4th Week at the Hospital and Mount Mulanje.

This is my fourth week here at the hospital. Things are going extremely well. I have two talks this week, one on tuesday and one yesterday on antiretroviral therapy. Also, I had a meeting the director to discuss the needs assessment document i have been working on. Very exciting stuff.

This past weekend I made the trip down south, roughly 5 hour drive, to Mount Mulanje, the highest mountain peak and range in Malawi.  I joined up with some Michigan State Med students for the trip (yes, they rubbed it in my face that they beat MD at the buzzer).  It was an adventure. Pics are below

\

Thuchila Hut. This is where we stayed the 2nd night. Absolutely beautiful. 

View outside of Thuchila hit. Feels like your on the roof of the world. Cool shot.

A jungle stream with crystal clear water. It was magnificent. We went swimming. 

Climbing the near 50 degrees sheer rock slops on the way to thighest peak in Malawi, Sapitawa. In Chichewa, Sapitawa means, "do not go here"

On the summit.

Cape Maclear and third week at the hospital

Last weekend I made the difficult journey to Cape Maclear.  The trek proves to be difficult due to the fact there is no good direct route from Lilongwe, and the last 25km are so in on a extremely sketchy dirt road, which, in the rainy season, can sometime be un-passable if there have been recent heavy rains.

Earlier in the week i had been bargaining with a cab-driver that gave Jeff and I a ride back to Namitete from Lilongwe. I was pricing out how much he would charge me for a return trip, Namitete to Cape Maclear and Back, He first said 50,000 kwacha, but i haggled the price down to 30,000. I told him that i would txt him a few days before to confirm the trip ( i needed to check with some house mates to see if they could go or not, i wasn't going to pay for the whole thing myself). So it turned out that all the housemates in fact, couldn't make the trip, so therefore I txted Manny, the cab driver, letting him know I couldn't do it, and that i had to take public transit, aka torture transit.

So, guess who shows up at the door of the guest house at Sat AM, at 6AM, with his girlfriend in the back seat, ready to goto Cape Maclear? Yes, it was Manny the cab driver. I wasn't thrilled. So I got in the car with manny and began bargaining.....Eventually, after a lot of back in forth in broken english, i talked im into havinh a lil vacation for himself at Cape Maclear, with his girlfriend, i offered him 15,000 kwacha for the trip as well as paying for his hotel both nights. He agreed, and off we went. The trip took about 3.5 hours. Well worth it. pics below.

ART clinic has been great this week. We have beens seeing about 70 patients per day, Im really starting to get the hang of things here. Over the next few weeks there is a new computer system being installed, electronic medical records, refill data, etc etc, touch screen...should be interesting....Consulted on a few patients in the mens ward as well, SJS 2/2 to nevirapine, cyrpotmeningitis, severe debilitating PN from d4t.....

This weekend I am heading down to climb mount mulanje....very excited....

A roadside village on the way to Cape Maclear. The landscape in the background was absolutely brilliant. We went through a twisty, curvy pass road through those mountain picture in the background. Full of switch backs, the road reminded my of a pass road out west. 

Beautiful sunset picture fromt he window of my beachfront cabana. Epic.

Lake Malawi. We took a boat to this island and swam for the whole day. Lunch consited of freshly caught Chambo, a poplar fish to eat from Lake Malawi, and rice.

Practice paddling in a custom made, hollowed out canoe used by the local fisherman.

Some of us slept here in these hammocks. 

2nd Week in ART Clinic

Week number 2 officially in the books. Jeff and I have now seen, and collected data on, a total of 243 patients. Not bad for only 5 days in the clinic.  Today we tied up loose ends, finished up abstracting some data, and rounded on some patients in the mens wards. Also, Jeff gave a lecture on quinolone, Bactrim and Flagyl.  Tonight we are having dinner with the Director of the hospita at his home to say goodbye to Jeff.

This weekend I am traveling to Cape Maclear to do some scuba diving and to grab some beach time. 

