Esther's Medical Elective in Malawi

A week of hiking – Zomba and Mount Mulanje.

2009-02-21T03:44:00.000-08:00

Fri Feb 6th
I left Lilongwe about 11.30am after driving around the city doing various things – collecting things I had lent people at the hospital (avoiding seeing if my patients were dead or alive on the paediatric ward), collecting assessment forms, going to the police station to get a police report for my stolen camera (success!), trying to go shopping but there has been no power for most of the week and the generator in Shoprite is broken so they are closed (have been closed all week). I get the rest of the camping food at nice but pricey Foodworths. Eventually I have the car packed and am ready to leave. Its a lovely hot sunny day, feels like holiday already. I drive to Dedza (about 100km south) for lunch at the pottery cafe and some pottery shopping. Then drive further south, past Liwonde where we were for Christmas holidays, then the road bends east and the Zomba plateau comes into view: steep-sided cliffs arising from the lush green maize and tobacco fields. The drive down is so different that it was at Christmas time: now the maize is so high you can’t see over it, and the tobacco is being dried in open-sided, thatched roof huts by the side of the road.
I drive around the bottom of Zomba plateau into Zomba town to find Kate where she has been working in a rural health centre for a week. Its a town, lots of trees. We drive together up the steep-sided hill of the plateau, and into the mist. Mist combined with increasing darkness makes it easy to get lost and we do! We end up driving down a tiny track and asking a nice man in a hut with a fire the way. We arrive at the trout farm in the dark and are given the option of a very pretty, basic guesthouse as an alternative to camping. Its beginning to rain so we take up the offer. We cook pasta on an open fire by candle light and sleep under mossie nets under a tin roof that is very noisy all night because of torrential rain.
Sat Feb 7th
I awake late because of lack of sleep because of rain. We organised a guide last night and he (Edgar) takes us up the hill after breakfast. We climb up a dirt track, through overgrown forest and then large areas of deforestation. The trees are mainly pine, with some other species mixed in. Lots of beautiful vines and flowers all tangled up in between the trees. We climb to the highest point of Zomba plateau, whish when we get there, all that is visible is the 3-4 communications towers! The rest is mist. Good hike uphill though. We then walk around the edge of the top of the plateau, with intermittent views of the flat plains below. Edgar takes us up to ‘the hole’, a deep hole in the rock surrounded by trees where apparently lepers and naughty people used to be pushed into. There are men desperately trying to sell ‘crystals’ which they have dug out of the side of the mountain. They aren’t very impressive – look more like rocks to me! We have our sandwiches (we made one for Edgar too) overlooking the river Shire running south to the Zambezi from Lake Malawi. Its a stunning view. We complete our 25km circular walk by visiting a large waterfall. The paths are very slippery but Edgar doesn’t slip once. He has plastic loafers on with soles like mirrors. We girls in walking boots slide all over the place. “I am used”, he says.
Home for a hot shower, heated by a cedar-wood fire, then we drive up to the posh hotel up the road and admire the astounding view down onto the plains, and even see Mount Mulanje in the distance. MGTs then an expensive dinner – feels well deserved after a long day in the mountains.
Sun Feb 8th
Up early for another walk with Edgar. This time we take in two view points – named after Emperor Selassie (Ethiopia) and the Queen Mother. Mist is about but not enough to spoil an aerial view of Zomba. We then walk to a natural and a man-made dam, all the time walking through wild and beautiful overgrown forest. We meet Malawians lugging bundles of sticks down the hillside, loads balanced precariously on their heads. We stop to help one girl who is having trouble re-loading her bundle onto her head after resting half-way down the steep, rocky mountainside. Barefoot and 11 years old. That’s a working life for you. The weather is misty and humid. After another hot shower and sandwich back at the trout farm (and a look at the breeding river trout in their rectangular concrete tanks), we drive back down off the plateau. Buy mulberries, passion fruit, and bananas on the way down. Mulberries look like blackberries and taste like blueberries/bilberries. Very good. We had planned to take a new road that links Zomba directly with Mulanje but were advised against this as the road is not yet completely tarred, and our is not suitable for such roads. Instead we head south to Blantyre. Each side of the road tall with fully-grown maize and umpteen stalls selling lots of vegetables, avocado, jackfruit. At Blantyre we head east, 60km along a brand new tarred road to Mulanje. Mulanje town is one road, underneath the massive rock face of Mount Mulanje. We can’t see the top because of low cloud and rain. There are lots of pineapples and avocados for sale on either side of the road. We drive 12km past Mulanje town into the tea plantations (looks so much like India) to meet a fried of our friend Nick in Lilongwe who is a key-holder for the huts on Mulanje mountain. Although the huts are open for all hikers on the mountain, equipment for cooking and eating are only available if you have a key to the store cupboards in each hut. These keys are only held by members of the Mountain Club of Malawi, having friends therefore helps, as we have none of our own pots and pans. We meet Lindsay Ross at his beautiful home in the middle of a tea plantation. He helps us organise our 3-4 day hike in the tourist information office in town, then invites us to stay the night at his home. Hamburgers and chips for dinner, then packing for the mountain before sleeping in a very big bed under a very big mossie net.
The Mount Mulanje adventure
Day 1
We were up Mount Mulanje for 4 days and 3 nights. It is one of the most beautiful places I have ever been. Again, nature astounds more than anything else. On day one we left Lindsay’s house after a cooked breakfast (he has one everyday, we just joined in) and several trays of local tea. We stopped at the tourist office to make sure our plans had been communicated to the forestry office, then drove 10km on a dirt road to Likhabula, around the edge of the mountain. It’s a beautiful sunny day but there is cloud covering the mountain top. At the Likhabula basecamp we are greeted by keen porters and guides who obviously don’t follow the rules of the mountain: porters and guides are allocated on a rota basis, so that everyone gets some income each month. We have decided to hire a porter today to help carry our heavy luggage up the steep ascent. Our porter is Patrick and Peter is our guide. Patrick is wearing flip-flops, Peter asics runners. We are swarmed by men selling walking poles made from cedar wood. They are beautifully carved and I remember them being helpful for steep ascents and descents on the Inka trail (remember that Else, we had fun!), we both Kate and I buy a pair. We start walking by about 9am, through leafy trees, getting steeper up a red dirt path, passing men with huge greenwood planks on their heads walking barefoot down the steep path. The trees begin to thin out, and allow a view of the plains below. The valley side opposite is a steep bank of solid rock, water cascading down it at numerous points. The sun is hot. We share the smaller of our two bags, with our essentials in it. Sweat, and wash our faces in each cold stream we cross. By 11.30am we have reached the top of the steep climb, and we’re up on Mulanje plateau. After a wee breather and some chocolate, we stride out through the Chambe basin, devastated by deforestation and bush fires. The mountain of Chambe peak looms above us, a mass of solid rock. But otherwise the scenery is a bit of a mess. We stop at Chambe hut for lunch and bask in the hot sun. Then its another 3 hours, op more than down but a bit of both, through a mixture of open hillside and woodland. Cloud comes down around us but as we near our destination and top the last ridge, it clears and we have magnificent views of the base of the mountain with wisps of cloud coming and going. Over the last ridge we also see the hut (Chisepo)where we will spend the night and the peak we will attempt to summit in the morning.
The hut is wooden and on stilts. There is already a fire going with a kettle boiling and 2 other hikers. We find a pool and strip off to wash off the sweat and dirt. Its very cold but refreshing. The rain starts when we are bathing. We warm up by the open fire, stocked with wood brought in by the watchman (there is a watchman employed by the forestry department that looks after each hut, supplying guests with firewood and water for cooking/drinking, and hot bathing water if required). We cook a mountain of pasta before bedding down on a pile of old mattresses and blankets around the open fire. The porter and the guide sleep with the watchman in his smaller hut. I am very grateful of my 1ºC sleeping bag. Brrrr its chilly. Lovely full moon and a sky full of stars.
