On the road to self sufficiency

So for some reason I thought that all the other hospital staff and volunteers would be dressed in attire that was purely functional and probably not have any money to buy a change of clothes. So I had only packed minimal items of clothing, mainly trousers for work, and all very boring and unflattering, no jewellery and eyeliner and mascara that had almost run out. You can imagine my dismay when I  see all the other volunteers wearing really glamorous clothes and make up, especially for dinner and the workers dressed in suits and the women wearing skirts and definitely NOT trousers while I am left feeling completely asexual, wearing the same clothes over and over again and covered in mosquito bites. So at the weekend I visited Mzuzu the nearest town and did a bit of ‘Eastenders’ - shopped from the second hand clothes market – I was searching for maybe something that I’d put in the ‘charity’ pile when clearing out my room before going away! I managed to pick up some dresses and skirts for work but haven’t been able to wear them yet as it requires the washing/ironing routine which I really can’t be bothered to deal with! My white coat has also turned into a brown coat with all the dust but I’m just enbracing it

The trip to Mzuzu also included another party for a volunteer who is leaving. She had a BBQ and I had the best steak like I never thought I’d get in Malawi. It was really great as well because there were people there from every continent in the world (except the Arctic and Antarctic) and lots of traditional dancing! (If I’d brought my shoes with bells on I would’ve Morris danced of course)

So still on the road to self sufficiency- I made cream cheese! Never realised how easy it was and felt very satisfied eating it with cucumber on bread for lunch. Especially good because it’s really hard to get cheese in Malawi and I’m having cheese withdrawals.

We also keep having power cuts, which is not great for the hospital as they’ve lost the key for the generator and it’s also run out of fuel so it means no operations/ lab tests/ fridges to keep blood cool/lights. Marianne told me that once they had to do a C-section using the front lights of a car shining into the theatre through a window!

On a more serious note though, it meant that I couldn’t cook my dinner and that all the meat I’d bought and stored in the freezer had defrosted and would go off. Rubbish. But I went back to nature and what the locals do and bought a stove and some charcoal and managed to cook some food over it without asphyxiating myself with smoke. Yey!

I think the bravest bit of the week so far though was the chicken killing – sorry vegetarians but it’s all about being self sufficient! Marianne showed me how to do it (vegetarians probably shouldn’t read this bit). She got the chicken as a gift from one of the clinical officers and it was handed to her in the middle of the ward while a lot of the patients and nurses ooed and aahhed at the size of it and wanted to weigh it on the scales normally used for neonates. We began by tieing its’ legs together so it wouldn’t get away and then Marianne stood on it’s wings while holding the head up. She took 3 knives because she wasn’t sure which would be sharpest and unfortunately chose the wrong one. It made a slight slit through the chicken’s neck but it was very much still alive so leaving the only option to try and break it’s neck. Chicken’s neck’s are really quite flexible so it required a 720 degree turn to finally get it to stop flapping! So we sliced the head off then dipped it in boiling water to aid the plucking. I was a bit ranked out by this point and had to wear gloves for that bit. We then cut off the legs and removed the innards (which makes a really brutal squelching noise) and gave them to the guard (apparently they like those bits). Eventually after the skin was removed it started to look like the chickens I’m normally used to looking at in Sainsbury’s at which point I stewed up some chicken curry I’d made the night before and it surprisingly went down quite well.

I have also learnt how to cook their local carbohydrate of zsima preparing enough for 30 people at a party put on for another volunteer who is leaving (boo). Apparently a Malawian man will only marry you if you can make zsima so I was a popular woman after that! Haha!

I’m settling into work a bit more. I’m still on ‘orientation’ so not joined the on call rota yet but just trying to get to grips with the ways things work here. I’m learning that there are problems at all levels in the hospital – from no reagent to do HIV tests, no ink in the photocopier to photocopy forms for test requests, that’s if the power’s working, so it’s just scribbled on bits of paper. (Identity is a bit of a joke as most people don’t know their date of birth.), no spinal needles on the wards so I have to use cannulas (the grey one!) for lumbar punctures –and there’s no local anaesthetic of course. In theatre I managed to get my hands on the right needle for a spinal anaesthetic but got severely told off when I threw it in the sharps bin after use as they only have 4 and all get ‘washed’ and reused.  There are not even any urine specimen pots so we use old glass antibiotic jars. Theatre was interesting. There were no caps so I had to wrap a pair of trousers round my head- elegant. Ketamine is given for most procedures and there was absolutely no monitoring, in fact the anaesthetist wasn’t even in the room.  Recovery means- lie in the corridor until the ketamine wears off.  

