Wrap up on Beit CURE Blantyre Malawi

The anesthesia equipment and staff at the hospital were terrific. I had a monitor with end-tidal CO2 and agent analysis and some wonderful people to work with and help me.

I mentioned Polena in my last post. I also worked with Steve, a CRNA who is six months out of training (vs. thirteen years for Polena) and Ruth, a registrar from England who has been working in South Africa and Malawi for the last couple of years. They were all happy about learning to do an infra-orbital nerve block for the lips.

Steve and me in the staff room.

I told Steve that I didn't think he was as good as Polena, but not to feel bad because I don't think I'm as good as Polena, either. Ruth will return to England this fall to begin training to become a consultant anesthetist. After her work in Africa she is more experienced than some of the junior consultants she'll be working under. She's a good soul, seems very spiritual and I think she will tolerate the experience well.

My one disappointment was a 2 3/12 year-old girl for a cleft palate repair. It was an isolated defect (her lip was intact). She was very small for her age, only 7 kg, but seemed vigorous and had trouble with milk coming out of her nose. So, despite some misgivings we put her on the list. She was our first case on Tuesday morning. The induction was uneventful but try as we might, none of us could get an IV in her.  During the IV flail Roy came to me and said that the palate instruments had not been sterilized and that it would be fifty minutes before they were ready. We decided to reschedule her for Wednesday, rather than keep her anesthetized for an extra hour. Wednesday, after making certain that the gear was sterile, we went ahead with the induction. The IV was a problem again but I managed to put one in a vein (name unknown to me) in the right side of her neck. I thought we'd be in good shape, but between her small mouth and the Dingman retractor we had it wasn't possible to get exposure of her palate without kinking the endotracheal tube.

I don't have a scale marker here, but the distance between the blade and her upper incisors was less than two inches.

As we tried different maneuvers the endotracheal tube popped out of her windpipe (this is not a good thing) and I hurriedly--fat man moving at the speed of light--replaced it with a larger tube. Still the kinking! I didn't want to try putting in a yet larger tube, so we reluctantly cancelled the case. Roy had the task of explaining to the mother why we had anesthetized her child a second time to no purpose.

I'll finish up with my success story. A seventeen year-old woman came into screening, hoping to have her cleft repaired. She brought her three month-old daughter, who also had a cleft, with her. She had been told that her daughter was too young for the surgery. I explained to her the “rule of tens” that I like to follow: ten weeks, ten pounds and a hemoglobin of 10 g/dl. She was skeptical and wanted me to show how I had calculated the baby’s age. Fortunately the doctor whose exam room I was using had a calendar on his desk, so we counted out the weeks for her and she agreed to surgery. He was our youngest patient of the mission. We operated on mother Tuesday afternoon and child Wednesday morning. The photos were taken on Friday afternoon.  There’s nothing better than getting a twofer and having such good results.

Blantyre: Screening and the first day of surgery

This is Roy, our plastic surgeon, checking his email.

I ran into Roy Kim in the line for check-in at the airport. The lady who checked me in was very friendly. She asked if I could eat a seafood dinner and when I replied, "I'm on a seafood diet. When I see food, I eat it." she gave me a high five. You don't see that at the Minneapolis airport. The airport in Blantyre is smaller than I expected but eventually we got all our gear and headed for the CURE Beit hospital to unload and organize. I looked at the anesthesia machines and hope they will let us use the one that has both halothane and isoflurane vaporizers. The two make a good combination: halothane for induction, isoflurane for maintenance. There seems to be plenty of anesthesia supplies so I should be in good shape.

Blantyre airport, Malawi. Nice big 737 from J'burg.

I talked to Kristie Bishop, a lady I've worked with in Egypt, about my plan for analgesia for the kids. She thought it sounded do-able so I'm anxious to get started. We got back to the hotel about 2:30 and talked, had some lunch, talked some more. The internet works best in the courtyard and there is a tent with table and chairs that is very pleasant. I managed to stay awake all through dinner and turned in at 8:00.

Later Sunday night


We just got back from the screening clinic. Twenty children and adults came through; we put 17 on the schedule for the coming week. One lady, 17 years old, came in for a cleft lip repair and we put her 3 month old daughter with a cleft lip on as well. She was hesitant to approve her daughter's surgery (someone told her the child was too young) so I went over the rule of tens with her: ten weeks, ten pounds and a hemoglobin of 10 g/dl. Fortunately there was a calendar on the desk I was using because she wanted to know how I'd calculated her age. Oh, and I got to practice my singing skills. The ditty about the fishies and the hootchie-cootchie dance was a big hit.

Courtney Bradley, RN from Cedars-Sinai LA, checking pulse
oximetry on one of our prospective patients.

Our first day of surgery went well. We ended up in an operating room with no windows and an anesthesia machine that was under the weather. The CURE staff switched it out for another and we were under way. Our four cases, all lip repairs, went well. I worked with Polena, an excellent CRNA, who was interested to learn about LTA for mask induction and infraorbital nerve blocks. Also got to treat some halothane dysrhythmias (nothing serious).

Immaculately clean and well-staffed hospital.

Kuche Kuche, the pride of Malawi. The Pride
of San Francisco in the background.

Polena, the CRNA who worked with me on Monday.
She's terrific.

Precious, our first patient, the resting after surgery

Berthe, our second patient Monday, enjoys a little porridge.

Overnight in Johannesburg.

The flight from Minneapolis to Johannesburg was long but uncomplicated. I changed planes at Dulles airport in Washington. The Dulles to Johnnesburg leg was broken up by a stop at Dakar Senegal at 5:30 in the morning. We were on the ground for about 1.5 hours while we refueled and accepted new passengers, but they wouldn't let us get off to stretch our legs. I was very fortunate in that I got an upgrade to first class from MSP to Dulles and had an empty seat beside me on both legs of the flight from Dulles to Johannesburg.
A man from the guesthouse gave me a ride from the airport. He started the car while I returned the luggage cart, and when I went to enter the car I nearly crawled into his lap. Left-hand drive!


Tonight I'll sleep at a quiet bed & breakfast, the Sunflowers Guesthouse, 15 minutes from the airport. I hope to leave at 7:45 Saturday morning for a 10:00 flight to Blantyre Malawi.