Last day!

It has been a great rotation!  I had a chance to see illnesses and disorders that I have never seen before in the US. I especially liked working in the ID unit and the HIV unit.  Both were full of enthusiastic professors and students. And my last week working in the surgery department with the cleft lips and palate specialist was amazing!

It was eye opening to work in an environment with such limited resources.  We are so used to ordering tests and images that sometimes we forget to focus on the history and physical,  on the clinical signs and symptoms.  But it also made me grateful for the abundant of resources that are available in the states.

These four weeks have been wonderful,  both working in the hospital and visiting the country. And now I'm off for more adventures! I'm heading to Siem Reap to see the great Angkor Wat! And then I'm off to Thailand before heading back to the states.  Hopefully some of this wonderfully hot weather will follow me home!

an almost encounter with the prime ministers wife

Day started with morning meeting, where the intern gave a summary of all admissions yesterday. There were a few hernia and fractures due to  motorcycle accidents. I decided to go straight to the operating theatre rather than round toys morning.  There was another cleft lip on the schedule. Then there was a second degree burn that needed to be cleaned and debrided.

By this time,  it was almost lunch time.  So I went home,  but I returned at 1 because the wife of the prime minister was scheduled to visit the hospital.  By 1:30, everyone was dressed in their whitest white coat and cap and waiting at the entrance to the surgery building.  By 2:30, the entourage arrived. We could see the cars and we could catch glimpses of her and her delegates add they went into the main building for a meeting.  The visit to the surgery department was scheduled for after the meeting.  So there we waited.  By 3:30, we could see activities across the courtyard. All of a sudden,  lights started flashing and the cars were pulling away.

So there went my chance of meeting someone famous.

Orthopedic consults and arthrogryposis surgery

Tuesday: After morning meeting and ward rounds,  I spent an hour with a general surgeon consulting on new cases.  We admitted a 6 year old with inguinal hernia.  At first, the parents aren't sure they would be able to afford the operation.  It costs about 200$ for the surgery. Fortunately, there is a governmental program that will with the cost.  Unfortunately,  if the parents decide to go with the  governmental program, they might have to stay in the hospital for several days until there is a free spot in the surgical schedule.  And each day at the hospital costs about 10$. If they were private pay, they were guarenteed to be on schedule that same day.

After the general surgery consults, I went with an orthopedic surgeon.  We saw about 30 patients in about 4 hours. We saw new patients and follow up patients with Developmental Dysplasia of the Hip. I was not expected to see so many cases and with such varied range of age,  from 6 months to 5 years old.  But in Cambodia,  newborns and infants are not routinely screened for hip dysplasia.  I also saw a few cases of arthrogryposis, something that I don't remember seeing in the states.  We also had several cars of scoliosis and one case of osteogenic imperfecta.

Wednesday: after the morning meeting,  I skipped ward rounds and went to the operating theatre. My first case was a 6 month old girl with cleft lip and palate.  Today, we were only correcting the lip and is one of my top ten procedure that I've taken part in. To me, it's like a
puzzle where pasta don't seem to fit our make sense, but once the procedure is finished, the result is amazing.  This is the second time I've worked with Dr. Vanna and I've been following my first cleft patient from Monday. If I had not seen this patient before surgery,  I would not have imagined that he had cleft lip.

After the cleft surgery, I observed an osteotomy procedure of bilateral femurs in a year old boy with  arthrogryposis. The procedure was performed to release the contractures at the knees so the legs can straighten and the patient can have some mobility.  The surgery was performed by a visiting surgeon from the states.

Surgical unit

I started in the surgical department today and it was a great day,  I started the morning in the ward,  rounding with a physician on about 7 patients,  4 had come in with open complex fractures from motorcycle accidents, another fell off a couple of stacked boxes. There was a newborn who had a colostomy surgery after an open  abdominal exploration for suspicion of  malrotation or vulvulus.  The last patient is a one year old who at 7 months old was somehow burned.  Now his face is nothing but scar tissues.

After rounds, I went and observed 2 surgeries, a cleft lip repair of a 6 month old and a palate repair of an 18 year old.  The surgeon was very friendly and eager to answer any questions.He does these repair every morning from Monday to Thursday and consult and follow ups on Friday.  He does about 200 of these repairs a year and completely free for the patients. The funding is from Smile Train, an NGO that helps many countries provide cleft surgery for free.

New week, new illness.

