We had more chance to work in A&E this week. It is one of the places where the IV drip monitor would be the most useful—other than the inpatient pediatric wards like pediatric special care. A&E, not by its own intention, serves as the triage of the pediatrics department. Queen Elizabeth is no doubt a huge, sprawling hospital. Potential patients seem to find A&E first and the doctors and nurses try to sort them, whether it is admitting them into the general wards or referring them to the different departments—oncology, dental, ophthalmology—with directions as to how to get there. It is a system not unlike the emergency rooms in the US except that Malawi has a public healthcare system so every doctor and nurse is paid by the government. What I was surprised to learn was that every service and medication provided by this hospital—in fact by all government hospitals—is free of charge. The only part that the patient needs to pay for is the transportation. It is one problem but it is a big one considering how most of Malawi is composed of extremely scattered rural villages with no paved roads leading anywhere. An interesting situation actually occurs from this: Queen Elizabeth is established as the country’s biggest referral hospital, but it receives a constant flux of non-referrals. In A&E, nurses are constantly telling groups at time to go to their district hospitals first before coming to Queen. From the nurse, anyone who can afford the transportation to get to Queen come and skip the visit to the district hospital. When asked why families would choose to do so, nurses feel that it is the level of service and amount of resources available here. In district hospitals, medication and resources are constantly out of stock. Families are much more assured and certain of the care at Queen, which is something I can believe. Going to the daily department meetings, the doctors and medical students I meet are of a different quality and upbringing than what I seen at Namitete; Queen also receives a lot of government attention in addition to many donations from Europe that I have seen.

However, this does not mean that Queen does not face a constant shortage of supplies. Nurses have to constantly improvise in face of shortages. When nasal prongs are used up, nurses improvise with nasogastric tubes connected to oxygen concentrators. Moreover, when doing research as to how to improve the IV drip monitor, I learned that although the hospital’s standard IV giving set is 15-, 20-, and 60-drops per ml; nurses have to use whatever is on hand. I tried to get a sample of an IV set for each option, but currently all they have are 60 drops/ml sets. In A&E, to make sure children are given the correct amount of fluid, liquids are measured in burettes and then given to the child. Not surprisingly they have currently run out of the burettes, so all the kids are hooked up to adult IV bags. The nurses were really excited about a way to automatically monitor IV fluids even though my model is no longer working from the various revisions and tests I did in-country. Queen Elizabeth is a hospital that is trying to perform to the standard of a hospital in the developed world. However, it truly lacks the resources to do so even though the nurses and doctors I meet are just as passionate and dedicated. It is definitely motivation for me to continue perfecting the technologies I have been working to help deserving hospitals like Queen Elizabeth.

Having trained the nurses and set criteria for candidate babies, we were ready to start CPAP in the neonatal special care ward this week. We eagerly set up the machine on Monday at the position where the old machine was located. The tubing wasn’t long enough to reach the resuscitation unit where the baby would be, so we had to use tubing from the backup CPAP. The pressure system—for the water bottle to bubble only when the prongs are occluded—is delicate. With the extra tubing, we had to adjust the pressure hole (i.e. tape over the hole and enlarge a new hole until the ideal result is obtained). The next model which is slated to have a knob-adjustable hole that would definitely be more convenient, as tubing needs to be added or subtracted depending on the setting.

Unfortunately, over this week, we did not have a good candidate for CPAP. There was a wave of babies with severe asphyxia that we must exclude because they had not developed enough to know how to breathe. CPAP is not a ventilator; it can only help babies breathe easier and with less effort, not teach them. Since the inclusion criteria consider babies over 1200g, low-birth weight babies are excluded as well because they simply don’t have a good statistical survival rate regardless of the intervention. We had one potential candidate of a baby of 30-week gestation age and six-days old, weighing around 1200g. He showed a chest recession and had a 88-91% oxygen saturation. The test for CPAP was whether his oxygen saturation stat would improve if he was put on an oxygen concentrator. He did, which was great. However, his situation reveals the difficulty of testing the CPAP device. Babies with a decent weight usually mean that they are developed enough and are resilient enough to live without too much help; these babies would mostly likely improve on oxygen concentrators. From our previous mini-mortality study though, babies between 1200-1500g still have a mortality percentage around 50%. We are hopeful that CPAP can make a substantial dent to this number.

