We had more chance to work in A&E this week. It is one of the places where the IV drip monitor would be the most useful—other than the inpatient pediatric wards like pediatric special care. A&E, not by its own intention, serves as the triage of the pediatrics department. Queen Elizabeth is no doubt a huge, sprawling hospital. Potential patients seem to find A&E first and the doctors and nurses try to sort them, whether it is admitting them into the general wards or referring them to the different departments—oncology, dental, ophthalmology—with directions as to how to get there. It is a system not unlike the emergency rooms in the US except that Malawi has a public healthcare system so every doctor and nurse is paid by the government. What I was surprised to learn was that every service and medication provided by this hospital—in fact by all government hospitals—is free of charge. The only part that the patient needs to pay for is the transportation. It is one problem but it is a big one considering how most of Malawi is composed of extremely scattered rural villages with no paved roads leading anywhere. An interesting situation actually occurs from this: Queen Elizabeth is established as the country’s biggest referral hospital, but it receives a constant flux of non-referrals. In A&E, nurses are constantly telling groups at time to go to their district hospitals first before coming to Queen. From the nurse, anyone who can afford the transportation to get to Queen come and skip the visit to the district hospital. When asked why families would choose to do so, nurses feel that it is the level of service and amount of resources available here. In district hospitals, medication and resources are constantly out of stock. Families are much more assured and certain of the care at Queen, which is something I can believe. Going to the daily department meetings, the doctors and medical students I meet are of a different quality and upbringing than what I seen at Namitete; Queen also receives a lot of government attention in addition to many donations from Europe that I have seen.

However, this does not mean that Queen does not face a constant shortage of supplies. Nurses have to constantly improvise in face of shortages. When nasal prongs are used up, nurses improvise with nasogastric tubes connected to oxygen concentrators. Moreover, when doing research as to how to improve the IV drip monitor, I learned that although the hospital’s standard IV giving set is 15-, 20-, and 60-drops per ml; nurses have to use whatever is on hand. I tried to get a sample of an IV set for each option, but currently all they have are 60 drops/ml sets. In A&E, to make sure children are given the correct amount of fluid, liquids are measured in burettes and then given to the child. Not surprisingly they have currently run out of the burettes, so all the kids are hooked up to adult IV bags. The nurses were really excited about a way to automatically monitor IV fluids even though my model is no longer working from the various revisions and tests I did in-country. Queen Elizabeth is a hospital that is trying to perform to the standard of a hospital in the developed world. However, it truly lacks the resources to do so even though the nurses and doctors I meet are just as passionate and dedicated. It is definitely motivation for me to continue perfecting the technologies I have been working to help deserving hospitals like Queen Elizabeth.

Having trained the nurses and set criteria for candidate babies, we were ready to start CPAP in the neonatal special care ward this week. We eagerly set up the machine on Monday at the position where the old machine was located. The tubing wasn’t long enough to reach the resuscitation unit where the baby would be, so we had to use tubing from the backup CPAP. The pressure system—for the water bottle to bubble only when the prongs are occluded—is delicate. With the extra tubing, we had to adjust the pressure hole (i.e. tape over the hole and enlarge a new hole until the ideal result is obtained). The next model which is slated to have a knob-adjustable hole that would definitely be more convenient, as tubing needs to be added or subtracted depending on the setting.

Unfortunately, over this week, we did not have a good candidate for CPAP. There was a wave of babies with severe asphyxia that we must exclude because they had not developed enough to know how to breathe. CPAP is not a ventilator; it can only help babies breathe easier and with less effort, not teach them. Since the inclusion criteria consider babies over 1200g, low-birth weight babies are excluded as well because they simply don’t have a good statistical survival rate regardless of the intervention. We had one potential candidate of a baby of 30-week gestation age and six-days old, weighing around 1200g. He showed a chest recession and had a 88-91% oxygen saturation. The test for CPAP was whether his oxygen saturation stat would improve if he was put on an oxygen concentrator. He did, which was great. However, his situation reveals the difficulty of testing the CPAP device. Babies with a decent weight usually mean that they are developed enough and are resilient enough to live without too much help; these babies would mostly likely improve on oxygen concentrators. From our previous mini-mortality study though, babies between 1200-1500g still have a mortality percentage around 50%. We are hopeful that CPAP can make a substantial dent to this number.

