As I am packing my bags preparing for my departure from Malawi tomorrow, I felt it necessary to update you all one more time on the last week and a half.
Last weekend six of the people living in the UNC Guesthouse traveled to Lake Malawi. It only took an hour and a half to get there and it was a beautiful drive. We were able to stop at several markets in different villages and towns on our way there and back. It was nice to be able to interact with individuals living in more rural areas than our lovely hometown of Lilongwe. We traveled to Senga Bay, which is near Salima to the south of Lilongwe. We camped on the beach, made a fire, and ate at a hotel restaurant nearby. We also tried Chibuku, which is the cheapest beer you can buy here. It comes in a milk carton and many non-Malawians add sugar and milk powder to it to make it more appealing. All in all it was a very relaxing trip. Pictures are posted on my webshots.
Last week in pediatrics, I was working on most of the same skills I did the first week. I started a few more IVs, drew some more labs, etc. I was able to work in the High Dependency Unit (HDU), which takes care of children that would typically be in our Pediatric ICU at home. I enjoyed HDU more than the ward, but I think that was due to the smaller patient load (only 5 patients to a nurse). There were also medical students and physicians around most of the time, so it was easy to receive orders and know what each patient's plan of care was.
Unfortunately, on Monday night, I became rather sick (I think it was something I ate) and was unable to go into work on Tuesday. Since I had no way of calling or emailing the individuals on the pediatric ward to let them know why I was not on duty, I decided to walk over to the hospital after I stopped vomiting and could eat some toast (pleasant, I know). When I arrived, the nurse-in-charge forced me to go get blood drawn to test for malaria. Since I had been in country for two weeks, it was the peak time for me to show symptoms of malaria. Even though I was pretty sure it was just food that made me sick, I was still scared at the thought of a malaria test. But I listen to the nurse-in-charge and reported to the Under Five clinic to have the test done. Since I knew the nurses there, it was easier to explain what I needed done and they didn't mind that I was the oldest patient (by 16 years) that they've seen in awhile. So here I was, nurse turned into patient. Luckily the test was negative, but Robert still advised me to stay home on Wednesday in case it was something contagious.
This week, I was able to work in the STI clinic on Monday. It is a very busy clinic located at the hospital. I was able to rotate through all aspects of the clinic which included data entry and quality control, pharmacy, HIV counseling and rapid testing, and clinician (aka nurse) visits. The clinic sees all patients for free. They also run two studies in addition to seeing clients that are not enrolled in either study. One study focuses on partner notification. They are testing three different ways to notify a partner of an HIV positive result. The other study is working on creating an HIV vaccine.
I found it interesting that the nurses ran the entire visit--they asked questions about a sexual history, symptoms, and performed the physical exam. They also administered standing orders of medications based on which symptoms the client had and results of the physical exam. It is too expensive for the clinic to test each patient to see what their infection is, so the clinic just treats patients symptomatically.
On Tuesday, I traveled to Area 18 to work with the Malaria vaccine project. This project just began enrolling clients on July 30th. I really enjoyed this clinic, as we only worked with children ages 5-17 months. This experience just reminded me that there is so much paperwork involved in studies and how accurate you need to be when assessing patients. I think we had to reschedule around 4 patients throughout the day because they were sick and unable to receive the vaccine that day.
This has been an amazing experience that I will never forget. Everyone here keeps asking me if I have plans to come back. I know it's going to be difficult to find the time to travel again, but I'm hoping that eventually I will be able to come back and work with the UNC Project again. See you all back in the states in a few days!
When I first started blogging, I was just so excited to tell you all about the things I was doing in the hospital that I forgot to tell you about the typical Malawian things I see and experience every day.
The UNC Guesthouse is in the capital city of Malawi, Lilongwe. Lilongwe is centrally located in Malawi and that's why the biggest hospital is located here. There are several other district hospitals around Malawi that are smaller and have less physicians and several of our patients are referred from those district hospitals. The city has a large vegetable market, but also has a Shoprite, which is pretty close to a typical grocery store in the states, just with less selection. There are two sections of Lilongwe--Old Town and City Centre. Old Town has a ton of shops that sell just about anything (within reason in Africa). City Centre has a few banks and holds mainly businesses. I found it interesting that there was such an urban aspect to this town, but I just have to keep reminding myself that it is the capital city and most other towns are quite like Lilongwe.
