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

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

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

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

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

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

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

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

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

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

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

Sunday, July 4, 2010
Happy Independence Day everyone!!!! I realized this is the third Independence Day I have spent out of the good ol’ USA that I can remember, last year was England, the year before that was in Mexico for another Beyond Traditional Borders thing and the year before that, well I had just finished high school and I hardly remember. Maybe Yiwen and I will try and bake something, or else we could stage a mock battle between us and our English medical school housemates which culminates in our victory and their signing of a Bill of Rights.
It has been an exciting first few days at Queen Elizabeth Central Hospital. We arrived into Blantyre from Lilongwe on Thursday with Dr. Oden and Dr. Machen. Queen Elizabeth Central Hospital is a large hospital in Blantyre, that has one of the largest catchment areas in Malawi according to population. It is much larger and busier than St. Gabriels, with more doctors. When we arrived we met Dr. Sarah Rylance, from Liverpool, who is in charge of the neonatal ward. She will be the person doing most of our mentoring I think. She took all of us on a tour of the neonatal intensive unit (NICU) the low risk room and the kangaroo room, all three of which form the neonatal ward. Usually when a child is born, it is taken to the NICU then observed. If it is stable and of a good size it is moved to low risk and then finally to the kangaroo room. Once a child is in kangaroo with its mother it is monitored for weight gain. If the child is above a certain weight, it must gain consistently for three days before it is discharged. If the child is under this weight the child must gain to it before discharge. All are expected to come back in a week for another check up. Yiwen and my eyes both lit up when we saw the NICU because it is so full of goodies to work with.
After our tour, we met with Dr. Molyneux, who Dr. Oden and Dr. Richards-Kortum have been working with for a while for feedback and ideas on design projects. She has also published some studies about pediatric cancer and other things related to the pediatric ward at Queen Elizabeth, so she also is a valuable researcher as well. After Dr. Oden and Dr. Machen demoed the CPAP, a fluorescent field microscope and the Sally centrifuge, Dr. Molyneux suggested that they demo for all the doctors at Friday’s morning mortality meeting.
After all the interest in the Sally centrifuge and the CPAP, they are going to be staying with here to do some preliminary testing. They have a more traditional CPAP in the NICU but it doesn’t seem to be working. Its good to give these devices a field test run before and more formal data collection goes on, since it will give us an opportunity to make any unforeseen changes that need to be done so that the device fits the environment.

During our last few days at St. Gabriels, Yiwen and I got to go visit two HIV support groups with Angela, who leads all the groups. The groups are designed for both HIV+ patients in the community along with the village AIDS committees which are leaders from the village. The group also has an adherence monitor and a community health worker as well. These groups will be particularly important for Jasper and Tiffany’s microenterprise training project so read their blogs for a more detailed info. Yiwen and I mostly just wanted a chance to learn about them since it seems like a really creative approach to helping people deal holistically with their illness.
Yiwen and I also got to work in the maternity ward to demonstrate the adult Veinlite and the pulse oximeter. The maternity ward is where the mothers go with their children just after giving birth to wait to be discharged. Usually after the births, the child is placed on a warmer, of which there is only one, for a bit (or another child is born) until both mother and child move to the maternity wing (from the labour ward).
There is so much light in the maternity wing that is quite difficult to use the transilluminator with the light shield over the top. The light shield improves visibility by blocking out ambient light, but it limits access to the vein for veinipuncture so it is a bit of a trade off. The Veinlite works by epillumination, shining light on the surface of the skin. However, transillumination is shining the light through the skin from the other side of the veinipuncture site (ie light on the palm, through the hand so that you can cannulate on the back of palm). Transilluminator refers generally to the device, regardless of which mode it uses. I really think transillumination would be more useful since it doesn’t obstruct the venipuncture site and, if your are working with the hand as is typical, you can get the patient to hold the device for you, which frees your hand for starting the stick and stretches the patients skin, making the stick easier. Although you are sometimes limited by the thickness of the site where transillumination will work.
The pulse ox we didn’t really get to test out, but just demonstrated to the nurses. They take pulse rate as part of the vital signs of the mothers every day, so this would help with this, but now they can test the pulse rate and oxygen saturation of both the mothers and children. However, it isn’t really clear id this extra information will be useful since none of the mothers are children ever seem to be put on oxygen. Apparently there is a bit of a stigma against having a nasal oxygen tube being put on the children since it is mostly used on children who are really suffering and frequently die. Consequently, providing oxygen is associated with death by the mothers and some are resistant to its use. The lesson here, it seems, is to start a new technology on children who seem likely to do well, so that both nurses and parents are more amenable to its use, rather than putting everyone off it from the start by using it on desperate cases. Also, that you never really know what sort of cultural barriers there are to a technologies adoption without first-hand experience. No matter how well your device works, you might be foiled if the device is never used due to cultural perceptions.

