Malawi Week 2 Summary

---

First let me say that this has been a splendid experience and I am grateful to be able to share it. First things first…quote of the week comes from Anna. Anna is one of my fellow classmates in on elective here in Malawi and she has an artificial leg. She said this during our conversation about shaving… “I don’t shave my leg anymore because no one ever looks at that one.”

I am adding phrase of the week to my weekly feature. This one goes to a UK medical student I met today. “What time do you knock off?”… Translation from British to American: “What time do you get off work?”

I spent last week in the Pediatric Special Care Ward’s High Dependency Unit and it was a bit more hectic experience than being in the Nursery High Dependency Unit (same as ICU). Liz and I followed Sarita, an excellent resident from the UK who is working in Malawi with her husband for one year. Apparently this is a fairly common practice among the British residents. Each morning the residents round on the patients in the High Dependency Unit while with the Interns round on the patients on the main floor of the ward. From what I understand, you only put patients on the main floor if they do not need much motorizing because there may be 1-2 nurses for 100+ patients. This is compared to the 3 - 4 in the high dependency unit, where there are 20 to 25 patients.

The saddest realization during last week and now is that is considered an accomplishment to the age of 5. One 14 year old child in the ward had been treated for TB meningitis back in December and came back to the hospital with a return of symptoms….headache, confusion, nausea. The suspicion was that he developed hydrocephalus (retention of fluid around the brain) secondary to the meningitis. He was supposed to go to surgery, but could not because his blood pressure was too high (>200/90). So they brought him to the special care ward. Typically one would give this child manitol to lower the pressure in his head, but this hospital here does not have that. So was just getting prednisone. In any case, Sarita was not there to go over the case with me. So I tried to discuss it with the other resident, but she didn’t know what was going on. I tried to review his chart, which was a disorganized pile of papers strung together with string. The progress notes were out of order and his current care management plan was not clear. Hoping to get more information from the resident, I asked her questions and she said she wasn’t sure and walked away. Now, she may have returned to the ward later with someone else, but she definitely told me that Sarita would be back around 10:00 am, which I took to mean “come back at 10 and you can follow Sarita because I am leaving.” I thought about throwing up my hands and just going back home at that point…but I decided to go back to the Nursery instead where I was actually able to contribute… performed a Lumbar puncture (successful on the first try), wrote the lab slip for the lumbar puncture and delivered it to the lab, and wrote a progress note on a child with bronchiolitis.

Unfortunately I found out during morning report today I found out that the young man with TB meningitis and high blood pressure died over the weekend. I wish I could say sad scenarios like this were a rare occurrence, but they are not. Last week a child died after a week stay in the hospital because of anemia…something that would not happen in the states. Another child died after a week stay from hypovolemic shock….after one week…plenty of time to correct the fluid deficit. However, according to our local rotation coordinator, fluid management is a weakness of the hospital here. About one quarter of the hospitalized children last week alone were HIV positive….and astounding number. With HIV comes a ton of other health issues…not to mention the social and psychological sequela.

On a lighter note, my favorite clinic during the week is the neurology clinic, which is led by Dr. Mack Mallewa. It is a 3-4 hour afternoon clinic where he predominantly sees children with epilepsy, cerebral palsy, and stroke. Epilepsy is very common here and can get genetic, but is frequently due to a history of meningitis (from Malaria, TB, or other typical bacteria). It can be difficult to manage epilepsy because now the hospital pharmacy only has one seizure medication in stock and they normally carry three. This is because of recent embargos placed on Malawi that have led to the withdrawal of financial and donor support recently. Cerebral palsy (CP) is essential a death sentence as living past 14 is rare here. About half of CP is due to birth asphyxia… OB care is not very good here in general.

Next week I will tell you all about my time in the Nutrition Unit. For preview…that unit treats children with malnutrition and most have some other condition in addition to that (like HIV or Cerebral Palsy). There are two forms of malnutrition, protein deficiency-energy deficiency (Kwashiorkor, like the children you see on TV with big bellies, swollen extremities and blondish hair) and general caloric deficiency (marismus, where the children look emaciated and wasted). Some children come in with both.

<strong style="mso-bidi-font-weight: normal;">About where the house…

I think I mentioned before, we live in a house that is rented by our professor Dr. Taylor. The house has two student bedrooms and a common bath and a master bedroom (Dr. Taylors) with a master bath, a large kitchen, moderately sized dining room and large common area. The student bedrooms have two bunk beds with mosquito nets over each bunk that hang down to the bottom bunk. We have a housekeeper/cook who keeps the house tidy, prepares our meals Monday-Friday and washes laundry. There is a gardener and a guard on duty at all times. The whole house is one level on a pretty sizeable piece of property. There are a guards quarters, additional guest room and laundry room in a smaller building in the back. Dr. Taylor’s nephew, Ian, is also living here for six months and currently lives in the separate guest room out back. It was an adjustment to live with 8 people in one space initially, but it actually has not been that bad. It is nice to wake up a little earlier though to get some me time…like now, I’m finishing this email at 4:30 AM Malawi time. One student on elective brought a laptop and Rachel who is here doing research for 6 months brought a laptop, so when they are not using them we all have access to them. For Rachel’s laptop, that means some evenings. In general, we mostly share the other laptop among the six of us. This is what makes emails and time on the internet tough, in addition to the slow, slow speed.

<strong style="mso-bidi-font-weight: normal;">Finally, a bit about our hike last weekend…

Last weekend 5 of us hiked up Mt. Mulanji, which is the largest mountain in Malawi. It took about five hours to ascend the mountain and 3.5 to descend. There were multiple river and water fall crossing, which made me uneasy …I get a bit nervous about heights and water…especially water these days. Then you throw slippery rocks in the mix at the top of a mountain…eeek! We all did great though and no one had an injury, minus a few bruise knees, elbows and egos after taking a dive on the slippery soil. We stayed the night on the plateau in an awesome shack. It had two rooms, a common room/dining area, two fire places and a pantry stocked with pots, pans, tea kettles... the works. We hired 3 porters to carry our clothes and food and a guide to lead the way. It was very relaxing to prepare dinner over a fire place in such a scenic and solitude place. Even though there were 5 of us in the cabin, the whole mountain was so immense that it was easy to get lost in your thoughts and enjoy the beauty of God’s work.

A last, my summary for this week has come to an end. We have a short week ahead because we are leaving for Safari in Zambia on Wednesday. It will take one day to travel to and one day to return, so we will get two days of safari and come home on Sunday night.

Cheers!

Angela

---