In Malawi, the prototyping process is hard.

 

In the United States, it is a lot easier because if I need a part, I can just order it online, and there will be a package on my desk in the next few days. This is especially important during prototyping when you are pursuing several design options and you might need to reorder a few components. The OEDK is especially helpful because there are so many materials at your fingertips to try out and experiment with.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Me holding up a sample of the parts we ordered from Mouser)

Prototyping is really hard in Malawi when most manufactured components have to be specially imported. Not only does this ramp up the cost, but it takes a lot longer too. In the design project we have been working on over the past week, we had it really easy. We ordered our parts on Mouser, had them delivered to the BRC, and then when our professors came to visit us, they delivered them. Even still, we had to made sure we ordered backups of each part. Otherwise, if one component failed, the project would be put on hold until the next time someone comes to Malawi.

 

(Our prototype for the IV timer based shut-off valve)

Thankfully, the future outlook for prototyping in Malawi is improving, at least for students at the Poly. The friendship that is being formed and that will continue to grow will hopefully be a gateway for more prototyping experience for these students. This is great news for the students at the Poly who have great theoretical knowledge, but rarely get to put it into practice. The opportunity for hands on experience will take their education to the next level, making them much stronger engineers for the workforce.
I know that I personally really enjoy being able to put pieces together; that moment when the light comes on and it all works is priceless. I’m glad that I have had this opportunity to prototype a little bit in Malawi, but I’m even more glad for the hope there is that the students here will get the same opportunity.

 

This is the last blog of the summer for me (I write at the DC airport, almost all of the way home). It has definitely been a fantastic time as you have hopefully been able to see through the pictures and blogs. I am amazed looking back on all that we have been able to accomplish, and I am so grateful to my program directors and sponsors for making it happen.

Tionana!

      

(Typing out this last blog in the airport)                                                        (Biting into the first burger back in the States: two patties, bacon, cheese, pretzel bun

                                                                                                                      …it was fantastic)

One of our house mates had a co-worker who plays cricket semi-professionally in the UK. While he was here, he joined up with a Malawian club team and we went as a group to watch him play in the championship game.

          

 (Jacinta and Emily watching the cricket match from the edge of the field)

 

Disclaimer: I knew almost nothing about cricket before a few weeks ago, so if this post doesn’t make a lot of sense, pardon me. I think there are some interesting analogies, so here goes…

 

5 ways our internship is like cricket

1. At first, it was hard to understand what was going on. As an American, I had never been to see a live cricket match before and knew almost nothing of the rules. Even with their patient explanation, it took a while before I got the hang of what things to watch for and what was important. In the same way, when we got dropped off in Blantyre, we were uncertain of what specific projects would come our way at first, but after a short while, we were able to find our niche.
2. Each team spends half the time fielding. Even worse than baseball, if you’re team is not up, you have to hold out through about two hours of being on the defensive, not being able to score. Although this seems non-productive, you’re setting yourself up to succeed later. As we have seen in our internship, results don’t come automatically, patience is required; just because you can’t see the immediate fruit of what you’re doing doesn’t mean that it doesn’t have purpose
3. There are two runners at the same time, but only one gets to bat. The other runner (the non-stricker) just watches and runs, but they are ready to take their turn at bat depending on which side they end up on. Teamwork is crucial. One lesson I have learned on this internship is that it’s hard to accomplish everything we set out to do. Sometimes I’ll have a rough day, and one of my teammates can carry some of the slack. Another day, someone will be sick and one of us will pick up a task they were going to accomplish. Throughout this process, communication is crucial, just as with the two runners. If one of them doesn’t communicate, they could be knocked out of the game.
4. One form of cricket is called a Test Match, which can last about five days. The title comes from the fact that these matches are demanding, specifically in the areas of endurance, perseverance, and strategy. The match is not won in the first hour. In the same way, medical device implementation requires foresight, planning, and a lot of sustained hard work. Even though we are only here for a couple months, this mindset changes the way we work. Instead of trying to swing for the fences, I can be most helpful to the project in the long run by fitting my work into the overarching strategy, supporting the program associates rather than trying to be a superstar and do my own thing.
5. Cricket brings people together. At the end of the day, you’ve worked hard, and whether you “win” or “lose”, you’ve had a chance to bond with some really great team mates. #teamworkmakesthedreamwork #malawi2014

