Different, and yet the same...

The following was written by DeAnna Friedman, 3rd year pediatric resident

So, I arrived in Cambodia about a week ago. The overland travel was hot and somewhat uncomfortable at times - glad to have it behind me. The first thing I noticed is that it is more like Africa than Thailand here - there's a lot more impromptu marketing on the street ("lady want a tuk-tuk?", "lady want massage?", "okay, you buy one thing", "please look inside"), etc. 

It's also been interesting to me that because it's a different language, it's a different accent, the misunderstandings that were improving are back to square one. 

The hospital here is much smaller, mostly since it is solely a children's hospital. They also do much more of the care as outpatient care, which is nice for families to be able to seek. The 6-7 doctors in outpatient on any given day see 400-500 patients. There is an area with room for maybe 5-10 children where they can receive ORS if they are mildly dehydrated and be sent home from outpatient if they improve with this.

The ICU also doubles as the ER and has approximately 10 beds. The inpatient ward has 30 beds.  There's also a surgical wing that has 10 beds. There's one operating theatre and one minor procedure room. There's also a separate building for eye surgery and ophthalmology consultations. 

There are many residents here, and this is one of very few official training programs with a longitudinal curriculum in the whole of Cambodia. We have 2 seniors and 2-3 interns on in the inpatient department, and there are 2 seniors and 2 interns on at any time in the ICU as well (I believe - they rotate taking days off, so sometimes it's hard to keep track of who is where and how many people there are). 

One large contrast from Chiang Mai is the availability of resources. The laboratory tests that we can order are ordered off of 1 of 3 pages, where there is space for the results and normal value ranges as well. They do have a good number of drugs, including imipenem, which is good. We can also get x-rays, ultrasounds, and echos for imaging. Many times, though, children become ill and we cannot figure out why. They get treated empirically, and while most survive, some don't (although the death rate here is much lower than it was where I worked in Uganda - so that is where Cambodia is more like Thailand). 

Many more children have a component of malnutrition, and a child was lost the other day, likely to complications of kwashiorkor. While the hospital has echos, heart surgery is only available to fix the congenital heart lesions when a team comes from the U.S. or Singapore. Also, because the surgeons are here only briefly, they all do simple surgeries so that they can fix as many children as possible.

There is a patient in the ward right now with an AV canal that is "unrepairable." There's also no chemotherapy yet, but the doctors here are working with some doctors from St. Jude to write protocols, and they should have simple regimens for chemotherapy by the end of the year. 

The residents have been very nice and very helpful, and we're already rounding on and writing notes on several children per day, which is great. It has been very interesting to me to see some of the more classic diseases that occur here.

We are starting to see dengue hemorrhagic fever and dengue shock syndrome; they tell us that it is early for this, and they worry that this year may be a bad year for it. They can diagnose it with very few clues in the outpatient department, and then as the next day or two passes, it becomes very clearly DHF/DSS. These children need boatloads of fluids to survive because of the plasma leakage that occurs, and I saw one who had a fairly uneventful course but received probably 2-3 L of fluid over the first 12 hours of admission. He really looked well the whole time, but could have really done poorly without the fluids we poured in to him.


The patient had a very classically positive tourniquet sign

So far so good - although I'm really starting to miss having a kitchen! 

DeAnna

Vislisel Arrives in Cambodia

The following was submitted by Amy Vislisel, 3rd year pediatric resident.

The front gate at Angkor Hospital For Children

I arrived in Cambodia on April 2 to start my elective month at Angkor Hospital for Children (AHC), and the first week seems like it has already flown by. After an interesting day of travel (delayed flights, lost luggage, etc.), I was able to explore the town and get acclimated to the heat before starting my first day at AHC. We had orientation to the hospital on Monday morning and shadowed in the inpatient unit during the afternoon. The following day, however, we were able to jump in and start seeing patients.

I based myself in the inpatient unit (IPD) and picked up several patients. My first patient turned out to be quite rewarding. He was 13 months old, and had initially been admitted with multiple skin abscesses that grew out pseudomonas. He then developed septic arthritis of his right knee. He was taken to the OR and had his joint cleaned out.

