Clinical Digest8

Orthopaedics in Malawi
My non-medical audience might just want to turn away for this one. But if medical jargon’s your thing, then please stay on! The week just gone has seen an escalation of my orthopaedic activity like none since I arrived in Malawi. I organised an exchange week at another district hospital up North, Rumphi, to coincide with another (more fruitful) surgical visit by Steve Mannion and the Feet First team (Bernie, Danni, Clive and James as well as Steve's wife, Mercy). Having beat them to the place, I had an entire morning to shadow the OCO (orthopaedic clinical officer) on his Monday clinic and ward round. Then I got given a full tour of the relevant departments, such as Xray, minor theatre, physio and the appliances workshop. That proved to be one of the most useful parts of my exchange, by putting a better perspective on things in the Malawian health care system and also questioning some of the assumptions I came to while in Ntcheu. I now know that a lot of our deficiencies which I had formerly attributed to stretched resources aren’t necessarily so: there is at least another district hospital, with the same resources, which is managing to function in these areas. Of course it’s not like UK, but it struck me as a fantastically well run department, given the available resources. The main one of these unfortunately is unique to Rumphi and that is the OCO himself, Mr Mwalanda. Along with a non-clinical assistant alone, he manages to get through more than both OCOs at Ntcheu can do. Still I believe (and hope) that, given the right motivation and organisation, we too can match this productivity even after I’ve left. My job is to find ways of instilling this great drive that, of his own admission, has led Steve Mannion to choose Rumphi as his main operating base in Malawi, into Ntcheu.
So the real medical onslaught began as soon as he, Steve M, landed there on Monday afternoon and tackled a clinic of some 30 collected complex cases to try and devise a feasible theatre list over the next 2 days. Being able to talk through the diagnostic process and management rationale with him allowed me to take on board concepts and skills that I’d only partially assimilated till now (try and explain the intricate relations between hindfoot and midfoot biomechanics to a pre-SpR Orthopod and you’ll get an idea of the level of masochism involved in learning it for oneself!)At the end, it was rather dumbfounding how we managed to get through so many cases in one afternoon, but we did. Among this small crowd featured a number of club foot deformities, genu varuses and valguses (including a case of both in the same patient- windswept knees) and poly/syndactilies not to mention complications such as contractures, sequestrae and post septic joints. This all built up two full day lists of about 14 patients, which matched our scheduled impeccably. As expected though, once we got down to the list, a number of cancellations had occurred for various reasons ranging from malaria to not-unlike-Ntcheu absconding! We were still left with 10 patients and 14 cases in total, ample opportunity for on-the-job learning.
To summarise the mind-numbing learning curve that ensued over the course the following days, I am now hoping to export the following operations to Ntcheu, since they require no expensive or specialist hardware... other than an osteotome and a button (yes!.. to secure the tension in club foot correction):
high tibial osteotomies for selected genu varuses, soft tissue releases for neglected club feet, release of syndactyly using at least 2 methods and, at least theoretically, morsellised skin grafts. So, all excitement it is going to be for the next few weeks back home! All the more so with the new donated kit that’s waiting to be tested out.
To cap off my week in style, I spent the final day of my educational break from Ntcheu back in Lilongwe, where I followed Mr Mannion around on a tour of pretty much all the orthopaedic services for the central/northern regions of Malawi. I got a real in-depth insight into the planning of this crucial aspect of health care in Malawi, where disability and trauma often tend to be given secondary importance, with maternal and neonatal care and HIV enjoying most of the worldwide support and funding. That is largely due to the priority these areas have been given through the millennium development goals, which I am not contesting. However the social and economic impact of neglected orthopaedic affectations, with the incredible number of road traffic and industrial accidents, congenital abnormalities and paediatric fractures and burns, cannot and should be ignored. And indeed, I found out there are a few organisations with the sole aim of addressing these problems in Malawi: MAP- Malawi against physical disability; CBM; and of course Mannion’s own charity Feet First. In addition to these are of course the orthopaedic departments at KCH (Lilongwe’s Kamuzu Central Hospital), the 500miles prosthetic centre and the aptly-named Dae Yang (pronounced Die Young!) Luke Mission Hospital, doing their own invaluable work, albeit with limited staff and resources. Unwittingly I got myself a nice little assignment from this field trip, which is to mediate the next meeting of the Malawian Orthopaedic Association, which regroups all these partners, in September with another UK-based organisation, WOC (World Orthopaedic Concern). With all this on my plate, I think it’s time I took leave of you and set myself to some serious groundwork.

