The Journey is the Destination.

I remember wanting a book by this title in high school. I have been on or involved in many journeys recently. The first was my trip to Phuket. I was happy in my last post because I’d managed to find out the bus schedule in Lao for the trip to Udon Thani Thailand, where I was catching a plane to Phuket. What I didn’t do that saturday morning was buy the actual bus ticket, and when I returned at 11 for the 11:30 bus, they were sold out. My plane was at 4:50, so I probably could have taken the 2:30 bus, cutting it close, but I definitely wouldn’t have been able to run an errand in Udon Thani. I was trying to go early to buy train tickets for my parents from Ko Samui to Bangkok, as we had been told the overnight trains sell out up to a week before, especially around Christmas. (Thai is Buddhist, but they celebrate end of the year holidays with the west.) So I took the city bus to the border and then haggled (a little) for a mini bus to Udon Thani.

This van ride was the first time I felt like it was winter here - all the fields and bushes in northern thailand were brown and dry, and looked like a more tropical version of the high plains in winter (no snow, of course) I arrived at the bus station there and people gestured somewhat vaguely in a through the bus station to show me where the train station was. I started walking, and after 2 blocks down a side street, asked again at a restaurant and was told I was on the right track. Soon I arrived at the train station and was able, after one failed attempt, to buy my parents the first class sleeper car train tickets they wanted. My lonely planet said one of the biggest malls in Northern Thailand was a few blocks away, so I set out again from the train station. I found the mall after wandering through a deserted market and a construction site. Unfortunately, no one in Northern Thailand was selling swim suits (I guess it’s winter, and I didn’t have time to search every shop, but I think in an American mall at least the department store would have some.) But I did have a pretzel at Autie Annie’s, so it wasn’t a total loss. Then I got a tuk-tuk through town to the airport, arriving with plenty of time. My flight was on Air Asia, and I had pre-ordered spaghetti bolognese as my dinner on board. I was craving pasta a lot when I purchased the ticket. It was pretty gross - really sweet sauce - but I still ate most of it, because by 5 PM I was fairly hungry, having only had a bowl of corn flakes and then the pretzel.

We flew through some pretty awesome cloud formations and then over the mangrove swamp and beautiful Ao-Phang-Na bay filled with limestone carsts as we landed in Phuket. I got a mini-bus to my hotel, which drove through Patong - the biggest, brightest, seediest tourist town on the island - on the way. It also drove straight up and down some hills that would be considered to steep to build on in America. Meanwhile, my parents were on a much longer journey - from Denver to Phuket via LA and Hong Kong. Their flights were also uneventful, but they were delayed at the Phuket airport trying to get money from the ATM, so they ended up spending more for a taxi to the hotel. (I’ve come to the conclusion that when a Thai ATM is broken, it just tells you that you’ve inserted your card incorrectly, no matter what the actual problem is. ) They were there at the hotel, tired but intact after a 30 hour journey, when I arrived. They had even walked around town some.

The view from the airplane.

Our next journey was from Puket to Ko Samui. My mom had researched this and knew that we wanted the big bus from Phuket town, not a mini-bus. However, the big bus company phone number did not work initially, and after several attempts with different numbers, when we go through to a person who spoke english, they told us to call another number. One which didn’t work on multiple attempts. So we booked a mini bus at the travel agent on the corner, recommended by the hotel. The mini bus arrived Wednesday morning at 7:50, already pretty much full of French students and their giant backpacks (these people had at least 1.5 times as much luggage as me, each, and I had a lot of extra stuff because my parents had brought a suitcase from home for me. Our terse mini bus driver managed to pile our suitcases atop the large stack behind his seat, and Mom and I climbed back to the 4th and last bench of the bus, where we sat with 2 french students. Dad got to perch next to the luggage, and spent the next 20 minutes trying to get the left half of his left butt cheek on the seat, while worrying that a sharp corner might cause the luggage to collapse onto him. Mom and I encouraged him to move forward to the passenger seat, which was unoccupied. But this was bad advise, because after our gas stop we picked up 3 more passengers. One of the french students had abandoned our row for the passenger seat by this time, so my dad was gestured back to our row. the luggage was rearranged to make about 1.3 seats in the first row by piling some of the suitcases into the aisle between the second and 3rd row of seats.

The view from my seat in the Mini Bus. At least with me, my Mom, and Dad in the back,we were able to share and redistribute space and stuff so all of us had the most legroom possible.

At this point, one of the french students protested, and was rudely offered his ticket back and a chance to get out of the bus. One of the new passengers got to sit in the front seat with the french student, and the other two got to share the first row. Somehow, despite their perch, the managed to sleep through the next several hours of the journey. I think they might all have been hungover, but especially the one who slept sprawled across the luggage, with his shirt buttoned incorrectly. Finally, after an early lunch stop at which none of us ate (we weren’t hungry, and with the AC working only somewhat in the last row of the bus, I was worried about motion sickness), we arrived in Surat Thani about 1:30 PM. We were deposited at a storefront with one table and 4 chairs (at this point, our minibus had 14 occupants) along with the contents of a second mini-bus. We waited here until about 3 while the man in the storefront tried to sell us taxis and accommodation on Ko Samui. Finally a songthao (truck taxi - like a pickup truck with benches and a covered back) took us to another place, this one a restaurant, where we were again offered transportation / lodging services while we waited for the big bus. The big bus took us the short (1/2 hr) journey to the ferry and there we waited only a short while (But were again offered booking assistance for hotels and taxis on the other end) until the ferry left at 4.

