Dear Colleagues,

first, an introductory note. This text is a compiled version of my working and
personal experience in Africa. Since most of you will not have an opportunity
to visit any part of Africa this material may prove helpful. 
Everybody will please understand that this is highly personal and subjective. 
Also, my web-pages will certainly provide some reference. All of them are
under permanent construction and re-construction, however.

Regards,

Predrag Maksimovich,

Bulawayo, Zimbabwe.

Roots

I was born and raised in Belgrade, capital of Serbia and Yugoslavia. There I
graduated at the University School of Stomatology in 1978 and Medicine in
1984. In the meantime I gained some experience in maxillofacial surgery during
post-graduate studies and thereafter specialized otorhinolaryngology. 
My wife Aleksandra came from the other part of the country but graduated at
the University School of Medicine.

Since 1986 I was employed at the Clinical-Hospital Center Zemun-Belgrade at
the Department of Otorhinolaryngology with Maxillofacial and Cervical
Pathology (a rather awkward title, I believe). My wife did not have permanent
posts.

Therefore, the political changes in Yugoslavia from 1988 till 1991 and the
Civil War from 1991 left us in a difficult position. We decided to leave our
country and find job somewhere else.

Change

Through some personal contacts it transpired that there is a possibility of
finding job in the UTH (University Teaching Hospital) in Lusaka, Zambia.
Although, previously, I claimed that I will go to Africa only if they invent
some pill which will make my hair curl, lips pout and skin turn black (I was
under impression that I was extremely funny) I jumped to this opportunity. So,
in September 1993, I took a bus from Belgrade to Sophia, Bulgaria, and then
with Air Balkan to Harare, Zimbabwe. There I met some friends. I was promptly
informed that Zambia in general and Lusaka in particular were in a bad shape
and that I should forget about it and try to find a job in Zimbabwe. Also,
later on, it transpired that I do not have a job as a specialist in the UTH
but I can go to the Copperbelt (part of Zambia with copper mines) and be a
travelling doctor. Rather promising career but not for a married ENT
specialist with wife and two kids.

Thereafter, I concentrated on two objectives. To survive in a foreign country
with an ever-dwindling amount of foreign currency and to find a job in the
maze of bureaucracy of the Ministry of Health. I had with me at least 20 kg of
various documents, photocopies, originals, etc which enabled me to register
with the Health Professions Council of Zimbabwe and submit my job application
to the Ministry. My wife and children joined me in November 1993 and after
five months, in January 1994 I finally got a job and started to work. 
We settled in Bulawayo. Our hospital is the Mpilo Central Hospital.

Details and Peculiarities

Zimbabwe is a land-locked country with a population of over 10 million.
Majority tribe is Shona living mostly in the central and eastern part of the
country. Minority tribe is Ndebele in the western part. It is estimated that
less than 500.000 are people of non-African origin: European, Indian, etc.
Capital Harare has more than 2 million while the second largest city,
Bulawayo, has more than 1 million inhabitants. Main tourist attraction is the
Victoria Falls, one of the World Wonders.

Before actually leaving Yugoslavia I read whatever I could find about tropical
medicine. So, every flying insect was observed as a malaria vector, and
occasionally abundant flora with interspersed rocks was judged as a potential
inhabiting place of various poisonous snakes.

First day after arrival, I took a walk from my friend's house in a very good
suburb of Harare to the nearby Highlands shopping center and almost got a
myocardial infarction when the first two black chaps that I met in the street
wished me a joyful "Good morning!".

Somehow, Africa, even in its most westernized parts, is completely different
from Europe (the USA also even through my Hollywood tainted spectacles). There
is a sense of adventure, wilderness, insecurity...

During the flight we stopped in Lagos where we did not leave the plane. Being
of a most delicate physical disposition (120 kg at the best of times) I was
very lucky to sit in a middle seat between an athletic Nigerian on the left
and a fat Nigerian on the right. The guy on the right promptly removed his
shoes and coat, produced an attache case and had a nice snack. I fondly
invoked my experience in the Yugoslav III class passenger train compartments
where all the passengers used to exchange this nice piece of chicken for that
excellent piece of pork and help it down with Coca Cola or some other not-so-
toxic fluid like, for instance, rakija (traditional Serb plum brandy) or young
wine (excellent in moderation but heavy headache the day after). Anyway, I
took the opportunity to straighten my shoulders and aching knees and went to
the door. Hot and humid air hit me in the face. So, this is the soul of
Africa.

