Mahidol University and the Grand Palace

It felt familiar this morning when I staggered out of bed onto the street in my scrubs and ate breakfast on the run. Adam, Angela, Courtney, India and I rode the skytrain to meet Dr. Ferguson on our way to the local teaching hospital. At the hospital, we met up with faculty of their emergency department and were able to chat with medical students and emergency medicine residents of the university, see their facilities and learn about how their department operates.

Patients are triaged based on vital signs and chief complaint into one of three acuity levels. We were told that the lowest acuity patients will wait about 2 hours to be seen in Bangkok. All patients are seen, regardless of their ability to pay, however patients are sometimes transferred after stabilization if they hold insurance with another hospital.

We were shown to the resuscitation bay, were we were amused to see a resident caring for a patient by holding a paper bag over the patient’s face (he was having hypocalcemic tetany exacerbated by hyperventilation). The resuscitation bay had a wall with all of the incubation gear laid out on hangers. Each patient care room had a statue of the Buddha. Adam learned the hard way not disrespect the Buddha by pointing a finger at the Buddha statues.

Throughout our tour of the facilities, we had an engaging discussion with faculty about the differences between our respective hospitals. This included systems issues like overcrowding and admission hold overs, as well as specific disease management issues, such as stroke treatment and tropical diseases. It was interesting to hear that physicians radio orders to the ambulance en route to the hospital in contrast to the more protocol driven system independent of physicians at home. Also, overcrowding in the Thailand ED was addressed through the use of an intermediate holding area between the emergency department and the ward floor.

Resident life seemed to be similar to the US in more ways than not, including the use of a simulation lab, sharing one cluttered resident lounge and having test anxiety (we happened to visit on a resident test day). Medical students and residents read textbooks and journal articles in English and receive lectures and discuss information with teachers in Thai. Their bookshelves had the same favorites as we do back home, including Tintinalli’s emergency medicine, William’s hematology and Nelson’s pediatrics.

We had lunch at the Mahidol University cafeteria, were we sampled various Thai dishes and fruit juices. We were astonished by how food could be so cheap but so good, and wondered how our lives might be different if we had access to the Thai cafeteria everyday back home instead of the Shand’s hospital food. Outside of the cafeteria, a poster session was being held for the various scientific disciplines at the university. The program for it included both English and Thai versions of the abstracts.

In the afternoon, we rode a boat bus down to visit the Grand Palace, were we learned about the traditions of the county and gawked at the beauty of sites like the Chapel of the Emerald Buddha. In the evening, the whole project group met up for dinner and ate Thai food before heading out to haggle at a night market.

Mission Accomplished!

By Tuesday we had seen nearly all the children and a couple of adults. The vast majority were well child exams but there were several with irregularities that needed follow up, such as tachycardia, mild hypertension, stool guiac needed etc. There were about 50-60 that required some intervention, ear infections and fungal skin infestations and most of the younger ones have head lice; there were also some that reported worms in the stool and a couple wheezers. We also discovered several with physical findings that will require more evaluation. Tuesday we each treated 2 children to elephant rides done by the Karan Hill tribe. This was the highlight of the trip so far afterwards we had lunch and ice cream and browsed the Karan shops before heading back to the Akha training center. That night they treated us! After dinner I received the best pro-fee imaginable. The children donned their native Akha costumes and performed several traditional dances and some contemporary Christian music too. The Akha are Christian and have been for centuries, but the blend of native costumes and dance to hymns was quite impressive. At the end of their first dance they held up a hand painted “Thank you Gators” banner. After concluding the dance they called us up to thank us one-by-one and each student was given an hand sewn handbag with exquisite needlepoint decoration. Once that was done each of us got about 400 hugs as each child mobbed us on the stage screaming, “Thank you” and “I love you”. It is as close as I’ll ever come to being a rock star. I took photos and video of the evening events but I took some time to just soak up the atmosphere. It was all very moving. We learned their special “handshake” and there were plenty of American high 5’s too. I was gratified to see several of the children for the 3rd time and one who is enrolled in the local university. This is an exceptional accomplishment as it is nearly unheard of for the Akha. She is studying international business and finance. The Training center is supporting her tuition but she works 3 part-time jobs to meet her living expenses.
Wednesday, we tied up some loose ends, some of the kids had slipped by but we had a mini-clinic and quickly completed the charts. There are still charts to be entered into the databank but this will be done by their staff as they are the essentially normal ones. After more hugs and high 5’s it was time to leave our friends and begin our journey home. This was the toughest part of the mission as many bonds have been forged. We piled our stuff and ourselves into the back of the pick-up one last time and left for the airport to a chorus of good-byes from scores of happy faces.
We are now in Bangkok and settled into our hotels. Tomorrow, I have arranged for the students with EM interests to spend some time in the Emergency Department of Ramathibodi Hospital and after lunch we’ll tour the Grand Palace. We are pouring over the tour books and will plan our R&R for Friday and Saturday. Most of us leave late Saturday night, actually 0135 Sunday. There are many places to shop and many sites to see, no doubt we’ll leave with many still on the list.
The main point though is the Mission went well.

Flight of the Flatus

With great relief that no ants had drilled their way into my ear drums last night, I woke up with residual excitement from the festivities from the night before and a brand-spankin' new energy to see the kids. Our last day at clinic was jam-packed with more visits (including a case of congenital cataracts!) and education about immunizations and catch-up immunization schedules. Time flew by so unbelievable fast! Just as the faces were becoming more and more familiar, and putting names to them as well, we had to say our goodbyes. Crowds of children began smothering each of us, wishing us goodbye and saying "you come visit again!"

