As another week comes to an end in Malawi, I can’t believe how fast the time has gone by. It’s hard to think that I’ve been here for over three weeks, one third of my internship is done! I can’t imagine how much I have learned in such a short time, and I can’t wait to see what future weeks have in store.

As I mentioned in my last post, this week Aakash and I have been busy travelling with Shannon and Carol to do data collection and CPAP visits in northern Malawi. We began the week in Lilongwe, the nation’s capital, where we worked at KCH hospital, a tertiary care center, and Bwaila hospital, a local hospital. The two settings could not have been more different! At KCH Aakash and I spent an entire day going through preexisting medical charts for all the babies who had passed through maternity in the past two months. From these charts, we sorted out the patients who had been on either Oxygen therapy or CPAP. After finding these files, we read through each set of notes individually, to determine how many days the interventions had been performed, and if they were successful or not, transcribing this data by hand onto CPAP forms which were then scanned into our computer system. In total we looked at over 300 files! Bwaila, however, is a much smaller hospital, and because of this most of the nurses had the chance to already fill out CPAP forms before we arrived, an exciting surprise!

 

While reading through dozens upon hundreds of individual files can seem daunting, thus far I have really enjoyed the work! It is exciting to see that, despite their similar conditions, no patient has the same story. I feel like my technical skills have developed as I have read through patient charts, and my medical knowledge increases as I look up terms or conditions I don’t know. I’ve even found that some of the common conditions, such as birth asphyxia, severe pneumonia, or neonatal sepsis, I have begun to recognize based on symptoms alone! Additionally, it’s incredibly encouraging to see the success stories of patients on CPAP who survived. Looking at how individual lives are impacted by this technology continues to affirm the importance of what Rice is doing here in Malawi!

When not doing data analysis, Aakash and I have begun to take over some responsibilities that Shannon and Carol usually have, allowing our team to work more efficiently. When we first arrive at a hospital, Aakash and I head over to the administrative block of the hospital to track down HMIS officers, employees of the ministry of health who keep track of, among other things, live birth data. Live birth data is valuable as it allows us to track neonatal intake, discharge, and death rates throughout the hospital as a whole, placing the data we gather from the CPAP patients in the context of the whole hospital. When we talk to the officers, Aakash and I get this data for the hospital for the past year, allowing us to look for trends that could change the interpretation of our data.

Additionally, we spend time inventorying and replenishing CPAP supplies that have been used since the last visit to the hospital and making sure our CPAPs and oxygen concentrators are still functioning. We also check up on the PAM officers, providing them with repair videos for CPAP and answering any questions they may have about the devices. So far, all of the PAM officers we have met have been excited to learn about the CPAP and how to fix it, and most of them have expressed interest in being kept up to date on any new information we may gather about the CPAP in the upcoming months. I imagine that the repair manual that Caleb and Jacinta are working on will be especially valuable here!

While we have definitely gotten a lot of work done on our trip, the time has not been without fun. Our long car rides allow for lots of time bonding, eating chocolate, and listening to music. Wednesday we left Lilongwe and arrived in Mzuzu, a northern Malawian town over a 9 hour drive from Blantyre. Even though Mzuzu is closer to the equator, it is known to be colder than Blantyre, and this is the first time I have had to wear a jacket this summer! Mzuzu is home to one of Malawi’s four central hospitals, which is where we will spend all day Thursday doing data collection. However, aside from Mzuzu Hospital, this city is also known for it’s locally grown coffee (yum) and it’s chitenje market (traditional female Malawian wraps that are worn as skirts). Hopefully we will be able to drink coffee and go chitenje shopping in some of our short time here!

Weekly Update

Well, today marks the end of another fantastic week in Malawi, and the beginning of a fantastic week as well! Aakash and I finished up our traveling last week with two day trips to Neno and Mangochi district hospitals. It was nice to be able to sleep in our own beds for the rest of the week, and it was extra nice to get back to the nightly insanity workouts our team has been doing. Hopefully this week we will be able to keep up the workouts on the road – today at 2pm we left for Lilongwe, the capital of Malawi, and we aren’t getting back to Blantyre until Saturday! While I will miss Blantyre, Emily, Jacinta, and Caleb, I’m also super excited to see the northern half of Malawi. Tomorrow we start data collection at KCH, the QECH of Lilongwe – a hospital that has over 19 CPAPs. I can’t wait to see how they integrated CPAPs into their daily routine, though I’m sure it will mean lots of data collection!

