Sukhothai

My trip to Sukhothai was lovely. I hired a bike and spent the weekend riding around, finding old temple ruins and Buddha statues. Unfortunately I managed to develop a fever and fell asleep under the gaze of one of the larger statues. Subsequently I dissapeared off into a rather surreal feverish dream but even this was rather pleasant. After a rather sad and stressful week, a couple of days out of Mae Sot was just what I needed!



I've moved from the Child ward to the Adult ward. It's pretty hectic: We have maybe 40 patients at a time and they have a massive range of illnesses. There are a lot of medics about, some with years and years of experience (who I've been getting some teaching off) and others who first stepped onto the wards last week. I've been helping some of the new medics clerk in patients and do the ward rounds. I've also been trying to teach about disease, medicines and examinations (some don't know the difference between bacteria and viruses).

Teaching English is going well and I've even gained an assistant: Myo Myo who I worked with in my 2nd week has a great understanding of English. He's teaching me grammar (breaking down sentances into ways I neer imagined!) which I, in term, hope to teach to my class. Enough. It's 7.30pm and I'm yet to go home so I'll write more later in the week.

English Lessons

To build upon the last rather upsetting post...the disabled child abandoned in our ward on Tuesday past away last night. The cause was an "aspiration pneumonia with secondary septicaemia" (A lung infection leading to an infection of the whole body). She had not even been here long enough to be given a name. One of the medics asked if I wanted to see the body and took me to a small concrete building housing 4 green body bags, tied with red ribbon. Hers was perched precariously on the edge of a table. We headed back to the ward without opening it. When I left the clinic yesterday she was fine. I cant really get my head round how she could have deteriorated so quickly.

I could follow this with stories of botched CPR or a 4 hour cannulation session (one 1 child...) but I think this blog needs some optimistic reading.

This week I started teaching English to some of the staff at the clinic. There's 33 students in my class and they're very much at a beginner level. I've never done anything like this before but I'm loving it. My class are all really keen: They take notes eagerly, shout out answers and some (the brave ones) are happy to stand up in front of everyone and have basic English conversations. Because of this, when I'm walking around the hospital, I'm regularly greeted by "Morning Sir" and "Hello Teacher" which is pretty amusing.

Lesson Planning

Often I've found myself at a loose end this week so I've taken a number of trips to the laboratory. Here the staff have taught me how to make malaria slides and recognise the different types using a microscope. This kind of thing was unbelievable boring back in 1st year but now that I'm hanging about on a ward where every other kid has malaria (by the way, this diagnosis fills me with relief as its treatable and managed extremely well), I suddenly find staring down a microscope fascinating! It is so rewarding when it clicks, and you suddenly realise you can recognise not just the presence of a malaria parasite but also what species and part of its life cycle it's in! Geek!

Yesterday as I was about to leave the clinic, two of the medics who I worked with in the first week told me their friend, another medic, was sick at home and asked if I would visit him and see what I think. (I wont go into the details but he probably has appendicitis and refused to go into hospital despite needing IV antibiotics: No appendicectomies here...) It was extremely touching to realise that even in such a short time I've managed to gain some trust and respect, enough in fact that they're happy to trust me with their own health! This is especially rewarding after some of the difficulties I've encountered this week working on the ward.

This weekend I'm taking a break and heading out to Sukathai - a national park filled with temples and ruins. I just hope it doesn't rain too much.

Burmese Tea: My favourite thing in the world at the moment.

Child Health

This week I have moved from the Outpatient clinics to the Paediatric Inpatient ward. This is a pretty big change in pace and style and subsequently I am feeling pretty overwhelmed by it. There are 2 medical Inpatient wards at the hospital: Child (which I am on) and Adult. Between them is only one doctor, an Australian girl, who focuses most of her time on the adult ward. This means that the Paediatric ward is run by Medics at all times with the doctor only checking out complicated cases.

