First day at Queens 25/5/09 Mainly of anaesthetic interest!

I went from that to my first day at Queen Elizabeth Central Hospital where I was put onto an obstetrics and gynaecology list, but thankfully not on my own and was shown how things are done by some very fine clinical officers. For the non medics you should look away now! Queens use draw over vaporisers and glostavents so I was glad I went on the course in Uganda last year so I didn’t look too clueless. Recovery is an unstaffed corridor with no monitoring, no oxygen, just trolleys lined up along the wall but there were, I’m glad to say, no untoward events! One effect of my time here is that I will appreciate recovery staff more when I go back to the UK! 

In the afternoon there was an emergency cesarean section. The mother’s uterus was necrotic from having been in labour for days as she had come in from the village and as a result the baby was stillborn. The woman continued to haemorrhage but there was no blood to give her and no oxytocics (drugs to tighten the uterus and stop it bleeding) beyond syntocinon so she ended up having a hysterectomy. All together the situation was really well managed and the mother well cared for. Queens run an ongoing audit of maternal deaths and they have only had one since January which is amazing in a country where the maternal mortality is staggering. Still births, however, are sadly not that uncommon. There is no paediatric or neonatal intensive care so if a baby has appalling apgars (a scoring system for the health of the newborn baby) they just don’t make it. Rather than be shocked by the equipment they don’t have here I was impressed by what they did do really well in spite of the lack of resources. The clinical officers work really hard, and there aren’t enough of them. 

My next day on obstetrics I was asked to step out and help cannulate a baby. When I looked in the corridor there was a cot unattended that one of the nursery sisters had left outside the theatre. I looked inside and pulled back the swaddling and inside was a scrawny scrap of premature humanity, probably about 6 weeks premature. I have never cannulated a newborn baby let alone a sick prem and the thought that I would be best at this was a joke. Thankfully one of the senior clinical officers saw my eyes standing out on stalks and gave me a hand and was successful with the cannulation. Premature births here are very common, Maternal HIV often results in early delivery and I don’t envy the paediatricians who try their hardest to throw what they can at these kids to give them a chance of life but without recourse to a neonatal intensive care. 

It was a couple of days of having my head submerged in the grime of unacceptable poverty but a day where I believe the care given to these women was outstanding and I was humbled to be witness to it. I think that’s why I have been away most weekends since I’ve come here. Work is a sensory overload and people choose to escape from that in various ways. 

Lujerie tea estate 23-25/5/09

Well, I’m not sure if I should really confess to having spent the weekend on a tea estate just in case there were still a few people remaining who thought that I was toughing it out in a mud hut somewhere. 20 of us, mainly people working between the government and the mission hospital went away to Lujeri which is about an hour and a half’s drive south of Blantyre. We went for walks, swam in natural pools and threw ourselves off waterfalls, and then chilled out with dinner on the verandah of the main lodge. It did me the world of good.

Man-Malaria

One of the doctors at Queens has come down with malaria. He was out for dinner with a few of us the other night and he felt a bit fluish. He went to work the next day and did a blood film and it came up with 1+ of malarial parasites. I was shocked but the seasoned infectious disease doctors here were un-impressed as the scale goes from 1+ to 6+. Which means he has the sub-saharan equivalent of man-flu and as a result has received no sympathy. 

0 - 60mph in a day

I have already mentioned that CURE have had to reduce their paediatric operations, which are performed for free, because so much funding has been withdrawn because of the global recession. So I have been feeling a bit frustrated as there are two clinical officers, a consultant anaesthetist and me...for two theatres - and even then there are maybe 3-4 cases on each theatre list each day instead of double that number which was their norm until January. So some days we are finished at midday. It adds to the thought ‘what am I doing here?’. 

So, today I went across to Queen Elizabeth Central Hospital which is the government hospital up the road. The head of the anaesthetics department has been away til this week. So I tracked him down and he was more than glad to have an anaesthetist working for free! So I am now going to work at Queens on Mondays and Wednesdays and alternate Thursdays and CURE Tuesdays and the other Thursdays. That leaves Fridays when I will do audit / research / teaching at CURE. The teaching programme starts in two weeks, as does a big audit of pre-operative nutritional status in the kids at CURE. 

I shouldn’t have complained about not being busy.

General elections 19/5/09

Today is a national holiday to allow everyone to vote. The urban areas are strongholds of the incumbent president but the rural areas are strongholds of one of the opposition candidates who it has been suggested was responsible for his opponents ‘disappearing’ at previous elections. Malawi is 80% rural, 20% urban - the opposite of most developed countries - so the race is certainly not over although it seems Bingu is in without a fight here. We have been praying for wisdom in voting but also peace around the elections. I wish I could show you a picture of the snaking lines out of the polling booths...if only I could upload it!

