Clinical Digest2

Clinical Digest: Monday 22/1/10
Today I spent my first day in Kamuzu Central Hospital, Malawi’s 2nd leading government hospital, after Queen’s in Blantyre. However, from my previous experience of the Orthopaedic service at least at the latter 2 years ago, there are certainly some developments I’ve seen here which would have been looked at as luxuries there.
I saw three operations today, all of which were performed by expats, who appear to be the only surgeons in the department. Most of them are unfortunately ‘de passage’ and bring about a short burst in activity (and hope) that soon subsides. In a way, this is what VSO tries to avoid, by laying the greater emphasis on the sustainability (not environmental in this case, issue which I will take up with them) of our work over service provision. Two surgeons have been here for many years though. One, the godfather really of this department, is an American-trained Filipino surgeon, who literally will take on (almost) anything! He has been here for 25years now and has the coolest demeanour about him. Not one to moan about such and such kit not being available (Oh what a contrast with the cliché from home) and really one to just approach things in a slow thought out manner. That really reminded me of the importance of such an approach today, where overenthusiasm and hastiness, could really result in you falling way behind your starting point. I’m referring to the epidemic of AIDS of course here, the prevalence in hospitalised adults being much higher than in the overall population. I saw him train another (clinical officer) to do a tracheostomy today. I guess that is the start of my training in this procedure too, as I’ll probably be called upon to do some in Ntcheu.
The second surgeon, a Tanzanian national who’s been here about 6years, is again a remarkably well composed operator. He performed a modified radical gastrectomy with splenectomy. This was for a gastric antral tumour, which was originally thought to be a hypertrophied pylorus from a chronic duodenal ulcer. In fact the original operative plan was that of a vagotomy and pyloroplasty. I was actually dead psyched up to see an operation that’s almost historical in the UK now. Maybe another time...
The case that stole the show however was the one orthopaedic case I assisted in today. A mammoth of a case it was- a retrograde femoral nailing combined with external fixation of the most comminuted pilon ankle I can remember seeing, the lot not helped by a set of really blunt instruments. The surgeons were a pair of Norwegian guys, again really relaxed and affable, who are here on short-medium term placements. One of them comes to Kamuzu on a regular basis for varying lengths of time. They used a SIGN nailing system, which is a charitable venture set up by a Vietnam war surgeon. His main motivation for this project was the injustice he felt in treating only the fallen American soldiers while leaving the others to die. Thus came about his scheme, in which free nails are provided to third world hospitals, with one minor condition: that the operating surgeon fills in an audit form after each nail used and sends it back. The SIGN nail, originally designed for the tibia, worked quite well as a femoral nail too. The jig is used for both the proximal and distal locking screws, which actually are designed so the proximal end is expanded and sits in quite tight. Of course, with natural error and bend, the distal locking screw doesn’t always slot in as expected and a few tries at least are needed. But given the absence of target drills and reliable image intensifiers, I think they are an excellent alternative- which brings me to one of the improvements I was really not expecting to see here in Lilongwe: a functioning image intensifier. It might have been wonky and tricky to operate at times, but it worked and the results are the same. The final reduction and quality of the fixation was, in short, commendable (better than some I’ve seen with state of the art equipment). Isn’t Orthopaedics simply fantastic?!