Last night, one of the children on our ward died. He had severe diarrhoea and severe malnutrition. I was pretty shocked by this and had a look through the log book to see if many children died here and it seemed to be about 1 in 20. Looking up I counted nearly 20 children lying on mats on the floor (no hospital beds) and wondered if they would all make it through their various illnesses.

At first, the ward seems to run pretty smoothly and after the 1st 2 days I felt pretty useless, spending my time trying to understand the treatment of malaria and malnutrition rather than being a particularly active member of the team. Indeed on the few occasions that I tried to get involved and express my opinion, I felt like I was interfering. The medics seem to be under the impression that as I am from a different part of the world, I don't know anything about the management of the children here. Which is a fair point. I've never seen malaria and I've never seen malnutrition but that doesn't mean I know nothing.

Yesterday a girl came in struggling for breath. Her neck was held forward and she was making a sound called "stridor" which is the noise of the upper airway becoming obstructed. She also had a fever, couldn't eat or drink and her voice seemed somewhat muffled. To me this sounded like it could quite possibly be something called "Epiglottitis" (This is where part of the throat becomes infected and inflamed) and this can very often get so bad that it obstructs the airway, suffocating the child. Despite being extremely rare in the UK (we are vaccinated against the bacteria responsible) it is so deadly and important that ALL medical students are taught to obey 2 golden rules if they suspect this:

Until you secured the airway through intubation (sticking a tube down it to keep it open) you must:
1) NEVER look down the airways
2) NEVER distress the child through unecessary procedures such as trying to get intravenous access or taking an X-Ray.

I watched as both of these rules were broken (tongue depressor shoved right down her throat and intravenous access attempted 3 times) and could not help but speak up. I was ignored. This morning she was really struggling for breath. I managed to persuade the medics to check her blood oxygen levels which turned out to be swinging between low and borderline normal (84-94%) and suggested giving her oxygen. This was again ignored. Luckily the doctor turned up, gave her oxygen and referred her to the big hospital in town. Because of this, I lost any rapport I had with the head medic and spent the next few hours feeling pretty awkward and in the way.

(Just to clarify, this was not necessarily epiglottitis. In fact it probably wasn't - her tonsils were massively inflamed, as was her uvula. Whether the epiglottis was involved is unknown. However the rules should still apply)

Seeing this kind of thing is incredibly frustrating but I'm learning more and more about working in this kind of environment. You cant just turn up and expect everyone to listen to you (even if you really should be heard). You have to built relationships, gain confidence and show respect towards the local method (even if it goes against your own rules sometimes). In a week I cannot expect to really manage this. To make a true difference in this kind of setting you need to spend months, even a year (like Dr. Nicky, the Australian) working with the department. But I've made amends with the medics, having a nice long chat with Lucky (spelt Hla Khin), the boss man this afternoon and helping explain some medical conditions and English words to the junior medics. Hopefully we can spend the rest of the week working together in a productive fashion.

To finish off this rather unhappy post: This morning a child (aged 1-2 years?) with learning difficulties was abandoned by her mother at the clinic. She has moved into a side room on our ward. The saddest thing is that shes not the only one there. 3 months ago the same thing happened to a 4 year old boy with quite severe cerebral palsy. Both have very rigid arms and legs and subsequently will probably never walk The 4 year old cannot say a single word and just stares with a rather glazed expression around the room. They've been essentially fostered by the ward and no one knows what will happen to them. The little one hates to be on her own, screaming the ward down when she is, so we all take turns playing parent unless there's too much going on, when we just shut the door...

Sorry, no pictures today, just sad stories.

The Rubbish Tip

Today, my friend Maung Maung Tinn (who I wrote about in this post) took myself and 3 med students from New Zealand on a little tour. Starting at the clinic, we jumped in a truck full of HIV positive patients who were being taken to a monastery for the day. This was a monthly trip that the clinic run but due to the large number of HIV patients and the limited number that can be taken, a different group goes each month. I suppose this acts as a sort of support group. Having never really been to a Buddhist monastery before I was quite keen to sit quietly at the back and see what went on but rather embarrassingly I was called to front by the head monk and made a bit of a fuss of. An ex-nurse taught me some meditation techniques that I never got to put into practice as Manug Maung Tinn was keen to get moving.

