New adventures with old folks

  This week has truly been a great picture of family medicine and its broad spectrum, from prenatal ultrasound to procedures to geriatric care, we did it all!  I have always enjoyed the variety of family medicine and flexibility challenge that is required.  This is especially magnified in this setting, where you have to be prepared for everything since you never know who is going to walk in next through the door from the long "queue" waiting outside. There's so much I'd like to share about the full week, but in keeping the Malawian tradition that elders go first, I'll start with a bit about our geriatric experience:

   On Tuesday, Elizabeth and I journeyed into the rural southern region to the Mchere district.  The family medicine department at the College of Medicine was recently asked to partner with a new "Elderly Care" health center there that just opened in June 2014 and serves patients >60 years old.  This project is funded by the government of Finland with a vision to provide quality healthcare and services to Malawian elders. (quite random, but true-http://formin.finland.fi/public/default.aspx?contentid=286981&contentlan=2&culture=en-US)  COM Faculty (aka Elizabeth and Martha) have agreed to do some teaching, and in exchange, the Malawian doctors-in-training will rotate through the facility as part of their geriatrics curriculum.   

    Elizabeth had done some lecture trainings several weeks ago, but this was the first day of coming alongside direct clinical care at the facility. We saw patients with common aging concerns from vision loss to arthritis, along with some more unique pathologies, including a new diagnosis of polymyalgia rheumatica and a likely disseminated parasitic worm infection.  We "precepted" patients alongside one of the clinical officers named John and he was eagerly taking notes on the learning points Elizabeth discussed and remarked, "This teaching is what we've been craving!"  Geriatrics has not been a part of medical training here up until now, and the staff are thirsty for knowledge about geriatric issues and approach to care to help fulfill the center's mission. This certainly made me thankful for the quality geri training we have at Swedish!  Although the setting is so different, many pillars of elder care hold true at this clinic: longer visits to address multiple issues, focus on maintaining function in their families and communities, and supporting mental and emotional challenges of aging.

    It was also fun to hear John report that this center has become somewhat of a social hub for seniors in the area.  They like to gather and compare stories to see who is the oldest, since exact birthdays are usually unknown.  John told us that the oldest patient at the center is 115 years old and had ridden his bicycle from his village to the clinic just the day before!  Apparently, he was able to trump everyone else's stories by recalling events from both World War I and WWII!  

  Although there is such a burden of early mortality in Malawi, I think it totally makes sense to develop comprehensive geriatric services here, as it parallels the vision being set forward to establish primary care in this country with family medicine as its base.  The average life expectancy is currently about 60 years, so that makes every patient at this clinic surpassing the odds of survival, with a particular hardiness and wisdom that should be celebrated and can likely teach us all a great deal.  Hopefully, as development efforts continue to extend longevity here, this center will be the foundation of infrastructure to sustain older generations to come.  Perhaps one day, more vibrant Malawian octogenarians will use the opening of this center as bragging material during their age competitions!

Figured out the photos, enjoy!  

-- Janelle :) 

  Here's Elizabeth and John at the geriatric clinic

Here's Elizabeth and John at the geriatric clinic

  View of Blantyre from Kabula Lodge where I'm staying

View of Blantyre from Kabula Lodge where I'm staying

  Reunited with UrbanPromise friends Wanangwa and John!

Reunited with UrbanPromise friends Wanangwa and John!

Partnership

Takulandilani, that's "Welcome" in Chichewa!  Janelle here, trying to revive the blog!  Hope it's okay for an R2 to commandeer this R3 project :)  I can't believe my first week in Malawi is done already, this month is certainly going to pass quickly!

    For me, this rotation resides in the context of ongoing relationships with Malawian friends since 2007 that have spanned years and continents that began through an organization called UrbanPromise International (UPI).  I had the opportunity to spend 3 months in this country back in 2010, so I have been eagerly awaiting a return to the "Warm Heart of Africa" for quite some time.  This trip is different in many ways than my last, most notably the urban setting and medical focus this time around, but it is already proving to be a equally captivating experience.

     I have reflected much in the past week on partnership. For myself, it has been especially meaningful to connect with friends again face-to-face, exchange updates about life, and hear about the growth of their youth programs.  I am in awe of how things have evolved thanks to their visions and hard work alongside the mentorship and support of the UPI community! 

     I have also gotten to play the fun role of liaison between my Swedish Medical Center colleagues and the Malawian family medicine team, since we are now about 6 months in to this arrangement of rotating residents. Folks at our lodging facility seamlessly welcomed me as the "next Seattle one" and staff members at Ndirande Health Center are eager to ask how my coworkers back home are doing.  In fact, my first conversations with the clinical officers sounded something like this:  "Nice to meet you, Janelle, how's Kannie? Do you know Laura? How about Beth?" I think this really highlights the beauty of coordinating our investment as a team rooted in one place that wouldn't be the same if we were doing haphazard individual global health efforts.

      For Elizabeth and the Seattle/Swedish-Malawi College of Medicine partnership, this week has actually been quite a challenging one with difficult situations navigating team dynamics, communication, and future plans for this project site. While these things get sorted out, I have had the privilege to witness Elizabeth and Martha (her counterpart on the Malawi COM Faculty) have honest and tough conversations about these challenges.  Partnership is guaranteed to be frustrating at times, especially when trying to create change while balancing the values of humility and advocacy in a cross-cultural context.  I remember how precious it has been to me to have trusted friends in such situations (looking especially at you, Tinashe and Maggie!), and it is neat to see how that type of relationship has developed between Elizabeth and Martha.  It certainly takes a large amount of trust and a bit of faith in each other to journey forward together, and I am encouraged to see that happening at the leadership level here. 

     I am proud that both the UrbanPromise and Swedish teams in which I have participated choose to focus their energy on the ground in Malawi and across the ocean on investing in people through relationships and education.  Both partnership and knowledge are seeds that take time to grow and bear fruit, but seem to have the most genuine potential for lasting change.  How great it will be to see what emerges as these partnerships continue this next month and the years ahead!

Thanks for reading, I'll try to figure out how to add photos for next time!

 

A Word (or Two) About Babies

Here are photos of a super cute baby boy (with permission from his mom) who delivered Friday morning just before handover.  He was weighed in the early morning light, then wrapped in a colorful, new Chitenge (printed fabric) that his Mom had brought for his first swaddle.

After my first call night, I have a few reflections on babies. I hung out with Dora and Loveness in the labor ward and got to witness two SVDs.  To state the obvious, this does not make me an expert.  About the babies: Firstly, they are super-duper absurdly cute.  Secondly, it’s rainy season in Malawi and evidently that includes raining babies.  The nurse midwives informed me that we are in peak baby season, which means that the 4 beds in the Ndirande labor ward produce about 200-250 deliveries per month in the winter months. During the rest of the year they average around 100-150 per month.  I guess people must stay inside a lot more as the rainy season drags on, thus causing busy labor wards 9 months later. A similar phenomenon occurs in Seattle where we tend to witness baby booms every summer. 

We in the medical profession often like to overstate our importance in the birth process.  Women have been delivering babies in caves, huts, forests and meadows since the beginning of time, so how different can a birth experience be from one place to another, right?  For the most part, the labors and deliveries I observed at Ndirande seem exactly the same as at the “Hotel Swedish” in Seattle.  However, there are a few differences that strike me as shocking.  First and foremost, there is the silence.  During my first day I toured the labor ward and asked, are there any women laboring today?  The nurse midwife pointed to a curtain, behind which apparently a woman was laboring in complete silence.  She was near completely dilated and uttered not a peep.  As a reminder, there are no anesthesiologists, no epidurals Tylenol is the only “pain killer.”  Elizabeth informed me that women are instructed by their families that they are not to make noise during labor, lest they disturb the health workers whose work station/sleeping area shares the room with the 4 labor beds.  In addition, there are no monitors and women do not routinely get IVs placed in labor. That means no background of galloping fetal heart beat and no incessant beeping of occluded IV lines.  Fetal auscultation is done with a metal fetoscope. The only Doppler on the Ndirande campus was brought a month ago by our Swedish team, mostly because we are not reliable enough at auscultation with a fetoscope.  In summary, the labor ward is silent aside from the conversations of the nurses around the work station. 

