Final exam

By Marcel

It feels kind of unbelievable, but this is the last blog entry. On the one hand, it seems such a short time that we have been here, but on the other, the things that happened during the first few days seem very far behind us.

We gave our students their final exam in pediatric anesthesia today. As Christina mentioned earlier, we included a number of actual board study questions from UVA in the quiz, and they found it quite difficult. After they had taken the test, we went through all the questions again, with the students divided into two groups, Jeopardy style. This, they found way more entertaining.

Huddle during pediatric anesthesia Jeopardy

We have come to know the students quite well during our time here. It has been pretty close contact, and a pretty intense schedule: a lecture and a case discussion every day, for three weeks in a row. It hasn’t always been easy for them since we have no interest in dumbing things down. But they did well, and really opened up along the way. This last week in particular has been excellent, with really good questions from them, extended discussions within the group, disagreements on anesthetic approaches that at times took quite a while to argue out – great learning opportunities for everyone. Most importantly, maybe, they were definitely no longer afraid to disagree with us, and to let us know if they felt we were wrong. And we have been very happy with that level of openness.

We said goodbye to Cyril Goddia, who heads the Anesthesia Clinical Officer program, and who has been an amazing host, surprising us every time with his thoughtfulness: from buying food at our arrival so we would have something to eat, to arranging for a car and driver from the College of Medicine to get us to and from the hospital every day – a great thing in the rainy season. We went out to lunch at an Indian restaurant with him today.

Lunch with Cyril

Also, we took leave of Gregor Pollack, the head of the anesthesia department at Queens, and Kai Jung, head of the ICU – the two German physicians who work here long-term. Both have been excellent guides to us in understanding the system here. And we owe Kai a great deal for sharing his coffee with us each morning, and for letting us be part of the ICU. Yesterday, the four of us ate lunch at the Beit Cure hospital café, where we had their excellent chocolate cake one more time.

We can’t say goodbye to our friend Ed , the dog. Somehow, halfway through our stay, he stopped coming upstairs and sleeping at our door – no idea why. We still see him on occasion around the apartment complex, but he hasn’t been up to see us anymore… Despite the cookies we bought for him.

And now it’s time to pack. We have a few days left in the country. Tomorrow we’ll be driven to Cape Maclear, on the shores of Lake Malawi, where we’ll hang out a few days to recover from the busy life of the past month. Then it’s back in Lilongwe, and back to the US. It has been a good month, but it’s a long time to be away, and we’re both definitely looking forward to seeing our significant others and friends again!

Yes, it has been a good month. As always, there are things that I will miss, and things that I will not. Things that will not be missed: irregularly irregular power and water outages, on occasion associated with flooding of the apartment; too-high-speed driving along dark country roads full of trucks, people and goats; randomly appearing trash heaps around the apartment complex. Things that will be missed: the students; Malawi Satemwa coffee from the French press coffeemaker that Christina brought all the way over here; Tennis cookies with Pralinutta (kind of like Nutella); elephants in the rain; morning coffee and discussions with Kai; trying to do a lecture in mime during a tropical downpour on the metal roof.

Things we don’t like: Christina rinses her hair in a cup of water

Since our work is done, we’ll close the blog here. Thanks to everyone for following our stories! It is a really good feeling to know that we’re not doing a trip like this on our own.

The next blog to chronicle a trip from our department is already set up! Mohamed Tiouririne and Albert Ardon will be teaching in Rwanda during the month of March, in a program run jointly by the Canadian Anesthesiologists Society and the American Society of Anesthesiologists. Their blog is at http://alandmoinrwanda.wordpress.com/

Once again, thank you for following, and we look forward to seeing all of you again once we’re back in the States.

Marcel & Christina

PS: There’s a gallery of trip pictures here

Last Week

By Christina

We are finishing up our last week of teaching and preparing our students’ final exam! The exam will be based on our lectures, but will also actually include some practice American anesthesia board questions. We are certain they will get them right, and they should feel good about themselves and their funds of knowledge (considering it’s taken me 12 years of post-secondary education to finally get those questions right…) They will have an actual test that we can grade and then we are going to play jeopardy, which should be really fun.