Our next stop was the rubbish tip. And in this dump there were well over 100 (I forget the exact number - I think it was around 300) Burmese people living there. A sort of village had been formed out of the rubble.


It felt strange wandering around, my feet covered in wet rubbish-tip mud (it was raining, which is probably why the smell wasn't too bad) with fly's buzzing all around. I felt horribly rich and touristy with my camera out taking pictures of the place. The New Zealand girls had brought sweets and crisps with them for the kids which was really appreciated and as we left a couple of kids came running out of their houses, desperate not to miss out. These people live in the most ridiculous poverty but that is what the situation in Burma has driven them too. They would rather live in a rubbish dump than be back at home.


Next to the tip was a school for the children who lived there. Even though it was a Sunday, it was thriving. The band from the US who played at the clinic for Aung San Suu Kyi's Birthday had brought their acoustic guitars to the school to play some songs. Now I'm a bit of a music snob and I thought these guys were pretty cringey when I first saw them in one of the bars in town, but what they're doing is actually pretty sweet. To the kids, these guys are rock stars. The atmosphere was exciting and there were arts and crafts and all sorts going on. Another one of the 91 migrant schools (of which 89 are illegal) had visited to join the fun and not too long after we arrived the band jumped into their van to play to a new bunch of kids somewhere else near Mae Sot.

Some kids from the school next to the rubbish tip

Aung San Suu Kyi's Birthday

Yesterday was Aung San Suu Kyi's Birthday. Across the world protests were held calling for her to be set free. It even made the front page of BBC News! Last night at the clinic, a party was held in her name. Volunteers, patients, medics and whoever else fancied turning up came to watch an American band (They were a little cringey...) and a local musician play in the clinics training room. Candles were lit, kids danced around in circles and free food was handed out.


Scattered across the the clinics grounds were a number of Thai army guards with shotguns and rifles. I found this pretty unsettleing with so many kids about but they seemed pretty relaxed as the atmosphere was happy and celebratory rather than argry and violent.


This week at the clinic I saw a lot of coughs and colds - the kind of thing a GP gets bored of, but trying to exclude serious illness in these patients is considerably more difficult with the language barrier. The medics don't like to ask too many questions and its much better to work in their style as much as possible. Some evenings I've headed back over to the Trauma department to see my friends there. Its pretty shocking to watch the medics there removing tumours on a non sterile table which they themselves are squatted on while operating, their bare feet inches away from the open surgery...but these guys have been working like this for years and challenging them only makes them less keen to work with foreigners. After starting there last week, it was days before the head medic in that department would even make eye contact with me. You get the impression that they've had a lot of foreign doctors come in and try to force change on them in a rather insensitive way.

I was asked if I'd start teaching an English to a class of the medics. Rather foolishly I accepted and so from next week on Monday, Wednesday and Friday evenings I will doing exactly that. As far as I can tell there will be no syllabus and no text book...yikes!

Playing the Burmese version of Pool with my friend Juriaan

Week 2

I have moved to General Medical Outpatients this week, working with 2 medics: Louisa and Myo Myo. Louisa is incredibly experienced but Myo Myo considerable less confident. We tend to see 2 patients at once sharing all the equipment. One of our big problems is TB. Not only are we unable treat this at the clinic but we can't admit any of these patients to the ward for fear of it spreading to others. Until last year, Médecins Sans Frontières ran a TB clinic in town and would take our patients but for some reason their program has been shut down.