Since those two Nigerian gentlemen disembarked happy to be at home finally I
had an opportunity to relax, ponder about the incredible adventure in progress
and look through the window. Observed from a plane, Africa is vast indeed.
Green flat or undulated fields, jungles, whatever! Towns and cities are far
apart but are very big.

When it is hot, it is very hot; when it is cold, it is extremely cold.
Extremes of all sorts chase each other all around the place. The sky is very
low and the Moon is askew. At noon the Sun is sometimes above your head and
sometimes in the South and sometimes in the North. And everybody is happy when
it rains!

First night in Harare gave us a chance to observe the Southern Cross which we
diligently did after recovering from the shock of seeing our familiar Moon a
little bit askew. One of the minor disadvantages of the "wrong" hemisphere
down under is that there is no single convenient star, like Polar Star in the
North, to indicate the exact position of the Pole. Therefore, one has to have
a small knowledge of geometry and to find a correct "diamond" which is the
Southern Cross and then with the two adjacent stars draw two imaginary lines
whose intersection indicate the Southern Pole.

Being extremely aware of all possible poisonous and/or dangerous members of
the local flora and especially fauna I was shocked to see a spider the size of
a tea-plate crawling across the wall. My shock and consternation was even
greater when my friend explained to me that those should not be killed. They
exterminate all other insects protecting the house in that manner. 
Zimbabwe has more than 10 million inhabitants. It also has less than 10 (ten)
otorhinolaryngologists/head and neck surgeons. Even if one counts a
maxillofacial surgeon and a plastic surgeon. Zimbabwe needs at least 500-1000
doctors at any time. However, it took the Ministry some five months to employ
me and my wife. They did not have any expenses. On the contrary, we brought
some money (foreign currency, even) to the country and today, after five
years, we are still being supported by our parents and families from
Yugoslavia. Government salary is about 350 US dollars which multiplied with 40
comes to about 14000 ZIM dollars.

There is four major government hospitals in the country. Parirenyatwa (after
Dr Samuel Parirenyatwa, the first African doctor) and Harare Central in Harare
and Mpilo Central and UBH (United Bulawayo Hospitals) in Bulawayo. All of them
are extremely big. Maybe among the ten largest hospitals in subsaharan Africa.
Also, there are several private hospitals. The Avenues Clinic in Harare and
several others and the Mater Dei in Bulawayo. Foreign doctors usually get
permission to work part-time private after five years in the government.
Still, the country has serious economic problems.

Official numbers claim that around one fifth of the population is infected
with the HIV. Our experience is that every third person in the street has it.
Among in-patients, sometimes more than 50%. Once I had a moderately busy
session in the out-patients. Out of 45 patients, 15 were positive black-on-
white (the tests were done), 15 had all or some of the signs while 15 looked
reasonably healthy. An orthopaedic colleague did a survey on a basis no-
questions-asked. He just took the blood from all of his patients in the wards
and found them 2/3 positive.

The question is not if they are positive or not (we think that they are all
positive and behave in such a manner) but if they have diseases or
complications related to the HIV. Some of the general surgeons claim that they
operate on such patients and have good immediate results but later on, some 5-
6 months later, tend to die with no good reason. Is it only hearsay,
anecdotal, or what? I do not know. However, I noticed that my patients have a
nasty tendency of being in a reasonably good condition one day and very dead
next morning. There are some other different stories and experiences. High
temperature means malaria until documented otherwise. Confusion of any degree
- also malaria. Low hemoglobin and blood count, the same. I usually do not do
electives if hemoglobin under 10. One exception is a patient with malignant
disease. There I do a biopsy and send for irradiation to provide at least some
chance.