They have recently opened up and have become less shy about speaking up during discussions. In fact, this morning I gave a lecture on the Surviving Sepsis Campaign guidelines for both adult and pediatric sepsis. Then this afternoon, Marcel did the case presentation, and used a case that we had actually participated in that morning. An 18 y/o, otherwise healthy male had come in with three days of abdominal pain; he then started vomiting blood, developed a distended abdomen, and dropped his hemoglobin to 3. At this point he was transferred to the ICU, wherein he immediately arrested and was resuscitated and intubated. Kai placed a central line, of course all by landmarks, on the first stick, and we started epinephrine. I put in the arterial line this time and we rushed him off to the OR to get his dead bowel excised. Except, in the OR, he had perfectly pink and viable bowel. No pancreatitis, no abscess on the liver, no nothing! So the case was unclear. He was transferred back to the ICU, still with presumed septic shock, but no clear source. So when Marcel presented this to the TACO’s, they had a spirited argument about whether or not he met criteria for sepsis (lacking a source of infection) and whether or not a GI bleed was a source of infection. It was great!

They also had a good time during our pediatric advanced life support workshop (PALS) yesterday. We put them through various code situations and taught them how to work a defibrillator (which they may or may not have out in their district hospitals.) As you can see, they all had a good time, and usually saved the baby as well. On one scenario we even gave the neonate a congenital diaphragmatic hernia, so they had to recognize that their mask ventilation was making the situation worse. They figured it out…with some coaxing…and ended up doing the right thing. We are both really curious to see where these TACO’s end up after they finish training, and how they do in real practice. I think that they are going to be good additions to their district hospitals, but it is hard not to want them to have better opportunities. They will likely be the only people that can provide safe anesthesia and ICU care in their communities though, so it would be a disservice to the people of their districts if they went elsewhere. This is the problem with physicians trained in Malawi – they mostly all leave the country for better opportunities and lifestyles, and you can’t blame them. The TACOs on the other hand, are bound to their districts, so they will be headed home, no matter what.

And we will be headed home soon as well. We are looking forward to many things about this transition. We both want BIG salads. I want some yogurt and Marcel wants his own homemade bread. That being said, we again have been plotting how to raise funds for a return trip to give another refresher course (which we were invited to do!)

Third week wrap-up

By Marcel

Week 3 is behind us. We finished off Friday with a discussion on pediatric monitoring and equipment. This is not an easy topic, since so much of the monitoring and equipment systems used here are vastly different what we use. The central hospitals are fairly well equipped, with pulse oximetry, blood pressure and cardiogram used on almost all cases. Capnography is generally  not availab le. Many of their draw-over anesthesia systems (such as the Glostavent and the UAM) are not only completely unknown in the US, but also of fundamentally different design. It is therefore as much a learning process for us as it is for our students.

We use circle breathing systems for all cases, but the hospitals here use non-rebreathing systems for most general anesthetics; to be precise, the Jackson-Rees modification of Ayre’s T-piece, also known as the Mapleson F circuit. Therefore, there had to be some discussion of Mapleson circuits in the lecture. Now, as some of you know, I have never actually learned the Mapleson classification – my feeling being that (1) it was not worth spending time on it since it has no clinical relevance in our setting, and (2) it would make me miss, at most, a single question on the boards. My time was better spent on other topics. Hence, I can’t tell one Mapleson from another. Christina knows this, and she made sure that the moment of me with a slide of the Mapleson circuits in the background was well documented.

Marcel explains how he knows nothing about Mapleson circuits

After the lecture, we took a brief walk to visit the Beit Cure mission hospital, a small private hospital, focusing mostly on orthopedics. They are financed in an interesting manner: adults pay for their care, and that money is used to pay for the care of children, who are treated for free. Roy Miller, a UK anaesthetists who works there, showed us around. It’s interesting to see how different hospitals can be, even when close together. Beit Cure is very clean and organized, and quite well stocked. Most importantly, they have an excellent little cafeteria where we ate a sandwich for lunch, followed by some chocolate cake – quite a treat!

