Day 19 Prision clinic and Crisis Nursery

Day 19 was spent at the Maula Prision in Lilongwe. There are 60 women housed in the prison and approximately 2,300 men. This is a minimum security prison, so many of the prisoners are in for fighting, theft, and even wondering the streets at night. The justice system in Malawi isn't the best so many people spend several years incarcerated for false allegations. Some of their paperwork may be lost during their time and they may never even know why the person was incarcerated in the first place. The women's quarters are much better than the men's as the population is much less. The women can keep one child up to 5 years of age in prison with them. We saw approximately 10 babies during our clinic all very well appearing. The men sleep several hundred to a cell, which means they are basically all spooning on the floor together each night. Skin diseases are rampant among the prisoners, scabies being the worst. Those affected by HIV have a hard time keeping up with their ARTs as the clinic frequently runs out of their medications. This inmates don't last very long. Death due to disease is very common in prison. Unfortunately no pictures in the prison!

Our team at Maula Prision, Charles who was a previous inmate, now runs a ministry in the prsion. Our translators
are students at the African Bible Clinic. And Laci and Selina were are pharmacists. We had one guard!

Our afternoon was spent at the Crisis Nursery in Lilongwe. This nursery houses and feeds children from the ages of birth to two years old. All of their mothers have passed away either due to HIV/AIDS or due to complications in labor. You can visit the babies every day from 2-4pm. The have 12 babies at this time. Some of the children will go back to the extended families once they are able to eat table food at 2 years old, and some are adoptable.


One of the Aunties preparing porridge for the children.



One of the babies with hydrocehpalus



Laci with twins and another baby.

I may steal this one!



Day 14-16 Pothawira Clinic



Peter and Emma Maseko the lovely
family I stayed with who run the Pothawira
orphanage and clinic

Days 14-16 were spent working in the Pothawira clinic in Salima, Malawi. Several hundred people would come per day some traveling great distances to receive medical attention. The district hospital in Salima is frequently out of medications and many patients look to outside private clinics to get help.









My clinic room




My consultation room



Henry the clinical officer helping me
with translation and standard
Malawian treatment regimens



an infected leg wound on a young
girl



One of my not so happy patients in the clinic
 




A young patient with chicken pox



Snake bite one week old, pretty sure that's
a tendon hanging out of the larger wound!



Peter and some of the locals in the clinic
who have donated rice to the ophans





Impetigo, incredibly common among the
village children



Ultrasound machine at the clinic
which unfortunately cannot be used
as it does not have a voltage converter
as it costs 40,000 USD





















JC was brought to the hospital
after his mother died enroute while
delivering the him. This is very common
and is one of many reasons there are
many orphans in Malawi.
His extended family did not have the means
to pay for formula to feed him.





Some of the largest abscesses I have ever seen
this boy was 2 and had a large abscess behind his ear
 







 









Several of the orphans from Pothawira

A trip to Salima District Hospital, proved to be quite dismal. There are several patients crowded together, there are approximately 400 deliveries per month so women cannot stay more than 24 hours post deliver. For C-section deliveries they can stay up to 4 days. The pediatric ward this time of the year is on the brink of becoming overcrowded as the malaria season starts. The pediatric ICU differs from the pediatric ward since it houses an oxygen tank for the children.

Pediatric death statistics



The number of obstetrical deaths per year

 

Causes of maternal deaths

Following the clinic we took a trip to Livingstonia for a trip to beautiful Lake Malawi!





The scene from lake Malawi

Monkeys by the pool

the local brew



The pool at Livingstonia, much needed
its summer here!

Lunch at Livingstonia an oasis in Salima




A young girl sells peanuts at the market

Some locals at the beach!



 

The crocodile farm in Salima. The crocodiles are raised to 5 years old
then sold for 8USD per square on their tail.



A real American Thanksgiving
in Malawi, without power of course!
 



Thanksgiving with Turkey!!