Meanwhile, I have been trying to fix the bilirubin phototherapy units that unfortunately, all have some sort of problem preventing use. The neonatal care ward, where they are mostly been used, is currently using newly donated phototherapy units like the ones seen in US hospitals. However, the doctors and nurses I have talked to admit that it is troublesome to obtain the right irradiance from the advanced phototherapy machines. We have built a simple irradiance meter that works by measuring the current produced from a solar cell powered by the light of interest and correlates the current to an irradiance measurement. Nurses are sometimes just too busy to constantly adjust the height of the phototherapy stands as the units are moved amongst the incubators. They would actually prefer to use the phototherapy units I built because they can be placed on top of the acrylic cover of the incubators (hot cots). Since the incubators are uniform, the irradiance of the phototherapy units does not need to be constantly adjusted. If they do, a simple knob can adjust the level of brightness from each LED.

I mainly face two problems from the phototherapy units. For the first generation I built in my freshman year, the socket for the adapter is pushed in because it did not fit the adapter head completely. So, nurses or medical student nurses would try to jam it in, loosening the glue and damaging the soldered wire in the electric box. Luckily, Liz and I have found a wonderful department called Physical Assets that is solely responsible for all the equipment in the hospital. The department is a giant warehouse of broken machines and scattered parts that are either in storage or in the process of being fixed. I found loose parts I needed and more importantly, a soldering iron that I could borrow.

For the second generation I build last year, all of the units work and all the soldered wire connections are holding well because of the improved circuit board design. However, because the power box and the LED strips are in one unit for ease of use ( a change from the older version), the heat produced by the power components after continual days of use has melted the glue holding some of the parts together—such as the sticker strips from protoboards where the LEDs are connected to. Fortunately, plastic c-shaped couplings found in the flea market can go around the protoboards and be nailed onto the wooden floor of the device, securing the protoboards. Overall, I was glad to find the units in good condition; I am relieved and happy to know that I did not had to do anything major to fix the units.

One of places recommended by Dr.Rylance for the Venulite transilluminators was the emergency (called the A&E) ward of pediatrics. Much of the sorting of patients is done there and thus cannulas are also started in the ward, which would make devicess useful. Liz and I decided to briefly visit the place to talk someone in charge who can then decide how to introduce the device to the staff at the ward.
A&E looked much better than the rest of the hospital with high ceiling, clean white walls and tile floors (we later learned that this building was opened around 2001). The construction was well-designed, which used clear plastic sheets in addition to the regular tin sheets to allow sunlight to filter in for a bright natural lighting. Moreover, specialty rooms were organized in a roundabout fashion that eliminated confusing hallways. We found the head nurse-in-charge, Mr.Tsamba, and demonstrated the device. He does see the potential use for the technology because they not only deal with small children where the veins are hard to find but also obese children. He already knows where to place the device for the most efficient use, but he wants to set a time when we can properly introduce the technology to the entire ward staff. Consequently, we will be demonstrating the device on the Monday meeting to the assistant nurses, clinical officers and consultants (doctors). Moreover, we will also be working in the ward on Monday and Wednesday, days Mr.Tsamba predicts would be most busiest for the ward and when device would have the maximum use.

Luckily, as the time was a slow Friday afternoon, Mr.Tsamba had time to give us a brief tour of the emergency ward. As the rooms are organized in a circle, the center region serves as the triage that is filled with rows of benches. Patients wait on the seats to see the two nurses at the head of the line to be weighed and assessed for the different services needed. This system is something we have also seen on our tour of the Kamuzu Central Hospital in Lilongwe; however, in the latter, the benches were color-coded to prioritize patients. In fact, the mortality rate at Kamuzu emergency ward almost halved because of the coloring system. Queen’s does not seem to use it; nurses see the patient based on a first-come-first-serve basis. Low risk cases are referred to one of three consultation room where consultants are situated. Patients to be admitted usually first stop by “room four” or admission room where IVs or cannulas are started. Emergency or life-threatening cases are directed to the resuscitation room equipped with a vital sign monitor, crash cart, oxygen concentrators and a ECG monitor. However, I was surprised that there was no defibrillator anywhere. A very basic theatre room—with x-ray screen, lamps and a bed—is right next to resuscitation; mostly orthopedic surgeries are performed in the theatre.

