I can't believe it's Wednesday. The days just seem to fly by so quickly. I haven't gotten homesick surpringly though. I've been pretty busy-as you can guess at the hospital this week. For the last 7 days I've been the attending on our team-as the person in charge was out for a conferance. Things got even crazier as the person in charge of the second team was away on vacation so I was kind of covering both teams and helping out when things are needed. It's been incredibly hard as we are very short staffed and the medical students who normally help out have been on vacation for the last 3 weeks- i haven't even met them yet. In any case, I've learned to accept the fact that I can't help everyone and i've now resorted to the, work as hard as you can till 4:30pm and then stop and pick up where u left off the next day.
I've seen a lot of interesting things and I"m learning tons.. especially when i'm forced to make decisions on very limited data. It was not too long ago-- maybe few months? where my mentor had brought a rack of ribs for our group to practice on how to place a chest tube. While i felt at that time it was an important skill to have while working internationally in underserved community I didn't really expect that I would be relying on this experience to help get me through.
I had just finished rounding on about 15-20 patients with my team. 2 interns, and a nurse that i have grown very fond of as he's excellent and just works with our team- i teach him and he helps us out a ton. After rounds, I walked which ended around 1pm I just walked through the outside balcony to see if i could help out in any way. There is always something to do. This one gentleman I passed by was laying curled in a fetal position. I stopped and looked for a moment and asked the guardan what the person's problem was. Not surprisingly the patient's chart was missing. The guardian of the patient could not speak english so I took notice of the patient's Chest X-ray just laying in a big manila envelope. Holding the x-ray up to the light and one glance at the left lung I literally let out a gasp of air. The patient had a huge left sided pneumothorax which literally compressed the entire left lung and there was tracheal deviation with midline shift of the mediastinal content. I quickly ran and asked a nurse to translate for me and apparently this patient had arrived the night before and had not been seen by anyone. The CXR was never even reviewed. I pulled out my stethoscope and placed the flat portion against the patient's chest. Wait a second why do I feel pops and why does the skin feel crunchy? palpating across the chest, into the neck and into the face it was apparent the patient had an air leak into the subcutaneous tissues. This patient had subcutaneous emphysema! A chest tube was necessary-this much I knew but I had never put one in before. I searched around to find someone anyone who could assist me. unfortunately everyone was out for lunch but i did find one intern who had put in a few during his surgical rotation. We wheeled the patient to the treatement room and a chest tube was found and a make shift pleuravac was constructed using a jar filled with water, one tube in the water 2 cm deep and a smaller tube that was just dangling in the water untouched and only exposed to air. this was thanks to my super intern who remembered how to construct one of these devices..
I decided to give the chest tube a try. a 3 cm cut into the 5th intercostal space midclavicular line and then dissection dissection dissection away until i heard a pop just like the cork of a bottle. the tube was inserted and attached to the tubing leading to the bottle. in an instance i saw yellow pleural fluid and air bubbles. it was a success.
the hardest part was suturing the skin as his skin was tough like sandpaper. I ended up finding only chromic gut sutures at the entire wards were out of sutures.
finally the chest tube was done and i was impressed and relieved I had done it successfully. the patient was actualy very calm during the procedure and granted i did lidocaine him he didn't complain at all.
Here's the kicker and the part that literally made me want to bang my head against the wall this morning. I was making rounds this morning to check up on my patient. Expecting the patient to tell me.. "i feel much better". I walk by him and my jaw just drops. His head was the size of a balloon literally. His eyes swollen shut. IN an instance i look at the bottle. The water had been emptied out and the tubing exposed to air... and unclamped!!!!! Who the hell did this. It finally became apparent that one of the staff members saw that the bottle was full and emptied the whole thing out leaving the tube not submerged with the chest tube exposed to atmosphere air and pressure. the tube was also left unclamped. Basically i was suprised the patient was alive.
Not knowing what to do,I just ended up asking the surgeons to help me out and one of them told me the subcuatenous air would just dissolve with time and just to refill the bottle. My anal retentive self opted to open up the suture wound and resuture the tube just in case the air trapped in the tissue had dislodged the tube. i was pretty mad.. spending so much time the day before putting the tube in and just b/c of one mistake the patient was worse off. I felt bad for the patient but I've also learned to accept that things like this happen especially due to lack of training.
I also took care of a heart failure patient today whose heart rate was in the 200s. he was so close to being discharged home from the triage area until i felt his pulse and it was super high. atrial fibrillation, a-flutter. given the heart rate i thought it was likely atrial flutter. I had him valsalva twice and did a carotid massage with no result. the only medicine that i could offer him was po digoxin or po propranolol. I opted for po propranolol and his HR came down a little. Let's see if he does okay.

