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!

Day Fifteen and Sixteen: A Tale of Two Cities

One thing that really struck me during my Khmer New Year travels was the level of poverty surrounding the city of Siem Riep. Lining the road to Angkor Wat are village upon village of thatched-roof huts and barren rice fields. Everyone and everything--from adults and children to the cattle--looks dried out and emaciated. It's a strange juxtaposition amidst the striking majesty of the Angkor temple ruins. After all, who would ever think that such poverty could exist along side one of the seven greatest man-made wonders in the world?

Contrast this with some of the sights around town. I took the majority of Saturday to do a walking tour around town with my friends. We walked around the area, taking note of the lavishness of some of the area hotels and stores and observing the lively hustle and bustle of tourists and locals alike. But what was really striking were some of the pagodas. The city of Siem Riep has a population of roughly 150,000, and to it's credit, there are 13 major pagodas. These so called "wats" are both where monks reside and where the locals come for worship and other Buddhist ceremonies. While each varies slightly in its construction, they all have in common a "preah vihear" or "sacred sanctuary" that's absolutely extravagant. Here's a picture of one (Wat Bo):

Obviously my camera does not do any justice to how grand this building is. And things only get more intricate inside, with walls covered with elegant murals and handcrafted tapestries.

For me, at least, it's difficult to reconcile the wealth of these pagodas with the abject poverty of the people who live around here. Of course, many of the pagodas were constructed at another time. Together, they form the voice of the Siem Riep city that thrived before Cambodia got sucked up in the Vietnam War and before its abject destruction at the hands of the Khmer Rouge.

I was talking to B, the Brown ID fellow, the other day, and he mentioned that Siem Riep had changed dramatically since the last time he was here in 2002. With tourism booming, the city itself is definitely becoming a key source of national splendor. But the real story, I think, is much more complex than that, with corruption and governmental disorganization still the norm around here. So long as that's the case, I know I'll always be haunted by the duplicity of wealth and poverty that is Siem Riep.

Day Fourteen: Holiday with a Bittersweet End

I went to work this morning, fully prepared to help M with his fever study database when news arrived that there had been a patient death sometime in the early dawn. V, a staff physician who had just gotten back from the U.S., came into the microbiology room with the report that a young child with acute gastroenteritis (whose parents I had spoken to a couple of days ago) had needlessly passed away due to medical error. Apparently the residents were too afraid to give the child much fluid due to his malnutrition, and the child started developing worsening diarrhea and an increasingly slow heartbeat. Eventually he was taken to the ER, and given pressors (drugs that make the heart beat), but for some reason, no the child still did not get adequate fluids during this entire time. "It's sad," said M, when he heard the news. "This child probably wouldn't have died if he was watched a little more carefully. Basically he died because it was Khmer New Years..."

And as much as I hate to admit it, M was right. Even though the hospital was still open during the holidays, it was run with as skeletal a staff as I've ever seen. With only a few residents managing the ER, ICU and the Inpatient ward all at once, it is in a way inevitable that something bad was going to happen.

For me, the fact that this happened to a patient whom I had examined just a couple of days before really hit home. I had spent the past two weeks floating around in the periphery, not saying much and writing random notes in charts that I assumed would never be read. But surely I could have been a better patient advocate? After all, M and B were there and had written a note for the residents to the effect that the child needed to be watched. Perhaps I should have stayed longer and reminded the resident to look for their note.

In any case, it was clear that M and B felt bad and even a little guilty too. What a way to dampen Khmer New Years.

But on a lighter note, I was able to get away in the late afternoon for a look at Bayon and Angkor Thom. Here's unfortunately the only view I was able to take before my batteries went dead:



True, it's not the sunset I was hoping to catch, but at least it was a bright ending when compared to the events of my day!

Day Thirteen: Khmer New Year Part Two

So, here's a picture of how my day started out:



After a rough night (yes, I'm still sick) and an early start at 4:30a.m., this view of the sunrise from the mighty depths of Angkor Wat was definitely worth the trouble.

Luckily I wasn't alone for this adventure. My new friend, A, who is a resident doctor from Australia, was my traveling buddy, and together we had a wonderful touristy morning.