But there seems to be a real lack in communication and working together which is holding the hospital/country’s health system back: no clinicians are allowed to attend meetings with management (so management are conducting themselves as a separate entity from the clinicians- ie spending money on lots of fuel for personal journeys and not spending it on essential drugs etc). And there’s ineffective communication with the Ministry of Health who seem to be blind to the lack of human resources. For example, stating that they have trained more nurses so there must be enough working, ignoring the fact that the majority leave to go to Europe or South Africa, and then deciding to remove the 2, only, auxiliary nurses at Rumphi. We did have a clinical meeting on Saturday though which was surprisingly productive, although Marianna has said that last time they had a meeting (2 years ago) nothing changed. And unsurprisingly no management turned up despite it being planned 3 months in advance

We’ve got some really interesting cases on the ward- a man with HIV who is twitching all down one side and then the next day his parotid glands swelled, now he’s becoming confused and hemiplegic and his blood pressure’s rising! Yikes! We’re thinking toxoplasmosis or mumps encephalitis, treating and hoping for the best (any ideas welcome). Unfortunately as the prognosis for HIV patients is so poor if they get sick the central hospitals don’t really want to take them to their oversubscribed ITU so we keep them here and hope for the best. And unfortunately we’ve had 6 deaths this week. All but one had HIV which were complicated by TB, malaria, sepsis, so kind of expected to die. Unfortunately the other one had a witnessed collapse but no resuscitation was performed as he was ‘dead’- there’s no equipment to resuscitate anyway and no ITU so there is a feeling of ‘what’s the point?’.  Also there is no such thing as palliation because firstly there is no morphine syringe driver or lorazepam but also if you are seen to withdraw any treatment the relatives will think you are trying to kill the patient. There is a huge belief in witchcraft and external forces. Relatives believe that if a patient gets worse in hospital it is because it is cursed and they want to take them away. Also I think that being exposed to so much death in hospital it is no wonder they think bad things will happen to you if you spend too long here. Dealing with death has been an interesting experience too- the relatives don’t accept that the patient’s dead until you actually say it to them upon which they suddenly start wailing. Then more and more join in and the wailing continues during the body being wrapped and slung onto a stretcher- all in full view of the other patients- and processed to the mortuary by which point there are about 30 followers, all wailing. Some of these are ‘professional criers’.

Gosh I think I’ve written quite enough, Hope you’re not too bored by now! Hope everyone is good at home and well. Missing you all.

XXX

Starting Work!

Well crazily enough the Malawian medical council said I could go straight to my placement and not have the normal 2 months orientation in a central hospital, god knows why! So instead Marianne said I should have a mini orientation around Rumphi District Hospital, which I took to mean following the very experienced other Dutch doctor and learning from him. Of course reality was that the dates were mixed up and he was not due back yet and I was left on male ward with a ‘good luck!’ (HELP!)

A clinical officer did show up to start some form of ward round but unfortunately for most of the rest of the week he did a disappearing act leaving me to carry on trying to sort patients out!

So basically everyone has HIV, TB or malaria which I know very little about! – should of read my tropical medicine book before I came out (which I bought about 6 months ago- whoops).  Most of the patients, if in England, would be on an ITU with their presentations, for example we have 3 patients fitting from presumed cryptococcal meningitis, related to HIV,  who we just give diazepam to until they are obtunded. There’s a man with severe pneumonia secondary to HIV who has a blood count of 2.8 (very very low) which the lab could only spare one unit of blood for so one of his guardians (relative or friend) donated a unit- this is common practice as we have very little blood. I tried to get blood for another man in heart failure due to anaemia (HB of 4) and the lab told me there was none but actually they just hadn’t bothered to go get it for me and they don’t get very excited because everyone’s anaemic! 2 of my patients have loads of fluid around their hearts and are in massive heart failure one of which I referred to the central hospital to have it drained only to find that they don’t do it so there’s no point.  I’ve got 3 patients with massive livers and one with tropical splenomegaly! There’s so much pathology but unfortunately there’s not the tests to fully diagnose people so there’s a lot of blanket drug treatment and hope for the best! It’s crazy as well because patients are hardly ever followed up, so if they get better they go home and there’s no further investigation into underlying causes or cancer- mainly because they don’t have treatment for cancer so what’s the point in looking for it? The differential is so different here and difficult to get my head round! I’m also looking after the TB ward so I’m racking up the list of possible diseases I might have – malaria, sleeping sickness, parasitic skin infection from larvae eggs and TB. Nice.