In other exciting news, after talking to staff members, nursing, other doctors, I've decided to give a huge grand rounds presentation on heart failure and how to do and read and EKG on a very basic level. I find that the EKG machine is underutilized. It will take me 2 weeks i'm guesstimating to make a powerpoint presentation. apparently it has to be in 2 weeks because anytime after that one of the doctors who is the president of malawi's personal doctor won't be able to attend as he is attending the president's wedding ceremony.

I guess i had a lot on my mind today. I'm surprised. haha

by the way, I saw city of angels last night. not bad for a nicholas cage movie.

Lake Malawi is incredibly beautiful. It reminds me a lot of Lake Atitlan in Guatemala in terms of it's majestic presence and it's peace and tranquilty. I decided to take a weekend trip this past weekend as I had been pretty much working 7 days a week for the past 4 weeks. Lilongwe is a nice city. It's the capital and things are pretty chill and relaxed. I stay near area 3 which has everything I need. A grocery store, internet cafe's and a man standing on a huge boulder every morning yelling versuses from the bible- which makes my ears ring sometimes.
That being said, Lilongwe is very spread out and not having a vehicle has really put a damper on my nightlife experience. It was time to head out to Lake Malawi and I was looking forward to further getting tanned (i'm browner than my normal brown) and lay by the beach with alcohol in hand.
I caught a bus from the old part of the city and headed to the town of Monkey Bay- yes that's the name of the town. The bus ride-well what an i say-- was very interesting. Most of the way I was sandwiched with fellow passengers and it was interesting to see vendors selling all kinds of merchandise-transactions being made through bus windows. Among the items I saw for sale during the 7 hour trip-- avocados, shelled peanuts, fried dough balls (my favorite breakfast), samoosas, raw fish ( a bundle of 6 if u wanted), a live chicken, a razor blade for shaving as well as a huge kitchen knife. I'm proud to say that I was glad no one opted to buy the kitchen knife.
I arrived in Monkey bay around 6:30 pm and while my plan was to head to the vibrant city of cape maclear which was only accessible through a dirt road, it was getting dark and decided to stay the night at monkey bay.
I met some travlers along the way and we headed to the same hotel where the night was spent drinking away and laying by the beach. I also met an australlian guy. Maybe in his mid 30s who was riding a motorbike for charity across the entire african subcontinent with the goal to reach Cairo by end of May. We talked a great deal about our experiences in Africa. Had a great dinner which took long to prepare and I was kind of uncertain what the meat dish on my plate was. I had ordered chicken, but for some reason it didn't taste like chicken. Luckily i found some "chicken tasting powder" bottle and poured a bunch of it on and wa-la it tasted like chicken.
The night was well... lets just say that i slept with my headlamp propped on the table and i slept over the sheets not under. There were lizards scurring around, spiders that look like flat taruntals on the wall-bigger ones than the ones at the place i stay in lilongwe and the sheets didn't look like they had been washed. Everything you would expect from a backpacker's hostel-but it's all about the experience.
The next day, i just sat by the beach and relaxed, did a little leisure reading until around 1pm decided to make my way to Cape Maclear. I was suprised but excited to learn that i would be standing in the back of a pick-up truck which was my transport to this part of the lake.
Bumpy roads, zooming so fast I thought my contact lenses were gonna peel out of my eyes and dodging and ducking branches from trees I made it to cape maclear. Cape Maclear was well.... simply amazing!! pristine waters, blue sky and a festive atmosphere. The town was lined up with beach front lodges making it a superb tourist destination and weekend get away.
I stayed in a large room that comprised of a bunch of bunk beds. This was also a backpackers hostel. Met some german ppl who were my roomates and we grabbed dinner and drinks where we met more german ppl. I was the only american and never before Have i heard so much german. Later that night I met an american from san diego who was traveling through africa.
After dinner and drinks, the plan was to head out to a local bar and have more drinks.
After 4 weeks of working- i felt alcohol deprived and what else could I do but replenish my liver enzymes.
We headed to a club called the hippo lounge which was great. Met a lot of locals, and even some familar faces that i saw in Monkey bay. There were plenty of drinks, dancing, laughter and many shots of liquor on the house by the owner until around 4 am I figured it was time to go back as i had to catch the 6 am bus back to monkey bay and then lilongwe
On the pickup ride back I ran into a medical student from Scotland who was doing a rotation at a rural clinic at cape maclear. he had spent 5 months in lilongwe working and what do u know, he worked on the same team as I at Kamuzu central hospital which is the hospital i worked. He knew all the health workers i interact with and we had a great time discussing the good, the bad and the ugly experiences we had. I am glad someone felt the same thing I feel working in the hospital.
I finally made it to lilongwe late in the evening, and after a dinner at a korean restaurant which has Wifi located close to where I live, i decided to call it a night.
A great weekend and definately a breath of fresh air
4 more weeks left in lovely Malawi.

