This past week, the other interns and I got the rip bCPAPs apart, piece by piece. This may seem strange since we are supposed to be promoting the bCPAP, not dismantling it. But recently, a new version of bCPAP came in from the manufacturers, so we needed to decommission the old machines to make room for the new ones. Our colleagues just came back from visiting the district hospitals and returned with a load of old bCPAPs that had no use anymore.

Mid-Decommisson of a bCPAP

But instead of just trashing them, which would likely be the practice in the US, we decided to get as much use out of them as possible. If we took them apart, then we knew we would be able to find a use for each and every piece.

We talked to the electrical engineering department at the Malawi Polytechnic University, who wanted the flowmeters, tube fittings, screws, switches, and some sheet metal casings from the dismantled machines for their design kitchen. We got an estimate from a scrap metal yard to take the rest of the casings, which we would put right back into funding the bCPAP project. We went to a plastic yard to see what we could get for the tubing and pumps. Sadly, there wasn’t enough plastic for them to buy, but they wanted to support the hospital in any way they could, so the manager donated “as many buckets as one could wish for” to hospital. The hospital is always in need of supplies, so this was much appreciated. We didn’t go in the plastics yards for free supplies, but what a bonus! In addition, there were a lot of parts that didn’t change between models, so everything else could be used for spare parts for the new machines. In a low-resource setting like Malawi, replacing broken parts on machines can be difficult/near impossible, so these spare parts are vital to keeping the bCPAPs up and running.

Old bCPAPs on their way to the metal yard feat. Kinsey

This whole process of taking these machines apart and repurposing each piece reminded me so much of how Native Americans would treat a buffalo. One animal for food, clothes, tools, you name it. Every part is used, not a thing wasted!

P.S. The title may or may not be a reference to a certain sequel to a Disney Channel Original Movie musical.

P.P.S. To all concerned, it’s from the fun-loving song “Fabulous” from High School Musical 2.

So what exactly are you doing in Malawi? An interview with myself about my time in Malawi.

Where are you exactly?

Malawi is a very small country in the south east part of Africa. I’m in Blantyre (denoted by the tiny green dot in the southern part)- the second biggest city in Malawi and not to be confused with the capital city.

How long will you be there?
9.5 weeks total, returning to the US the first week of August

Where are you working?
Queen Elizabeth Central Hospital

You’re not a doctor (yet), what are you doing?
A variety of things!

1. Working on the CPAP study: Elizabeth and Caroline, my two fellow interns, and myself have joined an existing staff of people working on a clinical trial of a medical device (the Pumani bCPAP that basically helps babies breath- let me know if you want a more technical or elaborate explanation). This means that we do a variety of tasks from decomissioning and disposing of old models to entering data in Excel and other random tasks.
2. Shadowing doctors and nurses: Getting to be on the wards has been my favorite part of working at the hospital. We start every day by attending the pediatric handover meeting and then can go watch care be delivered. This is cool because we get to see the CPAPs in use and important for number 3 below.
3. Needs finding: Every year teams of students at Rice develop medical devices for low resource settings around the world. Part of my job as an intern is to keep my eyes and ears open to potential project ideas to present to clinicians and the Rice 360 team.
4. An individual project: Hardest part so far, coming up with my individual project. I have some ideas, and have started researching them to see if they might be good. Stay tuned.

What is it like living in Africa?
Amazing! I have absolutely loved being here. We walk to buy groceries at the market, work on learning Chichewa, the local language here, and avoid the lions that prowl the streets. To clarify for those now concerned about my safety: there are no lions (or really any animals other than chickens) on the streets of Blantyre. We are, however, going to a wild game reserve this weekend!

What’s a normal day like?
Generally I wake up, get ready for the day, and then walk down the road to the main part of the lodge for breakfast. At 7:30 people start walking toward the shuttle cuing the chugging of tea and coffee and inhalation of toast and we leave for the hospital shortly after. (Yes there is a free shuttle from where I am living to where I am working, yes it is incredibly convenient).