Finally, after visiting the labor ward for rounds and borrowing supplies for over one week, I heard one woman make a few groaning noises while in labor, similar in scale to what one might hear in a public restroom if the person in the stall next door had too much cheese the day before.  The utterance of those few groans provided some relief to me that Malawian women were human, albeit with more “mind over body” power than I previously thought humanly possible.  And then, with one more push, she delivered a 2.7 kg baby, followed by a big gush of meconium stained fluid.  The infant was hoisted to her belly by a nursing student, who dried the infant with a chitenge and clamped and cut the cord.  He cried vigorously and I let out the breath I didn’t realize I was holding for those few seconds. A meconium delivery is treated with more fanfare in Seattle.  Mec deliveries are attended by a neonatal nurse in addition to the L&D nurse assigned to the baby, and usually involving suctioning and monitoring if not a brief intubation to suction beyond the vocal cords.  The newborn is whisked to the neonatal resuscitation table and ideally suctioned prior to taking its first breath to prevent meconium aspiration.  At Ndirande, there was no whisking away or suctioning, no additional helpers.  In fact, the one nursing student attended the birth, did infant care and cleaned the bed.  She delivered the placenta, carried the baby to the scale, swaddled the baby in a dry chitenge, and then gave the baby a dose of a milky liquid solution that I didn’t recognize.  It was Nevirapine, the first of 6 weeks of Nevirapine he would receive because his Mom is HIV+. 

At 6 weeks, he would be tested for the HIV virus and could stop the Nevirapine if no virus was detected.  I learned at the Ndirande ART clinic that the vertical transmission rate is 1-2%, and HIV+ women on ART are now encouraged to breastfeed because too many babies had died of malnourishment when breastfeeding was prohibited for fear of transmission via breastmilk.  At 6 weeks, seronegative babies are started on Cotrimoxazole (Bactrim) for prophylaxis (in case of  transmission via breastmilk), which is continued until they complete HIV antibody testing at 12 and 24 months.  After 24 months, they are done breastfeeding so their risk of mother to child transmission has passed, the Cotrimoxazole is stopped and they declared HIV free.  I can just imagine the neonatology and pediatric infectious disease consults that would likely accompany this child’s birth and neonatal care in Seattle.  But like anything, practice makes perfect and Ndriande has neonatal HIV care down pat. Based on the long lines at the ART clinic every morning with moms with babies strapped to their backs with chitenges, there is plenty of opportunity for practice here.  

I left my first call night feeling a little dazed and extremely grateful for the opportunity to learn from the vast experience of the providers here.  Elizabeth drove me to the Hutchinson homestead in the morning, and as always she was full of curiosity and thoughtful reflection about our role here as supporters of the ministry of health’s clinical and educational functions.  Dr Makwero’s vision for family medicine in Malawi is truly inspiring.  I am learning so much, thanks to the Malawian doctors and clinical officers who do this hard work day in and day out.  In my week of work I feel a shadow of the weight of what they experience routinely. For example, we have diagnosed 4 third trimester fetal demises in the week that I’ve been here.  Supporting Ndirande to become a family medicine model for comprehensive, decentralized health care will improve access and outcomes.  Dr Makwero and her team of clinicians need foot soldiers, assistants and colleagues to help materialize this vision, and I am so grateful to play a tiny part in it.

-Emmy

This Is Africa

8:30 really means sometime around 9, maybe 10.
- Rejoicing when running water comes out of the tap.
- Learning to keep expectations low when ordering ice cream from a vast menu with flavors including coffee, rocky road, and mint chocolate chip. The server will tell you that the available flavors are "vanilla, chocolate, and strawberry." When you ask again about the coffee flavor, he'll repeat "we have vanilla, chocolate, and strawberry." (It was still delicious!)
- The smell of burning plastic looms everywhere.
- Emissions testing would probably eliminate 90% of the vehicles on the road, including Black Mamba.
- The threat of schistosomiasis, hematuria, and cirrhosis is perceived as worth taking when beautiful Lake Malawi is in front of you. Thank goodness for praziquantel!
- The power company's slogan is "Towards power all day... Everyday." (They're doing much better than the water company so far!!)
- Learning to say just a few basic words in Chichewa goes a long way.
- Holding a baby with a chitenje is hard work!

-Kannie Chim, SFH R3

Mellow Yellow - or is it Yellow Mellow?

Desperate times call for desperate measures. We just survived 60 hours without running water and 24 hours without power. The play by play (not for those squeamish regarding bodily functions):

Hour 12:
I woke up in the morning to find that we did not have running water. This is a pretty common occurrence here and many of the houses, including the Hutchinsons', are outfitted with an extra water tank for this very purpose. In addition, Bill and Elizabeth keep 3 extra jugs of filtered water for drinking. Bill has a saying regarding our natural tendencies: "If it's yellow let it mellow, if it's brown flush it down." I thought it was a bit odd for us not to have water during the day as our previous dry-outs had just been at night, but I figured this was par for the course and NBD.

Hour 20:
Elizabeth and I return from Ndirande to find that we are still without water. The Hutchinsons were hosting bible study that evening so some of the tank water was used to wash the dishes from the previous night and for cooking. I learned a lot from their friends about water conservation, which totally puts repurposing in a whole new light. Bathwater, for example, can be reused to flush toilets and for watering the garden and some homes have the pipes wired to do this automatically! Wow! We ended the night still without water and the adults decided to forego their showers.

Hour 32:
Still dry the next morning, and we also were without power. I was thankful that it had cooled down in Blantyre the past couple days so I didn't feel as icky without a shower, and I knew that a baby wipe wipe-down was always a possibility. There were rumors that the water company was fixing their pipes so it was unclear how long water would be out for. Bill lamented at breakfast that he had forgotten to save the boys' bathwater the night prior. Despite the code yellow-brown state of our toilets zen prevailed and we all remained calm.

Hour 42:
We went out to dinner at Jungle Pizza given our lack of power and inability to cook anything in the house. While at ShopRite, we searched for 5 liter jugs of water but they were all sold out. We bought some buckets, and Bill called his neighbors with a swimming pool to ask if we could fill them in order to flush the toilets. He also made the executive decision that the men of the house would perform #1 outside. We were approaching a dire code brown. That night Bill and the boys ate melting ice cream from the container (there were no clean dishes or cups) and read Lord of the Rings by candlelight.

Hour 46:
I started my night call at Ndirande. I had taken to waiting until clinic to empty my system (I will refrain from further details), only to find that we were also out of running water in clinic. That night, I learned the art of flushing your own toilet with bucket water, that babies can be delivered just fine, and that washing your hands with D5W makes them sticky but is better than nothing at all.

Hour 60:
I survived my night call. However, just turning my head gave me a whiff of my hair - foul. I hoped beyond hope that when Bill picked me up he would say we had water and - HE DID!!! I have never been so grateful. Next time I use a public bathroom in the States that someone forgets to flush beforehand (a previous pet peeve), I will just smile and be ever thankful for the privilege of running water.

Unfortunately, as I write this we are going on another 20 hours without running water. It's mellow yellow time again...

-Kannie Chim, SFH R3

Malawi Musings

My first blog post ever feels rather momentous. I've thought about
this multiple times (ask Bill and Elizabeth), started, stopped,
deleted, and then heard Ben Davis's exhortations each night in my
dreams: "Kannie, come on! You've got to keep this blog going! If you
don't write anything it's gonna die."

Here, then, is my feeble attempt at resuscitation. I've been here for
a week now and can officially say that 3 hours of sleep in 35 hours of
travel equals, once landed, a relatively painless transition to Malawi
time.

I have many thoughts about what I've seen clinically, some of which
I'm still trying to process. I alternate between being humbled,
discouraged, hopeful, and grateful. I have learned that I can survive
running a clinic without a preceptor on my fourth day (!), that people
demand antibiotics everywhere, and that a constant language barrier is
really emotionally challenging. The allure of a low resource setting
was so powerful when I left, and now I find it often frustrating and
at times terrifying. Practicing medicine without an internet
connection is also a humbling experience when all I can do is try to
remember which meds are class D in pregnancy.

Staying with the Hutchinsons and seeing how they've navigated their
lives here is pretty awesome. I'll have another blog post with our fun
adventures and, in the Hutchinson household, "This is Africa" moments.
Interestingly, my experience here is probably the first time I've ever
thought seriously about what living in Africa with Nana and a family
would look like. It seems surprisingly reasonable.

Except - the mosquitos. They absolutely kill me, and I dutifully
followed the advice I was given not to read Ben's post before I left.
Only to find myself, in my first night at the Hutchinson's, joined by
a bunch of mosquitos in my net. I remember Ben saying you had to be
sure to kill all the mosquitos before you went to sleep - but 15? I
couldn't believe he had never complained about having to spend so much
time killing them. I always knew my poor hand-eye coordination would
come to bite me (no pun intended!), so an hour and a half later, with
15 mosquito carcasses on my hands plus the 4 extra that appeared out
of nowhere, I was ready to sleep.

I didn't know that mosquitos never let you sleep. Every 90 minutes
that night I was awoken by the ring of a mosquito next to my ear, the
most terrible sound ever. My first sleep-deprived thought was to admit
defeat but despite full sleeves and long pants they got my fingers,
neck, and feet. Painful, stinging bites. GAH!! I turned on Beth's
headlamp and 20 minutes later found the &@#$&#$ mosquito and killed
it. DONE. And then the same thing, 90 minutes later. By 430am I had
gotten so good I could kill a mosquito with one try, though I lunged
so hard I nearly fell off the bed.

