Problems one can run into at the clinic

Here are a few things I've run into this week that help paint a picture of working here.

I'm a bit ashamed to say that I didn't notice this one, but a 3 y/o came in with malaria, accompanied by her sister who said she was 12, but we later found out that she is probably just 10. It never struck me as odd that no one else was with them. I'd like to say that I assumed a parent or some adult came by in the evenings, but I really just didn't notice. Someone did though and a group focused on child protection came in to talk to them. No family had been to see them during the entire 4(?) day admission. The ten year old said they were from a village outside of Myawaddy in Burma, but she didn't know how to get there from the clinic, and didn't know how to contact her father. They are children from a previous marriage and have no contact with their birth mother. It sounds like their new family doesn't pay much attention to them, although they at least do live with their father and new wife.

After talking it was decided that the organization could house them when the little girl was ready for discharge and hope the parents could track them down. Thankfully, another sister, also saying she is 12 came by and knows how to get home. She decided to stay until the girl is discharged. In the end, the child advocacy group is going to stay involved to help them get home and see if they can help the family in any way. In retrospect, I should have noticed that there were two kids basically on their own at the clinic.

More clinically, a few days into his stay a little kid with malaria and questionably hygiene (but with a parent present) told us of symptoms that warranted doing a urinalysis. It showed trace leukocytes and moderate blood. The differential is suddenly broadened to a kidney problem or UTI. OR, the test is completely meaningless because the leukocytes could be hygiene related and the moderate blood could just be from the malaria-related hemolysis. Without microscopy and fancier tests it's impossible to know what's up. But, since he had UTI symptoms we are just going to treat that and see how it goes. In retrospect, one might have foreseen the limited usefulness of a UA and just treated symptomatically from the beginning.

Some kids are abandoned at the clinic. One of these is now 6 months old and still lives in the reproductive health inpatient department. It's a busy department with maybe 15 staff there round the clock. He's basically the department's baby. At lectures someone is usually holding him or feeding him. When staff get bored they play with him.

Someone elsewhere in the clinic has been working to find a home for him and succeeded. The staff are in an uproar. They want to keep him. The senior medics have gathered them together and said "if you want him, take him home with you," and "he's not a puppy." However, further protest led to a department-wide meeting with clinic administrators to talk about it. I think the younger staff still want to keep him (collectively). Maybe they don't trust where he's going to, or maybe they just like sharing a baby (they are mostly unmarried women in their early 20s). I'm curious to see how it works out. I'm not sure what it would be like to be raised in the staff room of the clinic -- maybe not so bad, but he's probably better off elsewhere.

And one more quick one: Probably the sickest kid I've seen here yet came in today. While we were struggling to get an IV started to give some medicine one of the medics gestured towards the door where I saw a dog curled up against the wall. Someone was quickly dispatched to run her off and then we all got back to the task at hand.

Every day is an adventure.

Quick Muay Thai followup

I did some research on the pre-fight activities and of went first to wikipedia: http://en.wikipedia.org/wiki/Wai_khru_ram_muay

And then to YouTube: http://www.youtube.com/watch?v=OPK5JtxjIM0 although that is much longer and formal looking than what the guys were doing. A lot of the stuff on youtube is by tourists and so they really play up the ceremony part.

Here is a full fight that shows the rhythmic movements. In a similar (though nicer) venue to the we were at and using Burmese rules (no gloves): http://www.youtube.com/user/shwefist#p/u/1/1bH0fDjnfkI

In search of "chauk Thai"

Or maybe it is "Bok Thai?" Not sure. Thai Boxing/Muay Thai, however it is translated. This is one of the better experiences of my trip so far and unfortunately I didn't bring a camera.

At the boxing class here one of the instructors said there would be boxing this morning near Mae Ramat. It's a small town about 30km from Mae Sot. Of my friends interested in this sort of thing, only one was able to get away from work on a Saturday morning (what's wrong with this place?). I rented a motorbike and joined him for the trip to Mae Ramat. We had no idea where it would be in Mae Ramat, but it's a small town. I assumed it would be at the school gymnasium or something similar.

We pulled into town and drove around a bit and ended up at the post-office thinking someone might know English or at least they would have a map. Gesturing and Jelwyn's limited (though vastly better than my) Thai confirmed that there was boxing nearby, and we basically figured out that we had to go back the way we came, take a left, then a right. The boxing was occuring about 10 km away.