A&E has its own pharmacy where patients can obtain common painkillers and drugs for TB or malaria. There is also a lab equipped to perform full blood chemistries and technicians to read malaria slides for the ward itself. I didn’t see a TB isolation room, but cholera and diarrhea are two serious problems that each has its own separate room: a cholera isolation room and a ORS room for severe diarrhea. There is even a walkway connecting the main building to the short stay beds where patients are temporarily housed before they are moved to the wards. Malaria patients waiting for their second dose of quinine (four hours after the first dose) also wait on the beds and are monitored for any adverse reactions. It is interesting that there is another procedure room next to the beds where consultants work on special cases. It is a room equipped with a bed, lamps and x-ray screen, but Mr.Tsamba says that ever since he has been here, only rape cases are referred to the room. Girls who are raped must first report to the police to receive a special note of permission before they can seek help from a hospital. It is a process different from the United States and I wonder if the requirement that the victim must see the police first may be a reason why girls often report the cases days after the rape. It is very often, from Mr.Tsamba, that raped girls go to the hospital three to four days after the incidence.

The ward seemed organized and I am impressed that there is a separate pharmacy and lab solely for this department. However, we did visit very late on a Friday afternoon when things were winding down and incoming patients have slowed to a trickle. It would be interesting to work here in the coming week at its busiest time to not only test out the transilluminators but also observe how well this ward function to meet demand.

Bubbles CPAP is one of the exciting new technologies Dr.Oden and Dr.Machen left with us. Compared to the expensive respiratory devices in the US, bubbles CPAP is a proven cost-effective support for respiratory distress in neonatal intensive care units, especially in developing countries where ventilators are unaffordable. The neonatal special care ward at Queen’s has a CPAP machine composed of a compressor, oxygen concentrator, a fan to keep the compressor from overheating and tangle of tubing. Seeing the CPAP device demonstrated by Dr.Machen, which costs about $150 and is the size of a shoe box, Dr.Rylance and Dr.Molyneux were eager to try out the technology immediately.

However, we have to first figure out which babies would benefit the most from the technology. At this point, it was interesting for me to learn that the success of an implementation does not only depend on the technology itself but also on the initial patient cases. If the first few babies die after being on CPAP, the nurses and families may associate the technology with eventual death. The nurses would be become reluctant to use it even though the deaths may simply be that the babies are too premature. Thus, the first few babies on CPAP must be picked carefully to be babies who can both benefit from the technology and be most likely to survive. Quite a lot of sickly babies come through the neonatal ward; almost every case is related to prematurity which can be caused by malnutrition, HIV/AIDS and infections. We have seen babies weighing around 600 g; however, babies less than 1kg may simply be too difficult for the CPAP to make a difference because the lungs are not developed enough. Liz and I actually collected the mortality data for the ward from January to June of this year for the babies under the weight of 1500g and studied it according to band widths of 100g. It was startling to find that babies under 1 kg had a mortality of 100%. Only starting with the band from 1000-1100g does the mortality percentage start to drop around 50% and lower. Dr.Sarah Rylance was keen to set the initial criteria at weights above 1200g as the survival rate on average hovers around 50%, a percentage which the CPAP may make a big difference.
Training the nurses is the next big step to implementation. There are currently about seven working in Chitinkha (name of the neonatal special care ward) but only three nurses work at any one time. It would be difficult to introduce the device to everyone in one meeting because half works the day shift while the other, the night shift. We were advised to talk to the nurses in groups, checking off the nurses from our list as we go through the week. All of them are experienced with the CPAP machine in the ward, as they have been trained by a Dutch doctor who first introduced the device. However, the current machine is not being used because it is not working properly or in the nurses’ words “making too much noise” and no one knows how to fix it. They were an attentive bunch at our presentations. Some took notes; they were happy to play with the device, connecting the tubes and such. From our interviews, I do not get the feeling that the nurses have any reservation about CPAP or the technology, but everything would be at the discretion of the doctor in charge. Previously, babies on CPAP were put on and off at a doctor’s orders and the nurses have never instigated CPAP based on their own judgment. However, they feel comfortable about CPAP and its benefits, but when asked about how families react to the technology, we received quite interesting responses. One, it seems that the mothers do not trust the device. Some become suspicious when they see that their children have a nasal prong for the CPAP/oxygen and a gastro tube for feeding; they wonder how the baby would breathe. Getting the mother more involved may help belay their fears, which this device has incorporated. The mother can watch over her child to monitor that the water bottle is bubbling. If there is no bubbles, she can alert a nurse or someone in charge that something is wrong and the baby isn’t getting extra help to breathe.

