Dave's reflections on the hospital in Malawi

I was looking for a file tonight on my computer and found these thoughts that Dave wrote about working in the hospital in Malawi that never actually got posted. I thought it might still be interesting.

5 February 2007

It’s getting near the end of my rotation here at Queen Elizabeth Central Hospital in Malawi. The past week has been somewhat odd because I keep meeting people who haven’t really talked to me for the past five weeks and they are just meeting me for the first time. So I have to tell them that no, I’m really going in just a week and I can’t stay any longer. But it is very nice because they always look disappointed when I tell them.

I meant to write a while ago my first impressions of the hospital, but obviously I haven’t done so. When I arrived at the hospital the first day, it was much like the first day of any rotation in a new hospital. I was trying to find my way around (and getting lost several times), finding who was supposed to orient me, and attempting to perform appropriately as a student from the U.S.

My impressions of the hospital on the first day were also a bit muted I think thanks to the short trip Sarah had taken me on to see a hospital in Kenya. Were it not for that short trip, I think I would have been a bit shocked during my first visit to the surgical ward. As it was I was not surprised to see the condition of the hospital (it is the ‘best’ hospital in Malawi). During my first ward round with the physician, I was a bit shocked to see the condition and status of the patients. For example, there was a man there with jaundice. The only lab tests that had been done was a blood count. He had also had an ultrasound. So he was just waiting for the doctor’s to figure something out or do another test. For any of you familiar with medicine in the US, you know that this patient would have had a battery of laboratory tests (CBC, lytes, Ca, Mg, Phos, bili, alk phos, etc), ultrasound, CT (before leaving the ER), and possibly even laparotomy within a day or two and discharged within five. This man had been in the hospital for a week or more, and was receiving no visible treatment beyond waiting for tests to be ordered, completed, and interpreted. And there were several patients who were just there in the ward waiting either for a diagnosis or for surgery. Some had been there a few days, others a few weeks. They were just waiting.

The other part of the hospital that I was anxious to see on arrival was the operating room (or theater as they say here). And my first experience in the theater was not bad. In fact I was quite impressed. Sure the room was a little behind the times, with cracked windows, carts that were falling apart or welded together several times, and no climate control. But, the equipment was quite good. Anesthesia had a ventilator, full monitoring capabilities, and a wide enough array of drugs that the patients are always comfortable. The first procedure I saw was cystoscopy. The equipment there was in quite good condition and I have seen several successful cystoscopies in the five weeks here.

I should tell a couple of ‘fun’ stories about the theater. For the major operations, the drapes (reusable, cloth) are quite good, but for some of the minor cases, the drapes are a little lacking. Sometimes it looks as if you drape and create a sterile field with swiss cheese drape. One of the operations this week was one filled with statistics: estimated number of times this particular procedure had been done before in Malawi: 0. Age of the patient: 95. Number of insects on the sterile field during the procedure: 3 (two spiders and an ant). It was a remarkable surgery overall!

Last week the interns (in training just as in the US) decided to go on strike because they hadn’t been paid since August. It was a big deal because the interns do most of the work of running the hospital. They tend to bring in the physician (the attending or consultant) only when they feel things have gotten beyond their ability to deal with it. So, the consultant rarely sees a simple abscess or acute urinary retention, or even some cases that need surgery (the intern may just go ahead with the surgery). So, that was an interesting day. The interns got paid and so they came back to work the next day, but it certainly made a difference in how the hospital ran.

So, I guess that’s all about the hospital. Feel free to comment if you have other specific questions.

Dave