Sunday, 8 March 2009

Mobile Eye Clinic

Listening to: Rob Thomas - Streetcorner Sympthony
via FoxyTunes

Around the Hospital

Me with Madalitso (Blessings in english). A fully grown healthy 2 and a half year old. A rare sight!

When there's no x-ray boxes...the orthopod clinical officers

The casualty.....

Monday, 5 January 2009

So I'm done at Nkhoma now. It's hard to believe as it only seems like last week since I arrived. I'm in Blantyre and wait for it, there's internet so after just about a month I feel like I'm reconnected with life outside Nkhoma though I'm not sure I really want to be. I'm flying back on the 8th jan from Lilongwe then a grand whole week to get a blomming report about this whole sheebang written up before Wishaw (of all places) beckons me for the next 8 weeks.

I should write about Xmas and New Year and what not but am on this pre paid internet thing so will go now but will hopefully write again in the next couple of days!
Every day starts with morning report at 7am. Usually, it’s a member of the night staff from each ward who reports briefly on any new admissions, difficult cases or deaths. Sometimes, one of the staff do a presentation or discuss any outstanding issues. This morning it seemed like the hospital was falling apart as the generator ran out of fuel (the power goes off quite often as it’s the rainy season-a c section was delayed because of the power cut and unfortunately the baby died), the incinerator has broken again so back to the same problem as before of sharps being strewn everywhere at the back of the hospital, there are still no prescription charts, lab forms, discharge forms as something’s gone wrong with the admin department and they’re out of paper, they have no BP cuff in paediatrics, no stethoscope, no latex gloves (they keep running out everywhere as all the hospital cleaners are using latex gloves instead of their heavy duty cleaning ones which means they put themselves at risk of needle sticks while cleaning and lots of money wasted on these gloves) and finally I think the last issue raised was a problem with getting in contact with the people on call at night and at weekends. There’s no landline phones in the main hospital which work so people use their own mobile phones but people don’t often have credit on their phones so it’s left to the watchmen or messenger to physically go to the clinical officer or doctors house when they’re needed in the hospital. Unfortunately, there seems to be some confusion over whose duty it is to go to the house of whoever is on call and a patient died over the weekend after being left for 5 hours while bleeding after giving birth before anyone called the lab assistant to cross-match her for blood. It turns out there is a messenger who is supposed to go to the clinician’s house but there seems to be some problem with their rota leaving them with no days off and I guess they’re rightly unhappy and so have started to refuse to relay information. Some sort of telephone system would be very useful and in this women’s case, potentially life saving.

So after all that I was surprised anything was working and that the whole place hadn’t just come to a standstill. There were still 80 odd patients in paediatrics so no rest for the wicked as they say. Luckily there were lots of well children so lots of discharges but they reckon that admissions will be up in the 100’s by the end of the week. It’s a bit chaotic. I need to keep reminding myself to plot weights on the growths charts in the health passport books each child is supposed to have and check vaccinations too-apparently, 1 in 2 children are malnourished and often it’s hard to believe the age of a child when you look at them. It’s easy to forget how a well nourished child should look. There was another death this morning too. He was admitted with a haemoglbobin of 1g/dL (normal is >12g/dl). That’s the lowest I’ve seen so far, most are about 4-6g/dL. And I’m told it just gets worse until the harvest comes in March. The price of maize is already rising at 500-600K a kilo. Expensive enough if you only earn 3000-4000K a month and impossible if you are a subsistence farmer. So you don’t eat. Adults might just get by but the children are really pushed to the limit. The current president has apparently created much better food stability with maize reserves for famine but it looks like they’ll have to rely on more food aid as they wait for the next harvest.

Yesterday, I went walking up a hill close to Nkhoma with a couple of the other Dutch students (everyone is Dutch here now so I’m pretty outnumbered!). The views were amazing and the sky so clear. It just reminded me how beautiful it is here. I haven’t quite made it up in time for the sunrise yet mind you. Maybe one day before January. 4.30am is kinda of stretching it a bit!

what's in a name?

Here each vowel is prounced independently so a name like George becomes Georgee. Then if the name doesn't have a vowel at the end, well why not add one so for example becomes Josephe. I shout Josephy and he's nowhere to be seen and then if I yell Jospehy, he appears. It sounds like everyone has an ee at the end of their name. Spellings also vary lots which makes patient files a bit confusing, George was spelled as Joji on his health passport book and I didn't think of "George" till one of the nurses decided that Joji was meant to be George. Yesterday, I was searching for Richardee's file thinking it would be under R . Oh no, after a good half hour one of the clinical officers asked if I'd tried looking under L. Well, no I hadn't in fact. And low and behold for sure we had a Litchard under L. L's R's they're the same thing. I should've remembered.

