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.

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.

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.

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.