Welcome back to my blog! It’s been a very eventful weeks in which I visited two hospitals, traveled to Lilongwe and back for a pitch competition (and got a broken tire on the journey), and hiked a small mountain (or rather, a plateau) on our weekend adventure (while unknowingly having a fever). In an effort to keep my experiences on this blog in real time, this will be a three part blog (four if counting the customary fun photos section) featuring the highlights of what I’ve learned over the last two weeks.

Part 1: A Small Glimpse at What it Means to be a Doctor

Kyla, Liseth, and I have had the opportunity to attend to the daily handover meetings of the pediatric department at QECH, in which the doctors on call for the night shift inform the other doctors on new admissions and deaths that occurred in the various wards during the night. The first meeting I attended occurred on a Friday, on which the mortality report for the week is presented. Each case was displayed as a row on the spreadsheet with a patient number, a date of admission, a summary of symptoms, and laboratory test results. Initially, this information seemed so abstract—just tiny black text on a white screen in a dimly lit room. Then, it hit me.

Our path to and from the CPAP office passes a busy intersection that contains, among other things, the path between the pediatric wards and the morgue. The week prior, we saw a stretcher with white sheets covering the faint outline of a small body being wheeled along this path followed by a line of bereaving family members. In that moment, I realized that that small body could have very easily been any of the data points displayed on the projector, and it deeply perturbed me that patient—that child—could be simply turned into a collection of clinical criteria. The doctors’ discussion of these cases augmented this effect, picking apart the symptoms they witnessed and treatment details.

At one point, there was some confusion over which case was being discussed due to the symptoms being fairly common. Then, one doctor exclaimed, “I know who you’re talking about,” another doctor echoed, “the one with…,” several others nodded in confirmation, as if there was something more memorable than symptoms about this patient that was etched into their minds. Then, I understood: Being doctors, they had to simultaneously recognize the humanity of each of their patients in and think of them as cases whose symptoms had to be solved and, in the worst case scenarios, whose deaths had to be learned from to prevent similar ones in the future. Sometimes, it seemed, these two aspects were in direct conflict with each other, and like the doctors in that room, in my future, I will have to handle the precarious yet crucial balance between them.

Part 2: More Thoughts on Implementation

One of the things my team in the GLHT 360 course initially struggled with when designing the Ballard Score training model during the semester was envisioning a role for it. During our research process, we repeatedly learned that the Ballard Score was seldom, in practice, used to determine gestational age, and we struggled to see how a training model could change these established norms. The missing piece of this puzzle that we weren’t thinking about was implementation: obviously a training model by itself couldn’t compel healthcare providers to use the Ballard Score, but with proper implementation, it could be a key part of the process to encourage increased use.

The visit to QECH two weeks ago (along with the visits to Zomba Central Hospital and Mulanje District Hospital the first week) truly allowed me to envision how, at least hypothetically, implementation of the training model could work. At QECH, we met with student nurses in their final year of nursing school, and they, along with Prince (a nurse in the NICU who works with Rice 360), explained how training for the Ballard Score currently works. In short, during their unit on prematurity, for a few hours on one day, they are given a presentation on the Ballard Score, and, at best, the instructor demonstrates the neuromuscular signs on a normal baby doll at front of the room. However, there are other procedures that they practice on baby models during skills labs in nursing school, and I think it would be possible to incorporate the Ballard Score into a skills lab if an adequate training model were developed.

In addition, for nurses who have already graduated, this training model could be incorporated into periodic training workshops on the Ballard Score. From some of the checklists I read in the CPAP office filled in by national supervisors, I learned that trainings on other topics such as CPAP, COIN, and Helping Babies Breathe are currently held in hospitals throughout Malawi. Multiple nurses at all three hospitals also told us that they recognized the importance of the Ballard Score and, at least hypothetically, would attend Ballard Score trainings to be able to do the procedure more efficiently and use it more often. (This is in addition to the amazing app the team at the Poly is developing to make it easier to record ratings for the Ballard Score and thus reduce the time needed to perform it).

