Malawi Visit, June 2024
Wednesday 19th June 2024
As with all important events and trips team Project Kuyenda’s second trip to Mzuzu came round quicker than anticipated. Bolstered by positive annual review outcomes myself (Rosie Hackney) and Joe Esland set off to Edinburgh airport. Very aware of the pressure of our first “solo” trip without “Dad” (Sam Molyneux) we were utterly dismayed when we found ourselves in standby for the first leg of our journey to Paris with a wonderfully helpful “you might get there but around the houses” response to “how will we make our onward connection?”. We had time pressures, we were hosting the inaugural Northern Malawi Orthopaedic conference on the Saturday.
Thursday 20th June 2024
Thankfully we arrived in Lilongwe some 28 hours later. Sadly, my bag did not, thank you Kenya Airways. We had a relaxing evening discussing our plans for the trip in a lovely, calm hotel in Lilongwe which was a far cry from the journey that faced us the next day.
Friday 21st June 2024
After a 6am start we were driven to our transport to the north. In Malawi the favoured coach company is oh so very aptly called the “Kwezy Bus”. A few minutes on the road in one of these makes the frequency, and severity, of the road traffic injuries in Malawi make an awful lot of sense. Slowing down to avoid collisions is not an option, in our driver’s eyes a few honks of the horn and a heavy foot on the accelerator is sufficient. In Malawi the bigger vehicle gets the right of way.
Travelling through Malawi is an incredible experience. The dusty roads are host to some amazing feats of human ingenuity with every turning offering yet another “oh I wish I’d got a photo of that”. The stunning Jakaranda trees that had been flowering on our last visit were no longer, but the warm summer and rain allowed new, bright, flowering trees to flourish and the fields to become bursting with fresh produce.
We arrived in one piece and checked in to our home for the week, Macondo Camp. Joe and I both had a strong sense of returning to a place we both hold very dear and it was great seeing familiar friends and faces to welcome us back. The afternoon was spent preparing for the conference and attempting to locate some replacements for my missing suitcase (rather unsuccessfully).
Tim White, Al Murray and Tim’s daughter Katie arrived that evening after a day in theatre, and regaled tales and stories of their experience during their fortnight working in Mzuzu Central Hospital.
Saturday 22nd June
The Northern Malawi Orthopaedic Conference! We were all slightly anxious about a poor turnout but were delighted to see 23 orthopaedic clinical officers eagerly awaiting our arrival. The day was a huge success with teaching on topics requested by our Mzuzu colleagues on everything from open fracture management, spinal injuries, quality improvement work and peri-operative care. It was a great opportunity to meet the team responsible for the day to day running of Northern Malawi orthopaedics, and establish what barriers they face when providing care for their patients. Responses included a lack of theatre access due to emergency caesarean sections, theatre running out of general anaesthetic drugs, a lack of external fixators and a chronic shortage of casts. If you arrive to a district general hospital in the morning you’ll have access to an external fixator and, if at the beginning of the month to a plaster of paris cast. If, however, you sustain your injury later in the day or month you won’t. If your injury is open, where the bone sticks through the skin, your debridement will happen in the absence of anaesthetic with no immobilisation to stop the bones moving available. Other challenges include very limited staffing with one chap being on a rolling 1 in 3 24 hour shifts with no holiday or leave. Their knowledge and keenness to learn was fantastic to see and I’m not just talking about the post conference ceilidh dancing. The three men in “skirts” and a bottle of Highland Park whisky was a fitting close to a very successful day.
Sunday 23rd June
Some consider Sunday as a day of rest, perhaps to indulge in a lie in. Those people have never been away with Al Murray and Tim White. An early start took us to some new friends in Tafika. Tafika is a charity run in Northern Malawi we were introduced to thanks to Al’s friends and colleagues who are involved with it in Scotland. They are a sustainable, community focussed and run charity who promote education and development through their work. The work ranges from funding greenhouses to grow tomatoes which can be sold to fund school dinners, to introducing sport to communities to encourage community gatherings and for children to remain in education. We had a full tour of their incredible work. The morning closed with a singing performance from a group of widows who run the school feeding programme and care for orphaned children. We all felt very inspired by their work and passion.
Sunday afternoon allowed for some reflection and to plan the week ahead. With a lot of hard work behind the scenes by Paul Jenkins an electronic patient record system has been created. Our hope is that this will allow the orthopaedic team to have an up to date record of their inpatients. This will contain clinical photographs of wounds the nurses can add to, as well as up to date X-rays to allow efficient decisions to be made on the ward round and, importantly, for these to be communicated with the patients. It will also generate a jobs list and pending theatre list with urgency stratification.
