Before going to Lilongwe, I had never spent a significant amount of time in a hospital. I have shadowed rounds in the orthopedics at Shriner’s Hospital for Children in Houston, but that is pretty much it. Due to this lack of experience, spending time at Kamuzu Central Hospital in Lilongwe was surprising for a number of reasons.
When I went to Lilongwe, I had no clue what to expect. The other interns were going to small district hospitals, but I was going to a hospital that served the same purpose as Queen’s does, being the main hospital for one of the 3 geographic regions of Malawi. When we arrived, I was surprised to see how large it was. We went on a tour of the hospital lead by one of the technicians in their PAM office. On this tour, we saw many wards, including the general medical ward, the pediatric wards, the labor ward, and the neonatal ward. As we toured the hospital, many details stood out to me, some of which were difficult to see. I was struck by how crowded the hospital was. In some wards, there were people sitting on mattresses on the floor in an open-air hallway. In others, children shared beds as mothers crowded the floor space between the cots. The equipment shortages were apparent as well – in Pediatrics, the nurses would regularly put 5 patients on one oxygen concentrator (which only produces 5 L/min), and that would increase to 10 patients during malaria season. The hospital only had one CT scanner, and it had been broken for a considerable time before being repaired the weekend before we arrived. The medications in stock would constantly be changing, forcing clinicians to frequently change their practice to adapt to available resources.
One of the most difficult things I saw in the hospital was in the labor ward on the first day. We began by looking at the delivery rooms and speaking with nurses. Eventually, we got to the resuscitation area. At first, I only saw the radiant warmer with a pair of twins under it, They were wrapped in colorful chitenjes as they waited to be returned to their mother. However, behind them, I noticed 2 nurses and a doctor working on a neonate. When I asked what they were doing, I learned that they were doing compressions on the newborn. I stopped and stared, in shock at what I was watching. I saw the newborn, but I was not sure if it was alive or dead. Shortly after that, we left the ward. The team was still working. I do not know what happened to this baby. I do not know if it saw the end of its first hour, day, or week. I do not know if it is still alive. Through the rest of the week, I saw many patients in pain, and a couple patients pass, but the newborn has stuck with me. I was not prepared to see that, but I am now more motivated than ever to continue working and producing designs that could help with birth, resuscitation, and survival of newborns and premature infants.
Line of cots in the low-risk section of the neonatal ward at Kamuzu Central Hospital
Later in the week, I was shadowing a prominent physician, Dr. Peter Kazembe, who was doing rounds in the neonatal ward. At one point, he asked a nurse “Why are babies getting cold?” to which the matron of the ward replied “Almost all have hypothermia; our heaters are not enough. We need more.” We need more. This statement sums up what we saw in the hospital that week. In the words of Dr. Kazembe, “We have shortages of everything… except patients.” We are here to give them more. We spent the past week compiling information and are now beginning to work on projects to fit the needs they communicated. Specifically, we are designing a temperature monitor to help catch hypothermia sooner, so babies can be rewarmed before the temperature drops significantly. We hope this tool can be used to prevent hypothermia from becoming more serious in the neonates. In a way, we hope this too can be a small part of their more.
After completing the site visits to both Malamulo and Mulanje, I have really learned that communication is very important for building long lasting relationships. As Brighton and I walked around the hospitals observing different aspects of the wards, we found that we received the most information when we asked the nurses to talk to us or asked for access to the Operating Theater.
We specifically had a wonderful time at Mulanje with a nurse from the Operating Theater. She allowed us to go inside and asses their equipment and talked to us for at least an hour about her experience at the hospital and specific information about the equipment used. Fostering the relationships at the hospitals will help us get feedback later on about our designs and hopefully allow for more partnerships in the future with Rice and the Polytechnic.
A nurse and me in the Operating Theater at Mulanje
The site visits to Malamulo and Mulanje Mission Hospitals really opened my eyes to everyday challenges that the hospitals face. For example, the Operating Theatre is relatively far away from the Nursery. This means that if a mother undergoes a C-Section and the baby needs to be transferred to the nursery, they are exposed to the outside world for at least a couple minutes before being in a warm, temperature-controlled environment again. While the little exposure does not seem like much, it could cause a lot of damage to a premature baby already suffering from hypothermia. The hospitals already have blankets and foil wrappers in place to try to keep the baby warm during transit, but I feel as though more can be done to help. This is why I love that the summer we are not only worrying about oxygen concentrators, but hypothermia as well. Without our conversation with the nurse at the Operating Theater, I probably would not have realized that transferring the baby was still a challenge that needs addressing.