Pretty much everything I've seen is what people would "typically" expect of Africa. The women here do carry huge, bulky items on top of their heads--I really don't understand how they do it. They also wrap their children piggy back style on their backs and secure them with beautiful cloths. I think it's rare to see a younger woman walking without a child of some age strapped to her.
And food...although this hasn't been my favorite since I've gotten here, I've found some things that I do like. The typical Malawian meal consists of rice, beans, greens, and maybe chicken or beef. Everyday I eat lunch at the Tidziwe breakroom where most of the UNC employees (both from American and Malawi) eat their lunches. Lunches in Malawi also last from 12 noon-1:30 pm. I have to admit that while at first I did not know what to do with such a long break, I've grown to enjoy it. It gives me time to relax and do schoolwork in the middle of the day.
Malawians are very relaxed individuals, as you can probably gather from the hour and a half allotted for lunch. No one seems to really get angry or rush to do much here. I don't want any of you to get the opinion that they are lazy, but time is just not an issue. I think the transition back to the states where we are constantly pressured and most people are stressed for one reason or another might be difficult.
There are 7 people living in the Guesthouse now, including myself. There are two medical students from Cornell, one from Johns Hopkins, and three Grassroot Soccer employees. I have also met two medical students from Leeds in the UK and five or so medical students from Scotland who are working at the hospital--and all of them love to make fun of me calling them "y'all". It's been nice to collaborate with other students in the hospital--I feel that we all share similar frustrations with limitations in patient care. We all try to keep an optimistic attitude about things, but sometimes it's difficult when we have patients die day after day due to limited resources and staff. Although this is a factor I anticipated when I came to Malawi, I did not realize how frustrating it would be to see my patients die without me being able to do anything to advocate for them.
I also can't believe I only have 5 days left in Malawi. I finished my pediatric rotation on Friday and even though it was a frustrating rotation I learned a lot and will really miss the kids. I will work in the STI clinic on Monday and travel with the Malaria Vaccine (MAVAC) trial on Tuesday and Wednesday.
Now that I have three days of pediatrics under my belt, I thought it would be a good time to update everyone!
For my first two days in peds, I worked on Children’s Ward A (CWA). This ward contains the burn unit, surgical wards I and II, the special care ward, isolation area, treatment room, and nursery. Needless to say it is huge and sees around 400-500 patients a day. I followed along with Robert, the nurse-in-charge. Since the Unit Matron for CWA is on leave for the week, Robert has to take on her administrative duties while still providing nursing care to his usual patient load. He is very busy, but has still been a great preceptor with whom to work. After two days on CWA, I think the staff and patients are finally getting used to having me there. They are sometimes surprised that I am a nurse, as I don’t wear the typical white skirt, white top, and navy sweater that all the other nurses wear and instead am sporting my carolina blue scrubs. I also don’t answer to “sister”, which is what all the nurses, male or female, are called in Malawi. It isn’t because I’m ignoring them or don’t want to respond, it’s simply because I have never been called “sister” before and it’s not my initial response to answer to that calling.
I also have a shadow in CWA. This child, who has been following me around since I oriented to the unit on Monday, would not speak a word to me until today. I finally figured out that his Christian name is George (most Malawians have a traditional name and a Christian name), after asking him for the past three days in Chichewa what his name was. It is very possible that my Chichewa was that bad and he couldn’t understand what I was asking him, but I’m thinking that he was also very shy. He is absolutely adorable and to be honest I’m not even sure what his diagnosis is since I have not been taking care of him. All I know is that for some reason he has latched on to this “azungu” (the name for a white person in Chichewa) for whatever reason and I don’t mind the company. I just wish I could communicate with him more instead of just smiling and waving to him all day every day.
On the first day in the unit, I went to several meetings with Robert. One meeting was with the HIV counselors at the hospital. Having HIV counselors in the hospital attempt to offer HIV testing to each patient in pediatrics is a joint effort between Lighthouse, which is a local treatment center for HIV/AIDS, and Baylor, the College of Medicine in Lilongwe. There were several issues regarding collaboration between the Clinicians (physicians), nurses, and counselors. Counselors felt that nurses were administering drugs late so patients were unable to be tested, etc. The list of interdisciplinary issues goes on, but the important fact is that in this meeting both sides came to an agreement which ultimately improves the patients’ outcomes and numbers of individuals being tested for HIV in Malawi.
