July 16, 2010
In this week’s mortality meeting some interesting points came up. A lot of the discussion related to getting lab results. The intern presenting the mortality data said that three blood cultures had been sent but that one sample had been “lost”. Of course, one of the lab technicians took exception to that and explained that as soon as the sample is received from the ward, it is given a number and written down in book. The intern was also asked as he presented his case what the biochemistry results (blood glucose and protein) were for the blood culture ordered. His reply was that they were not done, again which the lab technician said was not possible, unless there had not been enough sample (~ 0.5ml), in which case, it would be noted down again in the lab book. It was probably a case that he had come when the white blood cell etc result were done, but not yet the biochemistry, and he had neglected to check back.
At the end of this presentation, he raised the question if whether or not there could be a lab technician overnight. The doctor who seems to oversee the lab asked him what he thought there wasn’t already a lab technician on call overnight, to which the intern said he had no clue. The answer seemed obvious, that there was a lack of funds available to pay for such a service, which is indeed the case.
After the normal mortality presentation was done, a lady gave a special presentation about proper documentation, especially when data is being collected for a study. She brought with her a few examples of forms that had been submitted that hardly had anything written on them at all. The whole presentation is in preparation for the electronic data record system that is going to be set up throughout Queen Elizabeth’s in the upcoming months. Its particularly important that lab request forms be filled out properly, otherwise the request for blood culture etc will be thrown out.
The overall theme of the whole meeting was one of how lapses in providing complete, accurate and correct documentation prevents good care from being given. One doctor pointed out that many times it is not doctors, or even medical students who are filling out forms, while another responded that even if your nurses fill out forms it is essentially the responsibility of the attending physician to be follow up and make sure forms are being filled out properly. Dr. Sarah Rylance has personally been trying to improve the morality data of Chatinkha ward by typing up all deaths, their causes and the patient information in her own computer. The problem of neat and accurate recording of patient progress and treatment seems to be a problem in all healthcare systems. For example, a study done through Weill Cornell Medical Center compared the error rates of handwritten prescriptions versus eprescriptions which are done through a computer programs which can also check for drug interactions and can supply common doses. The rate of error in handwritten Rx was 42.5 per 100 prescriptions written, while error using eprescription was 6.6 in 100. The electronic system helped alleviate simple numerical errors, poor handwriting and overlooked drug interactions.
Certainly helps reinforce the lessons we have been taught about keeping good lab notebooks and recoding everything we do for our design projects.

July 14, 2010
This week we have been preparing the nursing staff for the introduction of the CPAP, (see Yiwens blogs) and testing devices that the neonatal ward nurses think are broken. We also went into town to purchase a multimeter so that we can repair the old bililights, and try to figure out what is wrong with the oxygen sensor. We asked Dr. Molyneux if she already had one, but she said no, but wouldn’t we please buy one for the hospital, so we did.
We have been using the flow meter on the oxygen sensor to measure the flow out of each flow splitter on the oxygen concentrators in the neonatal ward. Each oxygen concentrator has a total flow meter, with a variable knob so that the flow can be set, up to 5 LPM (liters per minute). The output of the concentrator is then split by a flow splitter. After taking one off, we saw that these are just 4 nozzles that screw into a machined metal block with channels in it for the directing the air to the nozzles and another place to screw into the concentrator. Three of the nozzles are rated for 0.5 LPM and the fourth is rated for 1 LPM. In theory, this is the maximum amount of flow that can pass through the nozzles. The 0.5 LPM is most suitable for very small babies, like most in the high risk neonatal ward where the oxygen is used, and after splitting, provides about 30-35% oxygen, assuming that the oxygen concentrator is working properly and producing a main supply of approx. 93% oxygen. This seems counterintuitive at first that the oxygen concentration after splitting would be different from the main oxygen concentration supply.
The big problem is, however, that using the flow meter on our sensor to test the flow coming out of the 0.5 and 1 LPM nozzles, we get no flow at all on any of the machines. On one I noticed that there seemed to be a hissing noise, as if air was escaping from the splitter. It wasn’t screwed in very well and if I held it up to the screw hole the flow jumped in the 0.5LPM nozzles to 0.25LPM, however the flow in the 1 LPM nozzle was unaffected. This result was not consistent over the other machines. On the others the splitters were screwed in fine, but still no flow of air was sensed. Another problem was that several of the machines seemed incapable of achieving a total flow rate of above 2 LPM. On one Devilibiss model that sits on the ground, as opposed to up on the wall, I opened the back of the oxygen concentrator to see a missing outer filter and a filthy inner filter. The general insides were pretty dusty too. After acquiring a new outer filter and a replacement inner filter and cleaning things up, the flow did increase, but only after fiddling with the flow splitter! So it seems like something about the splitter affects how good the total flow is and what amount of flow comes out of the nozzles.
After this we tested two of the concentrators by sticking the oxygen tubes into a glass of water to see if there are any bubbles. There were, so that means there is flow coming out of them, even though our flow meter doesn’t show any (?!) but in some cases it isn’t very strong. On one machine that is split into 4 1LPM nozzles, not all nozzles produce the same bubbling rate. And if you compare the bubble rate on this machine to the bubble rate of the 1LPM nozzle on the one with 3 0.5LPM nozzles and 1 1LMP nozzle, the rates are different, so something is still amuck, but atleast the air delivery isn’t a placebo as we were initially concerned.