Anesthesia cart at Beit Cure

I also did the afternoon lecture for the whole department, and spoke on the WHO Safe Surgery Saves Lives campaign, and the safe surgery checklist. It is interesting to recall how much effort it took to have this implemented at UVA, and then to see how the same issues immediately arose when it was discussed in this so different setting: need for modification, buy-in from different medical specialties, need for support from the administration, etc… It is a discussion that is going to take a while.

And now we are in the Ku Chawe hotel on the Zomba plateau, about an hour driving from Blantyre. It’s time for a little rest, we have been going almost continuously lately. Here we are high up on the mountain, in cooler air, between pine trees. We’ll do some hiking tomorrow – if we feel like it.

The road to the Zomba plateau is the same one that we took to the Liwonde park, when we got stuck on the muddy road behind the minibus accident. It was a mud track at the time. The driver had his window open, and at one point (just when Christina had made a comment about how well everything was going) about a bucketful of mud water flew in through the window, straight into our faces. On the way back over the same road, a splash by a car ahead of us completely filled the windshield with mud. Our driver turned around with a smile and said: “Ha, blackout!”

But now it has not rained much for a few days, and everything has changed. Now we were driving through clouds of dust, and all the windows had to stay closed.

Well, we just finished playing a never ending game of bao (which we learned from one of the craftsmen on the street,) and it’s time to start thinking about some dinner…

Christina learns how to play bao

 

Expectation management

by Christina

It turns out Randy Blank, one of our attendings, is a genius. He always says something to the effect of “happiness is really all about expectation management,” which has proven to be unequivocally true.

There were country-wide demonstrations planned for today over the value of the kwacha. The previous president of Malawi had tied the value of the Malawian kwacha to the dollar, so the exchange rate did not fluctuate. When he died, the current president took office and floated the kwacha, meaning that its value was almost halved. In an already poor country, this had a huge economic impact. So, the Consumer Association of Malawi scheduled protest marches in the major cities. These were approved buy the government and planned to be peaceful. Great. However, last time they had demonstrations, things got a little out of hand, fringe groups and thugs (as they say here) joined in and started looting, setting cars on fire and generally causing a ruckus. This led to the police releasing tear gas and actually firing live bullets, killing 20 people across the country. The military was deployed and everything settled down after 2 days. So this time everyone was a little worried about what would happen. Cyril had said yesterday that we should be prepared for mass casualties at the hospital. The police also banned radio stations from reporting on the demonstrations live, so there was no way to get updates.

When we awoke this morning, everything seemed normal, other than the fact that there was BOTH hot and cold water. We heard some horns blowing in the distance, but nothing too scary. Our trip to the hospital also seemed fairly standard, other then the three flak-jacketed policeman that had been stationed in front of it. The police had also been stationed all along the demonstration route, with semi-automatic weapons, for security. There were a couple people missing from morning report, but it went on as usual and then we had a good discussion on blood transfusion management. This wasn’t planned for this day on purpose, the schedule just worked out like that! The OR’s continued with elective cases.

The town was very quiet, and no shops or restaurants opened. Marcel and I had come prepared with slices of bread and cheese (and coconut cookies, which are now an essential part of our daily diet.) The demonstrations went on peacefully, they delivered their petition to the government offices, and then by 1pm, the whole thing was over. We were, needless to say, incredibly happy about the way the day went. And as a bonus, Kai Jung, the German anesthesiologist, had us over to his house for lunch (since nothing was open.) We had delicious sandwiches and freshly ground coffee that he gets from a friend who owns a coffee plantation here. It was amazing. Marcel’s afternoon case presentation on massive transfusion, using the recent example of the 24-year-old woman who was gored by a rhino went quite well, despite the torrential equatorial monsoon that forced us to use sign language.

Torrential afternoon rain

Now, all in all, this day might not have seemed to be so great, but given our expectations, it was basically the best-case scenario. We were literally beaming when we got home. Man, that Randy sure does know what he’s talking about. He’s what we call an ‘about talker’ though, so we would expect that.

ICU rounds

By Marcel

I thought to give you today an overview of some of our patients in the ICU. The 4-bed unit does an amazing job taking care of quite sick patients.