Day 2
Up by 6am to prepare for our attempt to summit Sapitwa (in Chichewa this means ‘don’t go there’!) – almost 3000m and the highest peak in Central Africa. After peanut butter on bread for breakfast we start the climb, straight up form the back of the hut in the strong and hot early morning sunshine. Very soon the path becomes very steep, and we have to jump from granite rock to granite rock. Faded red arrows mark the way. We need our hands to clamber over the rocks and make the wide high gaps between rocks. Then there are large slabs of granite, sparkling in the sunshine. We have to walk up these, making sure our feet have a sound hold and we don’t slip. Some places are wet and slippery. After about 1.5-2hrs climbing we reach a slippery bit and Kate decides she won’t go on. Peter and I go on up a bit more, but soon come across an area which he says is impassable. I ask if we can go around it but he stresses the importance of sticking to the path. People have died on this mountain, so when someone who knows the mountain says it isn’t safe to go on, I don’t disagree. We have been defeated by the mountain, but at least we tried.
It is still sunny on the difficult descent but the cloud is rolling in, another good reason for turning back. Legs are jelly after the 45 minute descent, most of which is managed with our hands on the ground behind us – it’s that steep! Cup of tea back at the hut before packing up and carrying all our own kit this time (Patrick legged it back down the mountain early this morning). We head for Lichenya hut, a 4hr walk away. Rain comes in, heavy but warm. Again, the walk is a mix of open hillside and closed, lush woodland. It’s beautiful, even though our view is obscured by low cloud. It’s chilly enough for merino at lunchtime. After lunch we descend onto a lush green plateau. The path is slippery as it zig-zags down and across the grassy meadows. We reach the hut in hot sunshine. I walk an extra kilometre to find a stream and spend the next hour dipping in and out of the crystal clear chilly water, hoping there are no prying eyes!
I cook soup and flavoured rice on the open fire and we chat to a Malawian botanist who is staying at the hut for a week, doing research on indigenous species and collecting seeds for the millennium seed bank. We managed to dry all our damp kit in the sunshine, very satisfying.
Day 3
After sharing bread and peanut butter and tea with the botanist, we walk together with him through tall grass, overgrown bracken, and clumps of tress ferns to ‘the crater’. The crater is on the side of Mount Mulanje, where the mountain drops vertically down to create a crescent shape hole in the side of the mountain. On a clear day the view is astounding apparently, you can see the tea plantations, and Mozambican mountains. But all we see is a sea of cloud! Its still obviously the edge of an abyss though, and we sit and admire wild flowers (e.g. orchids) and nurse our very sore legs (from yesterdays steep descent off Sapitwa) instead. The flora is amazing up here. So many flowers, and the tress fern are an amazing plant (nick-named ‘dinosaur fodder’ because they are such an ancient species, and they do indeed look like they come from prehistoric times!). We have time to notice and admire small things today. Our next hut is very close to our last one, but we take a 10km loop to get there to take in the crater. We reach our next hut – Hope’s Rest Cottage, the oldest hut on the mountain (there is a photo of it on the wall from the late 1800s) – in time for an early lunch of hot soup. Its become quite chilly. This hut is a private one, not owned by the forestry. It has beds and a beautifully equipped kitchen. The watchman is beautifully and polite and welcoming, and help us boil a kettle for tea in a teapot with china cups!
After warming up a bit, we leave Peter at the hut around the watchman’s own fire to dry his wet shoes and we take the 45 minute walk to the edge of the mountain to find some swimming pools in the stream. The view is the best we’ve had so far. Tea plantations, Mulanje town, and the dirt road winding down below. We admire for a long time, overlooking the waterfall where the stream cascades down the rock face. The pools are deep and crystal clear. We wash and splash in the chilly water, and air-dry afterwards. So amazing.
Back at the hut for more soup and a less appetising supper of instant noodles. The watchman brings us freshly-cooked new potatoes and fresh pineapple, much nicer! He is excited by instant noodles so its a fair exchange. Peaceful evening by the fire drying wet socks and shoes.
Day 4
Wake to a cold misty morning, our first so far. We leave the hut by 7am and walk to the top of the coll behind the hut before beginning the 4-5 hour descent. The cloud clears now and again and gives us views of Chambe peak on the other side of this valley, the side we climbed up 3 days ago. The temperature gets warmer as we descend and the path gets slippery. I manage a couple of impressive falls, saved from injury by my rucksack each time. Eventually, with jelly legs, we reach woodland towards the bottom. Lots of butterflies in the sunshine. We have to take a detour to avoid a full river – too full to cross. Luckily the others we crossed today were just about manageable. Through maize fields and a village at the end – its strange to see other people again. I’ forgotten how annoying “Madam I am hungry” and “give me money” sounded! We arrive back to find the car safe and sound, and are immediately approached by the men who sold us their sticks, asking for them back. Apparently they were only rented. These guys are super clever! Quick look around the numerous stalls selling beautifully carved cedar wood before driving back to Lindsay for a magnificent spread of roast chicken with all the trimmings for lunch. He and all his staff are such brilliant hosts! After a delicious hot shower we devour our lunch – I have been so hungry this past 4 days, must be the exertion!
Spend the afternoon watching Lindsay’s staff clean our shoes and very smelly clothes – this really is a different life to what we’re used to. I take Bonzo the crazy jack russel for a tour of the tea plantations around Lindsay’s house, very peaceful and beautiful surroundings, I can see why these people live in this part of Malawi. I would chose this place too. In the late afternoon Lindsay has organised a tour of a tea factory for us. We spend an hour with the production manager going around the factory watching and learning about the tea processing. It;’s fascinating. Lindsay designed and maintains most of the machines in the factory as the company’s engineer. We watch the freshly picked tea arrive in tractor and trailer loads, all the way through to the end product. This tea is bought by Tetley, Typhoo, and Taylors of Harrogate to name a few. We then head to the Mulanje Golf Club to join the local expats for their weekly club night. Food and chat. Very tired and very stiff legs. I will sleep like a log in the big comfy bed without my sleeping bag tonight.
Its amazing how satisfying and contenting living up a mountain or in a wild place for such a short time is. Why is that? I think just because I love it so much. I know my life will have to have mountains and wild places in it on a regular basis!
Fri Feb13th
After another cooked breakfast with Lindsay, served by his cook on the table on the veranda, we drive to Blantyre. We spend the day avoiding heavy downpours by looking around Queen Elizabeth Central Hospital (where I will start 3 weeks of work on Monday), having lunch at a posh (ex-pat infested) art gallery, touring the Carlsberg brewery (another fascinating experience, tea and beer making all in the space of 2 days!), and visiting a paper-making workshop. Blantyre is much more compact that Lilongwe and ha a massive shopping centre with a cinema that reminds me of South Africa. The backpackers we have planned to stay in is a drinking hole for the locals. We try and be positive about pitching our tent amongst the noise and the inevitability of heavy rain. I miss the mountain.
Sat Feb 14th
We spend the day at the National Museum of Malawi (a small run-down place with some funny/interesting things on display), eating pizza in the big shopping mall, doing my food shopping for the next 3 weeks as I won’t have a car to go to the shops, and then the afternoon in the market. Its great fun in the market, lots and lots of junk, second hand clothes, new clothes, loads of fresh fruit and veg. I buy a basket and fill it with fruit and veg for the week. We then go and sit outside a posh hotel, drinking beer, and enjoying the evening sunshine. Then to an Ethiopian restaurant for food before drinks back at our backpackers with funny drunk old men. Tomorrow Kate will leave to drive back to Lilongwe, and I will move to a guest house. On Monday I’ll start in the paediatric A&E department in Queen’s hospital.

