First: This post
details some of the conditions at Zomba Central Hospital. I don’t say this to
suggest the hospital cares for patients poorly- it is run well by very
intelligent healthcare providers and saves countless lives. They simply operate
with very limited resources, making their work a challenge. Also few pictures for patient respect-sake.
It was time to meet Dr. France.
I got in a cab at 7 am and he drove me to the hospital,
where I had to ask for directions because who knows where the surgical
conference room is in this place? I embarrassingly circled around the building
I discovered was surgery before I gave up and called Dr. France again. He
laughed and said he’d come out and find me, which he did. He wasn’t at all what
I expected. I thought he’d be this young, glamorous, world-traveling
philanthropic doctor. He is philanthropic and certainly a doctor, but he is
this funny white haired balding bespectacled man, who is very tall. Though he isn't Enrique Eglasias, upon meeting him you immediately know he's very smart and very good at his job. Also very European,
at least accent-wise. His English is so understandable I can’t tell if he is
really French or English, and I still don’t know if his name is really Dr.
France or Francis. He’s Dr. France for everyone at the hospital though so that’s
what we’ll go with.
the surgical conference room
He led me to the conference room and sat me down a little
before 7:30 and grilled me. He wanted to know why I was in Malawi and what
devices we make and why I think I should watch surgery. He was quite skeptical.
He asked a doctor at the table if he thought I should be allowed to watch, and
the doctor asked which year of medical school I am. “She hasn’t started” was
Dr. France’s reply, to which the other doctor said “Oh, then she can’t really
help.” I thought they were going to kick me out. Because it was true, I add
nothing by being an untrained body in the hospital, I just take up space. It is
100% the hospital staff doing me a kindness by letting me see what they do.
Luckily for me, Dr. France referred to another physician who I found out later
is the orthopaedic surgeon, who said it could be valuable for me to see some full
cases, from diagnosis to post-op. Bless that man. As a bit of a joke maybe, Dr.
France assigned me to the care of the first doctor, the one who pointed out my
uselessness. His name is Wilson.
The meeting was a gathering of all the surgical staff-
probably 9 physicians and techs, all male and Malawian, led by Dr. France. He
asked the night on-call surgeon what happened, and he reported on a few cases.
Each case, Dr. France quizzed us: “how do you tell the difference between anal
and rectal prolapse?” (ans: anal prolapse is inflammation at the interface of
skin an mucosa, while rectal is inflammation higher up in the bowel so it hangs
down and is separable from the beginning of the mucosa). Also “what sign can
you use to differentiate between cellulitis and deep vain thrombosis?” (ans:
dorsal flexion of the foot is extremely painful in dvt). He was a great
teacher, almost jovial but almost severe. At the end of the meeting, he had me
introduce myself. He then said “I’ve assigned her to you, Wilson.
Congratulations.” Everyone laughed. It was simultaneously funny and terrifying,
I am definitely a burden. But it was time to prove I’m not a complete idiot.
That was easier said than done. Wilson was a scary teacher
at first because a. his voice is very deep b. he speaks very quietly and c. his
accent is very thick. Sometimes I was unsure if he was speaking English or
Chichewa. His English is very good though and I adapted over the day. First we
went to a sort of grand round where people from each department went to a talk.
It was on diabetes. It was really informative and in the discussion afterwards
there were some jokes and we had a good time. Dr. France mentioned that gastric
bypass is being used in northern Europe as a common intervention for Type 2
diabetes, even in children. Someone challenged that Malawi doesn’t have a large
problem with type 2, to which Dr. France said “I’ve seen your parliament on TV,
there is a problem.” WOW. Burned. That one got huge laughs too. It’s sort of
true though, the government is pretty wealthy here while Zomba Central can’t
afford anesthesia for all the surgical cases they do and there’s no emergency
room. Domasi Rural is even worse, that’s where Ashely and Penny went today (see
Ashley’s blog in the sidebar!)
Then it was time for rounds. Wilson is in charge of the mens
ward so we went there. Actually first we grabbed another guy and went to every
ward, but didn’t seen any patients. I was really confused because I didn’t know
who the guy was, they were speaking either Chichewa or English I couldn’t tell
at all, I wasn’t sure if I was supposed to listen, and I had no idea why were
were just walking around. It was good to get better bearings of the hospital
though and I eventually realized the other guy was an actual medical student and
Wilson was giving him a tour. We dropped him off in the ICU and then my lessons
began.
We went to the men’s ward. For hippa purposes (though I wasn’t
asked to sign anything, that is a big difference between clinical shadowing in
the states and here) I won’t say any specific cases, but here is some of what I
saw:
-
A LOT of orthopaedic cases. Wilson isn’t ortho
so we didn’t go past looking at their chart, but I was confused as to why there
were so many.