For next week, continuing to work in the ART clinic and collecting data.  I am also scheduled to give my first teaching session  on Antiretroviral therapy to the hospital staff next week. 

A view of the outside of the ART Clinic. The patients wait extremely patiently on the bench to left, in line, waiting to be seen first by the triage nurse, then by the clinician and finally the patient goes to the dispensary to grab their Medicine.  The triage nurse room, clinicians room, and the dispensary are all right next to each other less than 10 feet apart. 

Inside the ART dispensary with the Director of the ART clinic and an ART nurse, both amazing, and I am very thankful for all of their warm welcome, support and help. When the ART clinic is open, the patients come up to the caged window, pictured in the background, to pick up their medicine. On the shelves on the right are NVP+AZT+3TC (top right, greenish boxes, hard to see). Below that, is the workhorse, and first line regimen here in Malawi as determined by the Government, NVP+d4T+3TC, named T30. We go through about 135 bottles of 60 a day. Patients take this regimen one pill in the morning and one pill in the evening, all three drugs combined in 1 pill. One of the many problems with this regimin we have seen so far is the d4T induced neuropathy. A lot of patients we encounter have this problem (about 25 out of the 200 or so patients we have seen so far).  We manage it here with Elavil 25mg daily which, back when i learned about this drug at Maryland, I was taught it  does'nt work for peripheral neuropathy, o well.  If the patient faisl Elavil there supposed to try mortin, and then finally if they fail motrin, they are eligible for an AZT (AZT doesnt have the problem of neuropathy, but it comes with its own unique set of baggage) based regimin. Here in our clinic we havent been giving out Motrin, or any other Nsaid for that matter, we just switch straight to AZT, checking their hemoglobin first, as AZT can cause anemia at the dose used here. If their Hg is >8 we will switch. 

Another angle of the outside of the clinic. The pharmacy window is on the left side. Next to it to the right, are two evaluation rooms for the clinicians, and the third door down is the intake room where the triage nurses takes their weight, temperature, pill count (however no one brings their bottles about 1/10) etc. The patients wait extremely patiently here.  There have been some days where patients have waited over 5-6 hours to go through whole process. Patient satisfaction survey anyone?

A view outside of the guesthouse at dusk. It is here where we commonly toss the B after work. The sunsets and skies are beautiful here. We have a nice porch with table and chairs to enjoy it. 

Weekend at the Lake, Start of 2nd week

Jeff and I spent the weekend relaxing on the shores of Lake Malawi at an area called Senga Bay. It was a nice relaxing weekend after a busy week of travel, work, and getting over jet-lag. The trip to and from the Lake was extremely interesting to say the least. Public transit here in Malawi is an, adventure, a huge one.  We over came the odds, police road blocks, crazy pick up truck drivers, bicycle taxis, hitch hiking, and managent to have a good time. Some pics are below, the cottage we had on the beach was 25 USD a night and slept 4 people.

Today was our first day rounding in the mens ward. The ward consists of ~ 30 beds in a small corridor lined up next two each other in rows two. They also have a isolated TB ward which has about 6 beds in there. The team consisted of myself, Jeff,  Dr. Kiromera, the director of the hospital, an ID Fellow and Ilene, that family doctor from Toronto. We had some simple patients,  bee stings, simple PNAs, likely over diuresis but had some other, more interesting/complex patients  patients that are hard to diagnose, TB adenitis, HIV myelopathy etc....

We are giving a lecture this afternoon on anti-fungals and the management of crypto meningitis, highlighting the recent article by Nussbaum et al in CID:2010;50. Should be very interesting....

This afternoon we will round the palliative care team and prepare for the ART clinic tomorrow AM. The goal is to have all of the patients enrolled in the intervention arm by Thursday.

Pics of the pharmacies, the wards, the out patient clinic, the ART clinic will be coming shortly.

Corking view from our room, not bad. about 15 paces from the water.

Amazing flowers here.

Dusk view of the bar. 

A summers day in august....

