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!

DeAnna Friedman Arrives at Chiang Mai University

The following was submitted by DeAnna Friedman, 3rd-year pediatric resident:

Hi everyone!

Made it to Chiang Mai safe and sound. I'm staying in a hostel right now, but I have more permanent accommodations starting on Saturday. Everything is new and different, and I've been finding my way around. I've never been in a place where so few people speak English before - wait, that's not true - I've never been ALONE in a place where so few people speak English before (I've traveled through Central America plenty, but I usually have a Spanish-speaking friend with me). I'm getting by with some pantomiming and brand names and such, though.

I've already had the chance to take lots of great pictures, which I'm posting on a public gallery. There are all kinds of old beautiful buildings here in Chiang Mai. I'm still trying to learn what everything is (again with the not-a-lot-of-English thing, I can't just ask people). I hope I haven't made any missteps as of yet with my picture taking - again, still learning.

I started work at the hospital today. Everyone here is very nice and very accommodating. They helped me find a place to stay from Saturday on, and showed me around the campus. I attended wards rounds, and they were nice enough to do them in English for me for today. I am to be paired with an ID fellow starting on Monday, but he's out of town right now, so they paired me with a neurology fellow doing general pediatrics wards rounds with one of the resident teams that speaks English well. The residents were a little nervous about doing rounds in English, I think, but it all worked well.

Photo of the outside of the Faculty of Medicine at Chiang Mai

Outside another of the Faculty of Medicine buildings at Chiang Mai University

I saw several children with issues similar to what we have back in the U.S.: a 15 month old with medulloblastoma with an infected extraventricular device, on meropenem and colistin and still spiking fevers; a 7 month old, ex-28 week premie who came in with hematemesis and was found to have esophageal varices and portal vein thrombosis, likely from his UVC at birth; a 15 y/o with a suspected brain abscess, although it seems to not be improving well on cefotaxime.

We ended with a girl with high-risk ALL who's relapsing while on her induction therapy. This child would have been on the BMT consult list back home.

Overall, things here are similar to the setup back home. CTs, CSF studies and cultures, phenotyping for the ALL, and meropenem are available. We have morning report or other conference first thing (8:30-9:30), then wards rounds until noonish, then an afternoon conference for teaching. It should be an interesting 2 weeks!

DeAnna