Prison clinic and Crisis Nursery

Our Black Friday consisted of two trips to the pharmacy company - Intermed. When we first went, I loaded up and what extra meds I thought I would need for the prison clinic, then we met Charles at Papaya's resturant (the Malawian version of fast food - but not too fast because the power was still off!) for a planning session. He thought we should go to the prison to check the women and children before the actual clinic. After our lunch, we went to the prison, and the, seeing how many little babies were there, I went back to Intermed to resupply for children's meds! Somehow, that seemed to take up the entire day - oh, we did go to the grocery store for some perishable items (lettuce, etc).

Today, Saturday, we left for the prison, arriving about 8:15. Our team was Charles (the lead man as it is his ministry), myself, Dr. Jessica Best, Laci Butler, RN; Lucky Nyirenda, Clinical officer; Selina, pharmacist; and translators Clifford and Jolyn. The clinic went very well, with the patients not nearly as ill as they have been in the past. The Norweigan scabies is still present, but less intense. I saw no Kaposi's sarcoma (a major issue 3 years ago), no obviously active TB (pulmonary or otherwise) - but a few I referred for TB testing. Most of the HIV/AIDs patients were in pretty good shape, although a few said their medications did not 'come in' yesterday. Again, I referred some patients for HIV testing - they now have a VCT clinic on the grounds of the prison, staffed week-days for HIV testing, giving out meds, etc.  They owe Charles a huge 'Thank you' for raising the funds to make that happen!!  We saw many of the babies, but again, they looked generally well. There were some wounds and abscesses in the male population, and we were able to do a little for them. The prisoners now make soap and sell it - we bought 350 bars and gave a bar to each of the patients. We had a few left over - Charles will make sure any HIV/AIDs patients that did not come to the clinic will each get a bar.  It was a good day!

After the prison clinic, we had time to go home, get cleaned up, and then go to the Crisis Nursery - sort of a 'must see' for any medical teams. They do awesome work with those little ones.  Jessica and Laci played with the babies (ok, so did I) for a couple of hours.

Tomorrow - church at Flood, then Laci will take a minibus back to Salima while we prepare to start our last week at Daeyang Luke Hospital.

Praise /thanksgiving / prayers
Thanksgiving for a good, non-eventful time at the prison, for the fact that we had enough medications and hopefully showed the love of Christ to these people.
Thanksgiving for continued safety and wellness with us.
Prayers for the children at Crisis Nursery, that if they cannot be returned to extended family, someone will adopt them; prayers for their health.
Thanksgiving for Meredith Cantrell, who left some kwacha for some of the soap bought today.
Thanksgiving as always to those that have donated supplies, meds and money to make these clinics happen. When we do a clinic, not only do we supply the meds and medical supplies, but also food and drink for the team; then I am expected to pay the Malawians for spending their Saturday working instead of 'off'. All of this adds up, and I just want to make sure that people who have invested in this mission trip know just how valuable their donations are!!

 Pre-clinic logistic meeting, at Papaya's with Laci Butler, Charles Msukwa, and Jessica Best.

 The group - main guard who helped us (sorry, but I don't remember his name, but he has been there for other clinics and is always most helpful, and gets any 'referrals' taken care of) Jessica Best, Jolyn, me, Charles, Clifford, Lucky Nyirenda, Selina and Laci

 One of he aunties at the Crisis Nursery, stirring nsima

 Jessica with one of the crisis nursery children - a special needs child

 Beatrice, one of my favorites there!

A little guy, Madeula I think - busy playing!

Laci with Cornelius in her lap, his twin, Taongwa (I think that is the spelling) in the brown dress and little Beatrice looking on

Jessica with Chisomo - if you haven't notice, Chisomo is a very  popular name for boys and girls - it means Grace.

