EIQ Δ

α) “I think we should get an EKG on this patient…”

--blank stare.

β ) Pouring a bowl of cereal for breakfast while Blessings is in our kitchen

--a long stare.

Γ ) “I am Dr. Elizabeth Hutchinson. I am doing an orientation here (in the Emergency room) for two weeks.  I am happy to help in whatever way I am needed but I need a bit of guidance to see how things work.”

-- Chechewa words exchanged among the group followed by laughter. 

Δ ) Since moving here I have realized something about myself.  In my day-to-day life I rely heavily on a well-developed Emotional IQ (EIQ).  This realization has come out of an appreciation of the delta: an increment of a variable —symbol Δ.  Allow me to illustrate the vast delta between my EIQ in Seattle and my EIQ in Malawi.

α ) I have been working in the Emergency room for the past week (my 4^th of 6 weeks of orientation). The Emergency room here is called “AETC” or Accident & Emergency Trauma Center.  This great hall of a department welcomes patients from all over Malawi who have an undifferentiated medical concern from minor to severe.  There is an elaborate triage system involving patients moving through a series of check points at the door, registration, triage, nursing assessment and then they are seen by a medical provider.  As is the case when you are standing among a group who speaks a language that you don’t understand, you can see that thoughts and emotions are being communicated but you have little idea about what is being said. Looking on this scene on my first day, I could see many rows of benches arranged in different locations in the hall.  I could see some people walking around in scrubs with stethoscopes and other people in white uniforms with small white hats on their heads. People were moving in barely recognizable patterns, caring for patients behind rooms made of hanging curtains.  I could see single sheets of white paper with name and ID labels on the top. I saw people with bleeding wounds, people sliding off their bench onto the floor, I saw pregnant women grimacing, and cachectic people coughing.  I saw people who appeared well and were chatting and other people who were being held upright by their guardians.  Not only the language was unrecognizable but also the system.  My task was to see patients – because I am a doctor after all.  I quickly realized that in order to see patients I needed to know something about the bench system, the medications and lab tests available, a way to communicate with patients and the people in the scrubs who were unidentifiable to me.  After a series of futile attempts to see patients on my own, followed by attempts to “help” one of the medical providers (who did not want my help, and did not know what I was doing there), followed by asking the nurses about the bench system and how things worked, I finally came upon a patient who spoke English.  A 62 yo woman who was having left sided chest pain for several hours, radiating to her arm and jaw and she was nauseated and short-of-breath.  This is a language I understood and I understood it to be an emergency, a heart attack.  I asked the nurse how I could obtain a blood pressure, some oxygen, aspirin and an EKG. She told me that those things are only available in “resus” and walked away.  The next challenge--to find “resus”--involved questioning a few other people until I made my way to another cluster of rooms which were teaming with nurses, students, people in scrubs all attending to patients who were clearly sick.  There was an open bed and I asked if I could bring my patient back for evaluation.  I relayed the symptoms to the nurse.  In my experience these symptoms switch on the green light for things to start happening quickly.  Unexpectedly, instead I received just a blank stare.  “Maybe she has malaria” said the nurse after a long minute of looking at me from head to toe.  “Perhaps she does, but I think we need to rule out MI first with an EKG” feeling as confident as I have yet since coming to Malawi.  After getting the okay to bring her back, I put the woman’s arm around my shoulder as if I was helping a tired friend to the finish of a marathon and brought her to “resus.”  With my plan detailed on the piece of white paper, I set it next to the nurse and asked politely, “does this look okay to you?”  Another stare and she nodded her head vertically.  I left the patient and went back to the neighboring room where there had been a trauma thinking that maybe I could help while my patient was getting her O2, aspirin and EKG.  About 10 minutes later I came back to find my patient in the same position as when I had left her.  If I were to detail the next 15 minutes you would live along side me in the discomfort of “what am I missing and why isn’t anyone talking to me or my patient?”  I figured out that it was me who should do the EKG… using leads without stickers or gel…and it was me who was to figure out that the O2 machine was in a different location and being used by another patient. The EKG showed up on the screen and I took a picture of it because there is no paper to print it out.  I was relieved to see no ST elevation; no Q waves…no heart attack.  Feeling the pressure to get my patient out of the resus room, I communicated to the nurse that the patient could go to “short stay” where I was going to do a malaria smear and re-assess. With the same stare I had received 45 minutes earlier she said in a matter of-fact way “patients here don’t have heart attacks.”  This type of interaction occurred over and over again for several 9.5 hour days in succession at AETC and will continue again next week.  Many feelings were mingling around in my brain.  Of the feelings that I had, the one that is “wow--I have a lot to learn medically” was the most relaxing feeling.  The other feelings such as “I am a burden to the system, I don’t understand how things work, I can’t tell if people hate having me here or not, I am not sure who is who, what kind of training they have or if I can ask them for help.  Above all was struck by the stillness of the place.  Patients in pain do not make noise, medical providers dealing with an emergency do not seem stressed or in a hurry, and people respond both positively and negatively with stares.  The feelings that are a burden to me now are not the feelings of medical inadequacy but rather the feeling that my emotional intelligence has not been trained in this culture.  In the past, I have said in many situations ranging from medical student interviews to conversations with friends that being a doctor is much more than what you know but this experience is proving that to me.

