Too Few ICU Beds in Tanzania

The following entry was written by Dr. Doug Grey, former MedShare Board member and current Western Council Member, who is on a medical mission trip in Tanzania.

I began my fourth medical mission trip to Dar es Salaam just before the New Year in 2016. Having a number of home renovation projects finally finished, the travel was a welcome relief.

When I arrived in Dar I met Dr. Craig Lubbock who is also retired Kaiser surgeon and had been on our trip in October, 2014. We stay in the Kalenga House, a UCSF-sponsored house with rooms for eight, a common kitchen, and convenient proximity to the Muhimbili Hospital, the largest teaching hospital in Sub-Saharan Africa. It is a bit like being in something between a dormitory and a fraternity house. Cooking duty is shared, but there are those with culinary skills, and then there’s me.

The first weekend was dedicated to combating jet lag, getting the house provisioned for the month, and making initial contact with our Tanzanian colleagues with whom we will be working the next several weeks. Our new Pediatric Surgery colleague, Dr. Henry Lau, is a retired Johns Hopkins surgeon who is spending the year under the aegis of the US Peace Corps performing Peds Surgery at Muhimbili. He provides some consistency to the exchanges and efforts to assist with care at Muhimbili. He has taken a great interest in teaching the Tanzanian surgery residents basic surgical skills like knot tying, suturing, and some of the “craft” of surgery. One of the hazards of spending a year in any one place is you inherently feel much more ownership for both the problems as well as responsibility for solutions. Inherent in any medical mission is “doing your best with what you have in the allotted time.” There are advantages and disadvantages to almost any effort to help.

Our first day at the hospital began early. We passed the Baptist Chapel that finishes its morning service with a singing round by the parishioners snaking out of the chapel. The harmony was angelic and contrasted with the stillness of the hospital grounds. During the day, the hospital campus is over-run with humanity, but in the morning hours the corridors are empty and the gardens quiet.

We begin with rounds in the Intensive Care with the Chairman of Surgery, Dr. Ali Mwanga. This is a six bed ICU with the sickest of the sick, most on ventilators, and either trauma cases or patients with surgical complications. It is evident that the Muhimbili staff’s dedication and commitment to getting these ill patients better is exemplary. Intensive Care Units are complex. Getting some of the patient data is difficult to sort out in the bedside records. The patients can’t be weighed every day and some of the decisions are made with gestalt and not data. But this is not necessarily bad. Strain occurs in this limited resource environment when all six beds are filled and a new case is contemplated. The safety net of an empty ICU bed isn’t always available and patients can suffer because of the lack of resources.

One of the system improvements that has been introduced for the Surgery Department is a Morbidity and Mortality Conference, the standard forum for discussing complications due to lapses in care or unavoidable circumstances. The Residents presented several cases where this ICU bed shortage had led to delays in necessary operations. This was referred to as a “System Problem”. Those bad outcomes due to bad judgment or bad decisions were called “negligence”. The stark candor is both alarming and enlightening as now there has been a tangible increase in everyone’s awareness (and responsibility) for the need to improve care. This level of frank discussion was impressive and has already led to good decisions and discussions from the younger surgeons.

Four years ago the hospital campus was like an abandoned movie set. The hospital wards were concrete barracks. There would be areas of used medical equipment, almost like randomly occurring “equipment graveyards ” of old white iron beds, stainless steel, broken furniture, etc. This happened in a society where almost nothing is ever thrown away, but rather re-utilized in a lower tech manner.

Through government jobs programs newly introduced by the Prime Minister, the hospital now has several different categories of workers that are improving the physical plant. There are security guards, both male and female, who circulate on all the corridors outside and provide a feeling of safety. There are people assigned to raking leaves and picking up trash in all the gardens and public spaces. There are construction projects throughout the campus with rich red soil being dug by hand in several different areas. Many of the gardens have been finished and are now like public parks. The plumeria trees are in bloom and the fragrance of jasmine is pleasant. We no longer get the feeling of crumbling desperation that we had three years ago.

But that feeling of thriving culture disappears when we enter the wards where the patients are cared for. There would be 50 patients in a room otherwise designed for 30 patients. The rooms, which would usually house three beds in parallel, were now housing one bed, followed by one patient on the floor, then a bed, floor, bed, floor and so on. There were also patients in the corridors. There is no patient privacy.

Walking across the campus, I came across an extremely idealistic medical student who was going into Internal Medicine. She was proud that MUHAS was the most difficult medical school to gain entrance to as well as the most difficult to stay enrolled in and succeed. She was optimistic and happy with her decision, which was not based on reimbursement potential, something that she thought motivated her fellow students. She was grateful to meet a happy retired surgeon who shared her same idealism.

Again on this trip, the engagement of random passers-by with solid eye contact is alarming at first, then very reassuring. “Mambo Poa” is the standard “How are you?” And their response can be many variations of “fine” (“Poa,poa”, “Poa” , “Nzuri “). It certainly makes the walks more enjoyable.

– Doug Grey

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One thought on “Too Few ICU Beds in Tanzania

  1. The Alliance for Global Clinical Training is so fortunate to have both Doug Grey and Bill Schecter as exceptional role models who work with other volunteer surgeons and residents to help achieve improved clinical skills among their counterparts at Muhimbili National Hospital.

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