I'm definately a fan of second chances. I got mine today. Today I was on call which meant that I worked in the triage area called short stay and determined which patients were sick enough to be admitted versus those that could be discharged home with oral medications.
Short stay is a pretty crazy place. You see all kinds of patients.. the whole spectrum from patients that walked miles, starved, dehydrated, comatosed and on the brink of dying to patients who have a simple bout of malaria or gastroenterities. One of the most frustating parts however is how some patients are just brought in by stretcher from off the street and just dumped in the room with no one accompaying them.
I had 2 patients like that today.
The first patient of mine was brought in after he was found unconscious on the street. He came in gasping for air, a thick frothy secretion coming from his mouth. He must of been breathing 70 times a minute. Unconscious. no history and had a seizure right in front of me. a quick touch on his chest he was extremely warm and of coure rhonchorus sounds. I quickly placed an IV and told the nurse to administer 80mg IV lasix. She looked at me with a laize fair attitude as in "what's the use, i will take my own time". I then asked for the oxygen machine. 3 people were just sitting eating and drinking casually gossiping away. I turned to one of them. plz i need the oxygen. One of them just calmly stated don't worry when the patient gets admitted to the ward they will give oxygen. I raised my voice out of frustration with a bit of anger the patient may not make it. I need the oxygen now. The roused a few people the oxygen was found, lasix was given and i personally administered the aminophylline. |This guy was in florid heart failure. His accessory muscles started to weaken and finally when there was not more I could do i just let him lay there hoping he would get better. Was he already too acidotic? I saw the kussmaul breathing knowing that the end would be soon.
Right when i saw this, i had my second patient arrive in a stretcher. he was wheeled right in by a hospital worker and left there. No one to accompany him, ice cold. I turned to look around the room. all the staff had left. don't tell me everyone has left for lunch.This guy is going to die too. I went out in the hall and stated i needed an IV, fortunately i was able to find a nurse who wasn't too nonchalent about the whole thing. Unfortunately the patient barely had a pulse that was palpable. I ran quickly to the ICU and found a central line quit. None. Screw sterile techinque. I reached and found a 20 gauge IV canula and just blindly jammed it in the patient's inguinal area where i thought the femoral vein would be. Ah ha. god likes me. I hit it on the first spot. the catheter tread easily and i attached an IV line. using a peripheral line as a central line. that's a first for me. started fluids wide open. Next I felt gutsy and tried for the jugular. ah ha god likes me again for the second time. i did the same thing for the neck vein. 2 20 gauge IVS both in central veins with fluids running wide open.
I sent the patient up to the ICU equivalent on the wards. fortunately i have faith in the doctor in charge in that unit as he's pretty good. Lets see if we can save his life.
although i now found out that he came from jail. brought in by prison guards held on charges of murder. I guess maybe i would have preferred to be heroic on some other patient who had a good heart but i guess when you're a doctor all of that is irrelevatant. after all we did take the hippocratic oath.

30 year old patient with HIV admitted for altered mental status, tremors found to be febrile. I ask him how he is doing, he is like fine how are you. LP was done and it is positive for cryptococcal meningitis. I have started him on amphotericin B the induction phase which is for 7 days on top of high dose fluconazole. Every day, however I am amazed at how positive this person is. I ask him each and and every morning "how are you". His eyes deflected upwards with a persisted upward gaze, his neck stiff, occasinoally making jerking hand and leg movement he responds, I am fine how are you. That being said, he is febrile every morning despite being on paracetamol (similar to tylenol) at 39 degrees celsius, not to mention I poke him in his back to do daily LPs to decrease his intracranial pressure using a 16 gauge IV catheter (no Lumbar puncture kits here) but still each and and every morning he responds and says I am fine how are you. Fine? with meningeal signs. In the US this patient certain would be already in the hospital with a million pain medications, oxycontin, oxycodone, ativan and still would not be fine-- maybe patients back home are a littler needier? i begin to feel that each and every day. maybe it comes from wealth. who knows.