To the best of my knowledge in the past six years I have heard about at least
six doctors who actually died of AIDS. All of them were involved in
heterosexual activities that could explain such an outcome. However, nobody is
actually sure how big is the transmission of HIV from the patients to the
staff. Sisters are getting sick and dying on a daily basis but due to their
better medical knowledge they probably have significantly lower percentage
than a general population. However, we work together and see each other in the
hospital. So, it is a sad and personal loss each time.

There are other stories from my chamber of horrors. We have an endemic plague
location near Nkayi, a small town nearby. So, every now and then we have small
outbreaks of bubonic or pulmonary plague. Since our army is fighting in Congo
we are also afraid that the Ebola can spread here. Several cases were noted.
Cholera outbreaks are usual and are directly connected with shortage of
drinking water.

Diagonally, from south-east to north-west, throughout Zimbabwe there is a
mountain range, or at least high-ground, locally called high-veld (meaning
probably high bush country). So, all main towns are located there. Harare is
at about 1500 m above sea level, Bulawayo 1300 m, etc. Therefore, no malaria.
However, in low-veld, north-west and south-east, there is lot of malaria. The
spraying is done regularly in the appropriate time of the season. Rainy season
starts somewhere in October and should last till March or April but is usually
much shorter. If there are good rains, everybody is happy and agriculture is
good but the mosquitoes are also happy and death toll is significant. And vice
versa, of course. However, no water means no food and this leads to starvation
and diseases. Vicious circle!

There are four ENT surgeons in Bulawayo. An Indian chap is for a long-time in
private practice, doing tonsillectomies and occasionally some polyps, sinuses,
etc. One Egyptian ENT is in the UBH and part-time private. The other Egyptian
ENT is with me in the Mpilo. The arrangement is that the three of us share on-
call duties. So, each week one of us is on call. It comes to about 10 days a
month. However, all difference comes from the sheer luck. Sometimes somebody
calls me to one of the hospitals three times a day sometimes once a week. One
dental surgeon is doing maxillofacial part and I tend to be overworked only
when she is on leave.

Two microscopes. One is excellent, Wild, but extremely static. Needs quite an
effort to change the position of the head. The other one, Zeiss, donation of
the Rotary International, has a malfunctioning transformer. However, no ear
instruments. I did several tympanoplasties using modified discarded dental
instruments. One drill, also donation from the Rotary people. Extremely
delicate. I usually use hammer and chisel and gouges whenever necessary. No
niceties with canal up or down, stapedectomies et simile.

Rigid endoscopy in all its six forms is in complete shambles. No suspension. I
even managed to do couple of microlaryngoscopies holding the laryngoscope with
one hand and manipulating inside the larynx with the other. Still 2 or 3
Hopkins' rods working. Horror comes with a small child suffocating from a
bronchial foreign body or excessive laryngeal papillomatosis. Luckily, usually
not more than once a month or so.

Ludwig's anginas used to appear once monthly or maybe less. If they come early
enough, some of them manage to survive with huge doses of antibiotics. (See at
the MMJ part of my web-pages for a very good compilation about the Ludwig's
angina.) Also a lot of incredible neck infections.

Kaposi sarcoma is usual. If I find it obstructing the laryngeal inlet then I
remove it and send the patient for irradiation. The last one had a huge bulge
from the posterior pharyngeal wall so I did debulking first with no
anaesthesia and thereafter during direct hypopharyngoscopy. However, the base
was too big so macroscopic tumor was left behind and the patient was referred
to the radiotherapy.

One odd case of syphilitic changes in the mouth. Did not improve much after
two months of various penicillins.

Tonsilloadenotomies are not done by me if the patients are less than 36
months. If bigger, some substantial indication should be obvious. "Kissing"
tonsils, for example, Quinsy in an apparently healthy individual (no major
signs of AIDS), such enlarged neck nodes implying tonsillar source, asymmetric
tonsils, etc. Last year I did 3 (three) tonsillectomies and the year before
that 18. This year I did one tonsillectomy and one adenotomy (mistake, the
epipharynx was too small).