My last week on the male medical ward (written in retrospect)

2009-02-21T03:42:00.000-08:00

Although a long time ago now, I just wanted to write a note about my last week on the male medical ward as I remember it being packed full of interesting cases.
Following a trip to Nkotakota hospital (2.5 hours drive north of Lilongwe) the week before, Dan and I had seen a diabetic patient with a serious eye infection. His glycaemic control was erratic because of the infection, and he needed to have his eye surgically removed (enucleation). We arranged for him to come to Lilongwe, and he turned up this week (I love it when things actually happen as planned!). I took him under my wing, and with the help of Dr. Roland (a German physician here for a long time, at least 2 years I think, he’s been on holiday since we arrived and I’ve only just started working with him, but he’s fantastic. Cuts lots of corners but an impressive doctor and does a lot in a short space of time) managed to get him seen by the ophthalmology department by chasing clinical officers around the hospital. Most ophthalmology is carried out here by clinical officers, not doctors, including the surgery this patient needed. As well as poor diabetic control and a serious eye infection, this patient also had a swollen abdomen full of fluid. The patient was complaining that the distension was uncomfortable so I drained it following Dr. Roland’s instruction (he said we would wait until after the eye operation to investigate the cause of the abdominal fluid). The patient was very pleased with his now comfortable tummy, but not so happy when he came back from theatre without pain relief. The surgeons hadn’t seemed to consider his post-operative care. While I was organising some intramuscular pethidine (a drug like morphine, no morphine in this hospital) for this poor chap, Dan (who isn’t supposed to work on the male medical ward but had heard about this interesting patient and come to get involved, as he often does) and I were dealing with a 40-odd-year old man who had presented earlier that morning with loss of consciousness. He had no previous history of illness, and there was no further history available. The physical examination had revealed hypertension (high blood pressure) and bradycardia (slow heart rate). His pupils were fixed and dilated. This patient had raised intracranial pressure, that had already caused herniation of the temporal lobes through the tentorium (demonstrated by the fixed and dilated pupils) and demonstrated the cushings reflex (raised blood pressure with a slow heart rate). In a developed setting, this patient would have headed straight for the CT scanner to search for the cause of the raised intracranial pressure. But as I have mentioned before, there is no CT here in Lilongwe. The short history of loss of consciousness in a previously well patient made an acute intracranial bleed high on our list of differential diagnoses. Dan decided to do a lumbar puncture (LP) to see if this was the case. The most important contraindication to performing an LP is raised intracranial pressure, because if you remove CSF from a high pressure system, this can cause the brain to herniated through the hole in the base of the skull (foramen magnum) and cause death. Because of this patients certain poor prognosis, and because we had no other means of reaching a diagnosis, Dan decided to do an LP. Actually, he asked me to do it, but I refused because I knew what the consequence would be and thought it would be better if Dan did it. So, we were doing the LP while relieving the pain of the patient who had just had his eye removed. We had a diagnosis within seconds: bright red blood flowed into the needle chamber, we didn’t even need to take a sample. The patient had suffered a sub-arachnoid haemorrhage. While Dan explained to the family the diagnosis and poor prognosis, I catheterised the patient. The doctors who had clerked him in earlier that day hadn’t thought to do so and his bladder was distended up to his tummy button. It felt good to be able to explain to the family what the diagnosis was, rather than just shrug our shoulders and wait for him to die.
I chased the ophthalmology clinical officers around the hospital for another reason this week: while I was away for Christmas holidays and doing the audit last week, a patient was admitted with Stephen Johnson syndrome, a severe reaction to medication suffered by some patients. In this case it was a reaction to antiretroviral therapy for HIV infection. Stephen Johnson syndrome is a severe blistering disorder, involving the skin and mucous membranes such as the mouth and eyes. This guy was covered from head to toe in blisters and raw skin, and was being treated like a burns patient, underneath a cage covered in blankets. Ophthalmology input was needed because his eyes had bee sealed shut by the healing blisters. They came on several occasions to cut the adhesions that had been formed, and dress the wounds. This patient was well known in that ward because he had been an inpatient for about a month, and everyone was very happy with how improved his condition was. He walked out of the ward at the end of this week with a smile and wave. How lovely.
On my last day in medicine I was the first to see a condemned man, brought in by prison officers. My initial assessment revealed he was in shock (fast pulse and low blood pressure), probably caused by sepsis because he had a high temperature. I worked him up, pumped him full of fluid and made sure he received IV antibiotics, did an LP which turned out to be negative. Anyway, several hours after I had admitted him he died, not much of a surprise considering the state he was admitted in. Whilst confirming the death, I noticed the prison officers had handcuffed the patient to the bed, as if he was in a fit state to run away. Not only had they done that but they had left the hospital, so I can to call various people to organise unlocking of the handcuffs before the patient could be wrapped and sent to the mortuary. This country gets weirder and weirder.
In addition to these patients, this week I also saw a patient with severe mitral stenosis (narrowing of one of the heart valves), who had a thrill (you could feel the vibration of the stenosis when you put your hand on the patient’s chest) and a fascinating chest x-ray. I saw a patient with a huge (7cm) pericardial effusion (fluid in the sack covering the heart) who was on TB treatment but when Dr. Roland did a pericariocentesis (drainage of the fluid) it looked more like a purulent bacterial infection so we started treatment with antibiotics injected directly into the pericardial sack. I did a couple of therapeutic lumbar punctures in patients with cryptococcal meningitis to relieve symptoms of severe headache, and I did a pleural tap on a patient with shortness of breath and a large pleural effusion. I was reminded about the difference between the internal and external jugular veins in the neck through watching a central venous catheter insertion into the internal jugular, and inserting a venous cannular into the external jugular of a patient with a sickle-cell crisis who needed intravenous fluid therapy.
Its was a full and busy last week, and in general very positive with several learning opportunities. I am worried that I have become desensitised to all the suffering and death however, I don’t seem to react emotionally to sad things that happen on the ward.

