April 2012 Archives

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).

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


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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.


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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.

Vislisel's Final Week At AHC

The following was written by Amy Vislisel, third-year pediatric resident:

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Buddha statue at Preah Khan. Like most statues of Buddha at the temples, the head has been removed. The missing faces are actually from a couple of different reasons. First, the temples have changed from Buddhism to Hinduism (and some back again), and the faces of Buddha were removed at those times. Second, people over the years have stolen what faces remained to sell or to place in museums..

I am completing my 4th and final week at AHC, and I was able to spend some time in different areas than in past weeks. Specifically, I spent a day with Dr. Lyda, a pediatric radiologist who has been working at AHC since it was founded. He reads all imaging studies, including x-rays, ultrasounds, and echocardiogams.

I was able to observe several echos, and a new ASD was diagnosed.. Fortunately, a cardiothoracic surgeon will be at AHC in the upcoming weeks and will hopefully be able to close this child's ASD.

Another child with severe mitral regurgitation, however, will not be as lucky. The surgeons will not be able to repair his valve due to the severity of his disease and the poor outcomes they have had so far with bypass surgery. It is difficult to see a child with a fixable heart condition be transitioned to palliative (and soon hospice) care.

I was also able to spend more time in the outpatient unit (OPD). Every day that I have worked in the OPD, I have seen a child with an animal bite. These are usually dog bites, which didn't surprise me at first because there are so many stray animals on the streets.

It turns out, however, that most of the animals were pets and were able to monitored for rabies. This has been true for all but one patient I have seen. For that child, the family did not know the dog, and they thought it actually looked 'crazy' and was foaming at the mouth. There was clearly concern for rabies exposure, and the child was treated accordingly. Her bite was on the thigh, and given the location (a reasonable distance from the brain), AHC protocol is to give only the rabies vaccination. Rabies serum is not readily available and is reserved for people who have been bitten on the head and neck.

During my month here, I have had the opportunity to get to know some of the residents. I have found it especially rewarding working with the interns. Their medical education is quite a bit different than ours. They go to medical school for 4 years, as we do, but have no clinical experiences during this time. We performed a fundoscopy on one patient, and I was able to demonstrate for the interns the proper technique, as well as describe what a normal retina looks like (with the help of the internet).

I think it would be great it future resident volunteers were able to take some of their time to help teach basic physical exam skills, as this is an area where I feel we can be especially useful!

On a different note, I wanted to add some follow-up on a patient I mentioned in my blog last week. The 6 month old with kwashiorkor and zinc deficiency dermatitis is doing well, with remarkable improvement in his dermatitis. It is remarkable what zinc replacement and better nutrition can do!

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This was the 6-month-old male with kwashiorkor and zinc deficiency dermatitis, one week after admission. His rash has remarkably improved after only one week of zinc replacement - compare with last week

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Tree growing out of a temple at Ta Prohm, well known for being where Tomb Raider was filmed!

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The site of our cooking class. We learned how to make fish amok (traditional dish in Cambodia). Hopefully I'll be able to reproduce it at home!

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Garden at local house near our cooking class. Some families are able to use PVC piping as planters, which makes the plants easier to water (especially in the dry season).


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

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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.

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

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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!

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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.

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One of the many side entrances to Bayon, definitely one of
the most impressive temples we have visited.


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

It Is Time

The following was submitted by Lauren Haveman, a second-year Medicine-Pediatrics resident on international elective in Arusha, Tanzania, under preceptorship of Steve Swanson, MD.

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Interpreting an x-ray

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Holding a patient in the hospital

Yesterday I spent the day with an amazing and group of women who run the hospice and palliative care outreach for Selian Hospitals. There are over 4500 men, women, and even some children in four districts around Arusha who are blessed by the services of this outreach.

In a place where life is a constant struggle for so many people and it is all too easy for situations to feel hopeless, it was truly humbling to experience the care and compassion provided to so many people. We visited two Maasai men in their separate bomas (compounds or groupings of homes) in a sprawling mountain village probably less than 20km from Arusha Town but still more than two hours away by truck on a road that is not passable at all when it rains.

Both of these men were on their death beds a few years ago, literally dying from AIDS. One man, who is my age, had a CD4 count of 3 when he was reached by the palliative care team in 2008. Thanks to President Bush's PEPFAR, anti-retrovirals (ARVs) reached Tanzania and many other countries around the world for the first time, and both of these men, though still sick, have made dramatic turn-arounds.

