30 December 2011

Clinical Digest16 A retrospective

It feels strange writing this blog now and thinking back at the time I first set foot in a hospital in Malawi during this placement. Trying to link it all and witness this incredible journey and the transformations it has brought both to my personal and professional life. Trying to think about the impact it has had on the people of Malawi, and beyond if any. Trying to think of other ways I could have done it. Trying to summarise what the Malawian health care system is really all about and what the future has in store for it. Ultimately trying to work out if my presence here has overall been beneficial or not. I might not be able to answer that yet, because for the retrospectoscope to work best, time needs to elapse. Right now my subjectivity and sentimentality about leaving soon will no doubt introduce a certain bias. But lets try anyway.

Lilongwe- 6weeks

When I look back, this was one of the most fascinating times in my entire medical career. It spelt a complete new start, clean sheets, the beginning of an era. The mix of uncertainty and excitement was almost toxic, yet I’ll admit, somewhat intoxicating too. I’m sure that this wouldn’t constitute most people’s fix but for me, there was a certain thrill about deciphering the meaning of all of it then that kept me going. I found myself in areas I had not ventured into for months if not years, like the urology theatre or the labour ward. I found myself doing circumcisions and Caesarian sections. I found myself finding operations I would rarely see in the UK suddenly becoming routine, like limb amputations on young adults, sequestrectomies and bone drillings. I found myself in a maze of new pathology, using an almost entirely new medical vocabulary, approaching management from a totally new perspective. I was making a choice to unlearn some of the rigid set ways of doing things as I used to back home so I could integrate into this new system. It was intense and challenging but it was with one safety I would soon leave to enter the wild world beyond: consultant supervision.

Ntcheu- 1 year minus 6 weeks

My first day at work in Ntcheu. Surreal. A week’s orientation visit during my in-country training did hardly anything to lessen the shock. I was now an official employee about to work alongside everyone rather than a mere observer. I had to get to grips as quickly as I possibly could with all the intricacies of this new world so I could start operating within it. Lilongwe I found out was a very far cry from it. It gave me a good flavour of the Malawian health care, but had very little in common with the district setting. I would soon be reminding everyone about this so they don’t get misled by their placements in central hospitals that this is the standard of care most Malawians are receiving.

Ntcheu, my new workplace, opened my eyes to many challenges and led me to develop new skills to tackle them. For the first time ever, I would become a departmental manager, a data collector, a policy maker, a networker, an inventory maker and a procurer. I began working alongside maintenance to repair, improve and create equipment we needed. I became an advocate for improved sterility standards, almost in the style of the notorious infection control nurses I used to scorn at in the UK. I learned how to talk, present and teach in a completely new way, one which would make sense to Malawian students. I did all the usual things too, like ward rounds, theatres, clinics but developed a completely different approach to fit in with this entirely alien setting. I realised the need to balance efficiency with practicality. Never has the expression “more haste less speed” seemed more true. I slowed down, became more flexible but made sure to maintain my standards in the context of the hospital. I had to accept certain failures, but only if I could use them to change things so they wouldn’t happen again. Teaching by example became a very important philosophy of mine. I wish I could have done so without ever losing my cool at the heights of my frustration (which I won’t hide), but then that would be claiming to have cracked one of the most complex challenges of Malawi within a single year. In all truth, a lifetime might be too short.
Ntcheu, because of all these things, was my first in depth insight into the Malawian way of doing things, which would help me adapt my style to fit in better with the healthcare system, thereby enhancing my impact on it. Ntcheu, no longer so alien anymore, reshaped me for the better. Ntcheu prepared me for the journey ahead.