Cholera update

2009-01-29T07:43:00.000-08:00

Yesterday Kate and I gave a presentaion on cholera to the hospital grand rounds meeting. The room was packed and we stimullated some interesting and controversial conversation. We have been regularaly updated by the allocated choldera doctor in the hospital about numbers of cases and deaths for the purpose of our presentation. Last week, there were 684 cases and 26 nationwide, 99% of cases were within the city of Lilongwe. This week the national case number jumped to 1142, with 39 deaths. This week 80% of cases are in Lilongwe, and other areas have started to become affected. Its all a bit scary. And the terrible lack of organisation and education of the health system was well recognised by the members of our audience during the after-presentation discussion.
Sorry I haven't written on here for ages. Battling with paediatrics (which has to be hell on earth purely due to complete lack of strategy, and then you add all the disease and death) and essay deadlines. Its all in my head, just need the time to write it down.

On cholera

2009-01-14T11:27:00.000-08:00

On Saturday we went to visit a cholera camp. There is currently an outbreak of cholera in Malawi (people keep suggesting it may have come from the horrendous cholera situation in Zimbabwe, but I’m not sure how true that is), and as I expressed an interest last week in learning a bit more about the disease, Dan took Kate, Becky and I out to one of the poorest areas of Lilongwe to visit a cholera camp. There is also a small camp at the hospital, and there may be others throughout Lilongwe, no one really seems to know what is going on, even a doctor at KCH who is supposed to be the cholera specialist. Patients are taken to camps when they present at the hospital with suspected cholera, or are encouraged to present directly to a camp. There have so far been around 300 cases of cholera in Malawi, and 15 deaths resulting from the disease. I don’t know but I wouldn’t be surprised if the deaths are those patients who seem to sent back and fro between the cholera camp and the hospital because of uncertainty and disagreements about their diagnosis. There seem to be quite a few stories about this, and the end result is that time is lost on the treatment front, and patient’s die.
Cholera is a bacterial infection of the gut, causing profuse watery diarrhoea (patients can loose up to 30 litres of fluid). Cholera usually doesn’t present with abdominal pain. Of course never say never in medicine, but if you have the runs and a sore tummy, you are probably OK! If cholera is left untreated, death arrives quickly due to dehydration. This is especially a problem in children, but also occurs in adults. We had a patient on the medical ward with cholera (before the outbreak was recognised and there were camps), where I learned that people shouldn’t die from this disease because all they require is early fluid rehydration. This patient spent about a week on the ward, with continuous intravenous fluids (he had a drip), and went home when his diarrhoea had ceased. Antibiotics are given in severe cases to speed up the recovery process, but the mainstay of treatment here is rehydration. The main way cholera is spread is through human contamination of food or water supply
We arrive at a medium-sized white marquee, with big UNICEF letters on the roof. There is a brick shed next to the tent where we go first. Just near the door are two women with some children. One woman is holding a 16 month old toddler who is sleeping and very floppy. We are told this child can take oral fluids but her eyes are very sunken (I’ve never really seen real dehydration before), and she is very sleepy. Her skin turgor (this is a measure of how fast the skin returns to normal when you pinch it between your fingers and is a mark of dehydration severity) is reduced but not markedly so. The staff at the camp (3 nurses, apparently some doctors came earlier in the morning) haven’t managed to get a drip into this child, and so gave up and decided to stick to oral fluids. Dan rightly decides this isn’t enough and thinks we should try and get venous access. The mother carries the floppy bundle inside while we dip our feet in chlorine and put on aprons and gloves. The whole set up reminds me of the Cumbrian foot and mouth outbreak, with a foot bath outside the door, and signs reminding you to wash your hands in the tubs of chlorinated water provided. The baby is laid on one of the plywood bed next to an older toddler who is already receiving fluid through a drip. The room has 8 beds in total, either made from bare plywood or string netting with black plastic over the top. The plywood beds are quite high off the ground, about 3 feet, whereas the string and plastic ones are just over a foot from the floor. Each bed has a hole in the centre, measuring about a foot across in diameter. Adult patients lie on the bed with their bottom over the hole. When I heard about these beds I didn’t really see why this was necessary, why can’t you just get up to go to the toilet, or have a bucket at the side of the bed? What we experience at the cholera camp shows us why you need a hole in the bed. The diarrhoea is pouring out of people into buckets under the holes. There is one lady, looking quite cheerful while chatting on her mobile phone (don’t be shocked, absolutely everyone has a mobile here, whether they are rich government officials or paupers from the villages), but when you look under the bed the bucket is being regularly filled through the hole. We get to see what ‘rice water’ diarrhoea looks like. It’s not like anything I have seen before. The room doesn’t smell at all, which is a pleasant surprise. So, back to the wee one who has been placed on the bare plywood. Dan tries the internal and external jugular veins on each side of the neck with no success (I managed to cannulate the jugular on an adult patient in the ward this week, if you remember one of the first blog posts I wrote I mentioned I might like to try this procedure). Then he tries the femoral veins in the groin, the three of us holding down the baby, she struggled and whines a little bit but is very weak and sleepy so its not difficult to keep her still. By the time we’ve tried several times she even stops whining. She’s a lovely wee thing and it feels horrible sticking needles into her tiny body, but if we don’t her chances are probably quite slim. Just as we are about to give up, Dan gets the cannula sited in the left groin, and starts pouring in a litre of fluid. I am reminded that I need to re-learn all about paediatric fluid resuscitation, how fast it should occur, how much per kg, etc. She sleeps quietly when we’re done and Mum comes to sit on the bed beside her. She has a diarrhoea-soaked bottom but no one seems to mind. We had to use an adult cannula (pink for those who know what that means) for this child. The camp has no paediatric equipment, which would have made things much easier. I didn’t ask but am sure they don’t have intraosseous transfusion (using a fat, short needle screwed into the bone [usually the lower leg] to administer fluid when a child is so dehydrated that you can’t find any veins) equipment, which might have been the next step for this child if we hadn’t managed to get venous access.
There are a few other patients in the room that need to be seen to because their drips are not flowing. A couple just need flushing and another needs re-siting. We do that, making use of the chlorine bucket in between patients to wash our hands.
Then we go into the marquee. There are 14 beds here, all woven string covered in plastic, and all occupied, by patients who have stopped having diarrhoea and are recovering. Everyone looks quite cheerful, including a couple of cheeky young boys. This is good to see people recovering. There is not much to do in here. Before heading back to KCH we check on the little one in the brick shed again. She seems a bit more active now. Hopefully she will recover. Back at KCH we go to the small cholera camp at the hospital where there are two children, one looking very unwell, unable to brush the flies from his face. It’s good to see such impressive infection control practice though, with chlorine hand washing and foot baths, a marked change from our observations on the ward this week.
So, it’s been an interesting day. Something interesting I learned from Dan at the end of the day was that there is a cholera outbreak every year in Malawi. Despite this, the outbreak always seems to come as surprise to the health service, and there is no organised system ready at the right time of year (when the rains start). There appears to be confusion over who is in charge, about where patients should go, and about who provides care in the cholera camps. In addition, doctors don’t seem to be routinely trained in cholera management. Dan wanted to create a rota for some of the interns to come and help at the camps, but said not until he had trained them on cholera. This seems a bit strange in a country where there is an annual outbreak.