Currently, we have set up the device in the CPAP corner of the ward. All the nurses have been trained on the device and we have a picture protocol of how to use the device on file in the “technology protocol book” and on the wall. We are hopeful that candidate babies will be on CPAP starting next week. There was already a potential baby this week. He was a 1300g neonate three days old who was starting to show chest recession. When we check his oxygen saturation rate, he was at the 86-88 range. The consensus was to put him on the oxygen concentrator and if his saturation doesn’t improve, then he would be put on CPAP. He is currently doing fine on the concentrator, but this may be the procedure we will be using.

It was a sad day when we left St.Gabriel’s Hospital this past Wednesday. I will miss walking around the hospital, always having someone to greet and chat with. This was my second time at St.Gabriel’s but I feel that I have gained a new level of intimacy. Showing the hospital to Dr.Machen—the Texas Children’s Hospital emergency room attending who accompanied Dr.Oden—I realized that I knew most of the people who worked in each ward: pediatrics, ante-natal, labor, post-natal, maternity, female, palliative care, ARV clinic, mobile clinic, home-based care and HIV/AIDS support staff. I leave being proud and grateful that I have worked at such an amazing hospital and seen it continuously improve its care services ( I just learned that an emergency wing is under consideration). Sure, St.Gabriel’s is small but it is offering healthcare in innovative and comprehensive ways (social and economic HIV support groups, community health workers, end-of-life care) that Queen Elizabeth Central Hospital is trying to replicate
Our next site is the Queen Elizabeth Central Hospital at Blantyre, the economic center of Malawi. Our focus will specifically be on the pediatrics department under Dr.Molyneux, an inspiring Scottish doctor who is the source behind many of the ideas for the technologies we brought. The hospital is an intimidating place, a winding, sprawling complex of hallways and haphazardly-added buildings. From the outside, it looks like a dilapidated apartment complex with fading white paint, molding roof tiles and facilities for caretakers to cook and wash clothes. However, at least for the pediatrics unit, the hospital offers an extensive range of health services: pediatric oncology, emergency and intensive neonatal units to list a few.
We began our first day at the department daily morning meeting on Friday which is the weekly mortality report (a little over 10% for that week of over 300 admissions). One particular case that caught the doctors’ and mine attention was a child who died from rabies because the family did not recall the child ever had been bitten by a dog. Given the prevalence of stray dogs in Malawi, admissions due to rabies are high but the rabies vaccine is actually very hard to obtain. The rabies vaccine and oxygen are what Dr.Molyneux mentioned to be the two greatest medical shortages in Malawi. Malaria, tuberculosis and HIV/AIDS have caught worldwide attention but it is easy for easily preventable but deadly disease to escape the global radar.
We meet with Dr.Sarah Rylance, an English doctor who had also worked in Tanzania, to start our first day in the neonatal ward where most of our technologies are most applicable. The ward is separated into three sections: an intensive care unit, a low risk room and a kangaroo room. There are on average around 40 deliveries per day compared to St.Gabriel’s five, so Queen Elizabeth sees many sickly babies. When we first walked into the intensive care unit, four to five babies were on each of the three resuscitation units. The nurses tred to group the babies by weight on the resuscitation machines, but we saw cases when a large baby would be placed next to a under 1 kg baby; however the heating of the device would be adjusted to help the smaller baby retain its temperature while the larger baby was sweating profusely. There is no ventilator in the entire hospital, so almost all the babies we saw in the intensive care unit below 1 kg had died by the time we left. It was unnerving to see tiny babies skinny to the bones struggling to breath and know that there is nothing can be done to save them. In this setting, we stumbled upon a particular ethically-conflicting case. A baby with gastroschisis was delivered about a week ago; the surgeon wanted to operate on the baby because in the Netherlands, there is a 19% of survival. However, there was a counter-argument that in a limited-resource setting like Malawi, it would be a waste of resources and torture for the family and the child. The mother came from a very far village and was traveling back and forth to see her child. The big question is: is it ethical to bet on a small chance of success in the best of setting or to do nothing. The mother was to be counseled, but the child died in the morning. I have but seen two deaths in St.Gabriel’s, but the deaths are staggering at Queen Elizabeth. There is an urgent sense of need because any improvement would help. The unit has two pulse oximeters but both are nonfunctional. They use what would be disposable sensors in the UK, but since there is none in Malawi, the sensors are worn and dirty, hence the malfunction. The two syringe pumps were not working; the CPAP was not being used because the only nurse who could operate the machine was on leave. The oxygen concentrators had four or five splitters each, but there was nothing to check the oxygen level being delivered in each split. Needless to say, Elizabeth and I can’t wait to start implementing our technologies and carry new ideas back to the US.
Babies with minor problems such as jaundice are moved to the observational unit. Here are most of the original hot cots that senior design students have improved upon and where the phototherapy lights I build last summer are being used. The unit has a transdermal bilimeter that, with two clicks, can output a bilirubin reading that can help nurses and doctors diagnose jaundice. This is probably the reason why Queen Elizabeth actively treats jaundice while St.Gabriel’s rarely diagnose the condition, as it is very hard to spot on dark-skinned individuals unless the condition is severe. Unfortunately, there is only one extremely expensive bilimeter, which seems to be the story of everything in the hospital.
The kangaroo room is where stable but small babies stay with their mothers under a nurse’s supervision to use the kangaroo method to nurse the babies. When we first became introduced to the ward, the nurse wonderfully described the room as “ love, food and warmth” (and it is very hot in there). Babies stay until they reach at least 1.5 kg with three days of consecutive weight gain. It is definitely a feel-good room because I saw many committed mothers; many, from the charts, have stayed a couple of weeks in the room waiting for the child to get better.
Working at Queen Elizabeth will be a much different experience than at St.Gabriel’s. The neonatal ward at Queen’s, at least, seems to always be in a flurry of activity. Babies are crying, one or two nurses are trying to take care of 40 or more babies, medical students and interns are walking around making rounds with doctors. It is exciting, intimidating and wonderful to become a part of it all. Our list of technologies has kept expanding so it looks to a great month ahead. New technologies include:
1. CPAP: a currently $150 device for babies with respiratory problems that to quote Dr.Machen “remind babies how to breath”
2. Sally spinner: a hand-powered centrifuge that can determine hematocrit within 10% of accuracy
3. Hot cot electronic set
4. Oxygen sensor- measures the oxygen level delivered by oxygen concentrators

