I only realised this week that my Christmas holidays have already started....back home I would be enjoying the pre-festive excitement that doesn't fail to disapoint every year. At my age, its pretty embarrasing that this will be my first Christmas away from my family. I am contemplating this, but feel, somehow, that there are other important things going on where I am just now, important enough for me to change my focus for at least this year.
Kate and I are still working this week, and today, as I tried to conceal my frustration at a couple of nurses who ignored my presence and my requirement for help with a few jobs so that I could do other things (really, I must learn to not get so worked up), I began to think that going away next week for a wee break was quite a nice thing to look forward to.
I thought I'd briefly share the 2-week plan:
This saturday (20/12/08) we will travel to Liwonde National Park, south of the bottom of Lake Malawi. We will camp there for 4 mights and hopwfully play I spy with elephants, hippos, zebras, and crocs, as well as a few other beauties. Then we will move north to Cape Maclear for Christmas Eve and Christmas Day. There are palm trees and white sand, and probably no turkey or Christmas pudding. That's fine with me. My big brother spent Christmas here in the 1980s, will be fun to think of m in the same place. On boxing day we will hopefully catch the Lake Malawi ferry to Likoma Island, close to Mozambique but belongs to Malawi. We'll spend a night on the ferry. We will spend 4 nights on Likoma Island, then take the ferry back to Cape Maclear for New Years Eve and Day. Then its back to Lilongwe. I will continue to work in the medical department for another two weeks after Christmas, then need to consider the plan from there. In the pipeline is 2-3 weeks of Obstetrics, 3 weeks in the childrens ward here in Lilongwe, and perhaps 3 weeks in the childrens unit in Blantyre with a well-known Professor of paediatric A&E medicine. Its all exciting, and tiring at the same time.
Tuesday, December 16, 2008
Sunday, December 14, 2008
On the male medical ward
It’s been a very tough week this week. I don’t know if it’s anything to do with the rain which has been bucketing down most of the time, but we have been very busy with admissions, mainly of very sick young men. They come so late in their illness, by which time there is not much that can be done. On Thursday a man in his 40’s came in unconscious. The history was of five days of severe headache, neck stiffness, and fever. We were dealing with meningitis, and severe sepsis. His respiratory rate was through the roof, and his tongue was obstructing his airway, making his breathing very noisy. They don’t do anything about obstructed airways in unconscious patients, apart from occasionally some suction. I managed to find a functioning suction machine in the high-dependency unit (quite an achievement) and tried to clear out his airway. The suction isn’t very powerful, but it made a little bit of difference. After ensuring he was receiving plenty of intravenous (IV) fluid, I supervised one of the clinical officers while he did a lumbar puncture (LP). I’ve only been doing LP’s for two weeks, but in general the clinical officers knowledge of a sterile field is pretty much zero, so I’ve been trying to get them to understand the importance of a sterile LP technique. Their ability to actually do the LP is fine (as in it is usually successful), they just do them without being sterile, which worries me (Me: “now put on your sterile gloves. Good. No, you can’t touch the bed or move the patient or scratch your head with sterile gloves on. Go and change them”. I don’t know how much they take this in. Usually they just giggle at me and one of them told me to “chill out”!). Anyway, pus came out of this patient’s spinal canal, mixed with the cerebrospinal fluid (CSF). This is not a good sign. Charles (the registrar) told me he has only ever seen one patient with purulent bacterial meningitis survive. We started the patient on an antibiotic (they use IV ceftriaxone for bacterial meningitis here too, or sometimes IV cefotaxime because the nurses don’t like drawing up ceftriaxone as apparently its too much effort). The patient was moved from the admissions room to the ‘meningitis room’, and we carried about our business of seeing the rest of the very sick people, and reviewing others on the ward. I happened to be in the meningitis room, and noticed the patient we had just moved had run out of IV fluids. I set more up, then one of the interns decided to come to the ward (it is as haphazard as that!), and was asking me about the patient. We discussed him, and talked about what electrolyte imbalances he may have, as his urine output wasn’t great he was probably in acute renal failure. This intern is very good when he is on the ward, a lot of knowledge and for some reason he decided we might be able to do something for this patient. We decided to get urgent renal function tests (U&Es), so I spent the next couple of hours rushing around between labs, trying to find a signature (the KCH lab machine is still broken, so if we want U&E we have to take samples to the UNC lab, which is a 15 minute round trip from the ward, and only two people in the whole hospital can sign their lab forms, both of these people are difficult to find!), and collecting results. The patient did have renal impairment but his electrolytes were OK. The intern added a different antibiotic, as he said it might help, and I made sure his fluids kept running for the rest of the day. They probably wouldn’t be kept up overnight however, even though the intern said he would hand over the patient to the doctor on night duty.
The day before (Wednesday) I had done an LP on a 54-year-old patient who presented last week with loss of sensory and motor function of both legs. He also had urinary incontinence and constipation. The symptoms had started in his feet and moved up his legs. He was HIV positive and on antiretroviral therapy (ARVs). Guillian Barre Syndrome (GBS) was considered a differential diagnosis, and we needed a CSF protein analysis to confirm this. The KCH or UNC labs don’t do this test, so Dan (the consultant physician) had told me to send the sample with the patient’s guardian to a private clinic in town which would do the test. The patient would have to pay for the test. I wrote a letter to go with the sample, explaining that we only needed protein analysis. I had sent another sample to our own lab for other CSF analysis which would cost the patient nothing. The guardian came back at the end of the day with the results: CSF protein: test not available. They had analysed the CSF for everything else instead, and charged the patient for something we could have done at KCH. I was so cross. The patient’s guardian kept chasing me around the ward asking me what the result had shown and what was going to happened and would her husband ever walk again. The doctors who were supposed to be in charge of him hadn’t really explained everything and because I talk to the guardian, she has decided to follow me everywhere. I had to do a pleural tap (drained 2L off each side of a TB patient’s chest much to his relief) and couple of paracentesis (draining fluid from the abdomen) that afternoon (drained 5L off one poor chap because I just left him in the treatment room while I was dealing with another sick patient, gave him a litre of fluid quickly and made sure his blood pressure was OK before he went home), so this was not helpful being followed and pestered, but I understand why she was doing so. Dan was going to be away on Thursday (district hospital visit), and so had asked me to go down to the radiology department with the ?GBS patient to do the LP for a myelogram investigation. This investigation is no longer used in the UK, we use MRI instead, but it involves injecting contrast into the spinal canal and then uses x-rays to visualise any filling defects that might indicate that the spinal cord is being squashed my something (tumour, bone, etc). Another differential diagnosis for this patient was spinal cord/cauda equina compression, probably caused by TB, or schistosomiasis. I went down to the department in advance, and discovered I was to be the radiologist, and not only do the LP, but also inject contrast into the spinal canal. I was by myself, and decided this was not a good plan. A clinical officer came to supervise me, but after taking plain films of the lumbar spine (we had previous x-rays that were very poor quality), we decided there might be an abnormality, and he then said we should do the myelogram. I didn’t know if this was the right decision or not, but felt relived that I didn’t have to be a radiologist for a day. That would not be right. I have organised for this patient to have an MRI scan in Blantyre (the second biggest city in Malawi with better equipped hospitals) next week.
So, after not doing the myelogram, I remembered about patient with purulent meningitis, and decided to go and check on him. His fluids had run out again, and he was still obviously very unwell, with a high respiratory rate and needed suctioning again. I asked Cosmos, the amazing male nurse (really, the only one who does any work, and will do anything you ask him to) to suction him for me because he is better at it than me and I had to do something else.