Public Transport

This weekend saw me trekking once southwards towards the warm haven that be Blantyre, then back to Ntcheu for one night, then off north to Lilongwe this time on Sunday, in order to attend my central hospital orientation. Don’t question my reasoning behind this yoyo style of moving about. I just needed to touch base with the Orthopaedic team at CURE, Blantyre before my four week exile to the capital. It all proved quite fruitful in the end, with a lot of ideas now falling into place.
The journey started on Ntcheu’s makeshift bus stop, run on the day by a goateed yellow-eyed youth reeking of booze, whom I initially mistook for the driver of my intended mini-bus. I waited another 40 minutes as a result for a more ‘executive’ one to appear. The inside of the new vehicle felt every bit as crowded as its smaller and less popular relative. But I sat tight (I couldn’t complain as I got a seat), careful not to be impatient on my first interaction with long distance public transport here. In short, my drive was punctuated by an hour of loud Malawian rap, followed by Kenny G plays Celine Dion, the latter interrupted for another hour by a possessed man gesticulating and shouting behind me in the aisle. It took me about 30min to realise this was a preacher, when I overheard the words ‘when you are born again...’ and ‘amen’, to which the whole bus joined in chorus, before launching into another half hour of frantic chanting! The latter element was actually quite soothing after all that tympanic assailing.
30 min later than anticipated, courtesy of one of the numerous roadblocks along the way, where some uniformed chap gets everyone to disembark so he can walk around the bus with an air of self-importance, without actually doing anything, we arrived in Blantyre. And I was already late for the teaching session at CURE. This was not helped by the next bit of dwindling I fell victim to. I invested my trust in a minibus to get me to the hospital for 50Kwacha. What I hadn’t noticed was that I was one of only two passengers aboard. The minibus set off in the opposite direction from mine and dropped the other passenger off down the road. Then the driver turned round to me and said that he would take me to the hospital via the express way only if I paid him 500Kw. The conductor was nicely positioned by the door to block any attempt from me to get off. I decided to avoid the confrontation and asked to be dropped wherever I happened to be, paying them the 50Kw agreed at first, but essentially more than a mile farther from my original destination. I got to my teaching as it was finishing. On the upside, I managed to have a little tete-a-tete with the hospital director to pick his brains about loads of things I needed to find out about the Malawian orthopaedic world.
My other mission in Blantyre was to find a bike. Instead I got Indian spices after a quick scoot round the town the enxt morning! A few VSOs and a non-VSO couple I met on Friday advised me to go a certain shop for the bike. The non-VSO guys were in fact here to set up a project on social economics, selling bike trailers (at an affordable price) that could double as bicycle-ambulances. They’re called Care Car and I really commend them (www.sakaramenta.com). So upon this sound source of advice, I decided to look for the place the next day and as fate would have it, I needed a minibus. Would you believe it, I got taken for a ride again this time- in the opposite direction that is! Surprisingly, I got off without questions pretending that I needed to stop quickly at a shop. Later on I realised that the lack of fuss was probably explained by a police car being in the traffic behind us. So I said goodbye to my cursed bike plans for now, and went straight back to the bus station for my return leg to Ntcheu.
Three hours, three full-on preaching sessions and three unnecessary delays later, I was in Ntcheu. I never thought I’d be so happy to be back in a place I’ve only known for 1 week! That night I got to know it a bit better. I checked out its night life- a choice of three bars, a few restaurants selling local food and chicken&chips and Uncle B’s prostitute club! The bars had one attraction that made it all my worth going out that night- a pool table. I found myself reliving an epic episode while I was in Burnley, where Viv and I shot to prominence in my local pub through a combination of being the only drinking Asians around and being the ones to play down the reigning pool champ- by pure fluke! I didn’t win against the actual champion here but did well enough to be invited back. Maybe they just want my money, but that’s not how it felt!
And now to the last leg of my road-bound weekend: the trip to Lilongwe. In a semi-conscious daze of sleep depravation and hangover, I found myself boarding this minibus after seeing two large buses leaving in Lilongwe’s direction one after the other, seconds before I could get to the station. After a heated debate between the passengers and the conductor about not letting an extra passenger on (after me), which would quite reliably have replicated the atmosphere inside sardine tin for us in all truth, we set off without the extra man. Halfway to LL, we ground to a halt, not from the coppers at the road block, but from a flat tyre. I’m sure I checked them before getting on! That took another 45min to get fixed (I did worry we’d be stopping for the night) and off on our way we were again. I love this ride because the road veers off into Mozambique at one point and my mobile phone always sends me a text to welcome me to Mz! The scenery is also superb, replete with mountains (nice appetising rock faces on offer), birds and vast open fields. But 3.5 hours in a minibus can’t help being tedious. Arriving in Lilongwe at dusk felt like being airdropped in a rugby scrum. Everyone wanted to help me with my bags (and its contents for a month’s stay in LL) and take me to my destination independently. Rather than risk it with city minibuses this time, I opted for the safer bet, the taxi. And at long last, my lucky star shone and I managed to get a half price one, as I shared with a Jaica volunteer (the Japanese voluntary organisation; Peace Corps for the US).
Better late than never!!! Knowing what Malawian time means now, that is a saying I shall be reciting like a mantra for the two years ahead...