I think since most of technologies are for nurses and doctors, some aspects of our implementation and assessment processes are actually taken for granted. A simple day spend with Alex on his daily mobile palliative trips taught me a lot about the basic challenges that can undermine any global health intervention.
The case that has particularly engraved itself to my memory was the first patient we saw: a HIV positive woman with Karposi Sarcoma who had recently experienced swelling on her right side. This recent development had not only caused her increased pain but had prevented her from performing basic household duties. St.Gabriel’s doesn’t have the resources or the capabilities to treat the problems of patients on palliative care; moreover, often times, treatment actually worsens the situation. The best Alex could do for the woman was upgrade her level of painkiller from brufen to morphine. Here comes the problem: the morphine was only administered in a diluted liquid form. The patient was given a plastic measuring cup to give the morphine herself. However, she didn’t know how to read the cup and neither does the community health worker with us. Her ideal dose would have been 2.5ml, but it was obvious she didn’t know that 2.5 is between the 2 and 3 mark or that it is halfway between 5. Instead, Alex doubled the dose to 5 so that it would be easy to find and we also marked the depth with a black marker so she could not miss it. The next problem was the time of the dose. She is supposed to take the each every four hours. Again, mathematics proved challenging as the patient needed to do the addition that if the medicine is taken at 6, then the next dose needs to be at 10. Actually, the reality was that even if she could do the math, she didn’t have the clock or even the electricity for one to be able to tell time. The best we could do was to draw pictures of the sun’s positions at roughly the different times: sunrise for around 6am, vertical sun for the period around 10am to noon, then sunset for 4-5pm. Of course, not all of Alex’s patients lacked a basic level of education, but when asked, Alex would roughly estimate that 50% of patients in his care did not have a primary education. This is especially a problem for the elder population as primary education had only become free. I have never considered education from a treatment aspect before; the experience has certainly given me a larger picture of what implementation means, not only from a technological standpoint but also from a social infrastructural one.

