Never smile at a crocodile!

The students are now all on placement, they have been sent to a variety of hospitals around Malawi, including Queens in Blantyre, Zomba and 8 students here at Trinity. I am supervising the group here at Trinity. Supervision involves supporting them with nursing care, ensuring they represent the college in a professional way at all times and supporting their learning needs. 7.30 first morning and all the students arrive on time, we are off to a flying start! Unfortunately, few of the other staff has the same sense of time-keeping and it is not until 7.50 that the last ‘straggler’ wanders in; hardly the best example to be showing the students. A classic case of ‘do as I say, not as I do’! Report starts after Morning Prayer and includes the whole hospital (sounds daunting but there are so few patients it doesn’t take long!) That done and we are off to the ward…..   The ward is divided into male and female, which is then further, divided into medical and surgical. Not dissimilar to the UK but there is no division by specialty.  The students and I joined the medical officer on the morning ward round. This is where all my experience counts for nothing and I may as well be a student again! Typhoid, malaria, TB, sleeping sickness, sickle cell anaemia to name but a few of the conditions that confronted me. It is pretty clear that I am going to need to spend a considerable amount of time with the books!! Good nursing care however, is good nursing care and that is something I don’t need to consult the books on. I allocated each student 3 patients, I asked him or her to prioritize and then provided total nursing care. They looked totally aghast and said ‘three patients!!! Lizzy that is far too many” By the end of the morning each student had only managed to care for one patient, I am now seriously considering rectal dynamite!   One of the highlights of that first day was meeting Steve. Steve is the health care assistant on the ward; he has been there since the ‘year dot’, knows everything and does 90% of the work. I asked him why he did not take a break, his reply “madam, our work involves saving lives, there is no time to rest” Enough said.   So why the title “never smile at a crocodile” well, out of the 20 or so patients on the ward that morning, 5 were crocodile attacks. Nsanje district is the poorest in Malawi and the people depend of the Shiri river for many of their everyday needs. Unfortunately for the fishermen and the rice growers this comes at considerable risk to ‘life and limb’. The first man had been fishing in the early morning and had lost his leg and was probably going to lose his arm (what was left of it). The next was a young man who had lost his arm and the ‘croc’ had a little ‘nibble’ at his leg. I asked him how he escaped he told me he bit the crocodile in the eye! I have included a photo of this lovely and very brave young man. We also had rather an amazing lady; she had been close to the waters edge, baby strapped to her back, planting rice when the crocodile attacked. She fought off this crocodile by ‘tucking’ it under her arm, its tail at one point flicked up leaving deep gashes in her back. She escaped with only losing part of her right hand and right breast – her child was completely unharmed!

This young man is alive today because he bit the crocodile in the eye

This young man is alive today because he bit the crocodile in the eye

ImageImageOh, incase you are wondering, pain relief for a crocodile bite – diclofenac!!!

More Questions than answers

 

I have been in Fatima for 3 weeks now and the questions just keep coming!

 

I am undoubtedly having quite and adventure and my personal growth and to a certain extent my professional development is undeniable what is less certain is the impact my actions are having on those around me.

 

The past two weeks have been spent in the classroom, I have been teaching the year two-student nurses. You couldn’t hope to meet a nicer group of people. They are so eager to learn and are a pleasure to teach (if not a little daunting being faced with 60 students all hanging off what I have to say). However, there are some areas of concern. I have been reading through some of the exam papers that have been set for the students (these are done by the colleges, the final exam being the only one set by the Malawian Nursing and Midwifery Council) there are some blatant mistakes and misinformation. I have to be somewhat judicious with the concerns I raise as upsetting the tutors would be in no-ones interest. I was asked if I would help teach a clinical examination class that was a real eye-opener!! Listening to the tutor inform the students that the apex of the heart could be located at the sternal notch was a little worrying and in that instance I found a way to correct the situation and was ask if I would lead the teaching session, the relief from the tutor when I agreed was palpable! There were three classes before the one I helped with so there are now umpteen students coming out of Trinity college who believe they will locate the apex beat at the sternal notch!!! I wont tell you how they were listening to breath sounds or examining the abdomen!