One of the big projects that has occupied our past week is a repair manual for the oxygen concentrators used in the CPAP project. The CPAP machine uses oxygen blended with pressurized room air to deliver flow to the patients at around 50% oxygen. Thus the oxygen concentrators are an important part of the project. Although meant to be durable, every device will begin to fail eventually and the staff available to fix these integral devices do not always have the best training. Thus our goal is to produce a document that not only covers troubleshooting and possible causes of failures, but walks through step by step how to solve the problems and repair the issues. This pictorial manual is geared towards maintenance staff at the district hospitals, who may not have received extensive training.

 

 

 

 

 

 

 

 

 

 

 

 

(Picture of an Oxygen Sensor chip from an oxygen concentrator for our manual. You might be able to see where the bottom of the chip is burnt out; this circuit board needed to be replaced.)

 

 

My task has been to make a diagram of the pneumatic (air flow) pathway to aid the troubleshooting process. For a technician trying to repair one of these devices, with little prior knowledge, this flow chart is meant to show not only the flow, but also the basic function of each element. Using this diagram, and accompanying description, one can follow along with the broken oxygen concentrator and make sure there are no leaks at any point. While some of the main repairs require spare parts (see my earlier blog post), there are some simple interventions that we address in the manual. For example, leaks or failures in the tubing could be repaired without spare parts and without strong technical knowledge. Therefore, I want the pneumatic diagram to be as user friendly as possible, so, while it is still a draft, I would love to hear any feedback you have on anything that is not clear.

 

(Pneumatic Diagram of the AirSep Oxygen Concentrator. Email cjo4@rice.edu with comments)

One of the physicians in the pediatric department, Dr. Pam, has been such a servant, spending some of her time this past week cleaning out an equipment closet. The other day, she showed us the piles she had sorted and asked if we could figure out what equipment is still functional. It has been exciting getting to check out such a variety of equipment and see how it all works. Among the best finds have been a precision digital manometer (pressure sensor), and a half dozen or so BiliLight power adapters. Other gems were four syringe pumps and a dozen miniature ones. The past few days, during morning handover, I have heard a lot about failure to administer the right volume of fluids, whether it be too much, or not enough. Hopefully this equipment can be put to good use in the coming weeks.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Carissa, aka Mrs. Claus, wheeling equipment from the closet to our office for inspection. With all the packages, basically it was like Christmas. Note also the makeshift wheelchair: local ingenuity)

 

Our job as engineers sometimes seems slightly removed from patient care, but in this case, it is a joy to be able to help out. The equipment is in the same building as the patients that need it, all that is lacking is the knowledge that is there, and the confirmation that it can be used. One other common problem that sometimes keeps equipment from being used is the difference in plugs.

 

To fix this problem, Dr. Pam provided us with a handful of British plugs (the kind used in Malawi) to be fitted onto several pieces of donated equipment. Because the equipment comes from all over the world, either plug adapters or power strips must be used, but these are often either not available or misplaced. If the device runs on a 230V power supply, we have simply been chopping off the inappropriate plugs and re-wiring the new ones so that each device can simply be plugged straight into the wall. This simple intervention takes less than five minutes for one of us to do, but it can transform a medical device from being unusable, gathering dust in a closet, to being invaluable, in its rightful place on the wards. At the same time, installing these plugs is a big enough barrier for one of the physicians or nurses that it hasn’t been done. It is rewarding to be in a position where my skills correspond with filling a need that will make a difference.

 

 

 

 

 

 

 

 

 

 

 

 

(The bag of Malawian/British plugs we have been installing onto donated equipment. In the background is one of the power transformers we modified.)