In the afternoon, I observed the 2pm drug round which still amazes me. Robert also taught me about Emergency Triage Assessment and Treatment (ETAT), which is based off the American training course Pediatric Advanced Life Support (PALS). ETAT is a protocol for triaging patients upon arrival to the hospital. It provides health care workers with guidelines to follow to decide if a patient is an emergency case, priority case, or queue case. This protocol was created in an attempt to reduce the amount of deaths that occur within 24 hours of admission. Using this system, a triage can be completed in 15-30 seconds, which allows health care workers to treat the sickest of patients immediately. Robert also provided me with the training book and told me he would send me to triage later in the week.
On the morning of the second day, I inventoried all the emergency/resuscitation supplies. This experience was eye-opening. There is only one code cart for CWA. One code cart is theoretically supposed to serve 400-500 patients. In hospitals in the United States, there are usually at least two code carts on units that have 20 or so patients. This code cart was also in terrible shape. A code cart usually contains a defibrillator, supplies for CPR, emergency drugs, seizure drugs, tracheostomy supplies and supplies to intubate a patient. Although this code cart had these supplies, most of them were expired or covered in bugs and dust. This inventory needed to be taken in order to improve the effectiveness of ETAT-apparently in the past if a patient was deteriorating it was hard for health care workers to locate supplies. I attempted to organize them, but I just wish that the hospital could get a new code cart altogether. Regardless of the state of the code cart, Robert seemed to think that the inventory would be helpful in the future and appreciated me doing it since he would never have enough free time to do it himself.
In the afternoon, I was able to give drugs during the 2pm drug round. At first, I really had trouble calculating doses in my head and I think some of this was due to the pressure to be quick (as there are 8-10 patients waiting behind the one you are administering medications to). When we administer medications back at school we are required to show our work for our calculations on paper to ensure that we are giving the correct dose. I was able to give a lot of IV push medications and Intramuscular shots, which I have not done with children since last fall. Robert was testing me the entire time I was giving the medications—telling me to think faster because, in Africa, “you think! You calculate! You don’t just get the drug out of a machine here!” I heard these statements over and over for the rest of the drug round and although it may have stressed me out he’s right. If the Malawians followed the same procedure we do in the United States, it would take the entire shift to administer medications. So this experience was very hectic, but I have to admit that I was kind of proud of myself when it was finished. I don’t really see myself as someone who thinks that quickly and can do math in her head very well, but Robert said I held my own.
I also started my first IV in a child. I was really nervous, but I only had to stick the child once and he didn’t cry. I was so excited because these are the types of nursing skills I was hoping to work on when I was here. Hopefully this is a good sign for the pediatric nursing career I am planning for…
Today, I rotated and worked in the Under Five clinic. The best way to describe this place is it is an emergency room and pediatrician’s office combined. I worked in triage (as Robert promised). The only frustrating thing about this morning is that I was by myself for most of it. Luckily, a nutrition student sitting nearby realized how much difficulty I was have communicating with patients to ask why they came in and offered to translate for me. It was also stressful to be the one making the decisions as to whether the child is triaged as an emergency, priority or queue. Although I had the guidelines, it isn’t as clear cut as it would seem. For instance, one of the criteria to make a child a priority is if they have a fever. Since in triage you do not have a thermometer, I could only just feel the children’s heads and stomachs to see if they felt warm. It reminded me of my mom when she used to check to see if I had a fever—no offense mom, but it doesn’t seem like the best way to check for a fever unless it’s your child and you know them that well. After triaging, I worked on my venipuncture skills by drawing labs on older children. It is much more difficult over here to visualize veins (since, as Robert put it, the children I usually stick are just white), so if I did not see one I thought I could get I would not stick the child. I’m really glad I did this because most of the kids I passed on the nurse had to try 3-4 times before she was successful. The nurse even had to insert an external jugular IV (in the neck) on one child I decided not to stick. I really liked working here, which might be a good sign for eventually working in the pediatric emergency department…
Now for the difficult part of my day. I feel that I should add a disclaimer because the next part of my blog is not very pleasant, but I do feel comfortable sharing it with the people I know are reading.
