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.