Despite appropriate antibiotics, he continued to be febrile and had a painful right knee. Through discussion with the staff, I recommended obtaining an x-ray of his right knee/femur to evaluate for osteoarthritis. They agreed, and this was read as osteomyelitis of his right femur. He was taken back to the OR the following day, where he wasn't found to have osteo, but septic arthritis (again). After his joint was washed out, he has been a febrile and hopefully will be switched to oral antibiotics soon and discharged home. What has been frustrating about the patient, however, is our inability to really evaluate why he has pseudomonas abscesses, as the studies needed for work up of immunodeficiency aren't available.

My second patient illustrated how difficult treating severe malnutrition can be. She was a 1 year old female with kwashiorkor and had been admitted more than 1 month ago. Despite proper treatment, she passed away during the middle of the week.



In the upcoming weeks, I will be able to spend time in the low acuity unit, the outpatient department (which functions much like an urgent care clinic and sees on average of 500 patients a day!), and the ICU. I will hopefully also be able to accompany staff on a home visit as well.

Outside of work, DeAnna Friedman (also here for a month) and myself have had an incredible time exploring Siem Reap. There are wonderful (and inexpensive) restaurants, great nightlife, and interesting markets. I am looking forward to exploring Angkor Wat in the upcoming weeks!

I had the chance to visit Tonle Sap Lake, the largest lake in Cambodia and known for its floating villages. There are over 100 villages on the lake with tens of thousands of inhabitants. Above is a typical house and shop on the lake.

Floating house with its inhabitants.

The group of sticks seen in the background are used to anchor the oases during bad weather.

You could find children everywhere carrying water along the shore of the lake.

We also had the chance to visit a pagoda, which had lots of interesting architecture and art. The Khmer New Year is coming up soon, and many Cambodians are going to the pagoda to receive blessings from monks.

Typical market in Siem Reap

The One About Kites

The following was submitted by Ben Trappey, fourth-year Medicine-Pediatric resident.

A mural on the side of one of the orphanage walls, which are made nearly entirely of metal shipping containers

Having other people here has given me the opportunity to get away from the hospital a bit during the day. Thursday afternoon, I got the chance to tour the school and orphanage that are down the street from St. Damien and are also funded by Nos Petits Freres et Soeurs (NPH).

Both were set up after the earthquake and have been growing since. From what I've been told, the school was initially set up to establish some sense of normalcy for the many children who had taken refuge in and around St. Damien. At first it was merely a collection of tents out in a field where teachers would teach to children sitting in folding chairs or on the ground. It has since grown into a collection of concrete buildings where 800 first through sixth graders go to school every day.


 
The school courtyard

 
Inside one of the school rooms

The majority of the children live with their families in the area surrounding St. Damien and walk to school every day. However, 130 children live in the orphanage that is connected to the school. It, too, was established in the aftermath of the earthquake. It's clear when you look around that its inception was of pure necessity, as the organization was inundated with orphaned children.

The orphanage is made almost entirely of metal shipping containers, which serve as both its walls and the dormitories for the children. Initially, there was very little ventilation and few comforts other than a safe place to sleep. Now the containers are surprisingly comfortable and spotlessly clean. Ventilation slats have been cut into their sides, allowing the constant breeze with which Haiti is blessed to blow through. Toys are neatly arranged in and on top of a chest near the door to each container. Vibrant murals painted by local artists have replaced the industrial motif that originally covered the makeshift walls.

 
More of the murals that decorate the walls of the orphanage residence and school

Not all of the children who live there are truly orphaned. In Haiti, if a caregiver is unable to feed her children, it is not unusual for her to seek out an orphanage that will take on one or more of her children. Some mothers simply must abandon a child at a hospital or an orphanage.

A young Haitian man with whom I've been working closely every day was the third of five children. When he was nine years old, his father left and his mother was unable to provide for all five of them. She found a woman from Detroit who ran an orphanage for Haitian boys that agreed to take him in. He lived there until he was 20 years old. His mother, brothers and sisters would visit a few times per month.

He admitted that he felt quite abandoned at first and would cling to his mother every time her visit would end, and that he cried every night for the first year. However, he now realizes that his mother giving him up gave him the opportunity to go to school, to learn English and to have the job that he has today. He now pays for his mother's medical bills and for his sister to go to school. He is the sort of success story that drives the voluntary orphaning of these children.

St. Damien/NPH does not take part in this custom, at least not voluntarily. However, it still happens, occasionally, that a parent in Urgence will ask another to watch a child while she uses the restroom and then never come back. These children end up in the Abandoned Boys or Abandoned Girls rooms upstairs in the hospital, and, eventually, in one of NPH's orphanages.