Clinical Digest7

7/7/10
Mannion,Me,James,Danni,Clive,Bernie

Maybe the date should have alerted me that today would be a disaster. I nonetheless approached this rare highlight of my Ntcheu orthopaedic calendar with the utmost enthusiasm and hope. The reason for such excitement was a long awaited visit from the illustrious travelling Orthopod, Mr Steve Mannion and his highly committed team from the Feet First project, Bernie, Danni, Clive and James. Mr Mannion, aptly surnamed “superdoctor” by Lord Winston for the BBC, is usually based in North West of England, operating at the Blackpool Infirmary. Despite such proximity to my UK abode, our paths never crossed while I was there. We always seemed to miss each other. Not surprising when you consider his typical timetable, which is a sequential intercalation of 2weeks in the UK and 2weeks in some other part of the world, mending limbs and restoring vital functions! This routine sees him visiting Malawi up to four times a year, where he was one of the founders of the club foot programme. So, when I found out he was coming, I linked up to try and organise a surgical visit over at Ntcheu. This request was positively received and I went on from there to meticulously build an appropriate operating list for him. The task was no easy one, considering all the logistical hurdles this posed. Firstly, as at every district hospital maybe in Africa, maternity has first pickings on theatre space allocation. Therefore, I had to make arrangements, with the help of the DHO, for all maternity emergencies to be directed to our neighbouring district hospital on that day. I also had to make regular announcements at our handover meetings to remind everyone of this eventuality. Furthermore, I had to make sure that transport would be available for these transfers and that the transport officer was also at the ready. The job of ensuring anaesthetic and nursing cover for theatre on the day became a plea at times, where instead of (rightly) assuming that these people would simply turn up on time as they are meant to on any day, I had to entreat them do so like they were doing me a favour. But it’s best to play the game. So I did and it bore its fruit. Meanwhile, I put a paper request around all the potential points of recruitment for interesting cases, including our orthopaedic and outpatient departments as well as the physio outreach programme. This yielded 4 cases, 3 minor and one major to be done. With some kind of sixth sense, I at first told all the patients to come in 2days before the planned day. Then somehow, I got dissuaded from this by my colleague, who reassuringly told me that admitting them on the eve would be adequate. Little did I know that the eve would be a public holiday. What that effectively did was to completely sabotage the list. Only one patient turned up on the op date and, to make matters worse, it had been breastfed already, thereby delaying the only operation of the day! Fortuitously, that same morning there turned up a potential second case, a new one which presented in our clinic. All excited by this luck, we started preparing for the op. The patient, an old man with recurrent Dupuytren’s contractures, told us he’d go and lock up his bike and make his way to theatre thereafter. Again, as tends to happen a lot in Malawian hospitals, and escaping my all-too-informed vigilance, the patient simply did a runner! Did we scare him!? Did he just not want to have the operation anymore and live on with his rather debilitating deformity? Whatever the reason, our second case never materialised. So we did one single case, a tiny one indeed, a correction of a polysyndactyly at the fifth toe of a 7 month old tot. It was a great teaching case nevertheless, not just surgically but also from a nursing and general theatre planning perspective. Bernie, a senior theatre sister by profession, did a reckie of the entire department and came up with some pretty sound recommendations. The maintenance of sterility suddenly doesn’t seem like such a ludicrous concept anymore. Meanwhile Danni, a radiographer, had a productive session in our radiology department, providing that essential support this group of staff rarely gets here. Clive, ODP by trade, was our jack of all trades keeping the list on its feet (so to speak) and making sure all our equipment was there. James, baby doc just hatched out of med school, added a breath of fresh air, good humour and keen hands and feet to assist us with setting up the patient. He miraculously got a cannula in a 7months old’s hand, first time. Shot! Looking back, I realised that we managed to turn a seemingly disappointing start into a truly rewarding half-day. The time freed up allowed us to go around the wards, and for me to receive some feedback about patient management in the district context. It also allowed for a couple of highly useful presentations on specific management of a number of conditions I’m dealing with all the time here- skin grafting for wounds, femoral fractures, neck of femur fractures etc. Above all, it provided a real insight into the typical Malawian working style and patient attitude, which, if ignored in any enterprise like today’s, can leave you feeling pretty bitter and dejected. None of us did though, since, knowingly, we planned for the worst case scenario anyway. Today, certainly, was far from that! To brighten things up even more, I inherited a mouth-watering selection of surgical tools to supplement the rusty ones in our Ntcheu kit and hopefully open up new operating frontiers in the near future. What more could I ask for?!

Bafana Bafana Fever

Bafana Bafana Forever
Me & Kuduzela!!
Malawi has been the platform of yet another experience of a lifetime. It may have involved days of mile munching aboard a freezing-alt-sweaty bus, but it paid off in the end. I’ve seen, felt, heard (oh yeah!) and, above all, lived the South African World Cup as it was happening in South Africa. One item ticked off my own personal bucket list. In fact, my latest trip allowed for a few more items on that same list to be fulfilled, the first one being unquestionably cross country coaching from Malawi to SA.
I reached Johannesburg first, with a freaking sense of insecurity, what with all the scaremongering that goes on about this legendary city of crime. Despite it being daytime, the lonely 5 minute walk from the coach station to my taxi point felt like days, and the very prospect of bargaining with the taxi driver over his largely inflated price, like a death wish. But the air soon dissipated once I settled in and found myself sat next to a fellow human being, scraping a living out life. I was met at the other end by a chance host, the very acquaintance of whom I made less than 3 weeks previously. Of course, I knew of him well before but only met him by chance in Ntcheu as he came over to visit his wife on the eve of the world cup. He (Sandress Musuku) was the former DHO (District Health Officer) at Ntcheu District Hospital. We staged an impromptu celebration at the local club and he extended an invitation for me to join him in Jo’burg. Being a VSO volunteer, I could hardly dismiss such an offer. That gesture though was more than mere coincidence- it symbolised one of the truly unmistakable attributes of Malawians: their generosity. Whatever little they have, they will want to share it. There is absolutely no status boasting involved (we actually shared a tiny university all-in-one room) but it fills them with enormous satisfaction to have been of assistance to someone, anyone. Going to my latest read (30hours each way by bus does get me through a good few pages), The Shadow of the Sun- Ryszard Kapuscinski, I found parallels with his description of life for ordinary “Africans” (a term I use sparingly, all too aware how a Malawian is different from a Kenyan, from a Ugandan, from an Egyptian, Libyan, Malian and Mauritian etc), whereby interdependence is second nature. Survival under hardship depends very much on this unspoken social contract. But my host was no hardship-stricken Malawian. He was simply carrying forward the evolutionary trait that his people have acquired over generations, a trait that possibly unifies most central Africans. Having already saved me a little fortune, Sandress went on to treat me to some exceptional good times in Jo’burg. I was only able to meet my bro, Suraj, briefly there, considering he had tickets for games which I didn’t, but we caught up in style later on. Jo’burg, on the whole, was very short, albeit intense. It, doubtless, served to instil that first drop of the Ayoba in me (something like ecstatic fun in Zulu), but it is Cape Town that would see it develop to its full-blown grandeur! The connection to my second stop was by way of a no-frills airline (a treat in comparison to its European counterparts) at 6am. The airport turned out to be so far from Jo’burg city (no difference from European counterparts) that I only caught my flight by the skin of my teeth. Once on the plane, I couldn’t help being struck, almost guiltily, by its passenger demographics- almost all-white-, in sharp contrast to my very recent coach ride- almost all-black. This is one very typical facet of life in Africa that I still struggle to come to terms with sometimes.
Two hours (of deep sleep) later, I landed in Cape Town. Clueless really about what to expect (I hadn’t done my homework), somewhat underwhelmed, I was almost questioning whether it was really worth trekking all this extra distance just for a game. Within a couple hours, I found out it was more than just a football game. Way more. It was to be an escape, Ayoba!, of epic proportions. Flanked by juicy mountains and oceans, the very sight of which causes me to melt with desire, Cape Town boasts to be a gem of natural conservation. In less than 4 days there, I conquered the summits of two most subliminal peaks I’d been dreaming to ascend, Table Mountain (bucket list item) and Lion’s Head. The former actually forms a feature known as the twelve apostles when viewed from the sea- quite spectacular really. We also visited the point where the Indian Ocean joins the Atlantic, Cape Point in a national park where you could find ostriches and baboons roaming freely, and stopped by a penguin beach further along. Lion's Head
The grand TABLE
On top of that, Cape Town set the scene for a most unique family reunion, regrouping cousins from Germany, Mauritius and England as well as a long lost friend, Kushroo, whom I reconnected with in Cape Town itself. The city has a cosmopolitan mix of cultures, ranging from Xhosa tribal to Malay (Indonesian actually) to Israeli to a bit of everything, with a strong Dutch and German influence from its significant white population, making it a really colourful and rich city in many ways. Add to that the football fever that reigned supreme, you’d get all the ingredients necessary for the perfect city break. And it was.
A global reunion
SA beat France in public
It began in the most Wow-ing style with the live game of the South African Bafana Bafanas against France, being projected live on giant screen along the waterfront. I’ve never seen such an electric display of football frenzy before. Despite only having the remotest chance of qualifying at that stage, the yellow sea of South Africans didn’t let that get in the way of a good show, only heightened by the ever-sounding Vuvuzelas! Love it or hate it, the added decibels do transform an audience, literally. But if you love it, like I did, then the added spectator joy can only be measured on the Celsius fever grade!! As of now, it became almost a rule to watch all the games on public giant screens, except, of course, for the one we’d be watching at palpable distance from the players LIVE IN GREENPOINT STADIUM: Cameroun vs Netherlands! I will, no doubt, fail to convey the atmosphere of such an event in words for you, but just let it be known that watching a live game at a world cup, especially when it is the first one staged on African soil while I’m based there, is another of these experiences of a lifetime that I’ve now drawn a big tick next to! Seeing the Dutch orange invasion at close hand alone, especially when it undulates along a Hola! (Mexican wave), was worth making the displacement from Malawi for. And the flags, including those of so many countries having not even qualified, including Mauritius’, brought with them a sense of international unity I’ve not witnessed elsewhere. Indeed, forgive my callousness to my English readers, even the Germans were happily sharing jokes and drinks and hugs with us on the streets and pubs after the game. The way stadium floor would come alive even as the ball came close to 18yard box, let alone when it crossed the goal line, is a feeling that could only be matched by the splitting roar of the Vuvuzelas accompanying it in the air. In other words, you had to be there to begin to fathom what it was like!
Thus, one week of dizzying football fever has left its indelible mark on my African passage. One month if you include the ripples emitted throughout Africa, not least Malawi. Its presence for me has been omnipresent, from Malawi, through Mozambique and Zimbabwe to its core, South Africa. By way of illustration, I was even able to verify the scores of the matches I’d missed while on the coach with the immigration officer who recognised me on the way back in Mozambique. Only a week left to go, and already you can feel a vibration in the air, an anticipation of a greater African celebration. This time, it is African in the wider sense. The excitement of the entire African continent behind their sole representative left, Ghana, is, in one word, captivating. Okay two: addictive! Go on Black Stars!

