Orientation

It is the custom of the Malawi Medical Council to require an orientation and evaluation of physicians trained outside of Malawi when they first arrive. So, I have been assigned 6 weeks of orientation at a large government hospital here in Malawi. The hospital provides care, free of charge, to the public and serves as a referral center for the entire region. I cannot verify this statistic, but heard someone say there are about 250 physicians in Malawi, and 80 of them are at this hospital! The hospital is quite large with multiple medical wards.

My first day I accompanied a physician from Europe on rounds. Part way through I got sweaty and lightheaded. Sat down for a minute, the threw up. I, of course, stepped out. Unsure if I was ill from new food & water or from the overwhelming suffering surrounding me, I drank some tea and walked around again. This time more aware of how much my body had been filtering out the first time. The sounds and smells. There is a shortage of beds and of nurses, continually. There is no central cafeteria or kitchen. So, instead, there is space around the outside of the wards for family to camp, and they provide most of the meals and care for their loved one, the patient. So, the wards that are already over-crowded with patients, are also filled with family members attending to the needs of the sick. Still not feeling well, I rested for a minute and then called for a ride back to the hotel early. I had fevers, chills, and muscle aches through the afternoon and into the following day.

Slowly, I improved enough to head back to the hospital late in the afternoon the second day to do a cardiology consult as requested for an older man who presented with a large stroke and had been found to have severe hypertension and an irregularly irregular radial pulse. An ECG had been done, one lead at a time, along a long thin strip showing atrial fibrillation. I did a cardiac ultrasound at the bedside that showed an enlarged left atrium of the heart and thickened heart muscle consistent with affects of long-term high blood pressure. Treatment is with medications to lower the blood pressure and aspirin to reduce the risk of another stroke, which they can obtain (free of charge) 30 days supply at a time from the hospital pharmacy. Unfortunately, of course, the choice of medications is limited and intermittently out of stock.

I have now spent a total of 1 week on orientation there. I am amazed by the amount of true sickness and poverty on the wards. It is very different from my other experiences, even time spent at other (albeit private) hospitals in Africa! I’ll spare all the readers the medical details…but it is quite sobering. Meningitis, TB, profound anemia, malaria, and HIV are very common. Sometimes all in one patient! I need to continue to refresh myself on Tropical Medicine…bacteria, virus, protozoa, helminthes! And diagnosis/treatment with limited resources. But, the physicians I have been orienting with inspire confidence in the power of the clinical acumen from history & physical exam! They seem very capable of initiating treatment for these severe illnesses with a few lab & radiology tests. And then broadening treatments and testing as needed for those who do not improve.  (However, given the sobering statistics on Wikipedia about Malawi, there must be many who do not make it in for treatments, or who can’t continue with the full treatment, or in whom with such advanced disease that treatments are merely palliative.)