Dr Mark Moore

Mark Moore, MD
Tallahassee Anesthesiology, PA

Missionary Work

Dr. Moore's Journal

Report from Kilimanjaro Christian Medical Center in Moshi, Tanzania

Mark Moore, M.D.

It was just like any ordinary working day in anesthesia. After a long day at the hospital, I was now home, digging through some anesthesiology notes. The “Dirty Dancing” theme song was playing in the background; while reading by dim candlelight, the shortwave radio announced its call letters: “You’re listening to WQRT, Radio-Free Ethiopia.” No, I would not be having supper at McDonald’s tonight.
My interest in the ASA Overseas Teaching Program (OTP) began in 1990 while it was still in its infancy. Its teaching aspect, as originally arranged by Nicholas M. Greene, M..D. is what makes it so unique among medical world assistance programs. OTP set out to do more than just make a difference in the lives of a few. Its goal is to eventually improve the delivery of anesthetic care to an entire country, or even region, of the world.
To achieve this, OTP has coordinated North American anesthesiologists serving as volunteer teachers with pre-existing African anesthesia teaching programs. With the proper educational assistance, these hospitals could help create an exponential increase in their potential to serve medical needs in the countries where they are located.
Kilimanjaro Christian Medical Center (KCMC) of Moshi, Tanzania is one of the OTP chosen sites. It is a moderate-sized, 450-bed tertiary care center set at the base of 6,000-meter-high Mt. Kilimanjaro. There are 12 different schools of training; the Anesthesia Institute is just one of them. The Institute trains nurse anesthetists (one year) and anesthetic officers (two years), while also providing a year of training for physicians prior to postdoctoral anesthesiology residency training.
The country of Tanzania, with a population of 26 million, is located coastal East Africa, a bit south of the equator. With a land mass equal to that of Texas and New Mexico combined, it was formed as a protectorate after the First World War, combining Tanganyika (mainland) with the Zanzibar and Pemba islands. Original inhabitant of the mainland area were ethnic groups using a “click-tongue” language like the African bushmen. Foreign influences can be traced to the eighth century when monsoons swept Arab traders ashore. Centuries later, Portuguese first and then, more recently, German and other European explorers followed as did the missionaries. The famous meeting of Stanley and Livingstone occurred here. Tanzania is also known for Lake Victoria, the Olduvai Gorge (“the cradle of mankind,” where the English anthropologist Louis Seymour Leakey made his famous archaeological discoveries), the vast endless plains of the Serengeti, Mt. Kilimanjaro (the tallest freestanding landmass on the earth) and the island of Zanzibar, infamous as a center of the slave market.
All natural beauty and wonders aside, Tanzania’s per capita income is approximately U.S. $200. The amount spent on health care per capita annually is about $1. Disease is rampant as is poverty, graft, widespread malnutrition and underemployment, all of which contribute to the lack of motivation for advance training of any kind, but especially physicians. As a result, there is only one anesthesiologist for every 2 million people in Tanzania.

