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.