D-day -10

This is one is for my lovely wife, akazi kokongola Janeti!! Today is exactly 10days before she comes down for her first visit and it will also represent a symbolic 3months since I've been in country.
I might have made scant mention of our long-distance relationship till now but it's been a really important aspect of this experience of mine. Janet's support is largely responsible for me remaining upbeat through it all up till now. So a big thanks to you here Janet and I look forward to welcoming you soon to this great adventure/work/personal development...

A Zombie in Zomba

Caleb and I
Okay.. this time I won’t mention the lake! Too late! I went up to the mountains instead. Zomba plateau to be precise and immediately after heading down to Blantyre first on the Friday and waking up super early the next morning for my lift to the base town- hence the zombie state! The route to Blantyre was in honour of my educational meeting at CURE hospital for the complex cases discussion from Ntcheu. I almost didn’t make it because, en route, my minibus hit some pretty severe weather in the form of a flash storm, where we had a gobsmacking downpour of hail with a visibility of less than 5m, and streets being flooded on both sides. That didn’t stop our driver from keeping going, nor did my constant shouts and pleas from right behind him!
Flash Storm
Zomba is this picturesque mountain city, the old capital of Malawi in fact before Banda relocated it to Lilongwe, with limitless vistas onto the fields around and further onto the lake. The route to the top was essentially a road with few shortcuts off the beaten track. My intention to do the whole thing along a potato path obviously went wrong somewhere, but did nothing to curb my enthusiasm about rising up in altitude. At some 1800m in height, the air feels somewhat fresher and the heart lighter. I really enjoyed being back in that element as evidenced by the pictures. The temptation was there to stay in a hut at the top but unfortunately they had a rallye the same day and all accommodation was booked. So we decided to go back down and in the end that move paid off. I stayed at my mate Caleb’s house in a nearby place called Domasi and it was just the most fitting escape for me, as concerns the nightly drumbeat cadence of Ntcheu. There, I stayed on the veranda, fenced by a fine metal mesh, which kept the mozzies away. It was quite frankly like being under the stars, and what more, without disco noise but the natural roosting and humming and click-clicking of the myriad creatures around. Caleb was in top form and is currently working with the Malawian Institute of Education to enable them to produce some educational videos etc. His interest and knowledge in African current affairs is astounding and these insights are even available in electronic format on the web. Just type in Caleb Muchungu and you’ll be exposed to some real African views rather than the typical whitewashed one we often get.
From Zomba.. with awe
After my fix of altitude and silent night, I made my way back to Ntcheu on the minibus, which was another great incursion into the world of African transport. In other words, never run a tight schedule if that is your chosen mode of locomotion. It waits at every station to try and collect that one extra passenger at the detriment of the available bum space in the already packed vehicle. It slows down at the sight of every potential passenger along the way, to reaccelerate to some wild speeds I wouldn’t do on a British motorway, once it’s figured out that person actually prefers walking to being a passenger of theirs! It then always gets halted at road blocks, where policemen eagerly scan the vehicle for the slightest flaw to impose some fine. And that negotiating can take up to 30min easily. But the fun lies in the witnessing of all this crazy rigmarole and the ample opportunities for conversation with Malawians. Not only is it a great way to get to know the culture better but it’s also an opportunity for you to be an accessible muzungu as opposed to the convential image of a 4x4 barricaded white face in a segregated shopping complex car park, where they sell cheese, chocolate, pizzas and the like. The minibus, in a figurative way, allows people to see there are also tourists/expats who eat nsima and usipa (the local tiny fish from Lake Malawi which I had the priviledge to eat, as prepared by a local Malawian friend of mine according to a traditional recipe- truly succulent I thought.. although my other friends didn’t seem to agree so much). I think I am now starting to see beyond my Bradt guide... and for myself. Oooh Malawi!