 

One of the biggest areas VSO don’t prepare you for is the begging. I have found this so distressing. Everyday there are people knocking at the door asking for money. Some of the students have also approached me for funds for various things ranging from their fees (MK57000 that equates to half my monthly allowance!) To money for transport, ‘sisters shoes’, books or simply a bar of soap. You very quickly realize that you can’t help everyone, so how do you choose??? Every story is heart-rending and I have found myself in tears on more than one occasion. I spoke to one of the tutors who told me “Malawi is a nation of beggars, they believe the white man is rich, so why shouldn’t he help, they need to stand on their own” This sounds quite harsh but I am not sure that just giving money is the answer either. Thus my plan is to buy goods (I may need another suitcase to bring home all the gifts I acquire)! I have included a photo of a local man and his family, he made me a fantastic rush mat for the living room and one for my bedroom.

 

I went back to Blantyre last week to catch up with friends, it was the first time we had got together since going to our placements so there was lots to catch up on! Friday night was a party to say good-bye to one of the medics who was heading back to Germany. My hangover the follow day tells me it was a great night!!

Saturday was spent doing the usual Saturday things – shopping! The weekend passed way to quickly, as weekends usually do.

Just found out that uploading photos is not possible here in Fatima. The next time I am in Blantyre I will post as many as I can.

 

 

The road to Trinity

My last week at Queens in Blantyre was full of mixed emotions. I was so excited at at long last being able to get to my placement but also very sad at having to part with some really good friends (get togethers being planned as I type).

This last week found me dotted all around the hospital, I was in the ICU (intensive care), Family Planning and HIV/Aids clinic. I have included some photos, I though the supply of strawberry flavoured condoms was particularly thoughtful of the Malawian government!

Anyway, here I am in Fatima at Trinity college. The journey down here was long and a real adventure. Halfway through the journey the road disappears!! It is a track that Jeremy Clarkson would be proud to test one of his 4×4’s on. I now feel I have a rough idea what being famous is like, everywhere I go people are smiling and waving they are so excited to see a white person.

I arrived with Laura (my housemate) at about 3 pm. the house is lovely, amongst other things we have a fridge a cooker and a small backyard. It was a great feeling to finally be able to unpack. However, I had rather an unexpected reaction when I came across some of the ‘bits and pieces’ I had packed from the boys – tears, and lots of them. 

The next morning it was off to the college to meet everyone and be shown around. At about 10 am I was asked to go out with the students to help with health assessments at a local school. This was to be a week long activity which I was included in and found great fun. The students firstly assess the school premises and then the children. At the end of the week the students, parents and teachers gather for feedback. It was all very impressive.

Evenings seem to pass very quickly, by the time we have had an evening meal it is time to go to bed (normal times don’t apply here, you listen to your body and bed time seems to be between 8 -9pm!!) I was warned about the heat in Fatima but I don’t think anything can prepare you for the temperature or the humidity. I sweat so much it is difficult to keep up the hydration, I feel like I am constantly drinking (water that is). This obviously adds to the exhaustion but even just a week in I am coping much better. I must have spent 80% of the first few days sleeping! The electricity has gone off most evenings this week and we or rather Laura has ended up cooking on our little stove in the backyard. This all seems great fun at the moment and only adds to the adventure (I don’t think Laura feels quite the same, 6 months of it appears to have taken its toll).

I had the weekend here on my own, Laura having gone to a party in Blantyre. The village is so friendly I didn’t have a moment to feel lonely. Saturday night was film night with the students. followed by Sunday morning church (the whole village goes so it seems the right thing to do) in the afternoon the children came round and we all sat and watched an animated disney movie.

I start formal teaching tomorrow, this is obviously going to give me a number of challenges, not least will be the language. Gauging how much has been understood can be difficult as the student often just smile and nod. I think gently does it…..ImageImageImageImageImage

Faith restored!

The view from the chalet

The view from the chalet

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Early morning washing

Early morning washing

The children had made a boat out of a plastic bottle.

The children had made a boat out of a plastic bottle.

Snorkelling on Saturday morning.

Snorkelling on Saturday morning.

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Sunset!

Sunset!

Our chalet

Our chalet

Week 3 at Queens

I started this week feeling rather sorry for myself, I have a flu like virus that means I ache all over and feel like I have swallowed a packet of razor blades. I spend Monday tucked up in bed sipping Lemsip and drifting in and out of sleep.