Clinical Digest1

Clinical Digest: Friday 19/2/10
Last week was my settling in week at Ntcheu, where I was meant to familiarise myself with the surroundings and with the hospital. I did a fair bit of the latter, without getting too involved. I still managed to get a good glimpse at the kind of orthopaedic case mix I’ll be encountering. I spent 4 half days with a very experienced clinical officer, whom I can only liken to a senior staff grade in the UK- doomed to never be a consultant somehow. His knowledge is extensive and he even appears overqualified for this post, the main obstacle to his exercising of his skills being limitation of equipment. I found it hard to add to his practice in these 4 sessions as he really knew how to juggle this massive workload and the scarcity of resources, so as to maximise his output. Say he decided to spend some more time on one patient to treat him/her marginally better, the direct result would be some 5 other people potentially missing out on the most basic treatment. I do hope to be able to take some of the pressure off his shoulders during my stay here but also to refine it and work on this refinement being maintained.
In terms of some interesting cases I saw, there was one in particular which I had no clue how to tackle. This infant came in with what appeared like a congenital dislocation of the knee (which was hyperextended to his shoulder at birth) and now recurrently adopts the same position with the minimal effort. The hips were fine. I couldn’t work out if this would be a self limiting problem or lead to some chronic disability- which could potentially be reversed by a very simple intervention like some splint or taping. In the end, we (or rather they) taped his knee in partial flexion for 6weeks and hoped for the better. I shall try and find a more scientific answer to this problem in the meantime. Any ideas from my audience are very welcome as my wealth of orthopaedic references here is limited (baggage restrictions oblige).
Two other cases I helped in were interestingly both knees again. One was a kid with a spontaneous effusion that started 6months ago and been aspirated twice already (but never cultured). So I aspirated it again and requested cultures this time, thinking TB/osteomyelitis quite high. Early results are negative, but we’re still waiting enrichment. The second knee was on a HIV+ patient with no history of trauma or systemic illness. He was not on ART but didn’t show any sign of AIDS. Anyway his knee grew Staph and we’re treating him. Both cases were really useful for me to get into another role I really want to develop here, which is that of a trainor. I used these first opportunities to teach the students and medical assistants about a few dos and don’ts of the procedure, especially the importance of aseptic no-touch technique (ANTT). At the moment however, it’s funny how it’s actually me who feel more like the student learning from them the way things are done in a context they’re much more familiar with. I shall endeavour to turn this into a mutual learning curve as time goes by.
As for operations, I stood in twice to watch operations beings performed, really fluently, by clinical officers, from the operating surgeon to the anaesthetist. There were two uncomplicated Caesareans (breech and cord delivery) and on another occasion, I saw an ERPC (not to be confused with an ERCP!). That is one grubby operation I really don’t look forward to being in charge of during my stint at Ntcheu.