June 23, 2010
Today Yiwen and I went with Alex, the nurse in charge of all the community health workers, and Harold the driver to visit 5 patients. We got to meet and talk with 4 of these. I will talk about two and Yiwen will talk about the other two, so you will have to read her blog for this day too, in order to catch the whole story.
First off, the community health worker program was started so that men and women in the hospital’s catchment area, who are less able to get to St. Gabriels would be checked up on. Volunteers were asked for in the villages and these volunteers, after they were passed by the village headman, come to St. Gabriels for training in basic care. They are then responsible for checking up on sick people in their villages and reporting their status via SMS text to Alex. If some patients need particular care, Alex goes to visit them as urgency demands. Thus there is a network of health workers throughout the area covering things from home based palliative care to antenatal clinics.
On our second stop in this trip today, we visited a woman named Selina. The community health worker responsible for her is names Glay. Selina is about 46 years old and suffering from a lesion in the area of her left breast. She seems like a fairly happy woman, greeting us warmly and laughing sometimes with Alex. She has breast cancer and a mastectomy was performed in 2005, which healed completely, however now the wound has opened up again and a large abscess has formed, the border of which is growing and sensitive to bleeding. Alex suspects that the cancer was not full removed and that another surgery would actually make the wound worse. The bleeding is a consequence of the angiogenesis in the cancerous area, due to cancer’s increased metabolic need. Selina’s husband is helpful, learning how to help change the bandages on the wound and also how to appropriately dose her liquid morphine. I think the liquid dosing syringes/clamps would be great for this, since it is sometimes hard to explain how much liquid is necessary, and even harder to try and draw a line on the dosing cups the patients are given with a pen.

June 21, 2010
I haven’t been giving enough context in my posts I think. Just as a recap. I am working with Yiwen at St. Gabriels Hospital, which is in Namitete, a rural farming village, 45 minutes outside the capital city of Malawi. Jasper and Tiffany are also working here for BTB.
One of our devices that we brought with us was donated, a pediatric transilluminator called the “Veinlite Pedi”. Transilluminators are used to shine light, usually red through the skin to help visualize veins. The deoxygenated heamoglobin in veins absorbs light around the wavelength of red light, so when the light is shined on the skin, veins should appear dark. Finding veins helps reduce blind and unsuccessful sticking when starting a cannula to deliver IV fluids. Starting IVs successfully in infants can be particularly challenging due to their thin veins. The same can be said for adult patients suffering from severe diarrhea, since the dehydration shrinks the veins. Also, it is difficult to see veins in obese patients due to obstructing subcutaneous fat. These problems are compounded in our particular setting since it is even harder to see veins in dark skinned patients.
During this past semester I worked in a team developing a transilluminator which would be cheaper than the $100 it costs to buy a Veinlite. We were envisioning a handcrank device, so there would be no power requirement, to fuel red LEDs. In the end, the small LEDs didn’t turn out bright enough, so before the internships started I made several which have a large 1 Watt red LED (really bright for an LED) and are battery powered. Those transilluminators went to other sites and Yiwen and I got the Veinlites.
In the pediatric ward, the nurse tried out the Veinlite on three patients. He had only just be taught how to use it by the other nurse, whom we had demonstrated it to in the past week. On the first patient, he tried with the light shield, and saw a vein, but starting the cannula (the stick) wasn’t successful. Then he tried again after adding the neonatal adapter piece (to reduce the amount of light being used) and the stick using this mode was successful. Next he tried on an older child, 5 ½ years, and found the vein with the light shield in place and stuck successfully. On the final patient of the day, he used the Veinlite with the light shield, saw a good vein, but the stick did not work. When he tried again without using the light he was successful. One of the difficulties was deciding whether to try and hold the Veinlite in place while performing the stick, or to set it down once the vein has been spotted and try to remember the location. When my teammates and I were designing our prototypes, when had hoped to incorporate some sort of strap to help alleviate this problem.
It is hard to tell based just on this sample, how useful the transilluminator is. We don’t want the nurse to feel pressured to use the device, if he doesn’t feel comfortable using it, or if it doesn’t seem to help. I imagine there is a bit of a learning curve to using the device. Ultimately, starting an IV seems to be pretty hard, as well as a valuable skill. We decided that perhaps the Veinilite would best be used as a back up when veins are particularly difficult.
We also have an adult sized Veinlite, but it is not clear where it will be most useful yet.

