KCH and Bright Vision

Well, I had planned on Monday at KCH Casualty, but I was exhausted after all the wedding 'going-ons' so pretty much took the day off. Tuesday Anne and the kids left, but I didn't see them- there was a death of an orphan at Pothawira village, so they were dropped early by Maggie, who then stopped by here, and a funeral was held for the child down at Pothawira. I spent Wednesday at KCH in the Casualty. If you are not my friend on Facebook, you should be, as it is always sometime going on there. The interns and I had an issue with a radiology tech, but hopefully that is straightened out. We saw lots of urology problems - suprapubic catheters specifically, along with some RTAs (road traffic accidents), admitted kids with spinal bifida for surgery (apparently a common problem here). One poor little guy had gotten caught in a grass fire with major burns and was transferred from another hospital to the KCH ''burn unit". A youngish guy with an immense scrotal swelling, diagnosed with 'hydrocele' but I was concerned it might be testicular cancer. Lump, bumps, swellings and growths that I have not idea what there were / are. The interns are such hard working young doctors! I am always impressed by what they do with such limited resources. That night I had Charles Msukwa and his sweet family, along with Clifford over for dinner. It was very pleasant!
Maggie came Wednesday night, so Thursday morning we did ward rounds at Partners in Hope. They have some very, very sick people. At least they have more resources that most places here, but still they are limited. The doctors I had the privilege of making the rounds with are just flat out SMART! I mean, these guys have to deal with all the 'usual' problems of sick people - strokes, sepsis, newly discovered cancers, congestive heart failure, renal failure, Stephen Johnson Syndrome AND add on top of that, many (but not all) of their patients have HIV/AIDs, some who have defaulted (quit taking their meds) or were just diagnosed, so that have the overlying problems of miliary TB, metastatic Kaposi's sarcoma, etc. Obviously some of the meds for the different problems interact poorly. They have a real balancing act trying to treat their patients. Dr. Perry Jansen has put together an awesome team at Partners in Hope!
In the afternoon, Maggie and I went to the Children of Blessing Trust seizure clinic again. These patients can be challenging. And I get the easy ones! When they are doing well, no seizures, no side effects, no big weight changes, it is an easy refill. However, when things go back, it can get confusing. Are the new 'startles' in a child break through seizures or does he have malaria and fever? Is the medication causing the aggressive behavior, or is it part of the spectrum of the disorder the patient has? Should be change meds - risking uptick in seizures but maybe improved overall behavior? All this without any drug levels, liver function tests, and most of the time, without a clear idea of why the patient has seizures. Dr. Young, Dr. Hodges and Kathy Bowler are doing amazing work there and I feel privileged to be able to help in some small way.
Friday we all went to Bright Vision orphan care. We saw more adults than kids, and I have no idea how many but I think it was pushing 200. The nurse, Maxwell, was taking BPs but when he identified a straight forward patient (general body pain or just needed BP meds) he wrote the prescription and skipped over me. He did the same with the kids with malaria. It was wild, disorganized and just plain crazy. Fortunately, we had a strong team and managed to somehow pull it off, but I didn't drink, eat, or go to the toilet from before 8 AM until sometime after 3 PM. I figure I can sleep 8 hours without that, so I should be able to work 8 hours like that, right? However, I think next year we will work on our organizational skills with these village clinics. I realize we don't really make patients with hypertension, diabetes, or heart problems better in the long run. However, my translator and I spent some time with these chronic patients to explain the chronicity of their disease. I would like to start basic education in diseases as a regular part of these clinics (but I need more people!). I think we do make a difference to the people with acute infections, including malaria and infected wounds.  We also found a very small 2 year old with cerebral palsy (diagnosed in her health passport) whose Mom seemed totally unaware of the diagnosis and what that meant for this child's life. The baby apparently 'cries all the time' and 'startles'. We referred them to Children of Blessing - Maxwell lives in area 25 and was able to give them directions and I was able to give them the clinic dates. Hopefully the Mom will take this child, it is the best (and maybe only) chance this kiddo has! I leave Monday. I have no more clinics planned. I did treat one of the guard's little ones early this morning (in the living room clinic), but otherwise, packing, distributing left over medications, seeing people for the last time for a year. It is a melancholy time for me, especially with Whiskas and his wife.  They are precious people and this country can be hard on the older people. Enjoy the photos. Prayerfully consider whether YOU are called to this mission. Thanks for all of the support and prayers.