I can’t remember how Thursday ended, but it was late and I was shattered. Wednesday was pretty much like that too, I seemed to be going procedure crazy with the pleural tap, paracentesis and a couple more LPs.
I came in on Friday morning, and was surprised to learn that my meningitis patient was still alive, I noticed his breathing was becoming more eratic though. I asked Cosmos to suction him again, but he didn’t get round to it. While making sure his fluids were running another unconscious man (about 30 years old) came in, very similar to the one I was in the process of looking after. Exact same story, exact same late presentation. I did the LP, and viscous cloudy CSF came out. He got left in the admissions room as there was no space anywhere else. I was then called by one of the clinical officer students to see a patient out on the balcony area who has frank haematuria in his catheter bag. Turns out he hadn’t really had a proper work up, so I struggled for about half an hour working out the patient’s history and examining him. He had a mass in his pelvis that hadn’t been documented anywhere, and with Charles advice, I sent him for urgent ultrasound and x-rays, and took blood, and re-sited his venous cannula. This was a bit of a set back to the morning. I was then called by another clinical officer student to see the first meningitis patient. He had stopped breathing. I examined him, explained to the wife with the student as a translator, and informed the nurses about the death. Shortly after that, while chasing Dan around the hospital trying to get him to make a decision about the management plan for the patient with ?GBS ?spinal cord pathology, I walked past through the admissions room and noticed that the second meningitis patient had also stopped breathing. Again I did the examination and explained to the young wife (using a student as translator) who was sitting next to the bed with a baby strapped to her back and probably at least another couple at home. She looked at me with disbelieve and shook her head. The guardians never look worried when they bring in their half-dead husbands, and don’t seem to notice when they stop breathing. There was no wailing for this death, I don’t know why. But what will she do now? With several mouths to feed and limited ability to earn an income.
I was beginning to think the day couldn’t get much worse, and it was only about 11am. I admitted a patient last week, an 18 year-old boy with generalised enlarge lymph nodes, and splenomegaly. It looked like a case of advanced lymphoma, and the plan was to give him chemotherapy. He was severely anaemic though, and this needed to be corrected first. I hadn’t been following him up, but found out a few days ago he had only had one pint of red cells in the week he had been admitted, and was still awaiting further transfusion. In that time, his haemoglobin had dropped further. I was standing in the corridor when I heard his mother wailing. Just because the lab didn’t have any blood. I couldn’t really deal with much more, and after a few tears went to have a break for an hour.
Late on Friday afternoon Charles asked me to do an LP on an inpatient who now had a headache and had become confused. He was at the far end of the balcony, not sure if he’d been missed out on ward rounds (which happens quite a bit). Again, cloudy CSF. We quickly started antibiotics and moved the patient to the meningitis room. I went to work on Saturday this week. Charles asked me to come in to help him, and I sort of couldn’t leave sick patients I had seen on Friday all weekend. I found out near the end of my stint on Saturday that this new meningitis patient had pulled out his drip the night before, and no one had re-sited it. Even though he was prescribed IV antibiotics, the nurses just gave him them intramuscularly, which would do nothing for him (at least he was getting some antibiotics, other patients I have been managing for some reason don’t get them at all, even if they are prescribed). I asked a nurse to cannulate the patient as I needed to do something else, and she started at me blankly from under the coat she was curled up in sitting in a chair in the office (torrential downpour makes the hospital quite cold), and said, “I am resting”. Resting from what I don’t know, because she had done diddly squat all morning. I got cross and told her the patient was dying (because he is and he will) and needed a cannula now. “After I have finished resting”. I give up. Cosmos says they never do anything, and he is lucky if they come to work at all. He says sometimes they are sick (HIV) and need time off, but other times it’s because they just don’t come, or they are attending a funeral. Cosmos will cannulate my patient. Thank you Cosmos.
The day before (Wednesday) I had done an LP on a 54-year-old patient who presented last week with loss of sensory and motor function of both legs. He also had urinary incontinence and constipation. The symptoms had started in his feet and moved up his legs. He was HIV positive and on antiretroviral therapy (ARVs). Guillian Barre Syndrome (GBS) was considered a differential diagnosis, and we needed a CSF protein analysis to confirm this. The KCH or UNC labs don’t do this test, so Dan (the consultant physician) had told me to send the sample with the patient’s guardian to a private clinic in town which would do the test. The patient would have to pay for the test. I wrote a letter to go with the sample, explaining that we only needed protein analysis. I had sent another sample to our own lab for other CSF analysis which would cost the patient nothing. The guardian came back at the end of the day with the results: CSF protein: test not available. They had analysed the CSF for everything else instead, and charged the patient for something we could have done at KCH. I was so cross. The patient’s guardian kept chasing me around the ward asking me what the result had shown and what was going to happened and would her husband ever walk again. The doctors who were supposed to be in charge of him hadn’t really explained everything and because I talk to the guardian, she has decided to follow me everywhere. I had to do a pleural tap (drained 2L off each side of a TB patient’s chest much to his relief) and couple of paracentesis (draining fluid from the abdomen) that afternoon (drained 5L off one poor chap because I just left him in the treatment room while I was dealing with another sick patient, gave him a litre of fluid quickly and made sure his blood pressure was OK before he went home), so this was not helpful being followed and pestered, but I understand why she was doing so. Dan was going to be away on Thursday (district hospital visit), and so had asked me to go down to the radiology department with the ?GBS patient to do the LP for a myelogram investigation. This investigation is no longer used in the UK, we use MRI instead, but it involves injecting contrast into the spinal canal and then uses x-rays to visualise any filling defects that might indicate that the spinal cord is being squashed my something (tumour, bone, etc). Another differential diagnosis for this patient was spinal cord/cauda equina compression, probably caused by TB, or schistosomiasis. I went down to the department in advance, and discovered I was to be the radiologist, and not only do the LP, but also inject contrast into the spinal canal. I was by myself, and decided this was not a good plan. A clinical officer came to supervise me, but after taking plain films of the lumbar spine (we had previous x-rays that were very poor quality), we decided there might be an abnormality, and he then said we should do the myelogram. I didn’t know if this was the right decision or not, but felt relived that I didn’t have to be a radiologist for a day. That would not be right. I have organised for this patient to have an MRI scan in Blantyre (the second biggest city in Malawi with better equipped hospitals) next week.
So, after not doing the myelogram, I remembered about patient with purulent meningitis, and decided to go and check on him. His fluids had run out again, and he was still obviously very unwell, with a high respiratory rate and needed suctioning again. I asked Cosmos, the amazing male nurse (really, the only one who does any work, and will do anything you ask him to) to suction him for me because he is better at it than me and I had to do something else.
I can’t remember how Thursday ended, but it was late and I was shattered. Wednesday was pretty much like that too, I seemed to be going procedure crazy with the pleural tap, paracentesis and a couple more LPs.