I found out the next morning that it was actually a bit of a fluke to
be so mosquito-burdened, that the nets had been up for a little too
long during the day's cleaning which allowed the pests to nest under
the bed until their feast at night. I haven't had a night like that
again thankfully, but I still find myself hallucinating mosquito
buzzing as I fall asleep.

Whew. I got through my first post and it wasn't so bad. Perhaps more
to come later!

-Kannie Chim, SFH R3

Malawi Week 3/4

Over the past two weeks, Ben and I had 2 clinic mornings without a preceptor (Elizabeth was fulfilling her teaching duties at the College of Medicine). Of course, these mornings had some of the most acute patients that required quick management and transfer to the central hospital in an ambulance. Without telling you all the details, the patients included 1-2 patients who were probably psychiatrically unwell (I realized I don't know much about how mental illness manifests in Africa or Malawi), a patient with HIV/TB and pneumonia, a woman having a 20 week miscarriage, a woman with abdominal pain and sepsis (or severe malaria and we missed it), and a woman with sepsis likely from postpartum endometritis. As I am slowly learning more, I have realized how important it is to have a significant knowledge of the culture and the ways that diseases manifest, in addition to how to treat them. A month is much too short to do this well! In addition, knowing how to correctly diagnose and treat common conditions in Malawi is only one part of the entire picture.

The story of the woman mentioned above with abdominal pain/sepsis vs severe malaria encapsulates so much of Malawi health care. I initially saw her lying on the ground in the fetal position in the large courtyard between many of the clinics where different services are provided. Problem/observation number one: sick woman is lying on the ground. I was attending to another sick patient at the time, so the next time I glanced her way she was sitting up, breastfeeding. I surmised that she must be feeling better than she initially looked but actually, I was just observing problem number two: sick woman continues to care for her child rather than seek immediate help. I next saw her sitting closer to our clinic door, so I went out and instructed her to go get a rapid malaria test. She collapsed after a few feet. Problem number three: there are not enough health care workers to assess/triage someone who might be too weak to walk safely throughout the health center. We moved her to the short-stay unit, we took a few vital signs, did a rapid malaria test (negative --though we can't rely on this negative result in someone so sick) and found she had severe abdominal pain. Thankfully, an ambulance was already there to pick up another patient, one with HIV/TB and likely pneumonia (the ambulance had taken a good 45 minutes to arrive for him), so we added her to the pick-up request. Problem number four: our patient was going to have to ride in an ambulance with a patient with TB --so we gave her a protective mask. Problem number five: the ambulance didn't just contain the TB patient, it also contained about 6 other patients stuffed into the back of a van (one of whom was stretched out, stiff --my differential diagnosis for him at a glance included tetanus vs rigor mortis). The protective mask seemed ridiculous now. The patient's mother was now carrying the patient's small child and wanted a ride to the hospital as well. There aren't enough nurses for patients at the hospital, so each patient needs a "guardian" at the hospital to feed and bathe them and do their laundry. Problem number six: the baby was going to ride to the hospital and be exposed to several sick patients including one with active TB and one who was quite possibly dead, so that grandma can be there to support the patient.

Of course, there are a few admirable aspects of what I just described -- the heartiness of the woman who was still breastfeeding even though she was too weak to stand. The family support around ill patients who require guardians in the hospital. But there are too many unfortunate realities that make substantial improvements in safety and quality of care a very distant goal, even if we have impeccable diagnostic/treatment skills.

On to another topic: Ben and I just attended two days of malaria training --this is extremely relevant to the health care workers here because the protocol for treating severe malaria has recently been modified. Furthermore, our instructor reported that in a small survey of 30 health care workers in hospitals across Malawi, only one person was able to correctly identify a case of severe malaria. This mandatory training is part of an effort to expand the education of the Malawian health care workers to improve identification and treatment of severe malaria -- and it was extremely important for us to hear too. Given that we rarely see malaria in the United States, we have a poor understanding (beyond basic book knowledge) of when to suspect malaria, especially in the absence of our usual battery of tests. As mentioned above,  in the course of the training, I started to think of several patients whom (based on what we were learning) we should have treated empirically or presumptively for malaria. I feel humbled that, while there have hopefully been some patients whom we have helped by being here (and I hope we are helping/contributing with Elizabeth on a larger scale), there are probably some patients we haven't helped or those we have even harmed by our inexperience and lack of knowledge. This point represents why participating in Global Health can be so hard, complicated, nuanced.

On another note, our class was enjoyable/curious for numerous other reasons.

-We had a few singing stand-up/sit down breaks initiated by adults in the class (almost likeSunday school -- it was actually a song I remembered from Sunday school!).

-Though the class took place at a government hospital, there was an opening and closing prayer.

-It was fascinating and amusing to observe what points of lecture became points of argumentation between students and lecturer. To Ben and me they seemed to be the most minor points (for example, how do you place a suppository? was that sentence on the powerpoint worded correctly?) but they would often unexpectedly cause a prolonged quarrel in the class.

-The instructors used powerpoint but also a large paper/marker in the front of the class. They used this for drawing examples of what might be seen on a microscope view of a malaria slide (it would seem much easier to me to just put one picture slide in the powerpoint of the actual malaria smear - since we had powerpoint and video etc. But instead, large red circles were drawn with marker on a poster).

-Our classmates were called on individually to answer questions (we were spared this, mostly). One classmate was a large somewhat sweaty man -- well, we were all sweaty, it was around 90 degrees - named Precious.

-There was AC in the room and when it was functioning well on day two (finally Ben and I were comfortable), the ladies were wrapping themselves in their chitenjes, (their multipurpose skirt/shawl/baby carrying wrap) to keep warm. I was not even close to chilled!

In terms of the advancement of Ndirande health center, we had a few successes. We led a teaching session last week that received good reviews and actually felt like it opened the door for some further conversation and camaraderie. I had a call night with Loveness, a very talented clinical officer who loves obstetrics and with whom I felt a bond of friendship almost immediately. Clinical officers take overnight call often, though usually from home, and this was her first time sleeping at a  "hospital" (I reflected that I have slept --or not slept - overnight at the hospital at least 100 times). We saw 10-15 patients of variable acuity -- some of whom needed immediate stabilization and transfer to Queens hospital, some of whom we kept overnight to monitor. Lots of malaria, probable meningitis and florid pneumonia. Loveness ran the show and I assisted her (contrast this to Ben's call experience from a previous post). What was encouraging to me about working with her is that she too is passionate about improving Ndirande and had previously worked at a site that was much more organized (imagine, a nurse taking vitals and triaging patient acuity and an organized system for storing medication and tracking their use). Though Ndirande has been our only exposure to health care in Malawi, and though resources are slim and facilities overcrowded most places in Africa, it seems it is not the norm for health centers to be in such chaos and disarray as Ndirande. Loveness has vision for applying improvements based on her past experience, though she too is nervous about being an "outsider" or a newcomer who is pressing for change. But as she said, the change will come, "by and by," and I am thankful there are numerous people from various angles rallying to support this place.  

I have to admit, the mosquitos and the heat are getting to me, I'm looking forward to coming home! Though it's more arduous, there are some sweet aspects to life here. Liam (Elizabeth's 10 year old son) had great perspective - when the water is out (happened 5 times last week), or the electricity is off (happened 2-3 times last week),  you are unintentionally given something to look forward to (return of convenience!). When we were enjoying particularly soft bread (in contrast stale Malawian bread texture) at a dinner gathering, I overheard a girl say, "That's what I love about living here -- you'd never take notice of this bread's texture if you were in the (UK/US/developed world)." I think I still notice the great texture of Dave's Killer bread, even in Seattle, but I do agree that I have a new level of thankfulness for the simple things we enjoy so readily at home.

Amanda is here now, we greet Kannie tomorrow, and we have an African adventure planned for the next few days! See some of you back home :)

-Beth Thompson R3

The Medicine

I've avoided something important in my blog posts so far.

The medicine.

Frankly, the medicine hasn't captivated me in the way that seeing the bigger picture has. Seeing far reaching connections come to life to slowly give hope to a new vision of Family Medicine here in Malawi has been amazing. Yes, I've seen diseases that I would likely never see back at home. I've seen patients brought to the health center propped on top of the arms and above the heads of loved ones. Ones who've possibly had tetanus, TB, end stage HIV, and severe malaria. I won't ever really know for sure if it is what they had since our diagnostic capabilities are sorely limited at Ndirande. Empiric treatment is the name of the game here. Some good coming from it (ability to utilize less trained health staff) and some bad (antibiotic resistance, diagnostic inaccuracy). But overall, nothing has gripped me enough to merit sitting in the mosquito inhabited living room at the Hutchinson's to pound out a blog post.

