Day Twenty-Two: Reflections on Rural Care

Today (Saturday) is a fairly slow day with nothing to report, since the only thing I’ve got going is my voyage up to Phnom Penh to visit the sprawling Wat Mahamontrey. But this lack of activity is fine with me. Yesterday’s experiences were powerful and moving enough for me to warrant some reflection time, so I was only too happy to have some down time during my travels to sit back and think.

Shortly following the charged M&M conference yesterday, I skedaddled back to the guesthouse to grab a sandwich and then proceeded to head to the Home Care office. There, I was greeted by a small team comprising a driver, a nurse…and a comically-huge SUV. The nurse greeted me apprehensively, though his demeanor quickly changed after he learned that I was a medical student. “Great..you can help out a lot,” he exclaimed, perhaps a little too enthusiastically, “Just do all the physical exams and write notes!”

So the three of us (with our extraordinarily large vehicle) left the comfortable confines of AHC for the dusty, undeveloped roads of rural Siem Riep. We drove for maybe twenty minutes before we turned off the main road to our first village. After that, we clunked and clamored down a series of unpaved gravel roads that make my stomach churn just thinking about it. I am not sure how our driver knew where the patients’ houses (or huts, to be more accurate) were located, but suffice to say, we made it to our first stop in one piece.

Here’s a picture of the first patient we saw, who is a 13-year old patient with asymptomatic HIV disease. She is the girl in the very left, dressed in a white blouse and navy blue skirt.



First off, can anyone believe she is 13 years old? I certainly couldn’t believe it. And when I was able to fully examine her, I was convinced that she was probably the developmental equivalent of an American 8-year old. She was so thin and emaciated, it pained me to even look at her. Yet, she managed to look back at me with her charming big brown eyes and converse with me in my funny-sounding Khmer. Her smile was truly infectious. Fortunately, the ARV medication had been keeping her HIV in check for years, and at present she didn’t have any acute issues.

The second patient I saw, pictured below, was previously admitted to the hospital for dehydration but was now being followed for malnutrition issues.



I’m not sure what exactly happened to him during his hospital stay, but whatever it was, It made him deathly afraid of doctors. It took me much longer than usual to examine him, but in general, he appeared to be growing well and in overall good health. He did have a spreading skin infection from what looked like a small abrasion. The nurse with me told me the only antibiotics he had on hand were Cirpofloxacin and Amoxicillin. I felt really compelled to give him some form of medication, seeing as the wound was clearly infected, so we left him with a five day supply of Amoxicillin as well as strict instructions to go to an actual doctor if there was no improvement or if he was getting worse.

Hooray…I dispensed my first “prescription.” I sure hope the patient survives!

Interestingly enough, the family decided that they would educate me on all of the odd things they had to eat in order to keep alive. Here are some more pictures.



And then this little...I mean, big...guy:



The first one is of a woven container containing a huge mass of roaches scuttling around and over each other. The second one is of a very large water beetle. I’m not sure which scared me most. Needless to say, I didn’t even attempt eating either one of them.

Afterwards, we made rounds to see a couple more children who were being followed for HIV. Though we never strayed more than 15-20 kilometers away from the center of Siem Riep, it was striking to me just how long it was taking us to visit each patient. The nurse who was with me seemed to have every visit down to a science, armed with an armful of checklists so he would be able to visit every patient within 10-15 minutes.

It was almost 5pm by the time we got back to the hospital. I was told that the homecare teams usually average 2-3 patients per afternoon, so at four, we had done pretty good. It was overall an eye-opening experience, though I definitely wished I had more time to get a better sense of how things really are..

Hard to believe that there is such poverty just a short distance away from where I am…

Day Twenty-One: Haunted by the Past

It was a packed day today. So packed, in fact, that I’m going to split the events into two posts.