-
Lots of hernias and complications from hernias
-
Very very serious infections. Blisters eaten at
by staph so that I saw every layer of tissue down to the bone the length of the
entire shin. Abscesses the size of oranges. Enormous masses on scrotums. These
masses have to be biopsied to be understand what they are and how they should
be removed, but there is no analysis equipment for that at ZCH so it has to be
sent to Blantyre, and the patient has to have MK 10,000 to do that. That’s
about $14 USD. Many patients can’t afford it.
-
Open dressing often used to let wounds dry and
because dressings can’t be changed frequently enough to prevent further
infection
-
Patients carried their own IV bags and catheters
-
Everything is on paper so charts are pieces of
paper tied together using strips of fabric. They use folders in pediatrics. A
couple cases, Wilson knew a patient had undergone surgery but the notes for the
surgery were missing from the chart- communication is a challenge
-
There isn’t a formal way of identifying
patients, so for example, Dr. France came in trying to find a patient we talked
about that morning and Wilson pointed to someone and said “is it this guy?” and
Dr. France said “no he was on the floor somewhere” and walked off to look for
him.
-
There are mattresses on the beds but also on the
floors between beds, and sometimes multiple patients sit on one bed
It was crowded and confusing. Wilson was fantastic though,
speaking Chichewa to patients and nurses and English to me and the doctors
(Malawian or otherwise), telling me everything he was reading in the chart and
deciding as treatment. He is a wonderful teacher and doctor.
After the men’s ward we went to do some administrate things
like print and distribute the on surgical on call list for June. He joked in
the men’s ward that sometimes they hide the list so no one can bother them.
When he couldn’t find a stapler to add it to the bulletin board, he grabbed an
IV needle to stick it in the board and happily told me “improvisation!”
When I asked him how he felt about working at ZCH, he said “It
can be frustrating because we often have to improvise our care, and that can
mean that we don’t know if it will go the way we want. But it is good to do
something for Malawi and give back.” He has a wonderful heart.
We also made the list of surgical cases for tomorrow (surgery
is Monday Wednesday and Friday) but as Wilson was making it he saw that there were
no requests for pediatrics meaning no one did the round there. So we went to
check it out. Dr. France was working to help get it done too. The patients we
saw were mostly hydrocephaly, their heads were about twice normal size and we
checked the CSF for blood, which they all had. They can’t put in a shunt until
the CSF is clear so they just continue antibiotics until it clears. Wilson says
pediatrics are very challenging.
We brought the completed list to surgery and Wilson said
that is the toughest part because surgery often doesn’t like the list- they
only have a really appropriate amount of anesthesia for 4 full length cases
each surgical day and Wilson had scheduled 8. He said they can work quickly on
some small things like closures so they make it work but it is stressful. After
that he just led me back to the surgical clinic/ER. I asked about he ER and he
spoke fairly passionately about how the ER is bad because they aren’t really
prepared for anyone, particularly emergencies. It is also a separate building
from the outdoor hallway system of the hospital, so transport to other wards is
difficult. He did say that a German physician has taken notice though and wants
to help build an equipped ER, which will be great. I went home around noon because
after rounds there isn’t much to do and surgical days go very long. Once home I smelled like the hospital so I took a shower and a looooong nap.
The courtyard at the front of the hospital, with the outdoor hallway style in the back.
My personal thoughts:
-
I am feeling very torn. It is a little tough
seeing the Teaching and Learning girls preparing for each day so excited to see
all the kids (Malawi kids are so fun) and play games with them. I don’t look
forward to work here each day quite that much. I think this work is important but
I have some feelings of guilt that I feel nervous in my stomach each time we
are heading to the hospital. It is just not an easy place to be.
-
Today Mr. Kamanga asked me if I am falling in
love with Malawi and if I will return her to be a physician. Before I came to
Malawi that was the plan I was contemplating, that’s what I came here to find
out. But now that I am here, that feels like someone approaching me while I’m on
a first date with someone and asking “Are you going to marry this man and have
his children?” Look, Malawi, I really like you and you’re quite beautiful and I’m
having fun but I really just want to take this slow.
Those aren’t to say I’m not happy and still awed at least 7
times a day. I am unspeakably grateful to be here. Wish me luck in surgery
tomorrow!
With love and lists,
Lauren
I am grateful for…
1. Dr. France 2. Texts from mom 3. Ashley and her loving friendship
What will I do to make today great?
1. Listen well in the hospital 2. Have self-confidence so I don't seem completely useless 3. Pray for patients. and patience
Daily affirmations. I am...
Compassionate
3 Amazing things that happened today...
1. Seeing terrible wounds in the men's ward 2. Learning from Wilson all day 3. Processing and decompressing with Ashley in the evening over some chocolate
How could I have made today even better?
Been more productive after the hospital
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