β ) Blessings has continued to be a very important part of our lives.  His singing voice continues to bring us peace in the mornings and resilience continues to inspire and teach us.  He is staying near us now and we see a lot of him. He works for us, yes, but he is also becoming a part of our family while we are here. Micah and Blessings have a special bond and laughter comes easily when we are all together—which is good for our souls.  As per my routine, I had poured myself a bowl of cornflakes for breakfast.  Blessings was doing some dishes and looked with great interest in what I was doing.  His look of interest was more than a passing glance at my breakfast choice; I could feel that he was deep in thought about something. I had time to try to interpret his look—as I think you would all agree is the emotional intelligence’s natural response when someone is staring at you.  Perhaps he wants me to offer him some breakfast, perhaps he is looking at the gigantic box of cornflakes that costs as much as a day’s wages for him, perhaps he is wondering how many more dirty dishes I was going to make for him, perhaps he wants to discuss cornflakes.  So (subconsciously, with my well developed emotional intelligence) I cycle through the following thoughts of hospitality, guilt, social justice issues, how to interact with someone who is washing my dishes for me who is also my friend with whom it would be natural for me to discuss cornflakes.   I looked back at him questioningly.  In response to my glance he asked, “How do you make those?”   

I was not only off the mark… I was way off.  Did he really think that I had made the cornflakes?  Yes.  He did.  I have developed another neural pathway for what a stare might mean here.

Γ )  The final anecdote helps symbolize the reality that am here, 100% committed to the work that I am here to do. I know I am in the right place: this has been confirmed spiritually, emotionally, intellectually and practically (we are not going to get on a plane anytime soon.)  I am incredibly grateful for the collegial relationship I am making with my Malawian family doctor counterpart. I can see the vision that I held before coming gradually unfolding.  And beyond what I ever expected or imagined possible, I am strengthened by the support of friends and family in Seattle.  I am doing what I can to be competent, confident and carry on even when things are challenging.  At the same time, I do not take myself too seriously.  Along with learning the delta between my EIQ in Seattle and my EIQ in Malawi, I am learning that there is abundant grace in this country. 

(Bill) Malawi Stimulus

It is a strange dynamic for us to have a "staff".  We have a day and a night guard (paid for by the hospital).  We pay Blessings to basically help wherever we need him, whether it is to coax along my vanity projects (vegetable garden and a chicken coop) or wash the dishes.  We pay Brenda (one of our day guards) to do our laundry twice a week.  When I told Blessings that few people in America have "help", he raised his eyebrows in disbelief and barely mustered a, "wow".