The ferry had indoor seating upstairs (VIP, 50 baht to sit in it, with a slight smell of gasoline exhaust), indoor seating downstairs (regular, free, and completely filled with gas fumes), and the ability to sit on the deck in front or the walkway to the front (but no benches or chairs). The front quickly filled up, so we ended up downstairs, but made frequent trips to the back deck for fresh air and picture taking. At this point, we were too frustrated with the package transit company to give them any more money to sit in the VIP area.

The deck of the ferry - full of people who don't want to sit dowstairs in the fumes or pay for slightly less fumes. They're all young and on vacation, so they seem to be handling it well.

When we arrived in Ko Samui, we checked out other ferry options, and then got a taxi to our hotel - after calling the hotel and being told ‘their’ taxi was taking someone to the other end of the island. We payed the same price, anyway, and it was 50 bhat less than the kind offer of the man at the storefront enforced rest in Surat Thani. Our hotel was lovely, and we were more than ready to hop in the swimming pool and have some spring rolls and phad thai for dinner.

My last journey was from Ko Samui back to Vientiane. It started with the hotel hostess asking if I could go to the airport at 2 because my parents wanted the taxi to the ferry at 2:20, and she only knows one taxi driver. I told her no, I would walk to the taxi stand (about 3 blocks.) I needed the extra 20 minutes to eat lunch and pack. I got a fair price to the airport at the taxi stand, and we drove through what looked like small country roads to me, finally arriving at a small airport. Check in went smoothly, an I was soon inside security at the Ko Samui Airport. The whole airport is made up of small hut-like buildings, I suppose trying to be authentically island-style, with covered walkways between. It was actually quite picturesque, especially the outdoor shopping mall on the way to the 6 gates. At my gate, I sat and read the Bangkok Post, which was hilarious in that every article was both reporting and editorializing on the news. A fellow traveler tipped me off that I could get my very own copy in the “Courtesy court.” What is a “Courtesy Court?” I thought to myself. Turns out, it is a little hut filled with free food, drinks, and newspapers. Bangkok Airlines really is a boutique airline! I loaded up with croissants, cake, pudding, and newspapers and really enjoyed the rest of my wait for the plane. On board, after riding little golf-cart like trolleys to the plane, we had chicken sandwiches and juice or water during the 45 minute flight to Bangkok.

I knew that I could get to the train station in Bangkok on the new high-speed train that connects to the airport from the city, then by subway, or on an express bus. The subway/train would be cheaper, but the bus would be simpler. But, I made the mistake of asking a fellow Thai traveler how was the best way, and he told me to take a taxi on the express way (400 bhat) because 2 hrs between my plane arrival and the train departure might not be enough to get there on the train/subway. I don’t think he knew the express bus existed. But, that made me anxious while trying to find the bus stop. (It also made me decide not to risk the train/subway connection.) I did find the express bus, and after all that worry, was more than a half hour early for my train. The train station was also NOT confusing (my Thai friend reported I might need a half hour to find things) and I had plenty of time to buy water, juice, milk, and 2 donuts from Mister Donut before getting on the train and sitting for 20 minutes before departure. This was my first time on a sleeper train - I had booked a second class lower bunk with AC. I had been warned that the upper bunks are quite narrow (this is true, plus you have to climb a ladder to get to them) and the cabins are freezing (also true.) An hour or more into the trip, and after one donut, the train attendant came along and made my bench seat and the one across from me into a lower bunk. It was fun watching him - he clearly has an incredibly honed set of motions to make all the beds up as efficiently as possible. I changed into my pajamas and settled down for the night. There were some stops to pick up passengers and some longer delays throughout the night, and we arrived 2 hours late, but the bed was comfortable and I slept through most of the night. (I had to fold my blanket in half to have 2 layers, and wear 3 shirts, but luckily I am short enough that that worked.) And since I don’t have a watch and my cell phone battery was dead, I had little sense of the passage of time, and no ability to worry about it.

Two views of my sleeper bunk

My seat mate commented snidely on my profession in light of my breakfast; 1/3 of a baguette with spreadable cheese and 2 kinds of lunch meat and my second donut, plus a box of apple juice. I’m not sure what I was supposed to eat - it’s not like there’s a great supply of fresh fruits and veggies on a train (or in the train station.) Finally, we arrive at the Nong Khai train station, were I decided to try taking the little train from thai to Lao. This saves money because otherwise you get a tuk-tuk to the border which is the same price, and then a bus across. Plus, it’s more convenient. However, I discovered it does NOT save money on the other end - the train station is maybe 1 KM from the rest of the border, the city bus does not go there, and you are at the mercy of the tuk tuk and mini-van drivers who are waiting for you. I refused several expensive offers of rides into town (which would also have required me to wait for some of the rest of the train passengers, who were all still in line for Visas), but one of the mini-van drivers took pity on me, or appreciated my bargaining in Lao, or had to leave to come into town anyway, and offered to take me right away for 100 baht (3.3 dollars.) It’s 26 KM, so that seemed like a reasonable price to me. (Though the bus is <1 dollars, the minibus was also more comfortable, and dropped me at the end of my alley.) I ended up paying him in kip - 5 dollars - sort of a tip for breaking ranks with his compatriots. Returning along the road from the friendship bridge, I felt like I was coming home, which is a really nice feeling, and I’m glad to have it here after only 4 months.