Salima and Pothawira

This past week we spent in the Salima district, at Peter and Emma Maseko's home. During the morning we volunteered at the Pothawira clinic. This is a project started by Anne Maseko Alaniz and her Dad, Peter Maseko, along with some US partners. They have a clinic, seeing 100-300 patients a day, a school, and an orphanage with 106 orphans. It is a busy place!
Jessica worked with Henry, a young man who has finished clinical officer school but is awaiting his final scores - if he passes, he will start an 18 month internship. I worked primarily with Peter. We saw lots of interesting cases. There is currently an outbreak of chicken pox in the district, so many of those kids come into the clinic. There are also skin rashes of other sorts. This is the beginning of the rains and the planting season, so many of the patients are farmers, who are complaining of neck / arm / back pain - but if you watch them hand hoe in the fields, you will totally understand why they have pain! Jessica saw many children with dysentery, several of whom she would have admitted in the US - here we don't have that option!  At some future point, Pothawira hopes to have phase 2 - antenatel, delivery, and postnatal wards / clinics along with some neonatal capabilites, and phase 3 - an entire hospital. However, funding (as always) is an issue.
Peter and I saw a horrible ulcerative skin disease - starting on the young woman's arms and has now progressed to her leg. We were concerned it may be TB, so he arranged for her to have some special lab tests done at the nearby hospital.  We also saw a 3 week old snake bite - she was bitten on the foot and spent 2 days at Salima District Hospital, was released but her foot has gotten worse (although no pain). She doesn't know what type of snake (it was night time) but in my limited research, it appears consistent with one of the puff adder family because of the continuing skin necrosis.  There we also many, many abscesses that needed to be drained, along with coughs, colds, chest pains, abdominal pains, and problems with sexually transmitted diseases (too graphic for more discussion here). HIV / AIDS is of course a huge problem, and many of the patients had that as an underlying or complicating factor.  The rains have barely begun, so malaria in not a major issue at present.

In the afternoons we were 'free', as the clinic is very busy in the morning but most people do not come in the afternoon. Usually we ate at the clinic (thanks to Emma Maseko for cooking for us!) but one day we went to the lake and ate at the Livingstonia hotel. This is an old hotel, with a wonderful view of the lake, a nice menu, and a great pool!  For 1000 kwacha (a little over $2) you can swim in the pool and even get a towel. It is almost always empty, so we enjoyed the pool to ourselves. It is a great way to relax and cool down after the morning clinic (not to mention all that cholorinated water makes you feel really clean!!)  We spent a little time with the orphans. Joseph Chisomo is gaining weight - he is now up to 2.2 kg (from 1.9), and the newest baby, Blessings Chisomo is weighing in at 2.12 kg. Tiny but both look good and I am sure, barring any illness, they will do fine.
The last day we were in Salima was Thursday, US Thanksgiving. We went with Laci Butler (the RN working for Global Health Innovations on a system to track the babies of HIV positive moms). We went to the Lifuwu health center - a smallish village complex by the lake - to pick up samples, then to Salima district hospital to pick up samples. We got a tour of the Salima district - the pediatric ward was not very busy (not much malaria). The maternity is always busy, with 300-400 babies delivered every month. The still have the Kangeroo Care unit that Peter Maseko started several years ago. They have a neonatal unit - they have very small babies in there mixed with sick babies.... they had a 800 gm baby, so very tiny, with the only 'care' being oxygen via nasal cannula. The nurse said they usually do not live at that weight. However, the babe was 6 days old, so there is hope! The pediatric unit had a large posted with the types of illnesses admitted in 2012 and so far in 2013, along with the death rate for each category, and a total death rate. It was depressing. It appears that about 5% of all children admitted die. Before we headed back to Lilongwe, we visited the crocodile farm, down the road from the Masekos. It is always an interesting experience.

We drove back to Lilongwe, encountering a massive storm with wind, rain and hail shortly before arrival in Lilongwe. The bad roads of Malawi got so much worse! The power was gone the rest of that day! However, we had been invited to Michelle Clark's house for Thanksgiving. We had a feast by candlelight and made some new friends. It was wonderful.

I have posted photos on facebook, and I will try to post some here. Be forewarned, a couple are pretty graphic!