Touched as I was by the new life given to both of these men, I could not stop my heart from breaking for the many people, primarily women and children, who still have no way of protecting themselves from this deadly virus.

The first man we visited was in his 40s, and when he was started on ARVs in 2009, his wife and four children were reportedly tested and found negative. Unfortunately, as I also saw in South Africa, some religious leaders here make claims to be able to cure HIV/AIDS with a cup of medication, prayers, or chants. This man visited the spiritual healer, Babu, whom he believed to be an HIV/AIDS healer, in 2010 and stopped taking his ARVs. In October of 2011 his CD4 count was 48 and he was restarted on ARVs, but in the interim he again became very sick and we can only expect that his viral load was sky high, putting his wife (who was previously negative) at increasingly higher risks of infection.

Sadly, hers was not the only life at risk when this man stopped his medications; according to Maasai culture, he has and will continue to take additional wives, usually very young women chosen by village leaders. He told us yesterday that he now has two wives, but the first has not been tested for HIV since 2009 and his "young wife" (who we estimated to be between 15-17 years old) has not been told that her husband is seropositive because he feels that she is too young to understand.

He also shared with us his fear that if his young wife knows he is sick, she might get scared and tell others in the village the secret. In fact, he had sent her out of the boma when we arrived yesterday so she would not overhear any of our conversation.

This young Maasai girl, who was unable to finish school because it was her time to marry, is unknowingly exposed to the virus every time she sleeps with her husband. She has since had a child who may or may not also have the virus, but we do not know since the child has not been tested, at the father's decision.

In my four weeks working at Selian, Kelly and I admitted two babies with Stage Four HIV infection (the sickest a child can be), neither on ARVs. The first baby was about seven months old and presented with pulmonary tuberculosis, severe thrush, and severe malnutrition with wasting (he was the weight of a healthy newborn in the United States). The mother did not know she was positive.

The second child I met on Monday, a fourteen-month-old female who weighed 5.4 kilograms (the average weight for a healthy three-month-old female). She was too weak to cry, with marasmus and extreme abdominal tenting, and could not hold her head up. Mom told me that she herself was HIV positive and had been on ARVs during pregnancy, but her husband and family abandoned her and she had no resources to feed her child or seek medical care. The infant had not been started on ARVs, and she died three days later.

We also had a sweet seven-year-old little girl who looked about three years old, was known to be seropositive and previously on ARVs. Her mother had stopped her medications more than a year ago because she had gone to see Babu for a cure, but the child has returned to the hospital with severe malnutrition and in desperate need of restarting ARV therapy. I think about the young mother we met at the boma yesterday and how easy it would be for her child to be the next admission.

Interestingly, after I got home from the village yesterday, I opened an e-mail from Dr. Amman, a pediatric ID specialist at UCSF and a man who has been at the forefront of the HIV epidemic since the virus was discovered in San Francisco in the 1980s. He is also the president of an organization called Global Strategies for HIV Prevention and has worked around the world and especially in Africa, advocating for women and children.

I learned that the United States Public Health Service finally released treatment recommendations stating ALL people who are HIV positive should receive ARV treatment: "Antiretroviral treatment is recommended for all HIV-infected individuals."

No longer should we wait for absolute CD4 counts to fall in adults and adolescents or for CD4 counts to fall in young children. However, the World Health Organization's guidelines have not yet changed, and it is these guidelines that shape the ARV policies of most countries around the world, including Tanzania.

What if we did treat every HIV-positive individual with ARVs? Studies show us that transmission rates would fall as viral loads are lowered in infected individuals. We could further reduce the maternal to fetal spread of the virus. The virus would be prevented from mutating into resistant strains if hit hard (and early) by multi-drug therapy. Life-threatening opportunistic infections would be reduced. Infected children would not be as badly plagued by the malnutrition I see here every day. In short, HIV would continue to become a chronic disease instead of a life sentence, transmission could be further reduced, and lives would be saved. This would be an answer to many prayers.

What is stopping us from treating everyone who is HIV positive? For me, the scariest and easiest factor to change is the fact that as a nation and world, contact tracing has never been used in the fight against HIV. Unlike tuberculosis, syphilis, gonorrhea, chlamydia, small pox, SARS, ebola, polio, and other infectious diseases, there is no requirement that a case of HIV be reported in order to trace a person's contacts. Without this measure, there are millions of people in the U.S. and around the world who are HIV positive and do not know it (estimates are that 20% of HIV-positive people in the U.S. do not know they are infected, and up to 90% of infected people are unaware in certain regions of the world). According to the new guidelines, all of these people should be on ARVs now. If universal testing and contact tracing were used, the young mother I met would know she and her child were at risk of HIV. They could be tested and treated now, before they became sick. She could learn how to protect herself from the virus if she were negative and become empowered to advocate for improved heath for both herself and others in the village.