Until yesterday.

Back at home, I'm known as something of a "white cloud". For those not in medicine, a white cloud is someone who discharges a lot of patients, doesn't get killed with admits, and generally has a quiet day/night for better or worse. I've still had my share of crazy nights and stories to tell but overall I'm most assuredly a white cloud. 

Two nights ago I joked on Facebook before leaving for my first night call shift at Ndirande that maybe my white cloud would turn black since I'm half way across the world. 

Well, I was right.

Elizabeth joked that I may have been the first family medicine physician to have ever been on night call at a district health center in Malawi as they are typically staffed by clinical officers. I'm sure I'm not but I told her I will gladly accept the title. I also prefer to wear a sash that announces that dubious honor. And if it was an "honor" I received, it was surely baptism through fire.

The following is a chronological order of my night. It's the only way I know how to put all of this into writing. I've had two days to process the night and I think I can now get through discussing this without swearing in frustration but if I do, please either stop reading or accept my pre-emptive request for forgiveness. As always, this will be all in one take.

This was my night...

19:30: Bill drops me off at the steps of Ndirande. It's pitch black around with the exception of the florescent glow of the family planning clinic. I make my way up to the clinic area to be greeted by Jafundo (soon to be clinical officer who has finished training) and Phiri (clinical officer/head of Ndirande's clinical officers). As I set up shop, I'm told by Jafundo I already have a patient ready to see me. Phiri, the other clinical officer there for the night, sets up camp at his house for the night (he lives 1 minute away) and says good night to me.

19:35: 40yo, male, comes in with sore throat, fever, and a painful jaw. I'm limited in what I can do but I get his temp. I'ts 102.7. He's also tripoding slightly and bit of a muffled voice. I can't look into the back of his throat because it's so swollen. he's also hypoxic to 92% O2. I tentatively diagnose him with a peristonsillar abscess secondary to a dental infection. In addition, I suspect a PNA, he's unclear what his HIV status is (PCP?) The only antibiotics I have available to me are Ceftriaxone (thank God) and a vial of Gentamycin. I want to desperately get him to Queens but Jafundo tells me the only people that can be seen at Queens at night are "emergencies". By "emergency", he means actively bleeding out or dying. I give the man a gram of IV Ceftraixone and 2L NS. I check on him periodically in the night and his tachycardia improves and clinically looks stable. Sent him to Queens in the morning.

19:45: After seeing the first patient, Jafundo says he has another patient in the short stay/inpatient area that he wants me to see. I walk over to the area to witness what could only be described as something out of a horror movie. There is a 20 something year old woman covered in blood. I mean, covered. Jafundo tells me she came in about 30 minutes ago with acute vaginal bleeding. Luckily it has subsided and she is stable after 3L of fluid. I begin my line of questioning, a lot revolving around whether if she is pregnant. She isn't. I'm still mystified what may have caused this after my history taking so I tell her I need to do a vaginal examination. I put on my gloves. As I cautiously go to examine her she clamps her legs together. 

At that exact second I knew what happened.

My next question to the patient (via Jafundo) was if there was any sexual assault. I previously asked her about trauma and she denied it so I had to be direct this time. She declined to answer the question. 

That's all the answer I needed. 

Since she was stable, I told Jafundo that we don't need to do any further examination right now and we can wait for the ambulance to arrive to take her to Queens.

The ambulance never came.

She laid in bed with her infant child the rest of the night. Her partner came to see her. Of course I was pretty vigilant at this point but he seemed genuinely interested in her health and my spidey sense never went off. I would let her process this and tell him in due time (or not) but I kept an eye on her the entire night.

20:00: Two year old female comes in with tachypnea and fever for one day. Based on her history and exam I feel very strongly it's malaria. I ask Jafundo to get us a MRDT test.

We're out.

The only reliable test we have at Ndirande. The test that is probably ordered at least 50 times a day at the clinic and we're out. 

I oscillate whether to treat empirically or have her come back in the morning. I decided to treat her empirically and then come back in the morning. 

20:20: One year old female comes in with a possible allergic reaction. She took Amoxicillin for a likely viral URI which then her parents noticed what looked like a blood blister on her upper gums. No other allergic signs. I thought about SJS but it really wasn't characteristic. She was otherwise well. It was also unclear if this was just coincidence when the parents noticed the finding. I told the parents to stop the Amoxicillin because she likely didn't need it anyways. Warning signs were given for SJS and to stay hydrated.

20:45: Thirty something year old male comes in covered in blood. Turns out he got a nice head laceration from an in-law hitting him with a stone during a dispute. He gives me a piece of paper that is a request for medical attention. It's from the police station. The request is officially documented on  a loose, lined piece of paper. 

Otherwise, the guy is fine. I have Jafundo stitch it up since it wasn't too bad. 

21:15: While I go to see Jafundo clean and stitch another woman comes straight to short stay with fever, generalized body pain (a favorite symptom of Malawi), and joint pain. I go to take her temperature. Oh wait, I forgot to tell you my thermometer broke after the second patient. Oh well. I'd kill for an MRDT test right now but I'm convinced enough to also empirically treat her for malaria. I thought enough of her presentation to treat with IM Quinine (instead of LA) but I also covered myself with 1g Ceftriaxone and a bunch of IV fluids. She looks quite well in the morning, enough where I thought she could follow up at the clinic as an outpatient.

22:40: 30 year old male comes in with shortness of breath and lower extremity edema. This has progressed acutely. No signs of pulmonary edema, history suggesting that this isn't likely cardiac in nature. I look back in his health passport and notice he was treated with Amoxicillin for "tonsillitis" roughly 5-6 weeks prior. Great good treatment for possible strep throat. 

The problem is that proper treatment of strep throat actually doesn't protect you from post-streptococcal glomerulonephritis, only from Rheumatic Fever. He has dark urine. I tentatively diagnose him with ARF secondary to either post-strep GN or malaria since he had a subjective fever as well. This is one patient I told Jafundo needed to go to Queens. I had so little in my diagnostic and therapeutic tool kit that I just couldn't manage him if it all turned south. So I sent him off with his father and brother into the darkness and the hope that he was able to get to Queens.

00:00: It's finally quiet. I ask Jafundo if this is the norm for Ndirande. Thankfully he says no. We go to the back room in the Peds department (our HQ for the evening) and sit down. Jafundo then hits the hay in the bed. The problem is that there is no mosquito net in this room. I knew at that point I would be getting no sleep so I decided to stay up. I proceed to kill time by playing Plants vs Zombies on my phone. I quickly finish the entire game and am left bored again. In an act of desperation I pull out my secret weapon. The one thing I would rely on for emergency entertainment during my 5 weeks here. "Jack Ryan: Shadow Recruit". This most random of movies was a last second decision by myself to put a one on my phone prior to leaving. I didn't watch it on the plane as I knew I would need it in the worst case scenario. I decided this was the time.

The movie sucked.

But it kept me up for 1.5 hours.

At this point I'm pretty tired and desperately would like to sleep. The problem is that I'm literally in the middle of a mosquito swarm. The back room is hot and protected from the wind. Perfect breeding grounds for the worst creation on earth. I put on my hoodie in the heat to protect my flesh from their relentless attacks but it only served as a large neon sign that pointed at the only piece of bare skin I had remaining.

My ankles.

I'm estimating at this point I had roughly 40 mosquito bites in total. Twenty for each ankle. The picture to the right is just a small window into the beating my ankles took. Eventually they started to just burn instead of itch. The skin was taut from the swelling. Mountains beyond Mountains of mosquito bites (Paul Farmer holla back). I was officially at 3rd trimester levels now. This continued for the next 4 hours or so. It was an experience so unpleasant that it rivaled the infamous night of Ski to Sea 2012 where I stayed up all night in a frozen car due to being an idiot (not bringing any camping equipment).

02:00: Ten day old male with fever and increased work of breathing. In short, the kid looked toxic. Was grunting and had some tongue protrusion. Was overall stable (stable=not dying this exact second) but was on the brink of turning south. This is a patient I would immediate admit and do an extensive sepsis rule out work up/treatment back at home but I ended up sending to Queens. Jafundo said that they would have to call a doctor to come in to see the baby. Don't want to make up the doctor in the middle of the night, am I right?

This was one I insisted on. 

02:30: I'm back to getting eaten by mosquitoes.

04:30: I hear a banging at the outer peds doors (the official way to get our attention) and a man comes saying that "the doc" is requested in the maternity ward. My first thought is that I'm needed for a delivery! But who am I kidding, Ben Davis being fortunate enough to have a NSVD? Even in Malawi it's far fetched.

