the end of Qu E

Intensive Care?

The day I’d been dreading, ICU…having glimpsed the one in Lilongwe when Duncan and I were here 2 years ago, I was not looking forward to the day at all. The memories of seeing the patients ventilated but not sedated, naked and tied by their wrists to the bed frame, never mind the flies buzzing round their wounds made my usual ITU avoidance excuse of an aversion to beepy machines seem even more ridiculous. As with every ward I’ve walked onto in the past 3 weeks, they were not expecting me and after being shown round I was left to just stand there like a bit of twit.

There were only 2 patients, one a little girl who had had some pretty major bowel surgery and the other an ‘unknown’. He was about 25 and had been hit by a car on the road somewhere outside Zomba and brought in by police. The nurses didn’t know anything about him and are unlikely to, as he isn’t able to speak and the police paperwork has gone missing so everything in his notes is a question mark. His poor family won’t know what has happened to him and I suppose luckily for him he won’t either.

After listening in while the patients were reviewed by the anaesthetist (who is in charge in these parts) and then trying to busy myself by figuring out what half the machines were there to do, I decided that I’d quiz the students on their objectives. I wasn’t expecting much seeing as most of them were huddled round the 3 bar heater, playing with their mobile phones but actually they were pretty clued up, theory wise, about the skills they had to master but when it came to watching them doing anything it was a different matter entirely. The faffing about is incredible! Now I know I like to potter and move things from one place to the other and back again but not when a patient is choking on their own secretions and making noises like a walrus with whooping cough. No sense of urgency at all! What makes it even worse is that the patients are not sedated with anything much more than the occasional dose of diazepam and perhaps some sort of muscle relaxant if they are lucky. I hate to think that they are aware, or even half aware, of whats going on.

Enough was enough and I made my escape at lunchtime. I’ve never been so close to tears so many times as I have recently but after having the afternoon to think, what horrifies me more is the fact that some of the things I found awful in the first couple of days now seem semi-acceptable. I still can’t quite believe the level of incompetence sometimes and that ‘nursing’ here is so far removed from what nursing is at home but I find myself wanting to forgive them, despite the thousands of patients that probably die because of crap quality of care, because they just seem to have no idea of how to improve. What I can’t work out though is, do they have no idea because their training is bad? Is it a cultural thing? Is it because that the task of providing healthcare out here is so insurmountable that there is no point even trying?





The ward round from Hell…

I was determined to try and give each new ward I went to a chance to prove that they weren’t all like all the rest but I’m not sure why I bothered. The next one on my list was another surgical ward and the shift started like all the others – a round of bed making as pointless as they come – not just because there is rarely any clean linen to put on but also because the sole aim appears to be to get the patient tucked in as tight as possible so they can’t move. They flit from one bed to the other, flapping blankets about - paradise for the infectious airborne viruses that I’m sure are hanging about in their millions.

Most of the patients seemed to have had some sort of urology surgery or were in desperate need of some…I’ve never seen so many contorted and unhappy-looking, one-eyed black mambas in my whole life…I would have giggled about it later had I not gradually become incensed with fury as the morning progressed…before I tell you why though I must just describe the scene that was before me. The ward had 3 bays of about 18 beds each and some side rooms but there were people everywhere, patients in the beds, guardians milling about beside them, students trying to make them and nurses avoiding going anywhere near them. Without anything that I could usefully do, I decided to just stand and people-watch. The first man I clapped eyes on was a young guy in the orthopaedic section, manoeuvring himself out of bed. He sat on the side, reached for a plastic bag that was tucked under the mattress and then carefully wrapped his foot in it. In obvious pain, he then hopped on the other foot off to the bathroom. I wondered what he had done to it and when he might last have had any analgesia. I then saw a man sitting on his bed, shoulders hunched up, arms inside his tracksuit top, which was zipped up over his head – he looked freezing cold and I wondered why didn’t pop himself in bed and cover up with a blanket. As I looked down to his legs trying to work out what was wrong, what surgery he might have had, I saw his feet. Nothing was wrong particularly, except that he was wearing a pair of ladies shoes, black plastic with a delicate little bow on the toes. He saw me looking at him and I felt so awful because I obviously had smiled to myself about what was on his feet but as soon as I saw his eyes I wish I hadn’t. He looked up at me, from underneath his eyebrows, with the most forlorn look I’ve ever seen. I felt so ashamed for having intruded on him in that way. The man who’d hopped off to the loo then bounced back in and distracted both me and the other patient, so I took the opportunity to move away and stand where he couldn’t see me. As I did that though I wished I’d have gone over to him instead and been able to talk to him but with hindsight, 2 hours later, I’m glad I didn’t.