In preparation for the starting the CPAP on a few children in the neonatal intensive care unit run by Dr. Rylance, we have been looking at the admissions and deaths of children to Chatinka (the neonatal ward) by weight. We start recording a birthweight of 500g, (we have only seen one below this) up to 1499g, grouping admissions into 100g bands, ie 500-599g, 600-699g on up to 1499g. We gathered the data from the admission books that the nurses keep, where each patient has an admission number, admission date, a name (usually of the mother), sex, apgar score, weight, notes and an outcome. If the baby dies, it has the date of death, but if the child lives it just says “lived”. In all we looked at data from January to June 2010 and the overall mortality for children below 1500g was 57%. The mortality below 800g, however, is 100%.

When children are born so small (healthy full term size is 3500g) they are often very premature and undeveloped, lacking the basic components needed to survive, even with the support of Chatinka. Another complication is that many women don’t know an approximate conception date, leaving doctors to guess whether that child is full term, developed and very small, possibly due to lack of maternal nutrition, or is small due to prematurity, which can affect how the child is treated.

Considering the challenges of the environment and the resources of Chatinka, which are fairly good from what I can tell, this is decent mortality rate. It is unlikely that these very small babies, even in a Western setting would survive, especially without many complications in later life.

Once you reach a birthweight of 1200g and above the mortality starts to fall below the average, down to 35% in the 1400g band. Dr. Rylance thinks that we should use this as a guide when deciding which children to start CPAP on, starting with children who stand a chance of doing better, but are still premature and need the extra push to start breathing.

The CPAP, continuous positive airway pressure, if designed to force air into the lungs. This is useful for a variety of applications, but in the case of premature babies, they often suffer from surfactant deficient lung disease. Surfactant a fluid that coats the alveoli, helps reduce the surface tension created by the water on the alveoli. The same surface tension that makes water bead up, also wants to force the alveoli to collapse, letting the water be closer together, rather than spread out on the little balloon like alveoli. To breathe you must overcome this “collapsing force” to expand the alveoli. Technically you do this by moving your diaphragm and creating negative pressure in the chest cavity, encouraging outside, higher pressure air to rush into the lungs. Without surfactant though, more effort must be put in to do this and these small babies spend their few calories just in the effort of breathing. Without assistance they lose weight quickly and essentially become too tired to breathe, which is leads to apnea of prematurity and death. CPAP can reduce this weight loss and death by providing the extra push of air to help babies inflate their lungs. Dr. Machen explained it by using the example of blowing up a balloon. When you are first trying to inflate the balloon, it is very hard, but once it expands, adding more air, or taking a bit out and then adding a bit more (like breathing), becomes much easier.