So the paeds ward is still busy. One little boy passed away yesterday just as the nurse was about to put up blood for him. Strangely, another wee one, Lewis, needed a transfusion but his mother wasn't a match (here, there's no blood bank so if you need transfused a relative has to donate and be a match), luckily his blood group matched that of the boy who had just passed away and strange though it felt we were able to use the blood for this second little boy who is now doing grand on the ward. A gentle reminder, I guess,that things carry on. With so many kiddo's with high fever's, convulsions are fairly common and as a little one was in the throws of a seizure and his oxygen staurations were plumeting I once again felt like I was way way out of my depth then there was diazepam, not for me you inderstand though I could have done with some too, but for the wee one and wonders it did do. He settled, his saturations came right back up and we were back on land again. I was so happy to see him off oxygen and breathing well for himself this morning. What a relief. Somtimes, I pop to the outpatients department to see what's going on there. Usually just to sit in with the doctor or clinical officer who's on duty. Patient's seem to wait much longer before coming to the hospital here than at home. One elderly man had been having pains in his foot with reduced sensation for the past thirty years apparently, I'm still not sure why he'd chosen to come today, but it was decided that he needed to get bigger shoes and perhaps try some amytryptilline for the pain too. We also saw a little boy with tetralogy of fallot: he'd caught chicken pox and possibly had endocarditis too as he had black, gangrenous fingers on one hand. He was very ill but getting by just. On Monday, during the morning report, we were told he'd passed away. Lumbar puncture packs are scarce and I seem to find myself wandering round the hospital trying to find a pack most days. Today now that the rainy season has started, all the leaks and cracks in the hospital are becoming apparent as well as the paths which are not covered over so, duly, I got soaked as I went to the surgical ward to try and find a LP pack. One of those days I guess. As I type the heavens have opened again. Fingers crossed it'll go off before I need to walk home. It's not so much fun when everything goes all muddy and you forget your umbrella or coat. Bring back the baking sun I say. (but it is good for all the people who've just started planting for the coming year.) The rains also mean that drapes for sterile packs and surgery don't dry as quickly which means surgery nad procedures are just postponed. rain has a lot to answer for as it also means that whoever is on call can't come in to see any patients as well, it's raining of course and well, it's just not possible to go out in the rain. I wonder if that would work at home. I think it's worth a try, no? This week the x ray machine was also broken so fractures were guess work and stethescopes came into their own though it would have been a big help if my stethescope skills were up to scratch. They also regularly run out of testing kits in the lab so often tests which you send come back as out of stock. They've also run out of ceftriaxone, a fairly commonly prescribed antibiotic. But somehow, things still go on, things still get done and patients do get better sometimes against all odds. And usually they're still smiling. I can imagine I,for one, would not be.
I need to go to the market for the usual cabbage, tomatoes and onions but I'm not sure I won't melt in the rain so I think I'll stay in hiding till it goes off. I'm still keeping well stocked with mangoes and am hopefully not turning strange shades of yellow with mass consumption. I heard today that children who eat lots of mangoes are prone to twisting of the bowel and obstruction so I'm hoping the same doesn't apply to adults.
The hospital is forever short of things from paper and prescription charts to sterile packs and money. The staff who've worked overtime this month have had their pay delayed til next month and I guess understandably, staff get fed up of this and hence the shortage of nurses in the hospital. Apparently, governement hospitals are the place to be in Malawi as you get paid better, more training and paid for overtime. So the intern clinical officers all want to apply for government positions after they complete their mandatory year here. Again somehow things work out and there does alawys seem to be just enough staff at any one time but it's a bit like living on a knife edge. It still doesn't really feel close to Christmas here apart from the Christmas songs on the radio which just feel a bit out of place. I think I'm going to one of the staff from the eye department house's for Christmas day-they're have a barbecue and some friends over. Otherwise I'll be in the hospital for the rest of the week. Just in the process of working out whether or not to change my flight to give myself a few days before I disappear off to Wishaw. The only thing is if I change now I have to spend a night in Addis Abbaba so I'm not sure it's worth it.
I still have to make it to Blantyre so i've yet to see the kiddle winkle woos form Yamikani. It does feel strange to be going back to them now but will be interesting none the less.
Headed towards Mangochi and the lake yesterday to go to a couple of the health clinics there attatched to Nkhoma. They’re permanent fixtures unlike the eye clinics. And so every few weeks a land rover from Nkhoma goes with medical supplies and at the same time accounts are checked and some family planning procedures done. As usual, every man and his dog piles into the back of landrover so a very squishy few hours ensued. The first clinic was about 20km off the main road and unfortunately, they hadn’t quite finished a couple of bridges on the way so we (I say we but really the man driving) had to negotiate crossing two fairly full rivers. When we stopped in the middle of the river, wheels spinning, I thought we were stuffed but a bit of perseverance and we were through. Lesson no 2 from the day: a landrover can get anywhere if you rev it hard enough. Lesson 1 is of course: there’s always space for another person/sack of maize/bag of charcoal/ bucket of mangoes in any vehicle. Never say never.

