December 2010

I am in Malawi for 10 days, staying with an ex-colleague of mine who is on a VSO/RCPCH fellowship year working as a volunteer doctor in Mzuzu Central Hospital in north Malawi.  She is the only paediatrician here and one of only 4 doctors in the main tertiary hospital for the northern region.  She was keen to run a neonatal life support and care of the newborn infant course while she was here, managed to obtain funding from VSO for manikins and bag-valve masks and basic wooden incubators and then persuaded me to come out and teach on the course!  It is a 2 day course but once you add on preparation time, a ward round, busy outpatient clinic and another “under 5s” session in A and E it soon makes 5 days.  I am already looking forward to 2 days on the banks of Lake Malawi at the weekend…

Day 1      Arrived Lilongwe one hour late after a 16 hour journey via Nairobi and Lusaka.  Pretty exhausted but glad to be here and delighted that our bags arrived too!  I am travelling with my 10 year old son, Toby, who is an inventor extraordinaire and whose role is to make wooden toys with the hospital carpenter for the children on the ward as they have no toys.  Our rucsacs are full of nasogastric tubes, Laerdal masks, a manikin and urine dipsticks (the hospital has run out).  Customs let us through because they couldn’t understand what a manikin was.  Becky picked us up and we started the 5 hour drive north through lush grassland and then forest (conifers!) all set in the deep red African mud of the rainy season.

Day 2  Morning ward round on the paediatric ward and in the nursery.  I feel fairly comfortable here as I spent 6 months in north Namibia as a medical student when my parents were VSO doctors there and the set up is very similar.  The pathologies are also the same but there is less HIV here and it is more openly discussed as there are now antiretrovirals here which there were not in Namibia in 1995.  Spent the afternoon in the market buying bath mats for the new wooden incubators.  Yes, I do mean bath mats.  The mothers have been unwilling to keep their babies in the hot cot because it has a hard wooden surface for them to lie on.  We were going to get bits of foam as mattresses but were worried about keeping them clean as many babies don’t have nappies and those that do tend to leak out of them pretty often.  They don’t have towels in the hospital.  We did buy some in the end but thought they might disappear as they are quite a sought after commodity so we decided to buy bath mats to put in the hot cots.  Soft, warm and less likely to disappear.

Day 3  Cardiology clinic!  I wish I’d brought the cardiologist with me…  A water-hammer pulse and long diastolic murmur.  Wow, aortic regurgitation secondary to rheumatic heart disease.  And the child had chest pain – and the cardiologist said children don’t get cardiac chest pain.  I think I found the exception this morning.  My  echoing skills are fairly basic and the only ultrasound machine in the hospital has no colour Doppler on it but we may have found a tetralogy of fallot and confirmed an AVSD.  Not a huge amount to be done with either unfortunately as the nearest paediatric cardiothoracic surgeons are in South Africa and only a small number of curable children can apply to be sent there per year.  We spent the afternoon preparing for the course which starts tomorrow.  We were training the other facilitators who I was relieved to find do have some experience of learning by role playing with plastic dolls!  We could do with some more instructors but “from small beginnings” and all that….  Toby is making a conveyor belt and water wheel type thing to go over 2 sand pits he’s making out of old tyres.  I found him with a team of 3 workmen using a huge metal grinder to grind down 5 plastic cups today to make the wheel buckets out of.  Tomorrow they are going to teach him to weld as he wants to use old beds to make the frame of this sand-pit miner contraption for the kids to play with.  He spent the afternoon with a Malawian family as school has broken up for Christmas holidays.

Day 4 and the first day of our Newborn Lifesaving Course.  Teaching methods are not always transferable across different cultures and Becky and I were worried that the Neonatal Life Support bit of the course might fall flat.  We need not have worried.  The 16-20 candidates loved it!  I say 16 to 20 because it is not that clear how many we have attending.  They tend to wander off and then someone else comes back half an hour later in their place.  Some of them I think are popping back to the ward and allowing others to come and learn in their place.  Nothing goes according to timetable but we decided beforehand that as long as someone learnt something it would be worth it.  It is going much better than that.  The majority of the candidates are midwives and have plenty of experience with very sick babies.  I took them through an amalgamated version of the physiology and neonatal resuscitation lectures and they were well able to apply this theory to babies they had dealt with.  They pick up the practical skills much faster than your average NLS crowd in the UK and I think scenario teaching tomorrow is going to be great; they really do have a wealth of experience to draw on and, now that they have relaxed into it, are very enthusiastic.  We have two local clinical officers who work as anaesthetists helping out as facilitators too which is a great boon and means that they could carry the course on after Becky has left which is the kind of sustainability that VSO promotes but that VSO doctors rarely get to contribute to.  The matron gave a fantastic talk on Kangaroo Care and we all strapped plastic babies between our breasts with chitenje (local material wraps) – even the men, much to the mainly female audience’s delight.  I feel we’d earned our bottle of beer in the light of the setting sun this evening…

Day 6 and we are on the beach on the shores of Lake Malawi.  The second day of the course went well yesterday with the candidates rising to the challenge of the adapted scenarios (there are no ambulances, microwave ovens, drugs, pethidine or naloxone here) and really enjoying themselves.  They all passed the course with flying colours, looking totally at home with the equipment and obviously very experienced clinicians already in their field.  We also had an interesting talk from one of the nurses on management of HIV perinatally which is a continuing changing field.  Indeed the advice from the government changed on the second day of the course!  Instead of exclusively breastfeeding till 6 months and then weaning fast at that age, they are now to start weaning at 6 months but continue to breastfeed until 18 months.  This is because the risk of malnutrition in the early weaners far outweighs the risk of contracting HIV from breastfeeding at this stage.

Toby and his Malawian friend, John, finished the sandpit contraption they have been working on all week this morning.  The children were a bit non-plussed at first but soon got into all the activities – unlike their mothers who thought it was all a bit weird!  There is not such a strong concept of play here as in the UK but the nurses are very keen on this form of stimulation especially in the children with malnutrition who remain on the ward for long periods of time.

I won’t write any more on this blog as I have now entered the holiday bit of our trip and you don’t need to know about the white sand, warm water, lazy catamarans, craft sellers and cool beers….

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