Meanwhile, I have been trying to fix the bilirubin phototherapy units that unfortunately, all have some sort of problem preventing use. The neonatal care ward, where they are mostly been used, is currently using newly donated phototherapy units like the ones seen in US hospitals. However, the doctors and nurses I have talked to admit that it is troublesome to obtain the right irradiance from the advanced phototherapy machines. We have built a simple irradiance meter that works by measuring the current produced from a solar cell powered by the light of interest and correlates the current to an irradiance measurement. Nurses are sometimes just too busy to constantly adjust the height of the phototherapy stands as the units are moved amongst the incubators. They would actually prefer to use the phototherapy units I built because they can be placed on top of the acrylic cover of the incubators (hot cots). Since the incubators are uniform, the irradiance of the phototherapy units does not need to be constantly adjusted. If they do, a simple knob can adjust the level of brightness from each LED.

I mainly face two problems from the phototherapy units. For the first generation I built in my freshman year, the socket for the adapter is pushed in because it did not fit the adapter head completely. So, nurses or medical student nurses would try to jam it in, loosening the glue and damaging the soldered wire in the electric box. Luckily, Liz and I have found a wonderful department called Physical Assets that is solely responsible for all the equipment in the hospital. The department is a giant warehouse of broken machines and scattered parts that are either in storage or in the process of being fixed. I found loose parts I needed and more importantly, a soldering iron that I could borrow.

For the second generation I build last year, all of the units work and all the soldered wire connections are holding well because of the improved circuit board design. However, because the power box and the LED strips are in one unit for ease of use ( a change from the older version), the heat produced by the power components after continual days of use has melted the glue holding some of the parts together—such as the sticker strips from protoboards where the LEDs are connected to. Fortunately, plastic c-shaped couplings found in the flea market can go around the protoboards and be nailed onto the wooden floor of the device, securing the protoboards. Overall, I was glad to find the units in good condition; I am relieved and happy to know that I did not had to do anything major to fix the units.

[July 13, 2010]

Translating all of the lesson plans has proven to be a long and cumbersome process. As my fingers trip over “ndi-” prefixes and Word Auto Spell-Check continues to change “zonse” to “zones,” I’m finding out how challenging a seemingly simple task can be. Nevertheless, Angela and I have gone a long way with the lessons, managing to translate every written word, including phrases like “Lesson” and “Learning Objective,” into Chichewa so that the entire teaching material can be in the Malawian language – with minimal error!

If only the translation process could have taught me more Chichewa…

My struggle with the complex and mysterious language has unfortunately expanded to our training sessions. Speaking of which, I am proud to announce that Angela, Jasper, and I have finished all four meetings of the first part of our microenterprise training program! In the past two days, we held four separate sessions for the 43 different Support Groups and VACs that we had aimed to teach from the Kalolo and Mavwere districts (the districts in the catchment area of St. Gabriel’s). We invited three leaders from each group – the Chairperson, Secretary, and Treasurer – to come to the trainings, and had approximately 75% successful attendance. *Note: We were able to contact the groups through the SMS Frontline system that Josh Nesbit (another Nesbit family member!) implemented at St. Gabriel’s for communication with its widespread base of community healthcare workers. You should Google SMS Frontline for more info about this incredible technology!

Witnessing the trainings was an amazing feeling, despite my struggles with comprehending Chichewa. It was difficult to tell, as an outsider, how the Support Group and VAC members were receiving the information. All throughout the trainings, I kept trying to read their nonverbal behaviors and assess the intake of information by seeing who was responding to questions, how long their response was, what their response was (if it was repeating the example story, etc.), and even (as much as I could) trying to read their attitudes. Only by discussing with Angela after each session did I find out that some students were very interested in the concepts and were indeed introduced to new ways of thinking about business principles. Others, though, seemed to be familiar with the material but have had trouble implementing the knowledge.

As I mentioned, the Malawian learning style seemed to work best through repetition. When talking to Angela, she explained to me how she tried to describe the concept in different ways and stress repetition of the example stories. Yes, repetition.