Additionally, last week Aakash and I had the opportunity to work with PAM at the district hospitals. We went around to the PAM departments, introduced ourselves, and showed the employees a brief video about how to repair the CPAP. Caleb and Jacinta are working on a user manual to complement this video, and I hope to be able to join them when traveling is over. Also, we got to see the video implemented in real life; one of the hospitals we visited had CPAPS which were only outputting a pressure of 8, when the ideal pressure is over 9! When we called PAM the guy who showed up knew exactly what to do. He walked up to the CPAP, looked at it, and said “I bet the diaphragm is broken, I just need to replace it!” I then watched and assisted as he proceeded to walk through the repair process, doing everything almost flawlessly. There were also, from what I was able to tell, several PAM interns (high school aged boys) with him as well. As the CPAP was being repaired, I got to explain to these students how the machine worked, and what it was used for. Shannon, Caroline and I have confidence that these technicians will be able to handle problems that should arise in the future; the whole process was an example of the sustainability that Rice is striving towards!

Doctors

I want to spend a little of my blog post today talking about doctors in Malawi. Currently I am reading Claire Wendland’s A Heart for the Work, a book that examines the import of western medicine into Africa. So far I’ve only read the introduction, so hopefully I will have more thoughts on the book in about a week or so. However, the brief amount I have read has already gotten me thinking about the differences between Malawian medicine and medicine back home.

Doctors are named differently! In the US we have interns, residents, and attendings; but in Malawi they have interns, registrars, and consultants. However, the term “intern” isn’t widely used in the United States, the term resident is used as an umbrella term. This is not the case in Malawi, and if someone says they are an intern, a Malawian will assume that they are a licensed physician. Aakash found this out first hand on his flight into Blantyre, when he told the people at customs he was an intern from Rice! He was cheerfully congratulated on being an 18 year old doctor.

In Malawi, as in most of Europe, there is no undergraduate program leading up to being a doctor. People go directly from high school into a five year MD program, and come out as a doctor. Generally, I envy countries with programs such as these: I frequently wish I was a doctor already so I could help all of the patients I see here! However, when I discussed this with one of the CPAP coordinators at Mangochi, he told me that he prefers the American method of schooling! He said that it allowed for physicians with more variety and more combined knowledge – in Malawi you would rarely see a doctor who was well versed in history, but in the United States, history majors can become doctors!

Anyway, those are the two main differences I have noticed in medical education so far, but I will try to gather more information this week, read some more in my book, and report back with more fun facts!

SAFARI

On a side note, this weekend we went on a safari! All five of the interns, plus Becky (a medical student who did undergrad at Rice and is completing a clinical rotation at QECH) took a couple of taxis and drove up to Liwonde National Park. We stayed at Liwonde Safari camp, and spent time on a river safari and a driving safari. We saw lots of hippos, elephants, birds, impala, warthogs, and more. It was a gorgeous atmosphere, with baobab trees silhouetted against the setting sun. We spent much of the night stargazing and bonding. Note to any future interns: if you are looking for an inexpensive, chill, and breathtaking safari, GO HERE.  Even the food was delicious; we had the best chicken I have ever tasted for dinner, and in the morning there were pancakes!

Note: My camera didn’t have a charge last week, so unfortunately I don’t have any pictures of our data collection. I’m currently recharging my camera after our safari, and hope to have some CPAP data collecting pictures for my next post, but until then, here are pictures of our safari!