The pediatric ward has been extremely accommodating in helping us set up an apparatus to test the Smartdrip. There doesn’t appear to a extreme need for a IV monitoring device here because as mentioned before, the main IV fluid given is the 5% dextrose which is appropriated(squeezed) to 300 ml before use. However, I was able to gather some useful, on-the-field information such as the available tube size (20 drops/ml), maximum dosage of fluid for protocols (no more than 300 ml for about 5 hrs) and the usual drip rate (16-20 drips/min).
I still wanted to test device in a hospital testing, with the data I have collected, but without a patient. The nurses allowed us to use a separate room in the ward for testing. However, as always for a prototype, we ran into problems. For one, the circuit board has a loose connection that I have not been able to identify. At certain positions, the LCD shorts out. I have checked every connection with a multimeter; with every wire either soldered to the board or printed, all connections are through. Unfortunately, because of this problem, the LCD screen does not work in the upright position when it is clipped to the drip chamber to monitor the drip rate. At this point though, I anticipate that the weight of the device may actually become a problem in this particular setting as the drip chamber that St.Gabriel’s uses is a little smaller than the testing one in the lab. It is quite possible that the device can slowly slip off after a few hours.
To solve the electric short problem, we constructed an apparatus of cloth hangers, bucket-support and measuring cups so that the IV set and the device can be at an incline. Of course, the incline led to another problem: sensing the drops. When at an angle, the drops do not actually fall straight down, but fall off to the side. The device can only sense a droplet if it falls in between the infrared red diode and the detector (thus reducing the level of transmitted light). Otherwise, inaccuracies occur in detection and monitoring of drip rate and volume dispensed. We are still currently trying to figure out how to overcome this hurdle.
On another front, we introduced the ART adherence charts to Grace the coordinator for the program, as advised by the Matron. Grace is the main nurse responsible for maintaining HIV patient check-up. She is the one the patients come to hospital to see, to check their adherence and to restock on medication. A network of adherence community workers does exist, but workers’ main job is to periodically check that the patient is taking the medication every day. As adherence calculations are cumbersome and complicated, only Grace is in charge of precise adherence monitoring. The adherence charts would simplify the calculations and gave the community health workers the power to track adherence; however, Grace feels that the charts would not be useful at this time. Moreover, there is a patient records system set-up for HIV patients that have the capability to calculate and save the adherence immediately during the monthly schedule check-ups with Grace. The community health workers, on the other hand, neither speak nor read English, so using the charts would pose a problem. Thus, at least at this time, determining adherence and the consequent power of responsibility that comes with the knowledge has not expanded to the community health workers.
The adult Venulite transilluminator has found its home in the maternity ward. We introduced it at the department meeting, but we received the real excitement when I actually brought the device to the ward. Unfortunately, Elizabeth was sick that day, but I saw the enthusiasm when the nurse-on-duty Doreen labeled MATERNITY on every side of the Venulite box. She also demonstrated the device to any working staff—be it a cleaner or doctor—who walked through the doors. I helped Doreen use the device to start a few IV lines. It worked well at locating the veins in patients when the blood vessels were not visible; however, because there was no way to gauge the depth of a vein with the device, Doreen still had to try multiple times in some cases to properly start an IV.
The pulse oximeter donated from the company Devon, after much debate between the matron and the doctors, has been placed in the maternity/labor ward. I think it is a great place for the device as the hospital does not have anything that would accurately monitor the vital signs of neonates. The pulse oximeter comes with adaptors for neonates, pediatrics and adult, but I think it is the first option that really addresses an important need of St.Gabriel’s.

We had an opportunity to go on our first mobile clinic this week, to the farthest post no less, a village call Dzama. It is about 19 km from the hospital, which driving over unpaved, dirt roads, translated to 45 minutes of  a very bumpy car ride. We left around 8 in the morning to arrive eventually at a school house to a long line of already waiting women, pregnant or with children. While it was impressive that the hospital makes an effort to reach villages as far as possible, it is noteworthy still that some of mothers had to walk 5km to get to Dzama.

There are two separate procedures for pregnant women and women with children under 5. For pregnant women, they first need to be weighted and the number is then recorded in their health booklet. The mobile clinic offers tetanus immunization for the mothers, so if they need it, they then go to the immunization station. All pregnant women are tested for HIV using the RAPID test that yield results in 15 min. St.Gabriel’s is very active in PMTCT and if the mother is discovered to be positive, she is referred to the hospital for counseling and treatment. As I rotated amongst the stations, I was surprised that at the immunization station, we had a supply of syringes that are automatically set to certain volumes to prevent an overdosage, sort of like the dosing kit we brought.