KCMC is a gem among the sands of Tanzania. It supplies trained medical personnel for all parts of the country and beyond. Its Anaesthesia Institute is a widely respected center of anesthesiology for much of East Africa. The bulk of the teaching at KCMC is done by anesthesia officers. They are paramedical personnel who, after spending two years of training as medical assistants and four to six years working in clinics, become eligible for two additional years of training in anesthesia to become anesthetic officers. The clinical workload of student anesthetic officers and the anesthetic officer/teachers is often overwhelming with much of the didactic teaching put aside.
The Director of Anesthesiology at KCMC since 1983 has been Eugene Egan, M.D., a kind Irishman with a touch of silver in his hair, a heart of gold and the patience of Job. Unfortunately for some KCMC volunteers in 1994, this superb teacher is currently at the half-way mark of a sabbatical leave in Germany until the latter part of 1994. During Dr. Egan’s absence, S.O. Aseno, M.D., a knowledgeable and well-trained Tanzanian anesthesiologist, is the head of the department. He is also the only other physician, aside form Dr. Egan, in the department. The typical day at KCMC for an OTP volunteer begins just before 7:00 a.m. It is a 10-minute walk to the operating suite where preoperative rounds start at 7:15 a.m. Preoperative rounds serve the same purpose as calling one’s attending anesthesiologist at home the night before a case. The entire operative schedule is reviewed and anesthetic management is discussed.
The elective O.R. schedule begins at 8:00 a.m. in the four general O.R. suites and two obstetrical O.R.s, asking pertinent questions about cases and demonstrating appropriate clinical techniques, general and regional. Because few people wear name tags, it is sometimes difficult to know if one is talking to a student nurse anesthetist, a student anaesthetic officer or even a student nurse on brief rotation through the O.R. This can make teaching challenging, especially when added to language and inflection barriers.
The OTP volunteer quickly realizes that the students; knowledge base is much broader than the availability of their pharmacologic armamentarium. At least half of all cases are done under spinal anesthesia and lidocaine and an occasional single-shot epidural anesthesia (no catheters are available). In the rest of the cases, general anesthesia with halothane or, less frequently, ether is used. Thiopental, succinylcholine, ketamine and d-tubocurarine are the intravenous agents available. The best monitor is vigilance as in the United States; the only other monitor may be a manual sphygmomanometer. Palpation of the pulse replaces the ECG. Color of mucous membranes replaces the pulse oximeter. There is no equipment for the monitoring of end-tidal carbon dioxide or oxygen. “Disposable” endotracheal tubes, sterile gloves, syringes and needles are resterilized and reused until entropy prevails. Nitrous oxide is unavailable; sometimes oxygen is, too. As a result, one rapidly gains a unique perspective unlike any that one has had while working in a well-stocked anesthesiology department back home. Just prior to my arrival at KCMC, I had finished my residency training as the University of South Florida School of Medicine, Tampa, Florida, under the direction of John B. Downs, M.D. The challenge I faced at KCMC was not limited by ability or knowledge but by the available equipment and the consideration of its practicality to the students.