The power is out again. This seems to always happen at dinner time. If there is one thing I have learned in Malawi it is to expect the unexpected and to not be afraid wen your plans change. I was hoping to come home, make banana bread, do insanity, and then cook dinner. But instead I am writing in the dark with a flashlight (interns next year bring lots of candles). I really do hope by the end of this program to be able to adapt to different circumstances. I have definitely learned to not plan things too far in advanced or get too attached to plans already made.
Sitting in this power outage, I cannot help but think about the safety measures that must go into preventing outages in hospitals. On Tuesday while Brighton and I were at Malamulo, we experienced a power outage. Typically a huge generator turns on within six seconds. Unfortunately, the generator has been malfunctioning so someone has to activate it. The power was out for about twenty minutes before the generator finally came on. That does not seem like a lot of time (especially since power outages can last anywhere from 1-4 hours) but it could be the difference between life and death for someone that is hooked up to an oxygen concentrator or if the power goes out in the middle of a birth. It’s the little things like that that make me want to do more and get me thinking about different design projects. It is one thing for me to have read about the frequent power outages here in Malawi, but it is another thing to actually experience them and see firsthand how hospitals deal with them.
Being here it is really the little things that are important. Like tonight, even with the power out we still were able to do everything (make banana bread, do insanity, cook dinner). The power did not affect us, it just pushed our schedule back a little.
Last time around, I mentioned adjusting to a new culture and finding a little bit home away from home. I mentioned that this internship extends past the design kitchen. It’s not just about engineering and design. It’s about appreciating a different way of life and thinking. In order to give you a full picture of what I mean, it’ll help for me to show you my team and our home for the next two months.
My team consists of four of us from Rice (Christine, Leah, Theresa, and myself) and four from Malawi’s Polytechnic (Brighton, Harvey, Kate, and Vincent). This year, along with working together, we’ll also be living together.
Our first night together, Brighton and the rest taught us a Malawian card game (called “knock”? – I’m still trying to figure out the exact name). It’s similar to Uno, and winning depends a fair amount of luck and skill. (Theresa somehow ended up winning most rounds. Maybe she had a few extra cards up her sleeve?)
Along with cards, it looks like Brighton plays a mean game of chess, and he agreed to bring his chess board next time he visits home. I don’t know if I have a chance against him, but I’m gonna give it a shot anyway.
Harvey and I went running, and my cramps, sore muscles, and searing lungs reminded me why putting off running for more than a few days was a bad idea. I’ll need to start running every day if I’m going get back into any kind of shape.
Vincent and I are rooming together, and I’ve found a kindred spirit in him. It does me good to know that there’s someone else out there as bad at cooking as yours truly, but that’s alright. We’ll learn together (I have feeling Vincent’s more of a chef than he lets on).
Speaking of cooking, we’ve traded off cooking for the last few nights. We’ll probably end up cooking together one of these nights, but we’re eager to try each other’s respective local dishes. We made pasta a few nights back, and last night, Vincent and the rest shared a savory beef dish with us. We’re going to try cooking nsima, a local staple food.
That’s our life at home. We’re all learning, adjusting to one another, and beginning to understand each other.
I’m sitting here in an Axa Bus (think Mega Bus but with a radio announcer religiously calling out soccer plays in Chichewa). We’re leaving Blantyre behind for a few days so that we can head to Lilongwe, and these next few hours are a good opportunity for me to fill you in on these last few weeks.
