Tricycles and wheelchairs

INVITATION TO WILLING SPONSORS

Dear friends and family,
I won’t pretend that this is not yet another fundraising initiative from me but I can assure you this time it has a different flavour. The difference is that there is no Oxfam nor even VSO attached to the end of it in a way that makes you wonder how your money has been spent. This time round, it’s going to fund my own work here, which you’ll see the direct results of, and whose player on the ground (me!) you already know and trust (I hope!).

So what is it I’m trying to milk you for? Well it is an idea that has taken about a year to come to fruition but which I see as one of the most concrete ways of improving livelihoods here. As you know, effectively Orthopaedics is more about saving livelihoods than about saving lives and with the challenges arising from limited resources, at times I wonder how much I can assist patients with my bare hands alone (and brains arguably). But with a tiny bit of investment, my input can really stretch a long way further. And that particularly investment is towards purchasing bicycle wheelchairs (tricycles) for people with both legs paralysed or amputated. Effectively, once they have been afflicted by the above conditions, they are often reduced to a fully dependent status. Unless they have a supportive family with the means to assist them, they can be truly marginalised with little means to sustain a living. Having a bicycle wheelchair empowers them almost like a new pair of legs might do. It gives them the means to mobilise further distances and engage in remunerated work (you often see them conducting small businesses around markets). Above all it also frees them from the confinement that comes with having no legs and resorting to using the heels of your palms to get about.

As I said, it took me about a year to suss out the logistics of having them made for the patients. In brief, there are only a few centres that build them as they need to be made to measure. They cost 400000Kwacha each, which is somewhere in the region of £160. It might seem like an expensive bicycle but it’s professionally made and is essentially an orthotic device which would cost at least 1 extra zero in the UK. So here’s my business plan. For any of you who have always been interested in assisting with development work but never trusted that their money would be put to good use, here is your chance. Any amount is welcome. What I’ll do is just give you my bank account details for the transfer. Then I’ll pool the money donated together and retrieve it here to purchase the bicycle. Any excess money will be used towards new patients, whom I’m always finding, or at providing badly needed wheelchairs for the hospital. I have 3 patients in mind to start with for now.

If you’re interested in this charity venture, please email me and I shall forward you my bank account details. Please spread the word to potential donors. I look forward to your assistance towards this project.

Yours thankfully (Zikomo Kwambiri)
Ashtin
ashtindoorgakant@yahoo.co.uk

Before


The Bicycle Wheelchair (tricycle)

After

Clinical Digest11

One might not have got the real flavour of African medicine through my blog yet. That is because (grudgingly) most of that stuff belongs to the sphere of the general clinicians, more strikingly for the infectious diseases guys! That doesn’t mean that I haven’t seen these textbook conditions which I would never dream of seeing in the UK, like rabies (with its Oh so distinctive hydrophobic characteristic) or tetanus (with your pathognomonic risus sardonicus) or measles (Koplik spots- but then I had it myself in Mauritius!), not to mention the vast array of HIV related illnesses (Kaposi’s sarcoma, high pressure CSF of Crypto meningitis, PCP etc). But two cases in the last 2 months have certainly added the exotic flavour to my Orthopaedic caseload too. Not that I want in any way to rejoice about the suffering of the afflicted patients, but one can’t help but marvel at the science of medicine when manifested in such classic cases.

C4 transection
Granted you’re going to see that in the UK too. But most of the time, the patient will have been dashed off to an ICU unit and rigged up to countless tubes and machines far and safe from your regular ward SHO! As a result you (ie me, the SHO) have hardly had a chance to really observe the striking physiological effects of such an injury and the speed at which they progress. This is now the third case I’ve seen already here. It’s quite common in fact, owing to a certain hazard called the “Matola”. This is the open back pick-up truck I’ve referred to already, in which people cram in the back, most sitting on the edge holding on to hardly anything. That combined with the terrains for which these vehicles are reserved (far flung village rocky dirt roads where there is no road access for better vehicles) is a recipe for disaster. After a sudden bump, the patients tend to be jolted right up in the air, often landing on their heads. Those who make it alive rarely present without a crack somewhere. When the break is in the cervical spine and involving the cord, one is left to praying for the best. What with the lackadaisical approach to ATLS and C-spine immobilisation prevailing in this place! The pattern of this neurology is so fascinatingly typical though that it could easily be the equivalent of an anatomy textbook condensed in one clinical presentation. You can map out the level of transaction to the exact dermatome. In this last case you could do so even without laying hands on him. A simple eyeball would tell you that his thoracic respiratory muscles had been knocked out of action. He was reduced to diaphragmatic breathing, of which unfortunately he would very soon tire. Sadly there are no remedies to this diagnosis here. You just hope that some neurology, at least the respiratory control, will return. Any attempt at transferring the patient acutely often only means changing the place of death and, more worryingly, adding to the patient’s distress through cumbersome ambulance journeys. Even if you happen to come off your matola right next door to the spinal orthopaedic hub of QECH in Blantyre, and for that matter in Europe, your chances of survival are still pretty slim. The only difference is that in Malawi, the rapid decline is for all to see, with ITU reserved for only the few cases with a theoretically better chance of survival. Recognising this early is really a knack the tropical doctor must needs master.

