Recently in Partner Site: Cambodia Category

Satrom Gives a Tour of Elective Site

2nd Year Pediatric Resident, Katie Satrom, recorded a video presentation for the Annual Global Health Grand Rounds: While They Were Away: Resident Contributions Abroad 12-13 held on May 29, 2013.

Vislisel's Final Week At AHC

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

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!

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

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

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!

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...


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.

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

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!

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.

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

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

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.

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

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!

Looking up at the central temple at Angkor Wat

A monk studying Apsara

Biking through the Cambodian countryside

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.

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

Entrance to the ICU and ER

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.

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!

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

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

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

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.

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.

The patient had a very classically positive tourniquet sign

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


Vislisel Arrives in Cambodia

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

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!

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.

Floating house with its inhabitants.

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

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

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.

Typical market in Siem Reap