Both this week and next week Aakash and I have been traveling and collecting bCPAP data with Shannon and Carol, two of the BTB associates here in Malawi. The hospitals that we have been visiting are in phase 2 of the bCPAP trials, which means that they were the second group of hospitals throughout Malawi to become part of the bCPAP study. The study has two parts: First, hospitals are provided with an oxygen concentrator and tasked with gathering baseline data for infant survival on oxygen alone. Then, after several months of accurate data acquisition, they are supplied with two bCPAPS, training, and supplies. The hospitals are asked to keep track of the number of patients with respiratory distress, following how many of these patients are put on oxygen, how many are put on CPAP, and what the outcomes of these patients are. This information allows BTB to assess the efficacy of the bCPAP, and will hopefully provide us with data to justify an even larger scale rollout.

 

Currently, the hospitals we visit are working on implementing CPAP. Our visits are follow-up visits; we replenish disposable supplies, gather new patient data, and ask for feedback on CPAP execution. If a hospital is having difficulty implementing CPAP or collecting data, we work with the hospital coordinators to develop plans and provide resources to improve CPAP use. So far, I have seen two common key barriers to CPAP use and data collection.

 

1.    Lack of infrastructure         

          a. Missing files, changing coordinators, and rotating nurses all prove to be a problem when introducing CPAP.

                                i.     When CPAP is rolled out at a hospital, it adds more paperwork to what nurses must already complete – they have to track the treatments and progress of each child on a sheet we provide, and ensure that the files are stored until we can scan it into our computers. Like any human-based system, this can result in missing or incomplete files, leaving our data lacking. To combat this problem, Carol makes follow up calls with all of the hospitals on a weekly basis, working with nurses via the phone to ensure all data is accounted for.

                                ii.     Our CPAP coordinators are also known as ARI (acute respiratory infection) coordinators. They are appointed by the ministry of health to handle acute respiratory care in the hospital, so the CPAP falls under their jurisdiction. The degree to which a coordinator is invested in CPAP can make or break the project, and when coordinators go on leave or change hospitals, it can take weeks or month for a hospital to get back on track collecting data. Ideally, in the long run, the CPAP program will become ingrained in the infrastructure of the hospitals, like it is at queens, so that changing coordinators will have no effect of the success of the device, but in the beginning stages, much relies on the presence of a knowledgeable leader. For now, Carol and Shannon seem to always have at least one other person at each hospital who is invested in and knowledgeable about CPAP, which helps the operations run smoothly when coordinators change.     

                              iii.     Nurses and doctors frequently rotate throughout hospitals and the wards in the hospitals. This means that, in some cases, many of the nurses who were originally trained on CPAP are no longer around. Fortunately, many of the hospitals that we have visited have retained at least half of their trained staff. While we can continue to provide site-specific training, our ultimate goal is for the remaining nurses at each site will pass along their knowledge of CPAP when new nurses enter the wards.

2.    Fear of the unknown 

          a.     Introduction of something new is always tricky. In the case of the CPAP, mothers frequently fear that this noisy and new device, which they don’t quite understand, will hurt their child or make them worse. Because of this, some parents may be resistant to the idea of trying CPAP on their children. Because the nurseries in Malawi are so crowded, if one mother has a distrust in the device, this distrust can spread throughout the ward. Therefore, one of our projects while here is to create educational materials for mothers, informing them about the benefits of CPAP. BTB has also put together a video in Chichewa that contains testimonials from mothers about the effectiveness of CPAP.

          b.    Nurses also fear putting children on CPAP. While nurses were trained to put babies on oxygen, CPAP is new. In the trainings we provide, many contraindications for CPAP are also listed. In our rounds this week, Aakash and I noticed that many nurses were scared to try the device on a sick infant, being scared that they may apply the device incorrectly, or be overlooking a contraindication. To combat this problem, some of the coordinators at the hospitals have begun weekly meetings, reminding their staff to use CPAP and fostering a supportive environment. These meetings also allow nurses to ask questions or voice concerns about the device, allowing for increased confidence in CPAP.

 

While there are still areas that could see improvement, overall I have been very impressed with the physicians and nurses that we have worked with. While things may be disorganized at times, everyone we have spoken with has been willing to work with us. The coordinators actively engage us in conversations about ways to increase CPAP use at the hospitals, are open to new ideas, and are friendly and helpful. Implementing CPAP on such a large scale is definitely ambitious, and it requires the coordination of a complex network of people working towards a common goal. However, from the hospital visits we have completed so far, I believe that our goal can definitely become a reality.