A friend of mine introduced me to a Burmese artist called Maung Maung Tinn. I was invited to the unveiling of a new work of his. It was the first time he had used acrylics. His painting depict the poverty and troubles of the Burmese people and have been given exhibitions in a number of countries. You can check them out at his website

First Day Off & One More Dog

Sunday was my first day off. My friend Todd, a guy from New Zealand has a truck and so me and a few of the other guys from the clinic dived in a headed into the countryside around Mae Sot. We visited a temple, climbed waterfalls, trekked through the jungle, ate food from the hill tribes etc...It was great fun. We also visited the border. Now I'd heard about this but didn't quite understand it. Basically the border is a river, less than 100m across with the "friendship bridge" crossing over it - the official route into Burma. However in the river and next to the banks were a bunch of rubber rings with people crossing both ways (for the price of 20p, compared to the official 10 pounds).

Always there were at least 2 or 3 rings in the water. Apparently this is more than usual - There has been an increase in the fighting - the Burmese army are attacking the Karen state in the lead up to the elections (normally they like to wait and fight in the dry season). So as a result there has been a greater influx of refugees into Thailand.

And sat on the river side are the Thai border guards watching the whole process, posing with their automatic rifles...
Apparently Mae Sot is one of the best postings for a police officer or guard as the amount they take in bribes eclipses their salary. Unfortunately, as far as I can understand, the clinic does not escape this corruption. It has to play the game and pay for the fact that serves and employs a mostly illegal population.

Sunday night I headed over to the Internet cafe to write about this and on my way I got bitten by one of the grotty, aggressive dogs. I didn't even see him before the bastard bit me. Heading into the cafe in a slight panic, (there's a fairly large amount of Rabies and Tetanus here...) I showed the guys working there who let me use their sink to clean up. One of them then insisted on taking me by moped to the hospital, stayed with me for about an hour and then came back to pick me up when I was done. I tried to insist that I could get a taxi but he wasn't going to give in. So now I have to take antibiotics and need 2 more Tetanus jabs...but at least I made some friends in the process.

Dogs and Cancer

This Monk, as far as I can, tell had been put on the list for a cataract operation by a visiting doctor. He was very excited and kept pointing to his name on the list.

After 4 days at the clinic I'm pretty exhausted. On top of the intensity of the work, keeping me awake is a large population of wild dogs living around my house who get very territorial at night. From my room it sounds like epic battles with the barking and snarling of maybe 4 or 5 dogs, ending in wailing from the loser. Unfortunately their territorial instincts at night mean that cycling back from dinner or the Internet cafe or whatever, they go for me which is pretty frighting. Some of the Medics at the hospital enjoy a good meal of dog meat. I wish they'd come and eat those dogs...

The clinic is pretty frustrating. We have a small handful of blood tests available and no X-ray/ultrasound/microscopy (although in some cases we can request X-rays from the Mae Sot's main hospital). We have such a small number of different medications that I can pretty much memorise them all. Over the last couple of days I've seen a number of nasty cancers and the only thing I could do was send them back to Burma with 20 paracetamol tablets for Pain. The clinic cannot afford to get Biopsys/Endoscopies/Mamograms/ and while the patients may pay for these tests back in Burma, they almost never have the money to do so.

The Medics here don't seem very keen to break bad news to patients so I can never be sure if they know the severity of their conditions when they leave but today, a man with throat cancer who spoke very basic English. Clinically it was obvious what was going on and he brought with him an Endoscopy and Biopsy report (some do manage to scrape the money together) both of which diagnosed oesophogeal carcinoma...yet nobody had ever told him. So I had to break the news, something I didn't expect to have to do until much further on in my career.

I seem to be focusing on all the doom and gloom...I think it's the lack of sleep. On a happy note, a 2 year old girl I admitted 2 days ago with massive periorbital cellulitis (swollen, infected eye) in her left eye which was beginning to spread to her right, can finally see again. I made it my business to keep a watch on her as these can develop into meningitis and the medics here wouldn't let me give her drugs intravenously.

And now I'm off back home, to brave the dogs...

The entrance to our consulting room. There is a barefoot policy throughout the hospital...

