We're Not in Kansas Anymore, Toto

I\"ve been telling people for a year that I am going to be in Thailand.

I\"ve realized lately that geographically, yes, it is still Thailand. But being so close to the Burma border, this fellowship has very little intersection with Thai people, customs or language. Even the food here is heavily influenced by Burmese culture. At our hospital, everyone speaks Burmese or Karen, the staff is almost all Burmese, the patients are strictly Burmese. 

Traditional Burmese Karen clothing 

I thought I would need to learn Thai. But actually it\"s more helpful to learn Burmese or Karen. I know a tiny bit of Karen language from working with the refugee microenterprise in Houston in the past. I even have Karen clothes handmade by my Houston refugee friends. So I am happy to be among Burmese and Karen people again. 

The two biggest adjustments I\"ve been making at work in the clinic/hospital are:

1) Adjusting to the limited resources and the poverty of our patients (which limits their access to even the resources we do have)

2) Adjusting to tolerance for poor vital signs and delayed treatment

Honestly, the medics are quite impressive. They\"ve probably had as much didactic training as sophomore medical students and then further on-the-job training. They are good at managing primary care complaints and recognizing some emergencies such as bowel obstruction, alcohol withdrawal, appendicitis, possible heart failure. Some of the medics are facile with ultrasound abdomen. 

The way the site works is that patients typically present to the outpatient clinic which is located less than 100 meters from the inpatient unit. Medics in the outpatient clinic medically screen and examine new patients and admit them if needed. Right now, the outpatient clinic is only open on Wednesdays and Fridays due to COVID. On the other days of the week, patients present directly to the inpatient unit for medical screening and examination to determine if they need admission or not. 

Right now we have a room with 6 beds all filled with alcohol withdrawal. We also have 2 GI bleeds, an appendicitis, an epistaxis case, female lower abdominal pain, COPD exacerbation,  a young woman with lupus who may have some kind of genitourinary malignancy, a toddler getting blood transfusion, a toddler with congenital heart disease running fevers, severely malnourished and hypoxic 5 month old, elderly female with prior stroke who presented with 2 episodes of syncope and new left hand weakness, and a patient with prior stroke who is getting physiotherapy after being immobile for 11 months. Then there are other patients in the isolation unit next door. 

I think some of these patients need to be transferred to the Thai hospital for higher level of care. For example, the lupus patient who has been with us for over 2 weeks since before I started spending my time in the unit and at first was thought to have primarily a gynecologic issue (severe vaginal bleeding requiring transfusion) but then also was thought to have renal failure but had normal labs and then just never really got better. She has some shortness of breath and abdominal pain now. I ultrasounded her yesterday and beautiful bilateral pleural effusions and gross ascites.  I considered other causes for ascites and effusion such as a malignancy. In the USA, she would just get all the labs and a CT to rule out cancer. But here, she would need to go to the Thai hospital for that. She has had no abdominal imaging so far. She had a chest X-ray as part of an evaluation for TB. Her TB work-up was negative. I recommended this to the staff but they prefer to wait 3 more days until the weekend is over to talk to the support group who will help the patient transfer. She is currently slightly short of breath and having facial and abdominal swelling, dysuria and difficulty urinating. On one hand, she has been with us for over 2 weeks, so 3 more days probably won\"t change her prognosis. On the other hand, I really think she will be better served at the bigger hospital. She knows lupus is not curable, but I hope we can help her preserve her renal function.

Here is a beautiful pleural effusion and ascites and then suprapubic view

 

The other case I really REALLY want to transfer is the malnourished baby. This baby is 5 months old today but only weighs 4.3kg, which for all of my American friends is equivalent to 9.5 lbs. Basically, this kid is only the size of some newborns. And his oxygen saturation on room air is 40-60%. With 1-1.5L nasal cannula, oxygen level hangs out in the 70\"s and occasionally peaks to 80 or rarely to 85. When the nasal cannula is off, its hands and feet turn blue. The mom says baby has been turning blue for about 3 months at home and sometimes just stops breathing spontaneously. The baby was initially admitted for severe malnutrition so it could have monitored feedings. But I am more concerned with the severe hypoxia. I really love this little baby whose head is too big for its body right now and has little spindly limbs. 

The baby has been with us for 9 days now. Up until 4 days ago, we did not have a baby size blood pressure cuff. I wanted to do 4-extremity blood pressures to evaluate for potential coarctation of the aorta. With peripheral cyanosis here, uncertain if central or peripheral cyanosis at home and this level of hypoxia, I am concerned about a congenital heart or lung problem. However, there is no murmur. His heart sounds are normal but very fast. I attempted a bedside ECHO which was quite difficult due to the tiny chest and relatively cumbersome ultrasound probe as well as the baby\"s very rapid heartbeat. I\"m also not too good with Doppler of the heart so I didn\"t trust my evaluation of the blood flow, though I tried. I paid the logistics staff to help me track down a baby blood pressure cuff and I paid 600 Thai baht for it. 

At any rate, this baby should at bare minimum get a chest x-ray to help evaluate its heart and lungs. Reportedly, the baby has the M-Fund so a visit to the Thai hospital should be 100% covered. Any surgery would not be and there would be a 50,000 Thai baht limit to free care. I have been asking for a chest x-ray for this baby for a few days. Yesterday, the staff agreed but then postponed it until Monday because they feared that if the baby went to the Thai hospital to get the x-ray and became hypoxic there, then the Thai hospital would immediately admit the baby and this would be expensive. I didn\"t understand fully, because the baby has M-Fund, so an evaluation should be covered. But then again, maybe I don\"t understand it well. And maybe the family needs time to digest what is going on with the tiny baby.

And the staff is correct: The Thai hospital would absolutely admit him. This baby is going to need to be admitted there anyways. The hypoxia needs attention. As with the lupus patient, I want this baby to go to the other hospital because we cannot give it the care it needs. We can feed it, but it\"s going to have a tough time growing without oxygen. I am afraid it will develop heart failure or pulmonary hypertension (or just tissue or brain anoxia) if not diagnosed and hopefully treated sooner rather than later. On the one hand, the baby has been living at this level of oxygen all its life; will 3 more days make a difference? But on the other hand, cyanosis with oxygen saturation in the 40-50\"s at baseline is not ok. But I defer to the staff. 

The kicker was that yesterday I spent a while trying to track down the baby size stethoscope so I could try again with the baby blood pressure cuff. By the time I found it (it had been borrowed by another unit) and went to the patient\"s room again, a staff member told me that baby had gone home just now because the grandma needed to get her COVID vaccine and that the baby would maybe return to the hospital that night or the next day. I asked if the baby went with oxygen. No, he didn\"t. Sooooo he\"s just at home turning blue again? Oh dear. I was surprised that we can\"t monitor the baby for one night while the grandma goes home or why the mother or other family member can\"t take a turn with the baby. Regardless, the baby had left the building. 

But, I had been there since 7:45am and it was already 6pm and getting dark, so I went home after making the new plan in the baby\"s chart to obtain the 4-extremity BP and oxygen saturations once the baby was back and confirming that the chest X-ray will happen on Monday. 

There is a lot I don\"t understand about the culture, so I ask a lot of questions. But lately I stay up at night thinking about the patients and also realizing there is not much I can do to speed things up or magically create the resources the patients need for healthcare.