Surgical Care in Malawi

Melanie K. Sion, M.D.

Fellow in Surgical Critical Care at Brigham & Women’s Hospital

PGY-8

 Surgical Care in Malawi

Working in this resource-poor environment at a teaching hospital in Malawi has been the inspiration for my career but it can be an extremely frustrating experience to me.  Sometimes that is because of the challenging working conditions or because of the limited medical capabilities.  At this moment for me it is more because of the pathology, the poor comprehension by many patients about their conditions, and the chronic problem of inadequate communication between patients and clinicians.  While these are universal problems in healthcare, in Malawi these problems are worse.  I spent a year here as a resident in 2013 and have been returning twice annually to maintain my relationships with the clinicians here, to prevent myself from losing touch with this reality, and to contribute clinical time here in this extremely understaffed hospital.  My project for this trip is an assessment of the Emergency Room area, however, because of staffing issues there is a fair amount of clinical work I’ve been asked to assist with for this two-week time period.   This morning I made rounds on both the Male and Female Surgical Wards with a 4^th year resident, 2^nd year resident, and three medical students.  We saw approximately 60 patients with various conditions: some were post-op patients, some were trauma patients, some were patients with wounds from soft tissue infections too large to be cared for as outpatients, along with a mix of malignancies and other illnesses. 

These rounds do have some similarities to home and feel slightly like rounding as the acute care surgeon of the week where I did my residency.  The residents are introducing me to the patients, describing their hospital course, and I am a fresh set of eyes.  I feel that some patients are on track, i.e. admitted for an appropriate reason, receiving timely and appropriate care, progressing towards an eventual recovery and I expect them to have a timely discharge.  However, what struck me as so frustrating today more than ever, was the number of patients admitted with liver cirrhosis and late stage malignancies.  Of course this is not different than in the past, but for some reason I’ve noticed more this time. 

I’ve come to understand that cirrhosis is incredibly common in Malawi because it is caused by endemic infectious diseases such as schistosomiasis as well as Hepatitis B.  Of the patients I saw today, about 8 were relatively young in their third, fourth, or fifth decades of life, however all were unfortunately suffering from sequelae of cirrhosis.  These patients have presented to the hospital because they have liters of ascites in their abdomen or are experiencing recurrent episodes of hematemesis due to portal hypertension and variceal bleeding.  Some of these patients have traveled up to 4 hours by mini-bus to reach the central hospital at a price that is incredibly high to them and are admitted to the wards hoping for treatment.  The difficulty with this is that cirrhosis is a challenge to treat anywhere in the world and in a place that is so resource-poor, the condition makes me feel particularly helpless.  Some of these patients will wait days if not weeks for endoscopy to treat their bleeding varices and many will leave because they see futility in such long waiting periods or the endoscopist runs out of ligating bands.  Even if patients are given available medications such as diuretics and beta blockers, I can’t imagine this makes an resilient impact beyond perhaps mild improvement in an inpatient setting. 

The part that saddens and frustrates me that most is that the patients come here to the central hospital with hope.  It seems they are admitted with hope that resolution is a possibility and then they wait for exceedingly long amounts of time and most frequently leave with frustration, anger, sorrow, or a total lack of understanding regarding their condition.  I know the Malawian clinicians feel a similar degree of hopelessness and frustration that I do with this problem, however I think they are chronically faced with this reality and they must conserve their outrage for things that they will affect greater change.

A surgeon here once told me to try to learn how to do a TIPS procedure and said I should bring the skill to Malawi.  I would at least like to work towards a better understanding of the problem of cirrhosis in Malawi and come up with realistic guidelines for clinicians as well as patients for how best to diagnose the etiology, setting-appropriate treatment regimens, and culturally sensitive communication talking points.  This would take time and careful observation and communication with a cohort of patients to understand their environment and their access to local services as well as follow up at the central hospital but this trip has inspired this new goal I hope to work on over time.

On a more optimistic note, I’m a surgeon, not a hepatologist and I decided to take a patient to the operating room with a tumor that others thought was too large to remove.  I saw the patient on rounds and palpated a massive tumor in the left upper quadrant that was too large to assess for mobility.  I reviewed his images and felt that in fact the tumor was well circumscribed and resectable.  The patient was lucky because he had a CT scan performed two months prior when the CT scanner was working, for now it had been broken for weeks and not going to be fixed in the foreseeable future and I don’t think anyone would take a palpable tumor that large to the operating room without a CT scan, even in this environment.  The CT image and image of the surgical resident holding the extracted tumor are attached photos.  I’m particularly proud of this case because I’m not sure the case would have otherwise been pursued and I’m glad I was able to provide this service to that patient.

 

(At the time of this submission, I’ve learned that the tumor on Pathology report was indeed a GIST tumor, the patient was discharged uneventfully, has followed up in clinic and is found to be doing well and without complication.)