Of course, the flow of the discussions varied according to group dynamics. In the first session, we had hoped for more participation – but whether it was because of shy members or just the uncertainty of the first run-through, few students seemed to come forth with answers. A later session showed marked improvement, and we considered it a result of different leaders in the group that offered their opinions when they saw there was a shortage.

Regardless, the first part of our program was really insightful into Malawian education. We will certainly be using our experiences in these past two days to adapt the second portion of our program to be held in two weeks.

[July 9, 2010]

With Barefoot MBA under our belts, we can still incorporate some of our original lesson plans. Specifically, we’ll be teaching the process of drafting an Action Plan, creating a Budget, and the skills of Accounting. We have decided that this is still critical knowledge that the students can benefit from.

Combining Malawi-inspired Barefoot lessons on business principles and our lessons on microenterprise implementation, we’re set to teach.

Well, almost. Now comes the challenge of translating all of the course materials into Chichewa (the Malawian language). As Jasper and I discovered from a special American Independence Day gathering at the US Ambassador’s Residence in Malawi, there are many other people trying to tackle the same project of teaching microenterprise skills to Support Group members. We want these materials to have widespread accessibility, especially since we know that they can be useful to so many other people here in Malawi.

But even more than accessibility is sustainability. We will be leaving microenterprise training in the hands of the HIV Support Groups’ and VACs’ facilitator Angela, so we want her to take ownership of the program from the get-go. Luckily, the concept of individualized and varied Barefoot lessons allows her to do just that – pick and choose the business principles that she would like to teach and when. However, the issue of sustainability will also involve finding a way to measure the students’ progress with their businesses. As a result, I think a monthly “progress report” required from every Support Group and Village AIDS Committee would be incredibly useful. We cannot just evaluate based on understanding of the importance of Saving or imitation of a Cash Flow Ledger. We need to make sure the students are using these skills and achieving measurable results! With Angela’s role as a facilitator who spends her weeks visiting the groups out in the field, adopting such a reporting system would be easy to implement.

So that is our plan for this ever-adapting microenterprise program. Time to do some transcribing!

[July 6, 2010]

There really is no better way to learn than to experience. I cannot stress how much visiting the field, interacting with the HIV Support Groups and Community Healthcare Workers, and conversing with Malawians and those familiar with Malawian customs has opened my eyes to the application of our microenterprise training project. While I have needed the time to gain perspective, see the big picture and also investigate the finer details, I’ve actually discovered so much more to the process of learning.

Take Malawian learning style. By fate and good fortune, we had the opportunity to discuss our project (just in the nick of time, too!) with Casey Nesbit, mother of our friend and previous BTB student intern Elizabeth Nesbit. Casey shared with us her own experiences training nurses at St. Gabriel’s on the basics of physical therapy. Last summer, she held 25 1-hour sessions, in which each session covered one basic concept of physical therapy. She showed us her teaching materials and even a video clip of her training session, in which Casey would introduce new material with great repetition and then require her students to repeat and imitate the task. Casey found it effective to show both the correct and incorrect methods, using contrast to reinforce the concepts of what was proper physical therapy. Moreover, what Casey shared was that Malawians are very didactic learners. They are accustomed to lecture-style learning where the teacher presents new material and they repeat the concept verbatim.

This discovery initially posed a conundrum. We had left Houston with a comprehensive educational course based on a discussion framework. There was little straight-lecture, but rather the objective to create ideas through the formation of trust groups and discussion-based learning. Now, here we are, with real students who are used to a formal learning style. Will we be able to reach them through that same discussion framework? Can we still impart new concepts simply through discussion of shared experiences?

Out of fear that our original program would not achieve the desired effectiveness – and perhaps that our students would not be as forthcoming with their opinions, we have decided to incorporate more formal instruction into our lesson plans. Thinking back on the entire design process from the spring, we traced our steps back to a suggestion made by BTB staff and mentor Grace Wichmann, who recommended we look at a resource called Barefoot MBA. Barefoot MBA has established lesson plans for a variety of business topics, divided into modules of People, Businesses, and Markets. Each lesson plan follows the same structure: concept, background story, a comparison of two stories (in which one is “right” business behavior and one is “wrong” business behavior), guided questions, and finally the overarching lesson. According to Casey, the questions are even ordered according to a sequence appropriate to teaching – going from understanding information to application of knowledge. We have found that the beauty of Barefoot is that the concepts are so fundamental to business; they can be applied anywhere with just a few tweaks of the example stories such that the lessons can be culturally and economically relevant to different countries.