I saw a dead baby for the first time in my 21-years today. It was something I expected to encounter over here and was even part of a question in my interview, but I still don’t believe there was any way for me to adequately prepare for seeing it. The mother brought the child into the emergency room and I immediately knew something was wrong. The child was wrapped up in so many blankets that at first I couldn’t tell that the child was not breathing. The mother was speaking in Chichewa to the nurse with me. Although the mother was extremely frantic (speaking very quickly and almost shouting) the nurse was not acting as though there was an emergency so I questioned my initial thought that the child was unresponsive. She then walked out very calmly and spoke to a physician. While she was out, the mother put the 8 month old baby on the table and I just knew. I don’t know if it was the baby’s dilated pupils or just the limpness of her body, but I just felt like this was a problem past the point of fixing. Unfortunately, I was right.
I did not cry. I felt the tears start to flow but I just tilted my head backwards and that seemed to do the trick. I still haven’t cried, but as most of you know I am an extremely emotional person and I’m expecting it to happen at some point.
At first, I was appalled at the nurse’s lack of urgency, but now I realized she had just already come to that conclusion. Part of me is thankful for the way the nurse handled the situation. She deals with it so often she was rather nonchalant about it. I think since no one else was really reacting to the situation, it helped me not to react in the way I expected myself to.
And the other part of me just can’t accept that the death of children is so common over here (1 in 10 according to a friend) that it just becomes another part of a nurse’s day.
Sorry this post is another long one and ends on such a terrible note, but so much happens every day and I want to keep you all updated-on the good and the bad.
Hello all! Since I've been in Malawi for almost a week now, I figured it was time to update everyone on what I've been doing and how it's been going so far. Sorry if this is a long post, but a lot has happened in the past 6 days!
Last week, I spent two days working on a study through the UNC Project. This study focuses on discord couples, which means one partner is HIV positive and one is HIV negative. Participants come in for quarterly check ups where blood is drawn to check several markers associated with HIV and I followed several nurses running these appointments. HIV counseling is provided as well at the appointment. I was able to observe several interviews throughout my first morning. Although the interviews were conduced in Chichewa, the local language, the nurses took the time to explain to me in English what they were asking and why. I was also able to see all the behind the scenes work of a research project and I realized just how difficult it is to stay organized. It is a huge interdisciplinary effort and it is difficult to collaborate with the clinicians, nurses, quality control, lab, and data entry.
The second day I worked on the project I reviewed visit records and served as a quality control nurse. The nurses guided me on what mistakes to look for in the most recent visits' documentation and whether or not to approach the clinician or nurse to fix and/or complete the mistakes I found. In the afternoon, I sorted a folder of 700-800 labs of individuals hoping to qualify for the study. Although this may not be the type of work I envisioned doing here in Malawi, it taught me several things about being a research nurse and truly helped the team of study nurses who are extremely busy. It also reminded me how many different paths I can choose from once I become a Registered Nurse.
Since being in Lilongwe, I have found it difficult to explain the nursing education system in the United States. Here in Malawi, students attend a College of Nursing for four years. When I tell them our nursing program is only two years and the two years before that we take general courses as well as science courses, they cannot believe it. I try to reassure them that we are well-prepared even if our training is only two years, but I cannot help but imagine how much better nurses we would be if we attended nursing school for four years.
I met two of the three nurses who are leaving on August 8th from Malawi to travel to Chapel Hill last Friday. They have been taking an online course through UNC and are going to the UNC School of Nursing to complete the physical assessment portion of their course. They have both asked me about the weather in North Carolina and have been wondering what to expect. It definitely makes me feel better that they are as nervous about going to Chapel Hill as I was coming to Lilongwe.
Today, I went to the Nurses Council again to fill out the proper forms. Before I came it never occurred to me how difficult this application process would be to volunteer as a student nurse at the local hospital. I guess it was naive of me to think it would be so simple and they would accept me immediately. After a trip to the Nurses Council tomorrow (hopefully the last one!) I should be approved to work. But luckily today, while visiting the hospital to get my paperwork signed, I was oriented to the Children's Ward where I will be working by Robert, the nurse in charge. The ward is large and is comprised of three units. Children's Ward A is made up of a 28-bed Special Care Unit, a 6-bed High Dependency Unit, a 4-bed Isolation unit, and a large nursery (maybe 15-20 beds). There were around 6 patients in the Treatment Room today as well. And when I say "unit" I mean one room crammed full of cribs and cots. So in the Special Care Unit there are 28 beds, with sometimes more than one patient in each, and all of these patients' caregivers. Needless to say it is cramped. Some diagnoses of these patients included malaria, meningitis, and gastroenteritis.