Today i learnt that trying your best sometimes isn't good enough. You have to keep trying and don't stop when you think it's the best you can do. Especially when it comes to life and death decisions. I'm talking about an HIV positive patient severely anemic coming in with fevers, general body pains, dyspnea, weakness. pallor of the skin and looking at her eyes i could estimate a hgb in the 3 range. very dehydrated. tried many times to get a peripheral IV in- no success. i tried, the nurses tried, the other interns tried. the veins just collapsing. Thsi girl was cold as ice and barely palpable pulses. I knew she needed an IV ASAP and fluids if blood could not be found. I finally made the decision to place a central line. a femoral line which i now am an expert at. The canulation was a success however not suprising very poor blood flow. the problem came with threading the wire. i guess the vein just collapsed each time i tried to thread the wire. who knows. minutes began to an hour, then 2. sweating profusely- until everyone around me told me that i tried my best and we would have to try again in the AM. I kept trying and finally after the third hour I felt that I had to throw in the towel. She was mentating somewhat... but would she be alive in the morning if I left and came back. It was now getting dark outside--- and maybe it was a little peer pressure- i left the poor girl saying we would try again in the morning. I thought of her all the way home. She'll surely die. she's dehydrated. she just has to survive till the Am. then i can try again.
Today I return to find her bed occupied by someone else. I desperately went searching for her among the crowds of ppl lined up in beds. room by room until ultimately i checked with nurses and after a perusal their big book she died at 2:00 am.
so maybe I tried hard, and my best but sometimes when it comes to someone's life you have to keep trying till you are successful. That's what i learned today.

I never realized that nicholas cage acted in such horrible films. Few days ago I bought a 20 DVDS in 1 DVD from some guy off the street. The name of the title was will smith vs nicholas cage. With a cheesy name like that how could i resist-after all I always wanted to be an expert on will smith and nicholas cage flicks. I've seen some interesting items for sale while i make my morning commutes. Among my favorite ones include a barack obama belt buckle, "yes we can" bubble gum, and a "hello boss" t-shirt. Hello boss.... haha I get called that at least a million times a day-that's the malawian way of saying hello sir can i get your attention. Other common phrases I hear is "hello my friend" and "hello brother". I love malawi so far. It's been great.
The hospital has been busy at usual-but yes i am working hard and saving lines and learning tons. Today after work I just sat by one of the street shops and ate roasted maize. Sat on a huge rock and just thought about my day. It was an incredible day as usual-most days are-however i had to reflect on what i saw today.
Usually when things are quiet on my team. patients are as "tucked" in as they can be. I just walk around looking to see who is sick-who can use my help. I always find one or two. IV's coming loose, fluids not on, ppl not getting medication, ppl on the brink of dying. Today I just walked by one of the rooms and here is this poor lady laying with agonal breathing. audible crackles in chest, looking at me helpless-hopeless. Almost immediately i touch her-ice cold. Next I look at her arm for any IV. Any Iv at all? Nope. So i put an IV in, check her BP. systolic in the 50s. Oh great and she has crackles in her lungs. knowing her bp was more impt i asked the nurse to bring me an oxygen tank and i started fluids wide open. I ran to the stockroom to find any pressor that i could find. ah ha dopamine. now how do i mix this. I dilute it and finally come up with something i can inject and run back to the patient. The patient looks at me takes one final deep breath turns her head and passes away in front of my eyes. should I do CPR. wait i can't intubate her. all i could do was inject the dopamine. no atropoine in site. Squeezing the bag of saline so it could run faster. It was too late- she passed away.
I turned to see if i could get anyone to translate. The guardian-the mom was in the room. can someone please tell her mother that she lost her daughter? i saw tears and moments later a loud wail and a look of "why did u let this happen" in the mother's eyes. I felt horrible.. this is life at a government hospital. ppl on the brink of dying. Why are resources so limited here and plentiful elsewhere. It's just not fair.
So i ate maize today and just thought a little. Looking forward to going back to the house. May i'll switch it up and watch a will smith flick. Nicholas cage is getting sooo boring. or maybe play soccer with the grandkids of nancy. that's always fun.
Well i haven't thought about the weekend yet-however i'm debating whether to take a weekend trip to monkey bay to see lake malawi. should be fun. The clinical officer i work with gave me a list of must see places.
all in all a busy day. some treating seizures with phenobarbital, many LP's, 2 identical cryptococcal meningitis cases and a dude who has been in the hospital for 2 weeks that has a subdural hematoma. I wish i were a neurosurgeon so i could evacuate the blood and let him feel better. steroids really aren't helping.

that's it for now.