It’s definitely hard to backtrack on all of the hard work that went into our original course. However, being here in Malawi where our students are no longer just an idealized demography, Jasper and I are thinking that there is tremendous wisdom in the Barefoot lessons. Even so, we know that we can stay true to our initial discussion framework, since the simple concept of bringing together these Support Group members and Community Healthcare Workers can inspire trust-building and group motivation.

One of places recommended by Dr.Rylance for the Venulite transilluminators was the emergency (called the A&E) ward of pediatrics. Much of the sorting of patients is done there and thus cannulas are also started in the ward, which would make devicess useful. Liz and I decided to briefly visit the place to talk someone in charge who can then decide how to introduce the device to the staff at the ward.
A&E looked much better than the rest of the hospital with high ceiling, clean white walls and tile floors (we later learned that this building was opened around 2001). The construction was well-designed, which used clear plastic sheets in addition to the regular tin sheets to allow sunlight to filter in for a bright natural lighting. Moreover, specialty rooms were organized in a roundabout fashion that eliminated confusing hallways. We found the head nurse-in-charge, Mr.Tsamba, and demonstrated the device. He does see the potential use for the technology because they not only deal with small children where the veins are hard to find but also obese children. He already knows where to place the device for the most efficient use, but he wants to set a time when we can properly introduce the technology to the entire ward staff. Consequently, we will be demonstrating the device on the Monday meeting to the assistant nurses, clinical officers and consultants (doctors). Moreover, we will also be working in the ward on Monday and Wednesday, days Mr.Tsamba predicts would be most busiest for the ward and when device would have the maximum use.

Luckily, as the time was a slow Friday afternoon, Mr.Tsamba had time to give us a brief tour of the emergency ward. As the rooms are organized in a circle, the center region serves as the triage that is filled with rows of benches. Patients wait on the seats to see the two nurses at the head of the line to be weighed and assessed for the different services needed. This system is something we have also seen on our tour of the Kamuzu Central Hospital in Lilongwe; however, in the latter, the benches were color-coded to prioritize patients. In fact, the mortality rate at Kamuzu emergency ward almost halved because of the coloring system. Queen’s does not seem to use it; nurses see the patient based on a first-come-first-serve basis. Low risk cases are referred to one of three consultation room where consultants are situated. Patients to be admitted usually first stop by “room four” or admission room where IVs or cannulas are started. Emergency or life-threatening cases are directed to the resuscitation room equipped with a vital sign monitor, crash cart, oxygen concentrators and a ECG monitor. However, I was surprised that there was no defibrillator anywhere. A very basic theatre room—with x-ray screen, lamps and a bed—is right next to resuscitation; mostly orthopedic surgeries are performed in the theatre.

A&E has its own pharmacy where patients can obtain common painkillers and drugs for TB or malaria. There is also a lab equipped to perform full blood chemistries and technicians to read malaria slides for the ward itself. I didn’t see a TB isolation room, but cholera and diarrhea are two serious problems that each has its own separate room: a cholera isolation room and a ORS room for severe diarrhea. There is even a walkway connecting the main building to the short stay beds where patients are temporarily housed before they are moved to the wards. Malaria patients waiting for their second dose of quinine (four hours after the first dose) also wait on the beds and are monitored for any adverse reactions. It is interesting that there is another procedure room next to the beds where consultants work on special cases. It is a room equipped with a bed, lamps and x-ray screen, but Mr.Tsamba says that ever since he has been here, only rape cases are referred to the room. Girls who are raped must first report to the police to receive a special note of permission before they can seek help from a hospital. It is a process different from the United States and I wonder if the requirement that the victim must see the police first may be a reason why girls often report the cases days after the rape. It is very often, from Mr.Tsamba, that raped girls go to the hospital three to four days after the incidence.

