feeling better??

It's easy to feel better after a day of complete laziness. Tomorrow I think I'll go back and see how it goes. I did finish Shelby Tucker's Among Insurgents which was both fascinating and enlightening. He was in his early 50's when in 1989 he decided to walk across Northern burma. While en route to Asia he met a young Swede on holiday who decided to accompany him.

To frame the audacity of this venture, previous to them as far as anyone knows only one other westerner had ventured into that territory since missionaries were expelled in 1965. There weren't really any maps and the area had been in a civil war for around 45 years at that point. The story of their travel is well told and engaging, and he paints a beautiful picture of Northern Burma and the people who live there.

He also includes a lot of background information about the conflict in Burma. To me it was a great way to learn more history about people I work with every day and the land I can see from my window. To someone not here, it could either be an engaging way to familiarize with Burmese history or a bore, but if it is found to be the latter the history can likely be skimmed leaving only the travel narrative.

Maybe the greatest value is that while it is easy to find information about the Burman struggle (in Rangoon/Yangon and between the majority Burman people and their leaders) it is difficult to understand what life and politics are like for the minorities. This book fills in many of the gaps, and while each culture's history is different, they do tend to follow a similar theme. For completeness, it seems the author is not highly thought of in all Burma activists circles for reasons not entirely clear to me, but it seems to be an oddly elitist group and that shouldn't be off-putting.

I hadn't really intended this to be a book review, but not much else is going on. I still haven't taken any pictures of town to put on the internet. Will soon...

Chnaw pya deh

That means "I have a fever" in Burmese. The differential at this point is flu and dengue, with history and symptoms pointing towards flu. However, I'm not longer as afraid of dengue as I once was. A friend said that she had a fever for three days, then a rash, then got better. Not such a big deal. It is a bit frustrating though because, despite my characteristic nonchalance towards swine flu, the only group of people who have appreciably worse outcomes with it are pregnant women, and I'm in RH inpatient this week.

I left very early this morning amidst a septic 5 day old with an infected umbilical stump who we couldn't get an IV into, a woman delivering a breech, blue baby vaginally five feet away and all-the-while I'm having to hang onto something to fight the dizziness. So, I bailed out, came home and spent my afternoon watching The Hangover and Step Brothers. The blue baby ended up being okay, but I fear the septic one will not do well.

I did teach my English class tonight. At first I was dreading it, but now I almost look forward to it. They are really funny. The girls like to quiz me about any girl they have seen me talking to since the last class. One guy has a very constipated look while he is formulating a sentence, then he blurts it out quickly. And it's often 'creative.' Tonight we were talking about being able to do or not to do things, "I can play guitar. He can't swim," etc. This guy blurts out "I can make pee-pee!" He reminds me of Beavis.

So, not much new other than feeling a little bad. Hopefully I'll bounce back quickly. If not, I can take a week or more off and no one will care.

Photos etc...

I've set up an account with smugmug.com where I will put photos. I'm in the middle of uploading some from travels thus far. The address is www.andytrent.smugmug.com. I think. If that doesn't work I'll change it, so check my blog again later and I'll change it to the correct address. If I add photos of the clinic or anything somewhat sensitive I'll put a password on it - just email me and I'll give it to you.

I may not have mentioned, but I'm teaching an English class for the clinic medics. So far it's been fun. I think I might enjoy it as much as them. We've been talking about present continuous (I am typing) versus simple present (I am a student), as well as clothing. I ripped quite a few pages out of a friend's Vanity Fair magazine to use as conversation starters. Discussing them with people who grew up in bamboo huts in the jungle was a lot of fun. Since quite a few of them have dreams of resettlement, introducing them to various aspects of western culture seems appropriate. They also really enjoy when there is a word in our textbook, written by British speakers, that I don't know. Apparently what we call a sweater is a jumper to much of the English speaking world. A vest is a waistcoat.