Needless to say, the directions weren't adequate. We tried to follow them anyway and came to a sengthaw station (pick-up truck buses) and their directions were a little better. Thankfully everyone in town knew about the day's event. Go back to the highway, turn left, then turn right at some point. Again, about 10km. So, we went back to the highway and stopped somewhere. There was an American (by accent) having his bike repaired.

Thankfully, he knew the area very well and was (so far as I could tell) fluent in Thai. Like everywhere we'd stopped, people were excited that we were interested in muay thai, and they showed this by lots of boxing motions. Our directions from there were sufficiently detailed:

Go a few more kms past town, turn towards Tak, take a dirt track around a washed-out bridge, then look for a sign to a village that pointed towards a dirt road on the left. If we missed it, at the next police checkpoint was another road that would get us there as well.

Of course we missed the first road -- the sign was in only Thai. We got to the checkpoint and saw two rutted tracks running in the right direction. The police saw us looking uncertain and again we made the "boxing" gesture and pointed. They confirmed, and then pointed to someone who had arrived after us indicating that he was going there too.

The bad road led quickly to the nice dirt road we had initially missed. It wound back towards the mountains. Pickup trucks full of kids were passing us as well. Shouting "?auk Thai" at them yielded excited yelling. We must be on the right track.

We went through a very pretty village with a concrete road and then back to dirt. We crested a steeep hill and were confronted with some guys in fatigues (usually at highway checkpoints they wear olive uniforms or blue police uniforms). They asked for 20 Baht each which we paid, not really knowing why. Another 10 meters and it was obvious we'd paid the entrance fee. The valley was packed, although it was a really tiny valley. The hills are steep in the mountains here. A few hundred people was enough to fill the hillside.

We parked and looked for the ring. It was under a shelter of bamboo poles with palm fronds just laid on the roof to block some (but not enough) of the sun. It was 95 today and I hadn't thought I would spend more than an hour in the sun, so hadn't put on sunscreen. The end result was very Bloodsport-esque. Sun filtering through the palm leaves through the bamboo framing onto a rusty boxing ring. It was like boxing nights at home -- lots of bouts with 10 y/o boys fighting until they get tired and then kind of quitting followed by a few older guys who really know what they are doing.

After a couple hours of that the older guys got started, and it was amazing. There was definitely a Karen/Burmese contingent in the crowd, and they went nuts for their countrymen. We were the only two white people there and were given ringside seats. I kept hearing the announcer say the Thai word for foreigner and look at us. Jelwyn didn't know what he was saying. People (including one of the referees) kept asking us if we wanted to fight. I said emphatically "no." I've heard that in the cities they really like for foreigners to fight, though I'm not sure if they enjoy seeing proof that their culture is appreciated outside of Thailand, or if they like seeing foreigners get they asses kicked. I think it's likely that they were hoping one of us (or both?) were a Jean-Claude Vandam in disguise who just happened to wander into their little town.

There didn't seem to be weight classes, and it didn't seem to matter. I saw a really scrawny guy take out a stockier opponent in about a minute with one good kick to the xyphoid process. Another quick KO was when a guy ducked to avoid a punch and ended up with an elbow to the top of his head. As I understand it you can kick someone until they are fully flat on the floor, and a couple knock-outs were as someone slipped or fell and got kneed in the head on the way down. Often they just fought until they were exhausted and one fell over. The best bout went five rounds to a decision. The winner got a cut over his eye in the second round and bled all over his opponent for the rest of the time. Not much concern for blood-borne diseases. In general though not many people got hurt. They often ended the kids fights before they could get out of hand.

It was very egalitarian as well. One guy looked to be Burmese Muslim, which is about the lowest class a person can possibly be in Thailand. His shorts were threadbare and didn't fit him -- he was struggling to keep them from falling off about as much as he was trying to fight his opponent. People cheered him just as much as they did the guys from gyms with matching jackets and nice stuff. It helped of course that he was really good.