Bright Vision orphan care is set up next to this huge ? granite dome. The main building is on the right of the photo.

The people are gathering for the clinic

Maxwell is checking blood pressures. The small white cap is the pinkish pills - albendazone. We worm everyone who comes to these clinics.

Amy, my translator, trying to get a history from this gentleman. It was a challenge. You can see the crowds starting to gather in the back

Pharmacy staff hard at work, Annualitta Motope, Larry Brown, and others worked hard all day!

This lady had eruptions  on her foot. She gave the story that they would spread all over her body, itch, and then disappear but always stayed on her foot. I have no clue!

This was the smiling-est (if that is a word) baby I had seen in a long time! He looks much happier than Mom!

Again, trying to get a history from an elderly woman, fortunately she had her health passport with her, and it documented CHF and cardiomegaly. She had medications, but they were 'finished' and she was sick again and didn't understand why. We need some basic medical education here! Also note how the crowd continues to grow in the background. And it is very, very loud!

Pharmacy still hard at work, and the crowd grows!

At the end, we all had to pitch in to get the patient's prescriptions filled. I am not a  very good pharmacist!

The team (except for Charles, who was taking the photo). Do we look exhausted?  Well, we are!

This morning my guard, Grey, brought his little son, Samuel, by the house to be checked. Fortunately I had not packed up all the meds, and had some liquid antibiotics for him.

Wedding and Reception

Saturday Wezzie Maseko married Daniel Hara. African weddings (at least in Malawi) are really big, big deals. Since I am living close to both the church (for the ceremony) and the gardens (for the reception), the girls 'moved in' here to make the arrangements, cook cupcakes and wedding cake, meet with people, sleep here, eat here, talk here, and of course, brought the appropriate children. It has been a wild, wild week. The ceremony was very good, the bride was beautiful beyond words, the groom is very handsome, and everything went off without a hitch. The reception lasted for several hours, and was beautifully staged (enough that the girls were asked by several people for their 'business cards' so they could cater their wedding!).  I think everyone had a glorious, joyful time! I know I did. Some stayed for church on Sunday morning, then packed up almost everything and left. It sure was quiet last night! Today I started preparing for the next clinics, ordering meds, only to have Wednesday's smaller clinic canceled. However the 'big' clinic is still on for Friday, and the seizure clinic Thursday. I had lunch with Michelle Clark and her Mom, Pat, plus visitors from Nchetsi? who are German and with AIM, working in an orphanage and feeding program and promoting natural / herbal medications. While at Michelle's I met Princess Michelle, the baby of one of her workers, Grace. What a sweet baby, even fell asleep on my shoulder.  Charles the tailor stopped by last week, his wife had a tooth problem (probably dry socket, very painful), and then Watson, one of the cooks on campus, brought his little boy by - he tested positive for malaria so we got him on treatment. The dining room doubles as a clinic area! Enjoy the photos.

Charles the tailor and his beautiful wife, Mary, along with their youngest child

Me, feeding Robin (son of Foster and Wezzie) his breakfast porridge.

Kitchen full of activity!!

Table starting to fill up with cupcakes. I think they made over 200 cupcakes!

Morning of the wedding, a bridesmaid in the background, while work is still on going for the reception. Many of the cupcakes were put in these pretty little boxes to give away.

Beautiful flower girls, including Isabella (the 'left most') and next to her Alpha.

A most beautiful bride, Eddah Maseko

Happy couple, Daniel and Eddah Hara!

The cupcake stand, all decorated and filled with cupcakes, surrounded by fruit platters. To the right are the wedding cakes and to the left, the chocolate fountain

Craig Kindell, me and Isabella, as the reception is winding down. All those chairs had been full of people for most of the day!

Michelle Clark and little Princess Michelle. 

This was the cupcake stand as it started out BEFORE they decorated it and filled it with cupcakes!