Mekong from the train

My parents, in their journeys through Thailand, had even more adventures, but those are their stories to tell, and this post is already long. Each of these travel days was sometimes adventuresome, sometimes nerve-wracking, sometimes rewarding of good communications or planning, sometimes boring, and sometimes interesting or beautiful. I am sure I will remember some parts of these trips for as long as I remember the fish I saw snorkeling or the food I ate in Thailand - so maybe the journey really is the destination.

Holiday

It has been a busy couple weeks. The week Hakon and Karen (The health frontiers founders) were here, we had 3-4 meetings daily with various government and university officials. This meant I didn’t get out to Setta to round, and while they were interesting and useful meetings, it is fatiguing to have that many. I’m glad that in my day-to-day work meetings are rare enough that I generally look forward to them, or at least feel neutral about them.

The residents at Setta right now are not the strongest in english, so I feel especially bad for missing so many days with them - and today I leave for Phuket and Ko Samui (Thailand) where I will meet my parents. Especially because despite their limited english they are always happy to try and present a case, and if we both work we can understand each other, and then they are very happy to be getting teaching and english practice. But I’m excited to see my parents, and to have a vacation. Life in Vientiane is not as busy and stressful as residency was, but after a week of meetings and then 4 days of catch up and trying to get ready to go away for a week, I need a holiday!

This morning the first thing I did was ride my bike to the bus station to find out the times for busses to Udon Thani. I managed to find out where the busses were and get the departure times in Lao, and at the end of the discussion the bus driver said my lao was “Keng” (strong) which was the first positive comment I’ve gotten on my Lao communication, and then asked me if I was working in Laos and how long I’ve been here, all of which were questions I was able to answer. He smiled broadly at me when I told him I was working at the hospital, and I headed home feeling like I’ve finally made some progress in learning Lao. I hope this week I’ll have some beach time that can be spent with flashcards to expand my vocabulary. Last weekend I successfully gave directions to the pizza delivery place that got them to the end of our small road before they had to call help, so I am starting to be functional at the critical activities of daily living. Pizza and the ability to take the bus - what more could I want?

Aside from the mild fatigue of many daily meetings, Hakon and Karen’s visit was great. It was nice to hear more about the history of the organization I’m working for. But better than that, was the obvious recognition, respect, and appreciation of their Lao colleagues. So many foreigners are here in Lao working now, and Health Frontiers is certainly not spending as much as most of them. However, the Lao recognize that the establishment of the residency programs is a significant contribution, and remember that Hakon and Karen were here before most NGOs knew Lao existed. It is really great to be working for an organization you can be proud of. So I’ll be happy to be back at work next a week from Monday. . .

Thankful Again

My last post was exclusively about social stuff, and I think my work deserves a thanksgiving post as well.

A few weeks ago, one of the residents complained that some residents (not him) lack physical exam skills, and I should spend more time teaching exam skills. In general, Americans think of doctors in the developing world as having much better physical exam skills, because they have fewer imaging resources and lab tests to confirm their diagnosis. However, this has not been my experience, here or in Africa. I think it’s because you do still need a teacher skilled in physical exam to encourage and supervise your learning. My residents here are very good at some things - they can confirm ascites with a fluid wave or shifting dullness at the drop of a hat (thanks Hepatitis B!) - a skill I never practiced much in America because it requires 2 people, and also because American patients tend to look askance at you when you try to have one person press down firmly on the middle of their abdomen and have another tapping and feeling either side. And in America, if there is every any question, you just get an ultrasound (or look yourself with the portable.) But some of the more basic exam skills - good cardiovascular exam, neuro exam, etc are at or below the level I would expect from an American resident, probably because they don’t have good teaching for this. (They have a great GI teacher. They also have good cardio and neuro teachers, but I think they get less face-to-face time on the wards with them.) So I told the resident that was complaining that I believe learning good physical exam skills is mostly achieved by taking the time to do a thorough exam on many patients, even those you expect to have a normal exam, so you get in the habit of doing things well and efficiently, and so you get familiar enough with normal to recognize small abnormalities. Of course, this practice has to be paired with the willingness to ask a teacher when you’re not sure, and the availability of a teacher who can answer your question. I’ve been trying to do more exams on rounds, watch the residents do more exams, and focus more on physical findings in our discussion of assessment and plan since the complaint.

One of the things I have noticed residents here do not do (much like residents in America) is examine wounds. I have seen several patients with diabetes and possibly infected foot wounds who were presented to me and the residents could not describe the wound for me when asked. I have tried to model good behavior by unwrapping and looking at the wounds, but decided to do some formal teaching as well. So, last week I lectured on Diabetic Foot Wounds and created a hands-on lab where they used pig feet that I created wounds on to practice the probe-to-bone tests. (For my non medical readers, if you can feel bone at the bottom of a wound it changes your decisions about antibiotics significantly.) It turns out, pigs feet have pretty tough skin, too, so if anyone is tempted to repeat this exercise, I advise you to buy as scalpel or two before starting your wound-creation. I ended up using my matt knife extensively. The probe-to-bone demonstration was also harder that I thought it would be, because after visiting several medical supply stores I had to come to the conclusion that there are no sterile swabs in Laos. So we used Q tips soaked in Iodine as clean (but probably not sterile) probes. The residents all giggled when I brought out the pigs feet, but they did all practice, and hopefully learned something. And several cameras emerged from bags to take pictures, so I think they liked the exercise. Hopefully, it will change the way they approach (or don’t approach, currently) diabetic foot wounds and give them some confidence in their ability to examine and assess them.