No comparison

Travelling african style
Any pretension I may have held about being hardcore in my travelling, based on previous journeys, has been turned on its head after my latest flirtation with the African road. “African” I say without fear of over-generalising as the latest epic took 4 countries in its stride: Malawi, Mozambique, Zimbabwe and South Africa. 30 hours each way to use the typical term for distance measurement here, and that comprises a generous chunk for the sole purpose of negotiating border bureaucracies- or should I say idiosyncrasies! For those of you who still perceive distance in kilometres, then the grand figure of 1500 each way would be a rough ballpark figure!
Unwittingly, I started the journey with a self-inflicted hangover following England’s disappointing game with Algeria the night before. At 8.30am in Blantyre, a strange combination of moths (taking cover from the daylight), flies (trapped inside the bus and trying to escape), mosquitoes (from the nearby ditch) and butterflies (in my tummy, in apprehension of this unknown factor ahead) marked the start of this trip. An hour and a half later, after all procrastinations were done with, we were finally en route. I got a nice seat at the front and was pleased to have a friendly neighbour. Hardly 10minutes into the ride came my first and most dreaded challenge- the bus music/noise. Pure wailing Malawian gospel, absolutely identical, even the videos, which were being projected on a screen at the front. Unfortunately, changing seats so that I would be farther away from the epicentre of this cacophony was not an option, since each seat was specially endowed with its own speakers, with no individual volume or ‘off’ switch. Competitive inhibition was the only solution as of now, meaning that I would have to rely on my personal music to be blasted loud enough by my earphones to override the surrounding music. Every now and again, even through this, I could hear the bus noise and even worse, a certain high pitched beeping which could go on for an indeterminate length of time. At first I thought the sound system was defective, as is often the case in Malawi and that I would simply have to brace myself and suffer. But then I found out this was a speeding alarm, which indicated to the driver that he was going over 110 Kmph. Despite liking the idea in its concept, I was all too aware that, to the Malawian driver, such a deterrent would be as useful as Chambo steak to an edentulous! Noise encourages Malawians on the contrary! But prolonged exposure to an insult can ultimately condition one to it, and insofar as I can be conditioned to noise, I was. I sat at the back nonetheless on the way back, swapping toilet for beep, but still had a nice neighbour!