This is the end of our first week at Queen Elizabeth Central Hospital. A typical day begins with a meeting at 8 o’clock for all the pediatric doctors and medical students, and lasts about an hour. Medical students present mortality data in the different wards for the previous week and present interesting cases. You may remember that I mentioned the rabies case. It seems like these meetings serve the dual purpose of updating people like Dr. Molyneux about the goings on of each ward and helping the medical students refine their diagnostic skills and presentation style. For instance, there was one case presented the other day, with a long complicated history, that the medical student thought was related to HIV. But as it turned out in the end, the results from the child’s PCR (a definitive HIV diagnosis) had not yet been received and that if you looked at the symptoms without assuming HIV infection, it looked much more like cerebral palsy.

The first thing we tried to accomplish was to test the oxygen sensing device left here by Dr. Oden and Dr. Richards-Kortum last year when they visited Dr. Molyneux. Our plan was to then test the oxygen concentration output of all the oxygen concentrators in the neonatal ward. Unfortunately, after changing the oxygen sensor, changing the battery and fiddling around with the connections and calibration inside, we got it to work only intermittently and after a walking trip to and from the house back to the hospital, it refused to turn on again. Needless to say, Yiwen and I were disheartened by this set back, but we think we will still use it to atleast determine the flow rate of concentrated air from the concentrators to the individual children. We want to check this for two reasons:

1) the air output of one concentrator is split four ways here to supply as many children as possible

2) the CPAP device, (see next blog post) requires that you set the flow from the oxygen concentrator, so we want to know what sort of supply we can get.

[June 29, 2010]

Today was our second (and final) trip to the field to see the HIV Support Groups. We were able to visit three groups from the middle tier – groups that are relatively stable but not well-organized with their business management practices.

The first was named Mapuyu, and they were, like Geni, the most inspiring for the day. Every Tuesday, the members meet and spend time making HIV pins (beaded patterns attached to safety pins that they sell to other HIV/AIDS patients as a way to unite and raise awareness), practicing songs and drama, and distributing local medicine. When I first heard the term “local medicine,” I wasn’t sure what that meant. The first thought that came to mind was, “Antiretrovirals? Are they being produced locally?” Luckily, I didn’t have to stay confused for long because soon enough, one representative of the support group announced that she wanted to show us their medical supplies in the room behind us. When we entered, what I found was amazing. Spread out neatly on a blanket on the ground was a whole display of 14 types of plant leaves, stems, and flowers. As one woman proceeded to describe each herbal remedy and how it was used, I just kept thinking about the effectiveness. We’ve all heard of alternative medicine and its legends – maybe even its miracles, but what concerned me was the potential reliance of HIV+ patients on these remedies. Is it enough? Will adopting local medicines prevent them from one day seeking ARVs? Regardless of the actual usage, it turned out that Mapuyu Support Group was selling these medicines as a business. Producing these 14 types of herbs was their income-generating activity. And if it was a successful venture, then it would be of benefit. The problem now was sustaining this business. They have limited supplies to produce the medicine and are limited by transportation costs to reach new patients/consumers. They need some business management help.

The second visit was to a village called Mferamanyzi. They were also a “middle-tiered” group, who had recently suffered a setback that probably drove them to unstable, “bottom-tier” waters. 5 pigs and 13 piglets died recently, with unknown reasons, leaving the few active members of the group disheartened. As opposed to other support groups that seemed to have a lively spirit among their members, only three members were present to meet us and the mood was dreary. From asking questions, we found that there was, in general, low participation among members due to laziness. It seemed that the leaders were not motivating their members well enough, and without this foundation of teamwork, the recent piggery devastation only worsened the situation. Hearing this, I felt inspired to incorporate training in leadership in our program, though I’m not sure how much time we will have. It seems like such an important message to relay to these support groups though, that maybe it will need to be an entire underlying theme to our program.

The final visit was to Lonjezo, a village that had recently received government assistance to build an irrigation system for their crops. Unfortunately, they had also experienced a recent setback in the form of ill-growing maize, and had not saved properly to deal with such emergency times. It sounded like this support group could certainly benefit from our Savings lesson, which we had already developed over the spring semester. If anything, this visit provided verification that we were on the right track with our program components.