Not long after, the consultant surgeon arrived and I joined the ward round (along with the 11 nursing students and 8 medical assistant students, 2 qualified clinical officers and a Dr) and never have I instantly hated someone so much in my whole life. He swept into the first bay, didn’t greet anyone, patients or staff, and demanded that all the guardians leave. He approached the first bed and as one of the clinical officers began the history, he whipped back the blanket and instructed the patient to take off his chitenji (cloth, sarong, wrap thingy). So with 24 pairs of eyes watching him, the poor old guy fished about, untangled his catheter and flopped out his crown jewels. The surgeon then asked for some gloves, which no one had to hand and the box that a student dashed off to get turned out to be full of gauze instead. He then screeched something about how disorganised everyone always was and that how was he expected to work if no one ready for him. Eventually, a new box of gloves was found and with more orders to get some screens round the bed, he began to poke and prod the patient whose eyes screwed up with pain yet he didn’t say a word. Neither did the stick-thin man a few beds later, who had a hip abscess aspirated there and then, no local anaesthetic, no nothing. He also had one NG tube viciously pulled out his nostril, while another one was simultaneously shoved down the other. He was retching and struggling to breathe, but the surgeon just continued what he was doing without explanation, reassurance or any communication with him at all in fact. I just wish he’d been sick all over that arrogant so-and-so’s shoes, except he probably wouldn’t have had the strength. After watching what he’d done to him, I really wanted to just walk away. He carried on though, and I watched, silent but fuming, as bed after bed, he made these men wriggle out of their torn and dirty clothes, announce their problem to the waiting crowd and more often that not tell them he had done all he could and that they should go home. He was rude, impatient and such a jumped-up little twat but whenever he screeched about yet another thing that wasn’t right, the rest of the nurses giggled behind their hands until one of them went off to get what he wanted.

About an hour later, we got to the man I’d seen hopping about earlier, as I was standing at the back, as far away from him as I could, I didn’t hear what was said but I could see that his foot looked completely mangled - a mass of pink scar tissue and distorted flesh. The Drs discussed something, scribbled in his notes and then, as they moved on, they were flung back on the bed behind them. The patient reached for the folder and flicked through, searching for what had been written - it seemed to me that they hadn’t told him anything. I asked a nurse what had happened to him in the first place and she helpfully told me, ‘he had an accident’ – no shit Sherlock! Good grief these people - talk about stating the flipping obvious! Anyway, it transpired that, after whatever accident it was, he’d had surgery and now 2 weeks later he’d overstayed his welcome and should go home. He’d have to go and buy some crutches and just get on with it.

A while after that, as we were reaching the end, we came to the man in the ladies shoes. I still wasn’t quite sure what his problem was, but when I saw, my eyes nearly popped out my head. He unzipped his top to reveal his chest which looked like it had been skinned. It was all pink and shiny, from where his collar bone was right down to just above his tummy button. I’d never seen anything like it as much as it shocked me, I couldn’t take my eyes off him – I have no idea what my face must have been like, which is why I’m so glad I didn’t have the guts to go and speak to him earlier after he saw me looking at him as I just wouldn’t have been expecting what was under his jacket. When I asked afterwards what had caused it, I was told that he’d had a tooth abscess which had spread to his throat and then chest. I’m still not quite sure why he ended up with no skin but I’m not sure I want to either. He still had that awful look in his eyes and that, together with everything else I’d seen and heard that morning, made me so angry and incredibly sad. He was one of the last patients thank goodness, I wouldn’t have been able to stand anymore.