Infection prevention

2009-01-14T11:26:00.000-08:00

During our time in Malawi we are expected to carry out an audit or project on a topic of interest or relevance. It was the idea of Dan our supervisor and some of the organisers back home to look into infection prevention practices in the medical department. So last week, Kate and I designed an audit, carried out observational data collection, and got some staff members to complete questionnaires. We are looking at the safe handling of sharps (needles ect), the use of personal protective equipment (PPE) (this is things like gloves, aprons, masks, eye protection etc), and hand washing – occurrence and technique. For those of you who have done the Cleanliness Champions programme in fifth year at Dundee, this will sound like your idea of hell. How anyone can really want to study more of this topic after doing a computer programme that eats at your soul will be beyond most of you, and to tell the truth, I was expecting to do a much more ‘exciting’ audit, based on something rare and complicated and tropical. And really, can we afford to focus on something like this is a setting which has countless ‘more important’ things to worry about, like people dying of curable illnesses left right and centre for example. However, as we all know, infection prevention is a massively important aspect of healthcare, even in a resource-poor setting. Hospital acquired infections are important causes of morbidity and mortality in the developed world, and may very well be in the developing world too, if data was available to show this. What with the increasing incidence of HIV and other blood-borne viruses worldwide, healthcare workers are at risk of acquiring such infections, and therefore safe handling of sharps is vital in all health-related workplaces.
We began our week by visiting the school of health sciences (where clinical officers are trained) and the nursing school to learn about the infection prevention curriculum. We visited the matron in the hospital who is head of all infection prevention issues, and learned about the training of staff members and the policies that exist in the hospital. Basically, education and policies do exist, and are of a very similar standard to back home. Staff training does happen, but the hospital can’t afford to train staff on a regular basis and by the sounds of things, this makes training quite erratic. We got to see the sharps injury record book, where every reported (many are not reported as staff are worried about being tested for HIV apparently) incident is recorded. There is no confidentiality, staff members names just appear in a list, with what happened, whether or not the patient’s HIV status was known, and whether post-exposure prophylaxis was given.
On the wards, we took note of the availability of facilities for safe handling of sharps, PPE, and hand washing facilities. Then we observed practice. We watched different members of staff carrying out different procedures and took a note of the PPE they used, how they disposed of sharps, and whether or not they washing their hands. We haven’t finished data collection yet, or analysed the data we have, but from our observations so far, if the hospital policies are anything to go by, the situation is pretty dire. There are no proper facilities for hand washing. There are sinks, but they rarely have soap and never have drying facilities. Staff members tend to use gloves as an alternative to hand washing, believing that if they wear gloves, they don’t need to wash their hands. Gloves are worn for pretty much everything, even examining patients (I am guilty of this too, sometimes patients just look so dirty). This is about the only item of PPE that is worn. Catheterisations are usually performed using non-sterile gloves, and even though sterile gloves are used for lumbar punctures, I wince as I watch them being contaminated as soon as they have been put on. No one apart from Kate and I wear eye-protection when performing procedures where there is a risk of splashing of bodily fluids. No aprons or masks are worn by anyone for procedures where we would wear them at home. The nurses get a plastic disposable apron each day, and wear it to do the drug round, and when someone dies (they only get a handful of aprons each day, so reuse them to make them last). They also wear masks when someone dies, but at no other time. As far as sharps are concerned, I think this is the most worrying observation. The sharps bins are cardboard boxes, made especially for the job, but have the potential to allow sharps to stick out of the sides of the box, waiting to stab someone as they walk past. No one takes sharps boxes to the bedside. Instead, they walk from one end of the ward to the other carrying dirty sharps in their hands. Whenever I see this I run in the opposite direction for fear of getting caught up in the complicated sharps injury process and being sent home to Dundee! Of course I also consider the 0.3% risk of contracting HIV through injury with an infected needle.
It’s been and interesting and eye-opening week, and has given me some issues to ponder over. I wonder whether all this infection prevention palava is just first world fuss and something not to be adopted by places like this, where there are just more important things to worry about, and where there isn’t an endless supply of money for gloves and aprons and masks and goggles and sturdy sharps bins. Kate and I have been discussing how we haven’t seen any hospital acquired infections while we’ve been here. We have never seen a cannula that has become red and inflamed for example, and you should see the dirt that we try and wash of the skin before sticking the needle in. Is that because hospital acquire infections don’t exist here? If so, why not? Are people’s immune systems more hardy that ours due to their upbringing in the African mud and sand? But being immunocompromised by HIV doesn’t do wonders for your immune system. We spoke to Dan about it, and Arthur, an infectious disease registrar from Ireland. They think that there are hospital acquired infections in these settings, just that there is no evidence or data to show it. MRSA has been isolated, and they think the incidence would be very high if it was measured because of the large quantities of unnecessary broad spectrum antibiotics that are prescribed. Still, MRSA doesn’t feel like a big priority when you are dealing with patients dying from malaria and meningitis on a daily basis. This antibiotic prescribing thing is an issue though.