Clinical Digest5

If, by now, you are starting to expect some clinical stories from my new front, you’re right. For I’ve been in Ntcheu for 3 weeks already and have not sent any reports yet. That is partly because I was busy assimilating it all, and working on the contrast there exists between here and Lilongwe, sorely aware of the extreme contrast even this state-of-the-art centre presents next to the UK.
However it has not felt like a gloomy debut at all. There are so many facets of working in this environment that would make Lilongwe blush with envious shame, let alone the UK. For one the people working here are all approachable, all eager to help and all extremely welcoming. Despite there being a significant deficit in knowledge and skills, largely attributable to the resource-stretched training reality here, the affinity to learn on the job is remarkable in so many clinicians. The latter group comprises in order of seniority student medical assistants, student clinical officers, medical assistants, clinical officers, specialist clinical officer, medical interns and doctors.
The clinical highlight of my first week was really ward rounds and clinics, with little theatre work, besides assisting (mostly C-sections and a hernia). Orthopaedically, we did do one knee arthrotomy and washout for the management of a septic knee joint. I also saw some interesting cases of gross mal-union [a harsh reality of ORIF (metal implant)-deprived settings] and deep burns turned necrotic.
The second week saw me finally getting to the knife, performing salvage operations mostly. First of all, I did a below knee amputation (BKA) on a 3yr old for a necrotic snake bite wound on an ankle which had turned completely septic. My main concern about her management came intra-operatively when I discovered some suspicious looking fatty tissue as far up as the knee. I was not prepared to escalate to my first through-knee amputation though, with no guarantee that even that level would be adequate. So a careful decision was made to wait and see how the BKA alone would fare. By the day 10 mark post-op, I have to admit that, to my surprise, encouraging signs of healing were showing. The next operation came in the form of multiple disarticulations required on a man with severe septic eschars on his dominant hand from a burn injury. I did it under a wrist block (my first ever), which was somewhat helped by his HIV associated peripheral neuropathy anyway. In the end, after more tissue had to be resected than originally intended, he was left the best semblance of a hand that he will ever get. Time will only tell if that will survive or he will end up losing even that rudimentary pincer grip we have tried to preserve.
The second week also saw some colourful moments in minor theatre, which is essentially a treatment area, where most wound management is done. Most of it by junior clinicians, often unsupervised. The result of this state of affairs revealed itself to me in a pretty hairy manner, as I unintentionally found myself taking over a few times (at lunchtime as it typically happens) from struggling clinicians, completely out of depths. Firstly there was an excision of a dorsal wrist ganglion misdiagnosed as the universal lipoma! An unmounted blade was the instrument of choice for plane dissection and a big question mark on the clinician’s face, the method of choice to dissecting it out! Another case was the excision of an actual lipoma (correct diagnosis for once, even though they were unable to distinguish it clinically from a pseudo-aneurysm), over the radial artery territory. It came out very satisfactorily as a whole and so was the ultimate state of the radial artery. Finally, the scariest bail out of all was for a “lipoma” dangerously close to the femoral artery which the clinician was blindly pecking away at. This is a case I would of course have chosen to do under GA/Spinal in majors. But here I was using a tiny incision, to limit the damage done and resect as much of a pus filled lymph node (?TB) as was actually possible. The femoral lived on... by a very close margin!
Week two ended on an especially convened clinical meeting, at my request (excepting the timing), on the Saturday morning. This is a quality control exercise which is very laudable in its concept, the effectiveness of which remains to be seen. It should normally be conducted monthly but often months can go by without one. Most pertinently, it is a hospital-wide clinician reunion, where issues are raised by everyone on their own or their department’s behalf. The size of the institution in Ntcheu is really what allows for such an exceptionally democratic and wide-ranging meeting to take place. We discussed myriad issues relating to hospital organisation and the dichotomy between volunteers and locals was again starkly drawn out. Whereas we were banging on about issues of accountability, initiative and quality control, many of the points raised by the locals pertained to remuneration, satellite TV subscriptions and free diagnostic kits! Thankfully, the chair, a local Malawian doctor, was very impartial and did pick out priority issues for the main agenda and left “social” ones to be discussed as AOBs (any other business). I left with an overall satisfied feeling and a great urge to put our resolutions into practice.
Last week (week3), was when things really started to come together a bit more neatly. This was in part helped by competing operators being away at a training (ETAT- emergency triage assessment and treatment of under-5s). I therefore managed to get into theatre a bit more and to get to grips with the booking process and how to expedite work. My two main operations were both on hands for, you guessed it, necrotic wounds. With a slight difference, the first one was not a burn wound but a infection secondary to a foreign body. It’s worth remembering that tetanus is a real danger here and can kill pretty quickly too. This patient was not such a case but his middle finger needed amputating. With poorly functioning tourniquets and less-than-optimal lighting, ligation of tiny bleeders can be one serious challenge here. We had to leave the stump to heal by secondary intention and it will be quite a new experience to see the natural progression of such management on the ward in days to come. The second operation was almost a carbon-copy of the previous multiple disarticulation mentioned. This guy was not as lucky though and was left with only his thumb, which itself is unlikely to survive. We’ll be preparing for a definite below elbow amputation next week, rather than allow the infection to spread more proximally. The wards meanwhile, were being populated with an increasing number of people on traction for a number of different diagnoses. We had tibial skeletal traction for a couple of femoral shaft fractures (treated with skin traction in children), skin traction for femoral neck fractures and an amazing case of 900/900 traction through the tibia in a 60 yr old man with a femoral fracture but bilateral knee and hip contractures and shortening, secondary to multiple bony epiphysiodeses. What I particularly enjoyed was giving instructions to the elderly patients in skin traction regarding, regular exercises to avoid DVTs, as low molecular weight heparins are something of a distant dream in Ntcheu. The week was concluded by an educational visit to CURE hospital in Blantyre, which proved to be so useful and insightful that I’m going to be making of this a regular occurrence, with huge benefits for my patients.

