Training the trainers

July 28, 2009

One of my projects here at St. Gabriel’s has been to train the attendants who will be working in the surgical ward. The surgical ward is not yet open, but is expected to be within the next month. Now, the patients who have had orthopedic or trauma surgery are just in the regular wards. Their management will be a lot easier when they are on one ward.

The training has focused on the basics of care during recovery from orthopedic or trauma surgery: proper positioning, bed mobility, range of motion, strengthening, functional activities, and crutch training. The three attendants I have been training have had little experience with patients, and have completed at least some high school education. From my experience working with attendants in Malawi, they are excellent in imitating patient range of motion or exercise routines for a specific patient. If shown, they are able to repeat the demonstration accurately (often imitating gestures I was unaware of!). However, my training was focused on helping them to learn some basic concepts so that as they follow the doctor’s instructions for the patient activities, they will be able to not only imitate, but begin to relate the patient’s care to the learned concepts.

I have found the attendants very willing to please. They enjoy learning, especially if it involves the repetition of materials. I have tried to give them opportunities for this repetition in several ways: review of previous lessons before a new lesson, lots of visual materials, translation of some materials in Chichewa, and making videos of the lessons. The videos have been the most fun. I think because school materials are lacking in the schools, Malawians are accustomed to recitation as a learning method. They do not hesitate to repeat information provided by the instructor. The attendants helped to make the videos, so they were a combination of my instruction, and their recitation of the material. I encouraged them to use Chichewa in the videos so that the material was then presented in both languages.

The main objective of the training was for the attendants to become comfortable with using the training materials including a manual and videos. I have asked them to give each other review lessons if one of them has been off on a day we have had training. I have also tried to create an atmosphere where they help each other during the lessons. We are very accustomed to working cooperatively in groups in our learning activities. Here, however, I have found they have needed encouragement to help each other, provide constructive criticism and work cooperatively.

By the end of the week, they will have completed 25 lessons….and their training manual will be about 90 pages. It has been a productive process. My hope is that these materials will be used when I am gone to reinforce what the attendants have trained have learned, and to train others that help on the surgical ward. I will leave several copies of the manual, the DVD’s of the lessons as well as a portable DVD player. When I return next year, I can follow up with more lessons if needed, or reinforcement of the materials I have taught this year.

Together with my students, Dorothy, Alinafe and Patricia

Together with my students, Dorothy, Alinafe and Patricia

Daniel, my son and cameraman with Patricia, Alinafe and Dorothy

Daniel, my son and cameraman with Patricia, Alinafe and Dorothy

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Deus’ house

July 25, 2009

Four summers ago, we were met by Deus several times a day at the hospital because he was the gatekeeper. After work, he tirelessly made bricks for a home he was hoping to build. The bricks are made from mud mixed from dirt on his small plot of land. After making over 5,000 bricks, they were dried in the sun, stacked, and burnt (fired).

Deus making mud bricks

Deus making mud bricks

The mud bricks stacked, ready to be burnt

The mud bricks stacked, ready to be burnt

All night burning of the bricks

All night burning of the bricks

Deus wanted to build a home with a solid design for his wife, Regina and young boy, Prince Patrick. So, we took lots of pictures of the local homes, and shared them with Kevin Ruedisueli, and architect in Waterford, Virginia. Kevin enthusiastically drew up plans for a four bedroom, one sitting room, no bath, no kitchen, and no garage home. No plumbing or electricity to worry about either. The main concerns were for a design that could hold up during the rainy season, have a high enough ceiling to allow natural cooling, be made of affordable locally available materials and be compatible with the surrounding homes. So while Deus made mud bricks, Kevin analyzed dimensions and drew plans. The plans were sent to Deus, and each year there has been progress. Deus has built the home on his own with minimal help from a carpenter to make the window and door frames.

In progress last summer

In progress last summer

Front of the house, this summer, near completion

Front of the house, this summer, near completion

The back of the house, this summer, Regina carrrying dinner

The back of the house, this summer, Regina carrrying dinner

The kitchen, store room and laterine behind the house

The kitchen, store room and laterine behind the house

This year we prepared a meal together at their home. It was a once or twice a year event that they killed a chicken. It was special also because Regina taught us how to make nsima with corn flour. They eat everything from the chicken (except for the bile), but were kind as we carefully selected a leg or breast piece. They said that the chicken feet wrapped in the intestine were a real delicacy. Elizabeth, Daniel and I ate the cooked egg yolk – from the eggs that were inside the chicken! We always feel that sharing a meal with a Malawian family in the village is an honor. It is a humbling experience to see those who have little, give freely.