Tuesday came and I felt I really should try and get to work, to be honest I was slightly less than enthusiastic given my experience last week.  How things can change…. I was on a surgical ward this week and as I arrived it was clear that this ward was very different from the medical ward of the previous week.  The ward oozed calmness and organization. The young ward sister arrived promptly at 7.30 and ‘hand over’ started.  The night staff discussed all the patients, giving name, diagnosis, observations and management plan. They also discussed how each patient had been over night. We then went into the HDU section of the ward. The student nurses were expected to hand over. One of the nurses wasn’t quite sure about her patient or how to hand over. The sister made it clear to her what was expected – it took me back to my student nurse days!!

On this ward observations were done regularly, fluid balance was monitored AND recorded! The patient’s notes were kept in the nurses’ office to ensure some degree of confidentiality. The ward was clean and tidy, the sister ensuring that the area was washed down and beds made every morning. We also helped the guardians care for the patients, all very different from last week. I have felt very reassured that despite the lack of resources good care can be given and the wards can be run efficiently.

Boring nursing/medical bit coming up, sorry!

On the ward we have three patients with oesophageal cancer, I am obviously in my element and have been asked to do some teaching to nurses and student doctors alike. I have also spent time working with the palliative care team. Patients here rarely get offered an oesophagectomy the cancer is usually far too advanced. Oesophageal stenting is an option but only uncovered stents are available so the benefit is short lived. They also seem to dilate, this is very risky in patients with cancer and perforation is not uncommon. Malawi has seen a sharp rise in the incidence of squamous cell oesophageal cancer; it is believed that the preservative used to store the maize may be responsible. Phew, all done!

I am feeling so happy and settled in Malawi, Jo, Vicky and myself have talked about this many times, the three of us feel the same. I think comfortable is the feeling we all have.  The people here are just so friendly and happy; there is certainly no British reserve!! I was chatting to some school children on the way home today, there were obviously some language difficulties and three guys that were sitting on the side of the road just came over and offered their help with the language. That kind of thing is just normal here. When you walk down the road people just smile and say hello to you, it really is lovely!

We are off to the Lake this weekend; we are feeling very excited at the prospect of scuba diving, snorkeling, kayaking and generally lazing around in hammocks drinking cocktails. Watch this space…

Wow, Cape Maclear was amazing. We travelled down Friday afternoon; the journey takes about 4 – 5 hours. It is a long way but the journey is hampered by the condition or the roads, it certainly is not a boring M25 journey. We arrived at sunset and were shown our chalet, this was right on the lake front! We had a veranda plus hammocks OMG pure luxury. On the Saturday we went snorkeling and on the Sunday we decided not to over exert ourselves so just a little swimming and lazing around in the hammocks before the evening entertainment. Monday we went kayaking before heading back home. I have enclosed lots of photos because I cant adequately describe how beautiful it was.

To care or not to care, that is the question…

IMG_0067Week 2 at Queens in Blantyre

This week I am working on an adult medical ward. I arrived at 7.30 to what I can only describe as a cacophony of noise and chaos. It quickly became apparent that there had been 2 deaths that morning and the grieving families were at the height of their distress. I duly followed the nurses onto the main ward, the night staff had already put one body onto a trolley (which remained in the middle of the ward) but the second was still lying in his bed. Hospitals here offer little or no privacy and minimal dignity whether for the living or the dead, there are no curtains to shield the rest of the ward from the sight of this young man being unceremoniously hoisted by three nurses onto a trolley. The two dead young men (one 29 the other 34) were then wheeled into the sluice (see the photo) to be ‘laid out’.  Following this we were off to the mortuary. This for me was a moving experience as all along the way people stopped and bowed their heads in respect, the family following behind in open and very vocal grief. I don’t think I will describe the mortuary here but I think in a country where death happens on a daily basis your attitude and behavior must inevitably adapt to cope. I on the other hand felt quite traumatized by the whole episode and was very glad of my friends and a glass of vodka when I got home!!!

Unlike the UK there are no bed managers here saying the ward is full, if a patient needs to be admitted you just put another mattress on the floor and off you go! Prisoners are simply chained to the nearest bed with the prison guards visiting twice a day to take then to the toilet and give them a drink. Hmmm, I don’t think this will catch on in the NHS.