In Mozambique
Another unexpected inconvenience along the way turned out to be a mal-functioning AC or one cranked up sadistiscally by the driver, on pretence that it would keep him awake. I couldn’t argue with that one! This kept the entire bus shiveringly awake on the way down. On the way back though, probably from the aforementioned overuse, AC did not function at all and sweaty came to replace cold and dry. All the same, the latter was more comfortable as one can always open the air hatches.
Our first border crossing would be that between Malawi and Mozambique at the Mwanza/Tete immigration point. That was the scene for one great big- and expensive- surprise to me. My Mauritian passport would be categorically declined. Indeed I ought to consider myself lucky not to have ended up behind bars, as having two passports is considered illegal here. So I was forced to go on my British passport, which attracted the plump sum of ~$25 each way. Might not seem so much, but in the context of VSO wages, you will see that the cumulative effect of those payments (4 times in total only for transit visas) amounted to roughly what I had saved by opting for the road instead of simply flying down to South Africa. All this for that glamorous passport which I had to wait 12 years to get in England and which I’ve never had to use in Europe! To think that the Mauritian passport used to be my worst nightmare whenever it came to travelling in Europe, thanks to the ultimo of travel deterrents- Schengen Visa- , and now it’s that same passport I wish I had entered Malawi with! Too late. But I’ll be philosophical about it. I might have lost out in this situation (from oversight mostly) but in all fairness, I don’t think any European/Muzungu is in the right to moan about being imposed this charge. Not even at the slowness of processing the visa in actual fact. My bitter experience in Europe has had one single positive effect, which is to give me the opportunity to compare the way an African is treated by the usual European immigration system with the converse scenario. To get a Schengen visa in the past, I had normally to apply to the country’s embassy which I would be visiting first, at least a month in advance. This would have to be done over the phone at the premium rate of £1-£1.50 per minute, each call lasting around 2ominutes. During this call, it would be highly advisable for you to have your detailed agenda at the ready, where you have minimised any commitments for the ensuing month, as the time and date you are allocated are purely random. If you happen to be busy on the date given to you, then you have to keep the call ticking till a more acceptable one is offered you. Once you have the appointment, you have to also make the travel to the single place in England or Scotland (even though they can turn you down if you’re based in England, albeit next to the Scottish border) where they process these visas, early enough in the morning, so as not to miss your chance. There are usually loads of people there on the same desperate mission as you. I remember once queuing outside the French consulate in London from 5am, only to get to the counter at 10am. Once you’ve tackled this appointment hurdle, comes the more thorny issue- the right documents. Not only do you have to produce a return ticket (with no guarantee of even being allowed to travel) but you need a formal invitation letter from the town hall office of your host, or a hotel reservation. This invitation letter usually takes your host about a month to process, at least 2 trips to that office and 30Euro at least. Consider yourself lucky to have got those, you also need a travel insurance, a letter from your employer (job contracts don’t count) and proof of finances (bank statements don’t count). Financially, excluding your plane ticket, the whole process can set you back £150-£250. Damn that £1 Ryanair fare! Meanwhile, in Mozambique/Zimbabwe/Malawi, despite the greater threat historically posed by a European on these soils, it took us less than 1 hour to have the whole lot done and an upfront payment of $20- $30 (~£15- £20). On one occasion, it did take 2 hours but that’s because the English traveller ahead of me was visibly infuriated by the process and decided to get confrontational with the immigration officer. Consequently, everyone with a foreign passport was punished.
Border crossings constituted one dreary, heart-sinking moment of the bus journey. Each crossing required a visit to both countries’ immigration offices to have your passport stamped. Leaving was usually swifter than entering a country, naturally! Except, of course, if one of your fellow passengers decided to overstay his keep in the exiting country. Dealing with this situation is very crafty. Bribes are eminently du jour and they are not negotiated in any direct way at all. There’s no asking price here. The offender simply leaves a note in a page in his passport. The officer actively searches the passport for it, and if discontent with the amount presented, grumpily hands the passport back. A few minutes later, the offender, after having scrounged for some extra dosh, presents the cash in a similar way, and this strange bargain can go on a number of times until the passport is finally cleared or singularly dismissed. Somehow, in the latter case, the offending individual then simply vanishes into ether and the bus decides to leave him/her behind. Next thing you know, maybe 5Km or even 50Km into the next country, the person will reappear at some road junction and hop back on the bus. This s/he might not be allowed to do, in which case they will appear at the final station, again inexplicably, and collect their luggage there! The most remarkable example for me was a woman who sneaked past the Zimbabwe/South Africa border with her baby and was refused back on the bus, but somehow beat us to it at the terminus!
My experience of the borders was nowhere near as exciting but worth a mention. When leaving Malawi, one is allowed a maximum of Mk3000 and I had around 6000. So I had to spend the excess (in fact more like the whole lot) on wooden artefacts around there, only to find myself burdened with this extra weight, which I intended to leave with the Mauritian connection in South Africa.
One way bridge
Going through Mozambique, an additional delay declared itself, in the form of a single lane crossing across what is apparently the longest bridge in Africa- not the widest that’s sure! If you happen to be that first person to be held back after a batch has been let through, then I’m afraid you might as well take a little nap or get your Sudoku out. They rotate hourly here!
We're in Zim
In Zimbabwe, the immigration officers were exceptionally efficient and, on a personal basis, not adverse to foreigners at all. However, the intimidating presence of Robert Mugabe was distinctly manifest in the picture frame hanging behind them on the wall. That man decided that British travellers ought to pay the same numerical amount as others (Europeans/ Americans) except that the amount would be in pounds rather than dollars! Once again, I shot myself in the foot by using my British passport. There was also a strange incident of a stranded bag hanging on a tree outside the immigration office, that left all of us somewhat insecure. The bag -lady’s handbag- looked like it might have been left there deliberately, possibly to lure curious fingers hence, warranting an arrest, or, heaven forbid, waiting to tick down to a boom! At the South African border, my luggage got searched along with a number of other passengers’. Interestingly, I was made to go and register my wooden curios, while the guy next to me had all varieties of fish and vegetables stuffed neatly between his trousers and shirts and sailed through! The way back across the borders blended into a fuzzy dream for me, having exhausted myself to the limit in South Africa. All I remember was that the Mozambican immigration guy recognised me as the ‘Mauritius one’ and, on the other side, I (unethically!) used my status of (male) doctor needing to get back to work, to speed my baggage check through so I didn’t have to wait for all the luggage on the bus to be individually checked until we got to mine. This is what normally constitutes the longest delay in the whole return trip and I was in no mood for it. Malawians are renowned for their ability to shop till the last mm2, for absolute nothings most of the time, when travelling back (a bit like Mauritians used to do in the past/?still). I made a list of such improbable items crowding the interior of the bus and racks: large crisp packets, large pop bottles, oranges, bags, oil, biscuits etc.. I decided to alight here rather and make my own way back on Malawian public transport. This, I delayed till the next morning as a very important appointment was also waiting for me in Mwanza just as I cleared customs- the Germany v England game.
More on the South African world cup next....