Everything needs to be replaced when it breaks, or does it? From my experience, the norm in the USA is that when something breaks, more often than not, you just buy a new one. Here in Malawi, medical devices must be fixed. There is no budget to just go and buy something new.

 

Introducing PAM.

 

PAM, which stands for Physical Assets Management, is the workforce at Queens designated with the task of maintaining all of the hospital’s equipment. By fixing devices that break, PAM is the grease (literally) that keeps everything running smoothly. They also inspect each piece of donated equipment that comes in, making sure that it is safe and ready to use.

 

Before coming to Malawi, I had heard that PAM stored a lot of broken devices that they weren’t able to fix in their warehouse. Armed with a brand new tool kit, Jacinta and I showed up to PAM to see what we could fix; I thought I was going to solve all of the problems. I didn’t. The main problem was that we had not taken the time to understand their need.

 

After taking some time to understand what was going on, we discovered that the main problem holding PAM back from being able to do their job effectively is not lack of skill or spare hands, but rather spare parts. For example, below is a screen shot of a typical oxygen concentrator troubleshooting guide. As you can see, a large portion of the solutions require spare parts.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Screenshot of Oxygen Concentrator service manual. Most repair steps require space parts)

 

In order to get the spare parts, one solution would be to gut one machine and use the working parts to fix another. However, the donated equipment comes in all makes and models and it can be hard to find a match. Furthermore, each oxygen concentrator, for example, comes from a different ward in the hospital, each with its own individual budget. These two issues aside, this approach still has promise and we hope to give it a shot over the next few weeks.

 

As a long term solution, however, Jacinta had the idea that we should create a database where PAM can keep track of the spare parts needed for their repairs. While this does exist (somewhat) in the form of a few scattered word documents, we envision a centralized document that not only stores all of the data in one place, but also can print out a list of needed supplies with part numbers, etc. so that an aid organization could easily donate spare parts instead of entire machines.

 

This dream is still a long way off, but it seems like an economical endeavor, fixing more machines with the same amount of money. More than just providing money, this project would give dignity to the workers at PAM, allowing them to do their jobs and to make a greater difference at Queens. To me this resonates with the heartbeat of why we are here: not just to give out money, medical devices, or our time, but to empower Malawians to reach their goals.

Yesterday, I went with the travelling team to the Zomba Central Hospital. Our main goal was to scan patient charts from February to May for patients who were on Oxygen or CPAP. While Shannon and Carol got working in the office (the currently unused isolation room), Aakash and I rounded on our patients: the CPAPs and Oxygen Concentrators. Along with taking inventory of CPAP supplies, we had to swap out a two of the four CPAPs that were not working.
For the most part, I would say that this first trip opened my eyes to a new side of implementation: paperwork. In GLHT 360, Dr. Richards-Kortum talked to us about how the engineering design process involves much more than just coming up with a good prototype, but the trip to Zomba was a first-hand experience that helped it sink in. It was a good dose of realism.

 

Our paperwork consisted of going through the patient charts and scanning the doctor’s notes to find out how many days each patient had been on Oxygen or CPAP. After they are scanned, a subset of the charts will be reviewed by a doctor at Queens to verify that the diagnosis was correct. Collecting this data seems tedious at times, but at the same time it is a little bit exciting: the information I am helping to gather is helping babies survive.
On a side note, when I become a doctor, I hope my handwriting doesn’t look like that 🙂

At the same time, it was also a very encouraging trip. The in-charge nurse we met with said they had recently had a CPAP training with 40 nurses! This is really important because one of the problems with implementation is that only a small set of nurses know how to use the CPAP and they may or may not be on duty at the needed time.

Today I wanted to take a hiatus from updates on our work to talk about poverty: one of the issues I’ve been processing while here in Malawi. These thoughts are still a work in progress and represent my opinions; please feel free to disagree, or to inform me when I am wrong. The below graphic shows the GDP per capita in countries around the world, with darker colors being richer. As you can see, Malawi is in the poorest set.

