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.
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!