Highs and Lows at KCMC this week

Highlights: Teaching at a surgical skills course for 36 Tanzanian medical students from the Tumaini University medical school. This was a week long course sponsored by a Canadian organization. The Canadian Surgeon leading the course had to leave a day early and asked if I could fill in on Friday which was a day devoted to Orthopaedic skills. I was assured that everything was organized and that I just needed to show up. When I arrived, one of the students suggested that we start and since I was the only Physician there, I stood in front of the class and lectured for 90 minutes. We had a whole day to fill. Yikes. Eventually a couple of residents showed up and we cobbled together some patient assessment scenarios that the students acted out followed by critique from the class. Then we hastily put together some surgical skill stations while the students were on tea break. The stations included 1) x-ray reading skills, skin and skeletal traction, the latter using sugar cane to simulate the femur bone, 2) splinting and casting, 3) amputations using sugar cane as the bone wrapped with tape as periosteum, a catheter as blood vessels, a plastic tube as nerve, foam as muscle, and plastic cloth as skin, and 4) wound debridement using a goat thigh dragged through sand as the wound.



I had a blast. The students were very bright, inquisitive, and appreciative. I tried to learn all their names with some success and they called me “Chief” which seems to be a common way to address your superior in the hospital.



Photo: medical students practicing an amputation. The one with a nun’s habit is a Sister of Adoration, who practice “Contemplation in Action” through medicine, from India, getting her medical degree here.

On Thursday, Paul A. (another HVO volunteer) and I handled most of the clinic ourselves. We decided to admit every patient who needed acute intervention to the hospital (usually there are many patients who are sent home despite having displaced fractures or draining wounds. Because of this the census on the ward is over 90 patients). I was able to get the department head to agree to push for two Orthopaedic rooms in the operating theatre next week so that we can take care of the extensive backlog of patients needing surgery. I will not hold my breath on that actually happening, but perhaps it is slight step forward. Unfortunately we are running low on some crucial supplies that may limit what we can do.

I have been teaching the AMO students daily. They have asked for two hours of instruction a day which is fine. They are hungry for any teaching because when they finish their minimal training they will be primary providers in the district hospitals. We will have all five over to dinner early next week.

On Tuesday, we went to dinner at the Leopard Hotel with two other Orthopaedic Surgeons. Paul A. , the other HVO volunteer has also volunteered in Malawi, South Africa, Guatemala, and Bhutan. We met up with Paul M., a Pediatric Orthopaedic Spine Surgeon from Ottowa who was part of the Canadian group sponsoring the Surgical Skills course. Paul M. has also been to Bhutan as well as Nepal. We shared many stories from Bhutan where we have all served as well as many other stories from around the world that are hard to fully understand or even to believe unless you have experienced them in person. Paul M. talked about driving through a riot on the streets of Nairobi on the way here including police in riot gear and tear gas. We shared experiences and ideas from surgical situations in the third world and I came away with new hope and new ideas for future travel.

Lows: Arriving in the operating theatre and beginning a case of a 2 month old femur fracture in an adult, but having no xrays of the patient. I remembered seeing xrays several days earlier but I wasn’t quite sure of the patient and the operation listed on the schedule was different than I anticipated. We went with palpation of the thigh to determine where the fracture was located as well as my memory of what operation was planned (intramedullary rodding). The xrays eventually arrived but we did not have the right size rods available. We made do with what we had. At the end of the case we were told that there was no sterile gauze nor surgical gowns (broken autoclave) and that no further cases could be done that day.



(Photo: tray of casting supplies, showing toilet paper being used as cast padding).

Also, we met a Scottish medical student rotating through the internal medicine wards who told us of a patient who died with an arrhythmia (irregular heart rhythm) because the extension cord on the defibrillator was too short to reach the patient. Apparently, moving the patient closer to the machine didn’t occur to anyone.