Friedman's Final Week In Cambodia

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

Our last day at AHC has passed. We helped out on the Low Acuity Unit this week because a lot of the senior doctors were in a training about pediatric critical care that was being provided by some doctors from Australia. The LAU has a bit slower pace, as there are only 10 beds and 3-4 of those children are usually chronic kiddos getting either physical or nutritional rehabilitation.

One of my patients has been in the hospital for almost 2 months because he had encephalitis and now has left hemiplegia. He is improving with physical therapy and now is able to take more food by mouth (he initially had a pretty significant right lower facial nerve palsy along with his hemiplegia), but his progress is slow and steady. We don't know what caused his meningoencephalitis, as is often the case here. No bacteria ever grew in the CSF culture, and we don't have many viral studies available. His mother has been VERY good with him, learning the PT exercises, feeding him slowly and patiently, and always with a big smile on her face. She's easy to laugh and very talkative.

He has a little brother who looks to be about 6-8 months old (it's hard to know here; children range in size very widely) who is often bored while his mother is working with his older brother, so yesterday I just played with him for about half an hour while his mother was taking care of other things. She thought it was hilarious. It's amazing how happy and upbeat people can be in the face of adversity, which is a common thread I've found in all of the places I've worked internationally.

We rarely see a normal CBC here, between the iron deficiency, the malnutrition, the dengue hemorrhagic fever, the leukemias we can't treat, and the high rate of thalassemia. However, many of the children do not have clinical features or need transfusions, indicating that they likely are either nutritional or thalassemia trait (the test for thalassemia takes about 2 months to get back unless they have obvious Hgb H bodies on their smear, so we won't know for sure about many of the children we tested during our month here).

This child had clear signs of beta-thalassemia disease while in LAU this week. Here is a picture of his chest from the side.

The chest x-ray of the child with beta-thalassemia.

He has so much extramedullary erythropoiesis, and his ribs are so large, that he appears barrel chested from his large ribs. He clearly has not had good preventive care for his thalassemia. However, chelation therapy is not available here, so you trade less extramedullary erythropoiesis for increased risk of iron overload. It is a difficult balance here. This child also presented to the hospital by himself. He is 16. The social worker stopped by to talk to him, but it is not clear to me what his home situation is. He may have just come alone because his parents are busy working, but it is still a harsh reality that some of these children travel to AHC to get care alone and stay in the hospital without any family support.

We went around and said goodbye to everyone, and everyone was so nice. They all said that they would love to see us again, or asked when we were coming back. I'm not sure if it will be in the cards or not, but this place is always growing and developing, and it may be interesting to come back someday and see how it's changed.

AHC is currently building a neonatal area for the premature babies that they care for.

While there currently is no TPN, surfactant, or oscillators (so the VLBW babies likely won't make it), they can care for the later preterm babies that just need warmers, antibiotics, close monitoring and NG feeds. And with the sectioned-off area, hopefully the rates of nosocomial infections will decrease in these little ones.

And the hospital staff are looking for ways to improve. It is nice to work in a place that is making the best of what they have, moving forward and learning how to improve as they go. While I won't miss the constant barrage of people wanting to sell me things, I will miss how much less complicated life is here and the feeling that, while you may not be able to give these children everything that is available back in the U.S., you're giving them the best shot they have in Cambodia and how thankful the families are for that.

Could We Be Doing More?

_The following was written by DeAnna Friedman, third-year pediatrics resident_

Last week was definitely a week of presumed clinical diagnoses and unanswered questions. As I have said in previous posts, much of the testing we have here centers around a CBC with diff, a CMP, and cultures. There are a few other tests here and there, but on the whole, we often must make presumptive clinical diagnoses without having the tests to prove us right or wrong.

There was a child who died at the end of last week due to fulminant hepatic failure leading to bleeding complications and brain death. His hepatitis B and C tests were negative, so everyone presumed that hepatitis A had been the cause of his liver failure. However, his AST never rose above 780. He had a high bilirubin and a very high INR (>6), and then developed a high PTT, followed by kidney failure, then possible intracranial hemorrhage and brain death. Drug levels, a liver biopsy, more FFP, more options for helping his hyperammonemia (which I'm sure he had, even though we weren't able to test for it), may have helped us to save this child. But I really can't be sure. A liver transplant may have been his only hope, and there is no transplantation in Cambodia.