The sound of Ntcheu

My House
En route to Ntcheu
I’m now in Ntcheu. You probably guessed by the decline in my updates that internet here is not the widespread facility that we, in the west, consider of the same order as electricity or water. More reassuringly, the latter are available, albeit with frequent interruptions. So I’m not exactly in the wild but the town, if it can be called that, is very basic indeed. Parts of it remind me of my visits to Riviere du Rempart villages when I was a little boy and even that was relatively developed compared to here. The fact that Ntcheu lies on the main road between Lilongwe and Blantyre (ineptly named the M1) attracts some degree of trade and infrastructure (2 big petrol stations for example). Most of the settlements are down side roads, mostly dirt tracks.
The hospital itself is a stone’s throw away from my house, 3 minutes’ walk to be precise. It’s not very big but relatively tidy. The Malawians place a lot of emphasis on tidiness and on the attractiveness of their gardens, which makes for a pleasant working atmosphere. The hospital has 5 main wards: Female, Male, TB, Maternity and Children’s. It also has a main outpatient’s section, which acts as the casualty area and a follow up outpatient akin to our fracture clinic, where the Orthopaedic clinical officer sits. This is attached to a minor ops area for suturing, I&Ds and plastering mostly- all done under LA or neat! Main theatres are behind this block and I haven’t visited it yet. The laboratory facilities available aren’t too bad, with full blood count, microscopy and cultures possible. An XRay department exists and has the honour of being the only air-conditioned area in the hospital. It is however temperamental, the output very much a function of availability of chemicals and good running water from the mains. The only portable XRay and ultrasound machines are presently out of order and there does not seem to be much hope of an imminent recovery. The hospital also has public health and environmental surveillance offices, where other VSOs are placed. On the medical front, I’m joined by a general/obstetric doctor (Dutch) and a paediatrician (Indian), both very nice and helpful to me. In fact, my arrival here wasn’t scarily isolating, as I had a nice welcome dinner outing with some of these volunteers and I moved into a house where there was already another volunteer (in HIV/AIDS programme). However, I still expect it to take a little longer before I can safely say I’m settled in here- because let’s face it: this IS culture shock!
The chief of the hospital is the only Malawian doctor around. He has only qualified from medschool last year and is already the acting District Health Officer -title which comes with its fair share of administrative duties- such that our DHO is almost always immersed in paper work, when he has not been dispatched to some central ministry meeting. Extremely difficult to pin down but when you do, he is a very amicable person and undeniably has an air of competency about him. This is evident when you judge by the standard of some of the medical students attached to us here. Their knowledge base is impressively wide and most of them are also familiar with minor surgical and obstetric procedures- in stark contrast to our slack party-going lot at home!
As for the surroundings, well I couldn’t have fallen better- rolling hills into the distance, most coming ready with paths. Slight disappointment for now is that I’ll have to wait till the rainy season abates. The way the skies open up here is like nothing I’ve experienced before (save a brief encounter with the Bombay Monsoon- even that was milder). It trickles for a bit, then this massive sky-borne bucket the size of Ntcheu is suddenly tipped over the whole place for 2-3hours, bringing with it a pounding presto raindrop solo on my tin-roof (typically at night). Outside everything simply coalesces into a massive pool with gushing streams carrying the water downstream- so effectively in fact that it dries up quite quickly afterwards (at least up here).
The main road (M1) is the heart of the town. Littered with small shops and stalls selling exactly the same groceries, within ten metres of each other, it also has a number of higher end shops, which sell other basic household items. Anything, in the least, specialised is hard to find here and would normally require you to take a trip to Blantyre or Lilongwe. One such example, I found out to the detriment of my face is shaving cream/foam/soap. Eateries are elementary, serving mostly the Malawian staple food (Nsima/Rice/Chippy(!) + Beef/Chicken/Chambo) and nothing fancy. Vegetarian food can be hard to come by at times, although they will usually have a side dish of cooked greens, but this really does make it into a main dish. Bars can also be found aplenty here and one distinctive characteristic they share is the loud music. This only adds to the fanfare produced by the shops selling clothes, music and ‘gifts’. The way this music is typically played is what stunned me at first. Instead of pointing the loudspeaker, turned up to the max, into the building for the enjoyment of the customers, in here, it tends to be the other way round. Thus your eardrums are constantly being assaulted by random music from neighbouring shops competing for your attention. The one from the Uncle B bar reigns supreme as it goes on through the night most days to my great distress, given I didn’t bring any earplugs! I must have had them on when they repeatedly warned us at the VSO courses that we should have equipped ourselves with a good stock of these. So my nights are now tuned to the rhythm of a distant bass with occasional drums. It’s funny I should say this but it’s kind of starting to even feel normal to me- as long as they don’t push it (as they did on Valentine’s night!).
And now for the icing on the cake, let me tell you about the howling concerto from Ntcheu’s own dog/hyena ensemble when Uncle B’s Bar (aka Black Mafia) or torrential rain aren’t deafening all else. This is a unique choir played on the background of the nearby hills, which also help with the echo. Thus every night the howling conference takes place somewhere around 11 pm and dies out naturally by midnight. It’s so predictable that, again, it becomes almost part of your routine. In fact, I find it even soothing at times, but I still wouldn’t want to venture out there.
So this is Ntcheu, in a nutshell. Of course more anecdotes will come out of it over the course of the next year at least that I’ll be here. But for now I shall leave you to whatever music be with you to join my sweet melange of bass, howls and raindrops...

