27 June 2018

The weekend is over, and the safaris were unforgettable. Malawi is a beautiful country, and it’s wildlife and landscapes are both enchanting and inspiring. Of course my family was excited to hear about all the elephants and hippos, but I’m sure it’s nothing new for the Malawi blog! I would definitely recommend a visit to Majete, for anyone who finds themselves in the area, though.

My first couple of days at the Polytechnic Institute have been full of new and exciting things. First of all, I met the Poly students who have been working together with our Rice 360 team in the design studio. Day 1, everyone was already scheduled to make hospital visits outside of Blantyre, so I joined the Mathermal and Suction Device teams and we all hopped into a minibus together, bound for two district hospitals: on the first day, Zomba, and the next, Thyolo.

This was an eye-opening experience, which cannot be fully conveyed in a few small paragraphs. We really do take so much for granted, back home. Can you imagine sitting on a hospital bed in the Texas Medical Center, and being told that your temperature hasn’t been measured because the thermometer is broken, or needed in another ward? This is only a tiny example of the challenges doctors, nurses, and patients face here. Much of the way things are done seem hopelessly guided by well-worn twin ruts of under-staffing and lack of supply. These are forces which we may know of but whose consequences are nonetheless difficult to anticipate. From a problem-solving design perspective, I feel like so many of their challenges are just assumed not to exist.

This trip broke that perspective bubble for me. In these two visits to the district hospitals, we were given priceless first-hand exposure to their daily reality. The generous nurses and staff took time to discuss things at length with us, giving us insight into how things are done here, and what sort of environment, expectations, habits, and needs we were designing our devices for. The more we heard them speak, the more my belief in extensive needs-finding and local input grew. This sort of discussion was absolutely critical to good design! How many of my previous assumptions would have led me to miss what would be here a fatal design flaw? My time here was spent critically thinking about suction pumps and thermometers with the other teams, but I felt my perspective broadening in a way that will likely influence all of my future work.

I can’t wait to see more, and to learn more. This is definitely a mental change I was seeking. It’s one thing to hear about other people’s situations, and quite another to see them and talk to them directly about it. I am very thankful for this – for having the chance to open my mind this way.

It’s time to go back to the studio and get to work. Looking forward to lending a hand.

3 am is a great time for reflection. A week ago, I was able to ponder the plot to season 2 of Stranger Things. This morning I looked back on all the memories we made with the interns at the Poly. It’s such a bittersweet feeling. On one hand, I’m so happy to have met all of them. Their genuine nature and good humor brightens the environment in the studio. On the other hand, I’m regretful that our time together with them was so short. When we had dinner with the interns, Dr. Gamula (Dean of Engineering at the Poly), and some of the Poly lecturers, I looked around the table at each of them and knew they were people I wanted to see for more than just two months.

Alas, each journey has an ending point. Today we’re flying out of Chileka International Airport and heading to sunny Houston. I’m really going to miss seeing all the hand painted shop names and the minibuses crowding together. Really, I’m going to miss the friends we made. There’s my team, Nafe and Isaac, who have such hardworking attitudes when it comes to every aspect of projects. They’re unafraid to try new things and have sometimes truly ingenious ideas. Isaac had ingenious ways of designing the device and would always think of new improvements. Nafe’s zeolite experimentation actually gave us the push we needed in writing our regeneration procedures.

The other interns also have a special place in my heart. There’s Alfred, who has a way of making any story a captivating adventure, and Gloria, who has the most contagious laugh I have ever heard. There’s Taonga, who’s one of those people that says hilarious things without ever meaning to, and Demobrey, who has as much music smarts as he does academic. Finally there’s Matthews, who takes care of everyone like an older brother, and Timothy, who is definitely going to be a CEO one day. As much as we were all working together, I think I learned more from the interns than I ever expected.