Here in Malawi the ‘guardians’ care for the patients, they wash, feed collect medication, empty catheter bags, you name it they do it. With the nurse patient ratio as it is this is a system put in place out of necessity. However, sometimes the guardians need help and nurses here seem reluctant to offer that help, whether they feel it is just not their job I don’t know. Being a UK trained nurse where basic care is very definitely the domain of the nursing staff I was straight in there. Most nurses I know will describe the satisfaction of the transformation brought about to a patient following a bed bath and some TLC!! Just doing these simple things was quickly recognized by the guardians and patients who called me the ‘caring nurse’ and the ‘good mother’ both terms bringing a tear to my eye.

There are obviously some draw backs with the guardian programme here in Malawi but it also has huge benefits, some of which our struggling NHS might do well to take note of. It is commonplace in paediatrics for mothers to stay and care for their children I can clearly see the benefits of extending this to other areas such as elderly care for instance.

I spent the week working in the HDU part of the ward; this would be unrecognizable back in the UK. Resources are in such short supply that oxygen is shared between the patients. Being able to monitor your patient brings about its own challenges, with no ‘sats’ probe and no way of getting blood gasses analyzed how do you know if your patient is hypoxic?? With broken or no blood glucose monitoring equipment how do you know if your patient is hypoglycaemic?? Assessing renal function, well you can only do that if the family can pay!

The tenacity, dedication and sheer hard work of those working under these circumstances is amazing. Instead of losing heart it is a driver for creative thinking and I absolutely love it here.

Work aside Jo Vicky and myself were introduced to the joy that is DAPP. This is a huge second had clothes shop here in Blantyre, rummaging through the rails we found designer label skirts, blouses trousers shorts, each of us ending up with a carrier bag of clothes for MK900 (£1.20). How could I say no to Abercrombie and Fitch shorts for 20p!!! To top it all DAPP is a charitable organization and the money goes to good causes here in Malawi.

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Orientation or disorientation

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Paediatric A & E

Paediatric A & E

 

Theatre in paediatric A & E

Theatre in paediatric A & E

Orientation or disorientation

On arrival at Queens hospital Blantyre Jo, Vicky and myself waited nervously outside matron’s office for our month long timetable. Once in hand we were off to our respective departments. Vicky and I found ourselves in paediatric A & E. An enormous room with several smaller rooms off it. The sister gave us a brief tour and we were off. First stop triage, this is where the parents, predominantly mothers, brought their children to be assessed by a couple of nurses. The first thing that strikes you is the sheer number of children being brought in, the second is the quiet compliance. Not a single word of complaint from patient or parent. This all seemed a little ad hoc and Vicky and I found ourselves pointing out children that we felt a little concerned about. One of whom was nearly 3 and weighed less that 5.7 kg!! Malnutrition is a real problem and leads to many deaths. The nurses are trying to pick all these children up and they have quite a good screening programme.

Later that day we found ourselves in resus with a very poorly 2 day old. Very shortly after arrival the baby stopped breathing and I found myself assisting with resuscitation. He clearly needed to be ventilated but there were no beds and no equipment. It all seemed a little hopeless but to all of our surprise the baby was still alive the following morning. I was delighted that my A & E experience didn’t let me down but I have to be honest it is far removed from my work as a specialist nurse.

The following days have been spent on the paediatric unit and in particular in high dependency. On arrival Vicky and I just stood open mouthed and clearly in shock – nothing could have prepared us for what we saw. I have included some photos because whatever I say will not fully explain the chaos that confronted us. This large room was full of ‘cots’, wooden with only  4 inch sides, they had a mattress, no linen and up to 3 plus babies per cot. There were other mattresses on the floor where larger children were sleeping. All the families were with the children, including siblings which all added to the sense of chaos. Shortly after we arrived a woman in a uniform was barking instructions to the parents and they duly left the ward with sick children on their backs. Not a murmur of complaint! Two cleaners then came in and mopped the floor and wiped over the mattresses. Sounds good and this was done twice a day. However, the water was filthy and so was everything else in the ward. The cockroaches were running wild. It is very distressing seeing flies and cockroaches crawling all over sick babies in HDU!!

On our first day we saw two avoidable deaths of little children. It costs a lot of money for the children to go to the mortuary so the hospital lets the parents take the children home. The dead baby is strapped to the mothers back and off they set to catch the bus home!!! Bus drivers are not very happy about this and will kick the mothers off the bus if they find them so they try carefully to wrap the child up so as not to be noticed. Shocking barely covers it……