My limited number of years in the medical field have been enough to make me passionate about my responsibility as a doctor to notify and test people who are known contacts of HIV-infected individuals. Unfortunately, while I feel this is my responsibility, I am limited by national and international laws.

It is time for this to change.

As doctors, nurses, and public health providers in an age when HIV/AIDS is a manageable condition, in a time when drugs are available worldwide (though arguably not yet available to all who need them), we are now responsible if the epidemic continues to spread. If we are not willing to do everything we can to stop the spread of the virus--and this includes universal testing and contact tracing--then we are individually and collectively responsible for the millions of people who continue to be unknowingly infected, predominantly women and children.

It is time to change the way we notify, test, and treat people at risk for or infected with HIV. With the resources and knowledge we now have comes the responsibility to do everything we can to put an end to the HIV epidemic. As I prepare to fly back to the United Sates this evening, I find myself wondering, am I at fault if the young mom I met yesterday or her child die of AIDS or related infection, because I did not inform her or allow her to be tested when I could have? Am I responsible for her life and the lives of her children both born and unborn?

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Performing a patient exam

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Another patient exam at bedside

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Lauren and Kelly Bergmann distributing charts on the ward

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Writing up a clinic note


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.

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

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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!

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Looking up at the central temple at Angkor Wat

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A monk studying Apsara

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Biking through the Cambodian countryside

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

Vislisel Finishes Second Week At Angkor Hospital for Children

The following was written by Amy Vislisel, 3rd-year pediatric resident.

I have finished my second week of work at Angkor Hospital for Children (AHC) and had a great week. I was able to spend more time in the inpatient unit, seeing a variety of patients.

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This is an area in the hospital used for teaching families
the importance of clean water, well-balanced diets, etc.


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Entrance to the ICU and ER

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This is the home of one of the families we visited during a home visit. The AHC staff is
carrying food for the patient in the plastic bag.


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The hospital has its own garden to provide food for families. Fresh food and clean water is
free to all the families, but the parents are responsible for actually preparing the food and
feeding their children.

I followed a child admitted for cryptococcal meningitis (in the setting of HIV), and have been impressed at how well she is doing since being started on amphotericin B. It has been challenging trying to get a feel for how the staff here manages certain illnesses and treatments, as it differs from what we do in the U.S. At home, this child would have frequent blood draws performed to check for toxicity of the amphotericin. At AHC, however, electrolytes and LFTs were checked at four days after initial administration of medication. Abnormalities in her electrolytes and LFTs were found, but there were minimal things we could do other than supplement electrolytes as needed (as there is not an alternative medication for amphotericin). There is a fine balance between ordering tests that I think should be ordered and ordering those that will actually be useful to the patient.
   
A number of patients have been admitted with a diagnosis of leukemia, usually after blasts have been found in a blood smear. I've felt frustrated in treating these patients because chemotherapy is not available. Instead, they are treated symptomatically with transfusions and pain control. Fortunately in the near future, the hospital is planning on starting chemotherapy regimens for patients with ALL. The courses will involve less intense therapy to decrease the side effects, which will likely result in decreased cure rate, but this is still a huge step for these patients.

I was able to go on a home visit this past week as well. We drove for almost 1.5 hours into the countryside, and met with two separate families. Most of the patients being seen on the visits have HIV and most are under the age of ten. Proper administration of the medication was reviewed to ensure the children were being treated appropriately. The hospital also brings some food with them for the patients, as many of the medications should be taken with food. I noticed during our visits that all of the children were home, even though it should have been a school day. When we asked if these children go to school, we learned that there were many schools in the countryside, but not all of them have teachers. These children, therefore, had no one to teach them in their school.

This past weekend was the Khmer New Year, which is an important holiday in Cambodia. The hospital had a four-day weekend in celebration, and DeAnna Friedman and I were able to be somewhat more useful at the hospital by filling in, since many residents were off. We will hopefully have the chance to help out more next week as well, as many of the residents will be gone for a training course.