Praise / thanksgiving / prayers
Thanksgiving and continued prayers for our safety!
Thanksgiving for wonderful friends in Malawi.
Prayers for the babies of Malawi - Joseph Chisomo, Blessings Chisomo, the tiny newborn at the hospital, and all the children struggling - we do not know their names, but our Lord and Savior, Jesus Christ, knows them all!
Thanksgiving for the people who have generously donated supplies, medications, money, clothes, etc. I give thanks for you all every day = may the Lord pour back blessings on you!

 Little Joseph Chisomo, lying on a quilt made by Linda Redinger! Thanks again Linda, those quilts are coming in so handy for the new little ones at Pothawira - exactly what they needed!

 Jessica and Laci on the walkway at Kambiri Lodge - there was no water in the pond this time (or, as I call it, the malaria pit). Joseph Maenner, this should bring back memories!

 Boys on the beach outside of Kambiri Lodge

 Girl with chronic draining lesions on her arms

And on her lower leg. We are still hoping to find a cause

 3 week old snake bite. The large wound has what appears to be part of a tendon in the wound - she could not elevate her 5th toe.

 Lunch at Livingstonia with Laci and Jessica

 The pool at Livingstonia - the azungus (white people) are Laci and Jessica!

 Clinical officer 'hopeful' Henry and Jessica

 Thanksgiving activities included a trip to the crocodile farm in Senga Bay!

 Peter Maseko - the outdoor waiting area at the clinic - there are prayers, songs and some preaching before the clinic starts seeing patients.

 Buying packs of peanuts from a little girl in Salima

 Blessings Chisomo - another quilt from Linda Redinger!

Posted in Salima District hospital - causes of admission and death rates in kids. Very sad.

Village Clinic

Saturday we went to Steve Potani's village to do a village clinic. It is very isolated and close to the Mozambique border. Charles  was the driver and head translator, traffic controller and general 'make things happen' guy, while we had Jolyn and Clifford as our other translators. Lucky Nyirenda, a clinical officer from DLH, came along to help. Steve also came in another car, taking Clifford and Lucky with him, as the car we had was loaded with meds and our lunch (good thing, as Steve stopped and bought meat at the roadside meat market and we did not want to eat that).

Lucky and Jessica saw patients, while Laci and I worked the pharmacy and the 'skin disease' station. Most of the diseases were either fungal of some sort (ring worm is a huge problem here with the kids), atophic / eczema type or wounds of varying ages. We have worked to teach some of Steve's relatives basic wound care (cleaning with soap and water, protecting from further contamination, etc) and I think we have met with some success.  We were able to have both a malaria test kit and a glucometer. Most of our patients have fairly simple but chronic problems. We did have a child with what appeared to be mumps, which means more children in the village will likely get that illness. The country does not vaccinate against mumps. We had one fairly ill 3 month old baby, and several children with upper respiratory illnesses or diarrhea.  The rains came hard and heavy while we were in the village, but the weather cleared so that we could get out (about an hour from the nearest tarmack road).

I have not been able to post pictures on this blog, but you can see photos on my facebook. Friend me if you have not and at least see the photos!

Praise/thanksgiving/ prayer
Thanksgiving for all the people who have donated out of their hearts to this mission trip - money, meds, clothes, etc.
Praise for travel and personal safety.
Prayers as we leave today (Sunday) after church to go to Salima and Pothawira for 5 days.