Following the sunrise at Angkor Wat, we took a tuk tuk (basically a small carriage hooked up to the back of a motorcycle) out to visit Banteay Srey--a fairly well-known temple that sits on the fringe of the Angkor temple complex. Its name in Khmer roughly translates to "Citadel of Women," and it's easy to see why. Most of the arches and doors are low-hanging and narrow, and the entire temple is decorated with carvings so intricate that it's commonly thought that none but a woman's hand could have done them.

Here's a picture of me in one of the narrow doorways:



And below is an example of all the gorgeous carvings on the walls. They are definitely the best preserved of any of the temples I've seen:



On the way back from Banteay Srey, A had the wonderful idea to stop at a local butterfly garden that was located on the road back to town. It was an incredible experience. The garden was part of a NGO striving to find eco-friendly ways of improving the livelihood of the poor villagers in the area. Apparently the founder had a big heart for butterflies, which were systematically being destroyed by the villagers' logging habits. Since then, the organization has used grant money to train the villagers to create and maintain a wonderful butterfly garden that both preserves local butterflies while providing a way to earn income from tourists. All I can say is that I wish I had a better camera so I could do justice to how beautiful the butterflies were.

This is me getting friendly with the catepillars:



And here's where they keep all the pupae, providing them a safe place to emerge from their cocoons and transform into butterflies:



Last but not least, here's the final product:



After the butterfly gardens, we went back to the city. Wish I could say I did something else productive after this, but I pretty much passed out when I returned back to my room and slept away the rest of the day.

Hopefully Day 3 of Khmer New Year brings something more exciting...

Day Twelve: Khmer New Year Part One

So as a background, I’ll say this: Cambodian people love to party! It seems like they try to take public holidays whenever the opportunity presents itself, and Khmer New Year is no exception. For three days (April 13-16), the entire city shuts down so people can visit with their families or pay their annual respects to the temples.
Of course, it goes without saying that the hospital never completely shuts down.

Originally, I, too, was planning to take time off. This plan soon changed when I learned that B, the ID fellow from Brown, was also planning to be at the hospital during this time to familiarize himself with the place. I agreed to tag along...partly to see if I could help out, but mostly to make sure I wasn’t missing anything.

My first day of holiday was botched by my getting yet another about of food poisoning the night before. Don’t ask how I managed to get two bouts of food-borne illness in the span of 12 days, but in any case, I was fairly incapacitated for most of the morning. I was brave enough to go to a local pagoda with Dr. C and the residents around noon—which, between the heat, my nausea, and my aching belly—was pretty much a set up for disaster. Luckily, I made it back to my room without public incident.

Whether I was dedicated or simply delirious from volume depletion, I forced myself to go back to the hospital for afternoon rounds. This was, of course, before learning that there are no official attending rounds during Khmer New Years. For better or worse, M and B decided to do their own teaching rounds, which were greeted with a fairly lukewarm response by the residents. It's becoming clear to me that they are used to a more "hands off" form of rounds, where there's not as much interaction or teaching from the attending. So it was rather amusing to me to see the residents squrim and try to look attentive as M and B attempted to dole out clinical pearls. Not that I was in particularly top form myself, with my visible bouts of abdominal pain and trips to the bathroom.

Thanks to the hospital's skeletal crew, I was able to help out more than usual. In fact, I was able to do my first semi-H&P in Khmer, since neither M or B speak much of the language. Unfortunately, the patient whose family I spoke to was in very bad shape. He was a little boy, just over a year of age, who was admitted for acute gastroenteritis. When I examined him, he was malnourished, very lethargic, barely responsive, and extremely dehydrated-looking. His mouth was coated with gentian violet (an antifungal agent), indicating that he probably had significant thrush. B leaned over as I was examining him and said that the child probably had HIV. He also said that in the U.S., a doctor would be watching over that child like a hawk. Indeed, this was not the case in this ward, which was currently being watched over by one single resident who was ignoring the child while taking on another admission. We will see what happens over the course of next few days of Khmer New Year celebration...

But enough serious stuff. Tomorrow will be a day of fun and pleasure--the start of my own personal holiday. I'll be watching the famous sunrise at Angkor Wat, doing some more temple trekking, and paying a visit to a butterfly garden.