It's been an incredible first week so far and overall I've really loved my experience in Malawi so far. People in malawi for the most part have really good hearts and every day I find myself liking lilongwe more and more. My favorite part of the day is in the mornings when I make my 1 hour commute to the hospital. I love walking. It gives me an opportunity to think and just walking through town I see a lot and I love it. One of the things I definately will miss when I go back home is passing by all the young children who are heading to school. They all walk in groups and head to a school located close to where I live. I pass by them each morning and everyone has smiles on their faces-so adorable waving their tiny hands saying hello. It's great.
Everyday I get about 2 hours of exercise 1 hour going to the hospital and 1 hour coming back-and I don't mind it one bit. I'm debating whether to invest in a bicycle. I'll have to go to the old part of the town to see into that.
Yesterday I got back home a bit early from the usual.. as i was home by 5:30 ususally i am not home until about 6:30 or 7. I got a chance to talk to our cook, housekeeper-find out a little bit about her, her family and just get to know her better. She told me that she has family in a village and has planted maize and is very anxious to see the progress of the maize she has grown. Nancy is an incredible woman. Very knowledeage, a kind and warm heart and an awesome cook. I told her she should go see her maize today so she won't be anxious and she was extremely appreicative of that. I also went outside and played with her grandchildren. They are so adorable. In fact they were so happy that I was out interacting with them they put on a performance for me- a little acting, a little singing, a little gymnastics. They even built me a small car made out of clay. I told them I would play soccer with them on sunday-i plan to buy them a new ball as the one they have is very deflated covered in mud.
On another note, the housedog now has grown an attachment towards me. I don't know why animals tend to cling on to me-this is a problem I have had in the past. She follows me everywhere I go often waiting for me on the outside porch in the mornings.
I also have a roomate in my room. a tarantula that's flat and just sits on the wall near the window in my room. I notice that "henry" as i call him comes out around 8 and by the time morning breaks he is gone. We have grown to know each other very well and we don't invade each other's space. He knows I am there and I know he is there.

I've been meeting some incredible people and I have made soooo many friends in my first week. Today in spirit of the irish holidays, arthur has invited me for some festivites with games and then later on to a bar for drinks. I also randomly met 2 lebanese people yesterday who want to meet sometime for lunch. They have a shop out in old time and sell random things that are imported from the middle east. They even gave me a ride one day from the hospital to back home. The staff at the hospital have been awesome so far. One person who i have grown to like very much is a doctor that attends at the hospital from time to time and is the president's personal doctor. We plan to go out and keep close contact as almost immediately we got along really well.
As far as how things are going in the hospital. I really enjoy and find it rewarding working at the hospital. I feel as if i am indeed helping out and making a difference- and while there are some good and bad moments I have no regrets absoultely of coming to malawi. In fact the more I work here the more i wonder what the hell am i doing practicing medicine in the US. This is real medicine. there are no narcotic seekers everyone's abdominal pain is real.
I also have done tons of procedures which is great and I am now an expert in peripheral IVs and phelebotomy.
All in all a very enjoyable experience so far.

I need a case of beer

Ahhhhhhh. The past two days have been insanity. I can't believe how underserved this hospital is. For starters, the medical wards are divided up into 3 teams. I am on one team and I round and see all patient's on my particular team. Unfortunately for the past 2 days there has been no clinical officer to lead the team. So guess who was in charge. Hint... not some phantom or ghost... it was ME. On my team there was only one intern who just completed medical school and just starting out. The medical assistants or "students" are all out on vacation for the next 2 weeks so guess what. I saw 20 patients yesterday and 20 patients today with no guidance and I was responsible for making all the decisions... not to mention that there were 5-6 patients that weren't assigned a team and were never seen for the past 3 days. IN the US i never seen opportunistic infections from HIV, and tropical infectious diseases is completely foreign to me. so really i am just learning on the fly.