The ward seemed organized and I am impressed that there is a separate pharmacy and lab solely for this department. However, we did visit very late on a Friday afternoon when things were winding down and incoming patients have slowed to a trickle. It would be interesting to work here in the coming week at its busiest time to not only test out the transilluminators but also observe how well this ward function to meet demand.

Bubbles CPAP is one of the exciting new technologies Dr.Oden and Dr.Machen left with us. Compared to the expensive respiratory devices in the US, bubbles CPAP is a proven cost-effective support for respiratory distress in neonatal intensive care units, especially in developing countries where ventilators are unaffordable. The neonatal special care ward at Queen’s has a CPAP machine composed of a compressor, oxygen concentrator, a fan to keep the compressor from overheating and tangle of tubing. Seeing the CPAP device demonstrated by Dr.Machen, which costs about $150 and is the size of a shoe box, Dr.Rylance and Dr.Molyneux were eager to try out the technology immediately.

However, we have to first figure out which babies would benefit the most from the technology. At this point, it was interesting for me to learn that the success of an implementation does not only depend on the technology itself but also on the initial patient cases. If the first few babies die after being on CPAP, the nurses and families may associate the technology with eventual death. The nurses would be become reluctant to use it even though the deaths may simply be that the babies are too premature. Thus, the first few babies on CPAP must be picked carefully to be babies who can both benefit from the technology and be most likely to survive. Quite a lot of sickly babies come through the neonatal ward; almost every case is related to prematurity which can be caused by malnutrition, HIV/AIDS and infections. We have seen babies weighing around 600 g; however, babies less than 1kg may simply be too difficult for the CPAP to make a difference because the lungs are not developed enough. Liz and I actually collected the mortality data for the ward from January to June of this year for the babies under the weight of 1500g and studied it according to band widths of 100g. It was startling to find that babies under 1 kg had a mortality of 100%. Only starting with the band from 1000-1100g does the mortality percentage start to drop around 50% and lower. Dr.Sarah Rylance was keen to set the initial criteria at weights above 1200g as the survival rate on average hovers around 50%, a percentage which the CPAP may make a big difference.
Training the nurses is the next big step to implementation. There are currently about seven working in Chitinkha (name of the neonatal special care ward) but only three nurses work at any one time. It would be difficult to introduce the device to everyone in one meeting because half works the day shift while the other, the night shift. We were advised to talk to the nurses in groups, checking off the nurses from our list as we go through the week. All of them are experienced with the CPAP machine in the ward, as they have been trained by a Dutch doctor who first introduced the device. However, the current machine is not being used because it is not working properly or in the nurses’ words “making too much noise” and no one knows how to fix it. They were an attentive bunch at our presentations. Some took notes; they were happy to play with the device, connecting the tubes and such. From our interviews, I do not get the feeling that the nurses have any reservation about CPAP or the technology, but everything would be at the discretion of the doctor in charge. Previously, babies on CPAP were put on and off at a doctor’s orders and the nurses have never instigated CPAP based on their own judgment. However, they feel comfortable about CPAP and its benefits, but when asked about how families react to the technology, we received quite interesting responses. One, it seems that the mothers do not trust the device. Some become suspicious when they see that their children have a nasal prong for the CPAP/oxygen and a gastro tube for feeding; they wonder how the baby would breathe. Getting the mother more involved may help belay their fears, which this device has incorporated. The mother can watch over her child to monitor that the water bottle is bubbling. If there is no bubbles, she can alert a nurse or someone in charge that something is wrong and the baby isn’t getting extra help to breathe.

Currently, we have set up the device in the CPAP corner of the ward. All the nurses have been trained on the device and we have a picture protocol of how to use the device on file in the “technology protocol book” and on the wall. We are hopeful that candidate babies will be on CPAP starting next week. There was already a potential baby this week. He was a 1300g neonate three days old who was starting to show chest recession. When we check his oxygen saturation rate, he was at the 86-88 range. The consensus was to put him on the oxygen concentrator and if his saturation doesn’t improve, then he would be put on CPAP. He is currently doing fine on the concentrator, but this may be the procedure we will be using.