I came in on Friday morning, and was surprised to learn that my meningitis patient was still alive, I noticed his breathing was becoming more eratic though. I asked Cosmos to suction him again, but he didn’t get round to it. While making sure his fluids were running another unconscious man (about 30 years old) came in, very similar to the one I was in the process of looking after. Exact same story, exact same late presentation. I did the LP, and viscous cloudy CSF came out. He got left in the admissions room as there was no space anywhere else. I was then called by one of the clinical officer students to see a patient out on the balcony area who has frank haematuria in his catheter bag. Turns out he hadn’t really had a proper work up, so I struggled for about half an hour working out the patient’s history and examining him. He had a mass in his pelvis that hadn’t been documented anywhere, and with Charles advice, I sent him for urgent ultrasound and x-rays, and took blood, and re-sited his venous cannula. This was a bit of a set back to the morning. I was then called by another clinical officer student to see the first meningitis patient. He had stopped breathing. I examined him, explained to the wife with the student as a translator, and informed the nurses about the death. Shortly after that, while chasing Dan around the hospital trying to get him to make a decision about the management plan for the patient with ?GBS ?spinal cord pathology, I walked past through the admissions room and noticed that the second meningitis patient had also stopped breathing. Again I did the examination and explained to the young wife (using a student as translator) who was sitting next to the bed with a baby strapped to her back and probably at least another couple at home. She looked at me with disbelieve and shook her head. The guardians never look worried when they bring in their half-dead husbands, and don’t seem to notice when they stop breathing. There was no wailing for this death, I don’t know why. But what will she do now? With several mouths to feed and limited ability to earn an income.
I was beginning to think the day couldn’t get much worse, and it was only about 11am. I admitted a patient last week, an 18 year-old boy with generalised enlarge lymph nodes, and splenomegaly. It looked like a case of advanced lymphoma, and the plan was to give him chemotherapy. He was severely anaemic though, and this needed to be corrected first. I hadn’t been following him up, but found out a few days ago he had only had one pint of red cells in the week he had been admitted, and was still awaiting further transfusion. In that time, his haemoglobin had dropped further. I was standing in the corridor when I heard his mother wailing. Just because the lab didn’t have any blood. I couldn’t really deal with much more, and after a few tears went to have a break for an hour.
Late on Friday afternoon Charles asked me to do an LP on an inpatient who now had a headache and had become confused. He was at the far end of the balcony, not sure if he’d been missed out on ward rounds (which happens quite a bit). Again, cloudy CSF. We quickly started antibiotics and moved the patient to the meningitis room. I went to work on Saturday this week. Charles asked me to come in to help him, and I sort of couldn’t leave sick patients I had seen on Friday all weekend. I found out near the end of my stint on Saturday that this new meningitis patient had pulled out his drip the night before, and no one had re-sited it. Even though he was prescribed IV antibiotics, the nurses just gave him them intramuscularly, which would do nothing for him (at least he was getting some antibiotics, other patients I have been managing for some reason don’t get them at all, even if they are prescribed). I asked a nurse to cannulate the patient as I needed to do something else, and she started at me blankly from under the coat she was curled up in sitting in a chair in the office (torrential downpour makes the hospital quite cold), and said, “I am resting”. Resting from what I don’t know, because she had done diddly squat all morning. I got cross and told her the patient was dying (because he is and he will) and needed a cannula now. “After I have finished resting”. I give up. Cosmos says they never do anything, and he is lucky if they come to work at all. He says sometimes they are sick (HIV) and need time off, but other times it’s because they just don’t come, or they are attending a funeral. Cosmos will cannulate my patient. Thank you Cosmos.
Friday, December 5, 2008
A day in a district hospital
Today I, the consultant physician (Dan), and registrar (Charles) went to Kasungu district hospital, about 150km north of Lilongwe. The 2 hour drive there took us through fields of newly planted tobacco, clusters of mud huts with thatched roves, and town and villages full of people going about their daily business. Freshly cooked corn on the cob, mangoes, and live chickens for sale by the side of the road.
On arrival we were introduced to the district health officer, an anaesthetic clinical officer (someone who puts people to sleep who isn’t a doctor), in his plush office of fake black leather furniture. We were to see some outpatients first, who had been selected by the only doctor in the hospital (there are I think 2 interns too, that is newly qualified doctors, what I will hopefully be from August) as being difficult cases she didn’t know how to manage. We first see a 16 year old girl who has been on steroids since she was 5 years old for generalised oedema, most likely minimal change glomoerulonephritis. I was shocked by the length of time she’d been on steroids, with apparently no specialist review of treatment for over 10 years. We arranged for her to come to Lilongwe to collect some cyclophosphamide (immunosuppressant) and to make a steroid-weaning plan. While we’re discussing this case, the doctor and clinical officer who are supposed to be learning from the experience so they can further their clinical ability are wandering in and out, drinking fanta orange, and generally not paying attention. Dan tells them they have to stay and listen. They stay, but in my opinion don’t listen, because they don’t give any input at all.
The second patient is an elderly man (I remember I quite like old people and haven’t seen many as patients here) with a long history of a dry cough (i.e. for years). He is otherwise well, and Dan finds out the likely cause of his chest problems: he worked in some form of mine in South Africa. Dan then gets into some chat about lung diseases that are predominantly Western: interstitial lung disease, chronic obstructive lung disease (COPD) and asthma. Of course, no one knows much about these, and there are long periods of silence before I offer answer. Dan gives some inaccurate information about asthma treatment, and in my opinion gives too much information for these people to take in, they stare blankly at him. We need to do an ECG on this patient as palpation of his pulse suggests atrial fibrillation. I am instructed to show the doctors how to do an ECG. Someone eventually finds the ECG machine, and we link the patient up with the sucker-pads attached to his chest. Then we discover there is no paper for the machine, so we can’t record anything! I feel frustrated by this, but then think, what would we have done about it anyway, probably nothing. I can guarantee that the doctors here will not be doing many ECG’s in the future, not only because they don’t know how but because there are no facilities, and its just not a priority.
Next patient has tophaceous gout, very obviously so. He is on ibuprofen for the pain, no one has checked his renal function (NSAIDs combined with gout can cause renal impairment), but the hospital doesn’t do renal function tests. He should be on a drug that lowers his uric acid (allopurinol), the doctors don’t offer this information when asked, and apparently there is no allopurinol (Dan stresses this is a cheap drug and should be available). I think: this is a relatively simple case, why is Dan being asked for input?
The next patient is a young chap complaining of long term central abdominal pain. Only by looking at his abdomen I can see visible peristalsis, and can feel a weakness in the abdominal wall. I think this is a mild hernia, Dan has a few other ideas. This is obviously not a medical case! This guy needs surgical input, so why hasn’t this been arranged? Why did they have to wait for Dan to get this organised?
Dan’s passion is teaching, he takes about 30 minutes to see one patient because he goes off on long tangents, asking multiple questions, which I volunteer answers to and everyone else remains silent. That was the most prominent thing I drew from this morning, that no one answered Dan’s questions. Is this because they culturally don’t answer questions when asked by a senior? But it felt more like they didn’t know the answers! And they weren’t that complicated questions, even I had ideas for most of the answers. This made me worried about this apparently qualified doctor running a hospital....this fear was worsened in the afternoon....more later.
With the doctor, an intern and the same clinical officer that was with us (physically but not mentally) this morning, we move on to the male inpatient ward (there is one ward for men, one for women, on for little ones, and a maternity unit, all covered by this one doctor, with her ?2 interns, 5 clinical officers, and maybe 10 clinical officer students). The wards are much brighter and look cleaner than Lilongwe. There are TV’s blasting out a bible channel from Texas (that is enough to drive anyone crazy). The ward houses medical and surgical patients. There are big permanent signs on the wall in different areas of the ward, stating the diagnoses of patients in that section of the ward: ‘malaria’, ‘pneumonia’, ‘anaemia’, ‘orthopaedics’, ‘surgery’. We are asked to see two patients here. The first is an “HIV positive man with tremor” (he is in the ‘pneumonia’ section, which confuses me). This is the history we get. It soon becomes obvious that this chap has a cerebellar lesion. He has an intention tremor, dysdiadokokinesis, nystagmus, slurred speech, and hypotonia (this is not important for those who are non-medical, it was more the point that it was so obvious, but because the patient had never had a full physical examination, no one had elicited these signs and therefore been able to make a suspected diagnosis). I learn from Dan that cerebellar atrophy (shrinkage of this part of the brain) can occur in HIV infection. Dan asks if the patient has been tested for syphilis, he hasn’t. He hopes that will be arranged.
