Progress in Surgical Capability

It's been quite and interval since I last posted here.  In that time, we have seen the construction of a new extension on the Health Centre where surgery can be performed under better conditions.  Two new operating rooms, plus a recovery room with 3 beds, locker rooms, a staff lounge with three adjacent offices, decontamination and sterilization rooms.

Our first laparoscopic cholecystectomy

So the theatre is functional.  We are grateful for all the support given to make this possible, especially for the amazing fundraising done by my mom, Aileen Saunders.  Now we are beginning the work on Phase 2, which will include a 3-bed ICU, Labour and Delivery Suite, two private rooms, and a nurses' station, as well as some storage.  Hopefully this will also be functional before the end of the year.

Weekend In Malamulo

Last weekend I visited our sister hospital at Malamulo.  One of their surgeons, Ryan Hayton, is currently on leave, and the other surgeon, Arega Fekadu, was feeling like he was being a bit consumed with the clinical load and not getting time to give attention to some administrative and academic responsibilities.  So he asked if I could provide some coverage.  Went down Thursday Afternoon, and came back on Monday.  Prepared two lectures for the residents, and had a good time interacting with them.

Also enjoyed the hospitality of Arega and his lovely wife, who made sure that Friday evening I feasted on Ethiopian food.  Simply delicious.

There were several things of interest.  First of all, it seemed quite remarkable to see five patients in the hospital at one time with the diagnosis of esophageal cancer.  Two were post-op.  One was getting ready for surgery.  One was unresectable and really needed a stent for palliation, but such was not available.  One was very cachectic and could possibly be a candidate if they could get her nutrition up a bit.  This is more cases of esophageal cancer than I saw during ten years in Nigeria.  It seems that Malawi has a very high incidence and our surgeons in Malamulo and Blantyre have quite a bit of experience dealing with this problem.  Could lead to some publications.

It is the beginning of mango season,  There were at least half a dozen kids in the pediatric ward with wrist fractures from falling out of mango trees.  Happens every year.  Not sure how to change it.  Kids will always climb for fruit.

Sunday morning we were asked to see a woman and her daughter who had both been attacked by a vengeful ex-husband/father.  Very sad.  The woman had been stabbed in the eye.  Miraculously, the eyeball was still intact, but the eyelids had been filleted, especially the upper one.  It was a bit tedious putting it back together.  The pre-op picture may not be suitable for posting on a public site, but here's how it looked after repair.

The daughter was stabbed in her left arm, deep into the biceps muscle.  Our second year resident, Dr. Kamwendo, repaired that one.  Very sad that a family can have such dysfunctionality.

We also had a man come referred from Blantyre with a high velocity bullet wound to his thigh that shattered his distal femur.  It was a robbery.  Fortunately he didn't injure any major nerve or blood vessel.  We took him to the operating room to clean out any devitalized tissue.  He should be a good candidate for a SIGN nail, and should get a good result long-term.

One of my favorite animals in Africa is the chameleon.  There are lots of different kinds.  The ones we used to get in Ethiopia when I was  kid were fairly small.  In Nigeria we had bigger ones, but they still looked "normal".  In Malawi there are chameleons with horns on their snout, almost like a rhinoceros.  I had only seen them in pictures until this weekend.  While walking to Sabbath School, I saw someone kick something off the sidewalk ahead of me.  When I got to where it was, it was this chameleon.

After being so rudely treated, he was not in any mood to be sociable, but hissed at me when I tried to pick him up.  Then he promptly headed up the nearest tree.  I didn't pursue him further, since I was staying at the guest house and wasn't sure what I would do with him.

Sunday evening I was invited again to Arega and Bikiltu's home for supper.  The fourth-year resident rotating from Ethiopia, Surafel, was there also.  Good food, good friends.  A very pleasant time.

I headed back to Lilongwe on Monday, stopping in Blantyre for lunch and discussion with Kirby Kasinja, the CEO, who also helps keep track of administrative issues at our health center.  Made it home before dark.  I don't like driving that road at night, and I had specific instructions from my wife that I should not be on it after dark.  So I was compliant.

Thursday morning I attended the surgery conference at KCH.  They still have no x-ray, no labs at night, and difficulty getting emergency and sometimes elective cases done, as evidently the anesthesia is not getting paid their overtime and are therefore being less than helpful (obstructive) at times.  For a country that doesn't have enough health care professionals as it is, it is even more unfortunate to seen them not being utilized well.  Which way the future?

COULD IT BE DIFFERENT?