I walk down to the labour ward and I looked to my left. The left is where there are 4 beds almost side by side. It's where the silent but laboring mothers lay as they are about to give birth. Nothing going on to the left. 

The nurse points to the right. Focusing my glance to probably the worst possible scenario. A dying newborn. I quickly make my way to the warmer and see a blue, limp, barely breathing newborn laying there. I ask the nurse how long this has been going on for.

30 minutes.

THIRTY. MINUTES.

I go to auto pilot and listen to the heart/lungs and thankfully hear a heartbeat. I hear breathing as well, albeit agonal in nature. I ask for anything to do positive pressure ventilation (PPV) and after 30 long seconds am handed a wooden box full of odd bag valve masks. None of the masks are the appropriate size but hell, it was something. I start PPV and then tell Jafundo to continue with it. I hand it off and he sits there, unsure what to do. For the first time during my stay here I almost lost my cool in the midst of my frustration. Regroup. I re-instruct Jafundo on how to do PPV. 

At this point I ask them if there is any equipment for suction. Again, the urgency in the room was low at best. This is something that would have everyone in the entire hospital up in arms back in Seattle. I can just imagine the staff losing their minds at the site of what I was witnessing.

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But this isn't home (for better or worse). Unfortunately this is the norm here and eventually we all get jaded to things. I eventually get another suspect wooden box full of plastic suctioning equipment that take on various forms. None of which look familiar. I grab the one that looked like a penguin and went for it.

Nothing.

I take over PPV and have Jafundo look for deep suction equipment. Again, the sense of urgency is what feels like an all-time low as I stand there in desperation. Jafundo eventually brings over my saving grace - the deep suction equipment. I grab the cannulas and plunge them into the infants nares. Nothing comes out. I then stick them down his throat to find a substantial amount of gunk (no mec) sucked out. 

Finally, some progress.

I continue this a couple more times and eventually the infant starts breathing at a regular rate. Blue slowly turns to somewhat pink. I put on some oxygen via nasal cannula and wait. I probably waited 20 minutes in real time but it felt like a day in my mind. Just watching the baby breath. Standing there thinking what I would do next.

After about 40 minutes the baby starts to move his upper extremities. Thanks goodness. My main concern at this point was hypoxic brain injury, at least gross motor is intact. Who knows if there will be long term sequelae but for now I'll take it. We try breast feeding three separate times but the baby is just too weak to do it. I set a hard stop at 6am. If he can't breastfeed by then we're calling the ambulance.

Then again, the ambulance never came from my sexual assault patient.

Eventually, the child musters up enough strength to breast feed decently. He also starts crying for the first time which was music to my ears. At this point, I feel somewhat reassured at our trajectory and tell the mom congratulations in English which probably meant nothing to her. But in saying that to her, I think I was subconsciously saying that to myself.

I slowly waddled my way to the exit doors of the maternity ward and opened them to the blinding light of the morning. I went in to the maternity ward while it was pitch black and came out to the sun of the new day. It sounds quite poetic but it probably looked more like a scene from The Hangover to the women that were watching me.

06:00-06:30: I sit on the curb at Ndirande and bask in the sun and tranquility of the morning. Eventually, I start to process everything and what felt like devouring a layered cake of badness started to feel pretty rewarding.

06:30: I'm back in the Peds room eating a snack bar. My reward for surviving the night and maybe doing some good in the process.

06:35: As my feet are propped up on the desk and the crumbles from the snack bar are being wiped from my face, Jafundo comes in to say "we have one more patient". At this point I'm thinking I really don't want to see any more patients. Can't they just wait a bit longer until morning clinic starts? Before I can even stand up from my reclined position Jafundo places the patient on the bed in front of me.

A dead 4 year old boy. 

The exact moment the boy hit the bed, I didn't know he was dead. I knew it was bad but not the end. I grabbed my stethoscope and went to listen to the heart as his parents and grandmother entered the room. 

Nothing.

For the first time in my life I went to listen to a heart beat and heard nothing. I've experienced death in the professional setting many times before but never had I have to place my stethoscope to a chest only to hear silence. I stood up and just looked at the child. 

No chest rise.

I grabbed his tiny hand.

Ice cold.

I listened for a heart beat and felt for a pulse three more times until I said to Jafundo that this child is dead. His scrotum (often a marker of pediatric hydration) was as flat and dry as the skin around it. 

After I relayed this to Jafundo, I felt an overwhelming sense of anger. Instantly, I demanded to know the story of this child. He was seen yesterday at Ndirande and prescribed Amoxicillin for a fever. The parents didn't have his health passport so I wasn't able to see any history for myself. In my mind, I was about to demand to know which clinician saw this patient. I was hell bent on having my wrath felt by the unfortunate soul who "obviously" missed some warning signs yesterday.

I caught myself.

This child is dead. Who the hell cares at this exact moment why? I never asked the question and I stepped back and sat on the edge of the desk. I gave the parents a look that I hoped would convey my sentiments without the need for interpretation. 

After further discussion, Jafundo then began to prepare the body. I watched it from beginning to end. This was an unsettling event as Jafundo was incredibly proficient at this entire process. This wasn't his first rodeo. Everyone stepped outside of the room but the mother. She never said a single word but sat there staring at the ground. I wanted to put my arm around her to try and comfort her but who was I kidding? Her four year old son just died. 

I packed up my belongings into the bag and we eventually all left the room to await the arrival of whatever services they contacted to take the child.

As I stepped past the double doors to the peds department, I found the same scene I see every morning. Mothers and their children lined up along the pathway waiting for the doctor to arrive. The only difference today is that it was dead silent.

Everyone knew. Everyone looked at me. I had no answers.

I slowly made my way down to the front of Ndirande. Right before I made it to the front, Jafundo told me that he hopes we're on call together again some day in future. I never asked him why but I assume it was because we just saw the worst Ndirande had to offer. 

07:00-07:30: I sit on the curb once again at the Health Center. This time I'm waiting for Bill to arrive to pick me up. As I'm sitting there, the labor nurse walks by me on her way home for the morning. She says that the newborn baby is doing very well and thanks me. Only a very few have ever seen tears run down my face but at that moment many Malawians were added to that very few. 

-Ben Davis, SFH R3

 

 

 

Split or Steal

Jet lag can be tough. The first few nights in Blantyre I had to resort to additional sleeping resources other than my nightly browsing of Reddit. For this particular problem, I've looked to RadioLab podcasts to sweetly lull me to sleep. I typically listen for the first 5 minutes or so then dose off but one particular podcast had me up for the entire thing. "What's Left When You're Right" had one particular segment that resonated with me. Golden Balls.

For those who don't know, Golden Balls was a British TV show that aired for a couple seasons. Two competitors would participate in a variety of games together to earn money. The big twist is that this sum of money would be firmly placed between both participants as they would have to choose to "Split" or "Steal". Three scenarios were possible: 

Both choose "Split" - they split the sum of money.

Both choose "Steal" - no one wins any money.

One chooses "Split" and one chooses "Steal" - the participants who chose "Steal" wins it all.

The podcast featured participants who had varying strategies. One young, "innocent" girl played the cute card and was able to "Steal" from an older man. The main focus was on another man who blatantly told his counterpart that he was going to "Steal" no matter what but that he would split the money with him when the show was over. This lead to an argument that lasted well over 45 minutes that eventually culminated in both participants "Splitting". The rationale was that this strategy would be the best way to switch someone from a "Steal" to a "Split" which indeed did happen. 

The following morning I sat in the Hutchinson living room doing my normal morning routine - staring ahead emotionless. Micah and Liam were on school break and happened to be in the living room as well. As they passed through my field of vision it occurred to me that I had the perfect guinea pigs (I mean Pioneers, inside joke) for my own "Golden Balls" experiment. 

Micah: Age 6 - Erratic, loving, and utterly unpredictable. Cyborg combination of Tazmanian devil and a teddy bear.

Liam: Age 10 - Thoughtful, mature, and older brother to the utterly unpredictable one above. The Gandalf of 10 year olds.

With both participants eager to earn some free Kwacha, my experiment was under way. We played 3 games. The first was throwing cards into a hat with each successful card being K50. The second was pictionary with each correct answer being K100. Finally, we set up an obstacle course in the house and had each boy blindfolded and leading the other from the start to finish by only using verbal instruction. Each successful completion within 2 minutes earned K200. By the end of the 3 rounds they had earned a total of K700. Then came the fun.

As I hypothesized in my head, Liam went rationale.

He tried to convince the unpredictable Micah that by both splitting they could each earn K350 and walk away happy. Micah's response can only be done justice by video (yes, this was filmed vertical):

Brilliant.