One more thing before I end this lengthy story. I'd seen the instructors do some dance-ish stuff in the ring before but didn't think much of it. The same music played through all the fights -- off-beat drums, high pitched gongs on the main rhythm, and a screechy oboe-like instrument. In the ceremony before each fight all the fighters would walk around the ring and kneel in each corner (maybe some animism sneaking in?) and some guys would do elaborate dances towards each side of the ring before starting. Some people snickered and I think the announcer was ribbing them, but it seems to be an acceptable part of the pre-bout ceremony. Maybe a more traditional version? During the fight, the boxers movements settled into a rhythm with the music. If they stepped away from each other I could see them take a deep breathe and relax back into the swaying before stepping back in to pound each other. Really cool.

When it ended I had an uneventful ride home, drank two liters of water, slept for an hour, ate a medium pizza by myself, and am now killing time until I can justify going to bed. I'm really not fit for this climate.

Brief case presentation...

This is an interesting patient that I was lucky to see through to a diagnosis.

A few weeks ago a 6 year old girl came in breathing 60 times/minute, lethargic, and cyanotic with a heart rate of 130. History was limited. She's normally healthy and hasn't had problems according to her parent. Further physical exam demonstrated slow capillary refill, digital clubbing, and crackles in her lungs. No heart murmurs noted but she did have what I think would best be called a fierce right ventricular heave.

We treated for pneumonia with oxygen, ampicilin and gentamycin. Likely unnecessary, but she did get better. Once her respiratory rate returned ot normal a continuous "machinery-like" murmur was noted below the left clavicle. Still no cardiac murmur. We referred her to the clinic folks who have funding for fixing things like congenital heart problems in kids.

I did some reading, and her history sounded like a Tetralogy of Fallot, although on exam she lacked a harsh murmur from the pulmonary stenosis or a murmur from a septal defect. I decided it must just be a patent PDA that has lead to heart failure.

Today there was a rare visit to Mae Sot Hospital by a team of pediatric cardiologists. Normally they have to ship the kids to Chiang Mai for evaluation, but this makes it easier. The whole trip was interesting...taking a dozen refugees and their kids to a modern hospital. They looked so out of place. We took the stairs to the fifth floor either because the elevator would have been scary for them or because they didn't want to break up the group. They squatted in the hall while we waited to be seen. One kid puked on the fancy floor and I was happy to be able to say "it's not a big deal" in Burmese to the somewhat panicked mom. Another 37 y/o woman, 8 months pregnant, carried her chunky 2 year-old up all five flights, smiling the whole way. These people are tough.

They x-rayed the girl and found a classic boot-shaped heart shadow. Then an echo was done. The diagnosis was Tetralogy of Fallot. It turns out that (I think) from birth she has had a severely stenosed pulmonic valve and so most of the flow to her lungs has been through the PDA. I didn't see anything about a septal defect. The end result is no murmur other than the PDA (ie her pulmonic has too little flow to cause an appreciable noise).

So, TOF it is, although not the classic presentation. As great as Nelson's is, it lead me somewhat astray. She'll be going to Chiang Mai on the next trip to be evaluated by surgeons/interventional cardiologists. Because of the severity, I'm not sure if they'll have a great repair, but she'll have a chance.

This would have been MUCH easier if it had been diagnosed at birth. She was likely (as are most of these kids) born at home though. I may start doing newborn rounds every morning though because I'm not sure if the clinic is sensitive enough to pick up all these things. We'll see. It will likely be good for me and the kids.

New photos up on my www.andytrent.smugmug.com page! Email me for the password to locked galleries!

A visit to Umpiem

Today a friend and I returned to one of the English language education programs at Umpiem refugee camp. It's home to around 15,000 people, nestled up in the mountains. Last time I came (in 2007) I helped with a first aid course. This time it was more general health. They've had some anatomy so we talked about the locations of different GI problems that are common here and other things. We also answered lots of questions.

Umpiem really is a pretty place, it's just too bad so many people live there. The students spoke excellent English and didn't seem to have much trouble understanding as we talked about gastritis, reflux, worms etc. Some of their questions involved nutrition which was difficult because they have such limited access to meat, fruits, and veggies (ie anything but rice). One guy asked if it was okay to be vegetarian. I had to say "if you can replace meat with beans etc, it's fine. But here you should probably eat anything you can get your hands on." Most students agreed that this was the diet they plan to pursue.