Daeyang Luke, days 4 and 5

The last couple of days at Daeyang Luke we were beginning to feel like we understood the process.  Casualty (ED) is completely different in this hospital from US hospitals. However, I think the central hospital (Kamuzu Central - KCH) has more 'action' and more trauma. DLH is pretty quite, but with a lot of pediatric cases and medicine type cases. We have seen how they perform paracentesis here - they stick a large needle into the swollen, ascitic abdomen (no local anesthesia), attach some tubing, and drain it into a trash can. We saw one case that the clinical officer did, then he went off on another errand, not returning for a couple of hours - he drained over 5 liters off one guys belly (for the non-medical people out there - that is a LOT). The patient did fine (well, as fine as you can be with end stage liver disease). Most of the cases of liver cirrhosis have no known cause - they don't have the tools / tests or the time for look for the cause. In the US we always want to know 'why'. That does not seem to be an issue here. I have seen that in seizure patients, also - we (US doctors / students) want the 'why', here they just want to treat.  Considering their circumstances and lack of resources, just treating is an excellent option.... it is just hard for our US trained brains to get around it all.  There was also a displaced wrist fracture that came to Casualty. DLH has no ortho capibilites, so the usual process is a splint and send to KCH.  Jessica reduced the displacement and worked with the patient care technician to put on a more specialised splint. The patient was a nanny, and the employer did not want to pay for a post-reduction xray (something we do in the US).  However, as Jessica said - 'I felt the bones crunch and the wrist looked better, so I am sure it is as close as we will get it'.. an xray in the US at this point is to document what we did, not to really help with patient care. We sent the patient on her way, but her employer said they would not go to KCH that day, but go home and 'rest', spending another day waiting in line to be seen. There was also a 7 day old baby in maternity ward (where they keep neonates) who had a bloated abdomen and decreased passing of stool. The clinical officers did a nice investigation and found Hirschsprung's disease. It is apparently fairly common here (they see one / month in DLH). It is correctable by surgery. The parents refused surgery and took the child home. Pray for this little one! He will either die from complications / failure to thrive / aspiration, etc or his parents will bring him back for surgery.  We were not immediately involved in the case, but assessed the babe a couple of times, reviewed the history and the xrays.  Jessica also sat in on some of the VIAs done on Thursdays - a nurse is trained to examine the cervix with acetic acid swabbing to find abnormal cervical tissue. That tissue can then be 'frozen' off with liquid nitrogen. The nurse had told me she does about 20 VIAs a week, with about 8 being positive. When Jessica was there, the nurse said she had only recieved 2 cryo-tips (what is used to apply the nitrogen). When we return, we need to investigate and make sure this is not a common occurence, or they will never be able to treat all the positive VIAs!  Cervical cancer is the most common cancer in women in Malawi.

Thursday evening, Laci from the Pothawira project came into town. Laci and I went Friday to renew our visas - all went well, except the 'network was down' where you pay your visa fee.  We waiting about 30 minutes until someone decided they would need to proceed, using paper instead of 'the network'. Of course, after you pay, you go BACK to the immigration office for official stamps. A little tedious but not bad by Malawian standards.

Saturday we went to Steve Potani's village for a village clinic. I will try to blog and post photos on that adventure, but the internet, even for here, is horrifically slow right now!

Praise/thanksgiving/ prayers
Our continued safety in health and travel (both a praise, and a prayer request)
The relationships we are building at DLH and elsewhere
An uneventful visa renewal
Our patients, that we might reflect Christ and have the wisdom to treat them appropriately in such a resource limited environment.

For some reason, the internet is not allowing photos to post on this blog... please check my facebook for photos! Sorry!

Daeyang Luke days 2 and 3

Tuesday, Jessica and I went to the surgical rounds at Kamuzu Central Hospital, which was interesting. We made some good contacts if she decides to pursue returning to Malawi. We had a tour of the Casualty by one of the UNC surgical residents who has been doing research here for almost a year. We then went to DLH for the rest of the day. Jessica was able to do a bedside sonogram, we saw a few patients, but mainly seemed to concentrate on a young boy. I obviously cannot give any details, but pray for him! We had lunch in the cafeteria with Dr. Shin (both yesterday and today). They serve local food - nsima, rice, chicken or meat, vegetables and beans. In the afternoon we saw a few more patients and then attended the 'handoff' at ~4:30.

