Chief Resident reflects on residency program in Tanzania

By Brystol Henderson

After multiple plane changes and more than 60 hours of total travel time, we landed safely in Mwanza late in the evening. We arrived to find that the Serengeti house, our intended destination, was “full” with other visiting residents and medical students, so we were placed in a nearby hotel just down the road from Bugando Medical Center. This was the first of many lessons on adaptability that I would come to learn during my time in Africa.

Completely exhausted from travel, I was happy to settle into what would be my new home for the subsequent four weeks. I was excited and nervous to find what awaited us the next day. After a much-needed night’s rest, we arrived at Bugando early the next morning. We passed through several “security guards” with metal detectors that seemed to beep continuously without consequence. We were initially stopped at the gate because we didn’t have hospital badges. After stumbling through communication barriers with hand signals and broken Swahili, we finally made it into the hospital with a substantial amount of medical equipment donated from MUSC. We arrived in time for the morning report. This lasts for several hours each morning and is an opportunity for each of the anesthesia students to present the upcoming day’s cases along with their intended anesthetic plan. It is meant to be a learning opportunity for the students. The plans are directed to and critiqued by Dr. Matasha, the only permanent year-round Anesthesiologist at Bugando. They also discuss all of the emergent cases that were done overnight, in addition to a brief presentation of all of the current ICU patients.

This was my first exposure to the program at Bugando, and despite what I thought was adequate preparation from my predecessors, it was quite an eye-opening experience. The students’ lack of background medical knowledge was evident, and I quickly understood how large the task was that stood ahead of us. Dr. Selby, a visiting anesthesiologist from Australia, was present that morning. He sporadically devotes many months each year to teaching at Bugando and became instrumental in orienting us to the hospital. He allowed for a seamless transition by introducing us to the right people and obtaining our hospital badges all within our first day (a task that had taken others weeks due to all of the “red tape” that existed in the hospital system).

He was also able to give us an idea of where the students stood academically, and which topics to focus on during our time in Mwanza. Unfortunately, he had to leave shortly after our arrival, so it was our responsibility to pick up where he had left off. After a day of “learning the ropes,” we quickly joined in on leading morning reports and formulated a lecture series that included two to three hours of lecture per day, supplemented with operating room (OR) teaching in the afternoons. The anesthesia program at Bugando has grown substantially over the last few years and currently has close to 50 students. They are divided into three groups based on their time of enrollment: the September intake, the Kigoma group (a group of midwives from the Kigoma area that joined the program in December), and the largest of the three, the January intake. All three groups rotate throughout the week and have two to three days of lectures. The other two to three days/weeks are spent in the operating theatre under the guidance of their practicing nurse anesthetists. Unfortunately, the knowledge base did not vary significantly amongst the three groups, and their understanding of basic physiology and pharmacology was minimal. This became one of the major focal points of my lectures throughout the month.

I quickly learned that the traditional “African way” of teaching was one of intimidation and fear. Incorrect responses often resulted in belittlement and embarrassment in front of the group. As a result, the students were extremely timid. It took some time, but I feel that overcoming this obstacle was one of our greatest achievements throughout the month. This allowed us to eventually make significant progress in their knowledge base and level of understanding. As the students became more comfortable with me, I was able to pinpoint the disconnect that existed between book knowledge and clinical correlation. I finally began to see “light bulbs” going off as I attempted to correlate these textbook concepts to specific cases. It was encouraging to watch the students’ enthusiasm and progress over the subsequent four weeks.

The operating theatre was an entirely different experience. I was warned about the lack of monitors, drugs, and resources in general, but nothing really prepares you for these things until you see them firsthand. I was extremely thankful for the presence of a pulse oximeter machine (pulse ox) in each OR as well as the PACU (thanks to MUSC’s prior donations). However, when the power in the entire hospital goes out (which happens frequently), we are forced to rely on physical exam skills alone.

On one of my first days in the operating theatre, I walked into an OR mid-induction. As Ketamine and Suxamethonium were being administered, I noticed that there was no one at the head of the bed, no pre-oxygenation, and the pulse ox and BP cuff lie idle at the patient’s side. I scrambled to help attach monitors as one of the students began to mask the patient. The patient ended up intubated without complication, and sadly, there seemed to be the little realization that anything should have been done differently with induction.

I made it a point to focus on respiratory physiology and the importance of pre-oxygenation at my next lecture. I learned that I was not going to be able to change every little thing that I felt was done incorrectly, and I began to hone in on just a few key concepts that would hopefully improve overall patient safety. It was exciting for me to be able to use medications such as Thiopental, Pancuronium, Atracurium, and Halothane, which I had only read about in the past. I also learned a lot about flexibility and adapting to my surroundings. One afternoon, just prior to induction for an exploratory laparotomy for a suspected small bowel obstruction, I learned that the last vial of Suxamethonium was used earlier that day and there would be no more available until the following Monday. The only neuromuscular blocker available through the weekend was Pancuronium. As I adapted, I learned to work with the few resources that were at our disposal.

Outside of the hospital, I enjoyed getting to know the city of Mwanza. Several other attendings and residents were staying at the G&G hotel with us. There was also a constant rotation of visiting physicians and students in the Serengeti House down the road. I enjoyed getting to know these people and hearing stories of how things were done in different areas of the hospital. Most stories were filled with frustration and fear for patient safety; however, it was encouraging to know that we were all there with a common goal--a hope that we would make some small impact on these providers and improve the medical care delivered in Tanzania. We enjoyed exploring the city of Mwanza together. The hustle and bustle of the central market were exciting and a little overwhelming at times, but it was the natural untouched beauty of the surrounding landscape that really amazed me. The sunsets over Lake Victoria with its scenic mountainous backdrop were stunning. I was fortunate enough to go on a safari into the Serengeti and Ngoragora Crater one weekend during my stay. I was able to see practically every wild animal imaginable in their breathtakingly beautiful, natural habitat. Zebras, wildebeests, elephants, and giraffes were close enough to reach out and touch! It was an experience that will be difficult to match.

The people of Mwanza were friendly and welcoming. They were excited to share their language and culture with us. The hospital personnel was extremely grateful for our presence. Dr. Matasha constantly stressed that “education is the most important thing.” I was sad to learn that in our absence, the students simply do not have lectures or any formal didactics. They are lucky to have Dr. Selby sporadically throughout the year, and our presence certainly appears to make a difference. There was constant praise and gratitude at the end of each lecture, and the disappointment was evident when we had to announce our departure. I can only hope that our program and the presence of foreign educators continue to grow and prosper over the years as rapidly as their class size is increasing.

Another contribution that was made by MUSC was approximately 100 pairs of scrubs for the anesthesia students. Despite the many sacrifices that most of the students had to make in order to come up with the tuition for the anesthesia program, OR attire was not provided by the hospital. Most of the students had only one pair of OR-appropriate scrubs that they wore every day. They were so excited and grateful to receive a pair of scrubs from MUSC. A contribution that seems so minimal made such a significant impact on these students.

Overall, the rotation in Tanzania was an amazing, life-changing experience. It not only made me a better clinician and teacher but also changed my perspective on the many things that we take for granted in the US. I am so grateful to the department and to Dr. Reeves for this wonderful opportunity, and I would encourage everyone to get involved in similar ventures if ever given the chance.

This reflection was republished with permission from the Department of Anesthesia and Perioperative Medicine. Brystol Henderson, MD is a Chief Resident of Clinical Anesthesia in the Department of Anesthesia and Perioperative Medicine. See this reflection published in Sleepy Times, the Department of Anesthesia and Perioperative Medicine's newsletter.

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