An odd moment was at lunch. I was sitting with another med student and the teacher at the program at a tea shop on a hillside in the camp. It's just odd to look out and realize you are enjoying a nice lunch in a refugee camp, especially when they are playing an Aerosmith's Greatest Hits album in the shop. It's just surreal.

It all seemed to be a success and I hope to go back at some point. It was also nice to have a day where I didn't have to try and stay focused or busy. I left home around 7am and returned at 6pm and it flew by. Days at the clinic (just like any hospital when one is a student) tend to drag by.

The politics of shoes

This is just a funny thing that I've noticed. Southeast Asia footware etiquette is a bit strange to westerners, but it makes sense. Outside is dirty, and the shoes you wear there are dirty. When you come in, you take them off. If you want, you can have inside shoes that theoretically are clean, because they are just worn on clean surfaces. The same is true in the patient care areas of MTC. However, the floors are often not so clean as one would hope, so you definitely want your inside shoes.

I have a pair I bring around with me. If I'm in a department for a week, I leave them there. Sandals though are a somewhat communal commodity, and often mine (size 10.5) are often taken. No problem -- I just put on a pair of the ubiquitous pink crocs, except that these are typically size 4-5. It's kind of fun to tiptoe around in a shoe that doesn't extend past my mid-foot.

I wonder though why my sandals are often preferentially taken. I started to notice that there are some larger staff-issue crocs, and that these typically end up on the feet of the department and shift leaders. These are typically women who might measure to 4'10". The appearance is a bit comical, but I think those are spoken for and unofficially reserved. By bringing in a new pair of larger sandals, I'm giving someone the opportunity to upgrade into unspoken-for big shoes. So, the daily routine is either find the 80 pound medic flopping around in my sandals, or just wear the tiny ones until someone notices and then finds the petite healthcare provider who then bashfully kicks them off, laughing a bit, trades shoes with me then runs away.

Maybe they associate the larger shoes with the "prestige" of being a big westerner and, for better or worse, aspire to that. They definitely do look up to westerners here, and, interestingly, someone pointed out that aide efforts typically depend on how a culture views the first-world helpers. Here they (again, for good or ill) see us as superior in some ways and take the help. They are more likely to overlook the problems we bring with us. Other places (Iran, for instance) have the view that if they had been the lucky ones to have the right resources and technology at the right time, the tables would be turned. The only difference between us and them is that we were in a position to take advantage of the industrial revolution and they weren't. Needless to say, one lends itself to easy development work, the other towards antagonism and difficulty.

Or maybe I'm reading way too much into this. Either way, it makes for some funny exchanges (can't really call them conversations) at work.

In other news, I'm in the new apartment. So far so good. It's quite here and I think I'll get more work done. It's still a small town and I can find company with a quick phone call, so I don't think it will be lonely. The building is mostly Thai people, which is a bit odd for me, but will likely be a good thing. It's strange to have spent 4 months total in Thailand and feel uncomfortable around Thai people, but my work-world is strictly Burmese and my social life/living arrangements to this point have been Western/English speaking.

Photos of the apartment are up for anyone curious. It's small enough that without a wide-angle lens, it's hard to get a representative photo.

A friend and I are going to one of the refugee camps tomorrow to teach a health lesson. Not so much first aid as just general health and things they deal with a lot -- Malaria, gastritis, dysentery, parasites, skin infections. Should be fun but a lot of travel. And it's in the mountains so likely cool, which will be nice.

Moving soon!

This weekend I'll be moving to an apartment a few hundred yards from my current house. As long as things go well I'll stay there for the rest of my stay. It's a new apartment building, gated, with air conditioning and wireless internet. It's just a room with a bathroom, but it will do. It's partially furnished, but I'll still get a couple triangular pillow/mats to sit on and maybe a mini-fridge. I'm having a hard time with the fridge though because they seem really expensive, well more than a month's rent. Still, I'm only paying $95/month, so it's really not that much in the end.

I'm in pediatric outpatient this week. I'm finding outpatient clinics to be the most difficult because there's no time to think. You see a patient, give them a diagnosis, then send them out. At least when they are staying you have a chance to research things. Peds is the most like medicine at home: ear aches, bronchiolitis etc. After Loy Krathong we have seen quite a few hand injuries from fireworks.

