Wednesday, June 20, 2012

Pictures: Around the Hospital

 Cookout @ the Guesthouse, notice NFumu in the background.
 Amblessed in front of the UNC Project building, the Tiziwe Center
 Women hanging out breastfeeding (yeah!)
 Some hospital buildings

 In front of "casualty" aka the ER
 In front of the Ethel Mutharika Maternity Ward
 Open hospital corridor
 Adult Medical and Surgical Wards

 Families Waiting
 Children's Ward B, the Pediatric Oncology/ Burkitt's Lymphoma Ward
 My Malawian drink of choice, Pineapple Fanta

 Adorable Girls, Zione and Patricia on the Burkitt's Lymphoma ward.  Z is the mascot of the whole unit!

Dr. Charles is here with us now.  We just went to the market and collected some supplies for dinner tonight (including plaintains for frying!).  We have had a busy day in the OR, and we are now looking forward to a relaxing evening doing some cooking and research.  Amblessed an I are helping to gather data on the number and type of pediatric surgery cases at the hospital, and I must say that it is amazing how many pediatric surgeries are completed here and what percentage are for congential anomalies.  It seems like a really serious question and I hope that someone decides to research the cause of the high incidence rate of anomalies.

In other news, this past weekend I sent out an email to several surgical supply/manufacturing companies asking for donations of skin graft knife blades- and two companies have written me back.  One has decided to donate 10 boxes of 10 blades each.  Big thanks to Chris Taylor at Swann-Morton Limited in the UK!

Tomorrow we are going to Bwaila Hospital, where there is a public maternity ward and a fistula clinic (fistula is a congenital or obstetric complication where the vaginal are connected, either congenitally or through obstetrical trauma, to either the bladder or rectum or both.  There is a UNC OB/GYN who is a full-time Lilongwe resident who runs the fistula clinic at Bwaila.

I finally feel like I have learned most people's names here and have really settled in.  I even feel pretty normal driving on the left side of the road. I do miss you all though!

Sunday, June 17, 2012

Picture Update

Inside the compound at the Cohen/Surgery House

Rope/Tire swing for kiddos staying at the Surgery house

 My room at the Cohen house.  Love the nets that hand over the 4 post bed.
 The best type of mosquito net.
 Delicious peanut butter cookies from  Made using Malawian peanut butter and a chopped candy bar for chocolate chips.
 Beautiful Malawi sky en route to the guest house.
 Yummy cinnamon yeast rolls from the guesthouse gourmet chef, Rajeev.
 The humble Iron Chef himself.
 Love the way Willard wears his slippers.
 Group brunch
 DJ Will on the stove, cooking up some scrambled eggs for breakfast.
 Spiced apples and HOME. MADE. tortillas from Will.
 Amazing African hot sauce and brunch wine.
Amblessed and Will, brothers from another mother.

 Love the Chichewa version of "ENJOY" aka "N'JOY"
 Our group at dinner for Brian's going away party.
 Will and Brian, the guest of honor.  Brian spent almost a year in Malawi doing psychiatry, HIV, and TB research.
New roommate, Zaza. 
 Haphazard pumpkin pie Allie style (no real recipe)-will it work?
 It works!!!
Radishes, chard, and rape growing in the garden at the Surgery house.

Thanks to Alex Werner for the pictures below...
 Saturday we went to Bwaila market, here we are by the beans.
 Selling tomatoes and cabbage at Bwaila market...

Dr. Charles gets here tomorrow- he's our second preceptor and he is a trauma surgeon at UNC.  I'm really looking forward to working with him (but we miss you Dr. Shores).  We're going to round in the morning with a pediatric oncologist tomorrow in the Burkitt's ward. Ready for week 2!