So there’s a massive list of problems of course! The wards are really old, patients lie in really old beds with no curtains for privacy. There’s no oxygen in the hospital just the air concentrators, even in the anaesthetic room, but a lot of the patients refuse oxygen because they think if they have it they will die as they’ve seen others die who’ve needed oxygen. There is one thermometer on the ward and no blood pressure monitor. Observations are not done except maybe on presentation if you’re lucky and if they’re abnormal they’re not repeated. So I’m having to draw on my distant memory of clinical skills to work out peoples state without machines which dossing around at home for 2 months really didn’t help develop! Notes and requests for tests are scribbled on bits of paper and stapled together so you’re lucky if the nurses get the message to do their jobs and especially lucky if she has time to do them. The nurses don’t do nursing care like they would in England like bathing, changing and feeding the patients- this is left to the family and friends so if you have none you don’t get washed or fed. Instead they act like a junior doctor putting lines in, taking bloods and ordering tests the clinical officer or doctor has requested as well as ‘giving’ drugs. In inverted commas because drugs are often not given for days, also there are hardly any drugs to give! No paracetamol, penicillin, steroids, no inhalers or nebulisers for asthmatics- just intravenous aminophylline and oral salbulatmol. The lab can only test for very few things ie HB and then tropical stuff - HIV, TB, Malaria, schistosomiasis and trypanosomiasis- helpful when the patient has a tropical disease but not when they have something else! So I’m just guessing what peoples’ white cells, kidney and liver function etc might be according to how they look. There’s no resuscitation equipment but then if you were to resuscitate someone there’s no where to put them as there’s no ITU or ventilator. There is an ECG machine but no one knows how to use one or how to read an ECG and I needed to catheterise someone and there were no catheters! And to top it off there are chickens running about all over the ward.

So all quite exciting stuff and a seriously big learning curve!- when I get home from work I’m so tired that after the ordeal of cooking I go to bed really early! However I did have a bit of a late one last night Stephen and Wilson had been given a goat as a gift by a community so they decided to have a party,  (using a massive amp that VSO had kindly given them for their community work), slaughter the goat and we ate it on the BBQ and in curry! It actually tastes quite nice! I met a visiting volunteer team from Mwanza (in the south) and discovered 5 German gap year students who are also volunteering in Rumphi so it ended with lots of boogieing to a mixture of techno (which I sneakily put on),MJ and dodgy Malawian music.

Hope everyone is well. Missing you all loads. xxx

PS If anyone wants to post me recipes please feel free- I’m getting fed up already with my limited repertoire! Vegetarian ideas welcome too please coz after I’ve eaten my store of meat I can’t get anymore in Rumphi.

PPS Cockroach count - too many to count and apparently it’s going to get worse in the rainy season! There’s sooo many bugs.

Week 2

So surprise surprise the second week begins with the usual transport disaster!

My ‘truck’ picked me up nice and early, 8 am from the hotel in Lilongwe ready to embark on the 5 hour journey up to Rumphi. About an hour into the journey I questioned why they had sent a truck to collect me- it was then that we realised that it was to carry all my furniture for my empty house up from Liliongwe! So we had to turn all the way back to then spend another 2 hours loading up, from a dusty shed, old, used dining table and chairs, a bed and mattress and sofa onto the truck. We finally got on our way with my whole life plus a couple of Malawians, who wanted lifts, on the back of the truck. 2 hours into the journey what happens? A flat tyre. Joy. But when that was sorted, and I thought we were  finally on our way, oh no, it turns out that it is quite a useful time for the driver to run some errands such as – spend 1 hour in the bank, try and buy planks from the side of the road and collect a bed from another district. Along with travelling at no more than 70kph because the tyres were all bald we finally made it at 8pm by which time it was pitch black- no street lights of course! And I’d had no lunch so you can imagine how weak and irate I was by that point!