[June 23, 2010]

Earlier this week marked the first visit to the field – to actually meet members of 3 different support groups and understand their environments. It’s one thing to talk about owning a pig, and another to step foot in a piggery with this gigantic hog digging into the dirt in the corner!

In each of the villages, all of the community members were so kind in their welcoming. They provided us with chairs and benches, sitting around us to catch our every word. (Well, hearing us through Angela, the facilitator of the Support Groups who deserves a tremendous “Thank You” for acting as our translator and interpreter.)

In the first village (named Geni), after an initial conversation where group leaders provided us with some background on their community and answered some questions regarding their current business practices, the group members then led us on a tour through the village. We saw gardens of vegetables, fields of tree saplings, and collections of animals like fowls and pigs that could be sold. We spent the most time that day at this first village, trying to take in everything and ask as many questions as we could. I could sense so much happiness and excitement from our visit. As we walked, a group of women followed us and sang beautiful songs. Children gathered around us, smiling and waving frantically (and also yelling “Mazungu,” which we have gotten a lot). And as we departed with words of our intentions to help with training in business management, they even gave us a round of applause. The community members were so respectful and appreciative, and all I could think about was how honored I was to get to work with them.

The subsequent village visits to groups named Tidziwane and Namitete were a little more condensed, but followed with similar events. We had accidentally spent too long at the first village and were only able to talk a little with the other group members and take a short tour through their gardens and fields. Nevertheless, I felt more confident the second and third times around, as I knew what questions to ask and concerns to address with each meeting.

These three support groups are, according to Angela, the best of them all. They’re the most stable and organized in terms of group management and using their St. Gabriel’s starter packs. However, I noticed that even among the three, there were still very different levels of progress. Two wanted to draft an action plan. One had a budget to show us – though it was hard to follow and did not seem to track expenses consistently.

Next week, we’ll have the opportunity to make another trip to the field and visit support groups from the middle and bottom tiers (groups that are not as stable and possibly have had starter packs revoked from misuse). With the variation across the groups from just today’s visit, I have no idea what to expect. All I can hope for now is that they are operating within the realm of our help – and our potential training lessons wouldn’t be so out of context or inconsistent with their current activities. Until next week!