 

Side Note:

 

Our journeys to the hospitals take us all throughout Malawi! This allows Aakash and I to soak in culture throughout the country, not just in Blantyre. For example, on Monday night we stayed in a pottery lodge that was also a school for local pottery students. Additionally, our long road trips frequently provide us with breathtaking views, one of which can be seen below!

 

What an adventure the past few days have been! I apologize for the delay in blogging – due to non-functioning internet over the weekend and a three-day bCPAP trip throughout Malawi (stay updated for a blog about traveling in the near future!) it has proven to be quite difficult to upload this post. However, I am now back in Blantyre (home sweet home with internet sweet internet) and would like to take the opportunity to write about some of the technologies that I saw last week while working at Queens.

 

bCPAP

 

The bCPAP is probably the most written about medical device on this blog. Developed by a senior design team in 2010, it is now being produced by 3^rd stone design. In Chatinkha, the Queens nursery, four bCPAPs are currently up and running, and there are more in other wards in the hospital. While BTB is currently experiencing great success with the bCPAP – it has been shown to dramatically decrease mortality rates in infants at Queens – there is still a lot of work to be done. The device is currently being rolled out to district and regional hospitals in Malawi.

bCPAP

 

Oxygen Concentrators

 

Oxygen concentrators are crucial in the hospital, especially to the bCPAP project. When an infant is in respiratory distress, he or she will not be able to take in enough air to sufficiently supply oxygen throughout their body. This results in hypoxia, which can frequently lead to death. This problem is combatted by providing infants with a continuous flow of highly oxygenated air, thereby delivering more oxygen per breath. In the United States, hospitals store and use cylinders of oxygen to provide this supplementary air; however, in developing countries, commercially available cylinders of pressurized oxygen are not readily available. Oxygen concentrators take in atmospheric air, isolate the oxygen from the air, and output it in a concentrated stream containing over 80% of oxygen. As long as the concentrator remains functioning, this allows for a continuous supply of oxygen in the wards.

Oxygen Concentrator

 

Flow Splitters

 

Flow splitters are nifty little devices used to split the flow of oxygenated air when it is delivered from an oxygen concentrator. Oxygen concentrators can produce a maximum flow output of 10L/min, but neonates frequently need no more than 2L/min of air. This means that oxygen concentrators are frequently outputting 8L/min of oxygen that is not used. Flow splitters allow the 10L/min stream of air to be split into five 2L/min streams, thereby allowing more babies to receive oxygen. Unfortunately, flow splitters are expensive. While many can be found at QECH, many of the other smaller hospitals throughout Malawi do not have any flow splitters. For this reason, a design team at Rice worked on creating an inexpensive flow splitter for use in low resource settings. Hopefully we will be able to get feedback on the flow splitter from several smaller hospitals during our CPAP travels!

Flow splitter

 

Bilirubin-O-Meters

 

Bilirubin-o-meters are few and far between on the wards. From what I have been able to see, each ward has no more than one of these devices, and they are frequently circulated and loaned throughout the hospital. Bilirubin-o-meters are used to measure the amount of unconjugated bilirubin under the skin, thereby indicating if the individual is jaundiced. The meter functions through some type of spectroscopic means, though I am not entirely sure how. It is beneficial because the results are available instantaneously, allowing a doctor to monitor daily the levels of bilirubin to see if jaundice is improving or deteriorating. While these devices are available in limited quantity at Queens, they are expensive and require specialized charging stations and batteries. Frequently the charging stations are lost, rendering the devices useless until new stations or batteries can be brought to the hospital. Additionally, from what I have seen throughout my travels this week, the meter is not available at any of the smaller hospitals throughout the country. For her senior design project, Jacinta worked on a point of care bilirubin diagnostic test – hopefully we can gain feedback on her device this trip, eventually providing low resource hospitals with a less expensive way to monitor jaundiced infants.