About Malawi

The anticlimax set in rather quickly following Janet’s departure 3 weeks ago, her last week culminating in a crowning finale as we got to watch Lucius Banda in concert (second time for me) right next door to Ntcheu, i.e. his home town Balaka! This was made even more symbolic by the fact that most of our roadtrip had been animated almost entirely by him singing on the only player we had in the car- a cassette player, with the only cassettes available to buy here being local Malawian or Zambian music. It would be unfair to isolate lack of choice as the reason for listening to him though, as he is really good. Interestingly, he is also running for president it seems. Unfortunately, his party aren’t really showing much of an interest, while the current president has brutally sidelined him in response to a song on his latest album, where he indulges in a rather defamatory soliloquy on the president’s unpopular politics. Hence not only does the album get banned from airing on Malawian radio, but the entire artist’s work. To his relief, that doesn’t stop him being played all day (and night) all over Malawi on CD (...and tape)!
That sets the scene nicely for me to talk a little about politics for the first time here. Yes, it takes less than a week here to crack that one, but has taken 4 months to put in words. We have what is officially a democratically elected president in multi-party style election. Except that around the time of the elections, he, Bingu wa Mutharika, has quasi-monopoly of the media and the country’s resources. He is in his second term now, and won the last elections in December with an overwhelming majority. Since then, he has imposed himself in somewhat more of a dominant style and has been pushing for some changes that never really seemed to have any public consent. For one he is planning on changing the Malawian flag to one that suits his own eccentric taste- a move that will cost a small fortune to the economy, without any economic benefit as far as anyone can see it. Rumour has it the flags are already here in containers, while awaiting for the final bill to be passed. Secondly, as in many African countries, the president tends to affirm his authority by displaying pictures of him looking imposing in every office in every town. He is also on billboards everywhere boasting about some achievement or other. Whether this serves as a reminder to everyone that he is there watching you or mere propaganda I can’t tell. But what I can predict is that soon these pictures (must number thousands) will all have to be taken down and replaced with new ones, because, he has just been awarded some dubious professorship in China. He now boasts the title of Prof in front of the already present, Ngwazi Right Honorable President Dr... Ngwazi in fact being an appellation the former leader/dictator Dr Hastings Banda used to connect himself more to his people. Bingu now likes to compare himself with this still very popular past leader (remembered by many guide books for banning long hair for men, or skirts for women, or worse even the song Cecilia from S&G!). Bingu, of course, is also famous for the latest gay marriage saga that even made it to the European news. In a 180 move, highly likely to have been motivated by a strong pressure from the UN chief, Bingu pardoned the gay couple, who a week later had been sentenced to the severest possible term- 14 years IHL. The ensuing week, he declared publicly that for such “evil acts”, the law rightly punishes but God forgives! Speaking of marriage, Bingu too made the news this year at the grand age of 75, when he decided to get engaged on Valentine’s day and remarried in April. He hosted a royal banquet, paid by the state of course, with more than 5000 guests, and turned up in a flashing new Limo. All the papers had messages for each of the two events posted in them for the happy couple, most of them being from government offices and parastatals! The TV channel at that time, played similar reels of repetitive messages as much as they did actual programmes. Meanwhile, special glossy magazines were printed and distributed to remind people (in case they lived under a massive rock that only allowed glossy mags in) of that holy union. Let me not get too carried away with this bleak analysis because I might get expelled from the country soon. In his defence though, from talking to a few Malawian friends, a lot of positive changes have been made since Bingu’s arrival (“his predecessor was essentially a shameless thief who would even circulate counterfeit money in the country”), especially the quality of the roads. But when you ride a motorcade of 15 shiny 4x4s everytime you travel, if you’re not in your state-purchased private jet, you want your ride to be a smooth one!
Besides politics, one other item that’s featured prominently on the agenda here has been football. Of course there’s the world cup, but personally, I’ve also managed to join the hospital team lately and am finally back to weekly matches. Last time I was doing that goes back to more than 10 years ago and it feels great. As for the world cup, I shall save that for the next time, when I have fresh news from the hosting nation itself. Pepani!

Roadtrip / honeymoon

This week we took to the Malawian roads. This was also the first time I got to properly drive around Malawi (omitting that sedate and carpeted drive from when I picked Janet up from the airport). This time we had an altogether different mix of terrain, landscape and weather. I think this must be the longest drive I’ve ever done in my life, taking in at least a half of Malawi’s vertical diameter and combining high alpine plateaux with basking lakeshore escapes! Each day in this last week has been so rich in stimuli, interactions and discoveries that an individual page is what’s really needed for each. We shall endeavour to relate them to you each as a paragraph instead, which is going to be no mean feat.

Lilongwe Market
This will surely qualify as the first leg of our epic odyssey, even though Lilongwe was only intended as a practical stopover before springing up North. The decision to go and explore the market came almost naturally as we finished our overwhelming supermarket raid to stock up for the journey and felt in need of an antidote. Even though I’d already explored this market twice before, I never tire of going back there to be completely captured by the buzz of human activity and the profusion of colours, smells and sights. A kick to the senses really. From the meticulously stacked displays of fruits and vegetables at one end to completely dispersed messes of clothes and paraphernalia, we meandered along countless aisles, which revealed the true expanse of this deceivingly enormous market. The skill of bargaining quickly turns into an art here, and to any poker enthusiast I strongly recommend a visit sometime. Not even getting your shoes shined comes without some element of it! Having negotiated that little exchange, we proceeded to a systematic exploration of the specialist sections of the market and that took us along the traditional medicine quarters (be aware that taking photos on the sly might set you back a good few Kwachas!), the food “pavilion” where not a single part of an animal gets wasted except for bone maybe (by that of course I mean the inedible cortical part, not the marrow!.. and then again, I stare at my necklace pendant wondering which bone went into making it!), the tailoring&repairs, the kitchenware, the hardware and the megaphone-animated flea market style clothes areas. The market is such a beautifully organised mess that it is bound to lure you back any time you’re in Lilongwe. All the more so if you have a sense of adventure and decide to cross the flimsily erected paying bridges across the river that divides it in two (surprisingly it was not us getting paid for risking our lives on it but the astute architects of these totally uninspiring pontoons).

Donija Nkhoma

On Sunday, we did our first drive section to a community project called the Donija Nkhoma village. Thanks to my expert co-pilot, we experienced our first emotional moment when, at 110Km remaining to the destination, I was informed it was only 11Km away. Imagine my joy (read heartsink¬) after I discovered the stranded zero! Donija Project is essentially a close up look into the way traditional Malawian communities are organised, by staying and eating with them in their houses in the village. We had a fascinating guided tour around the different nuclei of the village to see how all these things come together- the nsima, the mudbrick or wooden houses, the ingenuous water supply and the wicker pens for cattle and corn. We also visited a fishpool constructed by the villagers miles away from the nearest lake, and learnt about the role of cattle as dowry! We were treated to a true delight of a traditional dance, where the women could best be described as yodelling, while the chief dancer gyrated and shook in his soft-drink-bottle-metal-cap-studded outfit at a speed my eyes could not fix. The sound was an eclectic bojangle beat.

Vwaza Marsh

After a very comfortable hospitality with some VSO friends in Rumphi (amazing food, courtesy of Marianne!), Vwaza was our next stop and first taste of a nature reserve. The road north form Rumphi becomes a dirt road for 100s of miles further, and really tested the car and Ash! The car resembled a pile of red dust by the end of this portion of the route and amazingly still has all its bits attached (which goes for us too!). Its original blue also proved to be the perfect lure for the millions of Tse-Tse flies colonising the marsh, which would come tick-ticking loudly at the windows in desperation for some human blood. Hence all windows up in the stifling afternoon heat while we attempted a mini-drive safari of the place.
Vwaza is a marsh surrounding a lake, where we stayed in a wooden hut on sticks, overlooking the lake. We were treated to the amazing sites of the park and got within arse-slapping distance of elephants (which Ash was very suspicious of their potential as man squashers [thanks to Janet’s white bait of a shirt!], though luckily we escaped unscathed). Also on the tick list numbered an entire herd of impalas, bushbucks, kudus, baboons, hippos and so many birds I couldn’t begin to name them (but there was a wicked Ibis couple in there).
A cook was at our service that evening, who conjured up some wonders out of our very sophisticated tinned offerings. As the night, its silence and crazy sounds closed in around us, we enjoyed the delight that be our candle-lit hut in total outside darkness and the sweet hiss of Malawi Gin with sprite.

