Muhimbili University of Health and Allied Sciences

Clothing

The dress is formal outside of the OR. People wear nice black dress shoes, slacks and freshly pressed dress shirts. Short or long sleeves are acceptable. Ties are optional. Bring your white coat, as you will need it for major ward rounds and clinic. Bring a handkerchief to wipe your brow if you sweat a lot in heat and humidity. The monsoon rains are torrential. A hat and umbrella can help.

Rounds

The registrars and residents generally make morning rounds after the 7:30 a.m. conference called Morning Report – this means generally between 8:30 and 9:00 a.m. Postoperative care is limited by severe resource constraints. Wound care, monitoring and recording of vital signs and fluid status remain challenges.

Clinic

Clinic is Tuesday for Firm I and Thursday for Firm II. It is in the OPD building, on the map, and if you go – you will see 15 or so patients. If you wish to schedule someone for surgery, send them to see the registrars to get signed up. There should be a medical student or resident there to help you translate.
The clinic begins at 9:00 a.m. but don’t be surprised if you are the first person there. Ask the nurses for a room and they will put you in it. Wear a white coat, the rooms are air conditioned.

Surgery Wards

The main block is the Kibasila block – Firm I has women’s ward 9 and men’s ward 13, Firm 2 has men’s wards 11 and women’s 12. Ward 10 is the intermediate care ward which is underutilized.

ICU

There is an ICU which is adjacent to the OT (see map) and has six beds. Think of this as a ward with 1:1 nursing and ventilators. Patient can received mechanical ventilation in this unit. Oxygenation is monitored with pulse oximetry as blood gas results take 6-8 hours to return. Intravascular catheters are rudimentary. If the ICU lacks required drugs or equipment, you can often get it in the EMD. They have most drugs and you can often get things that the ICU says don’t exist (e.g. adenosine).

EMD (Emergency Medical Department)

This is one of the better-supplied and more efficient departments in the hospital as it is funded by the Abbott Corporation.

Patients present LATE and it is hard to instill what we would consider an appropriate sense of urgency into trauma evaluations/resuscitations. There is an EMD operating room available, but even hypotensive trauma patients can take disturbingly long (1+ hours) to get to the OR. There are many causes for these delays. Most patients who survive long enough to arrive at the ED are likely to survive the requisite wait for the OR.

Operating Theater

The American faculty and residents are here primarily to teach our Tanzanian colleagues. Of course education is a two way street and we have learned far more than we have ever taught. Nevertheless, a collaborative attitude in the OR including sharing cases as much as possible is the key to success.

Scrubs and OR shoes: There are plenty of scrubs but we suggest you bring 2-3 pairs of your own. You cannot wear your own shoes in the OR. There is huge pile on unmatched shoes. We find a pair that fit, and keep them in a plastic bag. A cloth grocery bag works well for transporting scrubs, OR shoes etc.

Protective Eyewear: This is something in very short supply at MUHAS, and you should plan to bring your own; even the disposable clear goggles from your home OR would serve. Loupes, on the other hand, are rarely used in the OR, but if you need them, bring them, and carry them with you.

Careful attention to the conduct of anesthesia is important. A pre-operative discussion of the case with the anesthetist, assistance during induction, and discussion of the postoperative plan with the anesthetic team will avoid a lot of problems. The anesthesia is usually administered by anesthesia technicians with variable degrees of supervision. Intra-operative monitoring of fluid and hemodynamic status, blood administration, etc., is problematic. Post-operative mechanical ventilation is not routine. If you think your patient requires postoperative ventilation, insist on it. Otherwise the patient will be extubated.

You will gown and glove yourself; there is a side room to each OR with a scrub sink but no scrub brushes – just wash. You open your own gloves prior to scrubbing. The gowns have no cuffs and are made of cloth so it is imperative to wear one of the aprons beneath it, otherwise your scrubs get soaked.

Instruments

The scrub nurses speak limited English. The best method I found is to say “Naomba” (can I have) that is pronounced like “number” with a REALLY thick Boston accent (nomBah) and then the name of the instrument. It generally is easier if you ask for things as they know them - the best we can figure:

1. Debakey = smooth dissecting forceps
2. Rat tooth / English = toothed dissecting forceps
3. Crile = small artery forceps (or artery Ndogu - Swahili for small)
4. Bovie = diathermy
5. Uzie = stitch
6. Kisu = knife
7. Metzenbaum scissors = fine scissors
8. Suture scissors = stitch scissors
9. Raytec = swab (but no radio-opaque strip)
10. Lap pad = abdominal pack
11. They call stitch sizes as 3-zero and 2-zero, etc.
12. The needle drivers are of variable size and quality, often there is only one

Patients

Patients frequently present with advanced disease including stage IV breast and colorectal, pancreatic and esophageal cancer. Emergency cases include trauma and many cases of acute abdominal pain, bowel obstruction and incarcerated hernia. Generally only one or two big elective cases and one or two small cases can be done on a given day. Many cases must be cancelled due to lack of available blood, hypertension etc. Check out each patient prior to surgery. One of the most important teaching points is when not to operate. It is sometimes necessary to cancel unindicated operations in the OR itself. The operative schedule for the coming week is made during a meeting that immediately follows that firm’s major ward rounds. and being present for this is enlightening and usually results in getting asked to help with cases. Attendance at this conference is important.

Tumor board

This conference takes place in the Siwahaji Annex at 2:00 p.m. on Tuesday. Many patients with advanced tumors are presented and discussed. This is an emotionally challenging experience for most volunteers as there is little respect for patient privacy or dignity on the part of the visiting oncologists. It is worth attending this conference once but many of us have chosen not to attend regularly.

Resident Presentation

If you present a case at the weekly Morning Meeting (Mondays at 0730), there is a projector and a computer connection for a PC – if you have a Mac, you’ll need the adaptor to connect to the PC-specific connecting cord. As you will see, case presentations in the MUHAS format are usually heavy on background information (history, exam, etc.) and lighter on analytic thinking… feel free to mix that up a bit, and give (model) the type of presentation you’d give at your home institution. You can even have your attending introduce it as such, to deflect any criticism of a different approach in advance.