The entrance to the Mae Tao Clinic

Apparently there are around 5 doctors at the clinic. As of yet I've only met one, A Japanese girl called Aya who started yesterday like myself. There are no nurses, instead the clinic is maily run by "Medics". I still cant quite work out exactly whats involved in their training but its nothing like what we get back home. They have to rely on intuition and experience.

The Medics I've met are from Burma living illegally in Thailand. Some plan to complete their training and then head back home to their village's in Burma to use their skills while others head to the refugee camp hospitals. Some become "backpack medics" who illegally trek back into Burma with supplies and provide treatment. 7 of these have never returned.

I've started working in "Surgical Outpatients" which acts as something like A&E meets GP. On my first day I planned to just observe watching how the 2 Medics in our clinic worked. I soon found out that Candy, who was leading the consultations had a mere 5 months clinical experience and was regularly turning to me for a diagnosis and plan. Within half an hour of my first day I was basically co-running this clinic...here's some of the stuff we saw over the last two days:

• A shoulder the size of a coconut. No movement in his arm - probably caused by a tumour or TB
• A guy who was standing in the wrong place 3 months ago when a car blew up. He had burns which covered almost his entire skin, from the top of his head to his thighs. And in a lot of places this had got infected.
• An Inguinal Hernia the size of my head
• A Liposarcoma (fatty tumour) on a guys hip the size of...um...3 or 4 heads is the best comparrison
• A kid, maybe 2 years old with his forearm broken - both bones, the tibia and fibula but not uttering a single cry or moan while we tried (for about half an hour) to organise an x-ray at the local hospital.
• A "pubic shaving accident" that resulted in not one but two completely seperate wounds (each around 3cm long) on the penis and scrotum

Fortunately Aya, the doctor from Japan has also attached herself to our department and while she spends her time doing minor operations and procedures with the Medics, she pops in now and again to help when we get stuck. In fact everyone seems to pop in and out of the small consultation room we work in, often just for a chat, while we're seeing a patient. There's books and notes and people scattered everywhere but i'm beggining to feel that there is at least a little organisation to the chaos.

Elizabeth and Leuronwysi: 2 of the Medics from Surgical Outpatients

Blog!

I've decided to keep a blog while I'm away so that my friends and family can check up on how I'm doing. I might decide the world of blogging is not for me or I might not.



I am spending my 7 weeks in the Mae Tao Clinic in Mae Sot, Thailand. Mae Sot is on the border with Burma which has one of the most oppressive regimes in the world. Subsequently the Thai-Burmesse border is swamped with refugees. The closest refugee camp to Mae Sot is said to have around 200,000 inhabitants. And these are the lucky ones. Here they can get education, health care and there is always a chance they may get re-settled in a new country. Back in Burma there is no healthcare and very little in the way of useful education. On top of that, a number of the ethnic groups are actively resisting the governement creating a civil war which has been ongoing (under the western worlds radar) for around 60 years.

The Mae Tao clinic sees two types of patients and the split is about 50/50.

1. Migrant workers living in and around Mae Sot who have no other access to health care (the Thai system does not cover them)
2. Those living in Burma who cross (usually illegally) into Thailand as there is absolutely no health care in Burma. They often travel for days after hearing about the Mae Tao clinic through word of mouth. Because of the efforts and the risks involved, these people often have very advanced diseases.
   

I think now is also a good time to mention that the Burmese Junta are not cool with this. In fact they've gone so far as to cover the border with landmines. (The reason for this, as I have since discovered, is far more complicated) The clinic in fact has a prosthetics work shop to cater for the massive number of refugees who have lost limbs.

Burma's ray of hope, Aung San Suu Kyi, leader of the "National League for Democracy" has spent the best part of the last 20 years under house arrest which may soon turn into a prison sentance.

Enough about this for now. If you want to find out more Im sure you can follow some of those links. If not, then you've probably already stopped reading...

Working out how to use blogspot...

Music Test - Island Barbados