Beach Conference

In the hammock
Kande Beach
15/3/2010
This blog is one I knew I’d be writing for some time, but had also secretly been dreading for one simple reason: this blog will tell of some well good beach times, replete with all recognisable clichés of indulgence like day-long beer drinking, midday swims and hammock lounging... which to some will sound like I’m on some kind of sponsored expat vacation, instead of doing the hard surgical work I’m here to do!! But let me at least justify it. After 5 weeks in country spent mostly attending intensive induction lectures, acclimatising, settling into a new (crazy) town and workplace, attending a busy central hospital from 7.30 till 5pm most days for 4weeks now and trekking around on long distance bus journeys to establish some of the projects I’m working on (applying for a development grant [which got accepted by the way], set up of a trauma registry and joining a teaching programme), a 3 day weekend at a beach resort to recharge my batteries is hardly asking much I would hope!!
Especially since that weekend also happened to be the official annual volunteers’ conference with your VSO-type information overload packed in during the day; also bearing in mind that getting there and back alone could easily require 3 more days’ break to recuperate- 4 hours’ rough driving, the forward journey being notable for its 5am start. That didn’t stop the location being absolutely idyllic- Kande Beach along Lake Malawi- and the company simply wicked. And what’s more, the house rules weren’t the stuck up ones I’m so used to at home. This time they were so relaxed no one would actually notice if you went missing for part of or the whole day, which some certainly took advantage of, but not me. I was happy enough being near the bar, with most of the sessions being held in the open air just around it, and the beach being a few metres’ walk away. The session intervals were fairly generous and allowed for a dip now and again. The opportunity to discover all the different cultures that make up VSO in one place so far removed from home was to me a truly fascinating discovery. I’ve realised there are many different categories (if such a word can be used) of expats, each country having its own peculiarities. Many insights also were brought out into the balance between wealth and poverty, education and lack thereof, community and individual etc, which I’m only beginning to scrape the surface of. Incidentally I was rewarded for my interest by being made a VSO rep for my region. Actually the truth is that no one else wanted to do it!
The evenings were in a different league altogether, the first night being elevated to its unforgettable status by some pretty frantic Karaoke-ing by a motley crew comprising nostalgic Brits, Americans, Kenyans and Filipinos. The second night provided the scene for some fierce inter-volunteer competition fuelled by a very VSO-esque pub quiz (which my team won- only cause we managed to gather about twice the number of participants as any other team, had a VSO insider in it and a representative of every different country that VSO recruits from!!!). All this combined with regular rounds of Greens and Kuche Kuches happily turned every second of the last five weeks into a sweet drone of peace!

That certainly could be said for the live planetarium that was on display high in the sky, with many a constellation recognisable by anyone with an interest in astronomy. For those without, like me, the sheer immensity of it all and the profusion of shooting stars had all the magic one could possibly conceive of in their dreams. On the horizon, a different kind of spectacle was being played- that of the nighttime fishing tradition of the locals. They use a strong light to lure the tiny fish called Usipa or Katempa, and the turn it off before throwing their net onto them. (The catch is pretty good but the taste is very much an acquired one. These fish represent one of the main protein intakes of Malawians and are usually dried and salted by the time they’re sold. Of course, that’s next on my list of tastebud dares.) From a distance, at night, sat on a deserted soft sandy beach, this human milling looked just simply surreal, a bit like a lantern procession with the occasional firework. A Dali painting come alive if you may... That had to be my favourite part of the weekend.

Wifey and Hubby!!

