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.