That is, if I can get my own gastroenteritis to stop. :-(

Day Eleven: Micro Wonders

 

I have to say...it feels so great to have M as my current preceptor! It turns out he is not technically an “Infectious Disease Fellow” per se, having just assumed the title so he could pursue some independent projects in Cambodia and Thailand. He actually has some background in pulmonary medicine and palliative care. Just the past couple of days that I’ve had M with me on rounds, I feel like I’ve definitely learned more than all the days I’ve spent here combined. Definitely makes me appreciate the value of a good clinical mentor!

That said, my rotation here is quickly becoming centered on microbiology and infectious disease. In a way, I guess it’s a logical progression. After all, most of the pathology here is caused by acute or chronic infection!

So today, it was back to basics. I spent some of the morning helping M clean up some of his fever study databases. Afterwards, we methodically reviewed all the positive culture results with the microbiology techs. These “Microbiology Rounds” actually occur on a daily basis, and is actually a great way to double-check if a given patient is on the correct antibiotics.

The patients on the ward are growing some interesting (and frightening) stuff. Indeed, I’m now starting to associate the term “Gram Negative Rod” with “Oh crap...” More often than naught, these organisms turn out to be resistant to the broad spectrum antibiotics that are generally used to cover pneumonias and other infections (otherwise known as “Extended Spectrum Beta-Lactamases”). AHC is starting to experience a dramatic rise in these types of infections, which is problematic since the only other option for treatment here is giving a very powerful antibiotic (e.g., Imipenem).

To my delight, S, the lab tech, was more than willing to take me under her wing and show me how to do some gram stains and other techniques. Keep in mind that I haven’t done a single gram stain since 1st year of med school, so I was most definitely rusty. Thankfully, S was very patient. I got to do several stains (as well as a Ziehl-Neelsen stain for Tuberculosis), and then spent the next hour or so looking at slides with lots of bacteria.

It is fascinating to watch S go about her business, staining slides at the flick of a wrist. To me, a lab newbie, I found myself entranced by her sheer skill. Whereas the same task would probably take me eons, she looked as if she were perfectly within her element. I watched her enviously as she flitted around, peering at slides and preparing multiple lab cultures at the same time. I on the other hand, was taking forever trying to find a visible cluster of bacteria on my gram stain.

What a humbling experience. I came away from the lab definitely happy that there are people who are much better qualified to do these things than I!

So to top off my day, B, an ID fellow from Brown Med, has just arrived in Siem Riep. I was very happy to see him. In all honesty, it’s been nice being alone for a time so I could have the freedom to do what I want to. It’s definitely made me more of a self-directed learner. That said, I’m thrilled to be having people who can show me the ropes. It’s amazing to me how hungry I’ve become for good teaching in the span of a week!

Day Ten: Plague Studies

This morning, I finished writing notes on all the patients in the Low Acuity Unit and headed out to the Microbiology Lab. There, I met M, the UK ID Fellow. He gave me an enthusiastic greeting and then proceeded to put me to work. It turns out he has been working on a big Fever Study over the past year, the goal of which is to pinpoint associations between different clinical signs and common etiologies of fever at AHC.

So my first glorious task? Turns out he wanted me to scan an entire patient chart into the computer.

But to be fair, it wasn’t any old chart. It turned out to be that of a patient I had taken care of and discharged just a few days ago. This girl, barely 2 years of age, was Cambodia’s first confirmed case of plague. Yes, you read that right…Yersinia Pestis. Her total hospital course was 16 days, most of which was spent trying to figure out what was making her so ill.

There were over a hundred pages in her chart, which was filled with flowsheets, progress notes, lab sheets, culture results, and more. It was interesting to go through her initial presentation, which was fairly non-specific (high fevers, diarrhea and vomiting, lethargy) to about 24 hours later, when she became hypotensive, developed bloody diarrhea, and went into septic shock. She stayed in the ICU for a few days, requiring intubation and receiving multiple blood transfusions. At last, someone made the decision to test for Yersinia Pestis (which can cause sepsis), and sure enough, blood serologies came back positive. She was started on gentamicin and began improving just 24 hours after starting treatment. Fortunately, no one else in her family (or any one of her doctors) has gotten ill with the plague.