I’d like to think goodbyes are only temporary. The world is only as big as we try to make it. With Whatsapp and the internet, I’m sure this isn’t the last that we will hear from the Poly interns and it definitely won’t be the last time I visit Malawi. My two months in the warm heart of Africa have been truly eye-opening. I’m so thankful to have had the opportunity to do this internship and that’s largely due to the support of the Rice 360 donors who made this trip possible. I’m glad to have support from these donors as well as the Rice 360 staff who have prepped us so well.

Thank you for following my journey these few weeks. Zikomo kwambili, tionana! (Thank you, see you later!)

Time has a weird way of passing once you build up a routine. At first each day seems like an ordeal, a deep underwater dive into a new world where a day is only marked by new discoveries, not hours. Then when you break the surface and look back, what seemed like a week has somehow turned into two months. That’s only a fraction of the wonder I’m feeling at how we have adjusted to life here. While I had some expectations coming into the summer, I think it’s a given that life will throw whatever it wants at you and you just pick up the lessons along the way. So in the spirit of learning, I wanted to share some of the things I did not expect to do/learn during this summer.

• Coaxing a 3D printer: The first time I 3D printed something was during the internship training at Rice’s OEDK. Even though it was tricky trying to squeeze in your project among the others, the printing process was smooth sailing. At the design studio, they have a Prusa machine that gets quite finicky in the cold. The plastic sometimes drags and I have to watch the machine like a hawk (positive reinforcement also helps). But at the end of the day, I’ve learned so much more about the process of 3D printing and using CAD software like Solidworks.
• Making an oven: Alright, maybe it can’t be strictly classified as an “oven” but our device is resembling more and more like one everyday. In our original quest to regenerate zeolite, we found that the industry standard is to pass hot gas/air over the molecular sieves. Past teams have also used an oven to dry out the zeolite externally. While we want to push hot air through the sieve bed canisters, in the process of doing so we’ve researched a lot into household heating appliances, namely the oven. While it’s not quite at the final stage, the purpose of the box is to insulate the heat produced by the light bulbs inside, thereby warming the air above it.
• Teamwork makes the dream work: The hidden clause in being an engineering major is that you get used to working in a team for everything. Problems are no longer straightforward. Every new mind that looks at the problem is a new approach that could lead to a better solution. Communication styles differ here in Malawi compared to the States. People tend to be more indirect and lean on the more polite side. It definitely took some getting used to and our project was confused in its direction in the beginning. I feel like this has been a good practice at being a better listener and observer.

After many weeks of research and needs finding, we’ve finally started getting into the design process of sieve bed regeneration. Thinking about problem statements, design criteria, and Pugh matrices makes me reminiscent of Freshman engineering design class. Work at the Poly is flexible, much more than I’ve ever experienced in high school or college. It’s an interesting change of pace from the strict and timely schedule that’s the norm in most workplaces in the state.

Previous sieve bed regeneration teams have mainly focused on the research behind how zeolite and/or molecular sieves. From the start of hearing about this project, my team knew we wanted to design a device using the research from the previous team. From the brainstorming phase, we thought of several parts that could deliver heat to the zeolite. Our project centers around two elements: a heating element and an element that can push air. One thing I have definitely mastered is the art of sketching cubes, over and over and over again in an attempt to arrange tubes and light bulbs in a way that would deliver the most amount to heated air as possible to the sieve beds.

This Friday was also Republic Day! We took advantage of the long three-day weekend by taking a trip to Lake Malawi. We spent some time at the beaches at Cape Maclear and ate some local fish called chambo.

Hello everyone! I have just finished my fifth week here in Malawi. This week I spent a lot of time at Queen Elizabeth Hospital shadowing in different wards, specifically in the pediatric surgery ward, maternity ward, and audiology clinic. I also spoke with three different pediatric surgeons from Blantyre, Lilongwe, and the UK about our gastroschisis silo bags and got some great feedback from them.

Starting out with the pediatric surgery ward, I was able to observe Dr. Eric Borgstein for two days on different surgeries. He gave me a whole scrubs outfit and I got to wear crocs around for the whole day, which is always a win.