Micah took the traditional thinking of the game and threw it on its head. He did the genius method without any prompting and then he put in his own twist. You want to split the money? Heck no. The most fair options are I take it all or we both get nothing. To his credit, stealing is actually the best option. You have a 50% chance of getting 100% of the money while splitting gives you a 50% chance at 50% of the money. Bold.

This debate went on for a good 10 minutes. Logic vs. Counter logic. Brothers til the end but would a fist full of Kwacha break this eternal bond? It was tense. You can see from the picture that Beth was aghast with the raw emotion in the room. It came down to this...

They both chose "steal". 

In the end, Micah stuck to his guns and Liam knew his brother well enough that he would pick "steal" no matter what. And what good would a big brother be if he allowed his younger brother to win? 

Afterwards, Liam continued to try and reason with Micah that they should have both split. After much persuasion Micah caved and agreed they both should have split. K350 can buy you a couple packs of Maynards at the local ShopRite. Too bad.

Or was it?

Not being able to resist a potential "SLO" (the Hutchinson parent's code name for Significant Learning Opportunity), I offered them a chance at redemption. We went through the three games again but this time they only racked up K200 or so. Still, Kwacha is Kwacha. 

They sat at their respective ends of the table. Micah double checked several times with Liam if he was sure he was going to "split". Liam kept repeating "split split split". This culminated with a much quicker verdict.

Micah picked "split".

Liam picked "steal". 

As I had both of their paper submissions in my hand, I knew that WWIII was about to erupt once I announced their choices. I looked at Elizabeth in a failed attempt at having her read my mind and predict the chaos that was about to ensue. Then I announced it.

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No surprise, Micah instantly burst into a fury of anger and began chasing Liam around the house which ended in Liam running into the door frame and crumpling into a heap of humanity you see to the right. A heap of humanity that was ~K200 richer but was in pain on the floor with Micah jumping on him in a Tazmanian rage. 

It was the one combination that I didn't predict. 

Of course, this required much remedying by Hutchinson mom and dad. As I basked in the unexpected results of my fiendish experiment I began to think about "Split or Steal" and the work we're doing in Blantyre.

Global health efforts can really be boiled down to varying combinations of "steal or split". I don't pretend to be an expert or know which combination is the correct one but my rudimentary thought process breaks it down to the following:

Steal & Steal: Improving Global Health takes money, lots of it. Unfortunately, the reality is that the countries that desperately need improved health care are the ones that don't have the money to provide it. In this scenario, a country has to allocate money for health care from an already small pot. Advocates for infrastructure, agriculture, education, and others fight to get their piece of the pie. I think we can agree this is sub-optimal. 

Split & Steal: Much of the time the money can't or won't come organically and requires involvement from the outside. In this scenario, underdeveloped countries receive 100% of the benefit from outsiders. This will typically be something such as pure monetary donations, certain grants, and short term mission trips. These efforts all do help but to me they tend to lack what I find to be a more and more crucial element to successful, long-term Global Health endeavors - relationships. 

Split & Split: In this final combination, both parties receive some benefit. To me, examples of Split & Split combinations are endeavors that involve education that flows both ways and building infrastructure that have uses that benefit everyone involved. When we share the benefit, we're more inclined to continue whatever endeavor it was to begin with. It may be smaller gains as the money may not flow purely in one direction but it's something that will be sustainable.

The work we (aka Elizabeth and Martha) are doing here is most certainly Split & Split. There are too many connections and balls in the air to make sense of it in one blog post (Dec 17th Morning Report!) but I know in my gut that the direction we're going will be one that creates lasting change. 

In just over two weeks, we have already seen great changes at Ndirande. From no semblance of unity to morning reports and a lunch time Continual Professional Development that the staff are truly excited about. From Bactrim (which has 80%+ resistance rates in Malawi) for every child with URI symptoms to the seedlings being planted for judicious antibiotic use. From mass referrals to Queens to...

Well, we're still referring a lot of people to Queens.

But that will change too in due time as well.

I can't say how this will all work or what the end result will be. But what I do know is that anything of substance in this world involves relationships and the ones that are being made here will only continue to grow and strengthen as we move forward, together.

Ben Davis, SFH R3

 

Malawi Week 2

Ben and I have finished week 2, which means we are halfway done with our time here. It is going by quickly, especially because we are in the early phases of establishing what the clinic and rotation for other residents will entail after we leave. But, this kind of thinking/planning is really fun and rewarding -- there is a lot to learn along the way!

Week at a glance
This week we continued to work at Ndirande in the mornings -- except for Wednesday, when we were invited to help grade medical student OSCEs (more below)! The weekend was lovely and relaxing and involved a car trip to the Tea Estates. We left the dry dusty city for the beautiful green hills of the Tea Estates. We spent the afternoon with 2 other young families on the grounds of "Huntingdon House," where we were served tea and cake while the little boys played croquet. It was very British and so refreshing! A highlight of Sunday was observing a wedding reception taking place in the gym of the SportsComplex where I worked out. The wedding colors were bright red and yellow, the music was extremely loud, and there was lots of dancing and money-throwing :).

Ndirande update
Each small improvement feels like a step in the right direction. Our "accomplishments" from last week include -- we developed a schedule for our team (EHutch/Resident(s)) and proposed specialty clinics (diabetes, hypertension, procedures, etc). Of course, this is likely to change as we gain a better sense of the health center's needs. Also, we developed a way to track the patients we see and the desired diagnostics, so we can make a case for getting specific resources; and, we finally found a list of the essential medications in Malawi (all of which should be available at Queens, though the head pharmacist admitted there will constantly be medications out of stock). At least we know WHAT we can prescribe for patients.

These small steps are good, but we expect the overall process to be quite slow. It will take time for there to be mutual understanding and collaboration. We had a staff meeting last week (yes we did! And it is planned for this week too!), and Elizabeth suggested that we and other subsequent residents could be of help in certain ways. This meeting took place in the labor room (which was silent except for the meeting, though there were 3 women in active labor just 4 feet behind me). The labor nurses looked at us suspiciously and there was little response to the questions Elizabeth (and Martha posed); certainly no comment was made when it came to the new residents. I'm imagining foreigners coming to the First Hill clinic (my residency clinic) and offering to be of help to our struggling situation, just for a month at a time...It's not quite the same, because they acknowledge they are desperately in need of resources; but it's hard to welcome new people with open arms without experiencing how they will contribute to or integrate into an environment.

The Culture of Medicine... is different and challenging my framework for medicine.
--Clinical officers serve in most clinical roles and work independently at district health centers. These officers are medically trained but not physicians -- they are about the equivalent of a physician assistant, and operate based on symptom algorithms (often without an exam). These algorithms allow them to see the high volume of patients that wait to be seen each and every day; but unfortunately, I have observed those algorithms used incorrectly, such as applying an adult algorithm to a child and using a medicine unsafe for children.

--They, along with brand new interns, perform c-sections without supervision. Many OB-GYNs here don't use their skills for c-sections; rather they are called upon to manage the post-op complications of cesarean sectons (infection, ruptured uterus, "ruptured abdomen" as Elizabeth saw --the woman's intestines were protruding from her post-cesarean surgical wound)

--Many clinical officers are wonderful, but some, once they achieve a senior position, become less invested, and don't always come to work. I've hypothesized that some of that is likely related to poor pay, some is related to accountability (lack of a true structure to ensure accountability) but some is probably due to emotional fatigue -- the problems are so great that a day spent at a clinic giving out 40 prescriptions of Bactrim (more to come on that) without having the capacity to do much else feels like a miniscule gain; thus not participating in that process for a day or two feels like a minimal loss.

Medicine in Malawi (for my medical friends reading this...)
--Yes, there is antibiotic resistance here. One of Elizabeth's colleagues at Queens is here from the UK conducting research about Bactrim (or "Cotrim") -resistant Strep Pneumoniae, a common bacterial cause of pneumonia. The main problem stems from life-long PCP prophylaxis for HIV patients, regardless of CD4 count; but, as alluded to above, at least at Ndirande, Cotrim is prescribed for any fever/URI that is not malaria. One of our eventual goals will be to have some teaching sessions on viral vs bacterial infections! Sounds familiar...

--If you are ever concerned about a ruptured ectopic pregnancy in an under-resourced setting, don't hesitate to insert a needle into the posterior fornix and attempt to aspirate blood. In retrospect, I think I learned about this in med school (culdocentesis) but it has  been far from my mind until I witnessed Martha doing this in our clinic last week. 

--If you are a pregnant woman coming to deliver at Ndirande, you need to bring your own basin, sheet, and garbage bag to serve as an undersheet. You will labor in a small room with beds almost touching and if there aren't enough beds, you will labor on the floor. No matter what kind of patient you are, you will always bring a "Health Passport" to the clinic. It will have your name and date of birth and a few scribbled notes from the last clinician who saw you (as long as the handwriting is legible, this is actually extremely functional in the absence of an electronic medical record! It requires a level of patient responsibility with which I am quite impressed!)