Clinical Digest4

Clinical Digest: 11/3/10
Last Tuesday was a day I won’t forget so soon. That was the day when I, a career orthopod, did my first C-section! It was an awesome feeling, aweful too for sure, but uncomplicated in the end. I certainly have breached a barrier in my surgical abilities now. Such an achievement would hardly have been possible without the assistance of the great supervisor I had in the person of Dr Jobe Smith, American expat, having spent 8years in Norway and now here as a double-expat with the Norwegian charity Helse Bergen. Like him, everyday, I’m meeting people with a certain ‘je ne sais quoi’ to inspire me, be it their surgical skill, dedication to their specialty or their vision of development, in this bustling surgical department at Kamuzu in Lilongwe. Two other surgeons with Helse Bergen, whom I passingly alluded to before and who are currently keeping this overflowing orthopaedic department afloat are Drs Sven Young and Tor Nedrebo. Apart from their “affable personalities” I already mentioned, I believe the characteristic that does them greatest justice should be their passion. There doesn’t seem to be a ward round that’s too long (100+ patients at times), a clinic finishing too late (6.30pm) or a list too packed for them, as long as they have the reassurance that they’ve done all they can do to assist in this Malawian pandemonium during their time here. I’m enjoying working with them so much that it’s proving real hard to resist being drawn towards my Orthopaedic comfort zone, instead of widening my net to general surgery, obs&gynae and urology instead, as I’m meant to be doing.
Yes, as I found out on Thursday, urology will also form part of my repertoire in Ntcheu. It would indeed be extremely wasteful to refer such simple cases as phimoses and hydroceles to a central hospital, when I can learn the skills to treat them early by myself. So, with my new urological hat on, I had a go at doing a few circumcisions and was surprised how deceptively straightforward they can be. Most of them can be done under local anaesthetic or, as is often practised by “religious surgeons”, without any (aoow!). One of today’s cases ended up that way despite our care in administrating a meticulous nerve block to him. What a brave man! The tutor in this case was Dr Maher, an Egyptian expat, who impressed me at first as this most taciturn and self-composed surgeon in the morning handover meetings. Once in the operating theatre, it became obvious that he was no exception to the rule that all surgeons have a quirky (read macabre) sense of humour. He certainly knew how to relax his patients, by telling them that only 50% of the appendage had to be resected instead of the original 75% planned!! If there was one thing that seemed to work (in its own peculiar way), when the anaesthetic didn’t, then I’d have to say it was his kind of humour.
There is that quizzical aspect that I love about surgery. It is at once extremely serious (in the planning and execution of an operation), yet compulsively frivolous (in almost everything else- as evidenced by the countless innuendos related the passing of instruments- based on their shape or name!). It must be the way surgeons have had to evolve to preserve an overall balance.
My week was crowned on Thursday with yet another first: my first below knee amputation as the main surgeon. All those cases I assisted in suddenly disappeared from my memory bank and I was there trying to figure out how the book said to approach this operation and remember possible difficulties I might encounter. It was successful in the end, albeit slower than the clinical officer assisting me seemed used to (which he didn’t fail to indicate many a times!). This operation is very much a milestone for me and I feel much better equipped just for having this skill under my belt now. And what’s more, it’s potentially one of the most frequent life-saving operations I’ll be conducting in my time here. By that time, I hope I’ll have developed the speed my clinical officer would prefer ...