When I think about internships, I usually think about them as opportunities to grow and to learn from new experiences. Each day usually brings a new lesson. That’s how it was in the operating room last summer and at the lab bench the summer before. The exciting part about this internship, part of the reason why I applied, was that the chance to grow doesn’t stop when we leave the design kitchen and the Polytechnic. Each time we explore the city, we meet new people, learn to understand and appreciate a new culture, and pick up a few fragments of Chichewa. A few phrases I’ve learned:
Mwadzuka Bwanji – Good morning
Pang’ono pang’ono – Little by little
Ndili Njala – I’m hungry (my personal favorite)
Learning Chichewa’s only the tip of iceberg. With the lifestyle, the speaking styles, the approach to solving problems – there’s a lot of opportunity to reexamine my own way of thinking, comparing it to what I see around me. What do I do well? What can I do better? As I continue to adjust to life in Malawi, each new perspective, each shift from my personal normal, is a chance for introspection.
Even with all of the new ideas and different ways of thinking, sometimes, it’s the familiar that’s most surprising. A quieter style of speaking demands constant attention – a definite distinction from my own often fast, loud, and decidedly American style of speaking. And yet, this quiet style of speaking is not quite a new to me. In its own way, it reminds me of the operating room, where hushed voices combined with face masks and the din of machinery made just hearing the surgeon challenging. It’s an old experience in a new setting.
I’ve found another unexpected, wonderful piece of home here, a hemisphere away.
“Salaam”
Just being able to say that one word puts me at ease. Even as I pick up a little bit of Chichewa (pang’ono pang’ono), I’ve gotten to speak more Urdu here than I have in a long time. Whether it’s been in grocery stores, electrical shops, or at restaurants, it seems like each stop has offered me the chance to speak as if I were at home. The words roll off my tongue. The conversations shift from my asking where the bread is to our talking about good places to eat to talking about the internship.
The old and the new, the familiar and unfamiliar, are mixed together here in Blantyre. There exists an intersection between what is Malawian, Pakistani, and American. Whether it’s been finding a Malawian who speaks better Urdu than I do or a Pakistani raised to speak Chichewa, I’ve found a little bit of home in a place far, far away. Malawi has a vibrant, beautiful mixture of cultures, and I’m excited to see what these next two months will bring!
We’re approaching Johannesburg as I write (05/27/16). Being in a space that’s become so familiar – an airplane – offers a stark contrast to the fact that everything outside couldn’t be further from familiar. I’m on a different continent, but for now I’m just in another airplane flying at 39,000 ft. In another day, I’ll be in Blantyre, Malawi. On the one hand, I’m excited to begin working. I’m excited to become part of a new culture, to explore new places, and to make new friends. I’m looking forward to all the hands-on, practical experience we’ll be gaining over the next two months. Peppered in here and there are bits of nervousness about not knowing what to expect when we arrive in Blantyre. What does the Poly look like? Who are the interns we’ll be working with? How’ll we settle into the daily life in Blantyre?
Our internship actually started 3 weeks ago with the following goals:
Construct six medical device prototypes
Order any additional parts we’d need to work with at the Poly
Design survey questions meant for both the Poly and QECH
Familiarize ourselves with the line voltage monitoring system
Familiarize ourselves with oxygen concentrators and common mechanisms of failure
When we weren’t soldering or working on the device prototypes, I found myself on the phone talking with US Plastics, Parker Fluidics, DeVilbiss, or another company trying to figure out exactly which parts we wanted to order. (I don’t think any of us realized just how extensive the possibilities are for anyone interested in ordering tubing.)
In those 3 weeks, we made a real home for ourselves in the OEDK. There was no better way to prepare for the trip than to spend our time engrossed in the projects we were taking with us, building some of them from the ground-up and taking apart other ones to better understand them.
As we descend from 39,000 ft., I can’t help but wonder what adventures we’ll have and what lessons we’ll learn over these next two months.
Blantyre’s airport and our first glimpse of Malawi
Experiences gives ideas which then leads to project ideas. Today we celebrate the ideas our friends had to treat hypothermia and lung failures. Premature babies are born with low body weight and have challenges to regulate their body temperatures. In such cases different lines of treatment were invented to treat hypothermia.
Infant incubators have for some time been used as the most successful method of treating severe hypothermia to babies born prematurely. Baby’s temperature is regulated and controlled with a closed feedback system until the normal body weight is gained. Unfortunately, Malamulo has only one infant incubator and it is faulty while Mulanje Mission has infant incubators in place.