Bed 1

A 10-year old boy, who has been in the ICU for almost 50 days now. He was diagnosed with an obstructing stomach tumor and operated on by the pediatric surgeon (a Dutchman who has been here for a very long time). Since nothing but ultrasound was available for imaging, it only became clear during the procedure that the tumor grew into the esophagus and into the thorax. A partial gastrectomy was performed, and the esophagus was partially removed. He subsequently developed mediastinitis, was reoperated on, received a tracheostomy and is now going through a very prolonged and difficult ICU stay. His main problem is feeding: he gets fed through a jejunostomy, but absorbs little and has recurrent diarrhea. As a result he is terribly emaciated with arms like sticks and a thorax that seems to consist of ribs only. He floats in and out of consciousness; during his good times he waves at us with his left arm. He is unable to move the right; we don’t know why. His mother visits him regularly, and we saw her doing perfect passive motion exercises last week. He is not really getting better, though. His ventilatory support requirements have increased over the past week, and there appears to be some fluid collection in his right lung, which might need to be drained, but no one is very keen on doing another procedure on him. Prognosis is guarded.

Bed 1

Bed 2

This bed has had a number of occupants. For a while it belonged to a sixtyish, large man, who was walking along the street when hit by a minibus – which had swerved because it had just been hit by another minibus… He sustained a moderate head injury (no imaging is available), and a number of rib fractures on the right, with possibly some component of flail chest. He was intubated, and a chest tube was placed. He gradually recovered over several days and really got better when he was mobilized. This happened once his morphine dose was reduced, since before that was done, he was (as one of the TACOs put it) “just enjoying the vent”. Once he was extubated, he rapidly got back to his normal self: a happy and jovial man. We knew he was ready to leave the unit when he proposed to marry one of the nurses, which led to an outburst of laughter through the whole ICU. It’s such a funny business we’re in. Here are people close to dying around us, everyone is laughing, and the patient sitting in bed with a big smile on his face… After he left, we admitted a young woman after surgery for a bowel obstruction. The wound could not be closed, and was covered with a temporary plastic patch. She was on epinephrine for a while (the only available pressor), but this was been gradually weaned down, and she was discharged two days ago. Today, however, we were told that she had died shortly after on the ward, because of unspecified breathing difficulties. This was quite a shock, as she was doing very well and we had no reason to expect anything but a full recovery. Meanwhile, a young man was admitted to bed 2. He had been found unconscious after a drinking spree. He arrested after admission to the hospital, had a prolonged resuscitation, and now is deeply comatose. He is tachycardic and tachypneic, possibly alcohol withdrawal. We’ll see what happens over the next few days.

Bed 2

Bed 3

This bed was occupied for a few days by the girl who had the spine deformity correction done, but she left quickly. Now there is an unfortunate gentleman, in his sixties, who was to be operated for bowel obstruction. He was very sick when he came to the OR, and arrested prior to anesthetic induction. He was resuscitated, ischemic bowel was resected, and he was transferred to the ICU, where he arrested again (and got his CPR from Christina). He required large doses of epinephrine, a central line and an arterial line was placed, and then he arrested again the next day – and was again resuscitated. Now his bowels, amazingly, seem to be working somewhat again. The main concern is whether he has suffered brain injury from three cardiac arrests. Ventilating him has continued to be difficult, and several ventilators have been used on him (since not all work completely). The vents are run off oxygen tanks, and these sometimes are not available. One night, the ACO on call removed the oxygen tank and replaced it with an oxygen concentrator (which supplies much less oxygen), as the tank was needed for the woman admitted to bed 2. But he survived the night despite the low oxygen, and once new tanks came in the morning, he was put back on appropriate oxygen. Still, despite the fact that he has miraculously survived three cardiac arrests, his outlook is bleak.