First it was allergies. Then it was diarrhea. This week? The flu!
 The week started out so well,  but I must have picked up a bug from one of the patients on Monday.  Went to work on Tuesday and lasted through half the morning before I started sniffling,  then coughing.  I left work early and stopped by the pharmacy for some cold medications. Asked for guanfenesin, which they didn't have.  The pharmacist suggested Decolgen forte, which contains paracetamol and chlorpheniramine, which I recognized, and phenylpropanolamine HCL, which I didn't recognize.  But as I was feeling kind of miserable, I took some anyway.  Went home, went to sleep.  Woke up a few hours later with a fever.  And I've been fighting it until it finally broke late last night (on Wedsnesday). Between sleep,  coughing, and listening to the people ringing in the Year of the Goat, I researched phenylpropanolamine HCL. Turned out that it is a decongestion, but it had also been used in diet pills, and it has been banned from the US since the early 2000s for its potential effects of hemorrhagic stroke in women between age 19 and 49.

So I went to another pharmacy and found a drug where I knew all the ingredients, Sinex Forte. Manufactured in India, it contains phenylephrine,  paracetamol,  dextromethorphan, and cetirizine.

The good news is that the fever is gone and I'm feeling well enough to get up and go outside. The bad news is that I feel like I'm coughing every 5 minutes. Hopefully I'll be well enough to go to work tomorrow and hopefully I won't catch anything else.  But with my luck, it might just be malaria!

Happy New Year!

Week 3: respiratory unit

I started in a new unit today,  Ward B, the respiratory unit.  There are about 10 patients,  ranging from 5 months to 11 years old. Most have been diagnosed with bronchitis and pharyngitis.  One patient,  an 8 month old boy,  was brought in last night with febrile seizure., but has been stable since admission with no more seizure activities.

The unit is run similar to the Infectious Disease unit. There are 7 rooms in this unit, 1 room dedicated to those who can't make any payments, 2 rooms for those who could pay some, and 4 private rooms. There is a doctor and about 10 students assigned to each room, except for the private rooms,  which are seen only by attending physicians.

HIV ward cont.

Weds: First day actually working in the ward and we had three admissions. All around 10 to 12 years old and all taking ART. One came in with diffuser joint pain. Another with a groin abscess.  And the third with outer ear infection.  Her ear had swollen to its normal size.  Fortunately, their last CD 4 count were high and vital load was low.  However,  the little 12 year old boy with the joint pain barely weight 18 kg, putting him little above the fifth percentile.

Thursday: I checked in with our three patients in the morning.  The abscess was drained and the little girl now feels much better. The boy with the joint pain feels about the same,  even with scheduled Tylenol and Ibuprofen. The girl with the ear infection has improved. The swelling has decreased,  but it was still still painful to touch.
After rounding on the patients,  I went to clinic. And there I met two brothers, about 5 years apart.  The oldest has been taking ART since he was 9, about 5 years ago, and his brother,  8 years old, had been taking it since he was 3.

Friday: It's my last day in this unit and I'm back with PMTCT. New babies were brought for HIV testing and preventative medications.  Some have already been confirmed as being positive for HIV, while others are still waiting for their results.

Week 2 - HIV ward/clinic

New week, new ward.

On Monday, I followed a physician who worked in the PMTCT unit (Prevention of Mother to Child Transmission). We saw nearly 15 children, ranging from 3 months to 9 months.  Some have known history of parents who have the disease,  others are found or adopted with unknown history.  Some have already been tested positive,  others are still waiting for the results.  Most live in the city, but some had to travel many hours just to get here.  For those who live in the city, they have to be brought to the clinic every month for monitoring their symptoms and for distribution of their medications.  For those who live far away, the medications are given in 2 or 3 months  supplies. These medications are supplied by The Global Fund and given freely to most of the patients.  Those who can afford to pay are asked to pay what the could.

On Tuesday, I spent the morning in their clinic where children who have been confirmed by trains to have HIV are also seen monthly for monitoring and for distribution of their ART medications.  I met a little girl about 14 years old who have tested positive since birth from transmission from her mom.  She had been on the first line treatment since birth until last year when she became resistant to most of them and her CD 4 count drop to 9 while her viral load increased to more than 300,000. She was started on the 2nd line treatment. If she also fails this line,  her options become very limited as the 3rd line regimen is not easily available here. Unfortunately,  she is but one of the 5000 children in Cambodia currently infected with this disease.

How medicine is sometimes practiced in Cambodia

It was Friday afternoon and off we went to the coast for some abcs, air (the non-exhausted filled fresh air), beach, and crabs. The air was indeed better, cooler, and fresher.  The beach was beautiful with cool crystal clear water and hammock-filled stalls to while away the day.  The seafoods, however, did not agree so well with me.