Nyika Plateau- nature walk
Nyika rightly deserves the title of our ‘piece de resistance’ for this trip. It was, after all, the ultimate destination around which we constructed this sumptuous itinerary. Nyika is Malawi’s first and largest National Park, most parts of which are still inaccessible today, but to the most diligent and researched explorer. The motor-able route up put our dare-devil off-roading in Vwaza to shame, with the car threatening to skid off the road at least twice and forcing a maximum speed of 40Kmph on us.



Once you get to the plateau, you are immediately enveloped by a magical feeling of escaping to another world. In all truth, for Ash, it strictly represented the first time since in Malawi, where he felt altogether free from noise (Vwaza was a close contender, except that, of all days, ours was when the village gathered for a very rare mourning ritual on the edge of the park). In Nyika however, there prevails that silence which magnifies every other natural sound to its absolute sweetest (little wood insects, rustling leaves, water streaming etc). The setting is one akin to the highlands of Scotland, with one slight difference: inamongst the bracken (and seasonal orchids), there’d lay a herd of zebras (my favourite) or bucks or Roan antelopes staring at you with that quizzical face that says “friend or foe?!”. We managed to get close to the animals (including an elusive scrub hare just for Ash) on the first afternoon with the help of a local (black) guide by the name of White. It was an absolute treat to be able to not just see but also learn about so many species of animals, birds (herons, buzzards, bustards, cisticolas etc) and plants in one single day. And that made our day. Or maybe was it the delicious concoction created by our dedicated chalet keeper-cum-chef, Moses, who performed what can only be described as alchemy on the sweaty ingredients we’d be dragging along from Lilongwe. In this season, at this altitude (2000m), even in Malawi it gets pretty chilly. What better way to feel smug then than by a local firewood fireside with some more of that Malawian gin and real tonic before hitting a perfectly manicured bed...

Nyika Plateau- cycle ride/ village walk
Day 2 up Nyika was pedal powered along a myriad of paths and viewpoints onto vistas of the order only gleaned at on 'Planet Earth' or the like on TV. My position as the pack leader entitled me to the honour of approaching the animals first along the trip, often seconds only before they would rush back t o “security”, away from my trailing bike partners. White was again very useful in his local insight, even though that did not suffice to bring out the elands for us. Having exhausted ourselves to smithereens, we opted for the lazy stroll in the afternoon, which took us to the well kept secret that be the workers’ village on the plateau. That proved to be a great cultural extra (which we’re always keen on here) and also such excitements as crossing a derelict wooden bridge and balancing our bodyweights on some felled pine trunks near our chalet. This you need to picture as an amazing cabin warmed by an enormous central hearth and almost fully wood fuelled, including hot water (delight!)! Large windows let in plenty of light and gave us views out into the dense conifers to the back and into the small valley with its dams in front of us. As you guessed, dinner was consumed by the warm fireside, as prepared by Moses, and this time he managed to make us some bread and a perfect stir fry out of the fresh ingredients he sampled from a high up garden.
For two days, Nyika produced what would be best described as a little piece of heaven for us.


Nkhata Bay
From alpine silence and cool to humid lake-bound bustle, the transition could not have been starker. But then again a Malawian road trip wouldn’t be complete without including at least one stop at the lake. As it is clear to me by now, each bit of the lake has got its own personal character and charm. Far from the tranquil repose of Mangochi, or the posh resort of Cape Mcclear, Nkhata bay’s distinct appeal lies in its cliff-perched villas flanked by lush green wilderness. Once you’ve eliminated the thought that crocodiles might lurk somewhere in that water, it becomes one of the best for snorkelling haunts I’ve seen so far. You can really get close to those cyclet fish (which are unique for the propensity at evolution and rapid selection) and swim long distances without having to worry about tides or currents. If you’re lucky you’ll find a parked boat which you can climb and dive from... Simply ecstatic!

Senga Bay
In search of a more sandy version of the Lakeshore, the next day found us trekking another 350Km or so to Senga Bay, which is otherwise known as the capital’s swimming pool. This is where all these executives and short stay tourists rush to for a quick chance to immerse into Malawi’s biggest gem. However, partly owing to my state of sheer exhaustion and partly from a less than optimal choice of lakeside to stay at, Senga Bay will probably not remain etched in our hearts and minds as the preceding 6 days will. As for tranquillity, it certainly surpassed our expectations and we were glad to have a peaceful last night of a truly amazing holiday, recapping and recharging our batteries.

Lilongwe to Ntcheu- Public Transport2
Taking hitch hikers en route had become customary for us by now and the last leg of our journey was no exception. It was a reluctant reminder to us that our time of enjoying this luxury (lift offering) was also coming close to an end. The keys of the hired car would be handed over soon and we would become the ones either hitching or screeching and squeezing aboard a bus back to Ntcheu. This was precisely what happened after we managed to dodge past the horde of would-be porters to our bus. There we sat relieved that the bus was already full and ready to depart. Or so we thought. I was sat on the engine box at the front (my backside being guarded from smothering to an ash [!!] merely by an aptly placed wet towel from the morning’s swim!) and Janet on the steps. In the next 10 minutes the bus managed to fit another 10 or so passengers and within 10 miles of Lilongwe, it made this unexpected stop, where one person boarded together with their life’s belongings, followed, to our disbelief, by another, and another... until a miraculous 15 other passengers (less kids) found a space to stand somewhere aboard this bus. I don’t know how we managed to breathe after that. I think that if a preacher had joined us at this time, I would have stood up and preached back something about existentialism or some unintelligible metaphysical subject just to get it off my chest. Thankfully, the drive was quick, the music not deafening (thanks to my premier position next to the driver, hence controls) and the sun-setting scenery over the mountains of Dedza and Ntcheu an absolute treat for at least two exhausted contemplators.