Bed 4

In the final bed is the 9-month old baby who was transferred from the pediatric floor. The child had been admitted to pediatrics for severe diarrhea, possibly typhoid, and had become lethargic and requiring some assistance with ventilation. The ICU was consulted, and Kai (the anesthesiologist in charge of the ICU) saw the patient and approved transfer. As we described earlier, when the child arrived at the ICU, later, it was without oxygen or ventilator support, and it essentially arrested in transfer. CPR was done, Christina intubated, and we regained circulation. But then the child did not wake up. Epileptic status was considered (we can’t get an EEG), so he was empirically started on phenobarbital and phenytoin. His infection seems improved (although we don’t have a definitive diagnosis yet), and it is now a neuro problem. Yesterday, he became a little more awake, and was extubated. He seemed to do well on oxygen by face mask. But this morning, during rounds, his heart rate suddenly dropped from 140 or so to 70. Presumed airway obstruction from secretions. His SaO2 dropped. Mask ventilation did not make it better, so he received atropine, and then was reintubated. Again, we can’t really predict the long-term outcome.

Bed 4, prior to the almost-arrest of this morning

ICU is difficult in this setting, patients are sick, and mortality is high. Of 90 surgical patients admitted here who were followed as part of a study, 1/3 died.

And in the evening, preparing lectures by candlelight, as the power is once again out…

Chilembwe Day

by Christina

Yesterday marked the beginning of our 3^rd week of teaching, 2^nd week with the TACOs (we learned that this stands for “training anesthesia clinical officers.”) We had an interesting discussion about pre-op management for peds cases that included pre-op sedation. Now, Marcel and I had already noticed that all the babies around here are A) strapped to their mother’s backs in a colorful papoose, and B) NEVER crying. I have seen one crying baby out of hundreds. The end result is that they only very rarely give anything for pre-medication to children, and they don’t really have a problem with screaming or fussy kids. We have been trying to figure out why it is so different here than in the US or Europe. Is it the constant contact with a parent that pacifies them? Or something innate? Either way, it is pretty incredible. Then I gave a lecture on pediatric colds and when to cancel a case -  nobody seemed all that intrigued. Hmm…. I’m blaming it on being Monday.

Today is Tuesday, but not just any Tuesday, it is Chilembwe day! A holiday to commemorate the Reverend John Chilembwe, who led the first uprising against colonial British rule back in 1915. His motto was “Africa for Africans.” Unfortunately he and his people lost and they were all killed, but not before they raided some surrounding estates, killing a couple British, and a couple Africans. After that, he conducted a church service with the decapitated head of William Livingstone (relative of David) stuck on spear next to him, but he never gained enough local support. The uprising failed and Nyasaland did not gain independence and become Malawi until 1964. So, in honor of Chilembwe, the OR was closed except for emergencies and all the TACOs had the day off. We decided it would be a good day for the market.

Market

We have been to the western style grocery store here a couple times, and get the usual stuff…cereal, bread, milk, pasta, etc. But the local market is where to find all the really good stuff. Piles of fresh tomatoes, green beans, 10lb avocados, hot chiles, spices, fried termites, crates of live chickens, and of course, clothes. The standard dress for the big cities like Blantyre is basically conservative western dress. The only caveat is that up until a few years ago, all women had to wear skirts below the knees. Most people still adhere to that. However, everywhere else in the country, people wear chitenjes. These are just colorful pieces of cloth tied twice around your waist. Then a shirt is tucked into that.  The different countries have different patterns and they usually involve some sort of wax/dye process.  Now I know what you are thinking, Marcel WOULD look good in one of those as board runner, but he didn’t agree, so I was the only one that bought one. Please note that the woman in the photo walking past the market has the same one (pure coincidence, but it a standard Malawi pattern.)

My new Chitenje

Blantyre market – please note the same chitenje

Mango buying in Zomba

After that we got some Ethiopian food, which was delicious. However, when we ordered traditional spiced Ethiopian coffee, he said that we couldn’t have it because the power had just gone out. Ugh. Week two, these things are less novel and starting to get a little more irksome. For instance, we had no cold water Sunday. Then we used all the hot water and we couldn’t shower Monday morning. This morning, we didn’t have enough water for two showers, and that sneaky Marcel took his while I was busy reading about elephant poaching. Oh well, at least neither of us are ill. We are both thankful. And it does make us think about how we are lucky to live in a place where these things are normally taken for granted.

We also get really happy when we have electricity. Like tonight. With this amazing thing called the electric stove, we will cook up some of our newly purchased market goods (no termites, if you were curious) and Marcel will not have to work on his pediatric mediastinal masses talk by candlelight.