Monday 24th June
Al, Tim and Katie ventured up north to Livingstonia for the day while myself and Joe headed in to the unit for the Monday morning ward round. Those who have been following our work will remember this was an area we were hoping to develop on our last visit. We were a little disappointed to see that our intervention had not been quite as successful as we hoped. This was actually all down to a lack of access to coloured paper for the sheets! Reflecting on this, it’s very clear that when considering interventions in austere environments you cannot begin to imagine or plan for the barriers faced. We do feel though, that spending that little bit more time with the team in Mzuzu and being in Malawi is allowing us to improve our understanding.
Seeing patients on the ward is hard. Injuries that you would be in and out of hospital within a few days in the UK are left on the ward for weeks waiting patiently for a date for surgery. One gentleman had bilateral tibial shaft fractures, a horrendous injury having been hit by a car. He was lying on the floor on a thin sheet with no cast on because on the day he was admitted, they had run out. Another lady had been in hospital for months with a femoral fracture with no signs of healing but no upcoming available date for fixation. The children’s ward was jam packed with wall to wall beds and desperate parents doing their utmost to care for their little ones.
The afternoon was spent entering the all important patient information in the to the EPR. Data entry, as most registrars can attest, is mind numbing. We were both thankful for a beer and some delicious Macondo Camp Italian food to keep us going for the late night.
Tuesday 25th June
The operating theatre was open today. With Bitiel Banda, the Mzuzu consultant, away on a Feet First camp, Tim was the consultant of the day flanked by his trusty assistant, his daughter, Katie. Katie is a 2nd year medical student in Aberdeen and a budding orthopod. It was fantastic seeing them scrub together, an experience I know first hand to be incredibly special. Due to a lack of drugs to perform general , only lower limb cases could be performed and, at that, only 2 due to a shortage of anaesthetic for spinal anaesthesia. Al worked away in theatre 2 performing manipulations and debridements under a hefty dose of ketamine.
Patients are recovered in a small room by themselves and whisked quickly back to the busy ward. I walked through recovery to find one of our femoral fracture patients with his legs moved to the side of the bed in order to make room for a 3 year old who had just had her elbow manipulated. Imagine for a second if that was you after your femur was fixed, or indeed your child lying next to him.
Joe and I continued with our data collection and visited the nearest stationers to collect the all-important coloured paper for the new admission sheets. We visited the G4S office to enquire about my bag and I was told that a truck “full” of luggage would be arriving later that day – the excitement was palpable!
Tim, Al and Katie bid a very fond farewell to the Mzuzu Central Hospital team and we returned to camp for a debrief and to discuss implementation of the EPR.
By mid-afternoon G4S got in touch to advise that my luggage had arrived and Tim kindly ran me to the office to collect it. I was surprised when they also tried to return a large microwave oven with “Hackney” written across it. They took my word that it definitely wasn’t mine, eventually. Dinner that evening was a joy in clean clothes and a fitting farewell to half of the team.
Wednesday 26th June
Today marked the final day to finalise all the data entered in the EPR to allow Thursday to be a successful “launch day”. We entered data for 66 patients including their diagnoses, X-rays, clinical photographs and pending tasks. We discussed how to best conduct training and attempted to anticipate any potential issues. This meant a long, long time in front of our laptops and we punctuated the day with a walk to the local dam. Along the way we witnessed men cycling with an impossible number of logs on the back of their bikes, women with children strapped to their backs carrying buckets of freshly ground maize and hoards of travellers loaded on to the back of open trucks, some on the roof of the cab clinging on.
The dam itself was so peaceful and beautiful. It is home to the water supply for all of Mzuzu. We took a short walk around it and headed back to camp feeling more refreshed.
In the evening, I was fortunate enough to join the camp manager, Themba, at a local aerobics class. The personal trainer was like every other I’ve met before. Wearing a sweat band around his head, a bright T shirt and continuing to speak and enthusiastically motivate during an impossibly gruelling class despite heckles of “no, please, stop!!” from some! We met some fellow NGO and charity workers at the camp that evening and shared our experiences working in Malawi which was very helpful given the app launch the next day.