There is a certain culture of the t-shirt at the clinic. Any training awards a screen-printed polo to participants. Most departments have their own shirts, each shift will also have one. Any organization worth it's salt has one or more t-shirt. As a teacher of an English class I was awarded my first screen-printed polo with words on the back about the value of teaching English at the clinic.

The best part of that it's yellow. On Monday's a large portion of the Thai population wears a yellow polo with the royal logo in support of the king. I can now take part in this, although mine lacks the official seal.

A fun story...

Time has really kinda flown by. I'm getting into something of a routine here. I spent last week and this one in the pediatric inpatient department. Like most of pediatrics, most kids fall into one of a few categories. The categories are different here though: malaria, measles, malnutrition, thalassemia, worms, and the usual respiratory track infections. There are outliers though and, as always, picking those out of the rest is a challenge (for me anyway).

One kid, about 2 years old, was staring at me this morning, wide-eyed and somewhat afraid. I suggested to the medic that it might be because I am white. She said maybe. She then told me about when she saw a white person for the first time, when she was five.

Her grandfather was part of a Karen force that fought with the Americans in WWII. He made some American friends, and one came to visit their home in the jungle, a journey that must have been quite a trip (although the American had probably had too much experience in the Burma junble already). He walked in and she was amazed -- she'd never seen anyone white and never anyone so big. She asked her older sister (or maybe a cousin?) who or what he was, and she replied that he was a giant that ate people. The poor little girl was then terrified that he would eat her grandfather and maybe her. She cried the whole time he was there. Later she explained what she was thinking and they all had a laugh. I often forget that most of the people I work with are around five feet tall.

I also talked to someone who had been in the Karen National Liberation Army. Most of the stories were about the lack of food. Apparently they eat lots of plain rice with chiles, and early in the meal all the chiles have been picked out. I'm trying to understand the conflict in Burma, and have a long way to go. It does seem like one reason it has been such a long-standing conflict is because many of the forces involved are struggling just to get through the day, much less fight. Combine that with the impossible geography and lack of roads, and you start to see why it has been such a long, smoldering fight.

Life in the inpatient departent

I'm finishing my second week in the clinic's inpatient department. It's a rather small building with one room and around 50 patients arranged in rows. There are a few hospital-style beds (8?) and a lot of wooden platforms, and several patients are on the floor. It's not air-conditioned, but is tolerable because the walls go up about 5 feet and then about 4 feet of fencing connects with the ceiling. The beds are just far enough apart that one can walk between them.

Family generally stay with the patients, either sleeping in the beds or underneath. The family is responsible for a lot of the daily care, including getting food from the "cafeteria," cleaning patients, and even sweeping the floors periodically. If a patient lacks family the staff take care of these things, but typically there is at least one family member around. Many walk in, some are carried, others arrive in pickup trucks. One of my favorite features is that there are two opposing pairs of entrances to the building. It's a clear 15 foot shot in one and out the opposite. Sometimes dogs will trot through, but they never stop. One in particular seems to make the trip about three times each day. I'm not sure why -- if they even pause someone will smack them. Maybe it's just the easiest path to their destination.

It's generally a quite social place. One of my favorite patients has a kidney problem and came in weighing 57kg and is about 4 foot 8. Over the course of about nine days of gentle diuresis she got down to 37 kg, a loss of 44 lbs of water making up about a third of her admission weight. She had enormously puffy cheeks as well. When I was going around seeing patients, I would often find her sitting in other people's beds chatting, chewing betel nut, or if we were doing a procedure I would turn around to see her looking over my shoulder. At night as many people as can gather around the one TV and watch soap-operas in Thai that no one there can understand.

Patients are often quite sick. That sometimes makes diagnosis easier. Two things I saw this week that I thought were only theoretical things they force med students to learn were Virchow's Node in a woman with an epigastric mass and Cullen's sign in a woman who came in last night with abdominal pain and a soft belly but on exam this morning the pain was worse and her abdomen was rigid. Her pressure was good though and was given a prompt ride to the Mae Sot Hospital.