The first surgery was a lung decortication on a two-month-old baby. They took a layer of peely semi-liquid like substance off of the lungs to allow them to expand properly. This is the first surgery I had ever observed and I think the part that surprised me most was the ease with which the doctors were able to cut and make decisions right on the spot about what to do next. I had never realized that so much of a surgeon’s job is improvising on the spot when the patient’s condition presents differently once actually on the operating table than the doctor originally anticipated.

I was able to stand a few feet behind the operating table itself and ask questions to the surgeon once in awhile and even peeked over his shoulder at times when he wanted to show me something. The environment was much more relaxed than I had thought it would be. They had calm classical music playing and even carried on some light-hearted conversations whilst operating.

I saw the improvisation more so in the second surgery I shadowed in on when they were operating on a 15-year-old cancer patient. She had a burn many years ago that was never properly treated and it eventually lead to her cells multiplying uncontrollably and becoming a tumor. Dr. Borgstein had to remove the tumor and when he tried to take out her lymphnodes he found that the cancer had spread to the rest of her body. In that moment, he had to decide if he was going to continue with the surgery and try to remove more of the cancer or stop operating and close her up. Deciding to close her up, they stitched the patient and the surgery was over.

I am so in awe of the way a surgeon is able to think of all of the possible future scenarios for a patient in just a few moments, decide what they think is the best course of action, and confidentially go forward with it. I guess that is another lesson I am learning from the doctors here, not just from Dr. Borgstein, but from the OBGYNs, pediatricians, and nursing staff.

When resources are limited and costs are high, the doctors must decide how to maximize what they are given and do so without wasting materials. They also cannot second-guess themselves, which is something that I tend to do when I wonder if I am making the right decision, or not. Here, when there is neither time nor resources for a doctor to try multiple care options for a patient or weigh the pros and cons of a treatment plan at length, they trust that the decision they have made is the most educated they could make and move forward.

I also got to shadow in the maternity ward this week with some of the medical students and Dr. Sam Meja. We went on a round of the labor ward where the medical students assessed each mother, checked her for contractions or complications, and determined if she was in labor yet or not.

Most of the interaction with the mothers was done in Chichewa so I did my best to understand what they were doing through visual cues and then ask questions afterwards. I noticed that the environment in which the doctors assess mothers is very different in Malawi than in the US. In the US, everything is done very privately and the doctors and med students take permission from the mother before doing any physical check and ask questions very carefully. In Malawi, check ups are run much more publically and for this reason there were very few men in the maternity ward. I noticed mothers were rarely ever difficult about a test and overall talked very little to the doctors or asked questions.

After spending lots of time in the hospital this week I had a new found appreciation for how hard working, and for little recognition or pay, the doctors and nurses are here. I am so thankful to them for teaching me so much without even realizing they are doing so.

Over the weekend, we went to Cape Maclear at Lake Malawi and wow, was it beautiful. I have never seen such blue water in my life or a sky so clear and so filled with stars. We got to eagle watch, snorkel in the lake, and eat the freshest fish out there.

Warm Wishes,

Sajel

This second week has been one of eye opening lessons and challenges. I started the week in the CPAP office working on my data project. I am entering data related to the supervisor visits. As I started to learn more about the CPAP project and reading, I realized that treating infants with a CPAP related issue is just one small aspect of having overall healthier babies. The Rice CPAP team has found that a common denominator for infants with respiratory distress syndrome, sepsis, birth asphyxia, or other condotions is hypothermia among infants to some degree. So often times even if these babies are successfully put on CPAP, they are hypothermic which can lead to severe life threatening complications if not addressed.

This surprised me as I hadn’t really thought about hypothermia as such an important concern and made me realize that providing for basic health needs and general infant care is an equally if not more important issue to focus on. When I had thought about healthcare concerns in resource limited countries in the past, I had thought about things very one dimensionally: what is the problem at hand? How can we provide something low cost and easy to use? How successful is treatment of this single condition?