Blantyre – 1 year

This was in a way my graduation into the higher strata of tropical orthopaedics. Whatever little I had seen in Lilongwe seemed a long way back, and whatever I’d done in Ntcheu was a long way from this level I would be diving into. The learning curve was vertical, exponential, dizzying to say the least. My 2 hour lunch breaks were shrunk to minutes. My evenings of leisurely reading and work preparations were to make way for some of the most hectic calls I’ve ever done and assiduous reading about new operations and approaches. My very much self motivated presentations about topics of my choice to general clinicians and nurses were alchemised into specific lectures to medical students, trainee orthopaedic clinical officers and other doctors. My research imperative was cranked right up. With internet at work, no matter how intermittent and temperamental it might have been, I was able to get much more done in much less time. In addition to this Blantyre was also a city where I would be able to run projects on a different scale, with readier access to partners and resources. Hence I got the tricycle project going, thanks largely to your very generous support. I also got specialised splints made for traction patients, again with the help of sponsors from home. And above all, I got things moving like I could never have done in Ntcheu for the one biggest project of all: the editing (and future printing) of the Orthopaedic Resource Book. Right now, I am engrossed so much in this project everything else suddenly seems to have been put on hold. It is by far the biggest undertaking I have ever dealt with and its completion here or back in the UK will be my single biggest legacy to Malawi, in the name of my VSO placement.

All my time in Queen’s has also consisted of the bread of butter of orthopaedics naturally and on a scale that puts a lot of my previous work placements to shame. My operative logbook has benefitted from no less than 300 new cases, a lot of them being ones I would not have been able to perform before arriving in Malawi. I have received some of the best supervision ever from truly dedicated consultants here, both permanent (Dr Bates & Prof Mkandawire) and visiting, adding further to the wealth of that experience. My calls have brought me face to face with many socio-economic realities of Malawi: the political riots, the poverty that resulted in many patients presenting late with inadequate primary care, the fallen down houses and walls during the rains, the extra-ordinary motor vehicle accidents, to name a few. I became very much a frontline trauma doctor with a new sense of cool I will always be grateful to Queen’s for. My ward and clinic duties have assumed a higher level of responsibility which should see me evolve much more smoothly into registrar training once I get back to the UK. Beyond teaching, this notching up of my seniority has earned me the honour of presenting at some fairly high level fora such as the COSECSA (College of Surgery of East Central and Southern Africa) and Surgical Association of Malawi annual meeting, as well as the AO training for the Malawi Orthopaedic Association annual meeting.

I conclude this clinical digest feature today (having as yet failed to produce one on the complexities involved in dealing with convicted patients in Malawi) on an exceptionally high note. My 2 years in Malawi, and particularly my year in Queen’s haven’t completely gone unnoticed by my colleagues. Thus today I had the nicest sending off I have ever received from any workplace. The whole department gathered to say thanks for my work done and to wish me well in my future pursuits. It felt like a real tribute,indeed an epitaph to look back on, when doubts may arise about whether I made a difference or not. I know at least, I’ve touched my colleagues and, through them, I can be pretty sure, my working environment too. But above all, let me say this: it me who has benefitted the most from this incredibly rewarding time I’ve spent in Malawi. I’ll be a new person, a new doctor when I get back home.
Thus, today’s final review of Malawi signals more a new beginning to me than a conclusion...

25 December 2011

TOP 10 MALAWI

Slowest internet connection ever today... photos will have to wait a bit!Happy Christmas to ya'all!
(chronological)
Lilongwe 6weeks
My arrival in Malawi. Simply awesome. No time I look back upon compares with this period in terms of the pace of learning new skills, insights, ideas and expectations for the 2 year period here. The feeling of awe and excitement of being in this strange new country without knowing exactly how it’s going to pan out is one that can only be experienced, not described. Stranger in a strange land, with one difference. A very willing stranger.

Everest night out with Dutch students
This episode never made it as a feature on my blog, probably because I was too dazed for too long afterwards to write it up. Now is the time for it to receive its rightful accolade. For anyone who remembers the Carlisle church flat, one will remember how it’s the amazing parties it hosted (Knocking on heaven’s door, Heaven&Hell and Trilogy) that raised it to the legend status it still now boasts in our collective memories. For Ntcheu, it will certainly be the Everest nights out that will occupy that space. To be honest, it was probably a Friday night like most others in the Everest night club in Ntcheu. But somehow, it combined so many elements which, when mixed, gave the perfect cocktail. First ingredient of course was the novelty. Novelty always dies out, but then it was still fresh and exicting. Then came the build up. All good parties have a prelude. That night out had been orchestrated for a good few days and everyone discussing it at work that morning. Last but not least, the company. It’s rare for all your buddies to be around at the same time in Ntcheu. At least 1 person usually has a wedding, funeral, family trip of some sort or other thing going on in the home villages that they have to leave Ntcheu to attend. That night everyone was there. And what more, we had visitors. Special visitors. Everyone loves visitors in Ntcheu and the rest of Malawi too. 2 wickedly friendly medical students from Holland was one rare treat for the local crowd at Everest and it certainly got everyone one partying like there’d be no tomorrow that day. For my part, I was totally absorbed in the vagaries of this new culture and was quickly substituting one form of dancing (salsa) for a new one (local stylee)!
This one goes out to Craill and Nicorr!