When I met the patient on day 13 of her hospital course, she was still with poor appetite and extreme lethargy—both of which are characteristic symptoms of septic plague. As I examined and wrote notes on her over the next 2 days, I saw her transform from a kid who could barely sit up to one that was alert, interactive, and absolutely charming. The picture above shows the patient on the day of discharge. It still brings a smile to my face to look at it.

In all, it took me about 3 hours to scan the patient’s entire chart. Curiously enough, it didn’t feel like too much work. As I took apart her chart and scanned in page after individual page, I felt like I was reliving her mysterious presentation, her rapid disease progression, and her dramatic recovery. I know that the Cambodian doctors are planning to write up her case, and that people from the Centers for Disease Control are following along with interest. Someday, her case will be important and well-known, especially in the infectious disease community. But for today, it was just me and her chart, unraveling her story bit by bit.

Interlude: Traditional Khmer Experience #2 (Weird Snot-Like Fruit)

It goes without saying that Cambodian food is rife with odd tastes and textures. Well, the same is true for the fruit here. They come in all shapes and sizes, some with spikes, others with scales. Just walking out along the streets, it’s easy to come across all sorts of vendors selling wonderful portions of mangoes, dragonfruit, bananas, and yes…durian (see above picture…it's other wise known as the big spiky fruit that smells like dirty socks).

I’m lucky enough that there is a wonderful collection of fruit vendors just right outside my guesthouse. These days, I’ve certainly been eating more than my fair share of fruit, especially since it’s quite hard to get any in the U.S. Some of my favorites include those that…well…literally look like gelatinous globs of snot when the outer shell is removed.

Here’s an example of what I’m talking about:



Pictured above is a fruit called a rambutan. I’ve never seen this outside of Southeast Asia. It’s rather hairy on the outside, but the fruit inside is firm and a bit slimy. Biting in to it releases a burst of juice that is quite sweet and refreshing. To me, the flesh of a rambutan feels a bit firmer than a lychee, although the taste itself is pretty similar. Here’s a picture of what it looks like on the inside:



The other slimy mucous-y fruit I’ve had is called “tnaut.” Tnaut is a special fruit that comes from the palm trees around here. It’s a popular treat for people trekking around the temples of Angkor. Basically, it comes in a hard-shelled fruit that looks like this:



When you cut it open, there's this slick, slippery fruit that easily slides down the throat.

Texture-wise it is somewhat slimier than a lychee or rambutan, and it’s a bit messy to eat if you nibble at it. Curiously enough, there’s not a whole lot of taste. But that said, slurping a few of these down is definitely nice and refreshing when it’s sunny and close to 100 degrees Fahrenheit outside!

Stay tuned for my next “Khmer Food” entry, where I profile the copious amounts of strange chip flavors to be found in the local grocery stores!

Day Nine: Potato Poisoning

Early this morning, when I was starting at a copy of the Inpatient Department (IPD) census looking for new patients, I noticed one with a rather odd diagnosis: “potato poisoning.” I read through the chart, fascinated. This kid had apparently rolled in the ER over the weekend with nausea, vomiting, and worsening ability to breathe. He was doing so badly that he was intubated and kept in the ICU for a day. Somewhere along the line, a resident discovered that the kid had eaten some sort of “potato” before getting sick. Now out of critical condition and resting in the IPD, I had hoped to meet the patient face to face to figure out what had happened. When I came to his bed, however, he was nowhere to be seen. I then learned that he had just been discharged and that I had missed him by minutes.

*Sigh* I always miss the interesting cases!

Luckily enough, the attending who was there over the weekend filled me in on the details. Apparently it wasn’t just any ordinary potato that the kid ate. It was something called cassava root. Cassava, which is a starchy plant much like a potato, is a common food choice in Cambodia. In fact, it’s the plant that tapioca starch is made from (a.k.a the ingredient in those funny looking pearls that you get with bubble tea). Apparently, there is a high concentration of cyanide-like compounds in the leaves and the root of the plant that typically becomes inactivated when cooked properly. If eaten raw, what results is a paralytic syndrome that almost always results in respiratory distress if left untreated. The attending believes that the patient ate cassava that was only partially cooked, leading him to become intoxicated.