Another child I cared for was brought in with a knee abscess and fever. He also had thrombocytopenia. Given how well he appeared and his lack of schistocytes on blood smear (and the sheer number of dengue cases we've been seeing), it was presumed that he had a knee abscess with concurrent dengue hemorrhagic fever, as opposed to DIC. However, he also had Trisomy 21, and when I saw him the next morning, I was concerned that he may have ALL. Luckily, there's a hematology-oncology specialist here from New York right now who was kind enough to take the time to look with me for blasts on the smear. We found one, which could be a sign of early ALL, could be transient myeloproliferative syndrome, or could be normal. I hope for his sake that it's one of the last two, as AHC will not have chemo up and running until later this year. It will be hard to follow him closely, as many of the patients don't have the means to come to AHC on a regular basis.

I also saw at least 3 children between last week and today who had a congenital cardiac lesion (PDA, PS, or VSD) and congenital cataracts. Given the immunizations that are provided for the patients and that only a portion of the children receive them, I suspect that they are likely congenital rubella syndrome. I think they are being selected for as there was a PDA surgery day this past week and there is a team of cardiothoracic surgeons coming next week to do open heart surgeries. But, it is alarming to me that I saw 3 in the span of a week. These children could have been otherwise completely healthy if their mothers had received the MMR vaccine when they were younger. However, now they are likely going to be blind, possibly deaf, and may have problems with heart failure if they don't get fixed when the heart surgery team is here (who is only about to do about 15 cases per trip).

Some of these problems are easily fixable; MMR vaccine is not so expensive, and the freeze-dried version doesn't even require a cold chain (it only has to be refrigerated after reconstitution). With a little funding, it would be easy to have a nationwide campaign for catchup and education. Some problems are not as fixable. AHC is working on opening clinics in more provinces so that children can get care closer to home, but this requires doctors who are willing to live in these provinces and money to set up the clinics and their infrastructure. A liver transplantation program for Cambodia is something that, at the moment, seems nearly impossible--given the infrastructure that would be required--and very impractical, given how many other inexpensive interventions are still needed here. I can't help but wonder at times if we could be doing more for these patients...

DeAnna

Vislisel's Third Week At AHC

The following was submitted by Amy Vislisel, third-year Pediatrics resident.

I have finished my third week at AHC and continue to see a variety of interesting things. My time this past week was mostly spent within the inpatient department.

I admitted a young infant whose chief complaint was rash and fever. The child had been sent to AHC due to concern for a 'drug eruption'. Immediately when I saw the child being brought into the ward by his mother, I knew there was more to the story. The infant was 6 months old and slightly puffy. He had severe dermatitis with numerous raw and macerated areas. On further history, we found out that the mother only fed him 'ALASKA' milk. It was difficult for the staff to explain exactly what this was to me (they didn't know the English words), but it turns out to be a type of condensed milk, which offers poor nutrition for infants. We diagnosed the child with dermatitis from vitamin deficiency (likely zinc) as well as kwashiorkor. His rash has been slow to improve, but he is otherwise doing well clinically.

Six month old child with dermatitis from vitamin deficiency. He also had slight edema
and was diagnosed with mild kwashiorkor.

Another picture of dermatitis from zinc deficiency. We gave him oral zinc supplementation,
as well as zinc oxide ointment (the white cream on his skin).

As volunteering residents, we have the opportunity to attend ICU rounds every afternoon. This has been an interesting and worthwhile experience. It is in this ward that we usually see the most interesting and difficult cases, and it is here that the differences in the diagnostic and treatment capabilities between Cambodia and the U.S. are most evident.

There is currently a 10-year-old male with acute fulminant hepatitis who is doing poorly. The ICU staff have done all the testing that is available (hepatitis B and C), and both have been negative. The history of the illness is also not helpful in elucidating a possible diagnosis, and so by exclusion, the child has been diagnosed with hepatitis A.

It is frustrating to be involved in this case, because there are so many more options at home for diagnosis (liver biopsy, toxin testing, different viral testing, and liver specialist consultation), as well as the possibility for liver transplant.

The ICU also admitted a 28-week premature infant this week. Fortunately, this child has done remarkably well and has not required intubation. This is a good thing, because the hospital does not have endotracheal tubes small enough for this child.

The hospital staff on a regular basis discusses what to do if this child were to need intubation, and due to the overwhelming odds this patient faces (no TPN, surfactant, or premature formula), they will likely need to withdraw care. The hospital is working on the development of an NICU, and so it will be interesting to see in the upcoming years how the capability for caring for these infants will change.