However, I fully recognize how far away this hypothetical implementation of the training model would be even in the best case scenario (though the Poly team is making amazing progress- they are determined to prototype five neuromuscular signs this summer and have started at least two already!). I was made even more aware of this during the QECH visit. Prince showed us a broken syringe pump in the shelf of old devices in the NICU and explained to us how important syringe pumps were in delivering fluid medications and how the fact it only worked with one size of syringe was troublesome. The fact that even Prince, who works for Rice 360, did not know about the syringe pump being developed by Rice 360 addressing these exact issues, even though it has already been in the prototyping process for a few years (I think?) emphasized just how long the process from needs finding to prototyping to clinical trials to manufacturing and implementation was.  This made me appreciate the fact that the patients and maybe even the nurses and doctors that we meet on hospital visits aren’t going to be the ones who benefit from the technologies we develop based on their feedback; technology development and research in general doesn’t really solve the problems of today but those of tomorrow.

Part 3: An Overarching Theme in Needs Finding

Our visits to the nursery ward a QECH and to the Physical Assets Management (PAM) department at Kamuzu Central Hospital in Lilongwewere amazing opportunities for needs finding. Hearing two contrasting perspectives—the nurses that serve as the users of the devices and the biomedical engineers that are responsible for maintain them—successively was both intriguing and informative. There were definitely some differences in their views of the challenges that they face with medical equipment (viewing pre-set settings of suction machines as a benefit vs an obstacle, seeing the failure with temperature as user error vs a flaw in device design). Nevertheless, a lot of overarching themes emerged.

The theme that stood out most to me, that I had somewhat picked up on at Mulanje DHO and Zomba Central Hospital, was the constant scarcity of consumables. By consumables, I really do mean all types of consumables: plastic tubing of all kinds, stationary (both normal printer paper and special types of paper), test strips, etc. You name it, if it is meant to be used only once, there is definitely an issue of lack of availability with it. The consequences of this became apparent:

To make up for the lack on consumables, many disposable devices are re-used after sterilization with chlorine. While this is a clever and necessary work-around in these lower resource hospitals, it does not come without unintended effects (in addition to the clear possibility of insufficient disinfection). For instance, after sterilization, plastic suction tubes change texture and are more likely to cause trauma when inserted in an infant’s trachea, and the labeling on syringes used in feeding sets fade and then disappear, leading to less accurate measurements. When certain types of disposables aren’t available at all, sometimes other similar disposables are used in their place (suction tubes in place of oxygen tubes, components of IV sets for feeding sets). However, some consumables can’t be re-used or replaced—such as glucose test strips and hemoglobin test strips, and when these aren’t available, the critical functions they provide simply aren’t fulfilled.

While the scarcity of consumables may be, in large part, a distribution problem, I think there could be engineering design-based solutions to help address the issue—namely, creating versions of products that are meant to be reused. While, at least in my experience, the motivation behind designing reusable products is to reduce overall cost, it also ameliorates the difficulty of needing to continuously re-stock supplies. Looking beyond this, as suggested by Dr. Bond—the GLHT 360 professor that reviews all of our project ideas, designing better systems of sterilization that ensure more thorough disinfection or are less harmful to the material could fulfill part of this need, allowing some existing “disposable” devices to be become truly reusable and thus more compatible with the setting.

 

Overall, the last two weeks have allowed me to glimpse into the future—my personal future as a doctor, the future of the Ballard Score model, and potential for developing future technologies—with both hope and excitement but also an heightened awareness of the challenges that lie ahead.

