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!