Bilirubin-o-meter

 

Phototherapy Lights

As I have mentioned in previous blogs, phototherapy is an effective way to treat neonatal jaundice. The blue light breaks up excess unconjugated bilirubin under the skin, allowing it to be excreted from the body. Several years ago, students at Rice developed inexpensive phototherapy lights, several of which are currently being used at Queens. Excitingly, several electrical engineers at POLY used the design developed by Rice, gave it several modifications, and have manufactured several of these devices at the university. Last week, Jacinta, Caleb, and I worked with Rodwell, one of the engineers behind the modified phototherapy lights, to brainstorm ideas for a mobile stand for these lights, and we hope to be able to create a prototype stand before we leave. Additionally, Rodwell plans to give the new photherapy lights to Queens. Providing Malawians with the tools build medical devices for Malawi is significant, as it shows that we are doing more than donating supplies. Rather, we are creating an infrastructure for device development that is sustainable in the long run.

Jacinta examining the inside of the new phototherapy lights

 

That’s all for now…

While this list of devices was certainly not exhaustive, I hope it gave you a picture of some of the basic technologies that are used in the pediatric wards. Hopefully I will be able to learn about even more medical devices in the upcoming weeks, sharing about them via this blog as I go.
As a parting note, we climbed a mountain this past weekend! Mount Sochi is one of three mountains surrounding Blantyre. We took a taxi to the base of the mountain and stopped in a nearby town to ask for directions to the top. Our presence caused quite a stir among the children in the town, and 3 kids followed us up all the way to the peak! The hike was definitely more challenging than we expected, but the view and new friends were well worth it.

Aakash and our hiking companions

 

 

Emily and the view of Blantyre 

Muli bwanji!

It’s officially Thursday here, which means that Caleb, Jacinta and I have been in Malawi for one week. In some ways the time has gone by so fast that I can’t believe it, and in other ways it seems like we have been here forever. Caleb and I have spent the last 3 days shadowing two doctors, Dominique and Jalloh, throughout the peadiatric unit at Queens, while Jacinta has been busy coordinating with professors at Poly to coordinate out what the next few months will have in store for us. After several days of going about our official internship responsibilities, it’s nice to finally settle into a routine, recognize familiar faces, and know our way around the hospital.

 

Caleb and I before work at QECH

 

A typical morning on the peadiatric unit at Queens starts at 8:00am with morning handover. At these meetings, doctors discuss any unusual developments in patients that have occurred since the last morning handover as well as any deaths that have been reported in the wards. Though it is sometimes disheartening to hear presentation after presentation about cases that have gone wrong, I also find it encouraging that these cases are very few when compared with the number of success stories we see each day. Additionally, and somewhat surprisingly, I also found that I understand a large amount of what the doctors talk about in their morning reports!

After morning meeting I follow Jalloh to the Queen’s version of the neonatal intensive care unit, the Chatinkha nursery. For the past three days I have observed as he completed morning rounds, frequently checking up on over twenty patients in one morning. The wards are crowded, often with multiple babies in one incubator, which is incredibly different from NICU units in the United States. However, despite the limited space and resources, it is encouraging to me to see the passion that the doctors have for their work. One morning as we were rounding, Jalloh told me, “We may not have a lot of resources, but if we do the simple things correctly, we can make a difference.” I was blown away by the truth of this statement – frequently it is easy to get caught up in the development and use of new and groundbreaking treatments. However, a large number of patients can be successfully treated with basic interventions, as long as these interventions are correctly administered and the patients are consistently monitored.

 

bCPAP in Use!

 

It seems to me that the one of the main limits to care in Queens, specifically in the nursery, is not the quality of equipment, but it is the quantity. Much of the equipment used in Chatinkha is donated from outside agencies, and when this equipment breaks, the infrastructure and resources needed for repair are not readily available. This leaves essentially a graveyard of equipment that cannot be used. Today, I found three phototherapy lights and one suction pump in Chatinkha that were no longer in use for this very reason. Hopefully, Caleb, Jacinta and I will be able to work with PAM to repair these devices, and many others, in the coming weeks.