After rounds in the O.R. are finished, the OTP volunteer moves on to the medical or surgical intensive care units. Here, medical diseases such as malaria, encephalitis or tetanus may be presented and discussed, the fine points of physical examinations may be demonstrated or the art of history-taking described. Lunch in the nearby OTP “Blue Flat” residence where volunteers live is followed by afternoon postoperative rounds at 2:30 p.m. It gets even darker if the electricity is out. While working by candle or lantern, I could not help but think that only 100 years ago, the light bulb was invented. It was not until even more recently that the electricity to run light bulbs became commonly available in U.S. households, especially in rural areas. Electricity in rural Africa is a possibility, sometimes a probability, but it is hardly ever guaranteed. Evenings are spent preparing meals, reading or taking a run to a small, nearby grocery for a Tusker beer and some hot-spiced potato chip crumbs. A “big night out” would be to go to a hotel for fresh deep-fried chicken, to the Chinese Garden or to “Shantytown” for grilled goat.
Journal club is held once a month on Saturday morning, otherwise weekends are free. They are excellent times to take small “road trips” to experience the local living and local fare. Some of the best safari parks in the world are only a few hours away by Jeep. Mt. Kilimanjaro, “the shining mountain,” always looms as a snowcapped backdrop for the KCMC grounds. There are five- and seven-day climbs for the adventurous, but it must be done before or after your OTP tour is completed. A short climb through its fascinating rainforests can easily be done on a weekend. You will see wild orchids, furry monkeys and green moss covering everything. Climb 10 feet above the rainforest canopy and you are in stark, dry desert. I spent one night in an A-frame cabin at 3,000 meters. Besides the temperature being near -5ºC, the elevation makes it particularly uncomfortable to sleep (borderline hypoxemia). Of course, 30 minutes after retiring for the night, I needed to use the aptly named “outhouse”. Without any light, even from stars, it was the blackest night I have even known. I was able to use my wristwatch’s backlight to illuminate my path. Hakuna matata (Swahili for “no problem”).
Zanzibar Island is only a short airplane flight away. Until my visit, the first and only time I had ever heard the word “Zanzibar” was in the theme song of the Patty Duke Show. From the sky, it appears to be your average tropical island set in the clear Indian Ocean. Once on the ground, however, it is an interesting hybrid of African and Arabic worlds. Centuries of immigrants, slave traders, sultans, and pirates have shaped this tiny island. The architecture is Arabic. The streets are narrow and irregularly named. Famous, or possibly infamous, lodgings such as Africa House and the Malindi House can be found in Zanzibar town. It is the world capital of spices: nutmeg, clove, pepper, vanilla beans, curry, tamarin and lemon grass are grown here and then shipped throughout the world. Giant chunks of spicy octopus, 3 kg lobsters and the biggest stone crab claws I have ever seen are nothing out of the ordinary for local dining.
During my stay as an OTP volunteer, I had the good fortune to be part of the 21st Annual Scientific Conference of the Society of East African Anesthetists. Hosted by KCMC, it was presided over by its highly respected President, Nimrod Matakare, M.D. The conference was “dedicated” in honor of Nicholas M.Greene, M.D., described as “one of the rare breed who has backed his vision and faith with action.” The majority of the speakers and attendees were form Tanzania, but others were from Germany, Ireland and Australia as well as other East African countries. Some of the anesthetists had travel two days by rail, Land Rover and bus to attend. The scientific conference was coupled with a two-day anesthesia refresher course, which extended the entire schedule to more than a week. It all ended with a big dinner dance. We exchanged universal war stories of daring surgeons, obnoxious surgeons and our sickest patients. Dancing and singing continued until early morning with no one worrying about waking the neighbors.
The following week was a preparatory week for semester examinations. For the entire week, I gave hours of didactic lectures at the students’ request. Topics ranged from the physiology of the neuromuscular junction to the examination of the central nervous system. I was also given an active par n administering and grading both written and practical examinations. We all spent long nights working our way through the piles of test papers. In the end, the overall student body did well, and the teaching staff was pleased.

OTP volunteers have a big responsibility to the teaching hospital, its students and instructors and, finally to the entire ASA. The goal of this program is not to encourage dependency but to assume some of the burden of anesthesia teaching in underdeveloped and understaffed anesthetic training programs. By teaching anesthetists how to deliver safer patient care, rather than directly providing anesthesia services for patients, we are doing a far greater service to the future of the people. If you give me a fish, you will feed me today. Teach me to fish, and you will feed me and my family forever.
In return, the OTP volunteer receives much. There is time to think about our physician-patient relationships and the real reason we went to medical school and to do so undiluted by layers of paperwork, insurance companies, lawyers and government bureaucracy. You gain a new perspective on the true abundance and wealth of our country, you realize the absurdity of materialism and you dispel prejudices. There is a chance to make friends and experience students will make it one of the most gratifying experiences of your life.
The ASA Overseas Teaching Program is an opportunity not to be missed. “Karibuni sana, na kwa heri ya kuonana,” in other words, thank you for accompanying me on this journey, until we meet again, friends!

Dr Mark Moore - Missionary Work in Tanzania and Kilimanjaro
Dr Mark Moore - Missionary Work in Tanzania and Kilimanjaro
Dr Mark Moore - Missionary Work in Tanzania and Kilimanjaro
Dr Mark Moore - Missionary Work in Tanzania and Kilimanjaro
Dr Mark Moore - Missionary Work in Tanzania and Kilimanjaro
Dr Mark Moore - Missionary Work in Tanzania and Kilimanjaro
Dr Mark Moore - Missionary Work in Tanzania and Kilimanjaro
Dr Mark Moore - Missionary Work in Tanzania and Kilimanjaro
Dr Mark Moore - Missionary Work in Tanzania and Kilimanjaro
Dr Mark Moore - Missionary Work in Tanzania and Kilimanjaro

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