When Elizabeth and I lived in Kenya, we resisted having anyone help us in our tiny guest house.  We really didn't need help keeping such a small place clean and thought washing our clothes by hand would be a great life experience.  However, after turning down several hopeful applicants, we received wisdom from some Kenyan friends that informed us that employing people is an important part of the local economy.  Every time we say "no" to help, we say no to another job created.

So, as we relented then, we have relented now.  Not that anyone had to twist my arm NOT to hand wash my family's clothes or anything!  What we pay is exceedingly generous by Malawian standards, but the amount would probably have us featured back home in some television expose on labor abuse.  I have told Blessings that it is strange to have him doing work for us that we could otherwise do ourselves.  He has a refreshingly simple response to our discomfort, "No.  This is my job."  And so it is.  He is grateful for the work and we are grateful for his help.

   

More pictures!

Many (okay, 3) people have asked us to post more pictures and so, in an effort to satisfy, here you (3) go.  By the way, this is me (Bill) accomplishing this task.  Whenever Elizabeth did stuff with pictures on the computer machine, it all seemed like black magic and I would run from the room.  This is part of my ongoing development this year to upgrade my tech skills.  Not too hard, actually!

 This is our home.  Three bedrooms and, happy to say, three working toilets.  At the SAME time!  The picture of laundry day is taken from our front door looking out the direction of those white gates.  We pay our day guard to hand wash the laundry two times a week.  She is thrilled for the extra income and I'm pretty thrilled not to hand wash our clothes.

 Our church, Blantyre Community Church, hides behind this giant banner that wraps around the entire building.  Still bursting with flavour!  I guess it could be a good church slogan.  And from inside looking out the windows, it could remind one of carbonated stained glass.

 You know there's been a Young Life event when someone gets covered in green slime!  Notice Micah's particular glee in getting to participate in the sliming.

 We went with a friend from school to a football match between two local clubs.  Mikial is painted in his favorite team colors, the Bullets.  This was a seriously crazy thing that we did.  Not sure I would have persevered to get into the event without my friend's calm guidance.  Lots of fans wanting to get in and not enough seats.  Rival fans getting a bit heated all around us.  On high alert the whole time.

 Is this cow related to Bill the Cat?  Would you invest your money with this creature?

 Let's all go down to the chicken cottage.  YUM!

 Hope you wanted corn flakes for breakfast.

 Micah stars in his class production for the all school assembly.  Every Friday a different class puts on a show.  This one was a mash-up of, well, let's see:  the big bad wolf, three little pigs, snow white and the severn dwarves, and confusingly, spiderman, superman and batman.

 Liam with his buddy, Sharia, getting to watch Micah in aforementioned confusing play.

 Micah and his kindergarten teacher, Mrs. Ferguson.  The international community is very tight-knit and we have her kids involved at Young Life.

 These were the red velvet cupcakes we brought in for Micah's classroom celebration for his birthday.

 Micah's class just after the big show.  Forgot to mention the appearance of the Gruffalo.

 I will be uploading signs that strike my funny throughout our time here.  Shouldn't this be call Spot OFF Drycleaners?

 We got a hold of some DVD's from some friends and we had our first movie night on our laptop:  Lassie!

 Oh how cute.....

(Bill) Some Malawi Sounds

I was thinking about some of the unique sounds of Malawi in our time here so far.  Here are a few....

Kool and the Gang!
  Yes, it's true.  We didn't bring any CD's with us from Seattle and now I've inherited from the previous car owner of Black Mamba  Get Down On It:  Kool and the Gang's Greatest Hits.  It was in the glove box and he firmly insisted we keep it.  So, as I have been driving around Blantyre and I want to be transported to a completely other world, I push in the disc and...."If it's ladies night,  and the feeling's right,...  if it's ladies night, oh what a night....."

Church choirs on the air
  There are a few churches across the ravine from our house.  As I type, there is a beautiful song being sung on the sound system and it drifts through our open, screened windows.