Marianne, the other VSO doctor, who’s brilliant, met me at my house and showed me around- it looks very cute from the outside and blue and white striped! But the inside looked like a barn with walls and no ceiling. And there are a lot of bugs!! Cockroach count 4 so far and I’ve killed them all with ‘DOOM’! So I guess I expected to live in impoverished conditions but when I was confronted with it it was a real shock that I really was going to be living in a small village in Malawi with only very basic amenities. Arghh! We moved in the furniture, well as much as we could, because the bed wouldn’t fit through the door! Kindly Marianne let me stay round her house that night and the next 2 nights in fact! Until I had a bed.

The next day Marianne showed me round Rumphi. It’s a pretty little village set between mountains which means it gets really windy (I  feel like my house is going to blow down!) and it’s very dusty and hot at the moment so my feet end up being ‘tanned’ after about 5 minutes of walking around.  It actually has more things than I expected: 2 banks, several little shops selling pots and pans and household wares and a place they call a ‘peoples trading centre’ or PTC which basically looks like a shop you would see during the war with products being sold with the labels on indicating exactly what was inside with big letters. It also sells bread but hasn’t since I’ve been here because the bread maker has broken and sometimes you can get cornflakes. Unfortunately there’s no where to get meat unless you want to off the street with flies all over it and no cheese so I’ll have to eat lots of nuts to keep my protein content up- saying that I haven’t seen any nuts on sale either.

There’s a nice market which little wooden shacks selling essentially the same thing but also some tomatoes, onions, bananas and dried fish.

It’s very poor; most people live in brick or wooden shacks without electricity particularly in the rural villages and cook on charcoal, the dust gets all over peoples clothes of which they have very few and they’re usually torn and have no shoes, most families live off less than £10 a month and there are many mouths to feed as families want to have many children, to work in the fields, and there’s very little family planning. There are soo many babies- so cute wrapped around on the back of the mum while she is also carrying wood/water/ washing on her head. It’s the dry season now and last years rainy season was not good so people are getting desperate for the rains to come so that they can grow their crops again to survive.

I’ve also met some of the other volunteers, Rina a lab tech who lives with Marianne, who’s really lovely, Stephen from Uganda and Wilson from Kenya who were my absolute saviours the next day!

I was really overwhelmed with everything and all the stuff I had to do- it’s like moving into a new house in England which is empty, buying stuff for it, letting elec, water companies know that you’ve moved in etc etc but instead in remote Africa where everything takes so long and it’s so hot!

It began with an attempt to treat my mossi net but then finding there was no tablet of insecticide, to then attempting to boil some water to sterilise my water filter and discovering I had the wrong plug on the electric hot plates. If it wasn’t for Stephen and Wilson finding me in my house looking bemused about what I was going to do next then god knows what I’d have done. They brought round my fridge, had some carpenters come and make me some shelves at local price not ‘mzungu’ price, changed my plug on my cooker and helped me open a bank account! It’s really nice that the volunteers  support each other out here and there seems to be a good network across the whole country and in fact a national conference in a few weeks time. I also managed to get a couple of beds from the hospital store room one of which didn’t fit in the car so a few locals carried it to my house for me! One woman had a baby on her back- I did feel slightly guilty about that!

Marianne has also shown me round the hospital! It’s actually bigger than I thought. There’s a female ward, male ward, TB, maternity and paediatric wards and they have an outpatients, antenatal care, orthopaedic/physio area and a place where they can make things for disabled people and an HIV clinic. There is a measles outbreak across the country at the moment and they have a tent for people to be in isolation which gets pretty hot at midday! But there is also a theatre with air conditioning! Although very basic like something you might see in a museum at home. They also have one XRay machine and an ultrasound too. Since I was assigned they’d also managed to get one Malawian doctor 3 weeks ago and a dutch doctor who works with the UN. So relieved that there is help at hand! I think I may be allocated to female ward which currently has 24 beds but there were 2-3 patients per bed and lying on the floor too. And there is no doctor for paediatrics so I may be doing that too, as well as some anaesthesia. Resources are pretty bad- there’s no paracetamol and they’ve run out of condoms, not great if you’re trying to promote prevention of HIV spread.

I’m getting there with cleaning and furnishing my house now, after a trip to Mzuzu, the nearest city- I use that word loosely as it’s actually just 2 roads of shops essentially selling the same sort of things! But very exciting I got to buy some chicken and some cheese and chocolate spread for a serious amount of money! Everything here is actually quite expensive as it all needs to be imported!