Today (Wednesday) we were at DLH by 7 AM for devotions and the morning report, then to the Casualty for another day. The ED in Malawi does not function like the ED in the US - patients rarely show up in the ED as a first stop. They are seen in the outpatient department and then referred to the ED for wound care (and they can come back daily for dressing changes), for injections, for lab draws if the lab cannot get the blood, for IV meds or blood transfusions or if they are to be admitted they come to the ED for all the initial labs and 'stablizations'. Since they were seen in outpatient, they generally belong to that clinical officer, doctor, or med student. Many times they are fine with us assessing them, treating them and even discharging them. We did have a patient come with an IV today from an outside clinic - the clinical officer there had already spoken to one of the clinical officers at DLH and arrangements had been made for admission. She arrived in a lorry (those BIG trucks) with her husband holding the IV. Interesting. We left a little early today, as it was very, very slow (we were told 'it is because it is the middle of the week').
Tomorrow we repeat the process. We interact / work with med students, clinical officers and doctors. The med students are delightful and so intense!  If all the med students would graduate and stay in Malawi, it would be such a blessing. I am learning so much about HIV, TB, cancer in Malawi, treatments of various diseases, etc. I almost feel like I am a student again.

We remain well, although the heat is exhausting. Yesterday there was a minor sprinkle but the real rains haven't started yet. The dust is everywhere. We are enjoying very much coming home to a clean house and done laundry thanks to our friend, Mr. Whiskas.  He is a true blessing and makes our lives so much easier when we are here. He has a true servant's heart and takes pleasure and pride in his work!

Laci is planning on coming to Lilongwe tomorrow, and I am planning that the two of us go to immigration for visas (they only last 30 days and then must be renewed). Her plans are somewhat fluid at the present, but she may be able to go to the village clinic Sat as the wound care nurse / pharmacist. That would be a tremendous help! We are slowly getting our supplies / medications for that trip. I also ran into an old friend from COTN, Davie, at Shoprite (grocery store) this afternoon. He says there is a need for antifungal cream for the kids at a couple of the feeding villages. We gave some out last year and he reports that it worked very well. I have promised to buy more and deliver to him before I leave.

If you are wondering, all photos of patients are taken only after the patient and family members have given permission. I always try to respect the patients and their families.

Praise / thanksgiving / prayer requests
Thanksgiving for our health, continue safety and travel mercies
Praise for the generosity of friends in the US who, through donations, have helped finance this trip
Prayers for our young patient from yesterday.

Jessica holding Malambe juice - made from the baobob tree. We were told it was good - NOT -thick and weird. 

 Jessica reviewing a patient's health passport with Dr. Shin in the ED

 Drs Shin and Jessica Best, along with clinical officer, Owen

 Another sonogram

Boy with hot porridge burns on his arm and hand, along with his ear. He was been sedated in this photo.

 Debridgement of the burns - not something we do in the US very often, but common practice here.

 Lunch in the cafeteria with Jessica and Dr. Shin. We usually get rice, beans, chicken, and vegetables

 Lab techs examing slides

Unloading an 'ambulance' patient from a big lorry.

Daeyang Luke Hospital, day #1

Today Jessica and I went to Daeyang Luke Hospital (DLH) to begin our time in the Casualty (ED). We started with devotionals at 7 AM, followed by hand - off reports, then to the ED. It actually was a very slow day today, but we got to meet some new people - Clinical Officers Owen and Lucky come to mind as two very good clinical officers and were a great help as we were figuring out our way around the ED (and the hospital system in general). We had a couple of med students from the Malawi medical school with us a part of the day - Johane and Naomi. The nurses were great! Ellen, Grace, Kewisha (not sure of that spelling) and Luci. Susie Kim, the principal at the Nursing school, invited us for lunch - Korean food. And Dr. Dangsoo Shin, a retired surgeon who has come to DLH to help with surgeries and the 'theater' set up stopped by the ED and spent some time with us.
We didn't see many patients (they say unusual for a Monday) and the ones we saw were all referred from OPD - outpatient department. Very few patients just come directly into the ED - most are seen in OPD and then referred to ED.