Clinical Digest3

Clinical Digest: 8/3/10
I have been at the Kamuzu Central Hospital for just over two weeks now, doing my orientation, so I don’t feel that I’m being thrown in at the deep end once I start fending for myself in Ntcheu. It’s remarkable what spectrum of surgery I have covered in such a short time. I feel strangely like being a medical student again, learning many things for the first time. That is mostly true for my stint in Obstetrics and Gynaecology. This actually made up the bulk of my last week, where I split myself between two hospitals to try and maximise my exposure. The experiences worthy of making it on my blog include:
1. My first clinic in gynaecology, where from being a mere observer trying to gain familiarity in the typical casemix for Malawi, I found myself performing all manners of gynaecological examinations. It felt really strange at first and I was completely clueless as to what I was feeling. However, given the reality on the grounds, and the fact that I was being taught by a clinical officer (a non-doctor), I had no choice but to embark on a steep learning curve- which has become a daily feature of my orientation.
2. The gynae list in Kamuzu, where I saw some pretty revolting stuff- a powerful reminder of why I choose to do Orthopaedics instead. I even saw the mightily feared “Teratoma” twice here (complete with hair and teeth). This is a condition the very mention of which used to send nauseating shivers down my spine in medschool.
I made the approach in the second case and closed in both of the cases. It’s really rewarding being able to expand my skills so widely in so little time.
3. Unfortunately, such has not been my luck as far as Caesarean sections are concerned, that being one of my main objectives here. Even though I assisted in at least 4, they were all either complicated emergencies or the first one with a particular instructor. As a general rule of thumb, one has to see one (with a given instructor) before being allowed to do one (by that instructor), and ultimately teach one (to others). So goes the dictum.
One of the C-sections I assisted in stood out though. Indeed, it brought out a number of fundamental differences in the way doctors operate and that in which clinical officers do. Respect for the soft tissues and neurovascular structures appears not to rest on the same level between the two groups. Maybe this sentence will illustrate what I mean- Clinical officers are happy to chop and repair, whereas doctors spend a lot of time avoid the chop in the first place, so it does not need repair... since the success of the repair is indeed far from 100%... as that case I am referring to served to prove very convincingly. That was compounded by unorthodox approaches and surgical skills, which seem to get passed on from one generation of COs to the other without ever being corrected. One example is the transfixion stitch, which instead of being secured tightly once it has gone round the stalk, is, for some reason, taken round and round and round it, without ever having a solid 3throe knot to secure it!
Also, never mention a transverse C-section incision around here, because that might challenge some well anchored myths: that the one and only incision for C-sections is the laparotomy!
4. My next and most startling observation concerns the anaesthetic side of things in a resource-limited setting. Whereas one’s heart would sink, with the knowledge of a delayed list, at the mention of a spinal over a general anaesthetic, here one tends to be rather elated at the news. In fact, so far they have had a fairly good record, with the exception of the said C-section above, where the patient started ‘feeling’ us close the wound as the spinal was wearing out! General anaesthetics are generally a hit and miss business here, where I think Thiopentone is the drug of choice. This is often combined with Halothane, for the one main reason that patients are often already awake before the end of the operation, and sometimes even seek to indicate it to you through hemiballistic arm swings! I’m yet to come across the ubiquitous milky suspension (propofol) I know from England. A very prominent detail regarding the delivery of the GA is that mechanical ventilation tends to require a permanently assigned attendant, whose job is to continually press and release the oxygen reservoir bag.

Today I went back to general surgery, which isn’t a field that I would call myself entirely proficient in either, Orthopaedics being where I belong. I was set on learning how to do an inguinal hernia repair. Overjoyed was I to see that there were three on offer today. So I tagged along for the first one, which proved to be an extremely difficult one to reduce, hence limiting any chance of me learning some vital steps in a cool manner. The second one got robbed by the theatre next door and the third one, well, was a hydrocoele. That was in fact beneficial for me as I also wanted to learn how to tackle this condition. The slight drawback was that the instructor was a clinical officer and, as such, I stood little chance of learning any detailed anatomy.
My net of experience got widened further in the afternoon, as I was involved in a breast mass excision, which I had to complete, my colleague having stabbed himself during the op. The cherry on the cake was a debridement of some escharified septic burn wounds, which had to be done “on the rocks” as we had run out of gowns and drapes! What a joy! They had sterile gloves.

Disclaimer: Please do not interpret my humour as sneer that’s being poured onto the department I am presently working in. If anything, I am very impressed with what is actually possible here and, above all, with the hard work from everyone. Yet without some form of satyr at least, I could not begin to establish the contrast that exists between our over-resourced setting back home and the one here. [If you don’t laugh about it, you’ll cry about it!] The ability for the people of Malawi to cope with so little, the unconditional gratitude they express for it all (as exemplified by the numerous gifts of corn cobs our staff receive from the poorest villagers) and the warmth and overall happiness they seem to maintain through it all, is none but awe-inspiring. It beggars the question, to me, why one would ever want to complain so much about futilities, when they do have a system which entitles them to so much for free.