The second male patient is elderly, they are unsure of his age but he looks to be in his late 70’s (but its hard to tell with such a weather-beaten face). He is unresponsive, that is all the history we get. Dan states that he is no geriatrician, and this makes me think of the age of most patients I have seen so far in Malawi, and that this is because of HIV. Dan asks the medical staff about the eldest patient’s they have seen with HIV. I am surprised to hear that some have treated patient’s in their 80s. This means these patients must have contracted the virus very late in life. Charles (the registrar) tells me this is because they are either caring for their relatives with HIV and don’t take the necessary personal protection precautions to avoid contact with body fluids, or because there is child sexual abuse within the family where the children are HIV positive (most likely have contracted the virus through mother-to-child transmission). Have the staff through about sepsis in this patient? No chest xray, no investigation for urine infection has been done. The antibiotic he is on would cover a chest infection but not urine. We add in an antibiotic for the urine. From my experience over the two weeks I have been here so far, he will likely not get any investigations, just be treated for the differential diagnoses.
We then move on to the female ward. Its the same size as the male ward but I have never seen a hospital room full of so many people. There is noise and chatter. There are people everywhere. At first it is hard to tell who is who, but then I realise that there are patients on the floor on mattresses between the beds, and sometimes two patients to a bed. The patient’s guardians (not sure if I’ve mentioned guardians, these are the people the patient’s bring with them to the hospital to take care of all there personal needs, i.e. washing, preparing food, feeding etc) are also on the beds, some on the floor, some wandering around. There are crying babies, some of them being breast fed lying be the side of their sick mothers, some being cradled by guardians. Everyone starts laughing around the bed of the first patient (I’m horrified by the number of sick people in this room so am not feeling like laughing is an appropriate reaction, but find that perhaps laughing about the problems that are so obvious is perhaps just what happens here, a way of coping maybe? But it still feels inappropriate, and like they just don’t care). They tell us that this patient states that she “fell out of a plane”. I’m confused. They say it is something to do with witchcraft, and there is nothing wrong with her (despite the fact she can’t move and is in obvious severe pain). Dan pulls an 18month old child off the patients breast and examines her back, and discovers an area of tenderness over her cervical spine (back of her neck). She has had no x-rays taken, and Dan requests that these are done. Otherwise, she has been lying there without a diagnosis, waiting for nothing to happen.
The next lady looks very sick. She is tiny, with arms about as thick as two of my fingers. Her tummy is huge, sticking out so obviously on her tiny frame. She is in pain too. Its hard to guess her age, maybe 40-50? The staff don’t know what to do with her. They have taken abdominal x-rays, and established that the swelling is not solid or fluid but air (its sounds tympanic on percussion). The story is obviously one of intestinal obstruction (in an HIV positive patient). Dan asks them what they are treating, i.e. what are they doing for this patient. The clinical officer says it is palliative. Dan stressed it can’t be palliative unless you know what you are treating. Silence. Has anyone examined her back passage. “It’s not been done” (becomes the most frustrating phrase of the day). We do this examination (and check per vaginum as well because of the high incidence of cervical cancer in the HIV positive population) and discover a rectal tumour (interesting issues trying to carry out such intimate examinations in such a public place. No curtains so we make do with a couple of screens and making other patients turn the other way). There we have a diagnosis, through the simple yet invaluable measures of thorough physical examination. As an aside, the patient has no drip, and no nasogastric tube, despite vomiting on a background of obstruction. Dan suggests these management measures are carried out.
The next lady also has a distended tummy, and is just as thin, but she appears cheerful, and is obviously not uncomfortable. She is perhaps in her 50s-60s. This is a fluid filled tummy, and an ultrasound scan has shown liver lesions (likely malignancy, either primary or spread from somewhere else) but for some reason nothing has been done manage the problem. No fluid has been taken for analysis, so Dan does this now. Then he asks what medication she is taking. I can’t remember what she was on, but not spironolactone, a drug that would help reduce the amount of fluid in her tummy. Dan says how important it is that she be on this drug. He is told by the doctor that they don’t have any. The next patient gives us further info about the lack of drugs available.
She is in her early 30s, and is sitting up on the bed with another patient lying beside her. She is short of breath, and her ankles are oedematous (swollen). Even sitting at 90 degrees her elevated JVP is making her ear lobe wobble. Dan just touches his stethoscope to her chest, then asks the clinical officer to present the patient. He mentions something about shortness of breath and oedema and says she has mild heart failure. HIV can cause a dilatory cardiomyopathy, which in turn can result in heart failure. Dan asks him about his findings when listening to the chest, the clinical officer says there is a murmur (this doesn’t really mean much at all, we need timing a location of murmur). Dan asks us all to listen to the chest. I’ve never heard an S3 gallop rhythm before but this must be it, it so obviously sounds like a galloping horse! And on a background of heart failure/fluid overload that would make sense. No one else comments on their findings, no one has any suggestions about what the altered heart sounds are. I give my gallop rhythm suggestion. This is also what Dan thinks, but he wants the clinical officer, doctor, and intern to comment on what they heard, so that he can be reassured that they are learning from the experience. They just copy what I say when he asks me to reproduce the sounds I heard. Again I think, if I can do this, why can’t they? Dan establishes that this lady has severe (stage 4 New York Heart Failure for you academics) congestive cardiac failure by asking her how much she can manage to do for herself at home. She needs several medications that are not being currently prescribed (she is only on furosemide – which is relevant, and digoxin – not relevant before all the other important treatments fro heart failure have been initiated. Surprise surprise, the hospital has no ACE inhibitors, and again we have no spironolatone. Dan tells us these drugs are cheaper than the nsima (the porridge Malawians eat everday) this patient is eating. He tells me money for drugs is not an issue in Malawi. Where are these drugs? The district health officer’s plush office sneakily slips into the back of my mind.....
The last lady we see is in the TB room. A permanent sign on the wall reads “TB suspects”. There is a lot of coughing going on, and again patients on the floor as well as in beds, and guardians everywhere. The patient we are asked to see is 32 years old, and is sitting up in bed, gasping for breath. She is tiny, her arms as thin as the other two ladies we saw earlier. She has dilated neck veins, and dilated veins in her right arm, with puffiness of the right hand. The right hand side of her chest is about twice the width (in the anterior-posterior dimension) of the other side. There is obviously something growing inside her chest, compressing venous drainage from the right arm and the head (SVC obstruction). As far as I am aware, TB doesn’t do anything like this, and Dan agrees. She doesn’t have TB, but is in the TB ward, where her guardians are at risk of taking TB home to the rest of the family. Nasty nasty chest x-ray showing a sliver of left lung remaining, the rest is compressed my her mediastinum which is shifted far to the left by an unknown mass in the right side of the chest. She has advanced malignancy basically, what sort of malignancy would do that though I don’t know.... They keep taking fluid off her chest, but it keeps coming back. Dan explains that she needs a chest drain, then pleurodesis to stick the pleura to the chest wall to try and stop the fluid coming back, then she needs good palliative care for the distressing breathlessness. They are happy about putting in a chest drain, but not happy with injecting some iodine (“we don’t have” – apparently its only about 30 kwatcha [about 20 pence] in the shop, they could go buy some says Dan) down the tube to do the sticking. This seems a bit funny, seeing as the chest drain is the most complicated bit. The doctor wants to transfer the patient to Lilongwe to have this procedure done. There is no way she will make the journey. We ask for some morphine to alleviate the distressing breathlessness, there is none. Pethidine will have to do. Dan makes the important point that this patient and her family need counselling about her terminal illness, and that she could go home to die. I leave the bedside with the frustrating feeling that none of these things will happen. She won’t get pleurodesis (she will probably die before then to be honest), and no one will counsel her and her family. She did get some pethidine before we left the room.