Islamic calls to prayer
  At 4:45AM, I will often hear the calls to prayer from our local mosque.  I might be getting better at blocking these out as I haven't heart them the past several nights.  (=

Rats
  Our rodent friends have been a bit quiet the past few nights, but "If it's ladies night, and the feeling's right..."  I swear, there are the occasional parties (fights?) that sound as loud as a WWF bout.  There's no insulation in the attics of these homes and so as the rats do their thing, it reverberates through the panels that make up our ceiling.  There were a few holes in these panels and we quickly covered them with duct tape our first few days here.  Still a bit disconcerting.

The talk of the guards and the gardeners
  Most residences have guards 24/7.  Our guards are not an intimidating lot.  Most often, we have Brenda, mother of 4, who keeps an eye on things during the day.  Daridso shows up at 4:30pm and stays until 7am when he swaps out with Brenda.  Daridso is maybe 16 and not much taller than Liam.  These guards are paid for by the hospital and along with the neighboring guards and gardeners, there is a loose community of shared food and conversation.  Often the first thing I hear when I wake up is the chatter of morning greetings and people walking past our property on their way to work and school.

Mosquitos
  Unfortunately, Blantyre is not at high enough elevation to loose the mosquitos.  Our house is not perfectly sealed, so we have adjusted to the sound of these cursed creatures buzzing around.  Even with our sleeping net, I sometimes hear them indicating their bad intentions from a few feet distance.  I HATE them.  Before I hit the lights, I conduct a thorough seek and destroy mission flushing out the winged evil from the cool corners of the bedroom and smashing them if I can.  Elizabeth is a bit concerned with my obsession kill all mosquitos.

Accents
  It's almost jarring to hear the flatness of an American or Canadian talking anymore.  Especially at the boys' school, North Americans are a small minority and I've enjoyed all the different accents of spoken English:  Malawian, South African, British, Australian, Dutch, Brazilian, to name a few.

Sobbing
  One of the most difficult moments that I've ever witnessed is Blessings (our gardener/friend) receiving news of his sister's death.  I was outside with Blessings when his brother, Pearson, walked out of the darkness to share that their older sister, Mary, had died that afternoon.  I went inside the house to give them space and could still hear the heaving cries of Pearson.  I looked out the window and Blessings stood as if in shock while holding his younger brother.  Later, I sat with Blessings and we talked about his sister.  She was 31 and had 3 children.  She had basically taken the role of mother after Blessings' mother had died when he was 7.  He called her his legs to stand on and also his head, for the formation she brought to his life.  Finally, after some of the shock abated, he too began weeping.

Electricity AND Internet in the same day!

We are three weeks in and we have reached a new level of luxury today.  We have working internet and electricity in our home.  We are able to upload our photos and I will start with this one as a reminder of how far we have come in luxury.  We started with no blankets (other than the towels we brought) no mosquito nets and a bedroom floor that was periodically flooded with toilet water.  We currently have blankets (borrowed), a few rugs for the floor and working toilet (as of 2 days ago.)

 Perhaps the only thing that Liam was dreading about coming to Malawi was the school uniforms.  He had seen a picture on the school website and was mortified that he would have to wear animal prints every day (!) In fact they are adorable and I think they really enjoy wearing them after all.  Or maybe they just enjoy calling the sweater their "jumpa" and packing the "swimming kit."

The boys have been playing football on Saturday mornings with about 100+ other kids. The games are minimally referee-d and we have gotten into the habit of calling it "dirty soccer" which describes high kicks, uncalled fouls, illegal throw ins etc.  But wow some of these kids are amazingly good even in bare feet!  Liam will be trying out for the soccer team at school and this will likely take priority over dirty soccer.  

The BLACK MOMBA is now a part of our family.  It is great to be able to get around via automobile now.  We have been able to take one game drive already, a park only about 1.5 hours away from our home.  Sadly on the way back home the black momba lost is strength and we had her back in the shop for a few days.  It was not clear if she was going to make it past the mechanic (who was its previous owner) but she seems to be herself again.  

Liam received this award at school for an achievements.  I would guess this would not be an award given in the US. 