Today was the monthly Morbidity and Mortality (M&M) report. It is run much like the way they do it in the U.S., where a senior resident has the duty of presenting the cases of patients who experienced harm (morbidity) or death (mortality) due to medical error. M and B, the two ID fellows, were particularly interested in hearing today’s presentation, since the main case that was going to be presented was about the patient with the odd bacteremia (otherwise known as the potential case report publication).

In short, it was the most painful M&M I had ever participated in.

The senior resident presenting the case was R. I wasn’t clear on whether or not he was the senior resident on call when the patient was admitted, but in any case, his presentation of the history and physical was very, very sparse. This was the very kid that M, B, and I seen over Khmer New Years, who appeared to be malnourished, dehydrated, and otherwise in very bad shape. Yet, to hear the resident’s presentation, it would have seemed like the patient wasn’t that bad off at all.

So as not to repeat myself, I’m going to include this link in case anyone wants more background on the actual case. But suffice to say, the resident neglected to mention a lot of important details. Other than the admission physical exam, which appeared to be extremely brief, it seemed that the child had been left alone with fairly little monitoring for a day before someone picked up that his heartbeat was faster than normal. In addition, when M, B, and I examined the patient, we found him to be disturbingly lethargic, as well as with evidence of oral thrush. Typically, such details would be important indicators of the severity of the patient’s illness; however they were not present in the resident’s M&M report.

At the end of the report, M actually raised his hand and informed the resident about the oral thrush we saw when we examined the patient, saying that this finding may indicate that the child was immune-compromised, perhaps due to HIV. This comment led to a series of reprimands by Dr. L, who gave the residents in the room his usual impassioned lecture about the importance of taking a good history and physical.

I did not get to stay for the entire conference, since I was scheduled to accompany the home care staff on a visit to check up on patients out in the rural areas. But later on, M came to find me and said that despite the intriguing bacterial find in this patient, he really did not feel comfortable publishing a case report on the patient because of the numerous gross errors that occurred in the general management of the patient’s care.

My feelings were similar to his. Inside, it was still hard for me to accept that this patient had literally died because he was admitted during a holiday—a time during which everyone’s guard had been down. And as much as I loved the thought of writing about interesting microbiology, I hated the thought of this patient’s sad hospital course haunting AHC’s otherwise good reputation in print.

Day Twenty: Too Much Testosterone

Take a look at the image above. It’s a typical picture of the team of residents and doctors that conduct the hospital-wide rounds in the afternoon. What’s absolutely striking to me about this image is how overwhelmingly male it is. Coming from my medical school, where the ratio of medical students is more than 50% female, this is, for me, a sight to behold…

Yeah—things are very different over here.

I wasn’t going write much on this subject, but I will admit that it is somewhat jarring to be in a completely male-dominated professional environment. To the other Cambodian residents, it is *extremely* strange to them to hear that I’ve traveled here alone—especially since I have a boyfriend back in the U.S. No matter how hard I try, it is difficult for me to steer their conversation away from my relationship status or my looks. Maybe I am over-reacting, since no one has explicitly said anything about female doctors being less capable—but it really feels like it is difficult for them to take me seriously. Not sure if it’s because of the fact that I’m female or because I’m a medical student. But in any case, the experience has definitely taken me by surprise.

Having been to a smattering of medical settings in Latin America, South America, and Asia, I had been in countries where the ratio of male to female physicians was heavily slanted towards the former. But what I saw at AHC definitely takes the cake. It took me 3 days to come across a female physician on the wards. And I soon learned why. In all of AHC, there is only one female attending physician and one female resident on the staff.

To my amusement, many of the residents and some of the attending doctors have taken to introducing me to patients as “Niet Kru sa-at, moak bpee Amerik” (Beautiful Female Doctor from America). I wonder what American patients would think if their physician was given that sort of introduction…

Day Nineteen: Weird Bugs

Photo From: www.lg1.ch/cpg/thumbnails.php?album=12

For a small hospital, AHC really has a wonderful microbiology lab. Thanks to the help of infectious disease physicians like M and B, the lab facilities have really improved over the years. Just this past January, M was able to get support to move the microbiology department to a new building, which was fully equipped with a fairly modern lab with different incubators and a functional hood and vent. That, plus the fact that the microbiology techs are hard-working and well-trained, and there's an unexpected opportunity to be able to isolate and identify a number of weird looking organisms.