It was pretty chaotic-although I did keep my cool and calm as always but still what the heck. Everyone was super sick, had meningeal signs, HIV positive, possible TB and there were no labs done. As each day passes I begin to learn about the system and it is very easy to get annoyed. On the HPI's, clinical officers just write obtain blood work, cbc, malaria smear--and it is "hoped" that things will get done. I've come to realize fast that you pretty much have to draw the labs on the spot, not just write it down and give precise instructions. "Draw the blood work". I end up carrying bottles with me and i draw them as i round each day. I've already done tons of LPs and thoracentesis not b/c i was told to. but b/c i had as I am in charge of these patients. the little experience i have had in the past supringly has helped and i haven't made any procedural mistakes so far. but still, i felt like banging my head against the wall at least 100 times today.

the intern I work with, is super nice we get along well but i often get extremely frustated. ppl just write their daily notes and say, start IV fluids, continue antibiotics obtain labs and just move on-- and the thing is that nurses are so overwhelmed that it never gets done.

today we had a girl who had not been seen for 3 days. she was HIV positive came in with nonspecific complaints, llooked sick as hell and i rounded on her. checked her BP and guess what it was... systolic of 55. the person working with me just wanted to write down start IV, start fluids and move on. the mentality of i've done my part by writing stuff down in the plan and leave it up to the rest of the ppl to carry out orders is what really frustrated me today. but like i was told by a collegue back home. I am here for 2 months. this is their life. they job every single day.

I guess all in all i was pretty exhausted. 20 patients to round on, no one to supervise, all sick patients most of which had meningeal signs and sick as hell, and only one intern working with me. half the time the frustrating part was just trying to get a story as often the translator and the patient would break off in a conversation. I feel like I did injustice to my patients. the plan for a lot of them was track down labs, do an LP, but it never got done today b/c I was busy rounding.

i'm learning tons just super busy i guess. I plan to start getting to the hospital super early.. maybe 6ish. sometimes i feel there just aren't enough hours in the day. We'll see what happens.

Kamuzu Central Hospital-Day 1 on the job

Today I started my first day on the job. And let me tell you... what an emotionally exhausting day it turned out to be. I saw all faces of malawi- the good the bad and the ugly. Where can I start but say, everything I learned training in the United States takes a back seat when you encounter medicine and are forced to deliver health care with limited resources. The mere fact that there is often no data available and you presumptively treat patient's to cover them for everything that they possibly could have is what made today extremely difficult for me.
The medical wards well what can I saw. A total eye opening experience. Blue painted walls with hallways with beds lined up with patients, families all sick as hell. About 1/2 of the patients would certainly be ICU level acuity back in the US and here they were just laying around unattended to. I started today around 9 after I got all my paper work completed and registered officially with the malawi medical council. I met a really helpful person named Rashid who has been showing me around... over all a GREAT guy. He even was able to save me an extra 50 bucks by exchanging dollars to kwacha "underground" style by money handlers in the street-but i'll save that story for another day.
I finally met up with Charles, a physician. somewhat short in stature with dark skin, bald head and a serious look on his face althougH i was successful in getting him to crack a smile within the first 5 minutes of our meeting! With he, there was a 1st year medicine resident who did his medical training in turkey of malwaian descent now doing his internship for 3 months in the medicine wards at kamuzu. A really nice guy-fluent in turkish, english, and the local malawian language. We clicked almost immediately.
We started rounding on all the patients. The medicine wards are divided up into 3 teams and I am on team a rounding w/ Charle's team. We went patient by patient often spending approximately 5 minutes per patient. He HPI's were rather vague and written like "fevers, headache, diarrhea" and plan would be ceftriaxone, quinine, bisacodyl, paracetamol and sometimes TB medication depending on whether they cough. Everyone was treated as they were septic. For me this was a hard transition to make in my medical decision making as often times it looked as if antibiotics were just thrown onto the patients. I guess it's better than them being neglected and not getting anything but then u run into the issue of antibiotic resistance. One case I saw a patient who was treated empirically for cryptococcal meningitis HIV positive of course and an LP was never done.
I must say, working in an environment like this I am certain will teach me how to work just based on my clinical judgement and not rely so much on diagnostic tests. But this being the case, not one time did i see the physician put a stethoscope on the patient's chest. they just relied on history and the blood pressure it seemed.
Charles is a very smart physician and he knows his stuff however sometimes I felt that maybe he wasn't being thorough enough or not to bold when it comes to decision making capacity. Often times I disagreed with the assessment and plan however I am sure he has much more knowlege capacity when it comes to treating infection than me.
after all when someone comes in with chest pain, doe, i worry about an MI and he worries about TB pericarditis.
I got to do an LP today which was great. One story sticks in my mind however
A gentleman who is in his last 40s. scleral bleeding, delirious however sometimes speaking lucid and in english "sir i can speak english can u please tell me why i can't see". he had come in with fevers, abdominal pain. HIV positive too. found to have malaria, a huge liver and spleen and blood counts that continued to drop despite multiple transfusions. his platelets were 13 and he was obviously in distress. I seriously thought he was on the brink of dying. He was cool, diaphoretic, a thready pulse. We rounded on him. given that I did not have a CVP or an arterial line i asked "have u urinated?" the family looked at me and with a shocked look like i was a mind reader they said no. charles looked at me. I said. shall i put an IV in. I want to start fluids.
Charles looked perplexed. He is in renal failure from sepsis he replied.
I agree, but he needs a fluid challenge i replied, he is vasodilating, not perfusing lets see if he responds.
the problem ultimately lay with placing an IV with the low platelets. I wanted to try however charles commonly stated that we would wait another day as since platelets were not available in the hospital today and possibly available tomm we could transfuse and then place an IV.
He calmly added ceftriaxone to the regimen which included quinine and we moved on.