There are some guys doing optho surgery at the clinic. I've enjoyed watching them. There are a few hundred extra people staying at the clinic waiting for their chance to have cataract or other surgery. Not sure if these kids are related to the new influx of campers, but there are about 5 kids who have been playing in a certain area all week, and their only toy seems to be a handful of rubber bands. I've seen a lot of inventive games. Today it was something like bocce-ball except the rubber bands are on the pavement and you blow them to get them to move.

Things aren't too exciting. Every day is of course radically different from life at home, but I'm not noticing it as much. I'm staying very busy and being productive, but I'm so overwhelmed on all sides that it feels like I'm not doing anything. I think I'll emerge knowing a lot more than I used to. Lately my project has been reading all the neonatology stuff that I was supposed to read on my peds rotation 18 months ago. Not exciting, but useful.

Loy Krathong

I'm away from Mae Sot this weekend to see Loy Krathong in Chiang Mai. It's celebrated everywhere, but CM is probably the most famous. The tradition varies by region. The underlying idea is sending candles representing their bad luck floating away. Most festivals float something with candle in it. Here they tend to be small rafts made of banana leaves or bread. Elsewhere it is half a coconut shell with things in it. Chiang Mai also uses large paper cylinders, closed at the top with a candle at the bottom. This is lit, the upper fills with hot air, and it floats away.

The festival is only beginning, so last night was just a taste of what is to come. We had two very different experiences. We walked along the river and ended up at a temple where several Thai families and a few groups of younger kids were floating palm leaves and sending off the candle-lanterns. Then we headed back to the Tha Pei gate where a bunch of tourists were sending up the airborne lanterns. On the walk home we saw several burned-out lanterns littering the streets, so at least the environmental impact is not too widely spread. Tonight should bring more festivities.

I talk a lot about Burma here, so I'll spend a minute on Thailand. A couple years ago there was a bloodless military coup that sent Thaksin packing. The military handed power promptly to Abhsit. The people's loyalties seem split. Some friends were living here through it all. They said that after the coup there was a definite military presence on the streets, but the soldiers were smiling happily and waving to people, likely on orders. The point is "we are in control but are going to be nice about it." Thailand is a monarchy as well. I'm not sure what the king's powers are, but the people's admiration, respect, devotion etc ensure that he's a political force to contend with regardless of constitutional powers. He's held the post for 60 years and is currently in poor health.

People fear that as his health diminishes so will his stabilizing influence. Tourism is suffering, although none of the westerner's I know here are concerned about safety. Tourism is vital to the Thai economy and everyone on both sides wants to keep from scary people away. I was looking at the web page for a dive shop in Ko Phi Phi this morning and laughed to see, " Forget about the coup -- the diving is great!" scrolling across the top of the page.

Adding to these challenges is that the Thai border with Malaysia is very violent, and Burma is a perennial problem. Tension is mounting in the Northern states and conflict is likely to resume once the rains stop. The drug trade is constant across the Thai-Burma border but has been increasing as the militias export more and more opium to finance the military operations expected to begin soon in Burma's Northern Shan state.

The result of all this is that tensions are increasing all along the border. It doesn't really effect me directly, except that my passport is now being checked at checkpoints. In the past white people were just waved through. The increased scrutiny is causing hardship for the many undocumented persons who are vital to aid operations in the area. Clinic staff are still safe at the clinic but feel like the world outside the fence is even more uncertain.

In other news, I spent last week in the reproductive health inpatient department. It's run very well. I was surprised that they perform breech deliveries (feet or butt first) with good results. They all go straight to c-section. In fact, I didn't even realize it was possible to deliver a breech vaginally. Probably safer to do it surgically, but good to see it done a few times. RH also takes care of babies up to two months, so I saw a lot of pediatrics as well. Next week is outpatient pediatrics.

I'm currently at a Wawee coffee shop in the Nimmonhein part of CM. It's very much like a modern US city except for the language spoken. Even demographically it's about 80% Thai, 20% westerner in here, which could easily be found at home. Next door though is a sign announcing a new Tea, Cake, and Fish Spa. The tea and cake I understand. There are pictures explaining the Fish Spa part. Apparently it is advantageous to be in a tub full of small fish that like to nibble on you. I've experienced that feeling while swimming in lakes at home but never thought it was that enjoyable or beneficial.