DeAnna and I have had more time to explore Siem Reap and the temples, and will be taking a cooking class this weekend to learn how to make fish amok (a popular Cambodian dish). We have one week left at the hospital...the time has gone so fast!

Front entrance to AHC. This is the waiting area for the outpatient department (OPD), and
also serves as a place for families to sleep if they live a far distance away and are unable to travel

home at the end of the day.

One of the many side entrances to Bayon, definitely one of

the most impressive temples we have visited.


Carvings at Bayon, within Angkor Thom. There are 216 of these carved faces within the temple!

Happy Khmer New Year

Hello everyone!  We just finished a long weekend because April 13 was the Khmer New Year.  Amy Vislisel and I helped out at the hospital on the holiday itself because they were with holiday staffing, so took today off. 

This week was really busy. On Monday and Tuesday, I worked in the outpatient department. 

Our first visit was a four-month-old baby with constipation and URI symptoms. The resident asked about any traditional medications the mother was taking, and she was indeed taking some herbs to help her milk supply. The resident told me that many of the mothers do that, and that it often causes constipation in the infants, for which they prescribe the mothers metaclopramide, because they don't think that the mothers will stop taking the herbal remedy unless they are given something else to take instead.

Many of the children over the age of 1 get a one time dose of mebendazole when they come to clinic because of the high rate of parasites here. Many of the schools have anti-parasite programs, though, so before giving it, the residents ask whether the child goes to school. 

A stool study is currently being conducted that is going to send the stools to a more sophisticated lab to do more sensitive testing and some resistance testing.  There's some thought that single-dose mebendazole is selecting for parasites that don't respond to this treatment, or are now resistant.

I saw another child in clinic who was nine months old and had hypochromic, microcytic anemia. They suspected thalassemia, given the pattern on the CBC, so sent testing. I understand that it can take up to two months to get the results back, which seems like a long time when there is so much anemia.  

On Tuesday, we had an interesting dilemma. One of the girls who was back for follow up after a stool sample had a stool that was positive for hookworm and Strongyloides. However, she also had an ALT of 1,025. They're still working out why she has hepatitis, but they decided to treat the hookworm alone because of the side effect profile of the drugs that are available to treat Strongyloides. It also seemed interesting to me that a disease that is more prevalent in areas that have a higher incidence of hepatitis is usually treated with a drug that can cause hepatotoxicity.  

We also saw a set of brothers who were in for cough and fever. It sounded mostly like a URI, although one had a history of asthma. The other boy had marks all over his chest and back from coining, one of the traditional healing practices. For those of you who aren't familiar, oil is applied, and a coin is scraped in a pattern along the back and chest. I asked one of my older patients back in the US about it once, and he said that it felt "warm and nice," even though it looks like it would hurt. I thought it was interesting that the boy who had a history of asthma had the same symptoms but hadn't had the coining done.


Here's a picture of coining, a traditional healing practice


A wheelchair that was in the hallway outside the Low Acuity Unit

On Thursday, we went on a home visit with the Home Care Program. The Home Care Program makes home visits for at-risk patients who need close follow up.  The staff we traveled with told us that 70% of these patients are HIV-positive. The visits are helpful because staff can get an idea of what other supplies they need to keep the children healthy. 

There also used to be a lot of stigma associated with HIV, so many of the families found it very hard to work or find transportation to clinic visits. The Home Care Program visits them once a month, and then the children need to come to clinic for a medical check-up once every two months. They count the pills, talk with the parents about any challenges they have, and bring them a bag of food for some supplies.

One of the families we saw had a house with a thatched roof and some wooden sides.  They want to build a better house, but can't afford to pay the $200 that it will cost to do so.  The Home Care Program will go back and ask donors for help.  

On Friday, we went around helping out where we could. We rounded in the Low Acuity Unit (kids getting rehab or parents getting education in preparation to take the kids home), then helped in the ED.  

This past weekend, we went all around Siem Reap. We saw Angkor Wat on Saturday, then went on a bike ride in the countryside on Sunday, then went over to Angkor Thom today. It was all very awe-inspiring.  Here are a few pics for your enjoyment!


Looking up at the central temple at Angkor Wat

A monk studying Apsara


Biking through the Cambodian countryside


Bayon in Angkor Thom. There are 216 of these faces carved throughout this temple structure.

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