In the hopes of expanding my learning on the hypothermia issue as well as other basic healthcare concerns, I have started working on a hypothermia guide for mothers that can be put up in the NICU. This guide goes over basic preventative measures and things mothers can do for their infant if they are hypothermic.

Here in Malawi, mothers do something called Kangaroo Mother Care (KMC) to keep their infant warm. They place their infant on their bare chest so there is skin to skin contact between mother and child and then wrap the infant up with their clothing. In every hospital we visited, they had a Kangaroo Mother Care ward for mothers who have healthy infants who just need to be kept warmth. They also use radiant warmers and hot cots to keep the infants warm when mothers cannot do KMC or if they infant is not healthy enough to be outside of the Neonatal ICU.

Alongside working on that, I was able to connect with a doctor from Lilongwe (the capital city of Malawi about 4 hours away) on my gastroschisis project. Gastroschisis is a condition in which an infant’s intestines are born outside their body. This congenital birth defect affects about 1 in 2000 infants and tends to affect more premature infants, so the condition is more commonly seen in Africa than in the US. This past semester at Rice, my team worked on a low cost, easy to use solution to treating this condition. We developed an alternative prototype bag that essentially covers the intestines and allows them to naturally descend back into the body cavity. I brought this prototype along with me to Malawi and was able to connect with a pediatric surgeon in Lilongwe who has attempted to treat the condition in three infants using a female condom. He has not had success yet, and says that one of the main reasons why is because the basic nursing and surgical care cannot support gastroschisis infants.

This lesson of the importance of basic patient care is one that threads together many of the projects I am interested in here. It is very difficult to treat a complicated condition such as gastroschisis without being able to provide a conducive environment to care for infants after the surgery for those 4-6 weeks in which they must be looked after in the hospital and be administered IV fluids, nutrition, and constant monitoring. I am meeting with the head of pediatric surgery at Queens in the upcoming weeks and am looking forward to getting his feedback on our prototype as well as learn about how they do the surgery at Queens.This work week taught me a lot about adjusting to others needs and understanding that a strong foundation in basic patient care is needed in order to move towards sustainable improvement of healthcare in Malawi.

Over the weekend, we had the Malawi interns we are working with over for a barbecue. It was really fun to socialize with them as I don’t see them on a day to day basis. On Sunday, we hiked Michiru Mountain and the view from the top was absolutely incredible. We could see mountains in every direction and could even spot Kabula lodge (where we are staying) from the top. We are hoping to work our way up to more difficult mountains in the next few weekends…stay tuned for my attempt at a fitness regime to get ready for that.

Warm Wishes,

Sajel

There were several gray areas when our team started looking into sieve bed regeneration. One was the fact that none of us had ever focused on just the sieve bed in an oxygen concentrator before. We knew nothing of how the zeolite was packed inside, how many compartments existed inside, etc. On Monday and Tuesday we tried to solve that problem by revisiting Thyolo District Hospital and Zomba Central Hospital. We were based mainly in PAM, asking the engineers and technicians there about equipment details and examining some of the machinery for ourselves. It was actually really exciting to crack open one of the sieve beds and take apart all the components inside. We could finally start analyzing the zeolite and start experimenting with different regeneration methods. After the hospital visits, Isaac, Nafe, and sat down to brainstorm some ideas. Though the details of the design aren’t solidified yet, we’ve all agreed that an external device using hot air to dry out the moisture from the zeolite would be the best option.

On the hospital visits we went to the neonatal and pediatric wards to ask more oxygen concentrator specific questions. While speaking with the nurses at Zomba, we discovered more improvisations on oxygen distribution. The nursery has two working oxygen concentrators that over seven infants needed to use. Their solution is to increase the flowmeter from the standard 0.5-1 L (for one infant) to 4-5 L and using a splitter that could divide the main flow of oxygen from the concentrator into several streams. The issue is they couldn’t guarantee the flow rate/pressure going through each split. Since they’re using such a high pressure for their oxygen flow, the concentrators may someday accidentally cause harm to the infants by delivering too much oxygen. A good future project would be to design calibrated splitter that could control the flow rate of the split.