As I write this I'm feeling pretty down.  This afternoon a 54-year-old man was brought in who had had a couple episodes of vomiting blood.  He was stable and alert, with a soft, non-distended abdomen, and with good vital signs.  I had just finished a gastroscopy, so asked Mchonkhwe, our tech, to go ahead and quickly get the scope reprocessed to do another EGD.  We brought the man into the endoscopy room, and just as we were about begin, the patient vomited a massive amount of blood and clots, and then dropped his blood pressure and became unresponsive.  We squeezed in some IV fluids and he came around a bit, but I decided we had better transfer him quickly to Kamuzu Central Hospital, as we can't get blood very quickly at our facility and they have the major regional blood bank over there.  So I called Dr. Varela, the chief of surgery at KCH, and arranged a transfer.  We quickly bundled him into the ambulance and he was taken over to KCH.  About three and a half hours later I received a text message that the man had died.  So I'm thinking of the "if only's".  If only I had blood bank capabilities here.  If only we had anesthesia coverage, and, if only we had an operating room --  then maybe we could have saved him.  This strengthens my resolve to try and develop a better facility here.  I felt bad about having to transfer him to KCH, which I know is a dysfunctional facility, but at the same time their capability should be better than ours here at Adventist Health Centre.  We need our own OR, anesthesia and better lab and blood bank capability.  I hope that someday, not too far in the future, we will have that.  This just isn't right.

BEGINNING ENDOSCOPY IN LILONGWE

This week was another milestone.  We inaugurated our endoscopy equipment with the first colonoscopy performed at Adventist Health Centre.  All went well, The equipment functioned well, with good resolution.  We still have a few things to work out in terms of protocols, but we are functional as an endoscopy center.
 

Our medical director, Dr. Chibaka, checking out our endoscopy setup.

This week at the surgery morbidity and mortality conference I learned of a head injury patient that looks like he may need a tracheostomy.  However there are no tracheostomy tubes available at that hospital (the largest hospital in the city).  Fortunately, we have received a box of them in the shipment that came with our household goods.  So we are able to share with them.  The other unfortunate situation there is that their CT scanner is broken down and the technicians who do the repair are employed by a competing organization, so there is a conflict of interest.  Very sad for a country that needs all the help it can get.

Some people have asked for pictures of our house, so here it is.  A fairly nice place to live.  Parked in front is our little Toyota Raum, which gets us around a bit.

CHIANGMAI, THAILAND

During the last two weeks of April and first week of May we attended the Institute of World Mission session that was held in ChiangMai, Thailand.  We had actually attended a session in the Fall of 1993 prior to going to Nigeria.  Both times we have found it a good time for reflection on the how's and why's of what we do, discussion on cross-cultural interaction, and great fellowship with new friends, many of whom are heading for an extended cross-cultural experience for the first time (though there were a few experienced ones).  The weather was quite warm, the food was good, and we did get some free time to explore northern Thailand a bit.  Here are some pictures.

Entrance to the ChiangMai Zoo and Aquarium

One of many statues of deities around the area

View on a Sabbath afternoon hike

Ready to take us for a ride

Trying to keep our balance in a wobbly elephant saddle

Rafting on a rainy afternoon

Part of our group cooling off in a waterfall at the end of a hike

 At the mountaintop.  It was cooler up there.

One of the beautiful pagodas we visited.

 Agape feast the final Friday evening of the Institute.

Sabbath lunch at ChiangMai Adventist Academy.  Never-ending mango sticky rice.  Awesome!!

Family

This picture is a bit out of place chronologically, having been taken last September, but I wanted a more recent picture of the whole family on the blog site.  Taken at Sunriver, Oregon.

DISPARITY

I have been attending the Thursday morning Morbidity and Mortality conference of the surgery department at Kamuzu Central Hospital, which is the largest hospital in Lilongwe.  The surgery residents present the cases and we discuss them.  What I have discovered is that there is a certain level of underlying frustration among the attending staff surgeons there.  The hospital is large and has a pretty impressive infrastructure, but there is a certain level of dysfunctionality in the place.  Surgeons have been complaining that they have cases scheduled that get cancelled because there are no sterile drapes, or maybe no IV fluid.  This last Thursday there were two cases of femoral neck fracture that were presented.  Ordinarily such cases should receive internal fixation and be mobilized early on crutches.  But the two orthopedic surgeons told me they don't have the hardware to do the operation.  So these patients will end up lying in skin traction for several weeks, and probably end up with some disability.  Very sad.

Three weekends ago I was down at Malamulo Hospital covering for the weekend so their surgeons could take a little time away.  While there a patient was referred down from Lilongwe (Partners in Hope Clinic) for gall bladder disease.  She ended up needing a common bile duct exploration along with her cholecystectomy, which the fourth year resident from Loma Linda was quite excited to do with me.  The point is, though, that she was referred from the capital city to a rural hospital five hours away because the referring doctor felt that was the best option for her.

So the need for reputable surgical care in Lilongwe is quite stark.  We need a hospital that can provide reliable, attractive, modern service to the wealthy, and use the financial stability to be able to offer services to the poor, as well.  This is always a challenge to set up and sustain, but the needs are great and I think we need to face this challenge for the sake of the people of Malawi.  This is one of the poorest countries in the world, and one of the lowest per capita health care providers.  Malawi has just two physicians per 100,000 population.  The U.S. has about 265 per 100,000.  A great disparity.