Kangaroo Mother Care KMC, is a very effective method of combating hypothermia in premature babies. It is a skin to skin contact between the premature baby and mothers and it has turned out to be the most effective way of treating hypothermia cases. Both Malamulo and Mulanje Mission hospitals consider KMC as the most effective method of treating hypothermic cases than any other methods. Mothers and guardians are educated and encouraged to practice KMC. According to nurses on duty, KMC has 100% survival rate as the baby is always warmed up by the mother.
Radiant Warmer device is another mechanism for treating mild hypothermic cases. We found a good number of radiant warmers both at Malamulo and Mulanje Mission hospitals. Babies are being treated and saved from premature deaths.
An Oxygen Concentrator device is again playing a very important role in saving human life. Both premature babies with difficulties in breathing and adults with lung failures, are all being assisted with an oxygen concentrator device. It takes in atmospheric air, purify it and deliver 97% percent of concentrated oxygen to patients. The device has saved many lives and has been most effective. Both Mulanje and Malamulo have many oxygen concentrators that are working to save lives.
Think of how many people could have died by today if were not for KMC, Radiant warmers, infant incubators and oxygen concentrator devices? Innovations saves lives, I can do it!
A three days visit to Malamulo Mission Hospital and another two days to Mulanje Mission Hospital have been not only extremely rewarding but also an insight to hypothermia, oxygen concentrator and other devices of interest. Besides being excited with visiting wards like Labour, Delivery, Postnatal, Nursery, children and Theatre both at Malamulo and Mulanje Mission Hospitals, sharing the challenges faced by nurses and patients in these wards, was another key aspect as a bioengineer. Managing life immediately after birth to the level that the baby manages itself, suffers great complications. We have learned from the nurses both at Malamulo and Mulanje Mission Hospitals that Temperature changes immediately after birth, premature birth, neonatal Low birth weight, apnea, hypothermia, lungs failure and babies’ failure to suckle are a few common challenges faced by babies. Failure to control or treat any of these complications will lead to neonatal death. We also learned that delaying to treat or lack of proper treating devices, failure to use the devices or any treatment interruption may lead to serious complications or even death. I really wondered how neonatal survives in technology free areas. The experiences gave me enthusiasm to do more and saves lives. My conscious was not right when there was a Escom low voltages at Malamulo hospital during our visit and an oxygen concentrator device administered on the baby had to be stopped to avoid power fluctuations until the power stabilized. It was a bad experience but as an engineer, I had to face these challenges and think of solutions with the right heart and mind. Indeed, It’s good to share life experiences for a better tomorrow.
Last week, I had the privilege to travel with Sam, Allysha, Norman (from the Ministry of Health), and Elled (from CHAM) to six more hospitals in southern Malawi. It was interesting seeing and comparing the government-run district hospitals with the church-run Christian hospitals. Below you will find information about the current neonatal services offered at each hospital, as well as, visions for furthering strengthening and design of neonatal wards.
For reference, Malawi has set the following national goals for mortality, which we hope to help reach with renovations, trainings, and improved care:
Maternal 155/100,000 0.155%
Neonatal 12/1,000 1.2%
Infant 45/1,000 0.45%
Under 5 78/1,000 0.78%
Malamulo Seventh-Day Adventist Hospital is located 65 kilometers southeast of Blantyre in Thyolo District, one of the poorest districts in Malawi. The average income of residents is less than $1 a day. The hospital serves a far range of villages and is located at the center of a rural landscape encompassing miles of bright tea plantations. The hospital itself is quite beautiful and serves many. In fact, according to the CEO at Malamulo, 40% of Malawians receive healthcare from non-government hospitals. Therefore, it is our goal to provide access to neonatal care in as many hospitals as possible, no matter how far-reaching some are.