1st week in Ntcheu... together

Today I will add a twist to this latest entry as I have in my company a guest appearance by the name of Janeti! She will hopefully confirm such concepts as the “sound of Ntcheu” and “public transport” for you here but also provide a very fresh insight into life and work in Ntcheu, with her original views.
So here I am, and I has perfectly become we again, which is just great! We are sitting here together eating Lilongwe strawberries from today’s tour around the city’s market, in the best room in the VSO guesthouse. We’re preparing for our epic trip to the North which starts tomorrow, after a lot of organising from the well connected and diligent husband. So to take things backwards first, perhaps you all might like to know the other half of the Doorgakant’s impressions of Malawi...
It’s fairly impossible to know where to start, and even when you do start you can only make crazy generalisations anyway, so I’ll keep to the facts- I arrived in Lilongwe after a long but smooth flight via Addis Ababa, most of which I slept through after hauling an unfeasible amount of luggage down to London and then optimistically turning up with it all at Heathrow, only to be relieved of a significant portion of it at the gate (thanks Saj!), allowing the plane to actually take-off. It seems I’m not yet Mauritian enough to be able to get all I intend on a plane!

The happiest and most brilliant bit yet then came being reunited with the husband in the airport- you can all picture him there I’m sure, standing out in his brown felt hat! You’ll all be pleased to know that he’s the same as ever- full of energy, life and enthusiasm, but with one significant change, which I’ll leave you to ponder...and challenge you to spot on proceeding photos. (something quite bizarre, that I can’t explain- he puts it down to the washout of accumulated e-numbers and oestrogenated tap water from the UK!)

Back then to Ntcheu after reuniting my tastebuds with Nsima. It’s a long town based around a main road. I’ve seen the infamous Uncle B’s, I’ve climbed up the Mt. Ntcheu telephone mast (battling [psychological] heatstroke), heard the dog chorus, admitted that ‘yes’ there is quite a lot of noise pollution in Ntcheu, tasted the homemade marmalade, and loved meeting some of the great people already mentioned in this blog.
Briefly, to stop this being a complete epic (there are other things to do than write blogs on a Saturday night!) I’ve enjoyed seeing a little of how the lab works in the hospital, after very kindly being allowed to spend most of last week shadowing the work there. There is a main multidisciplinary lab for malaria films, FBC, some biochemical tests (depending on reagent availability- also less U&Es) CD4 counts, and then a micro lab which mainly can deal with CSFs and TB smears. One of the main challenges has been dealing with Dr Ashtin’s varied output ranging from specimens in contravention of the lab acceptance policy, to trying to get samosas through the door (also against the rules of the labarotory). In only 4 days it’s really opened my eyes to the realities of work here, and I’ve also been very impressed by the standard of the staff. I’ve also made media, which is something never really done in labs in the UK now, so a good education for me. I could write very much more, and will talk very much more, but for now back to this blog’s real author.

In case you’re already conducting an internet search to find out which newspaper or TV programme my illustrious wife has appeared on, let me clarify that by media she meant this funny plastic dish full of microbes, which gets microbiologists all excited for some reason! Never made my life easier as an orthopod because the next thing is usually a diatribe of Latin and Chinese to tell us that we need to use the antibiotics we were intending to use anyway. In any case, Ntcheu only has 3 or 4 on offer!
Also to get back to the Samosa event, let me just add that after spending your lunch hour doing your second operation of the day (the first one having been a killer in its own rights), namely a hydrocoelectomy turned Orchidectomy because the booking clinician had no clue about testicles, the very thought of even thinking of sharing the only bit of food you could lay your hands on before rushing back to theatre ought to be met with better gratitude... even if the offering was made on the threshold of a microbiology lab! At least it was not inside the lab, next to the dissected testicle!
Anyway, you’ve heard it from a second source now, Ntcheu rocks, but Ntcheu also needs a certain level of decibel tolerance and Ngoni-style energy. This is the local tribe around here, who really deserve a good few paragraphs of their own. Let’s just say for now that late night partying and heavy drinking aren’t exactly alien to them. It’s really been great having the wife around to see what’s going on in the hospital too. It surely wasn’t easy to spring into the same familiarity with it all as I have developed in at least 3 months, in less than a week, but she’s done pretty well indeed. She even knows more than me about what tests can be done here now and is able to give me insider information on how to find out when they’re available!
I won’t dwell too long on this first duo-blog because there’s a big trip ahead of us, which stills needs quite a lot of fine tuning doing on the organisation. One of the good things about being in Malawi though is that last minute planning tends to be the norm. Somehow or the other things just work out... I hear Bob Marley’s lyrics... but is it me musing or is it the Lilongwe Uncle B launched for the night!?