Liwonde Game Reserve photos

2009-01-09T21:57:00.000-08:00

Twisted tree in Liwonde

Stories from Christmas holidays

2009-01-04T06:37:00.000-08:00

20/12/08
I am sitting in the light of a paraffin lamp and my head torch, listening to a hippo grunting and moaning loudly close by, and a hyena howling. There are fireflies zipping around, circadas making a constant sound, and a few croaking frogs too. This place is alive with non-human life, but I can’t see it because it is dark!
We are in Liwonde Nature Reserve, south of the southern tip of Lake Malawi. We drove here today from Lilongwe:250kms of highlands – rocky peaks covered in trees and bushy shrubs, collections of neatly arranged thatch-covered mud huts, rows and rows of green and healthy looking maize plants, countless towns and villages bustling with people buying and selling vegetables and slopping around in mud from the recent rains. Our journey was slightly delayed when I decided it was a good idea to check the tyre pressures of our car. The man who did it for us at a garage discovered the front two tyres did not have valves, resulting in a couple of flat tyres when he unscrewed the caps! Luckily we were still in the outskirts of Lilongwe when we called our car hire man Wilfred and he happened to be close by. He took us to a car mechanic whose business resided under a large tree, and within half an hour we were all set to go with new valves.
After the drive through the highlands we dropped down to the warmer flat plains as we neared the Shire river delta coming out of the lake, lush with green like the higher ground. We ended our journey with a 6km drive down a sandy road and eventually entered the nature reserve. The next bit of road to the camp (Chinguni Hill Camp) where we had booked a place for our tent was only 2km but during that time we saw several birds, including a helmeted guineafowl (Dad’s bird book coming in handy), lots of antelope (impala, kudu), and a warthog. Lots of elephant poo too (but no elephants). We were shown our campsite, under a thatched roof alongside 5 other tents, in the middle of the bush. The kitchen is a different thatched roof, with an open fire and no kitchen utensils (we didn’t think about that!). Armed with the faithful swiss army knife we butter some bread. I heat up the veg dish I prepared this morning in Lilongwe over the open fire. My concern that we should stock up on food before we left Lilongwe was right. Anyway, we will just make do! It will be fun and a challenge to see how long we can last with three gem squash I bought form the side of the road, a loaf of bread, chocolate, and warm beer. We also have some spaghetti and a tin of beans that I threw in in desperation prior to leaving. We are surrounded by two South African families who are equipped to the hilt, with 4x4’s packed with 3 course meals and everything else who ever need. Its a bit embarrassing that we have nothing!
The hippo is still being very noisy, and no one really knows why. Hope we can fins some tomorrow to ask...... Being nibbled by insects that are attracted to the light from the lamp and torch. Tent time.....

21/12/08
Wow, who would have thought Africa could produce so much rain! It poured all night and well into this morning. A short break followed then more rain, before a warm and very muggy afternoon with some sunshine. We woke early with the other campers and managed to borrow a cup or two for breakfast tea. One South African family have left, the other made banana cake in a cast iron pot on the open fire, amazing! We spent the morning wandering down some tracks, apparently safe on foot but when we saw hippo footprints we decided it was best to turn around! We saw impala, waterbuck, several birds, warthog, lots of water lying on the ground, interesting tress twisted around each other, and lots of insects that were for some reason attracted to us.
After a tasty fresh pineapple for lunch, we were invited by the South African family to go for a drive in their 4x4. They have a fridge freezer (run on batteries, generator on the roof if these fail), the roof has fuel tanks, and there is a water tank in the back. These guys know how to be self-sufficient. They have enough food supplies to last forever, and think our ‘limited’ food supply is a bit strange! The drive is quite short. It isn’t possible to drive many of the roads because of all the rain. Yesterday these guys got their 4x4 stuck and took 2 ½ hours to get out! We see the same as this morning but kudu as well, and many more birds including fish eagles. Kate cleverly managed to spot some hippos in the far distance. We watched them through the binoculars. Lots of life, everywhere you look.
Back at camp we fill in the time before dinner with badminton with the South African family, wandering along the road, chasing baboons, etc. Delicious gem squash on the fire for tea. A Belgian boy has arrived by bicycle. He might join us for a safari drive tomorrow. Hippos are much quieter tonight. Hopefully they are preparing for our canoe safari in the morning! Saw two scorpions on the way back from teethbrushing. Must remember to look in shoes tomorrow before putting them on!

22/12/08
Again I am in the tent listening to hippos grunting on the river plains below our campsite. The highlight of today was a 2 ½ hour sunset drive through the southern end of Liwonde Nature Reserve. We saw lots of beautiful kudu, impala, and waterbuck, warthogs with their babies are plentiful, as well as lots of birds including several types of kingfisher, geese, and fish eagles. We saw huge iguanas (monitor lizards), and ground hornbills, large birds with black feathers and red beaks. We were very lucky to come across two elephants near the end of our drive, and got out of the roofless jeep to get closer to them. Amazingly large and yet so gentle-looking creatures. Beautiful sunset on the way back to camp.
This morning we took a ‘canoe safari’. Three of us (Kate and I and Jasper, the Belgian on a bike), plus a guide in a Canadian canoe, pole-ing through reeds, and paddling up the river. We saw a group of about 15 hippos floating in the deep river, and lots of bird life (herons, egrets, kingfishers). It was very hot today, I nice change after the torrential rain but a bit too much for 2 hours in a canoe with no swimming allowed! I needed a nap on the outdoor sofa afterwards.
We spent the afternoon learning new cards games from each other and getting one of the camp workers to teach us the Malawian game Bao. It’s a funny game with rules I think I now understand. You have to move pebbles between holes in a wooded board.
After the evening drive we made a fire in the grate in the kitchen, and cooked knorr soup from a packet, then spaghetti and baked beans! I was starving! Our food sources boosted by Jasper, thank you! Tomorrow we will leave this small paradise of wildlife-packed nature and head north to the lake.

23/12/08
We left Chinguni Hill about 9am and began our drive north to Cape Maclear. A very flat route, with plenty of potholes. Beautiful huts and fields of maize either side of the road. Rather too warm, and a smell of melting tar comes through the car window. We stop in Mangotchi for the bank, food shopping, and a delicious lunch of vegetable curry (there seems to be an Indian contingent here, alot of mixed-race looking people). When we have almost reached Monkey Bay we turn left to Cape Maclear. 18km down a dirt road, like driving on corrugated iron, our little car doesn’t like it much! It turns out the place we have booked to stay for Christmas is at one end of the bay, away from all the ‘backpacker’ lodges and at one end of a very pretty fishing village. Its very posh. Beautiful private beach, lovely camping ground (away from all the chalets costing 60USD/person/night), a catamaran moored in the bay, deck chairs in pairs sheltered by thatched parasols, and beautifully manicured sand. It feels like paradise. We pitch the tent, take a welcome dip in the blue lake, then drink MGTs (Malawi gin and tonic) on the deck chairs and order our dinner for later on. We play a game of Bao before dinner, then sit at our designated table when instructed to do so by the ‘dinner drums’! The place is full of Africaaners , and its a bit of a strange atmosphere. No English, lots of smoking, funny people! There will be no socialising here, which all of a sudden feels like the wrong thing. Kate to bed early. I wait up playing patience until a phone call from Mum and Dad.