 

 

Phototherapy Lights That Need Repair

 

When not working, our team has been practicing Chichewa, learning to cook, and sitting on the front porch of the guesthouse drinking tea and making friends. Additional leisure activities include weekly bachelorette watching parties and trips to the market (where we try, and frequently fail, to bargain). Finally, Emily and Aakash arrived in Blantyre today, and Caleb, Jacinta and I are having fun giving them the grand tour of the city. Tomorrow we will introduce them to our friends at Queens and settle even more into our official internship roles. Caleb and I will also have the opportunity to meet our mentors at the Poly and hear more about the work they have already been doing with Jacinta. I can’t wait to see what our next week holds!

 

 

Drinking Tea on the Front Porch

 

Other work we’ve been doing: Inventory!

 

Well, after 41 long hours of travel, we have arrived in Malawi! Our trip began with nine suitcases (filled with hundreds of suction catheters for the bCPAP) and a shuttle ride to IAH. After an eleven-hour layover in DC, we flew thirteen hours to Ethiopia, and six hours to Blantyre. Finally we had arrived!

 

Starting off with a full super shuttle!

 

 

 

 

 

Sleeping in the Airport

 

 

Traveling with so much luggage!

 

Shannon, a BTB program associate, picked us up from the Blantyre airport and took us to where we will be staying for the next 9 weeks – Cure guesthouse. Cure is an orthopedic hospital here in Blantyre, and though we won’t be working here this summer, many of our housemates will be. Our current roommates are from all around the world – Denmark, Iceland, Nepal, and Wisconsin! Many of them leave within the week, but it is exciting to get to meet people from around the world who are working towards the same goal.

 

 

Home sweet home

After having some time to get oriented and unpacked, Shannon picked us up again to show us around Blantyre. We drove to PAM at QECH to meet Godfrey, one of only four certified bioengineers in the country. PAM itself was almost exactly what I had imagined, and luckily we saw a lot of the equipment that we were taught to repair from medical troubleshooting lab; we are looking forward to getting to know Godfrey and learning more about how we can best help out at PAM in the upcoming weeks.

Once we were done touring PAM, Shannon took us to the shopping center where we went to a grocery store called Shoprite. We bought some food staples (bread, rice, chicken, and jam), and we also bought new sim cards for our cell phones. We then drove past the open market where we can buy fresh fruits and vegetables; hopefully we will be able to visit sometime this week! Needless to say, we were pretty worn out from so much traveling, so after touring Blantyre we went back to Cure for some much needed food and rest.

 

 

First dinner: PB&J, oreos, and nutella!

Today, our first full day in Malawi, we continued our orientation. Shannon took us to QECH and gave us a tour of the BTB offices as well as the pediatric wards. The BTB office is full of CPAPs for us to repair, and it is also very well organized and the staff we met who work there all were inviting and happy to see us. QECH itself seems like a huge maze right now. We only visited each ward for a couple of seconds, but I can already tell that things are going to be different than the hospitals I have volunteered at in the states. Shannon also told us a little bit more about the hospitals in Malawi. QECH is one of four tertiary hospitals; local clinics are primary hospitals, regional hospitals are secondary hospitals, and district hospitals, like QECH, are tertiary hospitals. This means that most people at QECH have been referred there by physicians from regional hospitals and that QECH is one of the gold standards for hospitals in the country. Working with the CPAP project, I will be traveling to several regional hospitals, and I am sure it will be interesting to see the differences between the levels of care.

 

After our tour of QECH, we returned home and cooked our first non-pb&j meal! Thinking the stove was broken, we cooked everything using a microwave before realizing that that it simply wasn’t turned on. Nevertheless, it was a huge success. We plan on spending the rest of the evening and weekend blogging, learning about CPAP and studying curriculum to teach at Poly. Next week I hit the ground running, shadowing a doctor at QECH and figuring out the scope of our project here. It’s certainly good that we have this time to rest and prepare, but we can’t wait to get started!

 

Jacinta working on a blog post