The leaders of the hospital informed us that although Malamulo has excellent facilities, it does not have a nursery. Although they have only faced two maternal deaths in the last 2 years, they have endured dozens of infant deaths. Each month, Malamulo serves 140-150 babies; the health professionals admitted that they tend to lose many of the sick babies because they do not have access to resources for adequate and sustainable neonatal care. Currently, Malamulo does not have phototherapy lights, heaters, transfusion machines, etc. and sick babies are placed with their mothers in the KMC room. Babies that need bCPAP do have access, but often the hospital runs short of supplies needed to maintain the bCPAP, being that the hospital is so remote. The hospital also needs more nurses and has the funding for them, yet it is difficult to recruit nurses in the rural setting. Malamulo created a previous plan for a nursery, but it was not completed – now, we hope to make their plan a reality and renovate a space that will serve thousands of babies in years to come.
Malamulo Seventh-Day Adventist Hospital neonatal care space
Mulanje Mission Hospital is a mission hospital of the Church of Central Africa Presbyterian and is located in a rural region near Mount Mulanje. Mulanje Mission has been renovating and refurbishing wards to provide better quality services for patients over the last decade – this includes renovating the neonatal ward successfully. Norman Lufesi, Program Manager for the Acute Respiratory Infections (ARI) program at the Ministry of Health, plans to publish a story showcasing the success of the neonatal ward renovations and consequent improvement in neonatal mortality. While we were there, we witnessed a baby born 600 g discharged and sent home healthy, as well as a baby born 700 g surviving well on bCPAP – how terrific and commendable is that?
Although Mulanje Mission has already invested resources and care into neonatal health, they are missing a few essential resources that could improve neonatal mortality even more so. The hospital leaders would like a second bCPAP machine, new heaters, oxygen splitters, and recessitation equipment to better serve sick neonates. Moreover, the phototherapy unit is currently broken and requires repair. We plan to equip the hospital with these necessary equipment and repairs within the coming weeks.
The Hospital Director also graciously provided us with helpful tips for renovations of the other hospitals. She emphasized the benefit of extra insulation in the ceiling to reduce electricity costs. Electricity for the rather small neonatal room at Mulanje Mission used to cost about $1 million kwacha (about $192.50 dollars) per month in order to maintain an ideal temperature of 30 degrees C (86 degrees F) to prevent hypothermia. Now, they are paying less than half of that to power the space. She also taught us that beyond a new space and equipment most important is regular, accurate training and equipping of doctors and nurses. She shared that this is what’s made a huge impact for Mulanje Mission.
Mulanje Mission Hospital neonatal care space
Mulanje District Hospital is located nearby Mulanje Mission but serves a different area of Mulanje which is more populous and urban. At Mulanje District, the leaders at the hospital admit that they “make do” with the nursery they have, for it is extremely small for the numbers of babies they typically serve a day. Sometimes, they are serving up to 12 babies at once. They informed us that some of the biggest issues, besides size, with the current nursery are 1) heating, 2) new healthcare workers coming in who are not trained to use equipment for neonatal care, 3) lack of space established for KMC, and 4) the lack of repair of the bCPAP machine. We hope to fix each of these issues and create spaces that will serve as many sick babies as possible.
We spoke to Mulanje District about the possibility of installing solar panels to store electricity for heating and equipment use, and hope to do this for each of the hospitals if we can find extra funding from environmental agencies in Malawi. We will also ensure that Mulanje District has more frequent check-ups and trainings for the bCPAP and other technologies.
Mulanje District Hospital neonatal care space
Holy Family Mission Hospital, located in Phalombe at the foot of Mulanje Mountain, has done an excellent job decreasing neonatal mortality in the last 10 years. According to leaders at the hospital, infant mortality was 39% in 2005, and in reference to a report from June-Dec 2015, the mortality has decreased to one-tenth of what it was in 2005: 3.9%. Holy Family has 8 beds for KMC, but no nursery and according to staff, KMC is often full. Presently, babies are situated in the Labor ward, and share oxygen concentrators, heaters, etc. with laboring mothers. Thankfully, space is available for a nursery which can serve 10-12 babies, and the leaders seemed excited to welcome this new innovation.
An important consideration in creating the renovation plans is having distinct spaces for infectious babies from the communities and babies born in the hospital who are sick and immediately delivered to the neonatal space upon birth. Mixing these populations in a single space could cause significant infection and mortality, which is certainly avoidable with conscious design. Lots of referrals come to Holy Family for neonatal care and unfortunately, most outcomes are not very good. We hope to work with hospital staff to design a healthy and accessible space for improved care for all babies.