I was greatly troubled by this as this patient i felt was super sick and would be neglected... however a sound in the back of my mind told me that I am in a new health care environment... the way I see things is not necessiarly the correct way.. he has more experience in these matters than me and hence esp this being the first day I have to step back and just understand why decisions like these are made.

AS we rounded I realized that our 6 following patients were as sick as our first gentleman and therefore you do what you can, treat with antibiotics and move on. If there are no platelets u just hope that there will be platelets the next day and move on.

As i walked around stethoscope around my neck i was approached by all kinds of ppl trying to garner my attention. asking if i could see their mom, or their dad. it was as if I had some special power in the eyes of these people. I did tons, started IVs, started fluids, did an EKG and charles's how is great at ultrasound showed me a little on how to do a quick bedside assessement to see if someone has pericardial fluid or is in heart failure.

On another note, today i had a visitor from back in pittsburgh. Siamak Malek arrived in malawi and was able to join me for rounds for part of the day today. It was great to see a familar face and he and I got a chance to talk about some of the challeges over here coming from western medicine.
I also met some great expatriates. Arthur an IM physician applying for an ID fellowship currently working in cryptococcal research showed me around. Had lunch with a group of other expatriates working in various NGOs at the british council. overall a great guy. We'll def be hanging out a lot.

Well. tomm starts another day. i feel like i need to do a lot of reading... as despite what i learned back in pittsburgh.. i don't feel like i have a full handle yet on delivering healthcare here in malawi based on clinical judgement and without data.

We'll see how it goes. but i'm having a blast and am really glad I am here. For all it's worth it's been a great experience so far!

Africa, the emperor's palace and lilongwe!

I'm back and in style as always. I've reached the city of Lilongwe located in the country of Malawi which is a tiny country located on the eastern part of southern africa.
The trip itself wasn't bad at all although I've had a few hitches along the way. I must say, however, that there is something about Africa- the people, the slow pace, the breath of fresh air that is very unique and brings about a sense of nostalgia the minute you step of the plane.

My journey began in Pittsburgh where I boarded a flight to D.C with a 5-6 hour layover and then onward to Johannesburg via, Dakar Senegal. Unfortunately I ran into my first hitch at the pittsburgh airport itself as the clerks for united airlines adamently stated that I could not check my luggage to Lilongwe and would have to collect them at Johannesburgh and then recheck them the following day when I board my flight to malawi as there was a new 16 hour rule in between flights that they would not know where to store the luggage.
In any case, it was not worth the argument and I let it go.

South African airways by far is the best airlines I've ever flown and the service was spectacular. They certainly were very generous in their alcohol beverage service as I got asked literally every 2 hours if i wanted another wine mini bottle. I slept a lot of the way there and listened to my ipod as I had purposely sleep deprived myself the night before travel. I usually hate long planes simply b/c i cannot sleep and then I get all restless making it a painful journey so sleep deprivation has worked the best for me.

I arrived in Johannesburgh on time and let me tell you-- the minute you step out of the plane and into the airport you just know that you are in africa. Just the pace things go at-- super slow.
the scariest part of the airport is wondering if your baggage will arrive. I had my fingers crossed,and alas I waited at the baggage carousel number 7 with all the other passaengers... 5 minutes, 10 minutes, 20 minutes, 30 minutes and there was only one bag left going round and round and no it wasn't mine! This is when a lot of cuss words started entering my crazy little head and checked baggage carouself number 6 which was from a flight arriving from Harare,zimbabawe and there was one of my checked in pieces of luggage. Unforunately it was not the one i was hoping to see as this was all computer equipment from Gerry's company baobab. With a mad and disappointment face I checked all the carousels and my other piece was not there. This was the suitcase that had all my clothes, shampoo soap, you know the suitcase that has your life in it... and where was it.
I walked up to the south african airways baggage inquiry desk and was empathetically (not really) told that it was still in Washington D.C. Oh great! at least I had packed 3 pairs of underwear and a pairof pants I guess.