The Cassava case was a bit of a rarity. But that aside, it seems like intoxications in general are extremely common here at AHC. Just looking around town, it’s easy to see why. Cleaners, pesticides—even gasoline—are bought in bulk and are packaged in water or soda bottles. Here’s a picture of a typical “gas station” for motorbikes:



Looks like some big bottles of refreshing lemonade, huh?

In other news, M, the ID Fellow from the UK , is officially back in town today. I met him for the first time during afternoon rounds, and boy, am I happy he’s here! He seems very willing to take me under his wing, in exchange for some basic data entry for his Fever Study. Unfortunately, it seems he will take off for Thailand after just one week of being here, so we’ll see how much I can learn from him before he leaves.

Day Seven & Eight: Angkor Wat and a Quiet Day Around Town

Whew…one week sure flew by! Thankfully I think I’ve gotten over most of my jetlag…just in time to have some fun exploring Siem Riep. :-)

Saturday was spent hanging out with one of the residents, as well as Dr. C, the ICU chief attending. I got a whirlwind tour of the temples of Angkor, starting with four smaller ones in the morning and ending with a two-hour exploration of Angkor Wat. I have a lot of pictures, but I’ll start by showing a few.

We start at the ruins of Banteay Samre:



Here's a bird's eye view of Pre Rup--a temple that many believe was built for funerals:



Moving on to Ta Prohm--the temple where some of "Tomb Raider" was shot. (Sorry for all the people in the picture...it was a busy day!)



And finally, a picture of me at Angkor Wat. (Yes, I know the hat I have on is way too big...)



For lunch, we stopped at a place wayyyy out in the forest. We had traditional Khmer food, which, to me, is coming to mean having a large plate of roasted chicken placed in front of you that you then proceed to rip up barbarically with your hands. Here’s our chicken (with the head intact).



And here's a picture of the lunch crew:



One of the things I love about Cambodia is that some of the most absolutely random things can end up serving as tourist attractions. This picture, for example, is of a very tall ‘Tree in a House.” It is located quite some way off the beaten track, somewhere in the forests surrounding Angkor Wat. All I know is that riding on huge stretches of unpaved, bumpy road lined with tree branches and brambles on the back of a motorbike is a terrifying experience! In any case, here’s a pic:



Sunday turned out to be a nice day of peaceful reflection and solitude. I walked down to the Royal Gardens and took my time wandering around the various paths. After a helter-skelter week of trying to learn my way around the wards and practicing Khmer, it was nice to pull away and spend some time alone with my own thoughts.

Sometime late in the morning, I ran into E, a pharmacist from the UK who is also working at AHC. We had a pleasant brunch in town, and it was then that I learned that she was actually staying in a guesthouse with other volunteers including an Australian doctor and an English teacher. So if all goes well, it looks like I might have a regular group of friends over here besides the resident doctors who keep on inviting me out. Fingers crossed…

Hyperventilation Syndrome

I feel like I’m playing a bit of “round robin” lately. Mostly due to the lack of a single preceptor, I’ve been floating around from department to department—eager to gain as much experience as possible without getting too much in anyone’s way. So it’s off again to the Outpatient Department (OPD), where I know I can vicariously see a large volume of patients by following a single resident.


Indeed, the patient volume in the OPD is overwhelming. It averages around 400 patients each day, split between six resident physicians and one attending. Doctors here function mostly like urgent care providers. It is tiring work. Each resident churns through about 20-30 patients in the morning, and the same number in the afternoon. Compare that to the 6-8 patients that a U.S. resident might see in a morning or afternoon time slot, and it really puts things into perspective.

But there are other things here in the OPD that are actually quite in common in the U.S. This morning, for example, Dr. R, the OPD director, lectured us on something called “hyperventilation syndrome.”I had no idea what that meant when I first heard it, but it seemed familiar the more he described it. Turns out it’s a common cluster of symptoms amongst school age kids that includes headaches, fast breathing, chest pain, and tingling in the extremities—usually due to psychological stress and/or trauma. I remarked to Dr. R that he was describing something that sounded an anxiety or panic attack. He agreed, saying that lot of the young OPD patients coming in complaining of “chest pain” were actually stressed-out kids studying at the school located across the street from the hospital.