Chinsapo Clinic

Wednesday we went to Chinsapo Village for a clinic. Last year, we held the clinic under the trees. This year, Mirjam Molenaar and her ministry has managed to build a school block, surrounded by a wall, and has a borehole and a separate toilet facility (squatty potties, but important that the children are not relieving themselves in the bush). She even managed to get the bridge repaired! So we held the clinic in one of the school buildings. Charles Msukwa, Clifford Kuyokwa, Alice Li, Jonathan (nurse from ABC), Annullita, and myself were the 'team'. Charles had a couple of volunteers from IBF (local church) and of course, Grace, who works with the Chinsapo ministry. I am not sure how many people we saw. Jonathan started by taking blood pressures and temps, but ended up seeing some of the straightforward patients. It was, as usual, a zoo. I completely understand that I really don't make a difference for people with chronic problems. Oh, we can give them a month's worth of blood pressure meds or diabetic medications, we can give some pain medications for their chronic pain, we can even give cough meds for the unrelenting coughs during this wintry dry season with dust and smoke everywhere. My goal is two-fold: first to show the love of Jesus to the least of these by going into these villages, and second is to find and treat the acute illness / injury. I also try some basic education about wound care (washing with soap and water), chronic pain (most are due to years of overuse of their bodies), and the fact that we don't 'cure' certain diseases and they need to continue with medication (high blood pressure, diabetes). I am not sure how well that works. I always see a lot of people with eye irritations (not infections) from the dust and smoke. If anyone has contact with an ophthalmologist willing to give me samples of allergy eye meds, I would be very grateful. Here they use a steroid eye medication, which is frowned upon in the US.  Several of the patients were 'reactive' (meaning HIV positive) with complications of their disease / medications. One had Kaposi's sarcoma of her leg and wanted me to 'cure it'.  There were some wounds in children that were infected. Lots of fungal infections (skin and hair). A few cases of scabies. One very malnourished, ill child (but Mom stated that child was non-reactive) - Grace enrolled her in the feeding / nutrition program. Lots of runny noses and coughs among the little ones. Seizure patients out of their meds. Diabetics out of their meds. Blood pressure patients out of their meds (I see a pattern here).  We were going to stop at 1, but so many patients were there we extended to 2, and then to 3 but then we had to leave. It is always hard when people still have not been seen. We need a better plan = like cutting off new patients at a specific time, but we are still trying to 'hone' our clinic management skills and it is always hard to tell people with sick children 'no'. I have posted some photos - beware that some are graphic. Also, if you are following this blog and not friended me on Facebook, please do so, there is additional information and photos there. Also, if any doctors are following this, look at the 'rash' patient's photo and see what you think! Enjoy the photos!

Grace addressing one of the groups of patients who have come. The new school block is in the background.

The 'triage' desk where patients get a number - first come, first served. Not sure how many we saw because the families of 3-4-5 all got one number. I do know that I saw a '157' near the end of the day.

This poor man had been blind since childhood, then about 10 years ago what sounds like cerebral malaria - since then he can barely walk, no longer communicates, talks to himself, doesn't sleep at night. His father is his caretaker. All I could offer him was thorazine at night time so perhaps his sleep cycle will improve (for his Dad's sake).

Jonathan and an IBF volunteer taking BPs and temps.

Awesome pharmacy staff!

This lady was covered in this rash for years and years. Seen at KCH and told 'no cure'. I don't know if it is psoriasis? Very unsightly and she kept herself covered. Any ideas out there?

Malnourished child who was taken to hospital about a week ago and given injection. Now with early abscess at injection site. This is very common here - US nurses tell me it is because they give huge amounts of meds in a single shot. This abscess was not opened at the clinic (no fluctuance combined with no real area to hold child / do procedure) but I gave her oral antibiotics, vitamins, probiotics and Grace got her signed up for additional nutritional support.

This wound was several days old. Antibiotics and wound care instructions. 

This poor child had her heel caught in bike spokes 4 days before the clinic. She is two. There was still dirt and grass in the wound. Alice took her to the well and washed the wound, bandaged it (gave Mom extra materials), used antibiotic ointment and oral antibiotics and wound care instructions. Her achilles tendon is intact, but if the infection spreads, it could destroy that tendon.

Packing up - left over patients just hanging out, watching us.