Over the weekend, I made my first trip to Angkor Wat. The place is impressively large, and the architecture and carvings are amazing to see! The place was packed, as many local Cambodians were visiting for the New Year. There are many more temples to visit as well, so that should keep us busy during our days off. We have also had the chance to explore some local swimming pools, which are desperately needed after a hot week. Some locals say that the month of May is actually a bit hotter than April, but I couldn't imagine it getting any hotter than it already is!

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This was snapped from our vehicle. I am amazed by how many
chickens he fit on that bike!


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Buddha statue towards the entrance of Angkor Wat. These
statues are still worshipped, and offerings and incense are placed at
the feet.


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This picture was taken within the central structure of Angkor Wat.
There used to be a pool in the foreground of the picture.


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Two monks sitting outside the moat surrounding Angkor Wat. My pictures do a poor job
of showing how massive Angkor Wat is. The place is huge! The central structure can be
seen in the background and there is some scaffolding where restoration is being performed.

Bergmann at Selian Hospital in Tanzania

The following was submitted by Kelly Bergmann, a second-year pediatric resident on service in Arusha, Tanzania, under the preceptorship of Steve Swanson, MD

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Kelly Bergmann cares for a patient on the wards at Selian Hospital in Arusha, Tanzania

On the eve of returning to Minnesota after five weeks in Tanzania, my impressions of my time here are mixed. On one hand I'm excited to go back home and see family and friends. But on the other hand, I will miss those friends that I've made, the people, the culture.

Most of all, it's the children in the hospital that I will miss, many of whom were staring death in the face and courageously took on each day with a smile. Their smiles brought joy to my heart and hope for their future, despite the limitation of medical resources and care that we could provide.

Selian Hospital, in my brief experience, does what it can with limited resources. It is difficult to get reliable lab tests and ultrasound reports. The x-ray machine, bilirubin lights and neonatal warmer work only intermittently. Vitals are taken once a day on the ward, usually by our team as we make rounds. Family members provide food for their malnourished children, but if they don't have money for food, the children aren't able to eat.

Just down the road from Selian is one of the top five hospitals in the country, Arusha Lutheran Medical Center. ALMC is actually a partner with Selian, and much of their profit is subsidized to help provide reduced-cost services at Selian.

ALMC is what I hope Selian will become one day: a beautiful new facility with resources that would rival some hospitals in the U.S. IV fluids can be appropriately administered, labs are reliable, x-rays are good quality, neonates can consistently be kept warm. Just a mile away from each other, these two hospitals are worlds apart.

I will miss Tanzania and the serenity I found amidst the sometimes chaotic day-to-day life. Most of all I will miss the children and their smiling faces.

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Faratha

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Joshua, who loved having his picture taken

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Helena

I will miss Faratha, a 7 year-old girl with AIDS whose smile was so beautiful. I will miss Joshua, a 4 year-old with kwashiorkor who finally smiled at me after about a week. Most of all, I will miss Helena, a 4 year-old with kwashiorkor. I took care of her for almost two weeks and never saw her smile, but I imagine it stretching from ear-to-ear, lighting up a room--the glimmer in her eye as she finally has the strength to smile. No, I never did see her smile.

But that is what keeps me coming back, knowing that someday soon, she will feel happiness again.

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Another patient at Selian looks out the window beside her hospital bed 


Going Home

The following was submitted by Ben Trappey, fourth-year medicine-pediatric resident.

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I'm leaving today. It's hard to believe that I've been here for nearly a month. Part of me can't wait to get back. I'll be glad to see Emily again. And to be back to the comforts of home. And that the vast majority of my patients will survive.

However, Father Rick likes to point out that despite the difficulties and trials and struggles he's encountered in his many years in Haiti, he finds that life is much simpler here. After just a month here, I must say that I agree. People are easier to understand. Motivations are less complex. People come to you for help because they live in poverty and you do not. They are hungry. They are sick. They need a job. They need money. They ask. They do not use passive-aggressive manipulation to attempt to get you to do what they want without asking. You are either able to do something to help them or you aren't. Life moves on.

Father also likes to say that evil is not subtle here. It is ever present and comes in many forms--illness, infection, corruption, kidnapping, theft, armed robbery, and murder. It is easy to recognize, and it nearly all stems from the one great evil here.

Poverty.

You hear stories from people who have been here for a while. Times when they were robbed or forced to pay bribes or prevented from being kidnapped by a sum of money which would seem laughable to most Americans. But throughout all of the stories, there is always a common thread. There is rarely ever a question of motivation. There are very few senseless or random crimes. People rob and kidnap people for the same reasons they ask for help.