For the mothers with under-five children, they are first lined up outside beside a tree where their babies are weighed. The method is a little awkward but fast; normally, the children are slung on the mother’s back in a backpack fashion. To weigh the children, the sling is shrugged off and then hooked onto the scale hanging from the tree, like weighing a pack of meat. The weight is then tracked on the health card that has a trajectory indicating the ideal range of weight the baby should be at certain ages. Extremely malnourished babies are counseled and referred to the hospital. Children are also given the polio, DPT and measles vaccinations in addition to the oral administration of BCG.

The services offered are obviously very basic, but they are focused on two important factors impacting fetal mortality in Malawi. Vaccinations are the most cost-effective global health intervention while PMTCT is essential in ensuring the health of all babies given the relatively high HIV rate in Malawi. Traveling on the road to this remote village, the landscape really gave a perspective of how hard it is for healthcare to reach the entire population of Malawi. There are small villages, usually made up of a circle of huts with bricks and thatch roofs, scattered kilometers apart. Everyone is either riding bicycles or walking; there is no sign of paved roads or cars. On the way back, we picked up mothers on their way walking to the hospital on a journey that would take a car 30 minutes to travel. Malawi is truly still a very rural country, which makes even the simplest intervention like the services offered by the mobile clinic important and of high-impact.

Meeting with Matron Kamera definitely helped us jump start our projects. Not only is she an administrative head of the hospital but she is a wonderful adviser for finding appropriate homes for our technologies.

Smartdrip: This is a device that I have been working on over the past school year. It monitors the drip rate and volume dispensed from an IV infusion for children. In many developing countries, IV bags for pediatric use are rare so hospitals have to use adult sized IV sets. However, because of the low nurse-to-patient ratio, lack of proper oversight causes unsafe administration of IV fluids, often over-infusion that can lead to death. Working in the pediatric ward last week, I have seen nurses use the adult-seized 5% dextrose, the most commonly administered IV fluid. To make sure kids receive within a safe range of volume, we helped squeezed the IV bags to the right volume, ejecting the extra fluids down the sink. I are excited to receive formal permission to demonstrate the device and possibly test it on a mock set-up in a real pediatric setting; however, the dextrose IV connection is actually different from a standard, so interfacing it with the Smartdrip design may pose a problem.

Dosing Syringe Kit: This kit consists of a 5c.c. and a 3 c.c. syringe with a set of clips for each that would be inserted in the syringe and thus, prevents more than a certain volume of fluid from being drawn. Nurses then can quickly, with accuracy and precision, draw the same volume of liquid—whether liquid medication or vaccine—each time. Matron Kamera advised us to demonstrate the kit in the pediatric ward as liquid medication is mainly administered there. Female and male wards use tablets while the ART clinic has decided to stop administering liquid HIV medication after conducting a pilot study with the Bill and Malinda Gates Foundation. It was found that mothers are less cautious with liquid medication. Moreover, once the liquid is spilt, mothers are unwilling to admit to their mistake and thus skip the return appointment. In the pediatric ward, benzylpenicillin and quinine are the two most commonly given liquid medication that are administered according to body weight. Unfortunately, the standard c.c. for the two drugs are smaller than 1 c.c. ( in the tenths range) while the kit has mostly measurements larger than 1 c.c. Moreover, the needle part used in the ward is too small to fit onto the nose of the syringe, which made us impossible to demonstrate.

Veinlites Transilluminators: These devices were donated from a Sugar Land biotech company. They may prove extremely useful because veins are not only hard to seen for dark-skinned patients but kids have especially small, seemingly-invisible veins. It is a common site to see nurses, like an acupuncturist, poking a needle on both arms, wrists and jugular area of a baby to try to draw blood or start a cannula. It is painful to feel the nurse’s frustration and the constant wailing from the babies.

