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…