Clifford and I discussing issues with this patient, who had seizures and was out of his medications. See how short our table is? I spent almost all day bent over like this, writing in their books. Hmm, I had chronic back pain by the end of the day! You can see Jonathan and the pharmacy in the background. This is early in the clinic, by noon, every area with a mat was covered with women / children / men sitting and waiting. I would have to step over people waiting to get to the patient I was seeing if I needed to listen to their posterior lungs, feel their back, look at their legs. It gets crazy!

Return to Maula Prisons

Today we went back to prison. Charles lead the team, of course, and we added Dr. Barrett Jones, a doctor from Partners in Hope, a medical student visiting here, Alice Li, Clifford as my translator, Lewis to help translate for Dr. Jones, and another young lady who was introduced to pharmacy in a trial of fire! Maggie and Marie Maseko also helped in pharmacy - Maggie has some experience but the others were first timers. There was also a new clinical officer or medical assistant from Doctors without Borders who also saw patients. I am not sure how many we saw. I did see a very sick man with a very complicated medical history including HIV and a second infection of TB on streptomycin, with a very recent acute malarial episode who was weak, could no long walk, was barely speaking, and had to be carried by his friends. His blood sugar was OK, but that was pretty much the limit of the tests we can do there. We recommended transfer to KCH as soon as possible. Then both Dr. Jones and I saw Ethiopians (never figured out how they got into a Malawian prison) with severe abdominal pain. The patient he was seeing looked like he could literally die at any moment, mine was not quite as ill but doubled over with pain and abdominal rigidity and guarding. Again, our only choice was to get them to KCH. From the prison, that can be a long, tedious process. We left the medical assistant, Jones Tambula in charge of that!  I also had an interesting patient with a cough with bloody sputum, weight loss (he claimed almost 20 kg in a month), and a rash. He is HIV positive. He had markedly swollen but non tender parotid glands. I am considering TB as the cause of his cough, with a possibility of bilateral parotid involvement due to the TB. Apparently that is a rare condition, but not unheard of. And TB here seems to show up in the darnest places! After we finished seeing patients, we got a tour of the new skills center, where inmates will be taught carpentry, metal work and sewing / tailoring. We also peeked into the chapel, where a prayer service was being held, and saw the school rooms. They teach primary and secondary school here, with some adult classes as well. Some of the teachers are inmates, some come from outside. Emily Prince, who came last year and stayed the entire time with me, sent a laptop to Jones Tambula and I was able to present to him today, in her name. He was thrilled! You usually see him in uniform, today he was working as the medical assistant - he is the #3 man in charge of the clinic there.  I also found out that Maula Prison is  the second largest prison in Malawi!  Enjoy the photos!

The young woman on the left (white jacket, black skirt) is our new pharmacy recruit. She is standing in the 'waiting area' before we start.

Maggie and Marie Maseko arranging the medications. Again, a huge thank you to those that have donated money for the medications. These are NOT medications that the prison had, these are the ones I bought here and brought

Diabetic lady with large foot abscess. It is on the dorm (top) of the foot, not on the sole as we usually see in foot abscesses here.

Presenting Jones Tambula with the laptop provided by Emily Prince.

Going over the passwords, etc that Emily Prince set up for Jones, with Clifford looking on.

Showing him all the goodies included (chargers, converter, bag). Emily, he was speechless and beyond thrilled!

Marie explaining the medication to a patient.

Dr. Barrett doing his thing in the wound care area, with Smart and Alice Li looking on!

Pharmacy girls working hard!

Patient with parotid gland swelling. Both sides looked like this.

In one of the school rooms. I think Barrett is reviewing some chichewa with Clifford!

Clifford, myself, Lewis, Alice and Barrett after our tour of the non-clinic facilities. Charles has done amazing work with the clinic and skills building, and he has had help with other buildings, but there is more to do, more supplies to buy, If you are interested in supporting his work in the prison system here in Malawi, get in touch with me.