At the hospital the other interns and I participate the the variety of activities listed above and stop for lunch (taking the traditional hour and a half off has not been much of a struggle for us)- usually we eat from the Malawian buffet for a full 650MK (less than a dollar). The bus then leaves again at 5pm to take us back to Kabula Lodge.

Evenings are pretty low key as we cook dinner, spend time with the other interesting people staying at Kabula, sometimes watch a movie or read my book, sometimes do work, and occasionally fight an unexpected circumstance such as power outage, minor flooding, or the inability to get keys to our room (a great story there if you’re interested).

Anyway, I’m having a pretty great time here and learning a ton both through conversations and just observing. Thanks for letting me share a little bit with you!

It seems as though every week is the start of a whole new, exciting internship. This week we are doing site visits to various hospitals in order to collect data on oxygen concentrators and hypothermia. To do this, we split up into teams of two. I am partnered with Brighton. Our plan is to go to Malamulo Hospital for three days and then Mulanje for two.

We are starting with Malamulo and spent the day Monday at the hospital. Malamulo is a really nice district hospital. It took about two hours to drive to from the Polytechnic and the last half of the drive is on a super bumpy, but really beautiful road through tea plantations.

Monday was all about introductions! Without a good intro, we would never have the chance to really get the data we want and wander the wards as we please. We met with the head surgeon, Dr. Hayton (he is from California like me). He is super nice and was very excited to have us look around and help improve the technologies. He especially liked that we came from a local school and that Brighton has the potential to come back even after the summer! Dr. Hayton gave us a quick tour of the hospital and told us where all the oxygen concentrators were located. He also gave us a lot of information on other technologies that have not worked for them in the past and we found out that their main method of preventing hypothermia was using Kangaroo Mother Care. After our tour, we then were given the freedom to wander the halls and look at the concentrators and how hypothermia is being treated at a nice, slow pace without keeping people from their work.

A key thing that Dr. Hayton mentioned was how some people come to the hospital to do research, take their data, leave, and never come back. This is definitely not something we want to do. Our goal is to establish connections and actively try to help the hospital in the end if we are able to come up with some solutions. Of course, my first task as a student and intern is to learn as much information as I can, but if in the process I am able to help just a little to improve the oxygen concentrators or find some simple solution to help with hypothermia, then that is even better!

Working with Brighton has been great. Here is a picture of us outside of Malamulo during our lunch break:

He is helping me be more confident in my abilities. Matt mentioned before we went on our site visits that confidence is the most important tool for gaining access to the different parts of the hospital. I was super nervous when we were first trying to establish connections in the hospital, but Brighton was very good about being optimistic and motivating which is the right attitude to have when it comes to tackling our two projects. Overall, Monday was a very successful first day at the hospital! We established the connections that will now let us conduct our research for the rest of our days at Malamulo. I know we cannot fix all of the problems at these hospitals, and we definitely cannot fix anything in just three days. But hopefully the knowledge we gain from our observations this week and the time spent during the rest of the summer developing the projects will help solve just one small problem.

It’s just our first week, and my colleagues and I are lucky enough to be able to attend and help run a bCPAP training course for Malawian medical professionals at Queen’s! I have always been interested in learning more about the implementation side of medical devices in low resource settings. Being able to witness this first hand is my main motivation for being here.
The training began with a few presentations that focused on respiratory distress syndrome, its mortality rate in Malawi, how to select the proper candidate to place on bCPAP, and how to put together the device for use. I had learned all of these things in the previous work days, so I could focus less on the information and more on how these doctors and nurses are learning about the bCPAP. The presentation concerning how to put the bCPAP together itself was short and to the point, and as someone well acquainted with the device followed it easily. But I wondered how well people new to this device retained this important information. Little did I know, that’s when the real learning began. The next portion of the training course was a practical skills session where the doctors and nurses would have to practice putting together and using the machine as a team. There were two bCPAPs, three overseers, and about ten participants. So each group had about five people, a mixture of doctors and nurses, at each machine with a bCPAP nurse/doctor to help the participants learn to use this device correctly.