“Marcel, are you being eaten by a hippo?”

By Marcel

That was how Christina woke me up in the middle of the pitch-black night. There was indeed sniffing, grunting and other very-large-animal noises going on just on the other side of the thin canvas on my part of the tent. As it turned out, it wasn’t a hippo, but an elephant family of 4, working their way around us, plodding through the mud and snapping branches to eat. Welcome to Liwonde National Park!

We’ve finished our first week of teaching. It has been very busy, particularly because all the materials need to be prepared. The schedule has congealed to a lecture in the morning, then teach in the OR until ICU rounds start. After rounds lunch, then prep time and a case presentation in the afternoon. The College of Medicine provides a driver to pick us up at the apartment in the morning and bring us back home in the evening, which saves a lot of time. Most evenings we have been on our computers for hours, preparing lectures and distilling the essentials that are applicable here from several textbooks, in particular the incomparable Oxford Handbook of Anaesthesia. Friday afternoon there was a full departmental meeting, and I gave a lecture. And then we set off for a few days of rest (we thought) in Liwonde, with a car and driver from the College of Medicine..

It was great – but far from restful. In fact, I’m more tired now than Friday afternoon… A quick run-down:

1. Road between Blantyre and Zomba under construction. Driving on a parallel mud track, until all progress is stopped because of a head-on collision between two minivans somewhere ahead. Too far away to go help – and not sure what we could do anyway. Turn around in the mud, and head for Liwonde by another, and longer, route, which will get us there after dark.
   

   Stuck behind a car accident

2. Driver does not like arriving after dark. Therefore goes 85 mph on an unlit 2-way road full of trucks, people, chickens and goats. Christina’s heart rate hits 120, and we provide each other with instructions as to what to do if we would survive the unavoidable crash but are tetraplegic (I want the vent off; Christina kind of likes the idea of getting all that attention)
3. Find the lodge after some phone calls and meeting someone in the middle of a small town. Eat a good dinner, go to bed. Woken up in the middle of the night by the elephants.
   

   Visited by elephants in the night

4. Next day, on canoe safari (the Shire river runs through the park and in the rainy season there’s plenty of swamp, with hippos and crocodiles). The two of us and a guide in a very small boat. Close-ups with hippos; Christina’s heart rate hits 120. Awesome experience of paddling through the swampy area: lots of birds, waterbuck, monkeys. Luckily no crocodiles.
   

   Close encounter with hippos

   Back to the lodge, sunburnt. In the evening Christina beats me at scrabble, then we sit around the fire chatting with the few other guests, and listening to the stories of the owner (who among many other things crashed with an overweighted airplane on exactly the same airstrip where we – Justin Ford, are you listening? – almost couldn’t take off because of our heavily loaded little Cessna). Unbelievable starry sky..

   

   Flashback to 2010: Justin Ford sharing the back of the tiny Flying Medical Services plane with loads of luggage, about to take off from Arusha airport for Haydom Hospital.

5. Crash into bed. Hours later, woken up by Christina: now there really are hippos around the tent… Torrential rain in the middle of the night.
6. Still raining in the morning. Supposed to go on a game drive, but the roads are impassable. A walking safari is proposed as alternative. Soon after, trekking a group of elephants. Christina’s heart rate hits 120. Liwonde elephants are described as “aggressive and nervous”. It is notable. Yesterday a safari vehicle from the lodge was charged by one. They look at us, flap their ears and occasionally trumpet. Luckily we get instructions on what to do when charged. Stand still, don’t move. It its keeps coming, sit down. Clap hands. Christina asks what happens if you don’t stand still, but run away. “Oh”, says guide, “then it will kill you. Charge speed is 40km/hr.” Heart rate hits 140 (OK: mine was at least 120).
   

   Walking safari

   

   Elephants

7. But we survive. It is an amazing experience traveling through the water-logged bush on foot and watching animals up close. More sunburn.
8. Then, back to Blantyre. Buy mangos on the way. Quick inventory at home: electricity: check, hot water: check, cold water: no…
9. Now, preparing lectures for tomorrow…