They need something, and you look like you can afford to provide it.

Cite Soleil is the poorest slum in Port Au Prince. It's a sprawling accumulation of homes built primarily of sticks and stone and tin and tarp which appear to be ever on the verge of tumbling down. It is quite possibly the most poverty-stricken and dangerous area in the Western Hemisphere and is effectively governed by the gangs who inhabit it. Father Rick has been going there for years--building more stable housing, providing clean water, and setting up impromptu street clinics. He has just finished building a permanent clinic and a bakery on top of a landfill there, and is in the process of building a hospital there as well. The clinic sits about a hundred yards from the ocean. Outside the windows of the clinic, you can see children playing atop mounds of garbage and goats and pigs foraging through the detritus as it makes its way to the sea.

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For now the clinic is staffed on varying days of the week by Father Rick, Sister Judy, and Dr. Charles (a Haitian physician). Father Rick, who is known as "Mon Pere" among the Haitians, is so well-known and liked there that anyone who is known to be associated with him is given privileged status by the gangs. It is not unusual for groups of young men with gold chains to go out into the street to stop traffic to allow the passage of any vehicle labeled with the decals of one of Father Rick's many projects.

Unfortunately for Dr. Charles, his car did not have such a decal when he first started working there. He was coming home from the clinic one day and was approached by a young man with a gun. He demanded Dr. Charles's wallet and told him, "My children are starving. If you don't give me your money, you will die, and they will die. If you do, everyone lives."

There is no subtlety there.

Dr. Charles gave his wallet to the man, who took the money from it and casually handed back the wallet with his ID and other belongings undisturbed. Dr. Charles now catches a ride to the clinic in one of Father Rick's vehicles, but he still goes back to Cite Soleil every day. Because people still need help, and the evil is apparent and almost understandable--"You look like you can afford to give me something that I need."

Despite the fact that this sort of very real danger is always in the back of my mind whenever I leave the safety of the St. Damien compound, I still wonder how I will cope with going back to the safety and comfort of my life in Minnesota, where I will face very different and much less weighty problems. I won't have to worry much about being robbed or kidnapped, but I will be plagued by the complexities of a life that some Haitians would literally kill to obtain.

I'm not sure how I'll adjust to that.

I imagine that for a few days I will be very aware of how very fortunate I am as I return to my very comfortable life and leave the struggles of this place behind. But I fear that I will slide back into the life I have spent my whole life living.

I'm afraid that I'll find my "First World problems" to be incredibly weighty. That I'll hem and haw over what restaurant to give the equivalent of several days wages for many Haitians in exchange for food which will slowly kill me. That I'll worry over how to afford more things I don't need. That I'll have anxiety over maintaining relationships I'm blessed to have. That I'll feel frustrated about some minor unpleasantness or some perceived slight at work.

I'm afraid that I will once again come to think these anxieties are all very natural and important, because I will lose perspective of what real struggle looks like--that I'll lose sight of what poverty and long suffering can drive a person to do. I fear that I'll fail to remember the beauty that lives inside of so many of the Haitian people, despite that poverty and the suffering--the patience of the families and patients sitting in the hallway of Urgence, the joy of the children playing in the orphanage, and the comfortable calm of the Madame Lazarus family sitting on her front step.

I fear that I'll forget the spirit of this place. And I'll complain.

Until I return here and am reminded how blessed I truly am.

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Kenscoff Orphanage

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Another group of residents and an attending from the U.S. arrived this week, and I was given the last two days off from work in Urgence. I used the opportunity to get out of the compound and see some of the rest of Haiti.

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I was able to catch a ride to Kenscoff, the site of an orphanage in the mountains that Nos Petits Freres et Soeurs (NPH) has been running for the past 25 years. It's only about 20 miles from St. Damien, but it truly seems like a different country. I suppose it's somewhat fitting that due to traffic and the condition of the winding mountain roads, it takes around 2 hours to travel those 20 miles.

The orphanage, which is home to some 450 children and provides school to hundreds more, is located 6,000 feet above sea level at the top of one of the taller mountains surrounding Port Au Prince.

The elevation allows for a much cooler and wetter climate where the locals grow onions, cabbage, turnips, and other vegetables in a patchwork of small fields precariously situated on the side of the mountain. One of the long-term volunteers at the orphanage told me that it's been said that "Haiti is the only place where you can kill yourself by accidentally falling out of your field."

