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.
Thursday, January 29, 2009
Wednesday, January 14, 2009
On cholera
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.
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
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.
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.
Friday, January 9, 2009
Sunday, January 4, 2009
Stories from Christmas holidays
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!
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!
Tuesday, December 16, 2008
Christmas holiday plans....
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.
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.
Sunday, December 14, 2008
On the male medical ward
It’s been a very tough week this week. I don’t know if it’s anything to do with the rain which has been bucketing down most of the time, but we have been very busy with admissions, mainly of very sick young men. They come so late in their illness, by which time there is not much that can be done. On Thursday a man in his 40’s came in unconscious. The history was of five days of severe headache, neck stiffness, and fever. We were dealing with meningitis, and severe sepsis. His respiratory rate was through the roof, and his tongue was obstructing his airway, making his breathing very noisy. They don’t do anything about obstructed airways in unconscious patients, apart from occasionally some suction. I managed to find a functioning suction machine in the high-dependency unit (quite an achievement) and tried to clear out his airway. The suction isn’t very powerful, but it made a little bit of difference. After ensuring he was receiving plenty of intravenous (IV) fluid, I supervised one of the clinical officers while he did a lumbar puncture (LP). I’ve only been doing LP’s for two weeks, but in general the clinical officers knowledge of a sterile field is pretty much zero, so I’ve been trying to get them to understand the importance of a sterile LP technique. Their ability to actually do the LP is fine (as in it is usually successful), they just do them without being sterile, which worries me (Me: “now put on your sterile gloves. Good. No, you can’t touch the bed or move the patient or scratch your head with sterile gloves on. Go and change them”. I don’t know how much they take this in. Usually they just giggle at me and one of them told me to “chill out”!). Anyway, pus came out of this patient’s spinal canal, mixed with the cerebrospinal fluid (CSF). This is not a good sign. Charles (the registrar) told me he has only ever seen one patient with purulent bacterial meningitis survive. We started the patient on an antibiotic (they use IV ceftriaxone for bacterial meningitis here too, or sometimes IV cefotaxime because the nurses don’t like drawing up ceftriaxone as apparently its too much effort). The patient was moved from the admissions room to the ‘meningitis room’, and we carried about our business of seeing the rest of the very sick people, and reviewing others on the ward. I happened to be in the meningitis room, and noticed the patient we had just moved had run out of IV fluids. I set more up, then one of the interns decided to come to the ward (it is as haphazard as that!), and was asking me about the patient. We discussed him, and talked about what electrolyte imbalances he may have, as his urine output wasn’t great he was probably in acute renal failure. This intern is very good when he is on the ward, a lot of knowledge and for some reason he decided we might be able to do something for this patient. We decided to get urgent renal function tests (U&Es), so I spent the next couple of hours rushing around between labs, trying to find a signature (the KCH lab machine is still broken, so if we want U&E we have to take samples to the UNC lab, which is a 15 minute round trip from the ward, and only two people in the whole hospital can sign their lab forms, both of these people are difficult to find!), and collecting results. The patient did have renal impairment but his electrolytes were OK. The intern added a different antibiotic, as he said it might help, and I made sure his fluids kept running for the rest of the day. They probably wouldn’t be kept up overnight however, even though the intern said he would hand over the patient to the doctor on night duty.