It's different from home. There is no non-infectious heart disease, diabetes is rare. One kid's differential diagnosis included Candida tropicalis fungemia, scrub typhus, and syphilis. He promptly got better with doxycycline so we assume it was scrub typhus (most common cause of fever of unknown origin in the tropics!). Another guy came in feeling generally bad and had a white count of 89,000, 3% of which were myelocytes. One had 1,000 white cells in his CSF and 32% eosinophyls on peripheral smear -- two separate but interesting findings. Diagnosis is not hard when people present with such advanced disease and have uncomplicated history. Treatment is more problematic. And with the exception of malaria, antimicrobial resistance isn't a problem.

In other news, I've figured out how I can feed myself well for $2 a day, eating out every meal. My favorite breakfast and lunch spots have dirt floors, but the food is just as good as the fancier places. I went running with a friend this morning about 5 miles from town on a maze of dirt tracks farmers use to access the fields in the area. It was great, but will I think one could get lost there for a long time. At least the people seemed to be Burmese, so I'd have more success getting directions were I to get lost.

Fun article highlighting life in Burma

A portrayal of life in Burma would likely be an absurd comedy if it weren't for the fact that it's really going on. Here's a great example: http://www.irrawaddy.org/article.php?art_id=16921

Especially the last paragraph:

"Import restrictions have skewed the prices of cars—new or used—to levels that would be considered absurd in neighboring countries. A used Toyota Land Cruiser in good condition, for instance, typically costs around US $100,000. However, the richest Burmese in Rangoon have been seen driving Hummers and Italian sports cars. Tay Za is known to have a fleet of luxury automobiles, including a Lamborghini and a Rolls Royce, but seldom uses them because of the poor condition of roads in the former capital."

Life continues here as usual. I'm in adult outpatient again next week. It will close my first month which has passed very quickly. I'm not quite meeting the reading goals I set for myself at the beginning, but I'm learning both medicine and Burmese. I'm making token efforts toward Karen and Thai, though mostly just to divert the ire of Thai and Karen who are offended that I'm not learning their language. Saying "I'm learning Thai," in Thai greatly pleases the locals, although that's about all I know. Similar with Karen -- I know good morning, evening, and night. To complicate things though there are two mutually unintelligible "dialects" of Karen, and I don't even know which one I'm learning.

It's raining cats...

It actually has been raining for almost two days, but this is about something else. It's a funny anecdote that for some reason symbolizes much about life here.

There is a nice little restaurant where some friends and I often eat breakfast, and sometimes dinner. The head waitress is I think Karen but also speaks Burmese and English. Her name is Kay, or something that my anglophile ears interprets as Kay. Kay has an endearing habit of seeming quite upset if regular customers go more than a couple days without visiting.

I arrived early one morning to find the restaurant empty and Kay standing in the middle looking horrified and making that flapping hand gesture that seems unique to the female gender and transcends cultures and national boundaries. I paused, wanting to figure out what was going so wrong before walking into the middle of it. Kay then ran to the middle of the restaurant and picked up a kitten.

The ceiling there is a two separate shed-style tin roofs with the gap and various holes patched with wicker mats. When I got around to asking what was going on, Kay explained that the cat had fallen out of the ceiling. She carried the scared, mewing kitten around with her as she got my placement etc. I asked if it was her cat and she said no. She set the kitten on my table while taking my order and giving it to the kitchen. Then, to my surprise, she took the cat to the other side of the restaurant, pulled a chair out, stood on it, and placed the cat back into the ceiling.

I didn't inquire further, the logic of these events being obviously beyond my reckoning. However, in telling the story to other regulars, I heard a couple people say that they occasionally heard or thought they heard meowing and rustling from the ceiling/roof. For whatever reason, the way I felt watching it transpire is the way I feel most of the time here.