I was determined to suffer as quietly as possible through this terribly uncomfortable ordeal and to push as much fluid as I could stomach until it had worked its course. My fellow travelers had other ideas.  One offered this Chinese typical balm compost of menthol and eucalyptus oil. Indications include cold, headache, rheumatism, neuralgia, insect bites, cramps, and, all chest complaints. Aside from its very strong odor, it does have is uses,  especially against cramps and insect bites.  I had no reservation using it for this particular ailment. As I have never used it for the other indications, I can't attest to its effectiveness,  but the Asians I've known would say it is a cure-all for all kinds of ailments.

Another friend offered 2 pills, which she swore would bring my pain to its immediate end. Other passengers agreed and no matter how hard I protested against taking medications not specifically prescribed to me, I finally gave in. Not surprisingly, symptoms did not disappear!

When I finally had access to the Internet and could look up those pills, I found that one was diiodohydroxyquinolone, used for treatment of amoebiasis. The other,  a black square pill, I'm almost sure was activated charcoal!

How did she come to think that these two medications would treat diarrhea? Well,  in Cambodia,  one could go to any pharmacy, describe the symptoms,  and be given the medications.  And depending on the pharmacist,  these medications could be prescribed correctly or erroneously. No doctor's order necessary.

Medical Education

The morning was filled with more patients with diarrhea, fever, and phatyngitis. Nearly 10 more patients were admitted yesterday with these same symptoms.  Most were from the city,  but a few were from far away provinces.  I spent some time with some of the new admits before rounds started. And in a fashion and rhythm that is only known by the natives, all 20 something patients were seen by 3 attendings and nearly 40 medical students, including yours truly.

After rounds, there is usually a student presentation of a case, but not this morning.  So I had more time with the students to compare notes on medical education,  in the states vs. Phnom Penh.

From what I understood, the medical education in Cambodia is modeled after the French system.  After graduating from high school,  those who have the capacity, financially and intellectually, can enter straight into medical school where they will spend the next 6 years. The first 3 years are spent in the classroom, where they learn the basic sciences.  Year 4, the students start their clinical duties. They spend the mornings rotating in hospitals and the afternoons in lecture halls. After 6 years,  those who want to specialize,  say in pediatrics or surgery, will spend another 4 years rotating between NPH and another general hospital that also provides pediatric care. After all these years, a selected few will have the opportunity to further their education in France.  Those who do not want to specialize can finish their education with just 2 more years of rotating through different hospitals.

When I told them about the medical education in the states, how students spend 4 years in college,  then 4 years in medical school, before finishing in residency and possibly in fellowship, they questioned the necessity of college.  They were even more puzzled when I told them that students can major in a variety of subjects, not necessarily in the field of science.  I can see why they are puzzled.  It might seem like wasted time.  Could I have succeeded if I had gone straight to medical school from high school?  I believe I could have, but I would miss out on the experiences I gained in college,  in the 6 weeks I spent studying abroad in France or the 3 weeks I spent volunteering in an orphanage home in India. The "extra" years have given me the opportuntities to go to new places, try new things, experience new cultures, like coming to work at NPH for a month.

Week 1, day1-3

After nearly 48 hrs of flying and wandering around international airports, I finally made it to Phnom Penh, Cambodia! The plane landed around on Saturday at 11:30pm and nearly an hour later, I obtained my visa, collected my bags and made my exit. I have long shedded my sweater, winter coat and scarf that I had brought along for the transit tour of Seoul, Korea.  I needed them in Seoul, but not here in Phnom Penh. Even with only one layer of t-shirt, I could feel the stifling heat and the sweat rolling down my back as I made my way to the guesthouse.

A few days later, I found my way to the technical office, where I was given my schedule for the month. This first week, I will be spending my days with Infectious Disease specialists. Day 1, I saw patients with diarrhea and fever.  Some were  suspicious of dengue fever.  Although the season for dengue has been over for several months, there have been some isolated cases. And living in the tropics, dengue is always in the differential for diarrhea and fever. After rounding with the physician, there was a presentation by an intern about hypoxic  ischemic encephalopathy.  The PowerPoint was in English, but the presentation was in a mixture of English and Khmer.

The next day followed similar pattern.

8am: preround on patients
9am: rounds and teaching  with physicians
10:30am: PowerPoint presentation by students
12pm: break for lunch

The afternoons have been very flexible.  Most afternoons,  students have lectures at schools and the physicians have their own meetings or they are the ones giving these lectures.

Only a few days into the first week and I feel like I'm learning so much,  about how medicine is practice here,  about how medicine is taught here,  and the pathologies that are seen here.