The Thrill and the Fear: “Living the Dream” in Malawi

Carly Brady, MD is our first global health fellow and will be finishing her 2 year fellowship in July 2019.  She is originally from West Virginia and completed her residency at Prisma (Palmetto Health) Richland as well as her GH fellowship.

January 29th2019 my family and I packed up eight suitcases with all our belongings and moved to Blantyre, Malawi. With six months left of the Global Health Fellowship, I was finally headed somewhere where I could couple both my passions, Emergency Medicine and Global Health.

Queen Elizabeth Central Hospital in Blantyre, Malawi has had a functioning Emergency Department (known as the AETC- Accident and Emergency Trauma Center) since 2011. It’s an imperfect system, (as all systems are) but compared to the facilities in the surrounding areas we are light years ahead in developing their acute care system. It is the only Emergency Department in the country staffed by Emergency Medicine trained physicians. We have x-rays and ultrasound most days. I can always get a CBC, thick and thin smear, and HIV testing. I can sometimes get urea and creatinine, LFTs, Hepatitis screen and CSF cell count/diff. If the urine pregnancy tests and urine dipsticks haven’t gone missing, I can usually get those as well. I have epinephrine as my pressor of choice, (commonly called Adrenaline here) and I can intubate as long as I call down to the ICU first to make sure one of the four ventilators are available. If I know who to sweet talk, if it’s a full moon, and if I have a patient with the right type of lateralizing signs I can occasionally beg for an MRI (available primarily for cerebral malaria research) or CT from the local private hospital.

Those of you who met me before I left know that this has been my plan for a while – fifteen years actually. So, oftentimes people back home will say, “Carly, you are really doing it. You are living the dream!” Then others will ask, “What does your regular day look like now?”

However, as any emergency medicine doctor knows, every day is different. That’s why we chose EM. The thrill/fear of never knowing what might walk/roll/fall through that door always keeps us on our toes. There are no “normal days” for us.

So, one Sunday, my first weekend “living the dream” on call (what an oxymoron), I drove in to the department expecting a slow morning. Malawians take their weekends and holidays very seriously so the AETC is usually relatively calm. As the day team started bedside handoff with the previous night’s team, we were all notified that a poly-trauma had come in to the department.

Unfortunately, this is not an uncommon occurrence. Minibuses filled with fifteen to twenty people or flatbed trucks providing cheap transportation for the masses often wreck resulting in 8-10 casualties and an equal number of traumas rolling through the door at once. As one of the only functioning emergency departments in the country we are often notified when these incidents occur as far as 2 hours away. Often, we wait on standby to hear whether the accident is closer to us or Lilongwe, the capitol city, wondering which hospital will receive the surge this time.

On this particular day it was an even stranger story. 24 hours prior a minibus was traveling from South Africa to Blantyre, Malawi. While in Zimbabwe the driver swerved to miss a pedestrian causing the entire vehicle to flip. I was never given a final number of casualties, but many died at the scene. The remaining fifteen were taken to the local trauma center to receive initial treatment.  After twenty-four hours in the Zimbabwean hospital they packed all the surviving trauma patients into a minibus and drove them the fourteen hours to our hospital.

So, this is how we started our “slow morning,” with fifteen trauma patients dropped in our AETC who had just driven 14 hours in a minibus after being stabilized in another country. Needless to say, we do not have fifteen trauma beds. We immediately converted our short stay unit into a mass casualty unit and begin assessing each patient one by one.

My first patient had a right arm amputation performed immediately prior to being stacked in the transport minibus, less than 24 hours ago. My second patient had a right arm amputation performed prior to transport, my third had a right arm… you get the point. Seven patients had at minimum a fresh right upper extremity amputation. All were at the midshaft of the humerus or higher.  I can only conclude everyone sitting on the right side of the vehicle had their arm out the window. It actually got to the point where the first thing I would do when seeing a new patient was pull back the sheet to see how many amputations had been performed. The remaining eight patients were a mixture of sorts: skull fractures, bilateral open tibia fibula fractures, pelvic fractures, femur fractures, degloving injuries… the works.

“Get a set of vitals on everyone! Make sure we have IV access!! And get me a sheet of paper so I can figure out how to keep track of these people!!”

Wounds/surgical sites were undressed, irrigated, and redressed. Everyone was given antibiotics (not inappropriately I might add…) fractures not going to the theatre immediately were splinted and pain medications administered to essentially anyone who asked.

Thank goodness for helpful consultants. The Orthopedic and surgical teams were notified immediately, and they came to the AETC at once.  In the next two hours we sorted through all fifteen patients, developing a new list: to OT immediately, to OT round 2, to floor then to OT round 3, and admit to trauma floor for OT sometime in the future not yet determined. Did I mention how strange it was for everyone’s primary injury to be right upper extremity?

Mind you, in the middle of all of this, we were trying to keep the remainder of the department running with one syncopal and unresponsive patient here and another hypoglycemic patient there. Our Magnesium and Aminophyline combo almost came too late for the poor asthmatic whose exacerbation happened to coincide with the arrival of the trauma patients.

Somehow, slowly, we got everyone taken care of.

First to the theatre, then to the floor, slowly they dispersed until all we were left with was the “regular” busy department. It was quite a day, to say the least. At the end of it I thought, “I don’t know if I can do that again… what kind of dream is it I’m living here?”

However, I was recently talking to a friend and said, “I guess moving here made me realize, you never ‘live the dream.’ You dream dreams, you live reality.” That’s the only choice we get. Some days are better than others. Sometimes I fight for 6 hours to get a CT on a patient, transport her to the private hospital for scanning only to have her die less than an hour after getting back to the emergency department. Some days I diagnose ectopic pregnancy with ultrasound and get the patient to the operating theater within an hour.  Some days I argue with ICU about why I keep sending them critical patients that often die. Some days I get the femoral central line in a dying hypoglycemic patient and she walks out of the ED less than 24 hours later.  Some days radiology accidently locks the keys in the department, and we go without x-rays all night. Some days I treat a crashing CHF exacerbation with severe hypertension with 10mg of Labetalol, 5L of oxygen and a prayer… and he gets remarkably, inexplicably better… until I don’t even need him to go to the ICU anymore.  Some days all of my patients that die are younger than me. Some days I have three patients with a GCS of three in the resuscitation bay, and then the third one wakes up and starts moving his extremities as we are performing the lumbar puncture and removing 40cc of cerebrospinal fluid causing increased ICP.

Some days I wonder if I’m even making a difference and other days I know I am. This isn’t a dream. But it isn’t a nightmare either. This is their reality and now it’s mine too. But I’m not done with my dreaming either. We are already in the process of starting a formal EMS system and currently have one ambulance staffed with trained paramedics! In the next year we are starting an Emergency Medicine post-intern training program with the plan of eventually developing the first Emergency Medicine Residency in the country. Just last week I was asked to consider being the Head of the Emergency Medicine Department at the University of Malawi College of Medicine – which was pretty amazing considering the fact that some days I can’t even tell if I belong here or not. I still have some time to decide, but the offer has opened a whole new range of possibilities.

Whether it’s a good day or a bad day, the kind of day where I wonder what in the world I’m doing, or the kind of day where I can’t imagine myself anywhere else. Every day is different. That’s why I chose EM.

 

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