Nyika trip with Janet (bike ride)
When you find out a few months later that the trip you’ve just been on actually features in the “Rough Guide to the planet- 1000 things you should do before you die”, you simply lick your index finger and draw a tick in the air! Nyika, Rough Guide or not, was the trip of a lifetime. The journey (but then again very much the destination also) was what made it. My first steps into the wild north were simply amazing. The different sceneries, villages, climate and people, not mention the fact that Janet was over for her first visit made for a holiday spirit that’s hard to match from our existing repertoire. To top that up with a ride on one of the highest, most idyllic plateaux of Malawi (often compared with the rolling hills of Scotland) on mountain bikes that worked elevated it to one of the top rungs surely of this retrospective blog today. When I dream of escapes from reality, Nyika lives on as that place I once visited that I would happily never want to come back from.

SAafrica
Okay, this one is not truly Malawi, but it encompasses a lot of Malawi and it would most certainly not have happened had I not been in Malawi at the time: Ayoba time in South Africa. Journey beat destination again. The start of it all was not surprisingly at Everest night club for that legendary launch concert (Black eyed peas, Shakira, K’naan). The spirit then just got better and better by the day. By the time I was on that epic bus journey, I was already in the zone. Then came the border crossings through Mozambique, Zimbabwe and Beitbridge in SA. Awaiting on the other side was the best football company ever- me bro Su, cousin Randhir and other friends and family. Roughing it in Jozie before a smooth finish at Cape Town was simply amazing. The utter football party spirit that reigned supreme is only possible for a world cup I think. But South Africa as a whole was a treasure I had not expected it to be. To say that it has whet my appetite for further exploration would be an understatement.

Lake of stars (both)
The 2 blogs already dedicated to this event attest to the sheer grandeur it boasts in my mind. Hence, I shan’t go on much more about it, but to say that this festival is not just the best I’ve been to in Malawi but certainly in the world too. I might not have done Glastonbury yet but this mixture of good people, good acts, good weather and a simply magical backdrop is definitely gonna be hard to beat.

Thyolo walk with Matt and Bex
Aloha Matt ndi Bex! Guys you simply treated us to one of our best walks ever in that post-apocalyptic period we were treading at the time. ZK! The lush green carpets of Thyolo tea estates were revealed to us in a way simply not given to outsiders. What with Mulanje lurking majestically, yet discreetly in the distance. Our passport into the estate was Matt who must have had the coolest VSO placement working there. No nook nor cranny seemed unknown to him and with him as guide, we were in for a treat. Out of this world!

Kamba
Now this one is an insider affair. It’s the bottlestore par excellence of Blantyre. It is a shack to be honest. But it is the closest thing to a good old old-man’s-pub Malawi can offer in my wide experience! Your local crowd in there ain’t the usual yobos and trouble-makers but a rather elite group of men (even in such a place the women haven’t made it yet) from different walks of life with a somewhat intellectual slant. The name “Silvergrey” kind of gives it away when I look back. This is the sort of place you have to be taken along to by an insider as otherwise you would simply walk on by, without ever being tempted to go in. The Friday night post-work sessions I’ve enjoyed in there with my mate Chris, topped up by the full on Malawian-style pool rounds, will live on sweetly in my memories.

Mulanje (the Lujeri trip)
This one again has it fair share of dedicated entries to its name. Its omnipotence in the Malawi skyline is on a par with the place it occupies in my consciousness. The one trip that remains most etched in my memory of it has to be the utter physical challenge we undertook on a short weekend to get up in and down in 2 days while bagging the highest point in Malawi- Sapitwa (literally “don’t go there”). That was the May trip to wish farewell to our Norwegian friend, Tor, great companion of ours in this Malawian journey. Little did we know that in his pre-retirement period, his legs were very much still at work like a Klipspringer one might say, in remembrance of this rare sighting we made during that hike. The combination of sceneries from the Lujeri tea estates, through the mountainsides, plateau and peak will be my live equivalent of the Shire in “Lord of the Rings”!