Congenital Hypophosphatasia
I admit it. I never even heard of it before coming here. That’s because this condition belongs to the weird and wonderful repertoire of metabolic bone diseases, that, unless you’re running up to an exam or the like, you would never willingly inflict upon your brain. To be more precise, the condition can be specifically attributed to the group of Vitamin D resistance syndromes. Wow! Completely unprepared for it, I got called one morning to review this 1year boy with a bizarre clinical presentation and even ‘bizarre-r’ looking Xray! The difficulty here is that everyone is somewhat expecting this “muzungu orthopaedic specialist” to come up with a spot diagnosis as he must have read about it before! But there I was as perplexed as them if not more. The child had a classic presentation of long bone fractures with minimal trauma and generally didn’t like being handled. The Xrays, I found out as I revealed them to the superior beings that inhabit CURE hospital, was quasi-diagnostic of the condition. It is so rare in fact most of you (medical readers) will never encounter one in your lives. Even google images failed to conjure up any decent pics for comparison. Once again, the treatment for this kind of condition is extremely limited here. Even at Queen’s Hospital (QECH) where the child got referred, the prospect of lifelong phosphate/Vit D replacement is extremely challenging without a family who can assist financially. The usual outcome unfortunately is a gradual decline into terminal renal failure.

So here again, I end up ending on a hopeless note regarding my patient’s outcome. However, in perspective, most conditions we see are common and treatable. We, as medics, have a natural tendency to get excited about rare conditions... I guess to counter the boredom that might arise from applying your 1000th plaster for a wrist fractured in exactly the same way. What can be frustrating is when even the simple stuff gets mismanaged. The danger then is to identify one single person/factor in the entire system to blame. But when the system is fraught with such severe deficiencies of staff and resources, one might instead remember all the cases that are actually being well treated by that person/factor and work on improving the system rather. From that premise however arises the conundrum that some staff feel completely exempt from blame as a result and take liberties with patients’ health. Who and how do you blame? Or should you blame? If you don’t (something or someone), how do you identify the fault? That really is the challenge that working here as a volunteer doc exposes you to. More than the pathology and surgery of medicine, you’re learning things far beyond these borders. And by one year, I can say that is also quite a rewarding experience.

New Horizons

...Phew! Almost a month since last blog. I guess that tells another story in its own rights- my internet connection here!


Reflections on an old year
It feels almost surreal to think about it. The recent year switch actually symbolised close to a full year of my placement here. 11 months by the time this blog will be up. It moves me to tears almost. So intense. So fascinating. So real... It has transformed me in the deepest of ways and this has surely not been without the mistakes and challenges which forced that learning curve very much down the hard way! I’m confident that I’m coming out at the other end of this chronological divide stronger, cooler and wiser in my humanitarian vision.