Global Health
The topic of global health is emerging as more and more complex as we focus on the small microcosms of Ndirande and the Malawi College of Medicine. I am so thankful that immediately preceding this international rotation, I was able to take an elective through UW entitled "Global Health Leadership" (this is an advertisement to all second year Swedish residents reading this). It was a class made up of residents from UW (except me) that met on weekday-mornings to learn about and discuss important/relevant topics in global health. I became more aware of issues of funding/aid, infrastructure, health technology, as well as disease and public health. My observations are thus within this new framework of knowledge, though Malawi as a country has its own complexities to learn. For instance, the Ministry of Health provides housing for all appointed clinicians (medical doctors) at various posts (including "registrar" or residents). If we are advocating for Malawian family medicine registrars to work at Ndirande, we also need a plan about how to house those registrars...  

Medical school
This was a funny place to observe similarities and differences. One thing was quite similar -- the medical students were nervous for their OSCEs (observed clinical exam)! They were extremely polite, shaking hands with each actor or standardized patient, even when the prompt clearly placed them in the middle of an encounter (no need to introduce oneself again). There was discussion about retaliation for disappointing grades and the need to abide by the College's official grading system (I may have heard of US students challenging grades once or twice...). The topics of medicine are similar but all within a cultural context --one of the scenarios was a patient with asthma and few of the students had ever seen an inhaler. I graded a prenatal counseling visit -- and common advice for women to deal with labor pains was to "distract yourself" (there is quite a culture pressure, I'm told, of being quiet so as not to irk the nurses). One scenario was about sexually transmitted infectious, and students are not yet taught to ask questions about multiple partners, genders of partners -- principles that are drilled into first year medical students about taking a sensitive sexual history.

That's all for last week! New things are happening all the time so more to come!

-Beth Thompson, SFH R3

Azungu

Definition: Azungu - Chichewa for stranger, foreigner, white person.

 

I know about 10 phrases in Chichewa. Out of that vast vocabulary my second favorite word is "Azungu". It's not a particularly malicious word. It can often be heard shouted at white folk as they/we drive by in crowded streets followed by a wave. However, I can't help but see Azungu peppered into layers of culture.

My first memorable Azungu experience came a couple days ago on Saturday. The Hutchinson family (for ease of writing the "Hutchinsons" will include Beth and myself unless otherwise noted) decided to go on a hike at the plateau in Zomba Town. As we eased Black Mamba into the town center the streets became progressively more narrow and cramped to the point where it felt like a single car couldn't even get through. We took several turns into what felt like a automotive chinese finger trap. The more we tried to find something, the more we got further and further stuck in the depths of Zomba Town. As time went on we slowly accumulated more and more stares from the residents of Zomba Town. It was reminiscent of scenes from Resident Evil 5 - which is a truly awful analogy but it was honestly the first thing that popped into my head while on the dirt roads. We finally were so lost we had to U-turn in what must have been a 10 foot space and ask a camo'ed guard for direction. 

Once we arrived at the plateau we were greeted by a 3 star resort with whatever modern day amenities you could want - including a life size chess board. Hospitality was abundant and we had an unending number of vendors attempting to sell souvenirs. I was initially weary of these meticulous souvenirs on the side of the road next to a fancy hotel. I thought they had to be manufactured somewhere else. But then I saw one of the vendors making one of the wooden art pieces by hand. Foolish was I to think I would be sold knock-off items in the heart of Africa. For us, it was a 180 degree turn in a matter of 30 minutes from dirt roads, shacks, and roadside butchers to posh amenities and a full service staff. 

The next experience was a 2 year old child who I saw in Consultant Clinic later that week. The children I have seen have largely been stoic but this child came in crying. I'm honestly blanking on the symptoms the child had but what stood out is the fact that the child cried every time she looked at me. I joked to Julius, my interpreter who's in clinical training, and said "Azungu". He confirmed it with an emphatic "Azungu" in return. It held a lighter tone than my first experience but was a notable one nonetheless. 

Later that day Beth and I was were waiting outside of Ndirande for the Black Mamba to take us back home. We decided to venture into the unrelenting sun to see the daily soccer, sorry, football match that occurs every day after school in the designated dirt pit. The ball appears to be made of a combo of plastic bags and fabric but is looks like better quality than most stuff we have. Once outside, Beth and I instantly received a bevy of stares in our direction. One of the kids yelled out "You are beautiful!" in our direction. I'd like to think I looked quite dapper in the Malawi sun but he was undoubtedly speaking to Beth. They also yelled "Give me my money". I bargained money after they scored a goal as we pulled away in the Mamba. 

More recently I've had more somber Azungu experiences. Today, Beth and I helped out at medical school grading OSCE's (essentially mock patient interactions). Afterwards, we had a debriefing with the other clinicians and faculty members. One in particular was speaking glowingly about one of the students. We'll call him Wussell Rilson. The conversation went something like this:

Non-Malawian, White Doc: Wussell has been great. He is clearly on another level than the other students. He clearly was not schooled in Malawi *slight catch*. He must have been schooled in the UK or elsewhere.

*Stare and silence of Malawian doctors ensues*

It was a brief moment that probably lasted a total of 1 second which was quickly followed by talking about the other students. However, it was a moment that stood out like a tall half Asian, half white guy trying to buy grilled corn on the side of the street in Blantyre. The statement wasn't necessarily untrue but it was one that further emphasized the Assign. 

The most poignant example of Azungu came last night. The Hutchinson Family sat down and watched a movie. The choice for this particular evening was "The Power of One". It's a fictional movie from the early 90's that was tale about an English boy who bridged the gap between whites (English, Afrikaners) and blacks in South Africa. Now it was obviously about Apartheid and isn't really relatable to Malawi in a direct manner but the movie included scenes of dilapidated housing and segregated facilities for the native Africans. What I haven't mentioned until now is that we watched this movie with Blessings, our wonderful, Malawian gardener/handyman extraoordinaire. By comparative Malawi standards, Blessings gets paid very well for what he does. He's going to school and he is treated like one of the family. But I still couldn't help but feel the stark difference in how we live each day. 

No amount of money I give or guilt I feel can ever make anything right. There is no easy answer in remedying the boundless distance that separates our worlds. 

So for now, I can only settle for popping open a couple of coke bottles and sharing a meal with Blessings while practicing my favorite word in Chichewa, "Tisangalalae" - Let us enjoy this.

-Ben Davis



Malawi, Week 1

Most of you reading this are being constantly entertained by Ben's musings and curious Facebook posts -- some of this may be a duplicate recap! But I do want to share some of my own observations and ponderings, most of which are probably self-evident, especially to those of you who have had extended international experiences. Please indulge my reflections!

Malawi life:
It goes without saying that life here is extremely different than life at home. Our (and "our" meaning the Hutchinson/Ben/Beth clan) day-to-day has fewer of the conveniences we are so used to (drinking water from the tap, constant electricity and internet access, reliable ATMs and credit card machines, carpeted or hardwood floors, paved roads, and Starbucks), and it feels more strenuous to live here. But Malawian men, women, children actually work physically hard for their livelihood. They walk miles around or between villages, carrying massive loads of lumber or huge bags of who-knows-what on their heads; they spend hours picking a bowl of berries to sell for the equivalent of $1 or less; they chop wood and stone, they carry babies (or multiple babies) all day long. I've started to contrast the physical stress people experience here with the mental stress we experience in our world. Of course there is mental stress here, especially in experiences of loss, scarcity, trauma -- but there is notable absence of certain stressors. Time is plentiful -- no one is rushing to get through the grocery store line in time for something else or to catch a bus ("minibus" crowded with 12-18 people) or subway (nonexistent of course). Additionally, something I expect to experience more in the future, there is less institutional pressure to perform, improve, and stay accountable. Some of this is certainly problematic but also diminishes the level of mental/cognitive stress. A specific example is that the clinic in which we have begun working is "supposed to" have periodic staff meetings -- however, they just don't have them. In a discussion with a clinical officer Jane (she is about the equivalent of a PA in Ndirande), she acknowledged this ("We know we are supposed to"), but for some reason, the meetings don't happen. I am of the opinion that meetings should occur at this clinic :) -- but imagine the difference in stress level if you never had to attend a staff meeting and discuss the things that are going poorly!

On a general note, other specific observations that have caught me off guard or challenged my expectations:

There are paved simple roads with dirt on either side --not too much rubbage or waste. 
Smaller roads are dirt, with potholes. MANY people walk -- there are significantly more walkers than drivers on the road.

There are ways of making money I had never thought of before: carrying piles of coal to market on a bike, selling a puppy by holding it in the air for all to see by the side of the road.