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The guest house in which I stayed is at the far end of the orphanage and is, itself, perched rather precariously on the side of the mountain. From its balcony, one can see the small footpaths that crisscross the hillsides and valley below and allow people access to their fields.

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Since it is such a small community on top of the mountain and so many of the people in the area have benefited from the orphanage, I was assured by those who live there full time that it was very safe to wander around up there. I was able to find my way down to some of the footpaths and hike for awhile. The view was stunning. The absence of dust and noise was particularly striking after having spent so much time "down below" in the chaos that is Port Au Prince.

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The presence of pine trees seems particularly remarkable for Haiti, were most of the country is barren and deforested due to the demand for charcoal, which remains the country's primary source of fuel and claims millions of trees each year. The area around Kenscoff is one in which the felling of trees is illegal. However, when I woke up to leave the next morning, I could hear the sound of someone felling a tree under the cover of darkness in the valley below.

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In the evening, we walked a few hundred yards down the road from the orphanage to the home of Madame Lazarus, an incredibly joyful Haitian woman of indeterminable age, who sells canned goods, soda, beer, candy, and toilet paper from her front porch.

The long-term volunteers at the orphanage know her well, and we bought sodas or beer and spent the evening sitting around her charcoal stove on the front step of her small stone house. We watched motorcycles drive or people walk past on their way to Holy Thursday church services as she and her family regaled us with the news from the surrounding area--marriages, births, tales of disputes over the ownership of chickens (the Creole-speaking volunteers would translate for me when something was particularly interesting), and her smiling grandchildren sang/rapped for us and gladly finished off the dregs of our sodas.

It was lovely to be able to get a glimpse of the real life of a healthy and seemingly well-adjusted Haitian family, who would be considered indescribably poor by American standards, but seemed quite content as they spent the evening in the company of each other crowded around a little charcoal stove as the sun disappeared behind the mountain and night fell around us all.

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.

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The patient had a very classically positive tourniquet sign

So far so good - although I'm really starting to miss having a kitchen! 

DeAnna

Vislisel Arrives in Cambodia

The following was submitted by Amy Vislisel, 3rd year pediatric resident.

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The front gate at Angkor Hospital For Children

I arrived in Cambodia on April 2 to start my elective month at Angkor Hospital for Children (AHC), and the first week seems like it has already flown by. After an interesting day of travel (delayed flights, lost luggage, etc.), I was able to explore the town and get acclimated to the heat before starting my first day at AHC. We had orientation to the hospital on Monday morning and shadowed in the inpatient unit during the afternoon. The following day, however, we were able to jump in and start seeing patients.

I based myself in the inpatient unit (IPD) and picked up several patients. My first patient turned out to be quite rewarding. He was 13 months old, and had initially been admitted with multiple skin abscesses that grew out pseudomonas. He then developed septic arthritis of his right knee. He was taken to the OR and had his joint cleaned out.

Despite appropriate antibiotics, he continued to be febrile and had a painful right knee. Through discussion with the staff, I recommended obtaining an x-ray of his right knee/femur to evaluate for osteoarthritis. They agreed, and this was read as osteomyelitis of his right femur. He was taken back to the OR the following day, where he wasn't found to have osteo, but septic arthritis (again). After his joint was washed out, he has been a febrile and hopefully will be switched to oral antibiotics soon and discharged home. What has been frustrating about the patient, however, is our inability to really evaluate why he has pseudomonas abscesses, as the studies needed for work up of immunodeficiency aren't available.

My second patient illustrated how difficult treating severe malnutrition can be. She was a 1 year old female with kwashiorkor and had been admitted more than 1 month ago. Despite proper treatment, she passed away during the middle of the week.

In the upcoming weeks, I will be able to spend time in the low acuity unit, the outpatient department (which functions much like an urgent care clinic and sees on average of 500 patients a day!), and the ICU. I will hopefully also be able to accompany staff on a home visit as well.

Outside of work, DeAnna Friedman (also here for a month) and myself have had an incredible time exploring Siem Reap. There are wonderful (and inexpensive) restaurants, great nightlife, and interesting markets. I am looking forward to exploring Angkor Wat in the upcoming weeks!

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I had the chance to visit Tonle Sap Lake, the largest lake in Cambodia and known for its floating villages. There are over 100 villages on the lake with tens of thousands of inhabitants. Above is a typical house and shop on the lake.

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Floating house with its inhabitants.

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The group of sticks seen in the background are used to anchor the oases during bad weather.

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You could find children everywhere carrying water along the shore of the lake.