The doctor then asks Dan to see some children. He reminds her he is not a paediatrician, but she complains that she has very limited paediatric support from Lilongwe. He is persuaded to take a look.
The first kid makes me cry. He is a little boy of about 9 sitting on the side of his bed. He has a puffy face, puffy ankles, and a hugely distended tummy. He lifts up his shirt obediently to be examined. They have tried to drain his tummy and its still leaking from the hole they made because of the high pressure. The notes and the staff say he has heart failure. Dan takes a history from the boy’s mother, and the swelling started in the tummy, not the face and legs, meaning this is more likely a liver problem, not originating from the heart (of note his heart sounds normal). He needs to see a paediatrician. Apparently he was in Lilongwe two weeks ago but was discharged. Dan says this was a mistake, and happened because the consultant paediatrician in Lilongwe doesn’t see patients, the clinical officers run the show instead. We make arrangements to transfer him back to Lilongwe, and Dan will make sure he is seen by the consultant. I cried because he is so sick, and because he is sitting in a room waiting for nothing to happen. And because he was so compliant with these people who are doing absolutely nothing for him. And because if he was somewhere else things could be so different.
The next little boy has lots of large lymph nodes. Obvious lympohoma. He needs a biopsy, but the hospital doesn’t have formalin to keep the specimen in. Otherwise he is unnecessarily in hospital. Dan reminds everyone that because his Dad is with him in hospital, soon the other children in the family will be admitted with malnutrition because the family won’t be able to afford to feed them.
The last patient is a boy with likely herpes encephalitis. Instead of listening to the conversation I go and find a healthy looking smiley baby without anyone looking after it to gurgle at and play with. We have a special 10 minutes together.
I’ve no idea how many beds the hospital has but there must have been over 50 female patients, about 20-30 male patients, and probably about 50 children. We didn’t see the maternity unit. No wonder this doctor is ?overwhelmed/?out of her depth.... What about the obvious lack of enthusiasm and drive though? All she did when Dan asked why certain management hadn’t been carried out was giggle (I was ready to throttle her at the end). And the clinical officer was too busy trying to do as little work as possible to make any effort whatsoever. Dan kept telling the doctor how easy it was to order drugs from the pharmacy in Lilongwe, but then told me she doesn’t really have any power over what the district health officer (DHO) orders (apparently the DHO now has hypertension and diabetes – i.e. he has money he didn’t have before). Dan also told me that the doctor we went around the hospital with is actually employed by the UN, rather than the Malawian Ministry of Health (she is a UNV – a Uninet Nations Volunteer). This is why she has no power.
It’s sad and frustrating, because the patients we saw today do not have access to simple and straightforward treatment. But what seems somewhat worse, is that patients seem also not to have access to simple and straightforward clinical knowledge that doctors/clinical officers should have, which means they are not diagnosed, either at all or correctly, and therefore can’t be managed appropriately. This seems to be mostly down to clinical training. On the way back in the car, in between buying mangoes from the side of the road, Dan tells me that the training of clinical officers especially (but also medical students) is out of date, and carried out by lecturers who have limited clinical experience, because by the sounds of things, they can’t be bothered to work on the wards. The clinical officer students in Kasungu spend 16 weeks in this district hospital, without any teaching other than what the doctor has to offer (I would be extremely worried if she was teaching anyone based on her knowledge I witnessed today). These people need knowledge, but also they need empowerment to make them care about the outcome of the patients they are looking after.
This makes me tired. I manage supper then an early night while everyone else goes for drinks and a game of pool.
The next day we drive north to Mzuzu, the largest city in the north of Malawi, about 400km from Lilongwe. The countryside is very different up here, lots of pine trees, cooler, wood planks lining the side of the road explain the deforestation, mountainous, and generally much more lush and beautiful. The road is windy, and our little car doesn’t manage the steep hills too well! At Mzuzu we turn right (east) and drive another 50kms downhill on a small road (mostly tarmac) to Nkata Bay. Lake Malawi appears infront of us as we come over the last hill, and a busy bay town. We find our accommodation: a place called Mayoka Village, built on the steep rocky shores of the lake, a maze of bamboo huts and steep stone steps, and a very lively bar area full of (far too) friendly Malawians and backpackers. We pitch our tent, and dive in the very warm lake before waiting for the “fantastic Friday night BBQ”, lots of delicious food. We manage a few drinks with the locals before bed. Today we are taking a boat trip and will hopefully see fish eagles, go snorkelling, and jump off a cliff (that is what the offer is anyway!). The weather is very heavy and cloudy, but perhaps it will clear up some this afternoon for a wee bit of bronzing opportunity (we look very pale compared to the other people here who have been doing beach things for years probably).
On arrival we were introduced to the district health officer, an anaesthetic clinical officer (someone who puts people to sleep who isn’t a doctor), in his plush office of fake black leather furniture. We were to see some outpatients first, who had been selected by the only doctor in the hospital (there are I think 2 interns too, that is newly qualified doctors, what I will hopefully be from August) as being difficult cases she didn’t know how to manage. We first see a 16 year old girl who has been on steroids since she was 5 years old for generalised oedema, most likely minimal change glomoerulonephritis. I was shocked by the length of time she’d been on steroids, with apparently no specialist review of treatment for over 10 years. We arranged for her to come to Lilongwe to collect some cyclophosphamide (immunosuppressant) and to make a steroid-weaning plan. While we’re discussing this case, the doctor and clinical officer who are supposed to be learning from the experience so they can further their clinical ability are wandering in and out, drinking fanta orange, and generally not paying attention. Dan tells them they have to stay and listen. They stay, but in my opinion don’t listen, because they don’t give any input at all.
The second patient is an elderly man (I remember I quite like old people and haven’t seen many as patients here) with a long history of a dry cough (i.e. for years). He is otherwise well, and Dan finds out the likely cause of his chest problems: he worked in some form of mine in South Africa. Dan then gets into some chat about lung diseases that are predominantly Western: interstitial lung disease, chronic obstructive lung disease (COPD) and asthma. Of course, no one knows much about these, and there are long periods of silence before I offer answer. Dan gives some inaccurate information about asthma treatment, and in my opinion gives too much information for these people to take in, they stare blankly at him. We need to do an ECG on this patient as palpation of his pulse suggests atrial fibrillation. I am instructed to show the doctors how to do an ECG. Someone eventually finds the ECG machine, and we link the patient up with the sucker-pads attached to his chest. Then we discover there is no paper for the machine, so we can’t record anything! I feel frustrated by this, but then think, what would we have done about it anyway, probably nothing. I can guarantee that the doctors here will not be doing many ECG’s in the future, not only because they don’t know how but because there are no facilities, and its just not a priority.
