Wednesday, 22 June 2011


Bwaila hospital plus fourteen health centers in the Lilongwe district rely on six ambulances and only one is functional at this time…..
Malawi is in the grips of a fuel crisis. Ever since I arrived here over three years ago there have been periods that it has been difficult to get fuel but none so much as during the past few months. The lack of foreign exchange in a country whose imports far exceed its exporting potential plus important political issues at this time is causing this dire situation. As you can imagine it affects all walks of life, all businesses, all people in some way, but here at Bwaila it means our ambulances cannot function and our women and babies are suffering.
This morning I was attending a young mother who had given birth to her first child in one of our health centers at 2.30am. At 5am. she had her first eclamptic convulsion. This condition, which is peculiar to pregnancy, but that may become evident even after delivery is one of the main causes of maternal death in Malawi. It was necessary to refer her immediately to the hospital so that she could receive the appropriate medications which are mostly not available in the health centers. It was impossible to find an ambulance with fuel. (diesel) At 7am. she had a second convulsion but still the ambulance did not arrive. Zione arrived at Bwaila at 10am.Now 5hours since she first became sick. On arrival she was semi conscious and needed immediate attention. Her guardian informed us that she had also convulsed in the ambulance on the way to us. Each and every convulsion leads her into a more critical condition. We immediately commenced her on the right drugs and management so that we could then refer her to the central hospital for admission to the intensive care unit. Working together with my colleagues we managed to stabilize her condition noting that her conscious level was improving. I sent a student to inform the switchboard operator that we would need emergency transport for the transfer. After 15 minutes I decided to check myself as to when the ambulance would arrive. I found the telephone operator sitting in the kitchen having breakfast. I asked him when the ambulance would arrive to which he answered that he couldn’t make the call as he had no ‘units’ for the telephone .I couldn’t believe what he was saying. Why hadn’t he come to labour ward to tell us this? Using my own mobile phone I called the District Medical Officer who promised to resolve the situation. 30minutes later, just as I was starting to make arrangements to carry her in my own car, the ambulance arrived and I accompanied her to the central unit to be further managed. Her condition on arrival had not deteriorated so I am hopeful that she will recover, although she may still have suffered some cerebral damage due to the convulsions that she had suffered. I will follow up her progress tomorrow.
The health personnel had cared for her well and adequately but the support services had failed. How long will this situation last? How many more women and babies will suffer and maybe die because the fuel tanks are empty? Or the telephones are not working?
This is yet another example of some of the challenges that we are facing when trying to deliver health care in Malawi. Challenges that are unimaginable in the developed countries but that are a daily reality here at Bwaila.

The first follow up HIV test after treatment was negative. I will repeat the test once more to be certain that transmission has not taken place but I am confident. I feel happy and positive. I accept the high risk situation in which I work but continue to known for certain that I am still in the right place, I am where I should be...for now.


Monday 30th May. It’s now one whole week since I completed the course of ARV’s (PEP) I feel so much better. I didn’t quite realize how much these drugs had affected me until I finished them. I feel so much stronger and far less tired. More importantly I feel so much more positive and emotionally stable. At the end of this week I will take an HIV test which will then be repeated again in two months time. It will only be then that I can be sure that the virus has not been transmitted. However, I am feeling very positive and believe that I will be tested negative.
Bwaila continues to be both challenging and rewarding. The in-service training that I set up within the first months of arriving over three years ago but that became irregular during last year due to the withdrawal of funding has now been started up again. I am pleased and encouraged to see how well this has been received by the midwives who are enthusiastic participants. My role in this has changed somewhat as I hand over the facilitation to my Malawian colleagues and take up my new role as mentor or teacher of the teachers. Since January I have taken on the leadership of the daily ‘ward round’ on Labour Ward each morning. This is an excellent teaching opportunity attended by all cadres including students and trained staff. We discuss each case at length particularly those that are more complicated or ‘high risk.’ The participants are encouraged to assess each case and make plans for actions necessary and care needed. I particularly enjoy this type of teaching sharing all my knowledge and experience with the aim of improving the outcomes for the mothers and babies attended at Bwaila.
We are specifically looking at improving our Neonatal death rates. Birth asphyxia, which is most often caused by lack of diligent care during labour, is the main cause of neonatal deaths on our unit. We need to prevent our babies being born in poor condition thus needing resuscitation and nursery care. Many of our babies born with birth asphyxia will be the result of obstructed or prolonged labour. I have been working tirelessly both in the clinical situation and in the classroom to address this challenge. I hope that this effort will be reflected in our statistics during the next few months but more importantly that our aim to discharge healthy mothers and babies will be achieved


