky, that it would be best not to place a shunt now, but instead place an external ventricular drain, close the wounds, and bring the child back for shunt placement next week. This approach would not have taken had we not been here. Now the child is in the ICU, where Natalia keeps an eye on him and works with the nursing staff, which has little experience with such drains. The child will get its shunt Tuesday next week.

We’ve drifted rapidly into a routine work division. Ricky operates, with Emmanuel Saguda. Diana does most of the anesthetics, with the anesthetists assigned to us. Natalia divides her time between the PACU and the ICU, and teaches the staff there. I do my part in the case-based morning report with the anesthesia students, and then give an impromptu lecture afterwards on some relevant clinical topic. We’ve talked about things like aspiration risk and prevention, pharmacology of muscle relaxants, and indications and risks of subarachnoid blocks. Two additional students have appeared this week, so we now have five.

For lunch, two of us usually walk over to the guesthouse to eat, and then bring back food for the others. For drinks, we either have the chai that’s always available at the OR, or someone picks up some soda at the hospital canteen (we can take it out, as long as we return the glass bottles!). Dinner is usually at the guesthouse, but we’ve been out to restaurants in town a few times with the medicine/pediatrics residents from Cornell who are here.

It’s tiring. The work load is not that bad, but there’s the added energy required to deal constantly with things that don’t quite work and that need continuous improvisation. And there’s a lot of emotional work involved, particulary in seeing small children with so much terrible pathology and a very uncertain future, even after we have done our part. Yesterday afternoon, when the work week was over, we were all quite tired, and we spent the evening hanging out in the guest house and watching a movie. Although we’ll have to make a few trips to the ICU to check on patients, there are no big plans for the weekend, and it will be good to have a few days to recover before we tackle the September shunts again on Monday.