I think in America if I had made residents practice exams on pigs feet, they would have felt like it was unrealistic and a waste of their time. So I’m thankful to be teaching here in Lao where any extra effort you expend in teaching is much appreciated by the residents.

Thankful

This week, I didn’t celebrate Thanksgiving, but I do find myself thankful on a daily basis for this opportunity. I’m also glad I know myself well enough to know that trying to orchestrate Thanksgiving dinner here was going to be a lot of stress and hassle, which would outweigh the small gratification I would get from sharing and American holiday with my new friends and colleagues in Vientiane. A few years ago, I would have felt I had to prove something to myself about my ability to host a good dinner. If there’s anything American residency taught me, it’s to carefully assess the benefit / cost of such and undertaking carefully, though. :) And tonight I’ll go have a nice French meal to mark the holiday, hopefully to include Chocolate Souffle, which will be a rare treat, will probably cost less than feeding a large group, and will not require any prep time or errand running on my part.

Pre-wedding photo

Friday was mostly devoted to Ning’s (our housekeeper) daughter’s wedding. At 9 AM I got dressed up in my silk sin and satin shirt and Amy, Amy’s parents and I went to the bassi. Each table in the tent set up outside Ning’s house had a bottle of Johnny Walker on it and several large Beer Laos in preparation for lunch. Before the ceremony even began, I was pressured to have a shot of whiskey, but Amy took it for me, since I was the driver. The groom arrived in a celebratory procession, had a gold belt placed on his waist, and had his feet symbolically washed by a cute little girl. The guests were all gathered in a carpeted room with 2 giant banana leaf and marigold and string centerpieces/altars with various items important to the ceremony gathered around the bottom. (Eg: water, sticky rice, a whole chicken, another bottle of Johnny walker, etc) The bride entered from inside the house with a fabulous tall, cone-shaped hairdo and long, sparkely fake nails. The officiant called the spirits and there was some rice and marigold leaves thrown (so everyone had rice in their updo’s for the rest of the morning) and then there was a ceremony which culminated in bride and groom tying white string around each other’s wrists. Then we all lined up to tie white strings on each of their wrists, with their parents and other important people going through first. Then everyone started tying strings on each other. It is important to tie at least 3 knots, and the string is supposed to stay on until it falls off on it’s own, but after 3 days you’re allowed to cut the ends quite short to encourage the process. There is a lot of dust in Vientiane, so my string is already looking kind of grayish after only 24 hours. We did not stay for lunch because by the time the ceremony was over Amy and her mom had each had 2 shots of whiskey, and her Dad had had 4, one of which was at least a half wine glass full. We had work to do in the afternoon, so we left before the heavy drinking began. . .
(The bride and groom with the officiant. You can't see it well here, but the groom still has his Faux-hawk, despite his otherwise traditional garb.)

Ning doing her string tying

At 6:00 I went to the hair shop next to Amy’s house where I had my hair coiffed - there were braids, twists, sparkely barrettes, and curls when I as done. We then went to the hotel for the reception. In Lao, there are no wedding gifts, you just put some money in your invitation envelope, and then put it in a giant box on your way into the reception after going through the greeting line. Then you have a shot of whiskey and entered the reception area. We arrived at around 7:45 and ended up sitting at table 60/67 (10 people/table.) Each of these tables also had a bottle of Johnny Walker. After some wait, the bride and groom and their families processed in and we were served dinner. Then the bride sang a song and the bride and groom cut the cake and opened a giant bottle of champagne which they poured into a tower of glasses. Clearly, the French did a shoddy job of teaching the Lao about champagne because the groom was instructed to shake the bottle vigorously prior to attempting to remove the cork. He had trouble getting the cork out so he ended up shaking it 4-5 times before he actually managed to get it open. I was worried that someone was going loose an eye, but it must’ve been the flattest bottle of champagne ever because it didn’t even foam after all that shaking. (The whiskey was authentic, though) After this, the dancing began. Unfortunately, I didn’t get to learn the traditional Lao wedding dance, because there was a lot of new Lao line dancing happening. But Ning looked happy, and we had fun. At about 10:30 we headed out, and after 15 minutes of waiting for a tuk tuk, we had the hotel call a taxi. (Oh yeah, there is not a lot of late night transport in Vientiane, so most of the guests drove themselves home. A good reason to leave early.)

Me in my silk sin and fancy shirt at the reception.

After all that, I see why Ning has been so stressed the last month or so, and I can’t imagine how the Lao afford such giant weddings - this would have been expensive in America, and I’m sure costs are equivalent or more than America in terms of what people earn and what weddings cost. I guess it’s good that they can use all the gifts to replete the bank accounts and pay the rest of the catering bill. I liked the basi - it was relatively short and sort of personal (thought the officiant had to ask the bride and groom what their names were, so not THAT personal) but the giant reception was a bit overwhelming. I hope the bride and groom are very happy, though, and I hope Ning feels like all her stress paid off.

Pbai Saa Saa

The longer you go without blogging, the harder it is to restart, because prioritizing what to write about gets harder as more events accumulate. . . So I’m going to just start at some random middle spot and write about a few things.

