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!