Holy Family Mission proposed neonatal care space
Trinity Hospital – Muona is next to Nafafa in Nsanje District near the Mozambique border. Trinity serves about 130 babies a month and 10-15 pre-mature babies each month. According to leaders at the hospital, during a 3-month period from January to March 2016, there were many neonatal deaths and the highest cause of death was birth asphyxia. Leaders at Trinity described neonatal care as “not adequate,” and are very eager to improve care. The District Health Officer (DHO) said, “We have to take care of the little ones – everything else comes afterwards.”
Because there is not a specified nursery at this time, maternal beds are used as neonatal beds. The hospital also does not have access to enough incubators, oxygen concentrators, or phototherapy machines at this time. Leaders at Trinity told us that there are typically 5-6 critically ill babies each month born within the hospital and another 5-6 sick babies born outside of the hospital who need extensive neonatal care. These leaders had the idea to create separate spaces for those babies who are critically ill and those babies which are almost ready to go home for infection control purposes.
They also explained that the power goes out about 3 times a week for over 2 hours at a time. They have a generator but it was donated in 1967 and no longer functions properly. The leaders of the hospital told us that some solar panels are actually already installed, but the energy is only being used to heat water. They would like more solar panels in order to store energy and utilize it during frequent power outages. This spurred our idea to equip each of the nurseries with solar panels if financially feasible so that each neonatal ward can continue to run when the power goes out, which will hopefully save many future newborn lives.
Trinity Hospital leaders and proposed neonatal care space
Chickwawa District Hospital’s neonatal ward renovation plan is already under-way. The hospital has hired an architect, a structural engineer, a civil engineer, and an electrical engineer to create the nursery. We will be collaborating with these professionals in order to coordinate optimal equipment placement within the new space. Another big need is modification and insulation of windows in several of the proposed neonatal ward spaces across the country. Being that the nursery must be kept very warm and low temperature/hypothermia is a major cause of mortality, we will work with the hospitals to select windows which will let in natural lighting but prevent the escape of warm air. Chickwawa District Hospital would also like to tile the entire space, including KMC, in order to improve infection control.
We look forward to working with these hospitals further on their renovation plans. We have begun creating budgets together for construction and equipment and are talking with architects and contractors in the area who are interested in assisting in the renovations. I am excited for this opportunity and all that is to come. My favorite part of these ward assessments has been meeting and learning from diverse leaders at each of the hospitals who are so willing to share their ideas and experiences, then work tirelessly to ensure the well-being of their little but oh so important patients.
Though I developed interest to start working with medical devices, I lacked exposure and hands on experiences in biomedical engineering devices. Poly-Rice biomedical internship programme has uplifted me to greater height. Hypothermia and Oxygen concentration device are the main project areas that we are concentrating. As a team, we are eager to identify and address problems related to hypothermia and an oxygen concentrator device.
Our first week to the project was spent in researching and understanding about hypothermia causes, symptoms, prevention and its line of treatment as well as getting familiarization with an oxygen concentrator device airflow, components functionality and general service maintenance as per device operations manual. We interacted and went out to buy some tools necessary for the project activities and prepared guide line document to necessitate our data collections in the targeted district hospitals. We then measured our preparations and competent by visiting Queens Elizabeth Central Hospital (QECH) and while there, I was privileged to visit Chatinkha ward for the first time in my life and I had a chance to interview a nurse who was treating a new born baby. The nurse was very cooperative and that gave me courage and more confidence. Finally, we visited PAM Office where we met Mike Nkosi, technician working with Oxygen concentrators and it was a wonderful moment meeting him. With Mike, we worked to troubleshoot a failing oxygen concentrator and indeed it was nice working with him. For the one hour we interacted, he gave me confident that all things are possible if and only if I’m optimistic with what I am doing and he has shown interest to instill hands on experience in me when I asked if I could join him in my free time to learn more about oxygen concentrators. Having reached this far, I’m enjoying being part of the biomedical engineering team working at Poly for Poly Rice internship programme and I’m even more eager to work with the current biomedical devices in Malawi as I find ways of improving their working efficiencies by identifying ideas which would bring in design solutions, automation and effectiveness.