Jon and Rose, the doctors from Regions hospital who ‘recruited’ me to be the HF residency coordinator are visiting Lao for 2 weeks. This has been fun for many reasons - they brought me some silver sulfadiazine for my burn and several tubes of Neutrogena sunscreen and moisturizer from home (the only thing I haven’t found here as far as cosmetics go - it’s hard to find moisturizer without whitening agents, which I don’t want and am pretty sure my dermatologist would not approve of.) They also brought me a gold Buddha poster from Luang Prabang - I had wanted to buy one but we missed the second night of the night market because we were busy sending our sins down the river. And they buy me dinner every night as a way to “support my volunteerism.” But most importantly, they give me good perspective about how things have changed (mostly for the better) or not changed (again, mostly for the better.) And after a few months here by myself, it’s nice to have some other people familiar with the systems of internal medicine to bounce things off. I know I could do this by e-mail any time if I had a big question, but for 2 weeks I can bring up small questions that might not be worth writing an e-mail about. Plus, there’s something that’s just different about discussing things in person - there are nuances that can’t be conveyed by e-mail. So one week into their visit, I am very happy to have them here.

I had several challenging patients last week - a woman younger than me with Acute Myeloid Leukemia M5 (A disease which is fatal more than 50% of the time in America) who had gone to Thailand and had several rounds of chemotherapy, survived at least one episode of neutropenic sepsis in Thailand, and been sent home after her last round of chemo. She relapsed and came in to the Lao hospital with GI bleeding, low platelets, and fever, with a high enough white blood cell to be sure her leukemia was back. (Which was the far most likely outcome after chemo, so not surprising.) She didn’t have enough money to go back to Thailand, so died at Setta of “cardio-pulmonary arrest” overnight one night. It’s always hard to see someone younger than you that you know is going to die (or has died) but it’s even harder when you also know that family just spent their life savings on chemo for a disease that is hard to cure even with bone marrow transplant, and to cure it with chemo alone would be almost a miracle. I don’t know what kind of informed consent is possible given the immense difference in education and the fact that Thai and Lao are similar, but not the same language, but I feel like it probably wasn’t enough. I think if you told most 27 year olds here that they could get chemo but still had a 90+ percent chance of dying, and it would deplete their family’s life savings, they would go home to spend their remaining days with their family, because there is a much more acute awareness here of the value of even a little money to make many people’s lives better.

On a happier note, yesterday I went to the Nam Ngum Dam with some lovely Swiss-Germans. Tanja invited me, I think as a sort of thank you for looking after her for a few days 2 weeks ago while she had Dengue. (Which I really hope not to get, after watching her have it.) It was beautiful - much larger than I expected. On the way there we stopped at a salt factory, which was really interesting. Then we drove on to the dam, which looked small from the bottom, but had a giant reservoir behind it, and supplies most of the power to Lao, plus exports a lot of hydroelectric power to Thailand. We had lunch on a restaurant overlooking the water - delicious lake fish - and then took a short boat ride in a giant, noisy boat before the minivan ride home. I didn’t get to swim, and the water wasn’t the clearest, but I think if you set out a bit earlier you could do some pretty cool hiking or boating with lunch on an island.

Lao Lao Liaw Laew

These four words mean: a person or thing in/from Laos, whiskey / alcohol, turn, and and then / already. I think I am understanding more Lao, but speaking is hard, and the more I learn, sometime the more confused I feel. Our teacher is very patient with us trying to figure out the differences between words that are clearly different to her.

I have had a visitor, Dr. Leila from Mung Sing, a former Health frontiers pediatrics co-ordinator who now lives in far northern Lao and helps children there. It has been interesting to hear all her stories of living in Lao for the past 7 years, but has also been time consuming, so I have not had much time to blog. (Or reflect on the last week and a half.) However, she has had some incredible experiences, particularly in looking for victims of Noma (a malnutrition / immune compromise related disease in which portions of the face of children essentially rot away - google image Noma if you have a strong stomach). They are located in the poorest areas of Lao (and therefore the hardest to get too. When Leila found the first victim, it was thought to be a disease which occurred only in Africa, though historically it had happened worldwide 200-300 years ago. She has now found 22 victims, and arranged for reconstructive surgery, which not only improves their appearance, but often restores their ability to eat solid foods communicate better, etc. Now she is traveling around the country again to follow up on the outcomes of the patients.

While Leila was away, I went to the COPE ( http://www.copelaos.org/ ) concert Saturday night. It was raining, but this didn’t really significantly diminish my enjoyment of the music, as it wasn’t cold. I saw two bands perform - a sort of Lao ska band who were quite good except when they allowed a female friend (girlfriend of a band member?) to sing with them - then we got a truly off rendition of “Knockin’ on Heaven’s Door.” The second band was “U Luv Us” - a band composed of foreigners who sing pop-esq ballads and faster songs in Lao. Their music is pretty good, and they are totally hilarious to watch with their faux hawks and heart shaped sunglasses and smoke machine. There were two Lao girls standing right behind us that kept screaming with glee when they started/ended a song etc, which only added to the experience. Luckily, no one fainted since we were outside in the rain and mud. Unfortunately, I was too short to get a good look at the hip-hop dancing troop that performed between the bands, but I think hip-hop dancing troops are quite similar world wide, so it’s probably ok. This suspicion was confirmed by the fact that one of them was wearing a Michael Jordan jersey. Dinner before hand was at the Taj Mahal - Lassi’s, samosas, nan, rice, daal, and chicken Korma for two, all for less than 9 dollars. Delicious!