 



 

 



 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day 12 Rural Clinic

Day 12 was spent running a rural clinic in a village south of Lilongwe. It was me, Dr.Ivey, Laci, Charles our driver, Steve the organizer, Lucky a clinical officer, and two translators Jolyn and Clifford. We saw over 200 patients, about half of them children. Many of the complaints were those you would see in your typical ED and outpatient clinic, with a bit of a third world twist. Many children here do not receive all of their vaccinations nor do they receive all of those an American child would have so there are many cases of Mumps and Chicken pox. We came with an arsenal of antibiotics, but many of the patients had complaints of bodyaches and dyspepsia. They use charcoal here to cook their food then run water through the coals to use for other cooking needs. This basically prepares lye and when ingested causes a lot of epigastric discomfort. They are also a hard working community where they are performing physical labor all day, so musculoskeletal complaints are common! Luckily they don't know anything about Norco lol! I tested several patients for malaria with our rapid malaria kits, it is the start of the season and may come up positive. The people here have had malaria several times in their lifetime so the disease is usually a mild course, with a short stint of quinine or LA (not in the US). It was amazing to be able to reach out to so many people who really need chronic care but do not have the means to get out of the village for care. You will not find any diabetics or CHF, or uncontrolled HTN patients here, as they do not survive!! These people are amazingly resilient!



Women lined up to be seen in clinic
 



One of the several hard working women
I saw in the clinic



Mumps!

The bathroom!

Day 7-10 First Four Days Daeyang Luke Hospital

First Day at the Hospital




Dr. Best and Dr. Ivey ready to
work!

 

Entrance to the Daeyang Luke Hospital
sadly it may be nicer than our county
Hospital!

The hospital starts the day at 0700 wit the morning devotional. There is singing and prayers. Prayers even to the shipping company who supports the hospital! We met Dr.Kim the director of the hospital to get our start. We started our day working in casualty. This is their version of an Emergency Room. There is a difference in that every patient needs to be seen at the outpatient department before being sent to casualty unless you are in distress.








The waiting room!

Tour of the Casualty Department (the Malawian ED)



The 6 bed Casualty Department



IV and mediation cart




Nebulizer! Need to intubate
a patient? Only vent in the OR!




Suction! If you are looking for
the EKG machine, check the OR!



Medications in the cart, one diazepam
left!

Crash cart in casualty, of note:
no monitor or AED or pacer pads,
the 1 Ambu bag is located in a closet
near by!

 

 

The wonderful staff and physicians!



Dr. Ivey and Dennis, one of the clinical officers

Me and nurse Ellen





The nursing station



Dr. Shin and I review a chart

One thing to note is that the hospital is a private hospital in Lilongwe, the patients have to pay for all services prior to being treated, in most cases. In order to be seen by the medical student or clinical officer in the outpatient department you must pay 100 MK ($0.25) then if the clinician orders any imaging, lab tests or treatment (IVF or medications). The labs cost about 800 MK for a CBC and a Malaria test (roughly $2.00). A vial of gentamicin for STI treatment will set you back also approximately 400 MK ($1.00). An ultrasound of the abdomen is one of the bigger expenses at the hospital at 3,500 MK ($8.00) and a hernia repair is 30,000 MK ($75.00) The patients must take themselves to the pharmacy, pheblotomy area, or for imaging. You better have brought a guardian with you to take you to all these places and collect your lab and imaging results.


Dr.Shin and Owen one of the clinical
officers.



To give you some perspective the average Malawian earns approximately $900.00 per year. Most individuals live in village huts, with no electricity or running water. There grow much of their own food. There is one interesting staple of note, Nsima, a corn based dish. Just imagine a giant lump of cornmeal and eating a giant bowl full every meal. There is no question as to just what causes chronic abdominal pain and constipation in a large portion of the population.



The list of medications available
in Casualty, some are missing, but
not that many!

Interesting facts about how health care works here.

1. The Malawian Health Passport. Carried by every patient. Contains all of their health information. Pros: patient carrying medical record, can be taken to different clinics and hospitals with no problem.
Cons: patient is in charge of this record, if it is lost, so is all of their information. Information is not secure. When one book fills up they may not carry all of books and information is lost. The book is made of paper, not that great when you live in a village hut that is not fully guarded against the elements. Last in a hurry you may forget the book!



The Malawian Health Passport!