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We also had the chance to visit a pagoda, which had lots of interesting architecture and art. The Khmer New Year is coming up soon, and many Cambodians are going to the pagoda to receive blessings from monks.

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Typical market in Siem Reap


The One About Kites

The following was submitted by Ben Trappey, fourth-year Medicine-Pediatric resident.

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A mural on the side of one of the orphanage walls, which are made nearly entirely of metal shipping containers

Having other people here has given me the opportunity to get away from the hospital a bit during the day. Thursday afternoon, I got the chance to tour the school and orphanage that are down the street from St. Damien and are also funded by Nos Petits Freres et Soeurs (NPH).

Both were set up after the earthquake and have been growing since. From what I've been told, the school was initially set up to establish some sense of normalcy for the many children who had taken refuge in and around St. Damien. At first it was merely a collection of tents out in a field where teachers would teach to children sitting in folding chairs or on the ground. It has since grown into a collection of concrete buildings where 800 first through sixth graders go to school every day.

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The school courtyard

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Inside one of the school rooms

The majority of the children live with their families in the area surrounding St. Damien and walk to school every day. However, 130 children live in the orphanage that is connected to the school. It, too, was established in the aftermath of the earthquake. It's clear when you look around that its inception was of pure necessity, as the organization was inundated with orphaned children.

The orphanage is made almost entirely of metal shipping containers, which serve as both its walls and the dormitories for the children. Initially, there was very little ventilation and few comforts other than a safe place to sleep. Now the containers are surprisingly comfortable and spotlessly clean. Ventilation slats have been cut into their sides, allowing the constant breeze with which Haiti is blessed to blow through. Toys are neatly arranged in and on top of a chest near the door to each container. Vibrant murals painted by local artists have replaced the industrial motif that originally covered the makeshift walls.

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More of the murals that decorate the walls of the orphanage residence and school

Not all of the children who live there are truly orphaned. In Haiti, if a caregiver is unable to feed her children, it is not unusual for her to seek out an orphanage that will take on one or more of her children. Some mothers simply must abandon a child at a hospital or an orphanage.

A young Haitian man with whom I've been working closely every day was the third of five children. When he was nine years old, his father left and his mother was unable to provide for all five of them. She found a woman from Detroit who ran an orphanage for Haitian boys that agreed to take him in. He lived there until he was 20 years old. His mother, brothers and sisters would visit a few times per month.

He admitted that he felt quite abandoned at first and would cling to his mother every time her visit would end, and that he cried every night for the first year. However, he now realizes that his mother giving him up gave him the opportunity to go to school, to learn English and to have the job that he has today. He now pays for his mother's medical bills and for his sister to go to school. He is the sort of success story that drives the voluntary orphaning of these children.

St. Damien/NPH does not take part in this custom, at least not voluntarily. However, it still happens, occasionally, that a parent in Urgence will ask another to watch a child while she uses the restroom and then never come back. These children end up in the Abandoned Boys or Abandoned Girls rooms upstairs in the hospital, and, eventually, in one of NPH's orphanages.

When I visited, it was clear to me that the orphanage has developed into a place of stability and refuge for these children who have lost so much, due to death, poverty, or both, at such an early age. Despite all that they have seen and all that they have lost (and the chicken pox outbreak spreading around last week), they come across as surprisingly happy (even when covered in calamine lotion).

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These girls have calamine lotion on their skin due to last week's chicken pox outbreak

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A boy in the play area of the courtyard

We came through for our tour in the early evening after school was out. In one corner, a group of boys was playing soccer with an under-inflated ball. They were using a bench as their goal. The smallest of them was making impressive saves, apparently unconcerned that he was diving onto concrete. In another corner, a mass of children was absolutely rapt by the television, which was playing Lady and the Tramp.

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These children are rapt by Lady and the Tramp, which is playing on the TV in the corner

However, it was a windy afternoon, and the most fun to be had seemed to be in the construction and flying of kites. The boys were making them out of plastic shopping bags, sticks that they found on the ground, and strips of plastic for tails. They were using string like we in the U.S. might use to tether balloons and would wind it around short sticks, which were used as handles.

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Talking kites


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Posing with their kite

To say that these boys were adept at flying these kites would be a vast understatement. They were infinitely better at flying these handmade kites than I ever was at flying the kind you buy in a store. They were able to keep them aloft without actually looking at them, giving subtle and seemingly unconscious flicks of the wrist to keep the string taut, while simultaneously helping their friends make new kites or posing for pictures. When their concentration was fully focused on their flying, they had incredible control using the kites to dogfight against each other, attempting to cut the strings or break the frames of their friends' kites.

