From: Daniel Dyer, M.D.
August 1, 2019

Muli bwangi! (A Malawi version of hello and how are you)

It’s hard to believe it’s my fourth day at Nkhoma. I’ve been so busy trying to get used to everything that is new that it has gone relatively quickly. No matter how many times I’ve worked abroad it always is still such a challenge to transition to a new place, especially into a new language and health system/hospital. 

I’m going to keep my blog posts brief as I have to write them on my phone. There is no WiFi here and the only way I can get internet is through data on a network plan (sorry Elisa! I really owe you this time).

There are two things I want to focus on. First has been the challenge of walking into a new hospital and not knowing what my role should be. As a resident I don’t fall into any easy category here. A lot of the hospital is run by clinical officers. As far as I can tell, they are the equivalent of residents in the US, but they don’t need (or get?) the same supervision. They are much more proficient than me in some things, for example procedures and managing certain diseases, but seem to lack skills/experience in creating a differential and thinking critically through a treatment plan. I have struggled thus far in knowing what role to take as I’m new, don’t know a lot about Medicine here in Malawi, but also want to help if I can and use what I know. And technically, as a doctor, I can be the one to sign off on something for a clinical officer if there is a question, which adds one more confusing part to the puzzle. I’ve mostly tried to listen and ask questions, occasionally giving suggestions of something to consider. But my main objective has been to be a sponge.

One interesting hung that I have found is that a lot of decisions are based off of protocols. Once a diagnosis and severity have been established, a protocol can be followed. It’s a system that tries to leave little up to chance in order to improve outcomes, which has the benefit of making sure medications are started promptly. This seems to come at the cost of appropriateness. For example, antibiotics seem to be prescribed for almost all patients, whether or not they truly need them. It seems to me that the doctors who have been here for a while still struggle with this a little, but benefit from being known by the staff and knowing the protocols (and reasons for them). 

On a very different note, I also wanted to share a story of one of my patients. Her name is Witness and she is 6 years old. She came in with fever, weakness in her arms and abnormal arm movements. She was started on Ceftriaxone for fever (like almost every child admitted here). Overnight she became very agitated and would periodically yell. When I examined her the following morning she was confused, seeing people that weren’t there, but had calmed down and seemed to have periods of lucency. We did an LP that was normal. However, on talking more with mom, one of the nurses learned that she had been bit by a dog about 3 months ago. I had to dig out a Pediatric text book to read more to confirm my suspicion. The incubation period of rabies is 1-3 months. It migrates from the peripheral bite to the CNS, so the incubation depends on how distal the bite is. As the virus migrates, it can cause local neuropathy until it reaches the CNS. Symptoms usually start with a prodrome of viral symptoms-fever, malaise, chills, etc. they may additionally hame photophobia and paresthesias with proximal radiation (which is what our patient reported). After this classic symptoms may develop leading to hydrophobia, hyperactivity and eventually paralysis, coma and death. Witness began to exhibit these symptoms before she was discharged home to die.

I find I almost have to intellectualize encounters like this or the sheer terribleness is overwhelming. Witness was a beautiful, sweet and curious girl when she was lucent, but would disappear in terror and pain as the disease progressed. Like so many diseases here, this could have been prevented, but has been perpetuated by poverty and ignorance. I have never seen rabies before this, like so many of the diseases we now have vaccines for, but it is one of the worst diseases and ways to die I’ve seen. It creates an almost primordial fear, this organism that has been present for so long and we still have no way of curing it. For a child with so much already stacked against her it seems almost unbelievable to add on a rare disease like rabies, but such is the current state of our world.

I don’t want to end on that note, so very briefly, we have a 3 month old child who came in earlier this week in significant respiratory distress. I had seen children like this die in PNG. But due to USAID, they’re are a couple CPAP machines here and we were able to support the child through the worst of their disease and today they looked significantly better and are now off of CPAP. Good can and is being done, even if there is so much more to do.