Monkey bay surprise boat trip
And this one will go down as my live equivalent of the beach scene from “The Beach”. Having decided to divert from the classic tourist trail that invariably ends in Cape Maclear, not out of choice so much as out of vehicle incapacity, we found ourselves taking the path down Monkey Bay with both Janet’s and my parents for a bit of discovery. To arrive just on time for the impromptu boat ride that was leaving the backpackers where we were putting up at was pure and serendipitous luck! Nothing could possibly have been a better welcome than this after a long and sweaty car journey, considering food and booze were to be found onboard too! My excitement would be manifested as manic backflips and rooftop dives from this party boat, but there was definitely something for everyone. Both Purcell and Doorgakant progenitors I’m certain will testify to this with the incredible lakeside landscapes, close up sightings of Pied Kingfishers and Fish Eagles and pristine waters on offer!

Boadzulu island trip
Back to the lake for this latest top-tenner of our Malawi sojourn. This was a truly personalised and magnificent send off from our friend Neville Bevis, director of the Open Arms Orphan Care that he runs with great passion. How our paths met typifies the way the greatest travel friendships start, that is a chance encounter. We were picked up by him some 4 years ago on our first trip to Malawi as we were walking back at dusk to our lodge located next to a township. He thought this unsuitable for us to do given the number of recent muggings of foreigners in that area. We exchanged ideas during that brief encounter and they must have been good ones since we have kept on exchanging them since. Our year in Blantyre really brought us closer to him and his Malawian partner, Enipher. To wish us goodbye in style, he invited us for a trip aboard his catamaran to an island off the Mangochi part of the lake, Boadzulu. To sum up how amazing this was, try and conjure up images of pelicans and terns, a cliff-side colony of cormorants, beautiful clear waters that felt warm as you swam through them and just stretching out in the breeze with a drink to savour this fabulous environment. Contentment in Malawi cannot be said to be complete without a last tribute trip to the lake. That one will certainly live up to the occasion.

Cross cutting themes (to use a perfect VSO jargon):
Meeting people and expanding world view
Today’s blog even surprised me when I read it back, as I noticed how intricately linked it was to the people we’ve met here. One can safely conclude that without the human factor, much of the above list wouldn’t have made it to the top ten. And likewise, with a good human vibe, rather dull moments can be transformed into memorable ones. The people we have included so far have been mostly fellow foreigners like us, with something in common, be it our desire to learn this culture in Malawi better, to work on restoring some balance in the world or indeed, a shared love for birds and animals. But what I don’t want to leave out just because we don’t go on trips with them are the unique and amazing people of Malawi. This sounds cliché and I won’t dwell too much on it for fear of reinforcing that cliché with more cliché words, but I have come across a form of friendliness here that I’ve never seen before. Although some of it has undoubtedly been out of self-interest (associate with the “rich” and you’ll get something), I am quite confident that most of the time, this welcoming attitude was genuine and truly selfless. Malawians have taught me lessons in humility, generosity and joie de vivre I will never let myself be distracted from again. Poverty, as has been proven here, is no obstacle to the achievement of these core human values.

Birds, animals, wildlife at so close range
A cursory glance at my blog so far would have given it away without me having to dedicate a special section to it today. Suffice to say that I have graduated from a Planet Earth documentary fan to a real field admirer of wildlife through Malawi. My appreciation of the delicate balance required to maintain such beautiful biodiversity has really been refined over here. The constant confrontation between the (allegedly) highest member of this ecosystem and the other members is clear to see. Developing a true love and knowledge of birds and mammals and fish and trees has brought me into an intimate relationship with the world where the concept of respect can stand out supreme. Respect surely can have wider applications.

...And that’s not even mentioning the joys of Zomba, Chilwa, Majete, Liwonde, Gongonya village week in Madzanje, the Blantyre arts festival and fantastic times with loads of other friends for life: Klaas and Gerdien, Sajir, Hanna and Raz, Helen and Mike, Marieke, Liora, the Bates etc.