COPE is a great organization that provides rehab, prosthetics, mobility devices, etc for victims of cluster bombs (Thanks, America!) and other disfiguring, disabling accidents. They also have a blind school and a deaf school on their campus. (There is no ADA here, so blind, deaf, or otherwise disabled children are often refused entry to schools.) They have a visitor center that has some information on cluster bombing and it’s prolonged consequences, as well as profiles of some of their successes. The conference to ban cluster bombs will be in Vientiane in November, which is appropriate as Laos is one of the most heavily bombed country in the world. Of course America has not yet ratified this ban. . . Anyone planning to visit me here in Vientiane can expect to visit the COPE visitor center as well.
Sunday I went to the Buddha park. The Buddha park is as statue park about 25 KM (or 45 -60 min) outside Vientiane, past the friendship bridge. It is filled with statues of Buddha and Hindu deities which were commissioned by a man who was out walking in the mountains when he fell through a sink hole landing in the lap of a Guru. This experience inspired him to make or commission giant concrete statues of Buddhist and Hindu deities, which were made by people who had no formal training in art or sculpting. In this context, the quality is actually surprisingly high. The statues are all packed pretty close to each other, which makes them hard to appreciate individually sometimes, but easier to see as a body of work and to think about the inter-relatedness of the myths etc. It was drizzling off an on, which hampered my enjoyment (and photographs) somewhat, but it was a nice way to spend an afternoon. On the way home I stopped and bought oranges and bananas at a local market all in Lao! My visitor from America arrived home from Vang Vieng Sunday evening, and I got to hear about his trip at dinner. Then Leila arrived from Khamua and Bolecomsai, where she was following up on Noma patients, and scarfed down some spaghetti (I’m not the only one that misses pasta!) and we walked home from downtown together.

On the work front, things are good. The “most talkative” (his own description) chief resident has returned from two months in Khon Kaen, Thailand, and the other 3rd year chief is away at Khon Kaen, so Phanivone has been ruling with an iron fist. Not really, but last weekend he called me at 7:40 AM on Sunday because the printer in the resident room was not working, and they wanted me to bring a new toner cartridge to the hospital. (I did not.) Turns out that the printing emergency was an organizational chart which assigns all the residents duties in teaching (eg: rheumatology, cardio, endocrine) and in more mundane tasks (budget, accounting, cleaning the resident room). The task and resident responsible were printed, and then they were all pasted to a poster-board, and once they add the resident’s pictures they will hang it. They love adding passport photos to things here - that makes it official. I will take a picture once they’ve got it complete. I don’t know if I’ll ever be able to tell whether people are doing their assigned job, or how the assignments were made (I suspect it was not a democratic process). The good news is, they were able to solve the toner emergency without me by shaking the ink cartridge. Phanivone has translated two or three of my lectures now and I can tell he is adding in things (because I’m hearing english medical words I didn’t say) but I suppose as long as they are accurate things, that’s ok. They seem to usually be things I was going to say later in a more detailed section of the talk. The residents are very patient with me - they do not complain when lecture goes over the 1.5 hr time, and even manage to still look interested and clap at the end. However, I must do better at limiting what I try to cover.

We had KKU grand rounds on Friday. The speaker was an Electrophysiological cardiologist trained at Duke. I remembered to check the gas tank this time, so there were no embarrassing trips to the gas station. The topic was update in the management of arrythmias, and I think it was better received in Thai than the recent french lectures on the same topic. In Lao, we do not have a cath lab, so there are no EP ablations (Or stenting for Acute MI, for that matter), but in Thailand they can do all of those things, and a pacemaker is only 1000$! (Though the Thai have socialized medicine, so they pay 1 dollar for each hospitalization) This doesn’t really help the Lao, because for most of them 1000$ might as well be a billion dollars - there’s an equal chance of them seeing that much money - but I think they are more likely to get cath labs, pacemakers, etc, if they keep hearing about it from their neighbors.

Excellencies, Ladies and Gentleman

Wow, it has been a busy week. Last night I went to a concert celebrating the 15th anniversary of the re-establishment of friendship between the Republic of Korea (South Korea) and Laos. In the introduction and concluding speeches, they addressed us as “Excellencies, Ladies and Gentleman.” I’m pretty sure that the excellencies were only the diplomats in attendance, but it was still funny. The concert was pretty cool. It was sponsored by a “Beautiful Mind” organization of South Korea which aims to promote friendship and peace through music, and to support disabled or underprivileged children in learning music. They played some classical music in the first half, then they had a pianist with cerebral palsy play after an inspirational video about his struggle to gain dexterity in his fingers. The second half was traditional Korean instruments, which was really cool. My favorite was the Haeguem, an upright stringed instrument played with a bow, because the woman playing it moved her shoulders and back when she moved the bow, so it almost looked like the instrument was playing her. They also had traditional drums, a long stringed instrument played with the fingers, and korean flute. For the finale, they played Edelweiss, a russian folk song, a korean folk song, and then a much loved Lao song about the Dok Champa (Frangipani flower) with the korean traditional instruments and piano, violin, and cello. Supposedly, there are only a few classical concerts each year in Vientiane, so I’m glad I made it to this one. Plus, it was inside the Lao cultural hall, which I hadn’t been inside yet, so that was an interesting bonus. Concert etiquette is very different here - people were arriving, leaving, and stepping out for phone calls throughout the concert, and they had the performers use microphones (which I don’t think they would have needed to do for a space that size) but it was free, so I really can’t complain. Afterward, we had dinner at as small Japanese restaurant, and then drinks at the Jazzy room, a bar up a small wooden staircase that had posters of famous American jazz musicians hanging.