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After 3 weeks in Haiti, it was nice to be able to see some healthy, happy children. To be able to realize that there is more than just suffering here. And to recognize the absolute resilience of these children who have lost so much but are still children. Still able to find joy in each other. And in the flying of kites.

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Shapiro In Bugobero

The following was written by Miriam Shapiro, 3rd year pediatric resident at University of Minnesota.

The rains have started here in eastern Uganda. The storms can be brief and, despite the significant amount of rain that comes down, the red dirt soaks it up in little time, leaving just a hint that it was here at all - the scent of dampness, a few puddles, a bit less dirt kicked up on the roads as we drive.

I am working at a rural health center in a village called Bugobero. It is about a 45-minute drive along these red dirt roads from Mbale, the largest city in the area. My primary task here is a clinical investigation of a syndrome of malaria, severe anemia and hematuria.

Though both severe anemia and hematuria are known complications of malaria, they were being seen at an increased frequency and with increased mortality in January and February of this year.

The health center in Bugobero is unique because it was adopted by an American health care NGO, which has partnered with the government to improve care delivery. Because of the extra funds provided through the NGO, the clinic is able to hire more staff and have a more reliable and wider supply of medications. The community has responded to the increase in services with a huge increase in patient visits.

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The health center includes adult and pediatric inpatient wards, a maternity ward, an operating theater and a steady stream of outpatients seen daily on a first-come, first-served basis. It is now drawing patients from all around the vicinity.

The health center has one doctor, who spends most of his time working on surgical cases, and is otherwise staffed by clinical officers, midwives, nurses and nursing assistants.

There is a laboratory here, which can do rapid HIV tests, thick blood smears for malaria, urine microscopy and urine dip stick. Usually they can do hemoglobin estimates, but of late have run out of the slides required to run the test. This limitation has required that I rely more heavily on history and physical exam findings than ever before. It also means there are several children here whose diseases fall outside the ability of the health center to diagnose or treat, even if they were diagnosed properly.

Our primary role here has been the malaria investigation, though we also see patients on the pediatric ward and outpatients, as time allows. Though the numbers of patients are not huge, the investigation is taking much of our time because, in addition to taking histories from the patients' parents and doing physical exams, we also draw the blood samples and prepare the thin smear slides. We also must leave from Bugobero early enough each day to deliver the samples to the research laboratory and have them run prior to its closing time. Because we are relying on an outside laboratory, we rarely get results back in time for them to be relevant to clinical care.

It is a stark contrast to the help we get in the hospitals in the U.S. - write an order and (usually) our work is done. Here, we rely heavily on the nurses and nursing assistants for aid in translation. Few of the villagers speak enough English to get through the detailed interview, and medical records as we know them do not exist. Each patient has a small notebook that is usually purchased upon arrival to the clinic, though occasionally is brought from home with information from previous clinic/hospital visits. When we are lucky, we can read about half of what is written in the notebook; generally the amount of clinical documentation is minimal.

Occasionally we are asked to see a child who is particularly sick. Last week, it was a 6 year-old boy with pneumonia who presented in severe respiratory distress. By the time we were called, they had already put him on supplemental oxygen via the one concentrator available. Despite the oxygen, he remained tachypneic and in significant distress, with an O2 saturation in the mid-80s. He was given a dose of ceftriaxone, which is sometimes present in small supply, and given fluids. The oxygen concentrator was then required in the operating theater, so he was taken off oxygen.

Given his persistent distress, the decision was made to transfer the child to the district hospital in Mbale, where hopefully more resources would be available. We made the 45-minute drive with him in the backseat, off oxygen; by the time we reached Mbale, his saturation was down to 59%. He was admitted in Mbale, placed on oxygen (delivered by an intranasal catheter, which was not very effective; at least at first, his O2 sat had only increased a small amount).

When we checked on him again later, it turned out that the hospital was out of the drugs that they had prescribed for him, so he wasn't actually getting them. We went to the pharmacy, purchased more ceftriaxone and paracetamol and brought it back. While we were there, the power went out, which meant that the oxygen also went off. In the end, this child was not getting much more at the district hospital than he was at the health center. Despite it all, he steadily improved, and a couple days later was asking for chapattis.

Sometimes these stories end well.

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Miriam Shapiro poses with some children at the health center in Bugobero.