June 16, 2010
Well we are still having internet issues here in Namitete. Yiwen and I will go into Lilongwe on Saturday to post this, and other blogs. It is very challenging not having internet or easy phone communication. I feel disconnected and more homesick than I have ever felt in 21 years of life, however, these feelings aren’t too severe and definitely not enough to distract me when at St. Gabriels. We finally got to meet with Matron Kamera. All of us discussed our technologies with her in turn, stating their intended goals, how they work and then asking where she saw them being most useful.
The hot cot electronics controls might be useful, but as it is missing their special thermostats right now, it is not very functional. The hot cot crib built by Elizabeth Nesbit and Yiwen when they were here last year still works and its use has been recorded about 4 times in this past year. It is kept in the “kangaroo room” which is a special room, with two kangaroo nurses, that is kept very warm. The kangaroo method is a way of keeping premature or low birthweight babies warm. The mother holds the child continuously to her chest in a warm environment. It helps maintain body heat through skin to skin contact, encourages breast feeding, neonatal health and mother-child bonding. It is a fairly new “method” and is popular for low resource settings because it requires little technology or direct cost. The incubator seems to be used much less than the kangaroo method here at St. Gabriels.
Yiwen and I were able to clear up a little confusion surrounding the use of the current incubator with the kangaroo nurses. The number or lightbulbs turned on is directly related to the temperature of the cot. If you get a child, you must look up on a table, its weight and age to determine the necessary air temperature in the cot. Then you refer to a table which says how many light bulbs you use to get that air temperature. They weren’t following this method, but we were happy to learn, that the nurses attentively monitor the baby’s skin temperature when in the incubator for safety. In any case, the nurses always use all 4 bulbs, the warmest setting. This made sense considering the tiny weight of the children, some less than 800 g (less than 1 lb). The electronics for this cot that we brought would help remove both the problem of choosing the right number of bulbs (by only allowing all 4 to be turned on) and would only allow a high and a low temperature setting, chosen based on the discretion of the nurses. Then they could be sure that the air temperature was indeed the temperature selected by the electronics. I hope to show the box to some of the pediatric nurses soon to get feedback.

June 17, 2010
On Thursday, Yiwen and I went with the “mobile clinic” nurses to a village called Dzama, 19 km (about 10 miles) from St. Gabriels. We hopped in the back of the pick-up truck with two nurses, and drove, slowly, though the countryside and small collections of houses over the bumpy red dirt road. With us we took syringes, a mechanical scale, immunizations, a blood pressure cuff and some record books. Along the drive we pick up a few more community health care workers.
Once we got there, we were greeted by a long line of mothers, all either pregnant, with their small children or both, standing outside the school house. (school is only Monday –Wednesday here) My job was weighing all the pregnant mothers on the scale and recording their weight in their “health passports”; yellow books especially for womens health, with sections for general health, family planning, ante and post natal checkup etc. Other things done that day were providing DPT (diphtheria pertussis and tetanus ) vaccines, weighing children to see if there are malnourished. All the pregnant mothers went to a back room for further exam, I don’t know what of.
Some babies on seeing me, especially if I waved at them, would turn towards their mothers and cry. A few even called out “mzungu” (foreigner) in fear. Most however are quite and curious. After all had been treated, I stepped outside to see a small crowd of young girls. I walked toward them to offer my hand for a hand shake, and it took awhile for a few to be brave enough to shake my hand. Soon though, with the help of some interpretation, I was teaching them how to play “red rover” and “duck duck goose.” Mothers gathered around to watch us. After games, the girls taught us their dances, and Yiwen and I danced with them. I bet we looked pretty silly but everyone was having a good time.
The pregnant mothers ranged in weight from 41 kg (90lbs) to 80 kg (175 lbs), however, this last mother was a bit of an outlier from the whole group. Almost all of the mothers were shorter than me, at my medial 5’7’’, even when they were standing on the scale. It seems like many of the women here are smaller in stature. It is difficult to tell if they are underweight because of the layers and layers of fabric they wear. Perhaps their smaller stature arises from consistent malnourishment, which is a problem here. When we were driving through the countryside there were many “feeding programs” organized through schools and some of the pediatric patients come in with little fuzzy orange-ish hairs on their heads, which, I think, is an indicator of malnourishment.
Malnourishment is an interesting problem that presents in all societies, even still in the overfed US. In medical anthropology, our class discussed some theories of malnourishment and there are even some, although not well respected scientists, who argue it is not detrimental to development. Here though malnourishment puts people and much greater risk for infection from things like a common cold to HIV. It creates a vicious cycle of malnourishment, weakened immunity, infection, increased caloric needs which in turn, exacerbates malnourishment.

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On Friday we tested the oxygen concentration sensor that was brought last year. It still worked well with both machines used in pediatrics to concentrate the oxygen. The technician says they use them about once a month when they are doing their routine checks of the oxygen concentrators. Since the O2 cartridges still seem to be working pretty well, we just showed the techs how to replace them once they start to perform less well. We are giving them a card with instructions on how to tell when it is going bad, how to replace the cartridge and how to recalibrate the sensor if necessary.