Saturday, June 16, 2012

A Week at Kumuzu Central Hospital

We spent a morning in the Burkitt’s Lymphoma ward this week.  Burkitt’s lymphoma in Africa is quite different than in the US. In Africa, Burkitt’s mainly affects children and is thought to be a consequence of an interaction between Epstein-Barr Virus (EBV) and chronic malaria infection.  More research needs to be done into how and why this interaction develops into a B-cell tumor.  The doctor who we followed was an older British man (in his 70s?) who was the previous head of the department of pediatrics for 15 years.  He is incredibly humble and has a deep passion to help these kids.  Something that is really encouraging about Burkitt’s is that a great percentage of the kids will respond very well to chemotherapy and there is a significant cure rate.  Most of the kids present with huge tumors in the jaw, neck, abdomen, and occasionally in the brain/spinal cord.  In several months, the ex-department head will run out of money to fund this department, so I am thinking about fundraising.  I think that if people saw the desperate need for this pediatric cancer care, that we could generate some serious funding.  I think the annual budget for the department (including the two wonderful nurses, both named Mary, who have been working with these kids for over 15 years and the chemotherapeutic medicines) is about 12,000 USD.  This will be summer project #2.   I’m planning on bringing my camera with me to ward rounds on Monday.  If any of you have connections to the Leukemia Lymphoma Society or any other Pediatric Oncology Associations or big donors please let me know.  Hopefully I will be able to set something up in the next month.
Back in the OR, we have seen a large number of congenital anomalies.  It really made me appreciate the clinical correlation lectures we had during the anatomy block of first year.  The condition of imperforate anus (where the bowel does not have a proper connection to the anus and the child cannot defecate) is more common than I realized here.  I’m not sure if that is purely because we are at a tertiary care center here or if there is a certain condition like malnutrition during pregnancy that contributes to this defect.  I was able to scrub with the current head of the Surgery Department on a pediatric case and I was just in awe of the precision needed for pediatric surgeries.  I felt the same way about watching the surgeon who operates on burn patients.  Burns are a huge problem here, as many children are burned around large fires that are used for warmth and cooking.  Watching the surgeon harvest tissue from the thigh of a young girl whose entire back was burned when her clothing caught on fire as she tried to stay warm was really discouraging.  There are special knives that are specifically used for harvesting skin grafts.  Unfortunately, the blades on these knives are supposed to be disposable, yet in this resource-poor country they must be sanitized and re-used again and again.  Harvesting skin with a dull knife is nearly impossible, and it wastes valuable tissue, since the skin gets mangled instead of getting a clean graft.  Put that on the list of things for me to find.
Yesterday, Dr. Shores’ first patient was a 3 year old who had swallowed a coin.  Doesn’t that make you feel like kids are exactly the same everywhere?  Luckily, the coin (10 kwatcha piece) was in the esophagus, not the trachea, so the kid was still able to breathe, which made the removal less emergent.  After about a half an hour wiggling with scopes and foreign object grabbers, Dr. Shores pulled out the coin and the whole room clapped.  The process is a little bit like a more controlled version of that arcade game where you try and grab the stuffed animal/prize with a claw.
It seems like it is the culture here (and in the US too, to a certain degree) to avoid discussing death with the patients and their families.  One morning this week we saw an elderly woman with a malignant tumor on her chin who is not a candidate for surgery.  Dr. Shores wanted to send her to the palliative care team, who would administer pain killers and send her home to be with her family, since the hospital cannot offer her further treatment.  I cannot tell you with certainty if this happened or not.  This came up as an issue in the Surgery Department morning report too, as patients are dying in the hospital alone, instead of dying at home surrounded by family.  I think as doctors we may be afraid to say that there is nothing else that we can do for someone treatment wise- that we feel defeated.   It’s part of our type-A personalities, to continue pushing until the end.  But this may be the wrong approach.  We have the ability to empower people through their process of dying, letting them be in less pain and with their families. 
When you walk through the hospital you see so many family members, mostly women, bringing food and supplies to their hospitalized loved ones.  Women come with giant containers of food balanced on their heads, as well as clean clothes and chitenje.  The hospital is a constant flow of colors and patterns and smells moving through the hallways.  In the wards, family members stay with their loved ones, often sleeping on the floor next to their cots.  The wards are so full here, it is such a distinct contrast to the private rooms we expect in the states.  The open wards are divided into smaller waist-high walled sections with about eight beds in each sections.  There are probably ten sections in each ward.  I will try and post pictures of this on Monday. 
Even with all of the issues I wrote about, I am so happy to be here.  The people in the hospital (and everywhere) have been very kind to me.  The surgeons have been great teachers, and I love talking to the residents and the clinical officer students about their training and what they want to do when they are done with their training.  Some clinical officer students asked for my name yesterday so we could be friends on Facebook!
This weekend we are going to go exploring a little bit, maybe with a trip to the south or the lake (Lake Malawi). I also want to go to the market again and pick up some more chitenje to take home.  Tonight we are going to a Malawian casino for a celebratory outing for Brian, a medical student from Vandy who has spent the past year here and is returning home.  I will have my camera on me this weekend, so there are more pictures to come.