Induction cannonball, football and volleyball

Since I signed out from my previous blog, I’ve probably accumulated more factual knowledge about Malawi and its health programme ( incorporating mine) than I have in the entire time I’ve known I’d be going away to do this project. The brainstorming has persisted unrelentingly with some extremely dreary administrative sessions interspersed in our schedule. Thankfully, the closure of daily events was religiously stuck to at a strict 5.30pm. Were it not for the intervening evenings, I don’t think we would have lasted long here. Yesterday saw the first kickabout in the African heat. Even though I certainly am no alien to it, remembering my heydays in Mauritius, it still hit me like a cannonball trying to float! I stared at the volume of sweat I could produce in pure disbelief. The limp that ensued was a reminder that I shouldn’t let myself slip into complacent heat-induced beer-drinking laziness. Today’s football was an answer to that...but I have to admit I’m only barely standing at the moment. But then again, the game went on for some 2 hours! Back to last night was another highlight which appears to animate this part of the capital every Wednesday. Like any curious tourists, we did not miss it: the local volleyball challenge. Some 6-8 teams from around the area (the majority being Muzungus- I’ll come back to that) battled it out from 6pm to later than 10pm, with all their energy, and to think that we’re bang in the middle of the week here. Crazy! I have to say it is a great spectator sport, when you can just sit in the open air, shirt half open with a bottle of Kuche Kuche in your hand. Sweet!
Now that I have reassured you that I am relaxing and having fun too here, let me just share with you some of the fascinating (although in a sad way at times) facts that I’ve been learning all these days.
Firstly, on an etymological level (which many of you realise is a great interest of mine), the origin of the term Muzungu (Caucasians for those not familiar with it yet) revealed itself to me in what was probably the most entertaining lecture we had. This guy, Samu Samu, local historian and outspoken critic of colonial abuses gave us an anecdote to illustrate his interpretation: “Trickster”. So in what was a proper guilt trip for over half of my colleagues, he told us how Shaka Zulu was tricked into giving up all his land to the British in exchange for an immortality potion. That turned out to be simply hair dye which made his hair all black again, so that he looked younger. After that the British said that every time he had the product, he should hand more of his land over. In the end, they pretended to strike a charitable deal by telling him that he could have all his surface land back in exchange for everything deeper than 6ft. Shaka Zulu obviously thought he was the overall winner in that nothing useful could lie 6ft under and concluded the deal. The result of that today is the Muzungu ownership of most of Southern Africa’s mineral mines!
Next on a more sombre note, these are a few hard (and harsh) facts to shed some light on my mission- Malawi’s health and education statistics:
1 doctor per 53 000 inhabitants (cf 1: 300-400 in Europe)/ 1 nurse per 3006 inhabitants
---that's less than 100 doctors in the country (excluding expats)
4 central hospitals and 6 district hospitals for a population of 13million
Life expectancy of ~40yrs
HIV rate of 12% (down from 14%)
40% of Malawi budget funded by donor organisations and governments
Free education only since 1994. 30% complete primary school.
20% enrol for secondary education, 5% for tertiary.
Student: teacher ratio 1:100 primary (only 1:120 if taken for qualified teachers)
Attrition rate of teachers (from death, retirement, move to greener pastures)almost = training rate.
Literacy rate 60%
Of course this is not meant to depress you but just put my work here in context for you- as I am here for work, not just a long sunny holiday! The work of VSO is really starting to inspire me more and more, especially since learning about their concrete successes here in less than 10 years. They place an emphasis on capacity building and empowerment, which very much silenced my fears about causing dependency in a system that might collapse once we all leave. Their support structures are also extremely well coordinated (possibly a bit too pampered- but we’re Muzungus after all!! I’ve resigned to accepting that I’m an honorary one now!) and consequently the individual projects of most volunteers have turned out to be mini-successes. There is no doubt a lot more work to be done, before we can even start contemplating a Malawi that’s free from poverty, serious health issues and under-education. However the current work seems to be moving convincingly in the right direction and for the sake of illustration, DFID (department for international development) and the WHO now consider Malawi one of the few countries to be on track to meet the Millenium Development Goals by the end of the year.
So there is hope.. a realistic one, and I, for one, will approach my mission over here with as much of it as I can possibly muster. Not long before it all starts.
Will keep you posted as and when internet connection appears.