24/12/08
Christmas Eve – never before have I sunbathed on the trampoline of a catamaran and snorkelled amongst multicoloured fish on this day! It is now evening and the sun is still as persistent. There are thunder-clouds hovering menacingly towards the north-west and the breeze has picked up. The fisherman has just been to deliver a catch for tonight’s dinner – I had the fish (kampango) yesterday, very good. Its almost MGT time, which will be very nice after such a lovely, satisfying day.
After feeling somewhat down by where I was last night, I awoke this morning and swam in the lake, then ate bread and chocolate on top of a large granite rock that frames one end of the sandy beach. We decided to risk the weather (it was cloudy but hot) and bought the catamaran for the day. What luxury, just the two of us and the captain (Harrison), sailing to a nearby island. So peaceful, with the sound of the water lapping the hulls and the awnings tapping in the wind. On arrival at the island we dived into the blue and fed the fish with bread. So many, all different colours. We spent the next 2 hours snorkelling and jumping off the boat, then sailed back along the shore drinking beer and looking at all the other lodges full of Christmas celebrators.
I dived off the boat before she came into the bay, and swam to the beach. Someone greeted me, and I returned the gesture, then we looked at each other more closely, and realised we knew each other! It was Sue, a friend I had in Swaziland! With her now-husband (boyfriend when I knew him) Mike and two children (Kelly 5, Aidan 2). How small this world is! It never ceases to amaze me how people get thrown together. Good chat and a drink. They now live in Lilongwe so we will do a lot more catching up. Lovely kids. They were with a friend who lives near Mount Mulanje, and invited us to go there. It all reminds me of how friendly people were in Swaziland and South Africa.
Steak for supper tonight then to the tent for what looks like will be a wild night weather-wise.

25/12/08 – Christmas Day
What a night. The thunder and lightning started a while before the rain. Flashes lighting up the tent and thunder so loud it made me jump. When the rain finally came it was heavy and persistent. With each extra cloudful I wondered if the tent could hold any more. I must have fallen asleep in the end but it was well into the early hours. We awoke at 6.30am on Christmas morning and were greeted by our Afrikaaner camping neighbours with a cup of freshly brewed real coffee, what a treat. After another chocolate sandwich and with red flowers in our hair, we boarded the catamaran again and this time sailed under the blue sky to the other end of yesterday’s island. Fish eagles perched on the trees, and I remember that last year on Christmas day I also watched fish eagles but over the Corrie Vrechan on the Isle of Jura. The water is quite choppy but the snorkelling is as good as yesterday. This time the fish follow us, our captain says this is because the fish at this end of the island are less used to tourists and are looking for food. It is so nice to be followed through the turquoise blue water by shoals of blue, white, yellow, orange, and black fish.
The sail back was quick because of the wind, and we arrived back on the sandy beach to the sound of the lunch drums. What timing! We sat down to a delicious buffet of cold meats and salads and a beer then a glass of red. Crackers on the tables too. Very festive. I ate too much delicious food so lay in the shade for the afternoon resting. We spent the evening sitting with our Afrikaaner fellow campers and they showed us their underwater photos from their snorkelling trip. Then to the bar to learn how to play backgammon.

26/12/08 – Boxing Day
Up early to depart this surreal paradise and head back into the real world. Harrison helped us inflate our front tyre which has a slow puncture, then we took an hour to drive very slowly down the rough 18km track to get to the road. The tyre luckily lasted until Monkey Bay where we got out puncture repaired by a nice man under a tree.
We made our way to the ferry (MV Ilala) dock, purchasing edible provisions on the way. The ferry only left 50 minutes late – which is apparently very good timing! So, here we are, on board a large passenger ferry, chugging our way North to Likoma Island. We can see lots of swarms of lake flies which look like columns of smoke coming out of the water in the far distance. We’ll see if the novelty of the turquoise blue lake and the royal blue sky wear off after 30 hours!
Luckily, we met some fellow backpackers who made our time on the boat go a lot faster. Lots of games of backgammon, scrabble, and Chinese poker, with beer to wash them all down of course! So glad we decided to splash out and travel on the first class deck. Second class is in a stuffy room downstairs with no view. I slept well, out on deck under a sky crammed with stars.

27/12/08
I woke at 5am to find that we were still in the port we had stopped in at 2.30am (Nkotakota)! They spend ages ferrying passengers between the ferry and the shore using small motor boats. These small boats are attached to the side of the large ferry and are winched up out of the water when the ferry is in motion. We chug at a slow 10knots/hour towards Mozambique and make three stops along the Western coast before getting to Likoma island at 5pm (a day and a half after getting on the ferry at Monkey Bay). We are dropped by the motor boat into the shallow water after a hairy ride from the ferry, purely because of the quantity of people and baggage they cram into one boat! After climbing up the beach we soon meet someone who is walking to our campsite, ‘Mango Drift’, on the other side of the island, and she will show us the way. We walk on a sandy road/path for about 3km, passing houses, bars with music spilling outside, children running after us, and almost everyone sharing a greeting (Muli buanje – how are you? – Tine bueno, ka-i-uno – I’m fine, and you?). We walk with Danielle (Aussie volunteer working in South Africa) and Pauline ( Swiss girl also working in SA). After a scramble down to the lake shore on a steep, rocky path, we arrive. We pitch the tents on a sandy beach, sheltered by mango trees, and within a few yards of the water’s edge. We eat good chicken curry with other travellers and share stories until bedtime.

28/12/08
We awoke to the sound of a storm. Rain not so heavy but lots of thunder and lightning. Luckily the wind wasn’t strong enough to shift the tent which was difficult to pitch securely in the sand. After real coffee and omelette for breakfast (a treat, after too much stale bread on the ferry), the rain stopped and I went to explore the island with Danielle and Pauline. We went on foot, heading North along the west coast. The island is only 3km x 8km (longest North-South). The path was very rocky, with either side full of bushes, mango, and boabab trees. Fish eagles close by in the treetops, and other birds including ?tawny eagles/?black kites, and a paradise fly catcher. Very hot walking, dripping with sweat weather!
We walk through a collection of houses, a fishing village by the look of it, with fish drying and nets in piles. Everyone very friendly and offering greetings. The kids are very keen to hold hands with us, run along beside us, and shout ‘what is my name?’! A pick-up comes past and gives us a ride eastwards towards St. Peter’s Cathedral. Built at the beginning of this century, this building seems to dominate the island, and the tourist guide book. Its Sunday today, and the service is still going on. We enter the cathedral and sit at the back, and listen to the beautiful singing. A toddler comes and sits on my knee for a cuddle – no child has done that since I’ve been in Malawi, in the hospital they are usually scared of me! Outside, another wee one comes to look at me and plays with my necklace.
Pauline (Swiss) and I leave Danielle (Aussie) in the small town and walk North, heading for the forest marked on the map at the north-eastern tip of the island. Lots more children join us on our way. We play a game with a group of them, I don’t understand the rules but you use a big stick to flick and hit a smaller stick from the ground. They thought it was hilarious how hopeless I was! We watched women hoeing their beautiful green and straight rows of maize, and saw a few small rise paddies.
At the end of the road we came to a beautiful beach. Couldn’t resist a swim so managed to change in front of about 10 staring children and dived into the warm blue water. We walked back to the village the smae way and stopped at a cafe called the ‘Hungry Clinic’! Great Malawian guy running it who quickly brought me a large plate of nsima and beans (nsima is the Malawian staple food, made of ground maize, bean are just red kidney bean in a sauce). Very, very tasty, I was so hungry! We walked back to Mango Drift the way we walked the first evening. Back on the beach for another swim. Excellent kampango fish and chips for tea, then a game of Pictionary before bed.