When I visited, it was clear to me that the orphanage has developed into a place of stability and refuge for these children who have lost so much, due to death, poverty, or both, at such an early age. Despite all that they have seen and all that they have lost (and the chicken pox outbreak spreading around last week), they come across as surprisingly happy (even when covered in calamine lotion).

 
These girls have calamine lotion on their skin due to last week's chicken pox outbreak

 
A boy in the play area of the courtyard

We came through for our tour in the early evening after school was out. In one corner, a group of boys was playing soccer with an under-inflated ball. They were using a bench as their goal. The smallest of them was making impressive saves, apparently unconcerned that he was diving onto concrete. In another corner, a mass of children was absolutely rapt by the television, which was playing Lady and the Tramp.

These children are rapt by Lady and the Tramp, which is playing on the TV in the corner

However, it was a windy afternoon, and the most fun to be had seemed to be in the construction and flying of kites. The boys were making them out of plastic shopping bags, sticks that they found on the ground, and strips of plastic for tails. They were using string like we in the U.S. might use to tether balloons and would wind it around short sticks, which were used as handles.

Talking kites

Posing with their kite

To say that these boys were adept at flying these kites would be a vast understatement. They were infinitely better at flying these handmade kites than I ever was at flying the kind you buy in a store. They were able to keep them aloft without actually looking at them, giving subtle and seemingly unconscious flicks of the wrist to keep the string taut, while simultaneously helping their friends make new kites or posing for pictures. When their concentration was fully focused on their flying, they had incredible control using the kites to dogfight against each other, attempting to cut the strings or break the frames of their friends' kites.

After 3 weeks in Haiti, it was nice to be able to see some healthy, happy children. To be able to realize that there is more than just suffering here. And to recognize the absolute resilience of these children who have lost so much but are still children. Still able to find joy in each other. And in the flying of kites.

Shapiro In Bugobero

The following was written by Miriam Shapiro, 3rd year pediatric resident at University of Minnesota.



The rains have started here in eastern Uganda. The storms can be brief and, despite the significant amount of rain that comes down, the red dirt soaks it up in little time, leaving just a hint that it was here at all - the scent of dampness, a few puddles, a bit less dirt kicked up on the roads as we drive.

I am working at a rural health center in a village called Bugobero. It is about a 45-minute drive along these red dirt roads from Mbale, the largest city in the area. My primary task here is a clinical investigation of a syndrome of malaria, severe anemia and hematuria.

Though both severe anemia and hematuria are known complications of malaria, they were being seen at an increased frequency and with increased mortality in January and February of this year.

The health center in Bugobero is unique because it was adopted by an American health care NGO, which has partnered with the government to improve care delivery. Because of the extra funds provided through the NGO, the clinic is able to hire more staff and have a more reliable and wider supply of medications. The community has responded to the increase in services with a huge increase in patient visits.

The health center includes adult and pediatric inpatient wards, a
maternity ward, an operating theater and a steady stream of outpatients
seen daily on a first-come, first-served basis. It is now drawing
patients from all around the vicinity.

The health center has one doctor, who spends most of his time working on surgical cases, and is otherwise staffed by clinical officers, midwives, nurses and nursing assistants.

There is a laboratory here, which can do rapid HIV tests, thick blood smears for malaria, urine microscopy and urine dip stick. Usually they can do hemoglobin estimates, but of late have run out of the slides required to run the test. This limitation has required that I rely more heavily on history and physical exam findings than ever before. It also means there are several children here whose diseases fall outside the ability of the health center to diagnose or treat, even if they were diagnosed properly.

Our primary role here has been the malaria investigation, though we also see patients on the pediatric ward and outpatients, as time allows. Though the numbers of patients are not huge, the investigation is taking much of our time because, in addition to taking histories from the patients' parents and doing physical exams, we also draw the blood samples and prepare the thin smear slides. We also must leave from Bugobero early enough each day to deliver the samples to the research laboratory and have them run prior to its closing time. Because we are relying on an outside laboratory, we rarely get results back in time for them to be relevant to clinical care.