At the first clinic, there was administration stuff to deal with so I had a wee look around with the nurse midwife (here all nurses are midwives too) who had been working for 40 years in various clinics. They do antenatal clinics, under 5 clinics, Voluntary Counselling and testing for HIV, general clinics run by medical assistants, family planning, a labour room and there’s also a small ward with 3-4 beds for the odd admission. Anyone with complicated pregnancy or labour or more major medical problems are admitted to the nearest district general hospital with whom they have a radio link to arrange an ambulance which can be anything from a bicycle with a stretcher, a motorbike with a sidecar stretcher to a landrover. That’s where landrovers come into their own, no sparkly, pristine white 4x4’s around these clinics, battered but functional. Unlike the huge things parading round the pretty smooth tarmac roads of Edinburgh whilst parents drop their offspring at some extortionately priced private school.

After the heavens opened and turned everything to sludge we headed to the next clinic which was just a km or two from the lake. Here they were removing contraceptive implants and doing the other administration bits and pieces. Nkhoma and these clinics are all funded by CHAM (Chrsitian Health Association of Malawi) which provides health care to about 30% of the population (much higher than I thought). The rest is provided by the government and a mix of NGOs. They were negotiating for free antenatal and under 5 care to be provided at the clinic funded by the government but provided by CHAM but it involves lengthy discussions with the villages chiefs and TA’s (traditional authorities) as well as with the government.

So after removing the implants, we went to see the lake and pop into to see one of the clinical officer’s friends. It turned out he knew half the village so 2 hours and lots of greetings later we started back to Nkhoma. Lesson 3 of the day: popping into see a friend equals greeting half the blooming town. But next to the lake was pretty idyllic so I shouldn’t complain.

By this time it was to 5pm and dusk was falling but we were on the road with one last stop, or so I thought, first to pick up a shield which was being carved for the Bike Race taking place at Nkhoma today to raise funds for the hospital. This involved using the loudspeaker and the siren attatched to the landrover whilst yelling the carver’s name through the loud speaker and nee-nooing. He was found and the shield handed over and the whole thing videoed by the video-happy accountant. Off we go again making good progress till we pass sacks of charcoal and mangoes for sale at the edge of the road so of course we stop and just as I was thinking I had a incy bit of feet space my hopes were dashed as I piled mangos by the bucket load into the back of the van along with a few sacks of charcoal. At least being like sardines means that it’s easy to dose off and the next thing I knew we were back at Nkhoma, albeit, a very dark Nkhoma as the power was out. And it’s still only half back which means everything is going off nicely in the fridge.

It was something different and a welcome break from the paediatric ward as we saw lots of healthy children which was so good after these past couple of weeks of very ill kiddos. Restored some of my faith I guess.

I decided to go to Dedza today to see the pottery there (and for the internet but no such luck). Some English man has a pottery workshop which sells some very nice and some rather odd things and there’s also a restaurant there too. So I thought I’d take a look. The buses went surprisingly smoothly and didn’t have to wait too long at all. To get out of Nkhoma you have to take the bus to a place called Kamphata at the junction with the main road and from there you can go north to Lilongwe or south towards Dedza and Blantyre. If Nkhoma seems to be a pretty law abiding, calm, generally church orientated place, Kamphata is it’s an thesis, with lots of bottle stores, bars and rather far gone characters. Apparently, it’s where to go for a night ( well afternoon it seems) out from Nkhoma if that’s your kind of thing. I guess everyone needs an escape. It makes waiting for a bus there an interesting experience to say the least mind you. And after passing some ESCOM (the electricity people here) pick up trucks I was hoping that the power would be back but it’s only half here for some reason which means the cooker and the fridge still don’t work properly. Well, better than nothing I guess.
For the next two weeks I”ll stick with paediatrics then I think I’ll spend my last week on the medical ward for a change. The time just seems to go here and I’m never quite sure what Ive done but there’s not many dull moments anyway.