Some things are more plain sailing than others

Hmmmm
El Capitano
Yellow submachine
For fear of including only jealousy provoking blogs about my lakeside evasions, I shall make this one only briefly and leave you with photos rather. Yes, I went back to the lake on Easter weekend. The appeal was too great, despite my rather shattered physical state (after the Lucius escapade!). It was in honour of a long-awaited reunion with my main contact in Malawi from my previous trip- Mr Neville Bevis. This man needs a full blog to merely paint a superficial portrait of his oh-so-varied-and-amazing life. In just a few words, he is a 60 odd year old widower and retired teacher from Harrogate, who’s been in country for >10years running an ‘orphanage’ by the name of Open Arms. He has recently opened a new branch in Mangochi, near Lake Malawi, and that is no mean feat. The level of organisation and dedication it takes to run even one of the ‘orphanages’ in Blantyre would scare the hell out of most normal good meaning people I can think of. He hates the term ‘orphanage’ with the same passion my friend Caleb hates ‘AIDS orphans’. Not least because, over here, these terms attract stigma and, rather than help, simply exacerbate the problem.
Besides his charitable credentials, Neville is also an experienced sailor and has spent the last couple of years spending his retirement money on his dream, that of building a sailing boat. That, he did pretty well here using local people and materials as much as possible. And this weekend was one of the early trial runs of his new baby. With his physically eager ”moussaillon” it was only a question of shouting out the orders before the sail was raised skywards, the anchor swapped (requiring an acrobatic and divine dive into the deep lake to reach it) and the catamaran moving (with the anchor-boy back on board after a rather Latissimus-testing scramble). The rest was a fairy tale fuelled by a heat-induced partial delirium and lack of food! Let me add that that was not our intention . Food we brought with us for sure, but little had we anticipated the spillage of fuel that turned our bread and cheese sandwich into a highly flammable carcinogenic timebomb... Not that I didn’t try to eat it at least, but the violent rejection from my tastebuds was a reaction I could hardly ignore!
What better way to test our weakened, beer-thirsty souls then, after some 4hours hard sailing and boiled lake water drinking, than to put a squall just at that spot where we decided to take down sail. I had no idea what and where it came from but it was like we suddenly left the eye of a cyclone to get right into its chopping jaws. How we managed to bring the sail down without getting hammered to death by these raging metal-fringed canvasses is a mystery to me! By then I was on my very last legs indeed and all that kept me going till the coast was a beer-gilded mirage. And Oh did it taste good!

Next day, we had a renewed trial with an additional member. By then, thankfully we had ironed out most of the teething problems from the day before (I’d like to take some credit for this). And this time we did have a plain sailing venture into the vast lake... under the same beating sun and drinking the same lake water tea, but less the squall. We had Mwera instead (a localised bad weather formation on the lake) in the morning but wisely waited for it to abate. By the next morning the Bwera had scaled up a few notches and any sailing would have been beyond our wildest ambition. But there was no need for any such death wishes then, because we had done the sailing we set out to do and it was our time to head back home anyway. This we did along some pretty fascinating Bwera-free landscapes environing the exquisite natural gem which is the Liwonde National park. I was one satisfied and sore-boned terrestrian stung by the sailing bug! PS: I do apologise for failing in my aim to keep this one brief, but I hope you’ll understand why I couldn’t!
escape...