Dr. R continued to talk to the residents about presentations of “bread-and-butter” psychiatry in Cambodia, which pretty much boils down to anxiety and depression. Unfortunately, there isn’t much that can be done in the OPD other than what brief amount of counseling can take place in the 4-5 minutes they spend with each patient. Most patients are usually told to seek outside help.

I thought back to the many patients I saw in the U.S. who were being followed up in primary care clinics for anxiety and/or depression. Day in and day out, there always seemed to be so much need for mental health care in our patients. I don’t believe I could even start to imagine the scope of the need that’s present here at AHC.

In the broad scheme of things, psychiatric disorders still make up a minority of the diseases that present in the OPD, especially compared to the amount usually seen in U.S. clinics. But they are still present. In the two days that I’ve been here, I’ve seen both a kid with “hyperventilation syndrome,” as well as another one with “hair loss” that turned out to be due to trichotillomania.

Dr. R, coincidentally, has been working hard for many years to get the Khmer health professionals at AHC to pay more attention to issues “outside” of medicine, especially palliative care. His battle has been an uphill one, unfortunately, due to the fact that the healthcare needs in Cambodia are still so acute. In general, doctors here don’t feel that things like mental health and pain control are important when you have loads of kids dying of malnutrition and infectious diseases.

Certainly, I can understand their general reasoning. But I still wish the Khmer medical profession could better understand the need for more mental health and palliative services. With so many children suffering from chronic disease, anxiety, and depression—conditions from which there is often no medical cure—it would seem worthy to help these kids feel better in other ways.

Day Five: Polyglot Medicine

When I was doing my rotation in the Dominican Republic, I remember how difficult it was to understand the residents as they would round on the patients in rapid-fire Spanish. So it is with no small degree of admiration that I observe the Cambodian residents go about their duties, as they both write and speak about their patients in English.

I spent most of today hanging out in the Outpatient Department, sitting beside a resident named B as he saw patient after patient in his busy clinic. B, who had attended medical school in Phnom Penh, said that he had to learn everything in French. He said that coming to AHC was the first time that he had to communicate in English since high school, and that furthermore, he wasn’t provided any support as he assumed his duties as a resident. I also learned that there are others in the group of residents who received scholarships to go to medical school in Vietnam. They had to learn everything in Vietnamese—which obviously is VERY different from English. It made me very humble about my own half-baked success of being able to speak little pieces of many languages.

The residents’ relative unfamiliarity with English does make for some interesting events, though. For example, a significant amount of time during rounds is devoted to clarifying English terms (e.g., dyspnea vs. apnea). In addition, their written H&Ps tend to be very minimal. Perhaps my favorite anecdote related to this involves a resident describing a chest x-ray of a patient with severe ARDS. In his note, there was no mention of the pleural effusions or the lung infiltrates present on the actual x-ray. Instead, he just used the following phrase: “Chest X-ray = Bad.”

What can I say? He definitely got the point across!

Indeed, there is talk about making the admissions forms contain more checkboxes so the residents wouldn’t have to struggle with writing English paragraphs. Hopefully this will help too with the history taking. But in the meantime, it’s forcing me to improve my Khmer so I can fill in the bits and pieces of missing history in the chart!

Meanwhile, it seems like the residents are finally catching on to the fact that I want them to speak to me in Khmer rather than English. Right now, I think my Khmer is at “Soap-Note” level with the patients. I definitely don’t have enough Khmer under my belt for a full H&P however. Oh well, baby steps, I guess!

Day Four: Of Big Heads and Small Bodies

Today, I decided to hang out with the residents in the Inpatient Department and help out with new admissions. Of course, this usually translates to me observing them interact with patients in fluent Khmer, maybe helping here and there with parts of the physical exam. But still, it’s a wonderful way to get exposure to a wide range of patient diagnoses.

So it was after I had seen a few patient admissions in a row that I found myself noticing a fundamental difference between the patients here and the ones I was used to seeing back in the U.S. For one thing, they are much, much smaller here. This is one of those very obvious traits that I failed to really appreciate until I had a couple of cases of babies with possible developmental delay. When asked by the resident whether or not I noticed any physical abnormality, I would say, “well, their heads look big…but I can’t tell if it’s because it really IS big, or if it’s because their bodies are so skinny!”