Next patient has tophaceous gout, very obviously so. He is on ibuprofen for the pain, no one has checked his renal function (NSAIDs combined with gout can cause renal impairment), but the hospital doesn’t do renal function tests. He should be on a drug that lowers his uric acid (allopurinol), the doctors don’t offer this information when asked, and apparently there is no allopurinol (Dan stresses this is a cheap drug and should be available). I think: this is a relatively simple case, why is Dan being asked for input?
The next patient is a young chap complaining of long term central abdominal pain. Only by looking at his abdomen I can see visible peristalsis, and can feel a weakness in the abdominal wall. I think this is a mild hernia, Dan has a few other ideas. This is obviously not a medical case! This guy needs surgical input, so why hasn’t this been arranged? Why did they have to wait for Dan to get this organised?
Dan’s passion is teaching, he takes about 30 minutes to see one patient because he goes off on long tangents, asking multiple questions, which I volunteer answers to and everyone else remains silent. That was the most prominent thing I drew from this morning, that no one answered Dan’s questions. Is this because they culturally don’t answer questions when asked by a senior? But it felt more like they didn’t know the answers! And they weren’t that complicated questions, even I had ideas for most of the answers. This made me worried about this apparently qualified doctor running a hospital....this fear was worsened in the afternoon....more later.
With the doctor, an intern and the same clinical officer that was with us (physically but not mentally) this morning, we move on to the male inpatient ward (there is one ward for men, one for women, on for little ones, and a maternity unit, all covered by this one doctor, with her ?2 interns, 5 clinical officers, and maybe 10 clinical officer students). The wards are much brighter and look cleaner than Lilongwe. There are TV’s blasting out a bible channel from Texas (that is enough to drive anyone crazy). The ward houses medical and surgical patients. There are big permanent signs on the wall in different areas of the ward, stating the diagnoses of patients in that section of the ward: ‘malaria’, ‘pneumonia’, ‘anaemia’, ‘orthopaedics’, ‘surgery’. We are asked to see two patients here. The first is an “HIV positive man with tremor” (he is in the ‘pneumonia’ section, which confuses me). This is the history we get. It soon becomes obvious that this chap has a cerebellar lesion. He has an intention tremor, dysdiadokokinesis, nystagmus, slurred speech, and hypotonia (this is not important for those who are non-medical, it was more the point that it was so obvious, but because the patient had never had a full physical examination, no one had elicited these signs and therefore been able to make a suspected diagnosis). I learn from Dan that cerebellar atrophy (shrinkage of this part of the brain) can occur in HIV infection. Dan asks if the patient has been tested for syphilis, he hasn’t. He hopes that will be arranged.
The second male patient is elderly, they are unsure of his age but he looks to be in his late 70’s (but its hard to tell with such a weather-beaten face). He is unresponsive, that is all the history we get. Dan states that he is no geriatrician, and this makes me think of the age of most patients I have seen so far in Malawi, and that this is because of HIV. Dan asks the medical staff about the eldest patient’s they have seen with HIV. I am surprised to hear that some have treated patient’s in their 80s. This means these patients must have contracted the virus very late in life. Charles (the registrar) tells me this is because they are either caring for their relatives with HIV and don’t take the necessary personal protection precautions to avoid contact with body fluids, or because there is child sexual abuse within the family where the children are HIV positive (most likely have contracted the virus through mother-to-child transmission). Have the staff through about sepsis in this patient? No chest xray, no investigation for urine infection has been done. The antibiotic he is on would cover a chest infection but not urine. We add in an antibiotic for the urine. From my experience over the two weeks I have been here so far, he will likely not get any investigations, just be treated for the differential diagnoses.
We then move on to the female ward. Its the same size as the male ward but I have never seen a hospital room full of so many people. There is noise and chatter. There are people everywhere. At first it is hard to tell who is who, but then I realise that there are patients on the floor on mattresses between the beds, and sometimes two patients to a bed. The patient’s guardians (not sure if I’ve mentioned guardians, these are the people the patient’s bring with them to the hospital to take care of all there personal needs, i.e. washing, preparing food, feeding etc) are also on the beds, some on the floor, some wandering around. There are crying babies, some of them being breast fed lying be the side of their sick mothers, some being cradled by guardians. Everyone starts laughing around the bed of the first patient (I’m horrified by the number of sick people in this room so am not feeling like laughing is an appropriate reaction, but find that perhaps laughing about the problems that are so obvious is perhaps just what happens here, a way of coping maybe? But it still feels inappropriate, and like they just don’t care). They tell us that this patient states that she “fell out of a plane”. I’m confused. They say it is something to do with witchcraft, and there is nothing wrong with her (despite the fact she can’t move and is in obvious severe pain). Dan pulls an 18month old child off the patients breast and examines her back, and discovers an area of tenderness over her cervical spine (back of her neck). She has had no x-rays taken, and Dan requests that these are done. Otherwise, she has been lying there without a diagnosis, waiting for nothing to happen.
The next lady looks very sick. She is tiny, with arms about as thick as two of my fingers. Her tummy is huge, sticking out so obviously on her tiny frame. She is in pain too. Its hard to guess her age, maybe 40-50? The staff don’t know what to do with her. They have taken abdominal x-rays, and established that the swelling is not solid or fluid but air (its sounds tympanic on percussion). The story is obviously one of intestinal obstruction (in an HIV positive patient). Dan asks them what they are treating, i.e. what are they doing for this patient. The clinical officer says it is palliative. Dan stressed it can’t be palliative unless you know what you are treating. Silence. Has anyone examined her back passage. “It’s not been done” (becomes the most frustrating phrase of the day). We do this examination (and check per vaginum as well because of the high incidence of cervical cancer in the HIV positive population) and discover a rectal tumour (interesting issues trying to carry out such intimate examinations in such a public place. No curtains so we make do with a couple of screens and making other patients turn the other way). There we have a diagnosis, through the simple yet invaluable measures of thorough physical examination. As an aside, the patient has no drip, and no nasogastric tube, despite vomiting on a background of obstruction. Dan suggests these management measures are carried out.
The next lady also has a distended tummy, and is just as thin, but she appears cheerful, and is obviously not uncomfortable. She is perhaps in her 50s-60s. This is a fluid filled tummy, and an ultrasound scan has shown liver lesions (likely malignancy, either primary or spread from somewhere else) but for some reason nothing has been done manage the problem. No fluid has been taken for analysis, so Dan does this now. Then he asks what medication she is taking. I can’t remember what she was on, but not spironolactone, a drug that would help reduce the amount of fluid in her tummy. Dan says how important it is that she be on this drug. He is told by the doctor that they don’t have any. The next patient gives us further info about the lack of drugs available.