Today was a good example. S, one of the microbiology techs, came back with the final blood culture report from the child who died over Khmer New Years. The result was distinctly odd: strongly positive for Pseudomonas Oryzihabitans (P. Oryzihabitans). Even B, who I consider one of the smartest doctors I've ever known, hadn't even heard of this species. Not much is written about P. Oryzihabitans, which, like most pseudomonas species, inhabits the soil and is somewhat linked to rice farming. It is rare that any psuedomonas bacteria other than P. aeruginosa is found in blood cultures here, and both M and B were very excited with the find.

Of course, there is the novelty associated with finding a potentially new, virulent bacterial strain in a patient population. But in this case, there was another dimension of significance. Previously, it was felt by many that the child died due to medical error (e.g., fluid mismanagement). But the appearance of this P. Oryzihabitans had the potential to change this. After all, it was a bacteria that was usually associated with severe disease in immunocompromised chidlren. Could the patient have had an underlying disease such as HIV, only to die because of severe sepsis from P. Oryzihabitans.

We shall see how this unfolds. M is particularly keen on writing a case report of this, especially if we start to see more cases of P. Oryzihabitans bacteremia in other kids.

Day Eighteen: HIV Clinic

With M away in Bangkok this week, I've been spending the past couple of days hanging around in the clinic with Dr. S, the HIV doctor. Almost singlehandedly, he oversees the care of the 800+ children who have been diagnosed with HIV at AHC. Since pediatric HIV doctors are so scarce in Cambodia, his patients come from all over the country just to see him. They come from as far as the Thai border, which, due to limited access to transportation,  usually takes about a day for travel to follow-up appointments.

Just thinking about Dr. S's job makes me tired. Because of his specialized training, he has no choice but to hold an outpatient HIV clinic every single day in addition to other duties in the inpatient ward. Despite all this, he still manages to provide excellent patient care, even having a reputation for being particularly strict with patient follow-up. Having lost many members of his own family to HIV, Dr. S has a burning passion to make sure that no other children under his watch will fall victim to the disease under his watch. His patients all call him their "father." Honestly, it's not hard to see why.

And it is truly incredible to watch. There is such a high rate of compliance in the HIV clinic at AHC that it really puts anything I've ever seen to shame. Dr. S only gives out 2 months of Anti-Retroviral (ARV) therapy to patients to ensure that they return for follow-up. And even if families come from hundreds of kilometers away, he will frequently admit patients to observe their HIV therapy and make sure that their families have places to stay. Since they are all generally placed on triple-combination ARV medications, the patients' caregivers are all given proper education for a week before they are allowed to administer medications on their own. In addition, there are staff members (usualy nurses) who organize homecare visits out to the rural villages to check up on HIV patients and their families. There is also a substantial food support program that is provided in conjunction with the medication, which is particularly helpful for the many families in the region who are virtually poor subsistence farmers.

It is amazing the range of patients that walk in to Dr. S's HIV clinic. There are HIV-infected children who have been treated with ARV therapy for years and are asymptomatic. Others are not so lucky, such as one 8-year old child who walked in with advanced stage HIV and TB, coughing violently and looking very much like a walking skeleton. I watched as Dr. S talked and examined all of them, seeing around 11 patients in the morning and 7 more in the afternoon.

In two days, I get to participate in the homecare visits with 3 HIV patients in the villages. Am looking forward to seeing how this all works outside the hospital...

Day Seventeen: Monkey Magic

I'll admit it--I'm at the level of medical training now where it is often painful to sit in the background without doing anything while another physician interacts with a patient. I used to dread this so-called "shadowing" back in the U.S., but here, it's definitely turned out to be a very educational experience. On a given day when I'm visiting the Outpatient Department, I can easily sit for hours watching patients and listening to the residents jabber to them in rapid Khmer.