On another note, we invited all the interns over to have a barbecue on Saturday. Even though we only met a short while ago, it seems like we’ve all known each other for longer. It’s been so great getting to work with a group like this. It’s so different to the teams that I’ve worked in at Rice and the experience is looking to be an exciting journey.

Day 20
Since we got our projects assigned to us, we visited our first hospital today to ask specific questions about our project. We started out by going to Zomba (which apparently is nicknamed Texas according to the Malawian interns? I’m still not sure why…). We visited the maternity and labor ward at Zomba Central Hospital, and met up with Daniel (the nurse I met a couple of weeks ago when we visited different hospitals). I got to ask him a lot of questions regarding the maternal temperature monitor. Ideally during labor, temperature should be monitored at least every one hour. However, because there are 25 mothers and only 1-2 nurses on duty at a time, temperature is actually monitored every 4 hours. And the main reason the ward runs out of digital thermometers is because of the batteries. They have a really short lifespan, and it may take a while for the pharmacy in the hospital to order more thermometers. The last time I visited the hospital, I noticed a TON of posters all over the walls with information for the nurses. There were posters about how to measure dilations, infection prevention protocols, what to do immediately after the baby is born, and other helpful tips for the nurses. I asked today if the nurses had a book with all this information that they could refer to quickly rather than searching the walls for the information. Daniel told us that a handful of books with this information were distributed around the hospital a while ago. There aren’t enough books for everyone, but the few nurses who got to keep these books will refer to them often. I’m hoping that we could try to get the necessary information on the posters and maybe compile it all into pamphlets for the nurses in maternity to have on hand.

Day 21
The next day, we went to Thyolo district hospital (which was also VERY busy). We went to the postnatal ward, where mothers and healthy babies are sent to be monitored immediately after birth. Most of our focus has been on mothers going into labor, but we found that mothers after birth should be checked up on as well. The nurse told us that temperature can vary after birth, especially for mothers who were given C-sections. They have to follow a strict protocol for temperature measuring: measure every 15 minutes the first hour after birth, every 30 minutes the second hour, and hourly afterwards. However, because there are so few nurses and only a couple of digital thermometers on hand, this is not followed all the time. We also received some really great suggestions from the nurse. An LCD display would be much easier to read rather than a four digit blocky display. Our device should also have memory of the patient’s information if the nurses need to check past temperature data. The nurse also said that it may be difficult to see all the patients from the nurse’s station, so having a buzzer and light that goes off at the station when a mother’s monitor reads fever would be helpful. I really liked the last idea, and hopefully my team can come up with a way to create that.

We stopped by the market in Thyolo to get some avocados (the avocados here are AMAZING and we go through A LOT). The interns also bought us some sugar cane for the drive back to Blantyre and I guess Karen and I don’t have strong teeth like them because they finished their canes in like 5 minutes! The Poly students were making fun of us the entire time we struggled through our canes.

Day 22
After visiting two hospitals with our team, we had to present our findings to the rest of the interns as well as a few lecturers from Poly. It was interesting to see what kind of findings the others discovered while on their trip, and I’m excited to see how everyone is going to approach their respective problems. We only have three weeks to work on our solutions, so we have a ton of work ahead!

Day 23
I was pretty satisfied with today. We made it official that the IR sensor is dead and cannot be salvaged. However, we decided to go ahead and use a thermistor instead. We updated our code and changed the circuitry of our device to include the thermistor, and everything seems to be working! We just have to see if the device is reading the correct temperature values so cross our fingers that it is.

Day 24
Yeah so our thermistor isn’t reading the correct values. We tried changing the resistances of our circuitry and after getting some readings like -75 degrees Celsius and 137 degrees Celsius, we finally got an accurate reading. Yay! Now we have to see if the device will accurately read body temperatures.

Day 25
We prepped all day for a BBQ with our interns! They came over later in the afternoon and we cooked with them and got to see them outside of the Poly which was a lot of fun!