Group of medical interns during the practical skills session

The third overseer, a consultant for the pediatric department, went between each of the teams and gave them different scenarios concerning the baby’s breathing and its symptoms and would ask how the doctor or nurse would respond in this situation. He came back and forth between the two teams and asked things like: “What do you do if the baby’s O2 saturation isn’t increasing?” “The baby’s heart rate is still too high and the baby has been on CPAP for 24 hours. What’s the next step?” This forced the nurses and doctors to think critically about the patient while interacting with the machine. If the answer would to be to increase pressure, then the medical professional would physically go through that step with the machine to save the baby (or baby doll, in this case). Beyond that, each nurse and doctor in the group had to show that they could put the machine together properly to their group and the CPAP overseer. Watching each team member go through the same steps over and over clearly cemented the process in their heads. The first person to go in the group was usually pretty uncertain with timid suggestions by their colleagues, but by the time the 5th person went, it was practically muscle memory.
This was a truly amazing thing to see in action. I bounced back and forth between the two groups and got to see nurses and doctors who had learned from mistakes in their own turn, coach colleagues about using the bCPAP. This really convinced me that each person taking part was learning and retaining the information in this training session. Seeing everyone work together also helped me see not only how these doctors and nurses learn, but how they will teach others in their ward.

The journey of the oxygen concentrator that took too long.

Oxygen concentrators are important for giving patients oxygen in a place that doesn’t have wall oxygen, this is especially true for babies in the Chatinkha nursery- the closest thing to a NICU here at Queen Elizabeth Hospital. On a visit to Chatinkha, we were told one concentrator was not working. We rolled it through the maze of hallways, bumped it out to the car, and drove it to PAM- the adjoining office of engineers that fix the medical devices for the hospital and more accurately, the graveyard of broken medical devices on gurneys turned to dollies. With a lack of spare parts, donated already broken equipment, and a small staff for the number of devices, the engineers at PAM face an incredible challenge. There we were instructed to return in the afternoon.

Following instructions, that afternoon we tried to find one of the engineers. Though we were successful, the engineer informed us there were two major problems that would prevent him from being able to fix the concentrator. First, the power was out in the building (and given that it had been out for a year, it did not seem to be coming back on any time soon). Second, he could come to our office to fix it there where we had power, because it was already 3:30 in the afternoon and so it was too late to come that day. The next morning the engineer came to our office and fixed the oxygen concentrator.

There are many complicated issues in place here. There is the challenge of identifying broken equipment when there are so many patients per nurse and limited testing equipment. There is a personnel challenge of needing the man power to fix the number of devices that break and the resources to be able to do so. Finally, dusty conditions and old equipment contribute to devices failing sooner and more frequently. All that said, I have been impressed with the quality of care I have found here at Queen Elizabeth Hospital.

 

Next week we will be travelling to other hospitals in pairs.  I am travelling with Kate to Zomba, where we will perform oxygen concentrator tests and observe a few wards.

This past week, we have been extensively studying the components and operation of oxygen concentrators.  We have read through user manuals, taken measurements on some broken concentrators that are in the design studio, and opened them up to analyze their parts.  In preparation for our trips, we have created a data log to record the oxygen concentrations and flows being outputted by the machines we encounter, among other measurements.  One of the four toolkits we created for each team is pictured below.

 

Oxygen sensor, pressure gauge, flow meter, DMM, tubing, screwdrivers, etc.