Dinner preparations

Dinner preparations

Stirring nsima

Stirring nsima

All together

All together

The Loudoun Road Runners are a wonderful group of dedicated and friendly runners in Loudoun County Virginia. Runners in this group are as varied as they come – some, known nationally for their uncanny ability to run 50 or 100 miles on treacherous trails and others, setting their own goals for a first 10K, a faster marathon, or the ability to finish a longer distance. The group has a huge heart. Last year, they sent me on my way to Malawi with over 50 pounds of power bars in addition to donations for food. This year, they are going to be helping with a phone donation campaign in the fall to support programs around the world that are connecting community health workers with health centers via SMS messages (see the Hope Phones link to the right for more information).  This year, also, some of the group gave me the medals they had accumulated over the years from various events – fun runs, marathons, ultras. Combined with some I also had, there were 39 medals in all.

While I am here in Malawi, the Loudoun Road Runners hold their annual Mule Run – a 100K run along the C&O tow path that starts in the evening and continues through the night. This year, five runners completed the run, and many more ran parts of the distance for support.

This year was the first Mule Run in Malawi. It was quite a different event. The Mule Run in Malawi was a lap course and was open only to children. The organization was as poor as my Chichewa, but the fun of it all prevailed. There were no penalties for going off course, no water stops, and no requirement for shoes. It all started at 5 o’clock, but ended before dark. At first the kids did not understand that this was a distance run, racing  off when we said “go” only to realize that they were far ahead of the pack. As I looked across the course, I saw a wide range of ages, from a little girl in a blue dress to teenagers who joined from their soccer game. There was a constant stream of Chichewa and laughter as they ran alongside Daniel and Elizabeth.

The start of the first annual Mule Run in Malawi

The start of the first annual Mule Run in Malawi

Lap #???

Lap #???

Heading out for another lap

Heading out for another lap

After the run, each child got a metal and a small certificate that was an adapted Mule Run logo including a “Congratulations” on the bottom. They immediately compared medals – some of the favorites were the ones with the red, white and blue ribbons. All the kids were proud, and tired.

Finishers with their medals and small certificates with the Mule Run logo

Finishers with their medals and small certificates with the Mule Run logo

The first annual Mule Run in Malawi was a great success. I can predict that the kids will be wearing their metals tomorrow as they play. I hope the pictures can convey the fun of the event, and the gratitude for the metals. Imagine, the metals we once received with pride, but put away in a pile, now have a new home and renewed meaning here in Namitete, Malawi!

A proud finisher

A proud finisher

Grace, one of the youngest finishers

Grace, one of the youngest finishers

50 years of progress

July 23, 2009

I walked to the village today with Father William to visit an elderly lady I treated last year. Father William is a White Father (also known as the Society of Missionaries of Africa). I believe he is Catholic because he performs the private church services for the Sisters from Luxembourg. He spends his time counseling at the hospital, and is one of my best referral sources. This elderly lady’s son is also a priest, and Father William visits her regularly for communion.

I call this woman “Azimayi” – a title of respect for an elderly woman. She is over ninety years old, has trouble seeing and hearing, but has no trouble talking. She tells me stories as if I understand every word, so I smile, laugh and politely say, I don’t really understand everything you have said. She doesn’t really care, returns the smile, and goes on to the next story. It was a pleasure to have Father William there today to translate parts of her story.

She began talking about all the people that came to St. Gabriel’s to celebrate the 50th anniversary of the hospital. She laughed and said that everyone thought 50 years was so long ago. Really, she said it was not. She could easily remember when the only things that were at the place where they built the hospital were sand flies! She worked at the hospital when it was first opened. She said she was not good at cutting the grass, so they made her work in the kitchen.