Used to have enormous numbers and enormous sizes of maxillary tumors. Now, the
dentals are doing some of them.

Ca larynx (luckily) extremely rare. In contradistinction with my previous
surgical philosophy - I send them all for irradiation. If and when they come
back with recurrences or regional metastases I do salvage operations.
Apparently, I lost (no proof, however) a significant number of patients
because the sisters in the ward did not know how to deal with tracheotomy
tubes. Once they called me to say that the patient removed the tube and now
they do not know how to put it back. I rushed to hospital, 7 km, all red
lights, etc and found a sister and the patient sitting in front of each other
with the sister holding an open forceps in the patient's tracheostoma. Once I
did a total panlaryngectomy on Wednesday, barely managed to suture the
pharynx, put in a nasogastric tube, sutured it to the septum, made a hopeful
look towards the Skies and went home. On Saturday a young nurse, obviously
proud of their achievement informed me that they managed to remove the
nasogastric tube and that the patient is eating nicely sadza (corn porridge or
something to that effect). Working in a general surgical ward she thought by
observing general surgeons who are always very happy when they manage to
remove the NG tube that the same applies for the ENT. On Monday the patient
had a small salivary leak and another NG tube in place. On next Friday he had
a huge fistula. After two months of dressings and invoking witchcraft the
wound and the fistula settled down. I decided to put just couple of secondary
sutures under local anesthesia to decrease soiling and aspiration. The theater
matron refused to let the patient in the theater claiming that he has too low
haemoglobin. Ten days later the patient developed some 10-15 small fungiform
recurrences. After next two months he started to bleed from a medium size
artery somewhere in the right submandibular region. Despite my 'do not
resuscitate' orders they omitted to give substantial amounts of morphine but
tried to bungle with instruments in the wound until everything started to
bleed and the patient eventually succumbed.

Luckily I had bad memory and am too lazy to write everything down. Otherwise,
this not so short story would have been much longer.

On the positive side of the professional matters, some of the patients
mysteriously failed to produce local recurrences or regional metastases.
Healing is usually uneventful. Patients usually do not complain. Explanation
and consent for an operation is usually obtained in less than 10 minutes. I
have to exercise extreme caution when making indications for an operation.
There is no second opinion or higher authority. At the beginning, JRMOs and
SRMOs (junior or senior resident medical officers) were attached for a period
of six months covering both specialists in the same time. Now, the period is
six weeks. Some of them know how to suture and almost all of them are trained
to deal with all sort of conditions. Some of them actually did tracheotomies
and even tonsillectomies under our supervision. However, none of them is
actually really helpful during a laryngectomy or a neck dissection. I am very
grateful for the extra pair of hands but the huge "crowds" that we had in
theaters in Yugoslavia dwindled to the "crowd" of one here. Not to mention the
sisters who are willing and helpful but did not manage to acquire enough
experience to provide active support.

In the out-patients I have a reasonable amount of metal tongue depressors and
Killian's nasal speculums. There are some artery and dressing forceps and
various other instruments. Until recently we used to work with head mirrors
which absolutely bewildered my juniors. I managed to used direct sunlight on
occasion and it is absolutely superb. Lot of sunshine all the year around!
However, being "above" the Tropic of Capricorn, the Sun is always too high. My
colleague managed to acquire (in some mysterious way) a Welch-Allyn head-
light. The one with a bulb which focuses when the outer plastic casing is
moved backwards of forwards. Not my ideal type but still functional. However,
the remaining head mirror was promptly broken for no apparent reason
(negligence!).

There is only one ear probe (Jobson-Horne, I believe) and only one scissors.
After much "suffering" and sterilizing those "unique" instruments during a
busy out-patients session I discovered a nice way around it in a book
dedicated to medicine in Africa. Simple paper clip or money clip as they
usually call it here is unwounded, the tip is bent to make a right angle
(about 1 to 2 mm long) and it works perfectly. Now I had a whole bunch of
them.