Tribute to Arnol

3weeks’ worth
It’s been hectic since I left this blog last. To try and recount all these events would make it far too long, so I shall simply summarise them and expand on a few. But before I do anything, allow me to pay tribute to a newly-met VSO friend of mine, who succumbed to a fatal road traffic accident on his motorbike only days after the annual conference: the exceedingly nice Arnol Pajaron, VSO volunteer from Phillipines who was working in Secure Livelihoods towards agricultural improvements in the district of Thyolo. May you rest in peace Amigo.
This was very much the first event since the conference. Sadly so, because I met him there. During the week that followed, I also undertook my last week of orientation at Kamuzu Hospital. This was mostly a week of wrapping up and refining some of my skills acquired so far- amputations, debridements, hydrocoelectomy, as well as clinic work. The visiting Orthopaedic surgeon, Sven Young, left at the end of that week, leaving the department without an orthopaedically-trained doctor anymore.
On the weekend, I went to Blantyre where a memorial service was being held in honour of Arnol. It was a truly moving service, where the close-knittedness of the Filipino community and their generosity were revealed at their best. The wider support of VSO was also evident, with more than 40 of us travelling from up and down the country. Probably the most humbling part of the service came from the very people Arnol worked with, the farmers, who also made this difficult trip to Blantyre just for him. The rapport he had developed with them and the fruits of his hard work were obvious from the brief but honest speech they did there. A slideshow of his time in Malawi, compiled by his best friends, concluded the service, with most of us struggling to hold back tears.
After this rather traumatic patch, my next week started afresh with a rather peculiar training for an orthopod- Anti-Retroviral Therapy provider certification (ART). Peculiar is starting to look like the norm now for me at this rate! ART is seen as being beneficial for anyone on the delivery side of health care in this country as I should hope “to become a player in the efforts to bring down the HIV/AIDS epidemic”. I use this very turn of phrase here to highlight a major division that manifested itself uncomfortably to me during the course: the cultural divide between Malawian and VSO participants. There is something that VSO volunteers very often talk, in fact, moan about, and maybe understandably so. It’s the allowance culture. Many key health care staff we work with are often absent from work, under the guise of such and such course. They get paid a hefty bonus (given as incentive) and generous living expenses for going to the courses. It often happens to be the same people who tend to go away on courses, such that they’re away getting trained rather than putting that training into real practice. The striking difference between “us” and “them” screamed out when we all got asked to express our expectations from this course at the start. Quite puzzlingly, the principal points raised by the Malawians were to do with their “accommodation”, “food” and even “allowance”. So, one of the VSOs finally added that we were also here to learn and develop our skills or something like that and I came up with the aforementioned quote! What tipped the balance of hostilities though was a complaint from the Malawians, who were being put up in a not-bad-at-all establishment. They found that room sharing was unacceptable, the water supply not good enough and the tea cold! This didn’t go down well with one of the VSOs who answered them back saying “they should stop complaining and get on with it like the rest of us are!”. This was a difficult one as that VSO would clearly not have interjected in such a way had some westerner raised this complaint in the west. Yet, given the economic situation in Malawi, having such high standards for educational meetings appeared to be somewhat eccentric. Point taken but still most of government meetings take place in one of the high-end hotel chains (which, I discovered, is owned by the government, hence attracts a massive discount) and civil servants want to have similar privileges. As for the allowance side of things, again I find that difficult. On the one side, I have depicted how they can represent a financial drain on institutions rather than a gain if the designated trainees are too frequently away on training. However, I also sympathise with them a bit as indeed, this is the only way they can acquire more skills to operate at a more advanced level, as required. Most won’t have had the privilege of a university education or tertiary diploma. Also, saying that they’re most of the time away on courses is probably an exaggeration (based on other volunteers’ experience), which I’m yet to assess for myself once I’m settled in my job. Regarding the financial reward involved in attending courses, one can hardly blame them, if one only looks at the gulf between their actual wages, all allowances included, and ours in the west (not our stipend here which is largely unrepresentative). Finally, there is a real problem here in the form of brain-drain of talent, as the highest skilled Malawians are often recruited abroad or in non-governmental organisations, leaving the government ones like hospitals starved for qualified staff. How can one blame the government on the one hand for not remunerating the staff well enough to ensure retention and, on the other, for giving them allowances to boost their wages? One is tempted even to congratulate them for attaching the financial reward to an actual educational activity rather than simply raising wages. Everything in perspective I think and whatever judgement be made, it ought to be made with due consideration of all relevant nuances. After the uncomfortable start though, the week eased off with some lighter humour and me acquiring the honorific of “Aphiri” probably for making sure I stayed neutral in that original rift. The amount of new information being force-fed into my brain was phenomenal, considering how detached I had become over the years from virology and infectious diseases (being married to a microbiologist unfortunately didn’t impart a chip in my brain with all this wisdom!). So the test in the end was something I was seriously apprehending. Thankfully they made it easy enough even I cleared it. So did the whole class!!