PS: the newly added photos are just a couple of quirky shots the tourist in me couldn't help noticing! Happy Happy!!

Africa a la VSO

Another P2V/SKWID-type VSO training day over and the feeling is one of neutral contentment- neither happy nor sad, neither isolated nor stifled, neither enthusiastic nor listless about anything. Partly jetlagged I suppose, yet somewhat more complex. Transition, I guess, is the word I seek, and the exact emotional meaning of it will manifest itself to me in due course.. in the way it normally does.. like a timebomb.
On a practical note, today has been quite productive. It started with a daunting language exercise, which rapidly eased into a more rewarding task once the words started coming back to me. I can now ask “Dzina lanu ndi ndani?” again or ‘what’s your name?’! We progress into more advanced territory tomorrow... the supermarket (let’s just hope it’s neither TESCO nor ASDA, nor their local counterpart Shoprite!). Which brings me to my pet hate, rather early as one might have guessed. We got taken on our first shopping trip today, as a team of “progressive, poverty-challenging, opportunity-creating, enterprising change setters” and guess where we ended! You guessed right. We chose the single biggest corporate, economy-winding western institution to pay our first tributes to. Yet there were quite a few decent-looking, well stocked Malawian shops on the 15min drive to it and even round the corner from it, as I found out by going there. But nobody else seemed bothered.
However (besides shopping-forgive my rant!), VSO's obectives, I have to agree are overall quite inspiring as outlined during the rest of our induction. Their early results are rather promising in all of their main programme areas: health, HIV/AIDS, secure livelihoods and education. My general programme for the next two years was also clarified today and I will be starting with a Lilongwe-based training for 4 months. The Ntcheu programme seems really exciting from the outset, with lots of scope for me to customise it to match my skills. The potential for bringing about life-changing improvements (mutually)is certainly there to see.
Today also saw my getting connected to the airwaves finally. So get your pens and paper (or mobile phone) out and get jotting: +265993583902. Your calls and texts will be much appreciated. I should be on Skype too by the way, even I though haven’t yet had a successful call to verify that. My nick is Ashwall2.
As a crowning of today’s developments, my luggage also arrived this afternoon. All three bags and their 64Kg’s worth. I can at last get into those shorts and T-shirts and feel like I’m in Africa properly now.
Tsalani buino (or Ciao for non-Chichewa parleurs)!
Ash

A long way to Lilongwe!