Liam and Micah are doing so well in school.   

 Some have been asking if I am running here.  I am running some in the mornings. It is more comfortable to run with others (because it reduces the amount of stares in my direction) but I have been running pretty comfortably on my own.  There is a track here... if I am ever inspired to do a track workout, it will be a scenic one.  

Shoprite!  This is where we buy our food, it is a nice supermarket with most everything that we would want.  We feel very lucky to have this only about 10 minutes away. I think many come from all over Malawi to shop here.  The boys look forward to getting fresh bread from the baker when we go.  

When Micah first arrived in Malawi he told people, "my 6th birthday is coming up soon, so I need to make some friends quickly."  He has indeed made a few good friends. This is Noah who is one year behind him at St Andrews but goes to the church we have been going to and is the son of a doctor friend of mine.  His other friend is Giavvana in his class at school.  We will have a party for Micah next weekend. 

Liam also is making some friends.  But it is wonderful to hear from friends back home.  Thank you Georgie for the surprise phone call!  We have loved hearing from all of you via email and Skype.  We miss you all very much! 

(Bill) Rollercoaster

Each day can be a roller coaster of emotions.  This is true in any part of the world, but seems especially realized here.  This morning, we rose at 5:45am as a family.  Elizabeth went off to run on her own—somewhat comfortable to do this now.  The boys changed into their school uniforms  (I still can’t get over how cute they are!) as I got going with oatmeal and lunches.  We’ve settled into a pretty efficient routine to afford us extra minutes of sleep ahead of the 7a.m. school start time.  The bus driver (me) got the kids off to school and I left the car in the lot to get my run in tracing the neighborhood roads surrounding Saint Andrews.  I’m trying to explore different parts of the city and I’m coming to a place of acceptance that I will never be an anonymous jogger in Africa. 

I get home to get cleaned up and outside my window I can hear Blessings, our gardener, singing song after song from church.  He has great pitch and the range of Mariah Carey.  I take extra-long to perform every bit of hygiene that I possibly can so that I can just listen to the beautiful worship.  This is the top of the roller coaster for the morning:  beautiful sunny day, kids off to a good school that they are happy with, Elizabeth running, ME running (!), Blessings helping me get my vanity project of a vegetable garden off/out of the ground.

And then I turn to the rest of the morning, dealing with much of what ails Malawi:  inefficiency and corruption.  Buying our car (“Black Mamba”), I knew, would be a headache.  There’s a certain degree of paperwork to deal with in purchasing a car in the States, but here, it’s a performance of black magic to conjure up the proper documents in the right order.  I feel that my role in coming to Malawi is, in part, to navigate these channels and absorb the stress related to it (hopefully better than I did my traffic stop last Sunday!) so that Elizabeth can be focused on what she’s here for.

I won’t go into all of it, but there has been a whole lot of driving around town, communicating with various parties.  The driving part is still a bit stressful as I fear I will be pulled over by the police that seem to lurk at every major intersection with seemingly nothing better to do than hassle drivers into coughing up Kwacha. 

The communication piece is the most frustrating, however.  There was a big corruption scandal in Malawi recently called “Cashgate” (funny how Watergate established the terminology for future government scandals around the world).  So now, the normally impenetrable process of buying cars has grown even a few more layers of bureaucracy to satisfy the accountability demands of donor nations and groups.  Sadly, these anti-corruption measures have only provided more avenues of corruption to bypass the anti-corruption protocols established for the original corruption.  Got it?

I have no doubt I would have all my proper paperwork by now if I were willing to throw money at people.   Instead, I go from place to place getting just one more signature or official stamp.  Former British colonies love their stamps!  I’ve had three different intermediaries who have provided different degrees of help and all these people know people who can help make sure that things go smoothly.  All this cloak and dagger stuff has me yearning for the DMV!

nonfunctional

Last Saturday we had a breakthrough with our internet connection.  For the first time we had about 6 hours worth of consistent email and internet access.  We listened to music, responded to emails, and I downloaded Malawian medical resources for which I have been starving.  We were connected and feeling content as if traveling down a river with a gentle current.  Ah Comfort. 