St. Gabriel’s displays pictures to represent the history of the hospital. Elizabeth took pictures of these pictures. The amazing thing about St. Gabriel’s, for me, has been seeing the growth of the hospital. The first year I was here, they were building the private ward. The second year, they were building the pediatric ward. The third year, they were breaking ground for the Palliative Care ward. This year, the Palliative Care ward is almost finished, as are renovations of the surgical ward. With expanded facilities, St. Gabriel’s is able to care for more people, under better conditions.

The Carmelite Sisters who founded St. Gabriel's Hospital

The Carmelite Sisters who founded St. Gabriel's Hospital

The original operating room

The original operating room

Dr. Kiromera, the Medical Director

Dr. Kiromera, the Medical Director

A Sister cares for a baby

A Sister cares for a baby

Patients waiting for outpatient care

Patients waiting for outpatient care

Dr. Heim, Dr. Kiromera, and Father William

Dr. Heim, Dr. Kiromera, and Father William

Present Pediatric Ward

Present Pediatric Ward

Me with a patient, representing those who come as guests to provide care at St. Gabriel's

Me with a patient, representing those who come as guests to provide care at St. Gabriel's

We are taught to make decisions for our patient care based on the knowledge available in the medical literature, our own clinical experiences, and the beliefs and preferences of the patient. These beliefs and preferences represent the patients’ way of life – their story.

It has been important, and challenging for me to appreciate my patients’ stories here in Malawi. With my own story rooted in such a different culture, I have had to develop a sense of the cultural roots here to begin to understand the way of life. My best tools for developing this cultural competence have been to watch and listen to the people around me. My best teachers have been my patients, and the relationship that we develop as I get a glimpse of their story –  across language barriers and cultural differences.

I am very hesitant to take pictures with the patients I treat. Sometimes this has been a comfortable thing to do, and sometimes, the patient will request. Generally, I do not take pictures in the wards or of my patients. I will share some of the pictures I have taken in a later blog; however, for now, just listen to a few parts of their stories:

These two men have spent a month in beds opposite each other in the male ward:

  • Bed #1. He is 24 years old, with a wife and one small child. He walked to the hospital because a tree fell on his back. Hours after he arrived the non-displaced spinal fracture became displaced and as a result, he was paralyzed below his mid chest area. A once strong family provider is now dependent upon the care of his wife and brother. Pressure sores are relentless over the next weeks, as is a urinary tract infection. He is now fighting for his life, and facing a significant battle. He is quiet, and has little energy to greet those who come to his bedside.
  • Bed #4. He is 64 years old, as best he knows. He was knocked unconscious when a tree fell on his head and left shoulder. He lost the ability to move his left arm and left leg. His right arm is weak. Initially, he could not sit. He has a brother with him and they have an amazing way of working together. It helps that the patient is cheery and talkative despite his circumstances, and the brother seems tireless.  He works very hard during therapy, and always finishes with a proclamation that he is doing very well. This morning, he decided to go home from the hospital, declaring that he needed herbal medicine from the traditional healer in his village. I respectfully wished him well, and told him not to forget to sit in the sun everyday, do his exercises and reminded his caregivers to change his position four times a day.

Why are trees falling on people? How can secondary conditions become life threatening? What is the basis for a belief in the herbal medicines of the traditional healers? Who is caring for the caregivers? How do the villages support members of their community who have significant disabilities?

I often tell myself to hold off on trying to find answers to the questions that often come into my head…and encourage myself to continue to watch, listen and let the story unfold.

Gathering

July 18, 2009

The people gather here – it is their most common form of communication, and of support. Observing from the outside, it seems the gathering of people is something we, in our lifestyle, have greatly reduced. Yes, we twitter, blog and skype…but do we really gather?

One other factor seems to be the concentration of people in their living place, or even at the hospital. In a small 10’x10’ round hut, there may be a family of 10 people. Or, one house with three bedrooms, may be a home for a family, the cousins, and grandparents. The children spend most of the time outside, in groups of children of similar ages. The mothers, as they are engaged in similar chores, gather to collect wood for the fire or travel to the well for water.Children playingMothers and children walking home from the market

IMG_0323

In the hospital, the ward is open and often crowded with patients and caregivers. There are officially 30 beds in the ward, with a separate 10 bed area in the back for patients with tuberculosis. The ward however, usually is holding at least 45 patients. “Bed” 4/5 is the one on the floor between beds 4 and 5. After visiting many patients in the villages, I have come to think that maybe the patients on the floor are indeed the most comfortable because they are accustomed to sitting on mats on the ground. Maybe it is the ones in the bed that are not as comfortable as I perceive?

