Friedman's Final Week In Cambodia

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

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

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

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

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

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

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

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

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

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

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

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