On this end-of-week note of success, I took myself down with some other vols to a bar in the capital city to watch the first of my Malawian music gigs. The band was The Black Missionaries, one the most popular bands around and they were supported by Anthony Makondetsa. Both were quite groovy, with a very typical Malawian beat to them (that one that unfortunately resonates every night on my bedroom floor in Ntcheu!) The crowd was equally interesting and I automatically made friends with some locals who were loyally ensuring my enjoyment throughout. There was none of this uncomfortable pressure of asking for things which I really like with Malawians. If anything they might ask for a beer maybe in exchange (which I would have offered anyway) or the chance to associate with the muzungu female company I was with (which of course, I had no control over!).
Next day, Saturday, was a memorable day as I finally set my bearings on Ntcheu for good, without any more orientation or training to do elsewhere. The settling in was invariably coloured by my very own priorities. Noise reduction and kitchen sorting strategy before house furnishing. I’m still working on both at the moment but hopefully will find a right balance. The location is simply great and it would be a shame to have to move. On Sunday (Palm), I went to my flatmate’s church out of curiosity and also because I knew a few people there from my short in Ntcheu already. It was an mind blowing experience to say the least. The church is a Born Again Christian one and the praying style is very much one of intense singing and going into transe, somewhat intoxicatedly. Also there was a strong focus on fund-raising (remember that previous do I went to? That was this church’s bishop’s wife). They had just acquired a set of drums and now wanted to get a keyboard. They pride themselves about having built everything themselves including the church building and essentially want to keep on upgrading... To get some balance back, that afternoon I saw my first ascent of the Ntcheu mountain with some other vols. It was a most rewarding experience, a mini-breakthrough in that it seemed like the rainy season had finally made way for some dryness. Unfortunately we were proven wrong from the very moment we began our descent... The view from the top alone would justify the climb and it took us less than 4 hours, so not too much of a pull for my aspiring visitors. Ntcheu Mountain Kids From the TOP
That done, I finally began working as a proper doctor IN Ntcheu district hospital this Monday gone. Hooray! It certainly feels like a big step forward for me with my numerous new roles and responsibilities waiting to be discovered. My job description is exactly defined and, for the rest of the week, I’ve been trying to find a way of making optimal use of my skills for the whole hospital. I have to, at once, try not to overlap with the other 2 doctors there, one obstetrician/surgeon, and 1 paediatrician (no problems there), and bear in mind that I will probably inherit some of the workload as they leave 4-6 months before me. Simultaneously, I’m also getting working on this project for which I got given a grant by VSO. I was exceptionally lucky to get this at such an early stage, and I’m going to use it to upgrade the orthopaedic department (ie replace rusty blunt instruments with one that cut). My clinical digest for this first week includes several Orthopaedic ward rounds and clinics, with little surgical work, except for assisting in an inguinal hernia and a Caesarean section.
The week ended up nicely at the DHO’s (district health officer- aka hospital chief) house on Thursday night, early start of the weekend courtesy of Easter. He is a 26yr old doctor who finished medschool 2 years ago, but is now looking forward to resume proper clinical duties once his term finishes next month. What started off as a few quiet drinks evolved into a full on night out, with us hiring out a minibus with driver (sober) to take us to the next town for some concert action. The big man from Balaka himself was performing on his home turf- Lucius Banda. So we couldn’t miss it. The socialising with locals was very much identical to the Black Missionaries do, but our own company was completely different. Loads of hospital staff- COs, medical assistants, doctors- and some non-medical people, the whole lot numbering 12. The one that stood out was the anaesthetic CO, who decided to hit on one of our female VSOs. Of course, he was married and she clearly indicated she was attached too and not interested, but the very fact she was chatting back to him nicely earned her the honour of being his girlfriend for the night... at least until it was time to get dropped off back home and hey presto, who was awaiting at the hospital gate?!!! None other than his fat angry wife, who announced her discontent by stamping solemnly into a water puddle before charging onto our bus. Little did our man know that she was not rushing in to join him onboard with loving cuddles, but with a vicious grip to drag him out! Ouch! As for the rest, your guess is as good as mine.