Part 4: Fun Photos from This Week’s Adventures

 

-Sally

Yet another week has gone by and this time with a bit of adventure. This past week seemed to be centered around people and opportunity. Before we left for the Malawi Technology Pitch Innovation Night in Lilongwe, we had the opportunity to visit the NICU at Queen Elizabeth Central Hospital (Rice’s main hospital partnership in Malawi) and speak with Prince an experienced NICU nurse who is well known in the Rice 360 community. Although Prince is a full-time nurse at the NICU, he has a technical background and is passionate about improving the healthcare at Queens and in Malawi. He has also served as a mentor to many Rice 360 class projects and facilitates the implementation of the new technology developed in the hospitals. Essentially, he is one of the main connections between the theoretical design of a device and actual patient use. Another memorable person we met at Queens was Nurse Florence. She is one of the nurses working with Rice since the very beginning of their partnership and has given feedback on majority of the Rice 360 projects implemented at Queens. While touring the NICU, we had the opportunity to ask Florence about our potential design solution and temperature specifications. She identified the current heating systems in the NICU, but what really caught our attention were the nonfunctional incubators shoved in a corner that are only used to transport babies between the wards and the stationary hot cots used to heat the babies once in the NICU. Originally our design for transport consisted of an enclosed environment with a water heater however after our visit to Queens, we decided to alter source of heat to light bulbs like that of a hot cot.  Although our design has gone through many iterations and we do not have all the specifications finalized, I believe this is potentially a reliable alternative to the current methods of neonatal transport between wards.

After we arrived in Lilongwe for the pitch competition, we arranged a visit to the Physical Asset Management Department (PAM), where all the broken and malfunctioning devices go to be repaired, at Kamuzu Central Hospital to gain some more insight to our projects as well as conduct needs finding for possible future projects. We spoke with one of the PAM technicians about some of the most frequent devices that they receive for repairs as well common challenges they face. He said the main challenge they face are insufficient funds which leads multiple complications such as understaffing, a lack of materials (parts, consumables, etc.), and lack of training. This also increases the duration it takes for a device to be delivered to PAM and then be ready for patient use again. Another major problem they face particularly in Lilongwe are dust and humidity. For sensitive medical devices such as oxygen concentrators, this causes the need for frequent repairs and a shorter lifespan of expensive equipment. Ultimately, our visit to PAM was insightful to the treatment and use of medical equipment. It also offered a new engineering perspective on medical devices used in the hospital setting which have not had the opportunity to experience fully. Being able to observe both nurse and technician’s interaction the equipment as an engineer makes me think about the different needs of both parties specific to design of a solution.

 

That night was the long-awaited Malawi Technology Innovation Pitch Night where ten student teams would compete against each other for the best design concept including one of our own, Simple Ballard. Not only were brilliant students gathering to present their innovative ideas, donors from the Lemelson Foundation and partners of NEST 360 attended as well (no pressure and my team wasn’t even presenting). As the competition began and presentations went on, each team seemed to get better and better. One of my favorite teams to present was Cold Box. The concept behind their project an insulated cold box made for transporting large quantities of blood, vaccines, and other biohazardous materials long distances across Malawi. What really surprised me was how much they had thought through their design to the point of having an existing relationship with the Malawi Blood Transfusion Services and sent a prototype to a company in Geneva in hopes of securing a partnership. Not only did I think this was great project so did the judges because they received second place. Overall each team did very well and was a clear representation of the passion and motivation of students to pursue innovate ideas and impact their community. Although every team was not able to showcase their talent at the pitch competition, there are plenty of students with the same passion for innovation we see working hard on their projects in the design studio and I hope to see them continue it.

– S

We spent Wednesday, Thursday, and Friday of this week in Lilongwe. There was a pitch competition happening at this place called mHUB. Alongside the Lemelson Foundation and Rice 360, mHUB supports what they call “innovation education”. In other words, they help empower young people to execute their amazing ideas. Ten engineering design teams from different universities across Malawi made it through the audition process in order to compete in the pitch competition on Thursday night at mHUB.

I was happy to see several familiar faces: Dr. Richards-Kortum, Dr. Oden, Georgia, and Raj! We missed Dr. L and Karen though. 🙁 I imagine the 360 office in Houston feels a bit empty these days, since it seems like this is the time of year that many of them travel here to Malawi.