The per capita GDP in Malawi is $268 (Worldbank, 2012), which is about 200 times less than the per capita GDP in the United States. Less than a dollar a day, and that’s average. There are still people who drive around in BMWs, and that definitely brings up the average.
On the other hand, you can go to the market here and get 3 carrots, a pound of potatoes, and a humongous papaya for that one dollar a day. Nsima, the Malawian staple, which is basically boiled corn flower, costs next to nothing to make and is eaten at every meal.
While these basic foodstuffs match up more or less to the Malawian budget, electronics, and other imports are through the roof. As an expatriate, I have American buying power and it is tempting to maintain my American standard of living, but sometimes that just doesn’t seem right in light of our surroundings. For example, we ordered pizza one night. It cost about $10 dollars a pizza because cheese is really expensive here, but that’s a price I would be used to paying. Thinking about it in terms of a local budget though, the five pizzas we ordered could constitute someone’s quarterly income!

One issue that I have seen so far is the availability of jobs based on low levels of training. On our walk to work, we pass several stalls selling fruits, peanuts, air time for your phone, or small candies that sell for around 2.5 cents. The profit margin on such things must be very minimal. There is definitely skilled labor here, but it is mostly up and coming. I don’t have any grand ideas on how to change a country’s economy. For that matter, maybe it doesn’t need to be changed; maybe that’s just my Western way of thinking.
On the one hand, things do seem to be progressing in Malawi. As technology progresses, more and more natural resources are being found within Malawi that will help boost the economy. The university (yes, singular, although it has multiple branches) is developing more programs to increase technical skills. There will be a day in the future when Malawi is more independent from outside aid. I think it will just take time.

I want to end on an encouraging note. A couple weeks ago, we met an artist named Maxwell, who had come to our guest house to sell us his paintings. After a few conversations, I found out that he in his third year of high school, paying his school fees by painting and selling his art on the weekends. While this makes his studies suffer at times, there’s no way around it. It is exciting talking to Maxwell, because not only does he have ambition to go on to University and develop more skill, his goal is to be able to give back. He told me that when he gets a job, he wants to be able to help other Malawians through school so that they can have the same experience he has had. People like Maxwell give hope for the future.

 

It’s been a great time this past week teaching our class at the Poly, and the best part has definitely been the students. I was stressed and anxious at first, but after the first couple of days I realized I just needed to relax: it’s about the students, it’s not a performance. When we weren’t able to get all the equipment we planned on, instead of worrying about how it would turn out, I learned to just do my best with what we had. In the end, I’m so thankful for all the equipment that we did have to work with, and I think the students learned a lot.

As electrical engineers, our students were very adept at troubleshooting electrical failures and following circuit diagrams. Our main goals were to educate them on the physiological background–why each medical device was needed–and to teach them to approach troubleshooting in a systematic way. One major difference between our students and students in the United States was that these students were much more reserved and hesitant to answer questions. However, especially in the practical, hands-on portions of the class, everyone was eager to share and try out their ideas. By the end of the course, we had covered Oxygen Concentrators, the Rice bCPAP, Suction pumps, Syringe pumps, and centrifuges.

 

 

 

 

 

 

 

 

 

 

 

 

(Hope examining a circuit board from a broken infusion pump)

 

Give a man a fish and he will feed himself for a day; teach a man to fish, and he can feed himself for a lifetime.

This class has meant a lot to me because I think that sustainable changes to healthcare in Malawi aren’t going to come with donations, or even with service, but through education. Money will be used up, expatriots will eventually leave, but training Malawians with the skills they need can make a lasting difference.

Below is a picture of a small group session of the troubleshooting workshop repairing a suction machine from the 80s. In perhaps the best success story of the week, our students were able to figure out what was wrong and bring the device back into working order, even when we the instructors were stumped.

 

 

 

 

 

 

 

 

 

 

 

 

 

(Atupele, Gilbert, Hope, Paul, and Isaac troubleshooting the suction machine)

 

Next week we’ll transition to some more CPAP related projects, but for now, it’s World Cup time!