Kamuzu Central Hospital and more

So much is going on it is hard to keep up. And the internet gets slow here. A short synopsis. Anne Alaniz, Mable Maseko and two of Anne's kids, Jayden and Isabella, arrived Saturday. They brought tons of luggage as they are carrying most of the supplies, dresses, etc for the big wedding next week. Saturday morning Julie and I went to Chitipi children's village to visit her sponsored child, Blessings and his sister / cousin (unclear what from the history) Sellina. I also saw Mandy's sponsored child, Caleb, and his brother, Thomas, plus all the other sweet children at the orphan home. The rest of the day was spent at the airport, getting luggage, getting it home, etc.
Monday Julie left for home (boohoo) and they left for Salima with most of the luggage. They didn't get out of here until late.
 Tuesday I was left trying to  arrange the rest of my time, catch up on things, go to Michelle Clark's to do a little minor surgery on Doriss's foot and have lunch. Oh, and organize the medications for the prison clinic next Tuesday and order more drugs.
Wednesday I went to Kamuzu Central hospital for the surgery morning report, and then met up with Anne and Maggie to make rounds with the new OB doctor at KCH who has learned how to do radical hysterectomies for cervical cancer. Cervical cancer is the number one cancer of women in Malawi. Thursday and Friday, I went back to morning report and then to Casualty. They don't allow photos in the hospital, so no photos but it was very interesting. I got to work with interns in the Casualty and see all sorts of things. Right off the bat we had a minibus accident (road traffic accident or RTA) with people and police pouring into the department. The department is small with only 4 stretchers. The Casualty also serves as a triage for other clinics - so sometimes you are just reading their outside records or doing a brief assessment and assigning them to other clinics ('book them for surgery clinic'). Fractures go to orthopedics right away. In the last two days, besides the usual RTAs and abscesses (lots of abscesses), we have seen and admitted several babies with hydrocephalus, animperforate vagina, a male infant with hypospadias, multiple hernias, HIV patients with surgical complications (usually involving infection and wound cleaning / bandage dressing), a large fungating mass on a foot that was possibly a  squamous cell cancer, a variety of adult urology problems ('book to urology clinic'), a child with a head injury today (minor, thank the Lord, as there is no CT here), did I mention abscesses?, small bowel obstructions, esophageal cancers (number one cancer of men in Malawi), a nasty Kaposi's sarcoma ('book to oncology clinic'), bone pain from various causes, mostly trauma, an child with a nasty ear infection and either an abscess over the mastoid area or acute mastoiditis. An infant with pyloric stenosis. Medicine patients are supposed to go to the medicine clinic (happens most of the time), but the surgery Casualty is where the EMS and the general public walk right in, so we have people coming in randomly to be seen. Remember - 4 stretchers. No lab, X-ray they have to 'go around the building for' (so if they are sick enough to be admitted, they get X-rays after admission), drugs are either given IM or mainline. No antibiotics given in Casualty for infections - only prescriptions. Only IVs I saw started were on patients being admitted and not all of them. They have no otoscope. They are short on suture instruments and sutures. I think I had the only pulse oximeter in that part of the hospital. The C-collars are reused (and look like it). There are no cardiac monitors but they can get vital signs if you ask (but no one could find a thermometer). Generally 2 interns and 2 nurses with some tech type people, although today we seemed to have an extra doctor (besides me, and I don't count). Quite frankly, I had a great time. And I learned so much from them. I did try to teach (these guys are interns, after all) but they already know a LOT.  If anyone is interested in coming in the future, be aware that I think a few days at KCH Casualty will be in your future! This afternoon, Charles and his wife, Erita and the newest baby, Emily, stopped by for a brief chat. Enjoy the photos!

Thomas and Caleb with some of the gifts, including those funny hats, that I brought them. Chitipi Orphan home, Lilongwe

Julie showing the kids how to play with one of her gifts. In the blue is Caleb.

 Julie with Blessings (her sponsored child) in the blue striped shirt, with Sellina standing in front of him in the pink print dress.

Julie outside with some of the kids, Caleb in blue.

My grand daughter, Isabella - she is wearing my jacket and my thick socks. I don't think she expected it to be this cold in Malawi! Nights are in the 50s (sometimes here in Lilongwe in the 40s!)

Lunch after church at Pizza Inn (no, not the REAL Pizza Inn, lots of places here 'borrow ' the names from American locations - best buy, 7-11, Pizza Inn, etc.

Michelle Clark in her beautiful Gardens Gate

Charles, Erita and baby Emily at 'my' house.