She is in her early 30s, and is sitting up on the bed with another patient lying beside her. She is short of breath, and her ankles are oedematous (swollen). Even sitting at 90 degrees her elevated JVP is making her ear lobe wobble. Dan just touches his stethoscope to her chest, then asks the clinical officer to present the patient. He mentions something about shortness of breath and oedema and says she has mild heart failure. HIV can cause a dilatory cardiomyopathy, which in turn can result in heart failure. Dan asks him about his findings when listening to the chest, the clinical officer says there is a murmur (this doesn’t really mean much at all, we need timing a location of murmur). Dan asks us all to listen to the chest. I’ve never heard an S3 gallop rhythm before but this must be it, it so obviously sounds like a galloping horse! And on a background of heart failure/fluid overload that would make sense. No one else comments on their findings, no one has any suggestions about what the altered heart sounds are. I give my gallop rhythm suggestion. This is also what Dan thinks, but he wants the clinical officer, doctor, and intern to comment on what they heard, so that he can be reassured that they are learning from the experience. They just copy what I say when he asks me to reproduce the sounds I heard. Again I think, if I can do this, why can’t they? Dan establishes that this lady has severe (stage 4 New York Heart Failure for you academics) congestive cardiac failure by asking her how much she can manage to do for herself at home. She needs several medications that are not being currently prescribed (she is only on furosemide – which is relevant, and digoxin – not relevant before all the other important treatments fro heart failure have been initiated. Surprise surprise, the hospital has no ACE inhibitors, and again we have no spironolatone. Dan tells us these drugs are cheaper than the nsima (the porridge Malawians eat everday) this patient is eating. He tells me money for drugs is not an issue in Malawi. Where are these drugs? The district health officer’s plush office sneakily slips into the back of my mind.....
The last lady we see is in the TB room. A permanent sign on the wall reads “TB suspects”. There is a lot of coughing going on, and again patients on the floor as well as in beds, and guardians everywhere. The patient we are asked to see is 32 years old, and is sitting up in bed, gasping for breath. She is tiny, her arms as thin as the other two ladies we saw earlier. She has dilated neck veins, and dilated veins in her right arm, with puffiness of the right hand. The right hand side of her chest is about twice the width (in the anterior-posterior dimension) of the other side. There is obviously something growing inside her chest, compressing venous drainage from the right arm and the head (SVC obstruction). As far as I am aware, TB doesn’t do anything like this, and Dan agrees. She doesn’t have TB, but is in the TB ward, where her guardians are at risk of taking TB home to the rest of the family. Nasty nasty chest x-ray showing a sliver of left lung remaining, the rest is compressed my her mediastinum which is shifted far to the left by an unknown mass in the right side of the chest. She has advanced malignancy basically, what sort of malignancy would do that though I don’t know.... They keep taking fluid off her chest, but it keeps coming back. Dan explains that she needs a chest drain, then pleurodesis to stick the pleura to the chest wall to try and stop the fluid coming back, then she needs good palliative care for the distressing breathlessness. They are happy about putting in a chest drain, but not happy with injecting some iodine (“we don’t have” – apparently its only about 30 kwatcha [about 20 pence] in the shop, they could go buy some says Dan) down the tube to do the sticking. This seems a bit funny, seeing as the chest drain is the most complicated bit. The doctor wants to transfer the patient to Lilongwe to have this procedure done. There is no way she will make the journey. We ask for some morphine to alleviate the distressing breathlessness, there is none. Pethidine will have to do. Dan makes the important point that this patient and her family need counselling about her terminal illness, and that she could go home to die. I leave the bedside with the frustrating feeling that none of these things will happen. She won’t get pleurodesis (she will probably die before then to be honest), and no one will counsel her and her family. She did get some pethidine before we left the room.
The doctor then asks Dan to see some children. He reminds her he is not a paediatrician, but she complains that she has very limited paediatric support from Lilongwe. He is persuaded to take a look.
The first kid makes me cry. He is a little boy of about 9 sitting on the side of his bed. He has a puffy face, puffy ankles, and a hugely distended tummy. He lifts up his shirt obediently to be examined. They have tried to drain his tummy and its still leaking from the hole they made because of the high pressure. The notes and the staff say he has heart failure. Dan takes a history from the boy’s mother, and the swelling started in the tummy, not the face and legs, meaning this is more likely a liver problem, not originating from the heart (of note his heart sounds normal). He needs to see a paediatrician. Apparently he was in Lilongwe two weeks ago but was discharged. Dan says this was a mistake, and happened because the consultant paediatrician in Lilongwe doesn’t see patients, the clinical officers run the show instead. We make arrangements to transfer him back to Lilongwe, and Dan will make sure he is seen by the consultant. I cried because he is so sick, and because he is sitting in a room waiting for nothing to happen. And because he was so compliant with these people who are doing absolutely nothing for him. And because if he was somewhere else things could be so different.
The next little boy has lots of large lymph nodes. Obvious lympohoma. He needs a biopsy, but the hospital doesn’t have formalin to keep the specimen in. Otherwise he is unnecessarily in hospital. Dan reminds everyone that because his Dad is with him in hospital, soon the other children in the family will be admitted with malnutrition because the family won’t be able to afford to feed them.
The last patient is a boy with likely herpes encephalitis. Instead of listening to the conversation I go and find a healthy looking smiley baby without anyone looking after it to gurgle at and play with. We have a special 10 minutes together.
I’ve no idea how many beds the hospital has but there must have been over 50 female patients, about 20-30 male patients, and probably about 50 children. We didn’t see the maternity unit. No wonder this doctor is ?overwhelmed/?out of her depth.... What about the obvious lack of enthusiasm and drive though? All she did when Dan asked why certain management hadn’t been carried out was giggle (I was ready to throttle her at the end). And the clinical officer was too busy trying to do as little work as possible to make any effort whatsoever. Dan kept telling the doctor how easy it was to order drugs from the pharmacy in Lilongwe, but then told me she doesn’t really have any power over what the district health officer (DHO) orders (apparently the DHO now has hypertension and diabetes – i.e. he has money he didn’t have before). Dan also told me that the doctor we went around the hospital with is actually employed by the UN, rather than the Malawian Ministry of Health (she is a UNV – a Uninet Nations Volunteer). This is why she has no power.
It’s sad and frustrating, because the patients we saw today do not have access to simple and straightforward treatment. But what seems somewhat worse, is that patients seem also not to have access to simple and straightforward clinical knowledge that doctors/clinical officers should have, which means they are not diagnosed, either at all or correctly, and therefore can’t be managed appropriately. This seems to be mostly down to clinical training. On the way back in the car, in between buying mangoes from the side of the road, Dan tells me that the training of clinical officers especially (but also medical students) is out of date, and carried out by lecturers who have limited clinical experience, because by the sounds of things, they can’t be bothered to work on the wards. The clinical officer students in Kasungu spend 16 weeks in this district hospital, without any teaching other than what the doctor has to offer (I would be extremely worried if she was teaching anyone based on her knowledge I witnessed today). These people need knowledge, but also they need empowerment to make them care about the outcome of the patients they are looking after.
This makes me tired. I manage supper then an early night while everyone else goes for drinks and a game of pool.
The next day we drive north to Mzuzu, the largest city in the north of Malawi, about 400km from Lilongwe. The countryside is very different up here, lots of pine trees, cooler, wood planks lining the side of the road explain the deforestation, mountainous, and generally much more lush and beautiful. The road is windy, and our little car doesn’t manage the steep hills too well! At Mzuzu we turn right (east) and drive another 50kms downhill on a small road (mostly tarmac) to Nkata Bay. Lake Malawi appears infront of us as we come over the last hill, and a busy bay town. We find our accommodation: a place called Mayoka Village, built on the steep rocky shores of the lake, a maze of bamboo huts and steep stone steps, and a very lively bar area full of (far too) friendly Malawians and backpackers. We pitch our tent, and dive in the very warm lake before waiting for the “fantastic Friday night BBQ”, lots of delicious food. We manage a few drinks with the locals before bed. Today we are taking a boat trip and will hopefully see fish eagles, go snorkelling, and jump off a cliff (that is what the offer is anyway!). The weather is very heavy and cloudy, but perhaps it will clear up some this afternoon for a wee bit of bronzing opportunity (we look very pale compared to the other people here who have been doing beach things for years probably).