But more shocking than the accommodations is the fact that there were only six nurses covering all these patients. SIX nurses including the charge nurse. That ratio is unheard of in the United States where in pediatrics there is usually one nurse taking care of 4-6 patients. I am interested to see how the nurses are able to handle this high patient load without being overwhelmed. I was able to observe medication administration today as well, which was extremely different than in the US. When it is time for medications, two or three nurses roll a medicine cart into the unit (aka room). Each caregiver brings a stack of papers to the nurse which has the list of medications on it. The nurse then give all medicines taken by mouth to the caregiver to give to the patient and administers the rest (either IV or an Intramuscular shot). I have no idea how they keep straight which medicines go to which patient when you are essentially administering medications to 28 patients, but they do. I'm sure it's going to take me awhile to adjust to this setting with a different set of resources than UNC or Baptist Hospitals.
I also toured Children's Ward B, which is for patients who need observation for a day or two and will most likely be discharged. Children's Ward C is for orthopedic and oncology patients. There is also an area of the ward dedicated to severely malnourished children. I'm not sure which area I will be working in the most yet, but I hope to work in a variety in the short 9 days I have left at KCH.
Again, sorry for the long post, but hopefully this updates everyone on what I've been doing. I'm planning to post pictures soon, assuming the internet is willing to cooperate.
Miss you all!
Hello all! So I have safely made it to Lilongwe and the UNC Guesthouse. I have to admit that I am extremely relieved to be here. I was so nervous about traveling so far by myself, but I think things went pretty well in that area.
On the plane I met a couple who were traveling to Malawi to work in the Malawi Children's Village. They were very helpful and gave me lots of clues about how to travel safely and reassured me that I was doing a good job. They traveled to Malawi for the first time last year, so they could sympathize. The husband was going to work on an irrigation project. His wife created a new project this year, which was teaching Malawians how to make soap. She said last year she just couldn't believe the lack of resources in this country, especially soap. At first, she tried to contact some larger soap companies in hopes that they would donate large amounts of soap. Then, she came up with the idea to bring the supplies to Malawi and teach the individuals how to make the soap so they supply would last longer. As she was telling me this story all I could think of was the "give a man a fish vs. teaching a man to fish" idea.
I arrived to the UNC Guesthouse (pictures to be posted soon) yesterday at 3pm or so. I was greeted by Joyce, who has a house on the UNC property and serves as the UNC Guesthouse housekeeper. She was extremely nice and repeatedly told me to "feel free", meaning make myself at home. There are several other students staying here, but unfortunately most of them are leaving on Friday or Monday. There are 5 Dental School students who will be in Malawi for 10 days, a Medical School student who has been here for two months, a microbiology student who has been here for a year, an IT employee who has been here for a year, and a surgical resident who has also been here for a year. And ALL of them are leaving except for the surgical resident who will be here for another year.
Last night I continued to settle in at the guesthouse and ate dinner with all the students here. They taught me the card game "Tonk", which apparently they play every evening. They said I wasn't terrible for a beginner, but I didn't win either.
Today, I met with the Director of Nursing for the UNC Malawi Project, Mary. She directed me to the Malawi Council of Nurses and Midwives where I had to register this morning. After three trips to the Council, I was registered. Needless to say it was a frustrating morning, but I expected things like this to happen and I'm glad it's taken care of now. I also met the Assistant Director of the program, Innocent. Everyone at the UNC Malawi Project was extremely helpful and very welcoming which cancelled out the frustrations of this morning. I also ate lunch at the Tidziwe Center, which is the UNC Project Center. You can get rice, greens, beans, and chicken for 250 kwacha which less than $2.
That's all for now. This afternoon I am tagging along with the students who are going goat shopping. Yes, goat shopping. They are having a big cookout tomorrow to celebrate before they return to the US. Tomorrow I will meet with Mary again and will most likely be going to the hospital for my first day.