I know…what else do I expect in a country where many people subsist on less than a dollar a day?

The point was driven home to me when I was showing the residents my new Pocket Pediatrics book. Flipping through, they came to the chapter dedicated to “Overweight and Obesity” and immediately burst into laughter. “We don’t have this problem here,” one resident told me, “it’s more like the opposite…”

I vaguely remember a tip that I learned during my pediatrics clerkship. It was some clinical pearl that went something like “when a baby is starved, the body will fight to conserve head circumference at the sacrifice of both weight and length.” I don’t think I ever realized the validity of that saying until now…

Big heads aside, what amazes me is that in talking to the parents, a lot of them think that it is normal for their children to have some degree of emaciation. When asked, parents usually voice some degree of surprise that their child can eat so much yet be so skinny. I’m told that the problem is often that a lot of people are unaware that children must eat a variety of food to grow. As a result, it’s not uncommon for children to subsist on a diet of rice and little else—both because it’s cheap and because parents may not know any better.

Luckily, the hospital has a lot of educational programs going on. The staff offers cooking lessons to parents, focusing on how to make a palatable cheap nutritious stew for kids. There is also a fairly impressive vegetable garden on the hospital grounds, part of a project to encourage sustainable living in the countryside. Here’s a picture:



Overall, today was a better day than the previous three. I can’t wait to fast-forward to the point in this trip that I finally get over my jetlag. On the plus side, I think I’m finally able to understand about 65-70% of the Khmer that is spoken. Now if only I could speak back with as much precision.

Speaking of food, I've got another outing with the residents and attending tonight. Not sure if it will be as exotic, but given my state of exhaustion, I'm certain that whatever I eat will put me to sleep!

Interlude: Traditional Khmer Food Experience #1

This is the first of what will undoubtedly be many food posts, especially if the residents keep taking me to far-flung exotic places!

Pictured above are some of the items offered at the traditional Khmer BBQ we went to. Situated at the front of Angkor Wat, the place (not sure of its name) was actually one of many barbecue stands in the area. Despite its touristy location, I was struck by the fact that there was not a single foreigner to be seen.

So what's in the picture? Well, moving from left to right, we have four "combo" skewers (egg, chicken heart and liver), three rather large frogs (yes, I know--they look like small birds in the picture), and a whole fish. The residents, to my surprise, passed up the combo skewers and frogs in favor of fish and chicken. Oh well...I can't say I wasn't happy!

Our Khmer BBQ meal was served with a copious quantity of rice, watermelon, pickled vegetables, and dried meat. And after all was said and done, the tab came out to be about two dollars a person. Yes, one can eat very well here for very cheap!

And on that note, here's a picture of what I was able to get the next day for lunch for $1.50:



Yeah...I'm really going to miss this place when I have to leave at the end of the month!

Day Three: Revisiting Low Acuity

One of the challenges of being a lone med student is that you don’t have a resident or attending who can supervise you to work with patients. Knowing this, I had feared that the only clinical exposure I would get would be through chart reviews and official attending rounds. Luckily I had nothing to fear. The residents, upon finding out that my language skills were adequate, were all too eager to put me to work. So right from my first day, I was sent to check in and write progress notes on the patients in the Low Acuity Unit (LAU).

To be a patient in the LAU means one of two things. Either you really don’t have any pressing medical issues, or you got moved there because there weren’t enough beds in the Inpatient Unit. Upon reviewing the patient roster, I couldn’t help but be surprised by just how sick some of these “low acuity” patients were. There was, for example, one patient who was still having 19 bloody bowel movements a day from dysentery. There were also several patients recovering from bacterial meningitis, and one patient with a high fever from an unknown source who seemed to be on every antibiotic known to man.

For the past two mornings, I would take my time reviewing the charts in the LAU and then proceed to examining each patient and writing notes. At first, I’m certain the patients and the families were quite taken aback by my presence and my horribly broken Khmer (the Cambodian language). But already, I think they are getting used to me.

What is really striking to me in the LAU is that some patients have been there for such a long time. The kids in bed 1, 5, and 7 are being kept there to finish off their IV antibiotic regimen. And in bed 4, there is a baby who is in for malnutrition and is simply being observed for adequate weight gain. Back in the U.S., keeping patients like that in for such periods of time is absolutely unheard of. So having gotten used to seeing kids sent home with PICC lines after a 2-day hospital stay, it is really refreshing to have the chance to keep observing them until they fully recover.