The corn is growing....the air is warm and humid....thunder clouds on the horizon.....

pretty much our typical day.  Today was very productive. Alot of hard work in the ART clinic, saw a karposi sarcoma. The main wards are very busy, lots of kids, lots of malaria.  Our  study is officially underway, we worked out some kinks, and are for more patients next week, we saw ~30 today.  Jeff gave a lecture on anti-microbials today during noon conference, every body was snoozing ;), JK....

food really has been OK. We have been making family style dinner every night, lasagna, fish, pasta, thai.

Jeff is skeeved out by the ANTS in the kitchen. Believe it or not, he actually cleans. His room is quite tighy, (thanks to the maid who comes every morning ;) )

Local bananas are good,  cucumbers are weird, they have spikes. The guavas are terrible, however we still eat them every night for dessert.  The coke has real suger, which we actually can buy in our remote village, in a glass bottle. There is no diet coke, Jeff is going through withdrawal, cheerios are the anti-dote...

No need for a formulary pager, as our formulary here fits on one page....

We actually got sunburnt yesterday, in the setting of globs of SP50,  but were managing OK.

Thats it for now, here are some pics from this morning and yesterday.

 Taken while on our long hike yesterday.....

Again on our long hike. Eileen, this ones for you.

Our guard dog bobby, doing his job.....

It takes a bunch of excited Malawian children to get Jeff to smile.....

Our luxurious accommodation....i like it...hot water....toilet....full kitchen.....

Some photos from around town

Dont have time to write a full report today because were about to leave to go on a long walk around Namitete. The hospital and clinics are closed for a Holiday today, Martyrs(sp) day i believe. Jeff and I worked in the ART clinic yesterday and saw aprox15 patients, extremely interesting.  I am just starting to begin to understand that challenges out here, have a long way to go....

 Played some frisbee last night as well. Back to work on thursday. Exploring Namitete today with my German friend Caroline.

The garden behind the ART Clinic. Brilliant.

Some of the children at a nearby village. They absolutely love having their photo taken and looking at the image on the camera LCD. 

Me posing with a few of the children I met yesterday.

A market near the hospital. It is here where we buy our lunch everyday, usually consisting of chips, tomatoes, and cucumbers. They also have very good bananas which we buy fresh everyday. 

Some of the locals hanging out in the village near the hospital. There is loud Malawian music being played in the background and everyone is chillin out. Its right near this spot where we buy the chips every day. 

Hard at work in the "research room" of the SGH HIV clinic. 

First Day, Tour of Hospital, Trip to Lilongwe

Today we had a tour of the whole entire hospital including the antiretroviral clinic. We saw all of the wards, the pharmacy and the laboratory. The day starts with ~30min morning report, where the medical team gathers to talk about patients currently in their wards. Once that was over, we were given a tour by the director which lasted until lunch time. For lunch, we walked over to a near by village and had some local bananas and fried potatoes. The food was really good and very fresh.

The plan after lunch as to travel via public transit to Lilongwe to exchange some money and buy some groceries. Public transit here in the "mini-bus' is quite an adventure i must say. A mini-van, designed for for 5-7 people, has about 10-12 people crammed in, not too mention a few 50kg bags of corn, some wild animals, puppies and bicycle tires. Actually, on our ride home, we waited over 45 minutes in the mini-bus while the operators struggled to smash in more bags of stuff, and also tie some stuff to the back of the van. All in all, we made it back in pretty good time, but needless to say, local public transit is quite an adventure. Dinner consisted of fish, rice, and some local mushrooms, that we were told were not poisonous, with the rest of the gang here in our dorm.

Tomorrow is our first day in the antiretroviral clinic. Will have a full report tomorrow.

Below are some photos I took today...


The 4.5km dirt (more like mud) road that takes you to the hospital from the main road. There are bicycle taxis that take you to and from the hospital.

A young girl outside of the hospital on her way to a nearby village.

Some mothers and their babies making their way into the hospital.
Namitete proper and the entrance to the dirt road which leads to the hospital. In the foreground, left side, are the mini-bus's used for public transit.