While we have learned a lot about repairs, we will be working alongside the PAM (Physical Asset Management) technicians, who maintain medical devices in Malawian government hospitals, to do any repairs (not performing them ourselves).  Independently, we will be working on diagnosing the issues we find and creating a detailed database so that when we return to the Poly, we can determine common issues occurring as well as their frequency, and perhaps find some non-traditional solutions.  We want to especially focus on making them easier to repair locally, because having to order parts is not ideal in this setting.  Of course, in addition to any suggestions we make, Matthew Petney has asked us for a detailed risk assessment, as we will be proposing alternatives to standard repair methods.

Our observations in the wards are focused on the treatment of neonatal hypothermia.  Hypothermia in neonates is a known issue in low-resource settings, but lacks research and low-cost solutions.  While several devices have been designed to aid in the thermoregulation of neonates in low resource settings, not many studies exist comparing the effectiveness of each one.

Preventing hypothermia boils down to the methods of heat transfer: conduction, convection,  and radiation.  Within each of these categories lies a plethora of minute details which must be accounted for to prevent heat loss.  For example, if a newborn is placed on a scale for a few minutes after delivery while the mother is still being cared for, any contact with the cold metal of the scale will draw heat from the baby.  Any draft in the room as well as washing the baby too soon after birth facilitates heat loss through convection.  Drying and swaddling is a standard method for hypothermia prevention, but this is much less effective if the baby is swaddled in the same cloth that was used to dry (common if only one cloth is available).

We will pay close attention to every detail of the babies’ setting: proximity to open doors or windows, ambient temperature of the room, etc. Behavioral factors like temperature measurement methods are also important.  We visited the neonatal ward in Queen Elizabeth Central Hospital today, where we noticed that only one nurse was on duty in a large room full of neonates.  Most care was provided by mothers.  We spoke to a few, who said that they measured their baby’s temperatures with the backs of their hands, a common method where thermometers are not available to every mother.  We are hoping to shadow a nurse in the ward, speak to some mothers, and maybe even observe a delivery to better understand common thermoregulation practices.

This last week has been so great! We finally met the Malawian interns (Kate, Vincent, Brighton, and Harvey) that we will be working with for the rest of the summer and we all moved into our lovely house so we can cook together and really get to know each other. The best part of this week, though, was finally getting to work with the oxygen concentrators and understand how they function before being sent out to evaluate them on-site next week. On Tuesday, Kate and I went to Queen Elizabeth Central Hospital (QECH) to work with Mr. Nkosi (an engineer working at QECH). He had two oxygen concentrators that needed to be fixed, but we focused on one and used the other for reference to see if the parts were the same. I loved actually working on the devices that I have been extensively reading user manuals for and trying to troubleshoot myself.

It was such a good experience to work on the concentrator with an engineer and see how the concentrators are actually repaired in Malawi. Mr. Nkosi repairs the concentrators by systematically going through the different parts and trying to detect what is going wrong based on sight and sound. For the concentrator we were working on, you could clearly tell that there was a problem based on the sound being emitted from the compressor. To fix the device, we started targeting components related directly to the compressor. One of the problems we tried to fix was replacing the compressor filter. The filter that we replaced was black and full of particulates. Even though replacing the filter did not fix the main problem, it was still important to do for preventative measures in order to make sure clean oxygen is still being produced. After replacing the filter and some other components, we still had not fixed the main problem in our first visit and came back Wednesday morning to do more work. I have learned that sometimes it is better to take a step back from what you have been working on to fully understand the problem and think of a solution.

The greatest part about working with engineers is that they never stop thinking about the problem. When Kate and I came back to QECH on Wednesday, Mr. Nkosi had already been thinking of solutions to the problem for the entire night before. We took apart the compressor and discovered that the noise was coming from the rubber fittings at the top of the diaphragm of the compressor. The picture below shows the compressor for the concentrator with the top component taken off. The red circles are the rubber fittings that caused the noise in the compressor.

It was so rewarding to finally discover the problem and come to a solution! I cannot wait to continue working on oxygen concentrators and hopefully be able to diagnose problems on my own.