Saturday, November 29, 2008
Photo: baby on sister's back
One of many small people being transported by a big sister. This was taken at a football tournament for school kids run by an organisation that promotes HIV testing in children.Thursday, November 27, 2008
First day working at KCH
I have ventured to the hospital today, after being ill for the first few days of this week. I'm in medicine at the moment, and the day starts with handover at 8am. At handover are lots of clinical officer students (second and third years - three year course), an intern (junior house doctor) who has been on over night, then a couple of registrars, other interns if you're lucky, and the head of medicine Dr Namarika, our supervisor and the only medical consultant. At handover we get a brief run down of the admissions, discharges, and deaths in the past 24 hrs. It’s quite hard to understand what they are saying because of the accent and quiet speech, and the diagnoses and differentials are obviously very different to back home. Basically, malaria, meningitis, sepsis, severe anaemia, lactic acidosis, or a combination. A clinical officer is then supposed to present a case to the group, sometimes they do, today no-one had prepared anything, that’s typical apparently.
Then we head of to our wards, Kate in doing female medicine, I am on the male side. There were 18 patients reported at handover, but there is a corridor full on the balcony outside, must find out if they are included or not! A ward round was started by one of the registrars. We started in the admission room, 6 old iron beds. The first patient we come to speaks a little English. The clinical officer student presents the case to the reg. He has been vomiting blood. The reg asks the student "how much blood"? Student: "I don't know". Reg: "how could you find out?". Student: "I don't know". We ask the patient. He says a litre, wow, thats alot. Then the reg examines him, and after feeling his tummy, he promptly vomits about a litre of fresh blood onto the stone floor. Covering most peoples shoes (I escape, and think, I really should be wearing my very unattractive protective eyewear all the time). This turns my stomach (I think because I am still ill, but also it’s quite impressive, I've never seen true haematemesis before). Everyone wanders off, and eventually the cleaners come and clear it away. I mutter something about how he shouldn't be on aspirin, and again the reg asks the clinical officers what aspirin does, and why we should stop it. They get it this time (he was prescribed aspirin when he presented with haematemesis, what was going on there???). Then I ask about getting a scope (camera test looking into the stomach), I don't even know if they have one at the hospital. Apparently they do but the surgeons will "send him back". What does that mean? And apparently the scopes are not for treatment, only for diagnostics. The reg doesn't seem very keen on my scope idea, probably because he doesn't think it will happen...not sure. He's not keen on a PPI (drug used to reduce acid secretion in the stomach) either, he doesn't know if the pharmacy has any. We move on to the next patient as the floor is still covered in blood.
He looks very, very sick. Apparently wearing a prison uniform. HIV positive (the previous patients' status was unkown). Mouth covered in sores, severe, bleeding oral thrush. No IV access so I assist the reg while he quietly cannulates the jugular (looked easy, I could try next time maybe, when feeling less wobbly). We give him fluid, and not much else. He feels very warm, differential: sepsis. But he looks sick to me, don't think he is a candidate for improvement. Meanwhile, another patient has been brought into the admissions room. On a trolley. Covered in a colourful sheet, head also covered. Very still. He's dead, must have died on the way to the ward from A&E. His wife is standing by, and when told, begins to wail. He remains in the middle of the room, people move him to get by, patients and staff alike. Eventually nurses come in to wrap him up, this happens in front of everyone.
At this point I am feeling rather weak and lightheaded. I've been on the ward about an hour, but that is all I can manage for one day! I feel a bit of a loser, but must be a bit soon to be getting fully involved. I did a bit, I taught a clinical officer about causes of haematemesis as he hadn't a clue what it was. I tried to get the reg to order a scope for the patient with haematemesis, he wrote 'endoscopy' in the notes, but not sure how far that will get, and we arranged cross match for blood transfusion.
So, that was my one hour today! Maybe I can manage something this afternoon, or tomorrow?
Then we head of to our wards, Kate in doing female medicine, I am on the male side. There were 18 patients reported at handover, but there is a corridor full on the balcony outside, must find out if they are included or not! A ward round was started by one of the registrars. We started in the admission room, 6 old iron beds. The first patient we come to speaks a little English. The clinical officer student presents the case to the reg. He has been vomiting blood. The reg asks the student "how much blood"? Student: "I don't know". Reg: "how could you find out?". Student: "I don't know". We ask the patient. He says a litre, wow, thats alot. Then the reg examines him, and after feeling his tummy, he promptly vomits about a litre of fresh blood onto the stone floor. Covering most peoples shoes (I escape, and think, I really should be wearing my very unattractive protective eyewear all the time). This turns my stomach (I think because I am still ill, but also it’s quite impressive, I've never seen true haematemesis before). Everyone wanders off, and eventually the cleaners come and clear it away. I mutter something about how he shouldn't be on aspirin, and again the reg asks the clinical officers what aspirin does, and why we should stop it. They get it this time (he was prescribed aspirin when he presented with haematemesis, what was going on there???). Then I ask about getting a scope (camera test looking into the stomach), I don't even know if they have one at the hospital. Apparently they do but the surgeons will "send him back". What does that mean? And apparently the scopes are not for treatment, only for diagnostics. The reg doesn't seem very keen on my scope idea, probably because he doesn't think it will happen...not sure. He's not keen on a PPI (drug used to reduce acid secretion in the stomach) either, he doesn't know if the pharmacy has any. We move on to the next patient as the floor is still covered in blood.
He looks very, very sick. Apparently wearing a prison uniform. HIV positive (the previous patients' status was unkown). Mouth covered in sores, severe, bleeding oral thrush. No IV access so I assist the reg while he quietly cannulates the jugular (looked easy, I could try next time maybe, when feeling less wobbly). We give him fluid, and not much else. He feels very warm, differential: sepsis. But he looks sick to me, don't think he is a candidate for improvement. Meanwhile, another patient has been brought into the admissions room. On a trolley. Covered in a colourful sheet, head also covered. Very still. He's dead, must have died on the way to the ward from A&E. His wife is standing by, and when told, begins to wail. He remains in the middle of the room, people move him to get by, patients and staff alike. Eventually nurses come in to wrap him up, this happens in front of everyone.
At this point I am feeling rather weak and lightheaded. I've been on the ward about an hour, but that is all I can manage for one day! I feel a bit of a loser, but must be a bit soon to be getting fully involved. I did a bit, I taught a clinical officer about causes of haematemesis as he hadn't a clue what it was. I tried to get the reg to order a scope for the patient with haematemesis, he wrote 'endoscopy' in the notes, but not sure how far that will get, and we arranged cross match for blood transfusion.
So, that was my one hour today! Maybe I can manage something this afternoon, or tomorrow?
Sunday, November 23, 2008
Senga Bay on Lake Malawi
After arriving at Lilongwe airport we made a quick getaway to the shores of Lake Malawi. Senga Bay is just east of Salima, a town about 100km east of Lilongwe. A great weekend of hot sand, big waves, frisbee, and Malawi G&T (MGT!). These photos show the beautiful flame trees and some of the many fishings boats that go out to fish at night.
Friday, November 21, 2008
Malawi: an introduction
Malawi is roughly the same size as the UK, and shares borders with Tanzania, Zambia, and Mozambique.
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