FUNDRAISING

28/2/2010
Rest assured. This time it isn’t for me, so you can put your credit cards away! I went to one in Ntcheu. It was in aid of an artist who was releasing a CD and now wanted to fund the production of a DVD. But hold on, which charity, which school or hospital was this going to benefit? Well, there need not be any. Fundraising events do not have that string attached here. So there I was in a massive hall in a private school, with some 300 people each having paid 250Kwacha (£1) on the door, watching artists perform for a couple of hours to playback. That’s cool, there would have been no means of getting live in Ntcheu and, in fact, the dance was the best bit. However this dance had a twist. Each performance was preceded by a little fundraise talk by a compere and the audience would be called forward to literally throw their notes at the artist or the whole stage (Bombay dance-club style, for those who’ve read Maximum City). Every now again, he’d innovate and set one artist up against another and make the audience vote...with their money of course. Highest cumulative bid wins!
My role in that was intriguing at first, as my flatmate, Henry, who took me along, told me that I’d be invited to dance with the crowd. Henry is a church deacon connected with the church whose bishop’s wife happened to be the performing artist. I took his statement literally and thought it meant the dancing I was already doing in front of the stage.... until I saw him approach the compere in the distance and point towards me. A little later, in a blur of Chichewa, I heard the name “Ashton” spoken clearly 2 or 3 times, with beckoning fingers. I was to join Zikoma, an albino artist who is also a legend in the area, for some on-stage dancing. From whatever compulsion that overcame me, I ended up on stage attempting to copy his moves, invariably producing some variant of sega instead for the next 10min. I also had to donate some 1000Kw, but the craziest bit was that I was having money thrown at me from the crowd this time. The cheering and applause I was getting as “muzungu” provided all the energy I needed to keep going.
Back in the audience, the money raising proceedings continued. The bishop came forward and the crowd went up in larger numbers to squander more of their notes. The bishop appeal is a certain winner in this part of the world. The people of Ntcheu have religion hard-wired in them and even though this had no direct charitable aspect involved, other than to promote an artist and contribute towards her earnings, there was a distinct feeling that this was going to a good cause, a church-sanctioned cause. I addressed this with Henry afterwards and he told me that an event of this magnitude was really rare in Ntcheu. The people were being done a real treat by having this on their doorstep. The artist had done most of the organising by herself (albeit with her husband’s huge clout), at some cost and this event would be the main remuneration for her hard work as an artist in producing this album.
And this brings me to a rough estimate of her overall takings for that day. After what must have been more than 100,000Kw as money spilled onto the stage, the final round involved live bidding for the first CD. The first two bidders were picked and people would add to either of their sums to produce two competing stashes. It didn’t matter which one was higher as they would BOTH get the FIRST CD and the money from both would be kept. Handy when that is the sum of 40,000Kw and 45,000Kw respectively! That actually brought the grand total to a neat 260,000Kw- no meagre pickings in Malawian terms, but still only the equivalent of £1000. That, less all the organising costs, is really only a fair wage for an artist’s countless hours working on and promoting her album.
So...question? Where were all these extremely poor people of Ntcheu getting all this money from? Two possible conjectures- 1) Poorer people are usually the more generous ones, as they only have little and are happy to share that little; 2) Poor areas always have some very rich people in there to dominate the key businesses, and events like today help them display that wealth and status publicly. I personally think it was a combination of both.
The bottom line is that I had a whale of a time and felt like a king for 10 minutes at least today (Sunday). Sure enough, the next day I was to enjoy a sudden rise to celebrity, as everyone from the hospital to the local shop to the bank would recognise me and make a comment on my ‘dancing’...
This is showbiz Ntcheu style! For those interested in groovy chuch music, the artist was Mary Kapenga (albums goign for 1000Kw!).