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!