Selian Lutheran Hospital

       - A hospital with a mission to serve the poor  and the sick in the name of Jesus Christ

• Opened with a mission to minister to sick Tanzanians in the 1950s
• Selian have a 120 bed hospital on the outskirts of Arusha and have built an additional 150 bed hospital in the city centre, Arusha Lutheran Medical Centre, which was completed at the beginning of 2009
• Provides both inpatient and outpatient care in:

1. Medicine
2. Surgery
3. Paediatrics
4. Obstetrics
5. Maternal and child health
6. Orphan care
7. Hospice 

• 50,000 outpatient clinic appointments each year
• Led by Dr Mark Jacobson, a very competent American physician and administrator who has served at the hospital for 22 years
• 25 medical staff

Surgical Department Overview

• 2000 operations a year including:

1. 100s of vesico-vaginal fistulas
2. 300 major orthopaedic cases
3. Trauma and acute abdominal surgery

• Managed and operated by three Tanzanian surgeons and Jenny.
• Visited by overseas surgical teams each year, doing procedures such as corrective surgery to children with skeletal flurosis, among the top five causes of crippling, and repair of cleft lips and palates

Teaching

• They currently have 10% of their staff doing higher education
• Three CME (continuing medical education) meetings a week
• They provide scholarships to Clinical Officers to attend medical school

Funding

• Government expenditure on health is less than $2 per capita annually
• Selian actively seeks to attract wealthier paying patients, in order to subsidise the poor
• 30% of the annual budget comes from donations to the hospital. A $US 2,000 donation will operate the hospital and clinics for a day.

Things I have enjoyed about working at Selian

• Surgical team – not being the only surgical consultant has meant I can learn off the others about various conditions and what are the best ways to manage these in Tanzania eg. rarely do primary anastomosis after bowel resection for volvulus as the anastomosis often leaks due to poor premorbid condition.
• Operating on a variety of conditions, many presenting at a more advanced stage.
• Still being able to continue my CME via the internet and journals, some having been donated by friends and colleagues.
• The patients – very grateful

What we don’t have

• Often preop investigations are minimal because of cost to patient or unavailability
  • Eg head tumour patient not having a preop CT or angiography because unavailability Limited equipment – have frequently run out of size 6 and 6.5 gloves for me, limited suture choice
• • It has been a challenge to learn when I need to change my practice to adjust to the African setting and when to insist on what are basic standards

Difference in practice

• Cold water for washing hands and using a cake of soap for surgical hand wash  
• Use alcohol in skin prep because patients skin is often so dirty provides a further level of sterilisation
• Having to make do with whatever suture is available ie a 2’0 prolene that has too big a needle
• Not having endoloops so having to do open appendicectomy after diagnosing appendicitis on laparoscopy – though going to make endoloops
• Power cut – these have occurred at least once a month – 5-7 minutes of no power while someone goes and turns on the generator
• Patients are admitted the day before for most operations (to ensure the patient gets there, they have the money and have appropriate preop preparations) and unless they are a skin lesion or gastroscopy are stay at least one night postoperatively.
• Cancer management
  • Many of the local people believe that an operation on cancer makes it grow, so after the diagnosis is made they often self discharge and go to the natural healers. When the disease progresses (to the incurable stage) they represent for their operation – a self fulfilling prophecy
  • Chemotherapy is too expensive for most
  • Radiotherapy is available free in Dar Es Salaam but they have the cost of travel and accommodation for the course of their radiotherapy – 5-6 weeks
• Hospital issues
  • One day when the hospital was full, due to a visiting plastic team, patients were sharing beds
  • Limited equipment, eg only have one paediatric BP monitor for the whole hospital, because it is too expensive or because donated equipment doesn’t work properly. Power fluctuations and cuts have destroyed some equipment
• Post op care 
  • There are only beds in the wards and no chairs, so often people are lying in bed which is not good for lungs etc
  • Don’t chart DVT prophylaxis as apparently no cases of DVT post op.