38 hours have passed since I woke up last. About 9 since I’ve arrived in Lilongwe. The intervening 29 have been spent in some form of transit or another getting from Manchester to here (train to London Euston, car to Heathrow, plane to Jo’Burg, further plane to Lilongwe, bus to VSO Office)- essentially sleepless. The travel was, among other discomforts, notable for the fact that my luggage never made it to the final destination. If it can be of any comfort, none of my other VSO partners received theirs either. Thus it suggests the whole baggage container didn’t make it and not just mine!
My jet lag does not lend itself to a very pleasant narrative right now, but my feeling of recent satiation with a typical menu of Malawian cuisine does inspire a few words. The Nsima (a rather bland cross between polenta and semolina) was just as I remembered it from 2008. This dish, which is very unpopular among ex-pats, is essentially an acquired taste and I count myself as one who’s done just that. Accompanying it was the unmistakable Chambo, which I shall describe as the bone-on-fish (deliberate inversion) with more bone than fish (the little of which is incredibly tasty nonetheless)!
The afternoon was otherwise quite light, with the usual induction session a la VSO, where all the bewildered ex-pats from different geographical and professional background had to break the ice. We therefore teamed up with someone random and presented them to the group. The group is made up of mostly Brits, but also Kenyans, Dutch and Filipino- and we’re all destined to different areas and placement roles: a motley bunch of very motivated individuals with quite a repertoire of skills to pass on. It’s quite exciting really. I guess the next 5 days of brainstorming induction within that group will confirm and dispel a lot of views about ex-pat behaviour abroad (including me) and pave the way for some unique milestones ahead. A top feature among this will be my tackling of the lingo- Chichewa. Chabuino Chabuino... Bring it on!

Departure Eve

“When you want something, all the universe conspires in helping you to achieve it.”
The developments that have occurred since last entry less than 48hours ago can only be summarised by the above quote from the Alchemist. As if by some inner force, all the pieces of the puzzle have started coming together of their own.
The collection box I set up in two theatres and plaster room at work, have each yielded a stash of extremely useful surgical material already- including sutures and dressings. As I’m told there’s another one already on its way. The Braun representative (Jennifer Tanner, whom I owe a great thank you to here) has got the wheels in motion to obtain me a nerve stimulator, complete with dedicated needles, on time for the big departure date. On top of all this, my spare specs have arrived, my home utilities have all been transferred, my broadband has finally been set up so Janet doesn’t end connectionless once I leave, and my video blog has been launched... It just feels surreal!
I’m about 25 hours away from take off now and this is the last entry that I shall be inputting from the UK. I would really like to take this opportunity to thank everyone who’s helped and supported me so much in this mission of mine. This support, I can assure you, has not just sprung up in the build up to tomorrow. I have felt it constantly as a real boosting force ever since I made my decision. It certainly culminated at the wedding and the leaving party and I am ever so grateful to all of you for the words and gestures of support you’ve extended to me. I look forward to my last get together in London tomorrow. To those whom I won’t see, I say ‘A Bientot’ ‘Ciao’ ‘Laters’ ‘Pitani Buino’.
This is the link to my first video blog:
http://www.youtube.com/watch?v=Sj5YjjM0fC4

Getting ready to go

The long wait is drawing to a close. The feeling is one of anticipation mixed with complete bewilderment at what lies ahead. My placement in Ntcheu, Malawi is very imminent now and currently it’s a frenzy of last minute planning and life sorting that I’m going through. The complexities of relocating for 2 years never really hit me until I’ve had to do it. The incredible organisation behind this big move deserves a few telling paragraphs, if only to put things in perspective. From cancelling or transferring utility contracts to arranging a smooth departure from all my contacts- a different kind of contract one could say, a social one- it’s just been absolutely bamboozling!! Add to that the forward planning of logistics of settling into a new place, a new country, a new culture, a new world and you can picture the fried spaghetti my brain has turned into!

The first aspect of that was the job side of things, which VSO has thankfully mostly handled on my behalf, but not without the incessant chasing of papers and references and personal statements, that formed the major part of my after-work duties for weeks.

The second aspect, also majorly handled by VSO, was the flight. Whether that helped alleviate or increase the stress level, I cannot decide yet- but relying on a third party to sort out travels for you can be daunting. Not only because I only found out about a month in advance when exactly I’d be leaving, but also because I would only have one month to try and sort out extra arrangements like excess luggage (believe you me, I’ll be needing that!). All that said, I do have to admit that having someone else sorting out immigration nightmare for you is a real blessing.

