A Doctor's Point of View: Report 2014 FIENS (Foundation for International Education in Neurological Surgery)

FIENS Report

Muhimbili Orthopedic Institute
Dar es Salaam, Tanzania

May 26 – June 6, 2014

David Pitkethly, MD FACS

 

   The Neurosurgery Department in Dar es Salaam is located at the Muhimbili Orthopedic Institute (MOI). The name, of course, is misleading because this hospital includes neurosurgery as well as orthopedics. The MOI bed count is stated as 450, but in actuality it is many more because a large percentage of patients are relegated to mattresses in hallways and between beds. On the pediatric wards there are two and sometimes three patients per bed. A new large seven story hospital is nearing completion adjacent to the existing hospital. The new facility will be a modern hospital with new operating rooms, emergency room, CT, MRI, CyberKnife, fully equipped ICU, Telemedicine, as well as patient beds. To complete the picture of MOI it should be understood that it is a small part of a huge campus that also includes additional hospitals for all medical specialties with a total of 1500 beds, medical school, dental school and nursing school.

   The Neurosurgery Department is ably chaired by Professor Joseph Kahamba, who trained in Zurich, Switzerland. He has a full schedule of surgical procedures, clinics, conferences and administrative duties. His leadership and clinical skills are excellent. There are four other fully residency trained faculty members. One trained in Japan and the others in South Africa. There are presently six other physicians in neurosurgery residency programs outside Tanzania. Several pre-resident registrars work up new admissions, follow patients on the wards, and assist in the OR.

   The daily schedule begins at 0730 in the Conference Room with presentations by registrars and medical students of new admissions (mostly trauma cases) for both neurosurgery and orthopedic services. After cases are discussed there is usually 30 minutes remaining for other medical topics. On two mornings I gave lectures at the conference. The topics were “Chiari 1 Malformation” and “Cervical Radicular Syndromes”.

   At 0900 the faculty members as well as registrars attend clinics or operating “theater”. On Thursday one of the junior faculty, with every available registrar and medical student on the service, conducts formal patient teaching rounds.  This is a 3+ hour exhausting process with about 80 – 100 patients being seen. The beds are in large open wards with about ½ of the patients occupying mattresses in hallways and between beds. We were constantly stepping over and sometimes on these mattresses as our group of a 12-16 doctors, students and nurses made our way through these rounds. The unfortunate reality is that many of the patients have been waiting for weeks and months to have needed surgery. I counted five children and young adults with huge craniopharyngiomas, blindness and large ventricles. The pediatric ward had at least fifteen children needing surgery for hydrocephalus and/or meningomyeloceles. The problem is that there are only five operating rooms in the hospital for elective surgery, and neurosurgery has only one dedicated room. Orthopedics, which has dominated this hospital, has the other four rooms. On one day a week neurosurgery has two rooms. Perhaps, when the new hospital opens in a few months, this situation will be ameliorated.

   Operating rooms are scheduled to begin at 9 am and finish at 3 pm. This translates to one craniotomy, two laminectomies, or three hydrocephalus operations per operating day. Another OR problem is a lack of working equipment. For example, there are power drills in the storeroom, but none of them work, either for lack of parts or poor maintenance. There is no gas sterilization and it appears that some of the drills have been autoclaved. All craniotomies are done with the Hudson brace and bits, and Gigli saws. There is a good working microscope with observer scope and small screen monitor.

     During my two weeks at the MOI I was in the operating room almost every day as first assistant. We did a variety of benign brain tumors, three spine operations for degenerative disc disease, and one ACoA aneurysm. I assisted on two extremely vascular meningiomas. Neither angiography nor embolization are available at MOI, and after two units of blood had been transfused in each case, the anesthesiologist called a halt to the operation. The patients were subsequently transferred to Apollo Hospitals in India under an agreement for funding between those hospitals and the Tanzanian government.

    I did not see any gliomas on the wards or in the OR during my stay. I discussed this with Prof. Kahamba and he responded that meningiomas are much more common than gliomas in Tanzania.  

   One of the neurosurgeons, Hamisi Shabani, completed the hydrocephalus training program with the Ben Warf group in Uganda. He received funding and has a complete setup with flexible endoscope to perform third ventriculostomies. He now does ETVs with coagulation of the choroid plexus bilaterally on all of his hydrocephalus patients. He is sending his data to Uganda to be included in the Warf study.

   Despite these challenges, the neurosurgeons as a whole are well trained, competent, and take good care of their patients. Professor Kahamba and others are in negotiations to begin a neurosurgery residency program at MOI. As mentioned above, the new hospital will have an MR scanner, endovascular services, modern ICU beds with monitoring, and technologically advanced equipment that will bring their department to a level of a European or American teaching hospital in a few years.

   There is no housing available on campus for visiting physicians. I found a terrific small hotel, The Swiss Garden, that is an easy walk of less than a mile from the hospital. The price was $120 per night which included an excellent breakfast. The only problem was that they do not accept payment by any means other than cash. If anyone chooses this hotel it is best to pay in advance.

   The weekend we were in Dar es Salaam my wife and I boarded one of the fast ferries to Zanzibar on Saturday morning and returned Sunday afternoon. We stayed at the Tembo House Hotel in Stone Town which had been the US Consulate during colonial days and the cost was $135. The hotel is beautifully preserved with many antiques, and has a perfect central location on the beach. Zanzibar is an idyllic island and I highly recommend a visit.

   The weather was somewhat hot and humid, but not uncomfortable. We had no rain and the rainy season should be avoided. Slacks and open collar short sleeved shirts are appropriate dress for all occasions.

   The overall experience in Tanzania and the Muhimbili Orthopedic Institute was outstanding, and I highly recommend it to interested neurosurgeon volunteers.

David Pitkethly, MD

Professor Emeritus
Department of Neurosurgery
University of Washington