As he finished with the final patient he cupped his hands and held them out for one of the med students to pour some meths in - no handwashing needed here! As he rubbed them together, peering over the top of his glasses, he looked like a nasty little fly that I would have taken great pleasure in swatting with a nice, big rolled up paper. I had to make do though with giving him one of my most evil, Frosty the Snow Bitch looks. Slitty eyes, arms folded. I made sure it was nice and lengthy, following him right down the corridor as he flounced out, followed by the swarm of students. As I left the ward to meet Kim, Ali and Antonio for lunch, I just couldn’t work out why people put up with, and even seem grateful, for the atrocious care they get?

I just couldn’t go back for the ward so went to a teaching session on the management of aggressive psychiatric patients instead. We arrived early at the library where it was to be held, so I had a look at some of the books and journals – doesn’t look as though many of them are used which I suppose isn’t too surprising as many of the most recent ones were from about 1985! In keeping with the African-Time tradition, it didn’t start when it was meant to and then about 5 minutes after it had got going we were told that we couldn’t use the room and needed to find somewhere else. Half and hour later, we re-convened in the outpatients waiting room, sat on the benches to one side as the clinic continued on the other. Odd, very odd! Not as bizarre as the hints and tips handed out by the Matron and her side-kick…Here is the guide to diagnosing and treating the aggressive ‘sick-o-phrenic’ client…

Signs and Symptoms – people that are wearing shabby clothes, are dirty and have not bathed recently, are talking loudly, have over-decorated their bodies and are jumping up and down are likely to be having sick-o-phrenia and might try to suicide themselves.
Management - it is best to try and restraint these people, put them in isolation, give them food and try to involve them in activities. Sedation should be given but if the patient wakes up after 10 minutes you haven’t given enough and must wait 6 hours, then try again.

Marvellous, lets all give that a whirl….



Mosquitoes will be the death of me…

It felt so good to have finished and not go into the hospital the next day - I celebrated by doing my washing, mopping the floors and having a nice tidy up!

Had a bit of a scary encounter with a crazy man in the afternoon, definitely one of those sick-o-phrenic types. I was waiting at a petrol station for Ali and Kim so we could walk home together when this chap approaches me and asks if he can be my bodyguard! I politely refused, saying that I thought I was probably ok, but he wouldn’t hear of it, on account of me being one of the daughters of Great Queen Elizabeth, Chief of England! He launched into a lengthy explanation of why I needed protecting but didn’t say who from. Without wishing to encourage him, I was intrigued as to who might be after me, as I’ve actually felt pretty safe since I’ve been here. Silly question…I should have known – apparently the wizard of Ndirande was out to get me. He lives on the mountain, behind the dam where the chickens that swim are…
“Chickens that swim?” I asked,
“Yes, these chickens that swim in water” replied my new best friend.
“Oh, you mean ducks…”
“Yes, these swimming birds”

I wasn’t really sure where to take the conversation after that but I needn’t have worried, Crazy Guy carried on and issued me with some useful instructions on how to get to the Wizard and make sure I got home safely…I must take a banana from his tree, and eat it while walking back to my house but be careful not to look over my shoulders because that is when he will jump out. This is why I need a bodyguard because he will walk backwards keeping an eye out for the wizard in case he spots me taking his fruit. As he paused briefly, waiting for me to accept his offer I suppose, I glanced over his head and saw Ali and Kim coming up the hill – at last! I thanked him again so much for the kind thought but told him I’d make sure I bought my bananas in the supermarket but that if I did fancy a trip to Ndirande I’d call on him to be my escort! Oh my goodness, how to I attract these people?

Anyway, back to why mosquitoes will eventually kill me…nothing to do with malaria this time you’ll be glad to hear (the Larium is going fine by the way – no reappearances of the Cocky Spider yet, shame!)