CURE 10k fun run

Today was the 10k fun run to raise money for the hospital here. It was a cloudless sky and although the run started at 8am I still got tatooed by the sun with a nice T-shirt line round my neck. The executive director tells me he has a picture of me after I’d finished, but I’m sure the glare from my bright red face would have ruined the exposure. I have been trying to add photos to this blog but it takes so long just to upload words that I have usually lost patience before the photo appears so I’m afraid you’ll never see that photo. Shame. 

Gaining ground 15/5/09

If you read the entry ‘clash of agendas’ you will know I’ve found it difficult gaining the friendship of one of the clinical officers. I have been advised that taking her out for steak in an overt display of bribery should help! (thanks Liz!) My heart soared today though when the more senior clinical officer had a quiet word in my ear and gravely said, “You are now ok to be on your own in theatre”. That is commendation indeed! Especially as I have had to learn how to use Halothane (hardly ever used in the UK any more - I’ve never seen it used ‘til now) and get used to putting in caudals (like epidurals) with large gloves as thats all we have!

Zomba Plateau 11/5/09

Zomba was the original capital of Malawi. It is a beautiful temperate area with a plateau and several old colonial style cottages which the Scottish missionaries built in the 1800s. It was a national holiday yesterday so a few of us took off for an overnight trip to Zomba plateau. Having loaded up with strawberries, gooseberries, passion fruit, and rasperries at the bottom of the mountain which vendors sold us through the car windows (didn’t even need to get out of the car!) we set off up a deeply rutted red earth road up to a cottage with a breathtaking view over Zomba valley. Sat in the luxury of our 4 wheel drive we passed dozens of men and women walking along side their bicycles which were loaded up on the saddle, handlebars, in the bars of the frame with  cut logs which they were bringing down the mountain to sell. Another guilty feeling. It is necessary to realise that all the problems of Malawi do not rest on my shoulders. 

However, I do think that a solution to the violence on the streets of London could be solved by putting a boy in the drivers seat of a 4 by 4 on an African road at the end of the rainy season and telling him to get on with it. It puts hairs on your chest - I can only speculate. 

The Blantyre Hash 11/5/09

Well, having had a bit of a cultural rebuff in theatres today I went along to the ultimate in expatriate pursuits this evening: a running club. Myself and the orthopaedic registrar arrived late so had to catch up via a sneaky shortcut. Most local people we ran past either laughed at us or just shook their heads. The little kids thought it was a great game to run along with us but I am thankful to say I am able to outrun the average 5 year old. The fact that I have to take pride in that leaves some clue to my current fitness, but that will teach me not to turn up late again.

Clash of agendas 11/5/09

Almost all of the anesthetics given in Malawi are given by clinical officers. These are people who have no medical or nursing background but have had usually about a year’s training in anaesthesia and then sent out to work independently. There is a great variety in standards as there is no continuing professional development or appraisal system once they have qualified. The two at CURE, however, are excellent and very experienced. However, they have not had as much training as we have been privileged to have in the UK and therefore tend not to have a ‘plan B‘ if things don’t go according to plan A. As anaesthetists in the UK we have it driven in to us that we should have a plan B, C, D, and maybe even E. Therefore when serious complications arise and there is no contingency plan things can go into a tailspin, and they did here at CURE in a particular incident last year. So, given this context, the clinical officers here are a bit wary of me and why I’m here. I want to learn from them as they have vastly more paediatric experience than me. However, when I ask a question they think I’m trying to trip them up. I met one of them for the first time this morning who spent the duration of the first case with her back to me. She seemed to make a point of speaking Chichewa and not English even though other theatre staff would address her in English. I wondered what I was doing here; and who did I think I was anyway. I can see where she is coming from but I was taken aback by her rudeness in the ‘warm heart of Africa’. I am not confrontational nor loud, so I guess I’m just going to have to sit this out until she thaws and I can convince her that I want to learn from her and am not here to pounce on mistakes. I passed a sign outside the seventh day adventists church today that said “A smooth sea does not a good sailor make”. I laughed at how appropriate that is to my education in culture and relationships in Malawi. Happy sailing!

Sidelines in chickens etc.

I have discovered that there are many ways to improve your lot in Blantyre. The reception staff do a sideline in selling chickens. The chicken man drops them off at the hospital at lunchtime on a monday. I came along after the list finished today and was directed to a freezer on the private ward that contained a few ambiguous drugs (Do you know of any drugs that need to be frozen?) and my lone, very cold and thankfully already dead (killed before it was put in the freezer I hasten to add) chicken. 

If you want a tray of eggs the pharmacist will sell you some. The sister on the children’s ward sells avocados. The travel agent in town doesn’t normally change money but they’ll do it for you for your convenience no problem at a slightly reduced exchange rate. Outside the travel agents are a couple of boys selling vegetables that they have just bought from the market round the corner but will sell them to you at twice the market rate to save you the walk down the hill. It pays to be a chancer.