The atmosphere in the wards is very communal. As I am working with a patient, often other patients and their caregivers will chime in to help me explain, laugh at my Chichewa, offer support, and give their version of my instructions. If I am on the ward, they all go looking for the caregivers of the patients I have come to see because I am always treated with the caregiver helping so that they can learn. Sometimes, they run all the way to the market to fetch a caregiver for me.

Women caregivers at the hospital

Women caregivers at the hospital

Men caregivers gathering in the male ward courtyard

Men caregivers gathering in the male ward courtyard

When a patient passes away in the ward, there is a community of support for the family. The patient’s eyes are closed, a cloth is put in their mouth (a belief to keep the evil spirits out), the doctor is called to confirm death, and the body is covered and carried to the mortuary. Because so many patients come to St. Gabriel’s from far (although they would say, it is not far!), they might need time to arrange transportation for the body to the home village. As the body is carried to the mortuary, all of the caregivers in the ward follow, wailing together with the family, holding them, and showing respect. As they travel through the hospital corridors and outside around the block to the mortuary it is a testimony to the hospital community support. The wailing that you hear several times a day, and several times a night is a constant reminder of this community gathering.

When you visit patients in the village, people gather as well. They greet you by putting out a mat. The mat is the “foyer”, and you enter it as you would a room, taking of you shoes and greeting all of those in the room when you arrive.  Others gather around as well, outside the mat. Everyone is involved. It is an expectation of the community. I have learned a lot just by watching these gatherings.

Friends and famly gather during a village visit

Friends and famly gather during a village visit

I had the pleasure of being welcomed at the SOS Children’s Rehabilitation Centre in Lilongwe (funded by an Austrian non-governmental organization) on Thursday. This center serves children with disabilities in a large catchment area – the central regions of Malawi – about a third of the country. It is the only center for children with disabilities in Malawi. They are starting a small pilot center to serve the southern region soon.

SOS Children's Rehabilitation Centre

SOS Children's Rehabilitation Centre

Children are brought by bus in the morning and afternoon for therapy sessions. Each child receives a morning of primarily group physical, occupational and communication therapy as well as a time for the mothers to talk about their concerns and for them to learn about their child’s play. Some of the children, the ones who have the most severe involvement, receive individual therapy sessions during the morning. Most of the children do have significant disabilities. The staff explained that the children with mild disabilities may receive services in their younger years, but don’t continue to come to the center as soon as they are independent in walking and eating.

Because it is group oriented, the mothers are the ones who are doing the therapy activities, with guidance from the staff. The staff consists of one occupational therapist (one of five occupational therapists in Malawi, the only one with a pediatric background), one physical therapist, one communication specialist (one of two in Malawi, the only one with a pediatric background) and two rehabilitation technicians. They have other supportive staff including an administrator, facilities head, receptionist, tailor and carpenter.

Occupational Therapy

Occupational Therapy

The children come two or three mornings or afternoons a week. Some of the children are able to attend the nearby SOS primary school, but they must demonstrate readiness for independence at school. The therapists do not support them within their schools. The SOS program, does however, also include outreach days, where the therapists goes to outlying villages to reach children that cannot come into the center.

Miriam Mwale is the physical therapist at SOS. She is quite amazing. With a lack of funding for equipment, she is resourceful. She browses through catalogs, and then gets her tailor, welder and carpenter to fabricate what she needs. Often, the children are also given equipment for use at home. I was amazed at how well the children functioned for their therapy activities, and how competent the mothers were with their children. Although they face many hardships, the time at the center seemed to offer a lot of support for the children and mothers as well.

The tailor at SOS

The tailor at SOS

Miriam, the physical therapist, and the carpenter

Miriam, the physical therapist, and the carpenter

Motor group

Motor group

Oral motor group

Oral motor group

I hope to visit them again before I leave, and continue contact with them on my visits to Malawi. The center served more than 30 children the day I was there. They have no waiting list, and no criteria for qualification for entry…they take whoever comes for services. What an amazing group of staff, children and mothers.