For ear-syringing, I used to use Janet (metal) syringes. They proved too
troublesome. Therefore, an improvisation was made from an ordinary syringe and
IV cannula which works perfectly. Theoretically, I should use a new one for
each patient but it was possible to use one or two for a whole day. 
One of the "ENT Ten Commandments" - do not syringe the ear with a perforation
of the ear drum - like in chronic suppurative otitis media et simile - was
promptly forgotten. Only ear that I do not syringe is a traumatic perforation
of the eardrum. Otherwise, there is no point in giving parenteral and local
medications for an ear that is full of pus, detritus, mycosis, etc. However,
the syringing is done very gently, the ear subsequently dries and the results
are excellent. Usual time of dealing with an otitis externa or more oftenly
and more importantly with a chronic otitis can be shortened significantly. The
suction machine is almost unusable and only increases the pain and discomfort
if actually used. Question arises what happens if we have a need for some
vital and fast removal of secretions in the airway, hypopharynx, etc. 
This being said one should bear in mind that the whole obsession with ear
probes, improvisations with paper clips, etc came to being because I wished to
avoid syringing if possible and to use the "dry" method for removal of
cerumen, foreign bodies, keratosis obturans (once a month, approximately),
etc. This due to the fact that they tend to develop otitis externa mycotica
and/or suppurativa after syringing even if all necessary precautions are being
taken. The only exception is a kid with a foreign body in the ear where
syringing is the "boss" if the foreign body is not very amenable for
instrumental removal.

There is couple of anesthetic laryngoscopes and otoscopes.

My personal operative statistics are still being done and are not yet
finished. However, the general assumption which is very close to the reality
is that I do on average 20 operations per month in four theater days and
examine some 240 to 480 patients per month in the out-patients. Operations
are: 25% so-called major (parotidectomies, maxillectomies, face and neck
tumors, oral tumors, etc), 50% minor (tracheotomies, small tumors, very rare
foreign bodies in the ear, otomicroscopies, very common nasal polyps, etc) and
25% endoscopies (direct laryngoscopies with removal of nodules or biopsies of
lesions and removal of laryngeal papillomatosis, bronchoscopies and
esophagoscopies for foreign bodies). Peritonsillar abscess (Quinsy) is being
opened in the out-patients under local topical and infiltrative anesthesia if
mature enough. Parapharyngeal and retropharyngeal abscesses are being opened
in theater under general anesthesia transorally being usually in kids and with
great danger of accidental rupture and "drowning" of the airway. All other
neck and face abscesses are being opened also in the out-patients with the
exception of parotid abscesses and really huge neck ones which are dealt with
in theater.

Gloves, surgical and rubber for single use, are sometimes out of stock.
Therefore, in the out-patients I have to examine some of the patients without
gloves. In the theater, I applied a technique from a paper intended for
maxillofacial surgeons. Since the brushes are non-existent or definitely non-
sterile, scrubbing is done only perfunctorily or completely omitted.
Thereafter, the first pair of gloves is put on, then the gown with the cuff
over the gloves, then the second pair of gloves with the gloves over the cuff.
The third pair of gloves is put only if it is necessary to do a thorough
cleaning of the operative field and/or repositioning of the head of the
patient. They are discarded before proceeding to drape the field. The second
pair of gloves is usually changed during the procedure. For instance, when
going from the initial phase of dissection to the deeper tissues; after
removal of the tumor and washing of the wound, etc.

In the follow-up, all the patients with tumors are advised to come for a
follow-up every last Friday of every month and basically none of them respect
that. Therefore (not excluding my obviously insufficient technique) they come
with huge recurrences. An absolute record was made by an unfortunate chap who
came with a huge maxillary sarcoma. Was removed with radical maxillectomy.
Came after six months with an even larger tumor and thereafter did not
reappear for the first follow-up. Some of the pictures can be seen at the MMJ
web-pages.

Since this text is approaching 4000 words now is the time to stop. 
Hope it was not too boring.

Any comments and additional questions are welcome through my personal e-mail
to avoid the congestion of the list.

Regards,

Predrag Maksimovich,

Bulawayo, Zimbabwe.

Snail mail:

9 Alexandra Gardens
Galway Road
Famona
Bulawayo

Phone:
263 9 71369