Thirdly, in a league of its own, came the medical preparation for the journey ahead- not just the medical of course, but the whole battery of vaccinations that my deltoid have fallen victim to (thank god the days of gluteal jabs are over!). Then also, I’ve had to think hard about how to build up my little arsenal of essential meds like antibiotics, antimalarials, antiemetics, antiseptics and, lord forbid, antidiarrhoeals. And how can I forget the dentist! That man, whom I wish I’d never seen, almost threw the biggest spanner in the works, but I decided to ignore him and get my crown sorted out when I come back here...

The fourth aspect, a big one for me, has been about how to keep myself sane while I’m out there. Making sure I’m able to pursue at least a few of the hobbies I’m addicted to has had huge implications on my packing. After making huge sacrifices on my climbing gear, it is very unlikely I’ll subject my cycling to a similar fate. I dearly hope I’ll be able to find stuff out there too. Intriguingly my hiking plans have led me to trawl yet another heavy array of gear with me, a lot of it being winter clothing. That was inspired by a fortunate trip I did in Malawi in 2008 when I experienced the full force of the Mulanje Massif’s microclimate while relying on a flimsy summer sleeping bag to keep me from turning hypothermic.

The fifth, and of course, principal aspect for me going to Malawi, is the job in hand. So, making sure I’m prepared to undertake this challenge has been a long and arduous process. The VSO training comprised two 4 day weekends of 8am-8pm brainstorming in the idyllic setting of Harborne Hall. To all VSO aspirants reading me now, let’s say that if only for Harborne Hall, your decision might be entirely justified! Besides that, there’s also been a great deal of skill and knowledge consolidation. This has taken from very familiar territory as Orthopaedic workshops to far flung corners of medicine as Obs& Gynae. On the whole, it has been hugely rewarding and the urge I now feel to put all this wealth of training to good use is gnawing at me. I made the deliberate choice to finish work quite late so as not to be away from medicine for too long and get rusty. Another big component of planning point five has been the early preparation of projects to embark upon while on base. These include the setting up of links with Orthopaedic colleagues whose knowledge and skills in the developing world I’m sure to tap into at some point. I am also setting up a collection scheme for redundant surgical equipment, which I hope to be able to ship across to my hospital. NHS buddies out there, spare a thought for this and expect me to poke you at some point for supplies if the project goes according to plan. It also goes without saying that my suitcases have had to be loaded with as much of a reading material as I will be allowed to carry- so much that I’ll probably expand the existing library created by my medical predecessor in the district hospital of Ntcheu to twice its present size.

The single most important challenge, my temporary (geographical) separation from Janet, can rightly be said to have been the most laden with emotions. As a true sign of its strength and of our mutual belief in the value of such a life decision we have decided to take, our relationship has not been strained by it. Our marriage of vows and souls in November certainly helped to strengthen it rather and, since then, it’s been going from strength to strength. An early, honest and joint approach to this decision was probably the key factor in enabling such a smooth transition. After all, the whole experience will be one embedded in partnership.

Well, obviously the reality of relocating for two years cannot be conveyed in six mere points. It is only through experiencing it that one can start to have a real feel for it. Before even starting my actual placement though, I would certainly recommend it to anyone after a good buzz in life. That says it all for me. After months of laboured activity and rigorous planning, I can now say I feel readier than ever before to leap into that new world now. The hardest step indeed, was the one I took ages ago when I decided for the first time to sign up with VSO. The change of mindset has already occurred now and it’s just a question of applying it to the world it has changed itself for. So here I go, all excited about that new adventure, all in tears from leaving my beautiful and inspiring wife, all upbeat about the myriad of fascinating medical and surgical experiences in store for me, finger-nail-less from the dread of having to do my first caesarean section, all impatient to get into my shorts and T-shirts finally and also all too aware how my mosquito defences will have to go up. Here I go to live it all for real.