The day before (Wednesday) I had done an LP on a 54-year-old patient who presented last week with loss of sensory and motor function of both legs. He also had urinary incontinence and constipation. The symptoms had started in his feet and moved up his legs. He was HIV positive and on antiretroviral therapy (ARVs). Guillian Barre Syndrome (GBS) was considered a differential diagnosis, and we needed a CSF protein analysis to confirm this. The KCH or UNC labs don’t do this test, so Dan (the consultant physician) had told me to send the sample with the patient’s guardian to a private clinic in town which would do the test. The patient would have to pay for the test. I wrote a letter to go with the sample, explaining that we only needed protein analysis. I had sent another sample to our own lab for other CSF analysis which would cost the patient nothing. The guardian came back at the end of the day with the results: CSF protein: test not available. They had analysed the CSF for everything else instead, and charged the patient for something we could have done at KCH. I was so cross. The patient’s guardian kept chasing me around the ward asking me what the result had shown and what was going to happened and would her husband ever walk again. The doctors who were supposed to be in charge of him hadn’t really explained everything and because I talk to the guardian, she has decided to follow me everywhere. I had to do a pleural tap (drained 2L off each side of a TB patient’s chest much to his relief) and couple of paracentesis (draining fluid from the abdomen) that afternoon (drained 5L off one poor chap because I just left him in the treatment room while I was dealing with another sick patient, gave him a litre of fluid quickly and made sure his blood pressure was OK before he went home), so this was not helpful being followed and pestered, but I understand why she was doing so. Dan was going to be away on Thursday (district hospital visit), and so had asked me to go down to the radiology department with the ?GBS patient to do the LP for a myelogram investigation. This investigation is no longer used in the UK, we use MRI instead, but it involves injecting contrast into the spinal canal and then uses x-rays to visualise any filling defects that might indicate that the spinal cord is being squashed my something (tumour, bone, etc). Another differential diagnosis for this patient was spinal cord/cauda equina compression, probably caused by TB, or schistosomiasis. I went down to the department in advance, and discovered I was to be the radiologist, and not only do the LP, but also inject contrast into the spinal canal. I was by myself, and decided this was not a good plan. A clinical officer came to supervise me, but after taking plain films of the lumbar spine (we had previous x-rays that were very poor quality), we decided there might be an abnormality, and he then said we should do the myelogram. I didn’t know if this was the right decision or not, but felt relived that I didn’t have to be a radiologist for a day. That would not be right. I have organised for this patient to have an MRI scan in Blantyre (the second biggest city in Malawi with better equipped hospitals) next week.
So, after not doing the myelogram, I remembered about patient with purulent meningitis, and decided to go and check on him. His fluids had run out again, and he was still obviously very unwell, with a high respiratory rate and needed suctioning again. I asked Cosmos, the amazing male nurse (really, the only one who does any work, and will do anything you ask him to) to suction him for me because he is better at it than me and I had to do something else.
I can’t remember how Thursday ended, but it was late and I was shattered. Wednesday was pretty much like that too, I seemed to be going procedure crazy with the pleural tap, paracentesis and a couple more LPs.
I came in on Friday morning, and was surprised to learn that my meningitis patient was still alive, I noticed his breathing was becoming more eratic though. I asked Cosmos to suction him again, but he didn’t get round to it. While making sure his fluids were running another unconscious man (about 30 years old) came in, very similar to the one I was in the process of looking after. Exact same story, exact same late presentation. I did the LP, and viscous cloudy CSF came out. He got left in the admissions room as there was no space anywhere else. I was then called by one of the clinical officer students to see a patient out on the balcony area who has frank haematuria in his catheter bag. Turns out he hadn’t really had a proper work up, so I struggled for about half an hour working out the patient’s history and examining him. He had a mass in his pelvis that hadn’t been documented anywhere, and with Charles advice, I sent him for urgent ultrasound and x-rays, and took blood, and re-sited his venous cannula. This was a bit of a set back to the morning. I was then called by another clinical officer student to see the first meningitis patient. He had stopped breathing. I examined him, explained to the wife with the student as a translator, and informed the nurses about the death. Shortly after that, while chasing Dan around the hospital trying to get him to make a decision about the management plan for the patient with ?GBS ?spinal cord pathology, I walked past through the admissions room and noticed that the second meningitis patient had also stopped breathing. Again I did the examination and explained to the young wife (using a student as translator) who was sitting next to the bed with a baby strapped to her back and probably at least another couple at home. She looked at me with disbelieve and shook her head. The guardians never look worried when they bring in their half-dead husbands, and don’t seem to notice when they stop breathing. There was no wailing for this death, I don’t know why. But what will she do now? With several mouths to feed and limited ability to earn an income.
I was beginning to think the day couldn’t get much worse, and it was only about 11am. I admitted a patient last week, an 18 year-old boy with generalised enlarge lymph nodes, and splenomegaly. It looked like a case of advanced lymphoma, and the plan was to give him chemotherapy. He was severely anaemic though, and this needed to be corrected first. I hadn’t been following him up, but found out a few days ago he had only had one pint of red cells in the week he had been admitted, and was still awaiting further transfusion. In that time, his haemoglobin had dropped further. I was standing in the corridor when I heard his mother wailing. Just because the lab didn’t have any blood. I couldn’t really deal with much more, and after a few tears went to have a break for an hour.