Incidentally we had purchased a router for our home in Seattle just before we left (to make sure that the internet was reliable for our tenants.)  The router we purchased in Seattle was the size of a cereal box, black and ugly.  In contrast, when we purchased a router here about a week ago we were pleased at its size (the dimensions of a thick credit card) and its sleek modern appearance.  How nicely it would into the stark modern décor of our home!  However over the past few days I have a new adjective to add to sleek and modern: non functional.  I think we shorted it out by trying to open a few web pages at once. 

Though I am frustrated with the lack of internet capability now, I do not share this story for that reason. Rather, I share the story because I feel that the router and I have a lot in common. 

My last blog post was about a week ago. It seems that I was contentedly traveling downstream with the current of life. I was feeling quite sleek and modern (if I do say so) in my bright white coat carrying my pulse oximeter and thinking about the ways that I could contribute to teaching in Malawi. I spent a week on OB/GYN, am now part way through my week of pediatrics and am certain that I am completely non functional.  I am shorting out.  There are too many web pages open in my brain. 

Web page #1:  Navigating Queen Elizabeth Hospital.  This is a building the like of which I have never seen before. It is a series of buildings connected by covered walkways which split and T to corridors leading to various wards and departments.  The first time I walked in I felt like a hamster making my way through a hamster palace of tubes and compartments.  Each time I have walked through the hospital I have found myself in new corridors and come to new end-points.  No one seems to be lost except for me.  And when I ask for direction the answer is the same, “just over there.” I have considered bring string in with me so that I could use it to retrace my steps. 

 

Web page #2:  Learning new abbreviations.  PCV is blood count, xpen is penicillin, LA is malarial treatment, R is HIV positive and I could go on and on and on. I am the only one who doesn’t have a clue what is written and spoken about and yet I am expected to be a “consultant.”  Being a consultant is not too effective when all I want to say is “what are you talking about?”

Web page #3.  Getting my head around morning “hand off.” Hand off takes place at 8am for all departments.  The forum is the interns (usually 2) who have been on call overnight discuss the statistics of the night and the difficult cases.  A common hand off on OB/GYN would sound like:  “there were 32 vaginal deliveries, 10 caesars, 30 admissions to antepartum and 33 to GYN.   There were 5 maternal deaths and 8 infant mortalities.”  They would then go on to talk about the “special cases” of the past 24 hours including all of the deaths.  The numbers of the pediatrics hand off is about double. There are over 200 patients on the pediatric service.   I have seen more pathology in the past  1.5 weeks than I have seen in all of my training and have encountered more morbidity and mortality than I ever imagined would be here. 

Web page #4.  Ndirande district hospital. This will be a big part of my role while I am here, but my time will not be devoted there until after my 6 week time at Queens is done.  This is where my heart is though and I am eager to start thinking about the work that needs to be done there as well as setting up for the Swedish residents who will be joining me in about a month.  I have been working with a wonderful Malawian family doctor who is incredibly smart, passionate and thoughtful and I can envision good things happening at this district hospital. The needs here are that of a medical director, figuring out the supplies, personnel and functions that need to be organized. Developing a budget, protocols and teaching.  The needs here are also of a researcher, figuring out what baseline metrics need to be established so that this pilot can be monitored over time.  The need is also for me to be a consultants to look over difficult cases.

Web page #5.  HIV, TB, Malara, shistosomniasis, rabies, tetnus, medical protocols that I should know like the back of my hand…

Web page #6.  I am a family doctor. I am supposed to be able to care for the family, the person in the context of her illness.  And oh right, I don’t understand anything that is being said around me. I need to learn chechewa.

Our sleek modern modem is overwhelmed, but alas it is not completely garbage.  Tonight, though it is not capable of opening any full web pages, it is allowing a few emails to download.  I will hold on to hope that I also am not complete garbage despite the way things seem now.