2. The medical team-
Physicians- at Daeyang Luke there are 4 full time MDs. MDs in Malawi you go to medical school after secondary school (high school) for six years. After which you are capable of doing any specialty.
Clinical Officers- three years of training after which they are capable of working as any specialist in the hospital and opening up a clinic. With a bit of additional training you can be a nurse anesthetist.
Medical students- they have a similar system to the US in that they have 2 years of basic sciences and 4 years of clinical rotations.
Midwives- deliver all babies unless there is a complication.
Nurses
Nurse Techs

3. There is a public hospital which is free! This hospital is overcrowded and frequently runs out of medications. They cannot do surgery at times because they have no drugs for anesthesia. They also run out of sutures, gauze, ect.....

4. The hospital does have advanced imaging. They have 2 ultrasound machines, an x-ray machine, and one CT scanner. The ultrasound tech is self taught. Any clinician who orders an x-ray must be able to read it themselves. The CT images are sent to Korea to be read and you can expect the result back in approximately 2 days.


They asked me to help read a CT scan since all images
are sent to Korea for results. Luckily nothing acute, but she did
have some calcifications from a prior old infection.

4. As mentioned previously there are no medical records kept here! I am unsure how the country adequately measures morbidity and mortality from certain diseases accurately. There are no autopsies. There are in desperate need of almost every specialist. Once they get an intensivist they can open their ICU. With the arrival of Dr.Shin from the US he has now started doing pre-op EKGs and CXRs. The only tricky part is that the patient must go to the OR to get the EKG. There is one monitor in the ED! You get vitals when you walk in and that's about it!


Clinical Protocols Posted throughout the Casualty Department. Of note, no internet, no computers, no looking anything up!





NO arguing with hospitalists here!

Best sign ever!
 

Hospital Protocols posted on the
bulletin board in Casualty

In Casualty at Daeyang they do not see much trauma, mostly the acutely ill brought in the side door by a family member or those that need to be admitted from the outpatient department. The first three days were a bit slow. There were a few interesting patients, one an  HIV+12 yo M on ART, prior Hx of TB infection, was tachycardic, and appeared very cachectic with a protuberant abdomen that was confirmed to be ascites on bedside sono. The pt was negative for HepB, he was pancytopenic, he was negative for malaria, and had a negative ascitic fluid tap. The ascitic fluid was sent for culture, but unfortunately this is a send out lab, which the parents would have to go and trace down the results. This is also the same for a viral load and CD4 count. The patient is presumed to have TB peritonitis vs. schisto vs. Hepatitis (Hep B-, cannot test for C/A) vs. complications of  AIDS. This boy has spent the last few days on the ward without TB treatment, the parents did bring his home ART medication. He continues to have persistent vomiting, diarrhea, and decreased appetite. We are concerned he may die soon.





The portable US looking for ascites in a 12yo HIV+
Boy with Hx of TB, weight loss, fever, diarrhea,
protuberant abdomen with enlarged liver.















The laboratory at Daeyang Luke Hospital



Working to stain Malaria and TB slides

 

The lab! Learning how to look for
malaria under the microscope!



Woman brought in from a village
clinic by truck

There is no EMS system in place in Malawi. But their are ambulances. You can frequently find them toting around hospital employees of friends to the bank and store. I have yet to find the phone number to call to have an ambulance come. If you need a ride from an outside clinic you will need to get a friend to take you! 

Local truck serving as an ambulance
for a village woman.

The playground at Daeyang Luke that serves as a place to dry your laundry as well.

Playground at the Hospital which also
doubles as laundry drying area.

 One of your patients in casualty with a burn on his arm from a porridge spill. The wound was debridement under some sedation with pethidine. Never used pethidine, but works just like a touch of propofol! 
 

Debridement of wound! Thank god for
pethidine, no childlife needed!

18 mo M with burn on right arm from
hot porridge.

One last patient a 60yo M tribal leader with a recent stroke and residual left sided weakness, now with back pain and urinary incontinence and a "lump in his back". The patient had polycythemia, leukopenia, and thrombocytopenia. His renal sono showed no mass. He had to return to his village to find more money for a CT scan, and unfortunately has not returned back to the department. We suspect a cancer in the abdomen or pelvis, but we may never know!!!


More interesting cases to share next time!!!