Late on Friday afternoon Charles asked me to do an LP on an inpatient who now had a headache and had become confused. He was at the far end of the balcony, not sure if he’d been missed out on ward rounds (which happens quite a bit). Again, cloudy CSF. We quickly started antibiotics and moved the patient to the meningitis room. I went to work on Saturday this week. Charles asked me to come in to help him, and I sort of couldn’t leave sick patients I had seen on Friday all weekend. I found out near the end of my stint on Saturday that this new meningitis patient had pulled out his drip the night before, and no one had re-sited it. Even though he was prescribed IV antibiotics, the nurses just gave him them intramuscularly, which would do nothing for him (at least he was getting some antibiotics, other patients I have been managing for some reason don’t get them at all, even if they are prescribed). I asked a nurse to cannulate the patient as I needed to do something else, and she started at me blankly from under the coat she was curled up in sitting in a chair in the office (torrential downpour makes the hospital quite cold), and said, “I am resting”. Resting from what I don’t know, because she had done diddly squat all morning. I got cross and told her the patient was dying (because he is and he will) and needed a cannula now. “After I have finished resting”. I give up. Cosmos says they never do anything, and he is lucky if they come to work at all. He says sometimes they are sick (HIV) and need time off, but other times it’s because they just don’t come, or they are attending a funeral. Cosmos will cannulate my patient. Thank you Cosmos.
The day before (Wednesday) I had done an LP on a 54-year-old patient who presented last week with loss of sensory and motor function of both legs. He also had urinary incontinence and constipation. The symptoms had started in his feet and moved up his legs. He was HIV positive and on antiretroviral therapy (ARVs). Guillian Barre Syndrome (GBS) was considered a differential diagnosis, and we needed a CSF protein analysis to confirm this. The KCH or UNC labs don’t do this test, so Dan (the consultant physician) had told me to send the sample with the patient’s guardian to a private clinic in town which would do the test. The patient would have to pay for the test. I wrote a letter to go with the sample, explaining that we only needed protein analysis. I had sent another sample to our own lab for other CSF analysis which would cost the patient nothing. The guardian came back at the end of the day with the results: CSF protein: test not available. They had analysed the CSF for everything else instead, and charged the patient for something we could have done at KCH. I was so cross. The patient’s guardian kept chasing me around the ward asking me what the result had shown and what was going to happened and would her husband ever walk again. The doctors who were supposed to be in charge of him hadn’t really explained everything and because I talk to the guardian, she has decided to follow me everywhere. I had to do a pleural tap (drained 2L off each side of a TB patient’s chest much to his relief) and couple of paracentesis (draining fluid from the abdomen) that afternoon (drained 5L off one poor chap because I just left him in the treatment room while I was dealing with another sick patient, gave him a litre of fluid quickly and made sure his blood pressure was OK before he went home), so this was not helpful being followed and pestered, but I understand why she was doing so. Dan was going to be away on Thursday (district hospital visit), and so had asked me to go down to the radiology department with the ?GBS patient to do the LP for a myelogram investigation. This investigation is no longer used in the UK, we use MRI instead, but it involves injecting contrast into the spinal canal and then uses x-rays to visualise any filling defects that might indicate that the spinal cord is being squashed my something (tumour, bone, etc). Another differential diagnosis for this patient was spinal cord/cauda equina compression, probably caused by TB, or schistosomiasis. I went down to the department in advance, and discovered I was to be the radiologist, and not only do the LP, but also inject contrast into the spinal canal. I was by myself, and decided this was not a good plan. A clinical officer came to supervise me, but after taking plain films of the lumbar spine (we had previous x-rays that were very poor quality), we decided there might be an abnormality, and he then said we should do the myelogram. I didn’t know if this was the right decision or not, but felt relived that I didn’t have to be a radiologist for a day. That would not be right. I have organised for this patient to have an MRI scan in Blantyre (the second biggest city in Malawi with better equipped hospitals) next week.