Clinical Digest 6

Another 3 weeks gone in the hospital and so many new surgical adventures to recount. The nature of operating has not exactly changed, in that it is still mostly salvage surgery, but a few items have been added to the repertory. One of them is split skin grafting. Since I got to Ntcheu I kept hearing that we had the kit for it but I was yet to put it to the test. I judiciously chose a small case to be my first one. The surgery was uneventful, although remarkably slow, owing to some issues with positioning and kit. The knife in question is a donation from a very enterprising Dutch doctor who pioneered this new model based on its resemblance to the “Schick” razor and even uses the blades for it. Only drawback is that it only allows you to harvest tiny grafts which you then knit together on the wound. As it is, the wound on our patient in question was right over his Tendo Achilles and the anaesthetist was not happy doing him prone. So I kind of got him supine with a figure of 4 crossleg, which made the actual job of the final stitching tediously slow. It’s a question of time now to find out if it takes or not.
My level of amputation has also progressed and I now count a below elbow amputation in my logbook. One must wonder whether all this is really necessary or whether we could just debride radically and wait. Well that’s precisely what we were doing at first and discovered we were being too conservative and had to take patients back. Just to contradict this pattern, then came a case of a grossly septic leg which we were very close to performing a through knee amputation on but had to hold back as the patient refused surgery at the last minute. What ensued was rather enlightening. To my consternation, this leg which I had, by now, consigned to an irrevocably doomed fate, started to get better with stringent wound care alone. That threw me back to the original question of “to chop or not to chop”. I guess that there will always be cases, especially here, which behave differently from the norm. The actual protocol of practice however, should, I believe, be based on the average (which time and experience will aid my clinical judgement of) rather than special cases. And indeed, that below elbow amputation was another special case, which I thought was amputated high enough. Yet it gave me reason to worry that it was still infected, ie I hadn’t gone high enough. Thankfully, aggressive wound care sufficed.
By the way, you will have also noticed that we are consenting our patients, but the process is a far cry from our 4 pages of carbon-copy material plus all the other forms in England. The form here resembles more like an 8th of an A4 page with the following signed statement: “ I hereby consent to have an operation on any part of my body as deemed necessary by the surgeon,” or something similar!
The degree of sepsis encountered here is something of a completely different order to that found in the UK. Whether this is explained by the virulence of the pathogens or toxins (as in the few snakebites I’ve already dealt with) or by the time it takes to get to the hospital, or even by the time it takes from admission to get to theatre, or by the stubborn stoicity of the people who have faith it will get better by itself, if not with the assistance of the greatly revered witch doctor (whose involvement is often recognised by the tell-tale abrasion scars on the skin), I can’t really tell for sure, but it is likely to be a combination of many if not all of the above. The management of such sepsis is a real challenge and necessitates intervention on a number of different levels.
My latest case in theatre was a surprise last minute one I only picked up the day before and planned for the end of the 3rd week: an index finger drop. The patient had been severely panga-knifed, sustaining bilateral Tendo Achilles divisions as well as multiple scalp and bilateral forearm wounds. Poor chap (19yr), he looked like he’d just come out of a sarcophagus, with all the bandages around his body! (He was approached by some ruffians who wanted a mobile phone from him, which he didn’t have. So he ended up paying for it in the form of these unwarranted lacerations). The hand on the non-operated hand was afflicted by an ulnar nerve palsy beyond repair. The other hand needed an extensor tendon exploration and repair, which I had only ever assisted in them in the UK but never done one alone. Technically though, there was no reason why I shouldn’t be able to do it. So I approached this case, made more complex from the fact that he had two potential wounds on the dorsum of his hand/wrist where the tendon could have been divided, not to mention the fact that he was almost a week from the time of injury (hence starting to retract). I was quite pleased when I finally freed both lacerated ends of the tendon, although I only had a flimsy silk suture to reapproximate it. My first independent case of reconstructive surgery, provided the best booster at the end of this 3 week stretch I could ever wish for. And now also, my interest in hands has been properly rekindled.
Besides operating in the main theatre, minor theatre has also provided its fair share of excitement in the recent weeks. I embarked upon a poster teaching session forced by some of the practices I had witnessed earlier by the student staff. Hence we drew posters on safe administration of local anaesthetic and the differences between common lumps and bumps (a description which caused hours on end of giggling here). The rules behind the dosing of LA and its limits were completely alien to this staff group who had been administering them liberally for months if not years already. Being low resourced is not an excuse for letting your standards down on such an easy-to-implement concept. As for the lumps and bumps question, we now have a readily accessible chart to differentiate between them. This is been a welcome addition to the trauma room, where hopefully lipomas will now be diagnosed only when they are actually lipomas and not cysts or nodes or pseudoaneurysms anymore! As a real coincidence, that same day, we received a serendipitous casemix to examine in our clinical area: a real lipoma (which was enormous and I only just managed to excise under LA), a ganglion, a scalp sebaceous cyst, a skin tag, a histiocytoma and a pyogenic granuloma! What were the chances of that? What I found with the style of the teaching is that it is very participatory and depending on how it works, I can surely see myself exploring a wealth of topics during the year to come. Next one is already lined up- aseptic handling and sterility. The microbiologist in me, not to mention the one attached to me, could faint at the way some instruments and specimens are handled here!!

Aphiri

That’s Chichewa for mountains. That was also the fortuitous nickname I earned at the ART course from the Malawian candidates. Pretty fateful, since, now the rainy season is pretty much behind us, more and more unsuspecting people are being dragged up these breathtaking heights with me. The last time was Zomba with Caleb, Corrie (a VSO from Holland), and Claire and Nicole (CNN for simplicity- visiting Dutch medical students, who are a real laugh by the way). This weekend was the second ascent of “Mount Ntcheu Telecom Mast” as I shall name it, for want of an official name. My victim, for the second time in a row, was Caleb and his unpreparedness for this expedition was obvious from his power shirt and the NASA-mission-looking DocMarten type shoes he was wearing (only slightly worse than the ones that crawled up Zomba plateau in - so I thought he’d manage)! In the interest of variation, we chose an alternative descent route, which is what made this time around more memorable. Of course, the ascent involved the same toil of sweaty gradients and tall grass, with inescapable reminders of snakes lurking amidst the thick canopy. After losing his body weight in sweat and CO2 and demanding almost the same amount of time in rest as in actual walking, Caleb unbelievably made it to the top. Once we started our descent, the functional uselessness of those very shoes became apparent. The arch-less insoles, smooth as a baby’s ass caused his whole foot to keep sliding on the downward slope, with his great toe constantly abutting against the tough inside. Oh did it hurt...and slow us down. We were now taking longer for what ought to have been the faster leg. And how things weren’t helped by the fact that, unbeknown to us, this alternative route was some 7-8Km longer than the ascent route!! We found ourselves contouring the foot of the mountain towards another town some 7Km from Ntcheu. (I know of an old hiking partner who’ll spot a few similarities with some big hills once in Scotland!) We were on the flat now with the sun right above our heads, still clueless about the remaining distance to the main road. Our attempts at gauging it from the locals in our broken Chichewa attracted answers ranging from ½ Km to “forever”. So we thought it might be wise to hail a passing vehicle and cut short Caleb’s blatant suffering by now. The first vehicle was an ambulance driving too fast to be safe, which didn’t stop even though I was signalling quite desperately that I am a doctor!!! By the way, ambulances in here are mostly used for staff as opposed to patient transport. We passed on the second option, a pick up truck, with some 30 people sardined in the back, screaming some songs; alcohol-fuelled and football-related we concluded (some things are the same anywhere in the world). We finally met with better luck with our third vehicle, if luck it can be called. It was a relic of a 4x4 with the back loaded up to the top with sacks of potato, atop of which were some 6 opportunistic travellers like us, as well as a bike. Considering the rocki-ness of this dirt road and the local driving style (which is one of my main sources of work in the hospital!), we thought we’d negotiate a place in the front. There was already a passenger there and at a push (literally) it would accommodate another one. Its door was not closing and had to be held closed with some old tyre strips (the favourite strapping material in Malawi). Somehow we set off with 3passengers and a driver in the front, the far-side passenger (myself) hanging on fiercely against the door which my bum was pushing open, with my hand at the top straining feverishly to close the gap! It turned out we were only 3Km away, but given the state he was in, even that would have been too much for Caleb to leg. Thence we caught our final minibus ride home to Ntcheu, in search of food and more food. As it is, getting on a minibus is not something I take too lightly, given its high contribution to the Malawian trauma statistics. The driver is normally subjected to a breath test by me (both ways it stinks, but the alcohol-imbued one a bit more) and the tyres inspected for the adequacy of the treads. Today, despite bypassing all of these checks, it felt like the safest ride home that I’ve ever had....

Written upon Caleb Muchungu's request: VSO Volunteer at Domasi- and slowly becoming a seasoned mountaineer.

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...