Deering Scale: This small portable scale, originally used for weighing diamonds, has been tested by a senior design team to be accurate for pill counting. However, the hospital has access to digital scales that not only are more accurate to a higher number of significant digits but also are less sensitive to weight differences amongst pills. One big problem that we found testing the device at the pharmacy is that the range of the scale from 1 to 10 g is not universally applicable for all types of pills that need to be dispensed. Many pills, like Erthomyothin or Brufen , are not only very big but also given in a packages of 40 or 40, which weigh around hundreds of grams. The scale works for very small pills such as Diclofenac but when we performed an accuracy test, the packages using the scale are usually +1 in count, which proves its preciseness not its accuracy.

We did not have the opportunity to meet with Matron Kamera this week. In fact many friends whom I was excited to see again were gone. Alex, the nurse in charge of the community health worker outreach program, is at Blantyre attending a two-week study on palliative care. Sister Honesta, a nun in charge of the OPD pharmacy is also at a week-long training session. For a hospital constrained by resources in every way, St.Gabriel’s tries to fully utilize and mobilize its labor force. Because nurses are overloaded (for the Pediatrics Ward, I saw only one nurse managing more than 60 beds at a time), the janitors are trained to perform basic tasks, as counselors and administrators for HIV testing, as nurse-assistors, etc. It is notunusual to see janitors removing cannulas, taking vital signs or giving medicine. In fact, the hospital sends many to central government hospitals to become specially trained in an area. For example, a pair of lady cleaners, trained in the kangaroo method, are in charge of the neonatal ward where the hot cot and the phototherapy lights are situated.

We felt it was inappropriate for us to introduce the technologies we brought to the different wards without first talking to the Matron and receiving her permission. However, we used the time to check up on the technologies we left with the hospital last summer. Mentioned above, the phototherapy lights and the hot cot are in the neonatal ward where two specialized trained assistants are in charge. We learned from them that the hot cot is used for babies with extreme hypothermia. Otherwise, in most cases, the kangaroo method—where the mother straps the baby skin-to-skin in front of her chest—is one they recommend because they want mothers to bond with their children. Moreover, the kangaroo method is a easily sustainable way for mothers to maintain care for the babies after discharge. One other reason they are reluctant to use the hot cot may be that there is only one for the ward. Having one baby in the cot while there are multiple patients may cause discord. However, I was glad, and pleasantly surprised, that they do record the times they use the cot on the sheets that we provided them last time. Even though both ladies were not the audience I showed the cot to last summer, they eagerly demonstrated to Elizabeth and I how they used the cot and referred to the directions Z and I left them. There were, however, two areas of confusion. One was the placement of the board that the baby rests on. I guess when they wanted to check if the bulbs were all lit, the board was moved to the opposite edge opposed to the light bulbs; however, the correct placement is directly on top of the bulbs, which is designed so that the hot air can sweep across the baby before exiting the cot. Another problem was related to a part of directions that was not labeled clearly.  They were confusing the temperature the cot should be based on the baby weight and age (gotten from the Academy of Pediatrics) with the temperature the baby is at. As a result, they always used four light bulbs; however, they assured us that they always check the temperature within the cot when in use. Overall, I am glad to see that the transfer of knowledge from the doctors and head nurses I introduced the device to has successfully passed on to the ladies in charge of the ward.

The jaundice phototherapy lights (fondly called bili-lights) are also kept in great condition. The two units I left with the hospital are both working well. The two nurse-assistants know how to use the device with the cot and what the irradiance meter is used for. The device has not been used frequently because the doctors do not diagnose cases of jaundice often. However, the two units are currently the only working therapy lights as the donated unit from the US is broken.

We also checked on the oxygen sensor used to measure the oxygen level delivered by oxygen concentrators, which ensures that the machines are working properly. The main component of the sensor is the only replaceable part of the device aside from the batteries. The sensors are expensive and impossible to find in Malawi, so we brought a few to keep them in stock for the hospitals. We were just in time for the hospital’s monthly check-up of the oxygen concentrators and had a wonderful opportunity to observe how the technicians use the device. Everything was working fine and the sensor did not seem to need replacement as it was measuring the oxygen of the ambient air within the expected range. We taught the technicians how to replace the sensor if they ever notice the device measuring the ambient air oxygen level to be below 18.

Before arriving at the hospital, one of my greatest fears was that the technologies would not be used. I have learned before that it is emotionally hard to have high expectations in unpredictable situations, so I tried not to hope too much before coming. I am extremely thankful to St.Gabriel’s Hospital for their trust in our projects and their courage and enthusiasm to include new technologies in their healthcare system.