Clinical Digest16 A retrospective
on Ashtin Doorgakant (Malawi), 30/Dec/2011 11:06, 34 days ago
It feels strange writing this blog now and thinking back at the time I first set foot in a hospital in Malawi during this placement. Trying to link it all and witness this incredible journey and the transformations it has brought both to my personal and professional life. Trying to think about the impact it has had on the people of Malawi, and beyond if any. Trying to think of other ways I could have done it. Trying to summarise what the Malawian health care system is really all about and what the future has in store for it. Ultimately trying to work out if my presence here has overall been beneficial or not. I might not be able to answer that yet, because for the retrospectoscope to work best, time needs to elapse. Right now my subjectivity and sentimentality about leaving soon will no doubt introduce a certain bias. But lets try anyway.Lilongwe- 6weeksWhen I look back, this was one of the most fascinating times in my entire medical career. It spelt a complete new start, clean sheets, the beginning of an era. The mix of uncertainty and excitement was almost toxic, yet I’ll admit, somewhat intoxicating too. I’m sure that this wouldn’t constitute most people’s fix but for me, there was a certain thrill about deciphering the meaning of all of it then that kept me going. I found myself in areas I had not ventured into for months if not years, like the urologytheatre or the labour ward. I found myself doing circumcisions and Caesarian sections. I found myself finding operations I would rarely see in the UK suddenly becoming routine, like limb amputations on young adults, sequestrectomies and bone drillings. I found myself in a maze of new pathology, using an almost entirely new medical vocabulary, approaching management from a totally new perspective. I was making a choice to unlearn some of the rigid set ways of doing things as I used to back home so I could integrate into this new system. It was intense and challenging but it was with one safetyI would soon leave to enter the wild world beyond: consultant supervision.Ntcheu- 1 year minus 6 weeksMy first day at work in Ntcheu. Surreal. A week’s orientation visit during my in-country training did hardly anything to lessen the shock. I was now an official employee about to work alongside everyone rather than a mere observer. I had to get to grips as quickly as I possibly could with all the intricacies of this new world so I could startoperating within it. Lilongwe I found out was a very far cry from it. It gave me a good flavour of the Malawian health care, but had very little in common with the district setting. I would soon be reminding everyone about this so they don’t get misled by their placements in central hospitals thatthis is the standard of care most Malawians are receiving.Ntcheu, my new workplace, opened my eyes to many challenges and led me to develop new skills to tackle them. For the first time ever, I would become a departmental manager, a data collector, a policy maker, a networker, an inventory maker and a procurer. I began working alongside maintenance to repair, improve and create equipment we needed. I became an advocate for improved sterility standards, almost in the style of the notorious infection control nurses I used to scorn at in the UK. I learned how to talk, present and teach in a completely new way, one which would make sense to Malawian students. I did all the usual things too, like ward rounds, theatres, clinics but developed a completely different approach to fit in with this entirely alien setting. I realised the need to balance efficiency with practicality. Never has the expression“more haste less speed” seemed more true. I slowed down, became more flexible but made sure to maintain my standards in the context of the hospital. I had to accept certain failures, but only if I could use them to change things so they wouldn’t happen again. Teaching by example became a veryimportant philosophy of mine. I wish I could have done so without ever losing my cool at the heights of my frustration (which I won’t hide), but then that would be claiming to have cracked one of the most complex challenges of Malawi within a single year. In all truth, a lifetime might be too short.Ntcheu, because of all these things, was my first in depth insight into the Malawian way of doing things, which would help me adapt my style to fit in better with the healthcare system, thereby enhancing my impact on it. Ntcheu, no longer so alien anymore, reshaped me for the better. Ntcheu prepared me for the journey ahead.Blantyre– 1 yearThis was in a way my graduation into the higher strata of tropical orthopaedics. Whatever little I had seen in Lilongwe seemed a long way back, and whatever I’d done in Ntcheu was a long way from this level I would be diving into. The learning curve was vertical, exponential, dizzying to say the least. My 2 hour lunch breaks were shrunk to minutes. My evenings of leisurely reading and work preparations were to make way for some of the most hectic callsI’ve ever done and assiduous reading about new operations and approaches. My very much self motivated presentations about topics of my choice to general clinicians and nurses were alchemised into specific lectures to medical students, trainee orthopaedic clinical officers and other doctors. My research imperative was cranked right up. With internet at work, no matter how intermittent and temperamental it might have been, I was able to get much more done in much less time. In addition to this Blantyre was also a city where I would be able to run projects on a different scale, with readier access to partners and resources. Hence I got the tricycle project going, thanks largely to your very generous support. I also got specialised splints made for traction patients, again with the help of sponsors from home. And above all, I got things moving like I could never have done in Ntcheu for the one biggest project of all: the editing (and future printing) of the Orthopaedic Resource Book. Right now, I am engrossed so much in this project everything else suddenly seems to have been put on hold. It is by far the biggest undertaking I have ever dealt with and its completion here or back inthe UK will be my single biggest legacy to Malawi, in the name of my VSO placement.All my time in Queen’s has also consisted of the bread of butter of orthopaedics naturally and on a scale that puts a lot of my previous work placements to shame. My operative logbook has benefitted from no less than 300 new cases, a lot of them being ones I would not have been able to perform before arriving in Malawi. I have received some of the best supervision ever from truly dedicated consultants here, both permanent (Dr Bates&Prof Mkandawire) and visiting, adding further to the wealth of that experience. My calls have brought me face to face with many socio-economic realities of Malawi: the political riots, the poverty that resulted in many patients presenting late with inadequate primary care, the fallen down houses and walls during the rains, the extra-ordinary motor vehicle accidents, to name a few. I became very much a frontline trauma doctor with a new sense of cool I will always be grateful to Queen’s for. My ward and clinic duties have assumed a higher level of responsibility which should see me evolve much more smoothly into registrar training once I get back to the UK. Beyond teaching, this notching up of my seniority has earned me the honour of presenting at some fairly high level fora such as the COSECSA (College of Surgery of East Central and Southern Africa) and Surgical Association of Malawi annual meeting, as well as the AO training for the Malawi Orthopaedic Association annual meeting.I conclude this clinical digest feature today (having as yet failed to produce one on the complexities involved in dealing with convicted patients in Malawi) on an exceptionally high note. My 2 years in Malawi, and particularly my year in Queen’s haven’t completely gone unnoticed by my colleagues. Thus today I had the nicest sending off I have ever received from any workplace. The whole department gathered to say thanks for my work done and to wish me well in my future pursuits. It felt like a real tribute,indeed an epitaph to look back on, when doubts may arise about whether I made a difference or not. I know at least, I’ve touched my colleagues and, through them, I can be pretty sure, my working environment too. But above all, let me say this: it me who has benefitted the most from this incredibly rewarding time I’ve spentin Malawi. I’ll be a new person, a new doctor when I get back home.Thus, today’s final review of Malawi signals more a new beginning to me than a conclusion...