My next task is varnishing my kitchen bench, washing my used bed sheets from the market, which then need to be ironed because of the Tumbu fly which lays eggs in the material which then infest my skin!, finish mopping my house and making my curtains! Never thought I’d become this domesticated did you?! And also so resourceful- nothing is getting thrown away- my left over dinner goes to my guard! Feels really wrong but otherwise he doesn’t have anything!

I’ve also managed to be a bit of a tourist in amongst my home sorting! Went to the Vwaza marsh national park and saw loads of elephants and hippos! It’s the dry season so they all go down to the lake to drink and it was easy to spot them, so beautiful but did get attacked by tsetse flies, hopefully won’t get sleeping sickness!

Anyway I think that’s enough for this week! My next update will be about my first week in the hospital -arghh!!  I hope everyone is well at home. I’ve managed not to get the shits yet but you’ll be the first to know if I do!

The First Week!

Monile! Muli uli?

Oh my gosh what a week of mixed emotions! It started off with transport disasters- as per usual!

I like to be on time for flights but the journey began with a road accident, luckily not us, the air ambulance, massive delays on the A4 and big hissy fits from me panicking that I wasn’t going to make the flight! We did eventually make it- obviously- and the next pleasure to be endured was the flight with Ethiopian Airlines. Let’s just say I didn’t think they made planes that economy anymore. It was very old, smelly, with no leg room, no in flight entertainment, no space for overhead luggage and to top it all off a crying baby in the seat in front- who cried alllll the way. I then wasn’t overly reassured when the plane, after taxiing out to the run way then decided that there was a ‘technical problem’ and made it’s way back into the airport docking back where we’d started and then opening the doors. After waiting for around an hour and a half we did finally take off despite the rather overpowering smell of oil and burning rubber. The next leg from Ethiopia to Lilongwe, Malawi, was equally pleasurable as we ended up stopping off in Uganda on the way, as you do, for around 2 hours where we were strictly told ‘No standing!’ and ‘No going to the toilet!’ (I was really desperate and full of aeroplane gas) because apparently they were refuelling and you can’t move when that is happening.

I’m pleased to say though that that is where the transportation issues ended- all my bags arrived! Yipee! And a VSO rep was there to meet us in the airport. She’s called Mphatso (pronounced M-pat-so) and I met up with 6 other volunteers and we took a jeep to the hotel where I am now and where we are staying for the first week of training.

So the hotel is amazing! And not a true picture at all of what it’ll be like in my little house which apparently has nothing in it- joy. So I have been buying things to cook with- yes I am going to cook! And clean with- shock horror!

We have spent the week basically learning about Malawian Culture, our health programme, sorting admin out etc. It has been quite hard core- getting up for 8am starts and concentrating until 6pm! (I haven’t been working or used my alarm clock for 2 months!) And they have been seriously feeding us! I’m carbo loading (getting fat) in case I can’t get food where I’m headed or I get the shits. They have an interesting food called zima which is basically a large ball of maize and very plain but apparently if a Malawian doesn’t get it for dinner they ‘haven’t eaten’.

We’ve also been learning Chitumbuka which is actually a different language from the rest of Malawi who speak Chichewa (so lucky I didn’t bother learning any before I left!) It’s difficult but I plan to be a pro by the end of the year, hum.

The other volunteers (23 of us) all seem really nice and there’s a serious number of doctors! We’re getting posted all over the country – some in little rural hospitals like me and some in large places where they’re lecturing or teaching. There seems to be a good volunteer network and we’ve had reps speak to us about events where we meet up and I’ve already been roped into talking at some conference thing. Joy.

I’ve also managed to have a few beers- yippee! –There was a BBQ at the country directors house and last night we went to ‘the shack’ which is a bar/club with volleyball courts! Still was in bed by 10:30pm though!

Scarily the medical council have said I don’t need to do my orientation, which normally take 4-8 weeks, in another hospital before going to my little one! God knows why! So I’m going straight there on Saturday-argghhh! Luckily there’s another dutch doctor Marianne who’s there already and I think she’ll be able to induce me!

What I’ve seen so far or Malawi (out of the jeep window because we’ve been almost penned into the hotel other than visits to programme office) is it’s beautiful and reminds me of when I was in East Africa before. It is very poor but the people are lovely and smiley and friendly and I hope that they are up in Rumphi where I’m headed!

That’s all for now if you’ve managed to get to the end! I’m hoping the internet will be ok in Rumphi and if not I’ll get a Dongle – only 2G though, and continue the blogging!

Hope everyone’s well. Love and miss you lots