Mulanjie Massif 9-10/5/09

This is not the name of a Hackney gang but of a large outcrop of rock in the south of Malawi. Large being a plateau at 2000m and several peaks over 3000m. I was invited to join a group who were hiking up this weekend and we stayed at a hut on the plateau overnight, tucked up in our sleepingbags on the verandah, under the stars with a full moon above us. There are many perks to being here! 

As we were sweating our way up (despite paying porters to take our stuff we were still struggling) we were passed several times by people as young as in their teens carrying not just planks of wood on their head / shoulders, but whole trunks, which they sell at the bottom of the mountain for 50 - 70 Kwacha (about 20p). As a comparison we had paid the porters 1000 kwacha (about £4) for the day. Another reminder of how unbelievably fortunate I am to have been born where I was, into the family I was, into the opportunities my life has then held open for me.

Orthopaedic Grand Rounds 8/5/09

Friday afternoon is given over to training at CURE and I attended the first ever orthopaedic grand round that I honestly have to say was fascinating. To hear orthopaedic surgeons (for those not in the business - not normally reputed to be the top of the intellectual pile) discussing the medical syndromes associated with scoliosis was a revelation in itself. However, they let themselves down somewhat by putting cardiac and respiratory symptoms at the bottom of a very long list. Still, thinking outside the bone is to be applauded.

Credit crunch - Malawi version. Part 1

I imagine I will write further on this but today I heard that 60-70% of Malawi’s budget is generated from aid. In a country where money goes from hand to hand or goods are bartered it is well nigh impossible to generate tax from which to design a budget. So, if your country relies on foreign donations and that dries up because everyone is tightening their belts how do you keep your country afloat? At CURE, they have also been hit hard by the steep reduction in donations and have had to reduce the number of paediatric i.e. free operations and increase the proportion of theatre time given to private fee paying patients. They have also laid off 15 staff in the last month. And being laid off doesn’t mean there are many other jobs to be had or a dole to sign on to. As always, it is those closest to the bread line that bear a disproportionate amount of the fall out from our rich selfishness. 

A visit from the president 7/5/09

I pitched up for my first day at work today to find that everyone was fidgeting with excitement as the president had decided to visit an important businessman who is a patient in the private wing. The president’s name is Bingu (which means thunder - there is much in a name) and he arrived with very shiny blue shoes that had the letters of his party printed across the toes: Never miss an opportunity to campaign. I thought he had come to visit the hospital because he’d heard that I’d arrived and to wish me well but he didn’t shake my hand or ask after the welfare of anaesthesia in this country. Maybe I expect too much. His people wanted to know how far it was from the main entrance to the ward and yet no one would admit that he was not a well man. He is in his 70s and is looking to win the upcoming election on the 19th of May, which he seems likely to win judging by how many people are wearing his T-shirts. I saw a truck go past in town today piled high with shiny new bicycles with his logo on them. I wonder if I would change my vote if I was given a shiny new bike. All the same, he seems to be the best option, as he has put money into the country’s infrastructure - the roads have improved and the streets are safer than they were under the last regimen from what I hear. Still, I have been advised that a political rally is not a good place to hang out for white skinned people!

Shame 8/5/9

Went to the market today to buy vegetables and came away just feeling guilty. I bought my onions, tomatoes, nychees (like satsumas), bananas, ginger and the biggest avocado I’ve ever laid eyes on all from one stall. The expression of the man who owned the next door stall suggested that I had just consigned his children to starvation for not buying from him. When I got back to the hospital I discovered that many muzungus don’t go to the market because they don’t want to feel guilty for having so much money...but then the market sellers suffer even more for lack of custom! Maybe I’ll buy all of my veg from separate stalls next time. It is impossible not to disappoint someone. There are maybe 15 stalls selling tomatoes; who do you buy them from? Do you go for the one who gives you the best price when that difference is a matter of a fraction of pence? From the first stall? From the last? From the woman with the child on her back or from the one who stands in your path? 

What's in a name

Arrived on Wednesday. Picked up at the airport by a man called Innocence. Started in theatres on Thursday, first child on the list was Precious - a boy not a girl as I assumed. Thankfully Mayonnaise was cancelled as her ankle was too swollen. Witness helped me sort out my ID badge and Dobuitzo has taken my GMC certificate for the lawyers to peruse for my Malawian medical license. I hope the lawyer’s name is not Malevolence. 

Africa online

Well, I've been here a week and have discovered that internet access is one of the casualties of a country that doesn't have a reliable landline! It is virtually impossible to send and receive emails at the hospital and local word has it that you have to go downtown to one of the posh hotels, order a drink and sit in their lounge and use their wiFi. It shouldn't surprise me that in a country of extremes you can't get bog-standard internet but you can get wiFi if you're willing to pay! So thats where I am just now, having finished in theatres early today. I am just getting used to the laptop Ive borrowed since mine got pinched just before I left so this may take a while!