It was a sad day when we left St.Gabriel’s Hospital this past Wednesday. I will miss walking around the hospital, always having someone to greet and chat with. This was my second time at St.Gabriel’s but I feel that I have gained a new level of intimacy. Showing the hospital to Dr.Machen—the Texas Children’s Hospital emergency room attending who accompanied Dr.Oden—I realized that I knew most of the people who worked in each ward: pediatrics, ante-natal, labor, post-natal, maternity, female, palliative care, ARV clinic, mobile clinic, home-based care and HIV/AIDS support staff. I leave being proud and grateful that I have worked at such an amazing hospital and seen it continuously improve its care services ( I just learned that an emergency wing is under consideration). Sure, St.Gabriel’s is small but it is offering healthcare in innovative and comprehensive ways (social and economic HIV support groups, community health workers, end-of-life care) that Queen Elizabeth Central Hospital is trying to replicate
Our next site is the Queen Elizabeth Central Hospital at Blantyre, the economic center of Malawi. Our focus will specifically be on the pediatrics department under Dr.Molyneux, an inspiring Scottish doctor who is the source behind many of the ideas for the technologies we brought. The hospital is an intimidating place, a winding, sprawling complex of hallways and haphazardly-added buildings. From the outside, it looks like a dilapidated apartment complex with fading white paint, molding roof tiles and facilities for caretakers to cook and wash clothes. However, at least for the pediatrics unit, the hospital offers an extensive range of health services: pediatric oncology, emergency and intensive neonatal units to list a few.
We began our first day at the department daily morning meeting on Friday which is the weekly mortality report (a little over 10% for that week of over 300 admissions). One particular case that caught the doctors’ and mine attention was a child who died from rabies because the family did not recall the child ever had been bitten by a dog. Given the prevalence of stray dogs in Malawi, admissions due to rabies are high but the rabies vaccine is actually very hard to obtain. The rabies vaccine and oxygen are what Dr.Molyneux mentioned to be the two greatest medical shortages in Malawi. Malaria, tuberculosis and HIV/AIDS have caught worldwide attention but it is easy for easily preventable but deadly disease to escape the global radar.
We meet with Dr.Sarah Rylance, an English doctor who had also worked in Tanzania, to start our first day in the neonatal ward where most of our technologies are most applicable. The ward is separated into three sections: an intensive care unit, a low risk room and a kangaroo room. There are on average around 40 deliveries per day compared to St.Gabriel’s five, so Queen Elizabeth sees many sickly babies. When we first walked into the intensive care unit, four to five babies were on each of the three resuscitation units. The nurses tred to group the babies by weight on the resuscitation machines, but we saw cases when a large baby would be placed next to a under 1 kg baby; however the heating of the device would be adjusted to help the smaller baby retain its temperature while the larger baby was sweating profusely. There is no ventilator in the entire hospital, so almost all the babies we saw in the intensive care unit below 1 kg had died by the time we left. It was unnerving to see tiny babies skinny to the bones struggling to breath and know that there is nothing can be done to save them. In this setting, we stumbled upon a particular ethically-conflicting case. A baby with gastroschisis was delivered about a week ago; the surgeon wanted to operate on the baby because in the Netherlands, there is a 19% of survival. However, there was a counter-argument that in a limited-resource setting like Malawi, it would be a waste of resources and torture for the family and the child. The mother came from a very far village and was traveling back and forth to see her child. The big question is: is it ethical to bet on a small chance of success in the best of setting or to do nothing. The mother was to be counseled, but the child died in the morning. I have but seen two deaths in St.Gabriel’s, but the deaths are staggering at Queen Elizabeth. There is an urgent sense of need because any improvement would help. The unit has two pulse oximeters but both are nonfunctional. They use what would be disposable sensors in the UK, but since there is none in Malawi, the sensors are worn and dirty, hence the malfunction. The two syringe pumps were not working; the CPAP was not being used because the only nurse who could operate the machine was on leave. The oxygen concentrators had four or five splitters each, but there was nothing to check the oxygen level being delivered in each split. Needless to say, Elizabeth and I can’t wait to start implementing our technologies and carry new ideas back to the US.
Babies with minor problems such as jaundice are moved to the observational unit. Here are most of the original hot cots that senior design students have improved upon and where the phototherapy lights I build last summer are being used. The unit has a transdermal bilimeter that, with two clicks, can output a bilirubin reading that can help nurses and doctors diagnose jaundice. This is probably the reason why Queen Elizabeth actively treats jaundice while St.Gabriel’s rarely diagnose the condition, as it is very hard to spot on dark-skinned individuals unless the condition is severe. Unfortunately, there is only one extremely expensive bilimeter, which seems to be the story of everything in the hospital.
The kangaroo room is where stable but small babies stay with their mothers under a nurse’s supervision to use the kangaroo method to nurse the babies. When we first became introduced to the ward, the nurse wonderfully described the room as “ love, food and warmth” (and it is very hot in there). Babies stay until they reach at least 1.5 kg with three days of consecutive weight gain. It is definitely a feel-good room because I saw many committed mothers; many, from the charts, have stayed a couple of weeks in the room waiting for the child to get better.
Working at Queen Elizabeth will be a much different experience than at St.Gabriel’s. The neonatal ward at Queen’s, at least, seems to always be in a flurry of activity. Babies are crying, one or two nurses are trying to take care of 40 or more babies, medical students and interns are walking around making rounds with doctors. It is exciting, intimidating and wonderful to become a part of it all. Our list of technologies has kept expanding so it looks to a great month ahead. New technologies include:
1. CPAP: a currently $150 device for babies with respiratory problems that to quote Dr.Machen “remind babies how to breath”
2. Sally spinner: a hand-powered centrifuge that can determine hematocrit within 10% of accuracy
3. Hot cot electronic set
4. Oxygen sensor- measures the oxygen level delivered by oxygen concentrators