It is a stark contrast to the help we get in the hospitals in the U.S. - write an order and (usually) our work is done. Here, we rely heavily on the nurses and nursing assistants for aid in translation. Few of the villagers speak enough English to get through the detailed interview, and medical records as we know them do not exist. Each patient has a small notebook that is usually purchased upon arrival to the clinic, though occasionally is brought from home with information from previous clinic/hospital visits. When we are lucky, we can read about half of what is written in the notebook; generally the amount of clinical documentation is minimal.

Occasionally we are asked to see a child who is particularly sick. Last week, it was a 6 year-old boy with pneumonia who presented in severe respiratory distress. By the time we were called, they had already put him on supplemental oxygen via the one concentrator available. Despite the oxygen, he remained tachypneic and in significant distress, with an O2 saturation in the mid-80s. He was given a dose of ceftriaxone, which is sometimes present in small supply, and given fluids. The oxygen concentrator was then required in the operating theater, so he was taken off oxygen.

Given his persistent distress, the decision was made to transfer the child to the district hospital in Mbale, where hopefully more resources would be available. We made the 45-minute drive with him in the backseat, off oxygen; by the time we reached Mbale, his saturation was down to 59%. He was admitted in Mbale, placed on oxygen (delivered by an intranasal catheter, which was not very effective; at least at first, his O2 sat had only increased a small amount).

When we checked on him again later, it turned out that the hospital was out of the drugs that they had prescribed for him, so he wasn't actually getting them. We went to the pharmacy, purchased more ceftriaxone and paracetamol and brought it back. While we were there, the power went out, which meant that the oxygen also went off. In the end, this child was not getting much more at the district hospital than he was at the health center. Despite it all, he steadily improved, and a couple days later was asking for chapattis.

Sometimes these stories end well.

Miriam Shapiro poses with some children at the health center in Bugobero.

This Too Shall Pass

The following was written by Ben Trappey, MD, fourth-year medicine pediatric resident.

Last week was tough. It seemed that death was everywhere. And I was all alone. Nearly every afternoon last week, after the Haitian doctor who works the day shift in Urgence, as well as several of the nurses, had gone home, and I was preparing to end my day, someone--a father, an aunt, a grandmother--would hurry in carrying an infant wrapped in a towel. I've learned to fear the sight of a small bundle wrapped in a towel.

It seems that most women in Haiti give birth at home. I suppose the majority of these home-births go well and the babies do fine.

I don't get to see those babies.

In Haiti, it's not easy to get anywhere quickly, and most people don't own cars. So when something goes wrong with a birth at home--the baby too small, too weak to cry--these family members make their ways to St. Damien however they can: on the back of a motorcycle or in the back of a tap-tap (the garishly-painted vans and pickup-trucks with seats in the back; the Haitian equivalent of a bus), holding their bundles wrapped loosely in towels, moving as fast as Haiti will allow.

But it's rarely fast enough.

The Haitian tap-tap

Last week, when I would look into the towel, I would invariably find a dead or near-dead infant--cold and cyanotic. Usually premature. All born hours earlier. If they had a heartbeat, I would give them artificial breaths and try to warm them up to see if they would start breathing on their own. Unfortunately, none of them did. Every day last week ended the same way. Any victories, any "saves" made throughout the day, any feeling of accomplishment over a child helped were wiped out at the end of the day by the crushing sense of hopelessness as I tried (despite being aware of the futility) to save those babies who had been so cold and so blue for so long.

This week has been much better.

A group of two residents and two attendings from the Children's Hospital of the King's Daughters in Virginia arrived on Sunday, and at least two of them have been in Urgence with me at all times this week. Fewer of these infants have come in this week, but we've had our share of very sick children, several of whom have died. Still, it has been different with extra people here. Extra hands to help with procedures. Other minds to discuss treatment options. Other souls to share in the joy of the victories and the grief of the failures.

Yesterday, an 8-month-old came in with severe respiratory distress, to the point of being unresponsive. Less than 5 minutes later, a mother brought in a 9-day-old infant who was also unresponsive, hypothermic, incredibly pale, and had been transferred from another hospital because he had been bleeding out of his umbilical cord stump for 2 days.

Luckily, we had enough people available for one to be able to stand there for 30 minutes and give the 6-month-old continuous breathing treatments, to which she, thankfully, responded, another to hold pressure on the umbilical cord and warm the baby, and another to run the 9-day-old's blood to the lab and insist that they check the hemoglobin and blood type immediately. The hemoglobin was 3.5. (Hemoglobin in a child that age should be somewhere around 12 or 13, and back home we typically transfuse before anyone gets much below 7.) We were able to transfuse her within 30 minutes of her coming through the door, and she quickly woke up and started crying.