On Thursday, my first visitor arrived. Dr. S is an internist doing primary care in America, who has come to volunteer and teach for 3.5 weeks. He originally trained in Hong Kong, but has been practicing in the resource-rich setting of American medicine for the past 10+ years, and I think this is his first trip to the developing world, so he had quite a culture shock on rounds yesterday. For example, on Thursday I saw a patient with likely periodic hypokalemic paralysis (A very rare disorder of suddenly low potassium, often overnight, leading to muscle weakness.) On Thursday we had gotten his potassium lab back and it was 1.54, (ridiculously low, for my non-medical readers) so the residents planned to give oral and IV potassium and recheck the level. Friday morning. In America, this would be completely unacceptable, but here even if there is a lab tech who would run the lab at 4 or 5 PM after replacement, there is no doc to follow up on the result, as there is no formal cross-cover sign out. And his weakness was improved, so hopefully his potassium level was improved as well. Our visitor was shocked that the residents had not checked the level again, whereas having spent 2 months in Africa, once daily labs (at the most) are what I expected when I arrived here. (Bonus: I got to see real live U waves on EKG with this case, for the first time. Not small ones either. I have a copy of the EKG.)

Thursday I finally visited the temple with the little Buddhas. A monk who spoke a little english explained to me that the Stupa collapsed and they found all the little Buddhas. Since Stupas are filled with Buddhist relics or symbolic objects, I guess that finding the little Buddhas was not surprising. It is still pretty cool, though, because they are old. The little Buddhas had been placed on a table and baskets in the main temple which had been closed off, and a small altar set up in front of the table, where people are coming to make offerings of marigolds, incense, candles, and money. I will try to post pictures on Facebook. Thursday evening, at english class I was presented with a coconut pastry and a pineapple pastry for national teacher’s day. At my IM lecture (“GI anatomy”) I was presented with red wine and informed that not only was it national teachers day, but they wanted to keep my cholesterol low. I guess residents come up with the same excuses for drinking red wine worldwide. . . having used this to justify more than one glass of red wine over the past 3 years, I had to chuckle. Though I don’t think I ever combined red wine and a lecture in my day.

Now I am off the market to buy a couple more sin’s (Lao skirts) as I have been told that the residents will get bored of my first 4 soon. I have two medium blue, a purple, and a light blue now, all with horizontal stripes, so I think I’ll look for something pink or purple with vertical stripes.

Bor Pben Nyang

It has been a busy couple weeks here. And I have a cold. So I will apologize for not posting more frequently. Hopefully you, dear readers (Mom) will say “Bor Pben Yang” which literally means “no ask why” but is used to mean “no worries” or “it’s ok.”

Christine has gone home to Minneapolis after her trip to China. She got back to Lao Thursday afternoon and it was a whirlwind weekend of packing, saying good bye, and last minute information sharing. She was kind enough to lecture Thursday night on urinalysis and urine sediment while I got the microscopes set up. (They have recently returned from Bangkok where we sent them for cleaning.) Unfortunately, as I unwrapped them, I discovered that one was broken in transport, so we only have one working microscope right now. Frustrating, especially since Christine spent a lot of time in the last several months figuring out how to get them to bangkok and back safely. Thursday I also started feeling sick, and had a fever and myalgias by Thursday night, so it’s lucky Christine was planning to lecture. Friday night we had a going away dinner for Christine at “Moon the Night” a restaurant on the Mekong, and then went to a see a friend’s band “ULuvUs” play. The band is composed of all falang (foreigners) but sings songs in Lao (with some english phrases) and has quite a following of falang and Lao. Apparently, they have even made it fairly high on the charts in Thailand. Erwin, our friend, is Australian and plays the Keytar and keyboards. The music was pretty standard pop - but they had some good tunes and it was cool to hear them sing in Lao.

Saturday we had resident games as a going away event for Christine. We played soccer, did the limbo, played basketball, jumped rope, and finally had medicine vs pediatrics tug of war. Medicine won for the second year in a row, despite having Joey, our english teacher, anchoring their team. To be fair, they are mostly girls. I played soccer for the first time since elementary school, (which is to say quite badly) and the residents were all very kind and did not make fun of my lack of skills. We had a lot of fun, and it was good to be reminded of how much fun a group of adults can have with just a soccer ball, a mop, and a rope. Unfortunately, running around for 3 hours after being up late was not good for my cold, so I spent the afternoon in bed rather than watching the second Australian Grand Finals. Fortunately, Collingwood, Chris’s team, won by a large margin, so everyone in our group was happy with the day. Sunday we had a last breakfast and lunch at Kung’s (last for Christine) and I helped her pack her bike up. In the evening, we crammed a few last things into her 5 suitcases, weighed them. (I need to learn not to weigh my suitcases on bathroom scales. They are never accurate and just lead to more anxiety) Amy, Chris, and I drove her to the airport, where her total luggage weighed in at 133 kg (5 cases and a bike in a box) which is actually not a bad accumulation of stuff for the past 2 years, I think. Some of the residents met us at the airport with a bouquet of roses for a final good bye. It was sad to see her go, and I hope she is happy once she settles into her new job back in Minnesota.

I still have not made it to the temple near our house where the small Buddhas were found. But I have arranged lecturers for most of GI month (October) which took several visits to Mahosot last week. I will start with GI anatomy Thursday, and one of our fellows will teach GI bleeding tomorrow. Today’s lecture was cancelled because of a symposium by the IFMT (Institute Francophone Medicine Tropical) - I hear they have good teaching mostly in Lao at this, so that’s ok.