Like a dejected soul I went to find the shuttle that would take me to my hotel. The Peermont Metcourt is where my travel agent had placed the booking and while sounding fancy I really didn't have expectations as I was only going to be in johannesburg for 12 hours or so.
The shuttle picked me up and took me down this highway and as we made our way to the exit ramp I saw the giant sign for the Peermont Emperor's casino. Holy shit? was i staying at a casino. Within 5 minutes I realized that this was the case and when i was taken to my room I realized that the karma of losing luggage was balanced off by this majestic palace I was staying at. There for 3 freaking bedrooms, 3 bathrooms, a living room, a dining room, pure insanity. I was staying at the penthouse suite. making sure that this was all real I went downstairs to ask the hotelclerks who had stated that this was the only room available forthe night as they had overbooked so I was lucky in that they had to put me in the penthouse suite for the night.

So here I am, one suitcase, barely one set of change of clothes and I am staying in this penthouse suite for about 12 hours with a casino across the road. In an instance my jet lag went away and what else could a guy at the age of 29 do but head across the street to casino.

The casino itself was nice and they were trying to pull a mini vegas with the clouds in the sky theme. Knowing myself from las vegas I have a tendency to gamble more than what is good for me so I dropped only 100 rand at a poker table and won 200 haha.
I met a lot of interesting people. one family from Johannesburgh who owned a packing business and worked a great deal with great britain. they were super friendly and we spent the night away talking about africa, the good the bad and the ugly. they also felt inclined to show me the s. africanhospitalitity which included drinks. a lot of them put I politely turned them down after the 3rd rum an coke. I also met a bunch of singers who were from south africa that were doing a mini concert in the casino. they sounded great- i was impressed and we talked about the world cup and whether Johannesburg was ready. They felt that the stereotype Jo'burg got was too overrated in terms of how the world perceives the city and their crime rates stating that in any city if you don't have street smarts you will get into trouble.
Finally around 3 am I headed back to my penthouse suite (and no i did not bring visitors) as I had to catch a 10AM flight to lilongwe.

The flight itself was not bad, a little bumpy.. i thought i was going to die maybe twice but no big deal and we arrived in malawi on time around 12pm.
Malawiwellwhat can i saw. I loved it the minute i stepped off the plane. nothing fancy, everyone with smiles on their faces, the not so spectacular airport with the ghetto luggage carousel to finally the customs official who spent 15 minutes talking to me on america and barack obama. haha ppl really love that guy over here.

I was greeted by a smiling face when i exited out of the airport who had a sign with my name on it. although i can't remember his name. the airport is about 45 minutes to the house where I am staying and during the trip he kept switching the radio channels to english songs wheneer there would a song playing in the local malawian language just to make me feel welcome.

a right turn and down a street through some bumpy unpaved roads, I arrived at the house I will be staying and was greeted by Nancy the housekeeper/cook. A very good and nice person with a smile on her face. We chatted a bit she showed me around the cute little house that has 3 bedrooms, a living room, a small kitchen and a bathroom.Also a backyard with corn fields in the background and I swear I could hear elephants last night in the distant or maybe I was just hearing things. Nancy has grandchildren and a daughter who is in her 20s. Haven't met them yet. She asked me what I liked to eat and my nuances when it comes to food. I told her I would just let her prepare meals and then decide what meals I enjoyed and which ones not so much but i wanted to try mainly typical malawian dishes as this was part of mycultural immersian.

after our chat I realized i was tired and figured I'd take a nap 2 hours whichended up turning to 6 and I woke up around 8pmwith thunder and decided to just sleep the night away.

Today, i was met by Rashid, a medical officer who works at a pediatrics clinic. we went and go all of my registration stuff done and went to the kamuzu hospital which in itself was an eye opening experience in itself which I will talk about later on..... I start work on Monday. very excited. I met Charles who is supposedly my mentor. A very quiet guy with a smile but seems nice.

We'll see how it goes... more to come. today, sat and sun i plan to get familar with town. Lilongwe will be my home for 2 months.

I'm Back

I haven't updated this since my around the world adventure in '07-08'. Fear not however as I am off to conquer (or be conquered) new lands. For the next two months I will be in Malawi on the southeast coast of Africa. I'm very excited and hope to use this as a venue of expressing my thoughts as I venture out on this incredible journey. I leave tommorrow. Get ready :)