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…