29/12/08
Awoke to a blazing sun and perfect blue sky. After more coffee and omelette we set out walking again, the same way as yesterday, towards the cathedral. Much hotter than yesterday, really too hot to be out in the sun. But we need to explore. We spend a long time sitting in the cathedral, enjoying the relative cool and peacefulness. It is a beautiful building, with delicate stonework, small but intricate stained glass windows, and when you look more closely, faded but beautiful pictures on the walls telling the story of the 12 stages of the crucifixion.
We go to the village market, a series of small open-fronted stalls, mostly selling the same thing – materials, batteries, soap, etc. Then to Hungry Clinic for cold drinks and ‘fat cakes’ (I remember eating these in Swaziland – deep fried bread dough basically!). Then we start to walk the 3km back to Mango Drift and hitch a ride on the way (there are hardly any vehicles here, we are lucky). We are told it is too hot to be out at this time of day, I agree!
Back at our beach we snorkel, swim, and read away the rest of the afternoon. Too hot even in the shade. At about 5pm when we think it is a bit cooler, we head back out to Hungry Clinic for more nsima and beans, and try the Malawian beer ‘Kuche Kuche’. I prefer greens (green is the name used for Carlsberg lager that is drunk like water in Malawi). Skinny dipping in the dark in the lake when we get back as very sweaty.

30/12/08
Up at 5am to pack up and climb the hill by 6am. Apparently the ferry arrived at 4.30am – this makes us panic a bit. If we missed it then we’d be a bit screwed. The MV Ilala goes up the lake and back again only once a week. It’s all very vague about when the ferry will arrive and leave. However, there is no rush. By 11am we are still sat on the ferry, and there is no sign of any departure. There are bags and bags of maize being unloaded from the hold – food supply for the island so very important. By 12pm we are eventually on our way, after 4 hours of sitting on the motionless boat!
This time we are sitting in second class, as we don’t have enough money (there are no ATMs on the island) to go first class deck again. We find a table and comfy cushioned benches in second class, and figure this isn’t too bad at all. For one third of the price its great! We write, play cards, chat, and picnic. We pay regular visits to Danielle and Pauline on the upper deck. There are many fewer people on this trip than the last one, so I think second class will be bearable. There are lots of interesting things and people to look at. They like looking at us too. We see a man transporting tropical fish to be used in private aquariums, enough dried fish to feed an army, lying in the sun on the fron of the boat, and a young chicken making the journey with its foot tied to a heavy bundle to keep it from flying away. For dinner we find a canteen at the back of the ship, which only has nsima and beef stew left. It’s pretty horrific, so we give it away. Towards the night it becomes too hot, and I escape unseen to a corner on the top deck to sleep under the stars.

31/12/08
We awoke at 5am covered in lake flies from a recent swarm that must have hit the boat. There is the most beautiful sunrise and we still in Nkotakota where we said goodbye to Danielle and Pauline at 1am this morning! Apparently its take this long to unload all the dried fish that is distributed for selling from this town. We find a place to sit on the middle deck as it is still to hot in second class and we don’t fancy our chances upstairs too much as there are so few people we are likely to be noticed. It takes nine hours to the next stop (Chipoka), during which time we read, teach cards to some ferry workers, eat, and make friends with the ticket man by buying him beer and so move up to the top deck for a breeze, beers, and comfort. At Chipoka, we are assured that this stop will be very brief. There is only one boat-load of passengers who disembark. We should be in Monkey Bay by 6pm, in time to drive to Cape Maclear in time for dinner and New Year’s celebrations. However, the captain then goes ashore, and we are told that there is to be some short-notice survey of the ferry, as there are member of parliament, including the President of Malawi, in Monkey Bay who need to have a look at the ferry. The rumour is that the surveyors will take 4 hours to arrive! We prepare ourselves for new years on the deck of a boat! Luckily, the surveyors arrive within an hour, and we are underway again. We arrive in Monkey Bay in the dary at 7.30pm, find the car has been well looked after, and drive the bumpy road back to Cape Maclear. Once there, we find our campsite, and settled down to large pizzas, which are very welcome after another two days of ferry snacking. There are lots of people already enjoying the evening, with loud music and lots of booze. After washing off the ferry-ness, we wander along the beach until we find Gecko Lounge, the place renowned for parties. After feeling very tired and a little bit lost amongst all the drunk people, things look up after we meet a friend from Lilongwe who is lots of fun. Things get even better when we meet some brothers from Wales, a plasterer and a plumber (Gareth and Richie), who were brought up in Malawi, and come back for holidays. Their brother (Nick) works in Lilongwe and I think we have seen him about (he will come to Cape Maclear tomorrow). They speak fluent Chichewa (the Malawian language) with Welsh accents, and make my evening one of the most memorable ever! Excellent banter until bed at 4.30am. Happy New Year everyone!

01/01/09
2009 may be quite a big year. I’m feeling somewhat prepared (I think), and at least refreshed after these two weeks of not working, most welcome. Awoke late this morning after last night, to find the boys from last night plus others drinking beer for breakfast! I didn’t join in, but we spent the day with them, swimming, chatting, laughing at their hilarious behaviour, and generally enjoying the fun (and getting through an impressive amount of beer). We eventually managed to leave on a boat trip in the late afternoon, prepared with a large cooler box of beer (this must be their 3rd or 4th crate). We motored to the island and swam, or they floated with their beers and cooler box. After a few hours of this it was getting dark, and the behaviour was getting more interesting! Headed back to shore for showers and an attempt to cook meat and fish on a fire (but by this time they can hardly see, so most food ends up in the fire or with the dog). I drive them to a local bar when they run out of beer and we are drowned by a swarm of lake flies. Another fun late night with great people.

02/01/09
Back to Lilongwe today, after a leisurely breakfast with our new Welsh/Malawian friends. We picked up some hitch-hikers and drove up into the highlands (amazing views en route) to Dedza to visit a lovely pottery with an amazing (and pricey) cafe with famously good cheesecake. We arrived back in Lilongwe early evening to pick up Danielle and Pauline, the girls we met on Likoma island who will come and stay with us for the weekend. It’s been so refreshing to do no medicine for two weeks. I really needed this time away, and Malawi is a beautiful country. I’m quite looking forward to sleeping in a bed after two weeks in a tent without a mattress though!

Christmas holiday plans....

2008-12-16T10:57:00.001-08:00

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.

On the male medical ward

2008-12-14T03:31:00.000-08:00

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.

A day in a district hospital

2008-12-05T05:51:00.000-08:00

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).

Photo: baby on sister's back

2008-11-29T10:00:00.000-08:00

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.

First day working at KCH

2008-11-27T10:00:00.000-08:00

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?

Senga Bay on Lake Malawi

2008-11-23T10:00:00.000-08:00

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.

Malawi: an introduction

2008-11-21T08:28:00.000-08:00

Malawi is roughly the same size as the UK, and shares borders with Tanzania, Zambia, and Mozambique.