Babies are carried by women who wrap them around their backs. They appear so content peering out at the world but I haven't had the chance to interact with one yet.

My first bedtime in Malawi, I was joined by two geckos on the walls --they are harmless, but I was very thankful for the protection of the mosquito net.

Our first full day was filled with some interesting trials -- the car keys were accidentally locked in the car at the supermarket. Thankfully Bill saw a friend in the store who gave him a ride back to the house; we gathered groceries, waited in line only to learn the credit card machine was not working (for the record it is still not working and they don't know when it will work again). The ATM around the corner was functional, so we were able to get enough cash (Kwacha) for the groceries. No one seemed to mind the 20 minute delay we caused.

There are so many funny uses of the English language --on buildings, cars, signs, and T-shirts. For instance:
                              Yahweh followed by a Nike swoosh on a minibus
                              "Maximum Leisure Center" on a creaky-looking gated area, no evidence of leisure anywhere around
                              "Toward power all day every day" -the power company slogan
                               Handwritten "Cake Boss 2014" on a bright orange Tshirt, and "Number one Grandpa" worn by a twenty-something.

Culture
I've become more aware of which aspects of my life might be unique to my culture as compared to Malawian (or any other) culture. There is a cultural aspect to pain -- I haven't seen this yet, but Elizabeth tells us that Malawian women don't make a sound during labor. When we examine patients with clear abdominal pathology (mass, PID), their faces don't register pain at all. Babies and children waiting in line to see the doctor aren't crying. The 4 Hutchinsons, Ben and I went on a nature walk at the top of Zomba plateau -- a large hill/mountain with a precarious road with beautiful trees, waterfalls, birds and monkeys (as well as a conference center) at the top. We were decked out in rain jackets, running shoes, carrying granola bars, trail mix, and a backpack -- this contrasted to our guide who was carrying nothing and found us some berries by the side of the road for a snack. And when we went to Circuits (see Ben's previous post) -- it kind of looked like the composition of Community Fitness in Seattle (3:1 female to male ratio, spandex, ponytails, no Malawians except the leader). Some of this is related to income, but I'm sure some of it is also purely cultural.  Currently, Liam, Micah, Ben and Bill are outside having a water fight while Blessings (the 25 year-old employed house staff) smiles in disbelief -- he reports he never did this as a kid (of course, the bright green water gun might have something to do with that).

Medicine
We have only had two days in the clinic so far -- and a walk through Queen Elizabeth Central Hospital on a holiday (thus a slow day, because everyone thinks the hospital is closed on holidays) --but I have been amazed and invigorated by the amount of medical pathology. Working here affirms WHY we need Medicine -- because the human body will disintegrate and succumb to disease, infection, deformity to a much greater extent, much more quickly, without the tools of modern medicine.

My overall sense is one of thankfulness for the Hutchinsons and Elizabeth's commitment to participating in Global Health in a way that aims for sustainability and prioritizes the needs and desires of the community. We have much more to see and learn! Stay tuned :).

-Beth Thompson, SFH R3

I Hate It... But I Love It

I've had brief stints with mediocre physical fitness in my lifetime. In college, I had periods where I would go to the IMA and playing sports on a regular basis. The spring prior to residency I did about 4 months of P90x. That was pretty good. This past summer I did about 2 months of P90x again until I returned to my rightful slothlike baseline. One of my favorite lines to quote in life is from Tony Horton himself. It occurs during the Ab Ripper video right when I really start questioning why I'm doing Ab Ripper. Tony looks at the camera and walks toward it in a predatory fashion to say "I hate it...but I love it". That's kind of how I feel about underserved medicine. I hate seeing it somedays. Whether it's at DFM back at home or in clinic today. Sometimes it just rips your heart out and gives it an flying elbow from the top rope. 

We had our first work day today at Ndirande, one of the "district hospitals" here in Blantyre. It functions much more like a clinic at it's current state but with enough time and support the hopes is for it to be a full spectrum release valve for the overburdened Queens hospital here. Driving in Ndirande (see slide show), you really had the feel that this was different. Not different from the United States, that's a given. But it had a different feel than what surrounds Queens hospital. The streets were more crowded. The roads were more narrow. No signs anywhere indicated there was a health center nearby. You really didn't know it was there until you stood 5 feet from it.

Once we arrived we quickly set up shop and got to work. We estimated we saw around 20-25 people in the morning session. For me, it was pure medicine. Each patient wanted and needed to be there. Clinical acumen was at a premium due to there only really being HIV testing nearby. Pretty much most other labs needed to be referred to Queens. Beth and I watched Elizabeth for a few patients then split our two humble rooms to see patients on our own. We debriefed a bit at the local ShopRite after work as we had to exchange dollars for large stacks of Kwacha (see Micah making it rain in gallery). Here's just some of what we saw:

  • HIV (likely AIDS) with new diagnosis Kaposi Sarcoma
  • Molar pregnancy
  • Possible ectopic pregnancy
  • New onset afib + HTN + bilateral, severe cataracts that had been brewing for years
  • Lots and lots of abdominal pain +/- vaginal bleeding

Working with the underserved is a constant mash-up of feelings of inadequacy/outrage/fulfillment. You're constantly practicing medicine with one arm tied behind your back but you're treating the most vulnerable. The patients that likely need a stable bed or someone to acknowledge them more than a q3month hemoglobin A1c. Today was much in the same vein. I hated seeing what I saw but I loved that I was fortunate enough to be in a position to make a small dent into the unending burden of disease today. 

After work, Elizabeth, Beth and I tagged along with a local internal medicine physician here from the UK for a rousing night of "circuits". This is the first I've heard of circuits. It's essentially interval training but this most assuredly had a Malawi twist. There was about 20 or so of us congregated outside a nearby boarding school field. After some jogging we had our course director, a very buff Malawian man, come out to lead us in activities that included tire pulls, tire lifts, and tire carries. Sprinkled in were some running activities as well. We then transitioned inside for more interval training which included planks, squats, and weight training - and tire carrying.

It was a bit of a surreal experience. Here I am with Beth and Elizabeth. We're covered in dirt and lift/carrying/pulling tires around a boarding school in Malawi. Both people who I have known for several years and respect - now transported to a locale that I wouldn't have ever fathomed 3 years ago. These are the experiences you remember long after you have dementia. It's something I'll probably be telling my nurse when I'm 80 and in an assisted-living facility.

I couldn't help but harken once again to my old friend Tony Horton as my body shook in a feeble attempt to maintain a plank at the end of the night. I'm hating it (disease burden, inequality, planks) but I'm absolutely loving it (Malawians, Beth/Hutchinsons, clinical care and learning).

-Ben Davis, SFH R3 

 

Music of the Night

One of the most honest windows into an area is what you hear at night. Gunshots. Cars Honking. Crickets. What you hear when you really listen at night is unadulterated and unfiltered. I'm more guilty than most for not taking the time to listen but I've been blessed to have the next 5 weeks to sit in the stillness that is Blantyre.

As I type here in the Hutchinson family living room, I don't have to listen too hard to hear Blantyre's music of the night - choirs singing. I'm at least a couple miles from wherever the sounds are emanating from but they find a way to pierce through the wind and into this room. It's not just any choir music though. It's music that feels uplifted. Joyful. It's music that you don't have to be of a particular faith to appreciate. 

I've only been in Malawi for about 7 hours but from my short stint meeting people such as the infamous Blessing (Hutchinson's jack of all trades gardener extraordinaire), random house guards, or the guard who searched my bag at the airport who said "Land of the Free and Home of the Brave, eh?" (I replied "....sort of") - people here are different. It's not the polite, routine greetings we have back in Seattle. When someone talks to you they're really talking to you.

There has been other sounds during the night recently back at home. That of TV sets covering Ebola coverage. It would be a disservice to the petrified if I didn't touch on it at least a little. Curiously, Beth and I both had our temperatures scanned upon entry into Blantyre. One of the other travelers told us that pictures weren't allowed but I was able to get a couple in prior to that. I'm happy to report I dot have a fever and am not worried about Ebola. I'm more focused on the large spiders who's reputation precede them. I haven't seen one yet but I'm most assuredly hyper vigilant at this point. My plan is to just hurry up and see one to get it over with. Rip of the bandaid quickly. 

Tomorrow we head off to Queens hospital to see the wards. The stories I've heard from Elizabeth are harrowing. It's not a place for the faint of heart and is something I'm sure will continue to shape my outlook on our global community. It's truly an honor to be here with Elizabeth and her family. Her tour de force effort to make this opportunity a reality is one that I know is appreciated my all of us R3's. 

After 30 hours of traveling, I'm exhausted and look like death. But I hesitate to sleep knowing that there's so much to soak up here. Can't wait to see what tomorrow holds for us...

as long as that thing isn't a large spider at my bedside.

-Ben Davis, SFH R3