So, after not doing the myelogram, I remembered about patient with purulent meningitis, and decided to go and check on him. His fluids had run out again, and he was still obviously very unwell, with a high respiratory rate and needed suctioning again. I asked Cosmos, the amazing male nurse (really, the only one who does any work, and will do anything you ask him to) to suction him for me because he is better at it than me and I had to do something else.
I can’t remember how Thursday ended, but it was late and I was shattered. Wednesday was pretty much like that too, I seemed to be going procedure crazy with the pleural tap, paracentesis and a couple more LPs.
I came in on Friday morning, and was surprised to learn that my meningitis patient was still alive, I noticed his breathing was becoming more eratic though. I asked Cosmos to suction him again, but he didn’t get round to it. While making sure his fluids were running another unconscious man (about 30 years old) came in, very similar to the one I was in the process of looking after. Exact same story, exact same late presentation. I did the LP, and viscous cloudy CSF came out. He got left in the admissions room as there was no space anywhere else. I was then called by one of the clinical officer students to see a patient out on the balcony area who has frank haematuria in his catheter bag. Turns out he hadn’t really had a proper work up, so I struggled for about half an hour working out the patient’s history and examining him. He had a mass in his pelvis that hadn’t been documented anywhere, and with Charles advice, I sent him for urgent ultrasound and x-rays, and took blood, and re-sited his venous cannula. This was a bit of a set back to the morning. I was then called by another clinical officer student to see the first meningitis patient. He had stopped breathing. I examined him, explained to the wife with the student as a translator, and informed the nurses about the death. Shortly after that, while chasing Dan around the hospital trying to get him to make a decision about the management plan for the patient with ?GBS ?spinal cord pathology, I walked past through the admissions room and noticed that the second meningitis patient had also stopped breathing. Again I did the examination and explained to the young wife (using a student as translator) who was sitting next to the bed with a baby strapped to her back and probably at least another couple at home. She looked at me with disbelieve and shook her head. The guardians never look worried when they bring in their half-dead husbands, and don’t seem to notice when they stop breathing. There was no wailing for this death, I don’t know why. But what will she do now? With several mouths to feed and limited ability to earn an income.
I was beginning to think the day couldn’t get much worse, and it was only about 11am. I admitted a patient last week, an 18 year-old boy with generalised enlarge lymph nodes, and splenomegaly. It looked like a case of advanced lymphoma, and the plan was to give him chemotherapy. He was severely anaemic though, and this needed to be corrected first. I hadn’t been following him up, but found out a few days ago he had only had one pint of red cells in the week he had been admitted, and was still awaiting further transfusion. In that time, his haemoglobin had dropped further. I was standing in the corridor when I heard his mother wailing. Just because the lab didn’t have any blood. I couldn’t really deal with much more, and after a few tears went to have a break for an hour.
Late on Friday afternoon Charles asked me to do an LP on an inpatient who now had a headache and had become confused. He was at the far end of the balcony, not sure if he’d been missed out on ward rounds (which happens quite a bit). Again, cloudy CSF. We quickly started antibiotics and moved the patient to the meningitis room. I went to work on Saturday this week. Charles asked me to come in to help him, and I sort of couldn’t leave sick patients I had seen on Friday all weekend. I found out near the end of my stint on Saturday that this new meningitis patient had pulled out his drip the night before, and no one had re-sited it. Even though he was prescribed IV antibiotics, the nurses just gave him them intramuscularly, which would do nothing for him (at least he was getting some antibiotics, other patients I have been managing for some reason don’t get them at all, even if they are prescribed). I asked a nurse to cannulate the patient as I needed to do something else, and she started at me blankly from under the coat she was curled up in sitting in a chair in the office (torrential downpour makes the hospital quite cold), and said, “I am resting”. Resting from what I don’t know, because she had done diddly squat all morning. I got cross and told her the patient was dying (because he is and he will) and needed a cannula now. “After I have finished resting”. I give up. Cosmos says they never do anything, and he is lucky if they come to work at all. He says sometimes they are sick (HIV) and need time off, but other times it’s because they just don’t come, or they are attending a funeral. Cosmos will cannulate my patient. Thank you Cosmos.
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