Twenty eight days of taking ARV’s and only two more to go!
It’s been a long hard month which has been an extremely testing time for me. I was warned very seriously from those that had taken these medications(PEP) that the side effects were many and unpleasant but in true Rachel style I was determined that this would not be the case for me That somehow I would be stronger, more resilient and not let them effect me. So I started out on a positive note as usual which I was able to maintain for the first two weeks. I was truly amazed to find that apart from slight nausea, lack of appetite and a general tiredness which I could overcome keeping myself busy I kept myself remarkably well physically. Emotionally it was a different matter and I found myself rejecting the medication each and every time I had to swallow those three huge pills. It felt as if I really poisoning my otherwise healthy body. After two weeks I came down with some sort of infection. Whether it was ‘flu or some weird virus I started to feel a sickness come over my whole body. It started by finding hugely painfully enlarged glands in my neck. At one point I tested for Malaria even though the symptoms were not typical and I felt sure this was not the problem. I began to worry that I was developing full blown AIDS. I was sufficiently worried to visit one of our specialist doctors who reassured me that it was extremely unlikely. The underlying doubts still remain. I spent three days at home determined to care for my health and fully recover. It took nearly a week to clear with just a few painkillers and anti inflammatory drugs. The week ended with a relaxing three days at the lake which always serves to renew and refresh me in body and spirit. I am not feeling good. However positive I try to be, the fact is, I still feel as if these drugs are poisoning me and therefore am experiencing the side effects more acutely. I am tired, just so tired. The one thing that keeps me going is to be on Labour Ward. Once I am there and involved in my work I don’t even notice the tiredness. When I stop, when I come home it is there again. Just two more days then I will be eliminating the drugs from my body and start to be Rachel, return to the enthusiastic, energetic Rachel that I know I am. Until then I will care for me, I will rest and I will find the strong positive Rachel which has pulled me through so many difficult situations so many times.
Am I still worried that I may still test positive in a few weeks time? Yes…. I guess I still have that niggling doubt, however small. The chances are very small the statistics assure me that it is very unlikely, but…..


I’m confused but I’m not afraid, I’m strong but I need to feel comforted and supported.
It was one of those usual busy days on labour ward at Bwaila. Most of my time is now spent teaching students of all categories sharing my skills and knowledge so that others may learn. Clinical/ bedside teaching is what I love, what I do best. My role is well accepted and well established now and I am sought out by the students to supervise their work.
So it was that two weeks ago whilst supervising one of our students I received a needle stick injury. Having administered the injection of Oxytocin for the removal of the placenta I had carelessly left the uncovered syringe and needle on the bed. Later whilst wrapping up the cloths on which she had birthed the needle entered deeply onto my left hand. I removed my gloves (we wear two pairs for extra protection) and went to the sink to wash. The best thing in these situations is to squeeze the wound to make it bleed. Unfortunately as the entry had been deep there was little blood however hard I squeezed I knew this mother was HIV positive and that I should therefore seek assistance promptly. Alongside the maternity unit there is a busy and successful HIV clinic that supports our work. I hurriedly left the labour ward to visit their clinicians. I am working on the busiest labour ward in Malawi and possibly in the whole of Southern Africa, I am working at Bwaila. It is an extremely high risk situation in which we try to protect ourselves but inevitably accidents do happen. Since arriving here over 3 years ago I have been regularly tested for HIV as a matter of course. Small needle prick injuries whilst suturing have not alarmed me but this was different. After testing negative at the present time I was prescribed the usual medications to assist my body in rejecting the virus. Post Exposure Profilaxis (PEP) is a combination of Anti Retrovirals ( ARV) I will have to take these drugs for one month then be retested after three months to ensure that I havn’t been infected.
So how do I feel?
My first reaction two weeks ago was that of anger. How could I be so careless?
Every morning and evening I have to take the medication. This is the hardest for me. Consciously putting these powerful drugs into my otherwise healthy body to do all manner of harm to my cells and tissues whilst supposedly preventing transmission, which I may not even need, I find hugely distressing.
I was warned of all the possible side effects, nausea, diarrhea, weakness, tiredness etc. ‘you will feel sick for month’ I was told. I was having none of this I decided! I would be fine, I would feel fine, and life will go on as usual!
And to some extent it has. Sometimes I get a bit weepy, I am often very tired and weak but apart from the occasional wave of nausea, I am just fine.
I am not afraid; I truly do not think I will contract HIV
I won’t publish this now but wait for 3 months to share this with you all.