As for other news, the good thing is that I did not have the same near-fainting episode as I did yesterday during rounds. Unfortunately however, I didn’t have the chance to apologize to the attending I was with before. Oh well…at least I managed not to actively offend anyone today!

Tonight, some of the residents have invited me out to a “traditional” Khmer restaurant. I’ll be sure to post later on what promises to be an interesting experience.

Interlude: My Friendly Visitor

I awoke this morning to find the above bloodstain on my bedsheets. The little dark dot to the right is...you guessed it...a dead mosquito.

Looks like I have some "friendly" visitors in my room. I can tell this is going to be a great month...

Day Two: How to Stand Out

One thing’s for sure: if you’re trying to make a good impression on your first day on the wards, it’s generally wise not to have a near-fainting episode on rounds.

Of course, I had it coming. Having just suffered a bout of food poisoning the day before, I was already doomed to feeling unwell in the sweltering heat. Add to that my jetlag, the lack of air conditioning in the inpatient wards, as well as my inability to keep down huge amounts of fluids at a time— and it was the setup for a perfect storm.

We started out on our “hospital wide rounds” at 2pm. We had just made it past the 4-bed ICU patients and the ER patients when I started to feel extremely dizzy and lightheaded. I briefly debated whether it would be ruder to leave rounds all together, or if I should find a way to stay with the group at all costs. At last, desperate to avoid passing out, I walked to the back of the group and started squatting down at various intervals to get the blood back to my brain. Luckily, I managed to refrain from fainting during rounds. But later, I learned from one of the residents that squatting was considered extremely rude and offensive, especially to the attending. This, of course, was not my intent. I just hope I have a chance to find the attending and apologize for my behavior before too long…

Otherwise, the day started out innocuously enough. I showed up for my orientation session and got a nice tour of the hospital. Boasting humble yet practical facilities, the hospital has a 26-bed inpatient ward, a small surgical ward, and a 10-bed observational ward. It also has an incredibly busy outpatient clinic that sees approximately 400 patients per day.

After the tour, S, the volunteer coordinator, told me that I was essentially set free to do as I pleased. There was no other resident, and as luck would have it, my Brown Med faculty contact at the hospital was out of the country. I am truly by myself here.

So much for making a good impression on the first day, though. Let’s hope things get better from this point on…

Day One: Welcome to Cambodia

Well, after a day and a half of flying and waiting around in airports, this is what I look like:




Needless to say, I am thrilled to be finally on land.

I’ve flown all the way here from Providence, Rhode Island to experience what will be my final rotation as a medical student. For better or worse, I’ve chosen to spend the time thousands of miles away from home—in Siem Riep, Cambodia. I will be doing a rotation out of Angkor Children Hospital, which is one of the main hospitals providing free care to the populated Siem Riep region.

I had known about the rotation for quite some time, as it has been long sought by med students and residents seeking a quality pediatric rotation outside the U.S. But I had personal reasons for coming here. One, of course, is my selfish desire to travel as much as possible before entering residency. The second is to improve my language skills enough to interact more fully with the large Cambodian population in Rhode Island. Seeing that I have matched into Brown University’s Medicine-Pediatric residency, I figured it would be worth having some extra language skills under my belt! :-)

Unfortunately, my first day around town was somewhat waylaid by the sudden onset of food poisoning not more than 3 hours after I arrived in Cambodia. (Serves me right for eating some suspicious-looking Korean airline food...) To add to the misery, it is an absolute sauna out here. Temperatures are easily in the mid to high 90s during the day, and they only dip down to the mid 80s at night. Air conditioning is not a given here. I am lucky enough to have a room with a semi-workable unit, but I know that’s not the case with many of the rooms at the hospital.

On another note, here's what my room looks like. My last trip to Cambodia included a few days in a rural village where there was no electricity and running water. So this is definitely much nicer than what I had experienced!



Anyway, I’m hoping to be symptom-free and volume-repleted enough to be functional tomorrow on my first day in the hospital. Wish me luck…