We could still smell the lemongrass from the (in)famous "meatloaf patties" on our skin as we boarded the plane to Bangkok. It was during this flight where I began to appreciate what I learned in physics. I'm not sure if it was the dried bananas, coconut juice, meat-on-a-stick, the grass jelly drink, or just plain genetics, but I was farting like crazy on the plane. Thank God it was only an hour-long flight, 'cuz by the end of the flight, the monstrous toots started to smell oozing out of the seat cushion, which had so courageously secured them. After trying to pinpoint the culprit, I realized (with the support of resident physicist Ivan), that the reason I was farting so much was because at that cruising altitude, my intestinal pressure was much higher than the surrounding pressure, causing that oh-so-pleasant odor that Quincy and Kristen could not get enough of.

Elephant Rides

March 10

A late post due to technical difficulties....

The children at the Akha training center wake up at 5 am and begin their morning devotion time at 5:15 am. It is an incredible experience to have 400 singing children serve as your wake up call. Our day begins early as well. Many of the children will receive medicine for several days after we leave. Our nursing team, Kathy and Amanda, organized a medication administration record to help the training center staff administer the medication properly. In addition, Kathy collected the urine of a few children to test for urinary tract infections. We identified one infection, and this child will receive an antibiotic.

We purchased a multi-vitamin with iron for one of the older girls. We suspected that she had a significant iron-deficiency anemia based on her history and physical exam. Dr. Ferguson taught us to exam a patient's palms when looking for anemia. If the creases of the palms still have color, it is a good sign. If the creases lack color, "Get on the phone and call the blood bank. Now!"

Later this morning, we took a group of about 30 children into a local market area. There were many local crafts created by the Akha people. We walked around the various stalls and shared ice cream with the children. One shop was home to several large snakes. One weighed 120 kilograms. That is about 264 pounds! For a small fee, you could hold the snake with your friends and take pictures. The children were very excited about the opportunity to have their picture taken with the snake!
After a hot, dusty ride back to the training center, we shared our last evening with the children. Dressed in traditional attire, they performed a tribal dance for our group. They thanked us for coming and offered us many, many hugs. It was like the last night of summer camp. Many children asked if we would return. We are eager to return, and we look forward to seeing how much the children will grow and change over the next year.

We are off to Bangkok tomorrow. The adventure continues!

---Jenn

Morning Routine

So cute!

Pre-school morning stretches before class

Bus ride to school

Pre-schoolers brushing their teeth

Cleaning their dining area after breakfast

Laundry Time

Clinic Day 2

Today was another exciting day at the camp.  We awoke to the usual excitement of kids running, cooking, and talking.  It's simply incredible how the entire sleeping camp becomes so alive with activity.  In the distance you can hear pots banging and kids singing songs as they work and play, while each area is filled with children doing their assigned task.  And this is all by 6 am!  After a good breakfast, we started up the clinic and first saw the preschoolers.  They are such a cute bunch, how they enthusiastically smile every time we smile at them.  Sadly, when I talked with some of them, they were usually very sad because they missed their families.  Luckily, most of the children were healthy and their biggest problem seemed to be lice.  Also, they are in serious need of dental care and this would improve their situation greatly.  I am certain this is because of a lack of fluoride in the water and occasionally poor dental hygiene-although they do brush frequently from what I've seen.  

After the little kids were done, we then saw the older kids.  They were a little bit more difficult because we had to figure out what kinds of personal questions were appropriate.  It's also awkward communicating through an interpreter about something personal.  We managed to do it, and finished seeing all of the kids just shy of two days total.  After this, most of our group stayed to enter the information on the sick kids into a database.  A few of us went with Deng- one of the principle caretakers- into town to get medicine that we needed.  When the first store we visited was already closed, it began an amazing adventure.  We ran into another shop close by that had a pharmacist who spoke English.  He was very friendly and even gave us a discount on the drugs we bought!  He then told us about a hospital we could visit that might have the rest of the supplies we needed.  When we went to the hospital, we then met a Thai doctor who told us about a lab company that might have the things we needed.  We then managed to find this office in the middle of town only five minutes (!!) before they closed.  The people in the office were very friendly and even gave us their fecal occult developer solution because ordering it for us would've taken too long.  Instead, they will order it for themselves.  The cost of the items was of course very cheap, and we were able to afford it.  

When we returned, we were greeted by an emergency because a girl had broken her arm.  She fell on her outstretched hand, and she appeared to have a classic Colle's fracture.  Luckily, the ER nurses were here and knew well how to care for this kind of fracture.  We made sure her feeling and pulses were intact, and then splinted the arm to transfer her to the hospital.  Just after we took care of this problem, a young boy came in who had gotten a small cut on his head.  It was bleeding a lot, but it was not terribly injured.  We put antibiotic ointment on it after cleaning it, and then covered it.

We all shared a late dinner, and literally felt exhausted.  Living here is a struggle.  Everyday is joy and excitement, but it is living- it is not luxurious or easy.  Being here reminds me of things that I take for granted everyday.  I am also inspired because I see these kids that are so happy now, and I know that they have a good chance to grow up and be educated to succeed in society.

---Ivan