Thursday 27th June
Joe and I woke up excited, bright eyed and bushy tailed. In the absence of Tim and Al’s borrowed 1960s land rover defender we had organised a local taxi driver. His name is Philip, he’s a wonderfully jovial Malawian man who tells funny anecdotes while dodging through the busy Mzuzu roads. We arrived to find a “minors” list was running that day with Blackmore Magawa being the lead surgeon.
Blackmore is one of the orthopaedic clinical officers. Clinical officer training consists of a 3 year diploma at university. Having completed this, clinical officers then undertake a further 1 year internship subspecialising in orthopaedic surgery. Bitiel Banda is the only orthopaedic doctor in Northern Malawi so the service relies solely on the orthopaedic clinical officer work force. Blackmore is 54, has 4 children and is a great supporter of the Project Kuyenda work.
There are 4 further orthopaedic clinical officers who work in the department:
Hilda, a stoic, strong woman who cares greatly about the patients and development of care in the unit. She is a grandmother and cares for her grandchildren while her children work down south and overseas.
Maureen, the president of the Malawian Orthopaedic Association, who is a great asset to the department due to her links with the units in the south.
Machira, who’s first name is “doctor” having been born in a missionary hospital. The rate at which he sees patients in the outpatient clinic is like nothing we’ve seen before.
Mwalinga, the most senior member of the orthopaedic clinical officers who brings a wealth of experience to the team.
While Blackmore completed his list we spoke to Patrick Banda, a ward data clerk on the male medical ward, to understand more about healthcare in Malawi. He told us that the most common reason for a medical admission year round is anaemia and in the summer months there is a spike in Malaria admissions. He told us that sequelae of HIV and AIDs is a year round problem and that access to anti-retrovirals, despite NGO support, remains challenging.
We then joined Blackmore in theatre and chatted with the nursing staff and the anaesthetic clinical officer, Michael. Michael has been working as an ACO for over 20 years. He transferred last year from general theatres to work solely in orthopaedics. He delivers the quickest spinal you’ll ever see. The main challenge he faces in his work is the perpetual shortage of general anaesthetic drugs resulting in upper limb injuries needing to be left which mean, when they eventually do make it to theatre, they’re weeks old and thus more challenging for Bitiel. He is very keen to learn ultrasound guided regional anaesthetic blocks and was delighted to hear that Sam Molyneux will be returning in November with Adam Paul, an anaesthetic consultant in Edinburgh, to deliver training.
We also spoke to the nursing staff. The charge nurse, Peter, who we fondly remember meeting on our last visit, was very keen to explore how theatre can be improved through quality improvement. Joe was in his element and before long an Mzuzu based Quality Improvement group was born. One of the first improvements will be the use of the WHO checklist, a recognised international tool that reduces perioperative mortality and morbidity.
Once the list was complete we took Blackmore through the app and provided training. He was on call and a new patient needed admitting with an open tibial shaft fracture. It was amazing to see him use the app live and effectively. He was very enthusiastic about the impact the app will have on the department which was great to see. After 1 admission Blackmore’s data was diminished and it became apparent that in order for the app to work we needed to provide access to data for the OCOs and Bitiel. The evening was spent finalising the “how to” document. Joe and I aimed the guide to be simple enough that even my computer illiterate mother could follow (sorry Mum!!).
With Bitiel, the orthopaedic consultant in the unit, having been away for the duration of our visit at a FeetFirst camp in the north we video called him that evening to share our progress. He provided some very important feedback including how to get our hands on some all important data through a dongle!
Friday 28th June
This marked our final day at Mzuzu Central Hospital! Philip took us to the print shop where a new friend kindly printed our guides and then to the phone shop to pick up the internet dongles. We provided training to Hilda and Machira and spent some time in the outpatient clinic with Machira. We continued to stress the importance of contemporaneous data input, using the new access to data as a “carrot” to encourage use.
Magawa was on call and confidently added post operative radiographs and intra-operative clinical photos to the app that morning. It was also brilliant to see him training his colleagues in the use of the app.
Saying “see you soon” to the team was sad but we both feel the trip has been a huge success starting with the conference, the introduction of the app, the further development of rapport with the team and the improved understanding of the culture in this incredible country. We’ve got a lot of short and long term goals we want to achieve and will return in 2025 after another (hopefully!!) successful Project Kuyenda Charity Gala. 2024’s gala raised £27,500 which, given that 40% of Malawians live on less than a dollar a day, goes a very long way. The 2025 gala will be again at the amazing Prestonfield House Hotel on the 29th of March.
Until next time!