Lately, I've been hanging out with H, a resident who seems keen on having me know as much as possible about traditional Cambodian culture. Sometime in the middle of his morning clinic, we saw the above patient, whose mother had brought him to clinic for suspicion of dengue fever. As he was taking a history, H pointed out to me that the patient was wearing a special amulet made partly from a stone as well as from monkey bone. Such charms are popular in Cambodia, where it is believed that they hold special powers to protect people from disease and misfortune. But unfortunately, as H later told me, they also serve as the nidus for disease in young kids, who tend to haphazardly put the amulet in their mouth. As a result, a lot of them develop various infections from bacteria that are harbored in the bone.

Just goes to show how important it is to ask about traditional remedies, I guess…

Of all the residents I've seen, H is the only one who takes a full History and Physical, remembering to ask every patient who comes in about remedies they use at home. And of course, there are a lot of them. Although AHC certainly runs a busy, efficient outpatient clinic, many families simply don't have the means of being able to come to town when their child falls ill. As a result, they turn to traditional healers, who, armed with their arsenal of herbs, amulets, and tools, quickly fall to the task of trying to heal patients without the aid of medicine.

Sometimes, the treatments work. Many a parent has come in, professing the wonders of herbal tea that can stop a fever or cure cancer. There are also plenty of children who come in with marks from being “coined” (having an area of skin rubbed vigorously with the edge of a coin) or cupped (where a small jar is placed on the skin and suction applied)—both treatments designed to draw out disease from the body.

Of course, I flash back to my own experiences with coining during my trip to Cambodia a couple of years ago. I had had a horrible migraine, which the family I was staying with attempted to cure with coining. There is much more to the story, which you can read here, but in any case, what I remember most about the entire ordeal was how much it hurt! I’m certain that just the sensation of having a rough, abrasive coin rubbed on skin is enough to distract one from a variety of different ailments. However, the Cambodians swear by it. Some even say that being coined is a very soothing experience. I’m still going to stand by my belief that it is something of an acquired taste.

But sometimes, the treatment seems more harmful than the disease. During H’s clinic, there was one 6 year old boy who came in with multiple scars on his belly. Upon closer examination, they looked to be old burn marks. H told me that one of the traditional treatments for abdominal pain or diarrhea was to be burned multiple times with a small flame. I cringed at the thought of this, imagining the agonizing pain as flesh was seared time and time again.

As the patient with the monkey amulet left, I couldn’t help but feel incredibly grateful for having access to actual medications. Granted, it would be arrogant to discount the value of traditional healing methods, seeing as many civilizations have managed to treat ills and ailments without the help of modern medicine for centuries. But given the choice between taking an antibiotic versus being burned to treat a stomachache—I would definitely prefer the former!

Interlude: Junk Food!

What can I say? Temple trekking and recovering from gastroenteritis sure builds up an appetite, and there's lots around here to try!

I could spend an entire post talking about the exotic food items that are sold at the local markets here, but for now, I'll keep it simple.

For some reason, I had a huge hankering for chips, so I trekked down to the local "Western" supermarket and discovered these:



I know...it's difficult to read the writing on the bag, but these are Sweet Basil-flavored Lays. They are absolutely fabulous. They actually taste more like a super-spicy barbecue chip more than anything, but the basil notes do start to come through once you've had half the bag. :-)

My other finding was a bit stranger:



See the sushi rolls depicted on the left? No, that's not a joke. These are Nori-flavored Lays. To be honest, I was actually quite hesitant to try these, fearing some odd fishy taste that would sully my experience with potato chips for life. But they were actually surprisingly good. Not as good as the Sweet Basil flavor, but definitely tasty enough for me to finish the bag in a few days. (Okay...admittedly, this was not a very big bag...)

Stay tuned for the next "Interlude" post on local markets!