On Wednesday night I slid into bed (well, onto my mattress on the floor) and dropped off almost a once, only to wake up at about 2am with a couple of mosquitoes practicing their moves. I tried to ignore them but without a net I knew I should probably get up and hunt them down. I was so snuggly though, I just didn’t want to move. In the end, they really didn’t leave me alone so I flung back my blanket and got up, switched the light on and while blinking sleep away, searched the walls for the little buggers. I saw one and launched at it, clapping my hands together – trouble is I didn’t look where my feet were and before I knew it I had skidded on my slippery sleeping bag and landed with a crash on the floor, right on my bum. I wasn’t quite sure whether to laugh, because it was so funny – or cry cos it actually really, really hurt! I sat there rubbing my butt, giving up on the idea of killing the other mossie, and wondering if I’d done anything serious. I wiggled everything and all was ok, so I lay back down, pulled my blanket right over my head making sure the remaining mosquito wouldn’t get at any juicy bits and fell back to sleep. In the morning though, I didn’t find it quite so funny and I was sure I’d broken my bottom. I log rolled myself and managed to get on my feet but ouch! It was really painful. I dosed myself up with analgesia and spent the day enjoying some classic time-wasting at the traffic office – don’t ask!! We also did a bit of shopping and I found myself some marvellous mankwhala – Salimia Pain Killing Liniment. I wasn’t quite sure if it would be any use but that didn’t matter one bit when I read the leaflet inside – I’m going to copy it out so you can see what it said too…

Action: Salimia liniment contains counter-irritant and rubefacient that relieves pain and increases blood flow the affected areas. Methyl salicylate acts as a local analgesic. Capsicum oleoresion contains capsaicin that renders skin and joints insensitive to pain by depleting and preventing accumulation of substance P in peripheral sensory neurons. Substance P is the principal chemomediator of pain impulses from periphery to the CNS

It gets better…

Contraindications: in patients with aspirin or salicylate idiosyncrasy.
Side effects/Adverse reactions: Patients may feel warm, stinging or burning sensation at site of application, especially during initial few days of use.

Poisoning: Salimia contains methylated spirit, methanol can cause acidosis that can lead to blindness. Quantities of the other ingredients are small and may not case any toxic effects. Gastric Lavage and infusion of sodium lactate to be administered immediately. Haemodialysis may also be carried out in case of delirium, if it occurs, diazepam should be administered.

I’ve put some on…Ali is on standby with the gastric lavage kit and diazepam!!


Boogie-ing African Style.

The 6th was Malawi Independence Day and we had ourselves a very sociable day! Met up with two more VSOs from Zomba, Carol and Rachel for lunch in town and then went to Limbe to see my great-aunt, Elaine where we watched a bit of Wimbledon.

In the evening we went to The Blue Elephant – a bar/club sort of place for some drinks and to immerse ourselves in the sweaty atmosphere that is an African boogie session. It was like no where else – the barman was doing a double-act with another chap all kitted out chef’s whites who was flipping hunks of meat and chicken on a BBQ behind the bar. You could see the sky, full of stars, above the dance floor and there were lots of little Malawi Flags and balloons strung up all over the place. It was a very odd mix of people - old white guys in short shorts, long socks and desert boots, young black girls in a whole range of bizarre attire, lots of black men looking us up and down with great intensity and then going off to strut their stuff on the dance floor and looking fabulous doing it! Not sure it’ll become a favourite haunt but it was definitely worth it, if only to be able to tick it off on the Must-Do Before You’re 30 list!



Back at the Ranch…

We’re back in Malamulo now, ready to complete the last 2 weeks of this farcical orientation programme. Boss Lady is away in South Africa doing her Masters, so we might just be able to get away with bare minimum…fingers crossed! I

It seems odd being back here and it feeling so like home even though we were only here a week before we left to go to Blantyre. The house has been fine while we weren’t around thanks to Fly and Master, our watchman. The lettuces and carrots have sprouted – can’t wait to get the rest of the veggie patch up and running.