I really enjoyed watching the ten teams present their work. They were beyond impressive. One of my favorite teams presented an app to aid deaf people in Malawi by translating speech to sign language. Another impressive prototype was presented by our friends from MUST! Before we arrived in Malawi and began this internship, they created a prototype for a manual breast-milk pump and delivery system for premature babies who have a hard time latching onto the breast after birth. These young engineers and entrepreneurs are so smart and capable, and it made me think about my own team projects back at Rice, and how our success stories are largely attributable to the endless amount of resources and support that universities in the US offer their students (especially at Rice). I feel so spoiled: In the US, university students have access to labs stocked with any materials we could ever need. At Rice specifically, we have the OEDK, which is a huge facility and features employees and lab techs that are almost always available to give teams technical support. Engineering students at universities in the US have so many resources, and I know students here do not enjoy these same benefits. Don’t get me wrong, the design studio here at Poly is wonderful. It’s enabled so many teams to bring amazing ideas to fruition. But I can’t help but hold in my mind the idea that the OEDK is larger, more equipped, more heavily staffed, and undoubtedly much more funded. I don’t know if I have what it takes to have brought OxyMon to the success it has had if I hadn’t been given everything I needed in the OEDK at Rice.

The issue of funding is not localized to the experience of student-engineers: It is the same at the hospitals we’ve visited. In Lilongwe this week, we had the chance to meet with a medical engineer who works in Physical Assets Management (PAM) at the Kamuzu Central Hospital in Lilongwe. The medical engineer we spoke to was wonderfully helpful, and I’ve made a mental note to put him in contact with Rice 360. He’d make a great project mentor. He outlined for us a list of what he sees are the primary challenges of the PAM at KCH:

1. Under-staffing
2. Procuring consumables and spare parts for broken machines
3. A lack of tools necessary to fix broken medical equipment
4. Language barriers – donated equipment often comes with manuals in foreign languages, thus they don’t know how to install or fix these machines when they break
5. Dust and moisture levels are big contributors to equipment breaking down

He told us that these challenges are, in his eyes, the biggest things preventing PAM at KCH from providing and maintaining all the medical equipment necessary for the hospital to function. A quick look at this list tells me that there is one issue that most of these challenges boil down to: financial constraints. Like the teams presenting at mHUB, the staff at PAM in KCH – and truly all the hospitals we’ve visited – are constrained by money from doing the most they can do. Now, I don’t want it to sound like I am pitying these people or saying that they’re somehow lesser than engineers in the US for their lack of funding. If anything, these people are more capable, more resourceful, and 110% more hardworking. They’re forced to find clever solutions to problems that engineers in the US might solve simply by buying more expensive equipment. They work harder: Nanah once told me that she was doing a project for a lab in Tanzania, and her team spent days tracking down one critical part for their circuit. In the US, we’d probably just go to Amazon, use our lab’s money to pay for the part, and receive it in the mail two days later. We are lucky and spoiled, and I am impressed every day with the amazing things that both young engineering interns and staff members in hospitals manage to do despite the constraints they face. I feel more and more grateful for the resources I have access to in the US, and I feel a sense of renewed devotion to make the most out of my time at Rice in order to truly take advantage of what Rice offers and prepare myself for a career being the best I can possibly be.

My favorite moment of the week happened the night before the competition. That day, all 19 interns from the US, Malawi, and Tanzania traveled five hours from Blantyre to Lilongwe. We stayed in a hotel together, and after dinner we all gathered in someone’s room to help Alex’s team practice their pitch. Presenting on their team’s behalf was Rachel from MUST. It was a challenging pitch, because all the information had to be presented in under four minutes! I thought it was really special to witness all us interns gathering together at 10pm on a Wednesday night to support Alex and Rachel’s team (also including Betty and Rodrick). It wasn’t work hours, we didn’t have to be there, but almost everyone was present, sitting, listening, and offering advice. We were all genuinely invested in the success of their team, despite having our town teams to worry about, and I found that very touching. As much as stereotypes characterize engineers as being anti-social, loners, or bad at communication, I’ve witnessed us being exactly the opposite. Especially in global health, us engineers are a community. Rather than competing with each other, we work together, and I’m so grateful to be working in this field with these people.