A few weeks back, Kamal, Tara, and I had the opportunity to visit a palliative care hospice in Salima, Malawi called Ndi Moyo. A clinician from Ndi Moyo had been visiting St Gabriel’s Hospital when we demonstrated our technologies to the staff and was very interested in the morphine dosing technologies we had brought. We sent an Invertabottle and Doseright home with him at the end of his stay, and we were subsequently invited to come see the hospice where he works.

We got some great feedback on Invertabottle from him and got some first-person feedback from patients!

Current morphine dosing strategy for Ndi Moyo patients:
– Receive an upcycled water bottle which contains your allotment of liquid morphine for the week. (Palliative patients are typically seen once a week: they either are visited at their own homes or come into the hospice or check-up/care.)
– Pour about 5mL liquid morphine into the bottle top.
– From the bottle top, use a syringe to measure out the 2.5 (or 5 or 10) mL dosage of liquid morphine.
– Dispense from the syringe into mouth (or into a cup and then drink).

Invertabottle was demonstrated with two patients who use morphine regularly, and then they got to practice using it:

 

 

 

 

 

 

 

 

 

 

 

 

Snippets of positive feedback from patients after using Invertabottle even just once:

– “Invertabottle is 100% better than the original method: it makes sure that I am accurate, and it is cool!”
– “This is very cost-effective because it prevents me from spilling the drug.”
– “There won’t be any contamination or recycling of medication: I won’t pour out too much morphine when I take a dose and have to pour it back into my bottle.”
– “It is easy to use, even in the dark.

Informal method comparison:
– Invertabottle > Doseright clip on syringe > original method, according to the two patients and the clinicians who tried Invertabottle and Doseright.

Remaining challenges:
– Learning curve: it takes some time and practice for patients to learn the technique of inserting the clip into the syringe and locking it on.
– Overconfidence: patients, once demo-ed the device, are very excited about it but may be overly confident of its accuracy in light of problems inserting the clip. If the clip is not locked onto the syringe, then patients will experience systemic overdosages of morphine.

Overall: Invertabottle is a hit! There is still plenty of work to be done on the technology before it can be used on a wide scale (matching the luer-lok lids to the bottles commonly used for morphine, training programs, distribution, …), but we’re so very glad to have gone to Ndi Moyo and gotten confirmation and encouragement for a technology well done.

Sometimes it’s easy to envision the interrelatedness of medicine and magic. I feel a sense
of wonder, of awe, at the elegant mechanisms by which new technologies are formed, our
bodies work, and people interact in social settings. And that wonder, that mystery makes
me appreciate the things that I do know just that much more.

Prior to departing for Malawi, I had (somewhat) mentally prepared myself for the culture
shock of local attitudes towards health and medicine. Granted, my own perspectives on
what health is, what medicine is, and how best to deliver care to people are not very well
defined… but even so, I knew that my own subconscious presuppositions would probably
be refined here. And so they have!

Case in point: I have heard stories (and read stories) about the clash between traditional
medicine and “Westernized” medicine. But it’s very different reading a story in a book and
actually hearing said story first hand.

Story 1: Newly diagnosed cancer patient receives his morphine dose at his weekly
outpatient visit at the hospital palliative care unit and goes home. He decides that maybe
his diagnosis is wrong; after all, cancer is a disease that kills… and he certainly doesn’t
feel like he’s dying. So he goes to visit the local medicine man, bringing along his
questions and worries and his bottle of morphine. “Ha!” says the medicine man– “you don’t
have cancer! Give me that bottle the doctor gave you. I can make your pain go away.”
Bottle handed over, medicine man turns to make his pills… by mixing the morphine with
crushed herbs. And voila, the new medicine works! No more pain.
–> but he still has cancer, and his morphine is all gone, and he doesn’t go back to the
hospital for any more checkups. outcome? not good.

Story 2: Woman arrives at hospital claiming that she is in labor. She delivers… a stone. Surprise!
She and her new husband (she had already borne four children by a previous husband)
wanted a child. Visited one health clinic when she thought she was pregnant; was told that
she was not. Visited another, same thing. Visited a local traditional medicine man,
received some magic, and delivers a stone at the hospital.

Sometimes faith and medicine go hand in hand. Other times, they work against one another.
The lesson I gather is to listen and to learn — how to understand a patient’s worldview, and how to work with him to give him the best care possible.

Like dancing with a partner, medicine requires give-and-take, requires balance.

Belief is powerful.

11 June 2012

Right now, I’m sitting in my room in Zitha House, the temporary home of guests and volunteers at St. Gabriel’s Hospital in Namitete. Kamal Shah, Tara Slough, and I have been placed here at St. Gabriel’s Hospital by Rice University’s Beyond Traditional Borders international internship program for the summer.

Overview of our first two weeks here:
1) Settling in and overcoming jet lag (so glad that Kamal, Tara, and I were able to meet up in Washington DC to fly over together through Addis Ababa to Lilongwe! It’s so nice to travel with friends.)
2) Reinforcing and distributing a new set of file folders for each of the patient wards
3) Meeting the clinicians, nurses, and staff in each of the wards (especially in the Family-Centered Care Unit for Palliative Care and in Pediatrics)
3) Presentation of the technologies we brought, including:
– Dremofuge: low-cost, battery-powered centrifuge for urine/stool
– SAPHE Pads: visual estimation of blood loss for post-partum hemorrhage emergency
– Bililight phototherapy system: for neonatal jaundice
– IV DRIP: mechanical IV clamp system to prevent overhydration
– Invertabottle and Liquidose: dosing systems for morphine
– Length board: portable length board for measuring infants on community visits
4) Project: to put together an electronic medical record system for the Palliative Care unit
– Using Microsoft Access, we are putting together a simple interface for inputting patient records (demographics, appointments, drug dosages) and outputting easy-to-use data for monthly, semi-annual, and annual reports.
5) Exploring Namitondo, Namitete, and Lilongwe in our free time and learning Chichewa

We received lots of good feedback for each of the technologies, and I’m looking forward to seeing how they can be implemented here in Malawi. I think that the most important technologies we could bring here are things that free up hospital staff to do the work they are trained to do, to lessen the administrative load and to create systems that reduce time spent manually doing small tasks.

Kamal, Tara, and I go to Morning Report at 7:30am each day. Morning Report is the time when almost all the medical staff at the hospital gather to hear updates from each of the wards — new admissions, deaths, patients who are especially sick. It’s become more and more easy for us to understand what’s going on during morning report; a good sign that we’re more acclimated to St. Gabriel’s!

Despite many limitations (due to infrastructure, staffing, and financial constraints), St. Gabriel’s does amazing work serving the people of Malawi (and Mozambique and Zambia, since it’s pretty close to the border). Their official mission statement is “to provide excellent services to the poor rural community and to all those in need, in a transparent and accountable manner.” And they really do fulfill this mission. It’s an honor to be here, to learn about the way things are done in developing world hospitals with limited resources and to help where we can.

I’ll close this first blog post with a picture I took of the sunset last weekend on the walk back to the hospital from Namitete.