Today, both children were alive and well. I have little doubt that if there were not so many of us there, at least one of those children would have died. So, those were saves. Victories. I'll enjoy them while I can.

Friedman: On To the Next Adventure

The following was submitted by DeAnna Friedman, 3rd year pediatrics resident.

Got behind on my blogging because I was trying to cram as much as possible into my last few days in Chiang Mai!

Monday was great - we saw some patients in clinic again, and then made rounds. There was a patient who had SLE and got zoster, and then it progressed to SJS and then TEN. 

While there is not a separate burn unit here, they were doing some interesting things. For instance, while this was not my patient, my attending showed me how sterilized banana leaves are used for patients to lay on because it does not stick to exposed skin. It looked like it worked well. (Photo used with family's informed consent.)

We also got a consult in the afternoon about a child in the surgery ward who had schizencephaly and was admitted for VP shunt placement. Shortly after admission and before surgery, the nurses noticed some new skin lesions that ended up being varicella. This child was in an open ward, unfortunately, so nine other children were possibly exposed. Only two had a history of varicella infection, and none of the rest were vaccinated.

The vaccine is not a part of the free vaccine program through the government and costs about $30, which is prohibitively expensive for most families. The good part is that, since they were exposed in the hospital, those who can receive the vaccine will get it for free. Two of the patients were only three months old though, so hopefully they do not contract it.

Most of the original patient's lesions were healing, but I did get a picture of one of the feet with a few good lesions.

Today, my attending took us all out for lunch, which was very nice. Here's a picture of the people I worked with here in Chiang Mai. She told me that I should come back sometime - very tempting!!

Tomorrow I leave for Siam Reap, where Amy Schminke will be joining me, and we will be working for 4 weeks. So, on to the next adventure!

Friedman Continues Experience at Chiang Mai

The following was submitted by DeAnna Friedman, third year pediatric resident.

Today, I spent the morning in the outpatient Pediatric Infectious Diseases Clinic. We saw many children with HIV, some doing well and some not. One 17-year-old boy had a falling CD4 count and a rising viral load, so was stopped from his ARVs months ago.

They did resistance testing and found that he is resistant to all NNRTI's as well as 3TC (which was part of his initial regimen). Before starting him on a second line, they were trying to get him to commit to being adherent, and he kept stating that he was not ready yet.  His CD4 count is now down to 6%, so the doctor that I'm working with stated that she hopes that he will buy in soon before he gets a bad opportunistic infection.  I would have to agree.  

One interesting appointment was the first one of the day. It was a girl who presented because she was exposed to TB. Her skin test at the last visit was 20 mm induration, so she was started on INH. She was having some nausea and vomiting with the medication sometimes, and my attending stated that her dose was high for her age because she was above her ideal body weight.  The parents wanted to know how to get her to lose weight. We then spent about 10-15 minutes counseling on healthy eating and lifestyle habits.  Very much like an appointment back in the US.  

We also saw an HIV-exposed infant who was HIV DNA PCR negative at 1 month of age. She will get a repeat at 4 months and then antibody testing at 18 months to confirm that she is negative. Also, very much like the US. The government has really done a good job of committing important resources where they need to, even if they are more expensive tests/therapies.  

On the inpatient side, we saw an interesting case of endocarditis from S. aureus who presented with longstanding fever and inability to walk due to painful nodules on her feet (Osler's nodes). Her ESR and CRP were now normal (after 6 weeks of therapy), so she was being discharged home and will follow up with cardiology in a month.

That was just a smattering of the cases I saw today that I thought you guys might find interesting. I haven't had any opportunities to take good pictures of any visible pathology yet, but I'll keep you updated.

I had this past weekend off, which was much needed given all of
the traveling earlier in the week. Plus, the place where I was staying
at first only had a room available until the weekend, so I had to move
to another hotel (it's okay, this one's much nicer). That ate up most of
my Saturday.  




On Sunday, I took a cooking class (highly recommend if you ever find
yourself in Chiang Mai)...


...and then went to the Sunday night market (also a
fascinating cultural experience).

I hope you are all enjoying what I hear is very beautiful weather in Minnesota for this time of year!