Dr. Shin has invited us to the surgical rounds at the medical school by Kamuzu Central Hospital (KCH) so we will start our day there, with the surgeons, at 7:30 AM and then go back to  DLH.
Jessica is set to teach CPR to two nursing classes on Thursday - one morning and one afternoon. Joseph Maenner taught CPR at the ED in Daeyang Luke several years ago... he was unsure if he made any difference, but last year we ran into one of the nurses, Dennis (who is now in theater instead of ED) and he told Joseph he had saved a couple of babies using the CPR Joseph taught him. Today in the ED, two nurses remembered Joseph and his CPR class and said that they had saved a patient in dialysis using CPR. Good job, Joseph!!

Praise / thanksgiving:
Continued safe travels
The fellowship we have found at Daeyang Luke hospital
Our continued health
Katie and Meredith's safe arrival in the US!

Jessica and Ellen, our 'tour guide' to the ED

Another shot of the two of them

Medication trolley

Jessica by the 'emergency cart'. Sort of a crash cart, minus some important parts! But very well organized!

Viewof the ED

Another view - of the beds, and one of the two oxygen concentrators. There is one monitor on the wall. When we first came, all the beds had monitors. No one seems to know what happened to them.

Sad fact, but people who die get transported to the morgue at night. Now, I am not sure if that means if they die at night they go to the morgue, or if all dead bodies go at night. (Guess I should ask). The morgue is at Kamuzu Central Hospital (KCH)

Jessica and I at door to Emergency

Lunch at Susie Kim's - a feast of Korean food!!!

Jessica reviewing the medical record (health passport) of a patient - we had offered to read CTs for radiology as it sometimes takes 2-3 days to get a read from the telerad in Korea. Fortunately, this was a normal head CT.

Dr. Best and Majete Game Park

Dr. Jessica Best arrived Thrusday after a long a ardous trip. We then left Friday morning to spent Friday and Sat AM at Majete Game park in southern Malawi, outside of Blantyre. We did the tent chalets. I had asked Charles to drive - not only can he change a tire and check the car for issues, but he is also Malawian so he can run interference if we have problems. The trip is about  6 hours, so anything could happen! Fortunately, it was an uneventful trip. We stopped in Blantyre so that Charles could see his oldest daughter in school there. The Majete Park is by the Shire river so it is at a low elevation and it is AFRICA HOT. Oh my, I thought we might die that afternoon it was so hot. We did a night drive Friday night, then awoke before 5 AM to do a morning drive Sat morning, then headed back home. It was a very quick trip, but it was something to do while Jessica  overcame her jet lag. I think she is back on top now, and we will be ready to go to Daeyang Luke Hospital Monday morning.

We saw most of the usual animals, but no lion or leopard. However, we had a quick night sighting of a rhino. That means I have officially seen 'The Big Five'. The camp has a water hole, lighted, by the camp - we had wart hog and impala come up, that night there was a herd of cape buffalo and some zebra. In the early morning (before the drive) a herd of elephant came up, then wandered up by the tent and drank out of the bird bath. It was exciting for everyone to be that close to the big animals!

 Nyala

 Charles and Jessica

 Zebras

 Elephant at the camp - note the tent in the background

 Meredith, Jessica, myself and Charles - the elephants have just disappeared behind us (at the camp)

 Bushpig - this was out in the morning - usually a nocturnal animal - I had not seen one before!

 Charles using my camera

 Charles and I with the waterfall (the last hydroelectric dam on the Shire on it's way out of the country) in the background

 Family of warthogs at the water hole in the camp

Charles and his oldest daughter, Lauzo (I think)

 Charles, baby Ruth, wife Elita, and Praise.

Katie and Meredith left this afternoon. We picked up Lidson, my sponsored son, at COTN and he went with us to the airport. We had lunch in the waving bay, then we waited until the plane loaded and left. I think he had fun, and he was using his new tablet to take photos and videos.What fun for him! Back home now, not sure what the rest of our 'day of rest' will entail.

Praise / thanksgiving:
The safe travels to and from Majete
The chance to see some of God's creation in the wild
Time with Lidson (such a sweet kid!)

Special prayer request - safe travels for Katie and Meredith.