So what has this journey, which is yet to be half completed, consisted of? Allow me this nostalgic retrospective exercise for symbolism’s sake. February 2010, the 7th, the day it all started. A mind boggling crash course into this country’s diverse facets before being thrust down the deep end for a taste of the real thing. To be honest, my dive was somewhat cushioned by a month of central hospital “settling in”. The immersion into Ntcheu’s myriad sensations felt none the less absolutely dazzling! There was the initial period of unlimited enthusiasm at changing everything in the hospital, soon tempered to the confines of the orthopaedic department. That itself gradually got further refined and narrowed in its scope. In May, Janet paid her first visit after 3months of sage separation and we celebrated in style by hitting on one the best road trips in my life, going up north through the highlands to Nyika plateau and cruising back along the lakeshore road. By June, things had started flowing a bit smoother, with connections being made within Ntcheu and wider into the cities, where senior Orthopaedic support is known to dwell. I was finding my depth and could now let my hair down a bit (that amazing amount that rests atop my head!). Fortune obviously had it that the world cup was happening at that very time. The first one ever to be hosted on African soil and one to which I actually had tickets (thanks Su)! And what a trip that was too- 30+ hours each way aboard a cochlea-challenging bus through Mozambique and Zimbabwe. Jo’burg then Cape Town followed in the full frenzy of possibly the most electric of all sports gatherings to exist. Truly, truly a landmark of my African escapade, not to mention my entire life! The work in Ntcheu then resumed with the same momentum it had before the interruption. I was collecting data for the Malawi Ortho Assoc’s AGM. This was given a special boost by the visit of the super-ortho-doc Steve Mannion and his team Feet First, who visited Ntcheu and whom I later joined on a full-on surgical week in Rumphi. My insight into the Malawi health care was also deepening as a result and I already had my sights on VSO’s next doctors’ peer support (for which Klaas and I had been designated as main organisers at the last one in May, courtesy of Marieke). Just before the AGM came another biggie, which somehow never got its due spectacle on this blog, partly out of a desire to preserve its full independent sanctity, and partly because it would have eaten up at least 10 blogs’ worth, which was impossible with the AGM around the corner. I’m talking of the Mauritian instalment of Janet and my wedding in August. Back in Malawi things picked up extremely fast with the AGM first and the VSO national conference/doctors’ peer support next. I found myself very involved at the AGM in September, presenting two papers while also helping with coordination of the whole event. The short lapse before the national conference saw the amazing Lake of Stars music festival and a brilliant leaving party that surely put Ntcheu on the map and on the musical repertoire of a sizeable bunch of VSOs (look up the Ntcheu song in the slam section for clarifications- the tune is that of Alicia’s Empire State of the Mind!). An intense build up to the national conference and peer support it certainly was, with meetings and phone calls and internet sessions happening at an unprecedented rate. All that while work was also proceeding at full steam, putting into practice all the newly gained wisdom from our orthopaedic meeting. My stress level, not in the least helped by the escalation of loud music from Ntcheu’s nightclubs to honour the summer peak in alcohol consumption, at that time distracted me from my intended mission in some ways and I found myself back pedalling very quickly. A perfectly timed retreat into the heart of Malawian culture helped to readjust my system. This was the most intimate contact I’d made thus far with the real Malawian folk as I spent a week sleeping in a hut on a reed mat and eating the local food daily in Gongonya village. All this while having my evenings cradled amidst quiet starlit reveries under limitless clear skies. Back on track, my mind was now set on the next major transition in my Malawi experience- that of welcoming aboard that so-far solitary journey of mine a new person- Janet. What a reunion it was! It’s been so marvellous and intense at the same time that I cannot find words to express it in this blog. Not without its challenges as expected, this new journey of two has been rightly set to the tune of an exciting year and a bit ahead. All the excitement of Christmas and New Year was somewhat consumed in the mutual “settling in”- Janet’s first and my second. And here we are in the new year with new hopes, new insights and new ambitions for this kaleidoscope of experiences that be the Malawian reality...

What better way to confirm that we are indeed in a new year than with this latest spate of joint madness! We were busy chopping up a panful of basil leaves freshly harvested from our bountiful kitchen garden and garlic to make our own pesto (which costs an arm and a leg here) when hey lo! from nowhere appears a drunken bat, executing the most bizarre pitches and yaws. The microbiologist in me and the one next to me took less than a second to figure out the threat that dwelled aloft. No-one forgets rabies when they’ve seen a case of it and no-one knowing that would take the slightest risk when faced with a potential threat of it. But then the question arose- how do you tackle a potentially rabid bat darting at full speed in your living room with all escape routes securely closed? Next thing Janet (still in the kitchen) sees, after we isolate the bat in the living room, is me emerging from our room covered from head to toe in heavy duty water proofs, save for my face. I’m on a mission to set the bat free with the minimum fuss. But my face feels vulnerable, exposed in the face of this challenge. Suddenly Thandizo, my guard, [who cavalierly offered to readily pounce on the flying mammal to put it (and us) out of our miseries but then revised his proposition seeing me in my new garb], points out us that there in my living room resided a crash helmet left by my recent flatmate. The rest is a scene that could well have come out of a spoof of the X-files: this helmeted strangely attired alien with a huge flattened cardboard box in his hand engaged in a frantic mission to ground an enemy a hundredth his size!! This he finally does after ten or so attempts and, in a final act of elation, concludes the mission with a firm sweep to the concussed victim which sends it flying onto the outside. And that is how we are marking the first days of this exciting year. We promise to bring many more of those to you... Just give us time. Happy New Year everyone and thanks for your enduring support.

Ntcheu Market

Handy juxtaposition of services!!!

X-files...