Tuesday, June 12, 2012

In the 'Operating Theatre'

So yesterday was just sad.  We started the day with three pediatric cases.  Two were suspected malignancies and one was a young boy who had fallen from a tree (a common occurrence since many children pick fruit here).  One of the first things that struck me about the kids is how much younger they look than kids the same age in the states.  I assume it is from malnourishment and it is really saddening.  Dr. Shores and the ENT Clinical Officer (Southern African occupation which I would say is a similar profession to a Physician's Assistant in the US) did biopsies on the suspected malignancies of the two children.  One was just a baby.  One was fourteen.  He looked like he was 8 or 9.  If the results return saying that the tumors are some type of lymphoma, the cancer may be treated and cured with chemotherapy, which I will try and cling to as a glimmer of hope.  Realistically, these are very bad situations. The child who suffered the fall trauma will probably need to wait for a pediatric ENT surgeon to have the operation to fix his tracheal stenosis.  For now, he will leave the hospital breathing through his stoma, but will hopefully be a perfect candidate for future surgery.

Today, Dr. Shores had a schedule chock-full of meetings so went to "Theatre" (OR) with the new Chief of Surgery.  We saw several colostomy operations, repair of an inguinal hernia, and a child with Hirschprung's disease for a biopsy.  I scrubbed in on an operation with an Australian Orthopaedist re-setting an improperly healed femur fracture.  Orthopaedics really is like carpentry (and has similar tools).  Overall, today felt better.  There was more 'quality of life' value in the surgeries I saw or scrubbed on today.  A mere hernia repair, considered a minutia of a surgery in the US, is really a preventative measure to life threatening illness here.  A reset limb may provide ambulation, self esteem, and greatly improved quality of life. 

Amblessed and I have been talking about what life would be like choosing surgery as a career.  I think that it is important to remember that in this resource poor, medically underserved country, most people do not see doctors regularly for routine check-ups or small complaint visits, which are often the impetus for further medical treatment.  Thus, many people coming to the hospital are very, very ill and require serious attention and many of the surgeries are very serious and may be less helpful than if the patient presented earlier.  I don't this it is quite like that back home, especially for all of the specialist surgeons, who complete the same few operations all of the time.  Overall, I think surgery could be very hard and very rewarding.  Sounds like all of medicine.  Kinda sounds like all of life.
Lastly, a nice couple just moved into our house for the week.  They are working on a documentary about obstetric fistula repair at Bwaila hospital in Lilongwe.  I might try and go over there to hang out for a day during my time here.  There is a UNC doctor who is spearheading the program.  The couple was also talking to me about the idea of starting a school for the fistula patients (ages 12-80).  Sounds pretty amazing and transformative.

Our house at UNC Project is really wonderful.  I love hearing everyone's stories from clinic or work when we all return home.  I also really enjoy the American treats coming out of our kitchen, including rice crispy treats last night and the promise of cinnamon rolls tomorrow morning...

Saturday, June 9, 2012

Drinks at Harry's Bar, Dr. Shores Arrives, Bwaila Market

 Drinks at Harry's bar, where the ex-pats go to congregate
The only people dancing in the bar.

 Jen and Suzann, UNC Nursing students working in Malawi at the Malaria Vaccine Unit and KCH Maternity wards
 Amblessed and Urooj
 Urooj showing off her chitenje
 Chitenje at the Bwaila market
 Carrying past the market
 Street venders outside of Bwaila
 More vendors
 Selling fruit in Bwaila
 Everywhere you go, people are walking on both sides of the road.
 Walking past a seller of industrial equipment
 Crown Hotel
 Chick O' Rellos Fried Chicken
 Sounds like a good idea.
 Zsa Zsa, enjoying life at the Cohen house.
 1/2 Dane 1/2 Rhodesian Ridgeback
 Sweet girl

 Different market along the way to ShopRite

Last night we ventured over to Harry's bar, where we had a relaxing time.  Will and Amblessed led the bar in dancing.  We stayed for a while, but made sure to come home before we all turned into pumpkins, since Alex, Will and Amblessed were taking a 7AM bus to Blantyre to watch the Malawi-Nigeria World Cup qualifier game (Amblessed cheering on Nigeria and Alex and Will cheering on Malawi). 

Today, Dr. Shores came over and picked up me and Urooj from  the guest house and took us on a Bwaila market trip and running errands around Lilongwe.  Bwaila market is a giant market with tiny alleyways and booths selling everything from produce to paint thinner sold in re-used liquor bottles.  We ventured over to the corner of the market where they say colorful fabrics to use as Chitenje cloths (worn by Malawian women as skirts). 

After that, we trekked over to the Cohen/Surgery house where we made a salad for lunch.  Dr. Shores showed us her pictures from her trip to Victoria Falls, Zimbabwe which were beautiful.  Now I'm at the guesthouse relaxing.  Luckily, I haven't had jet lag too bag this trip.  Is it time for the hammock?