Today Tanja and I bought our tickets to Luang Prabang for the weekend before Halloween. We will ride the bus (8-9 hours on a “VIP” bus, with air conditioning) there on Friday, to see the country side, tourist on Saturday and Sunday, and fly home (1 hour) on Monday. I will take my zofran with me. Luan Prabang is one of the main tourist destinations in Laos - it is known for it’s old temples and scenic parading monks - and the weekend we are there will also be the end of “buddhist lent”, so they will be floating banana leaf boats down the river for good luck in the next year, too. We will miss the boat races in Vientiane, but I think we will be able to see more of the banana leaf boats, and it was the only weekend in October or November that I could take Friday and Monday for travel. So that’s something to look forward to, and I may soon have my multi-entry visa, so I can also think about a trip to Thailand.

Wat Miracle?

Apparently, at one of the wats near our house, there was some construction going on and something collapsed revealing tens of small Buddha statues, that are presumably old, since no one knew they were there. This is likely not an actual miracle, as someone probably buried them at some point, accidentally or purposefully, but it is the closest I’ve lived physically to any sort of religious happening. Tomorrow, I plan to go visit and try to see these Buddhas, as I hear they are quite attractive. (Oh, and get used to the Wat puns, I anticipate they will keep coming.)

I learned about the small Buddhas from my first independently-acquired friend in Vientiane. I have not lacked for social engagements or opportunities since getting here to Vientiane, but all of them have been with people that Christine or Chris and Amy are friends with, and you never know whether you’re being invited to stuff because people want you to come, or if they feel obligated. And I sense that there is some degree of visitor / short term guest fatigue that sets in amongst the people who have been here for several years. I don’t know if it would bother me, but I can see how many people would just get tired of meeting and getting to know new people at some point. So I am happy to have independently found a friend, because I was feeling a bit frustrated / worried. Although, when I think about it objectively, how many non-med school classmates and non-relative friends did I have a month after moving to Minnesota? The answer is zero, but I think I feel more pressured here because I am probably only here for a year so I need to get started. :)

Tanja is a Swiss doctor visiting Vientiane for 3 months to finish the 2 years and 3 months of work abroad she needs to do to qualify as a specialist in tropical medicine in Switzerland. Yes, MN friends, that is 2.25 years abroad. We are lucky with our 2 month requirement from ASTMH. She is also a pretty cool person. Her first year abroad was in the Congo with MSF. I told her I was impressed and I didn’t think I’d be brave enough to go to the Congo, and she replied that she really felt quite safe there. She was re-building an old Belgian hospital that had been destroyed in the civil war, doing clinical care, and training local MDs. The area was accessible only by bush plane or extended (many days) over-land journey. It sounds like it was an incredible experience, though in some ways very frustrating because of very limited resources. She was evacuated once, but she thinks MSF was maybe too aggressive about taking people out of potentially dangerous situations. That’s reassuring, I guess. Her second year abroad was in French Guyana where she had great resources and equipment, but struggled with the poorly trained and un-motivated to learn doctors. I think this supports my theory that patients and doctors are unsatisfied to some degree with their medical care system worldwide, no matter where it is. It’s not much comfort, but sometimes when you’re really frustrated with your situation at home, it’s a little. Her first impressions (after 2 weeks) is that the Lao doctors are really eager to learn and provide good care with limited resources. I think this is true in my experience as well, and since she’s on a ward with several of ‘my’ residents, I’m happy to hear she is impressed. And to be fair, the ID ward she is on has limited diagnostic resources, but Paul, the lab director and ID specialist seems to have picked those resources very well to tailor to accurate diagnosis and timely treatment of the problems they see most often here.

The Australian rules Football Grand Finals was very fun - somehow heckling is so much more enjoyable with crazy Australian slang and accents. And it’s a game that can actually be pretty edge-of-your-seat exciting, and worth heckling. This game in particular - it was tied at least twice in the last quarter with the last (and tying) goal being kicked in the last 2 minutes of play. There is no overtime, so we get to watch _another_ grand finals match next Saturday. From my perspective this is awesome, though of course the people who were rooting for a favorite team are pretty disappointed. Next weeks game probably won’t be as close or exciting, but we can hope. We are not sure if Chris will actually come home this week - he may stay if he can get a ticket for next Sunday’s match. We will miss him at resident’s games next Saturday morning, but will understand if he stays in Australia.

The letter R

There is no R sound in Lao. My understanding is that they used to have an R, but they got rid of it. It seems kind of harsh to me to just get rid of a letter all together, but they must have had their reasons. . . Thai has an R, though, so my residents and english students know how to say R, they just often forget to. And it does make some words more fun - curriculum, for example, sounds much more musical as culiculum. My Lao is very slowly improving. I know most of the question words now, usually understand numbers if repeated slowly, and am starting to recognize words here and there on the wards. There are still tonal differences that I will probably never be able to fully hear, much less replicate, and differences in the length of consonants that I struggle with. (For example if you say you are very tired incorrectly, you are saying that you have a lot of pubic hair, and if you say “I’m going to eat pork for dinner” but linger too long on the word pork, you’ve said that you are going to eat your friend for dinner.) The good thing is that there are no tenses to memorize and verbs are not conjugated depending on who they refer to. I’ve been struggling to teach irregular verbs to my english students, so I’m glad I don’t have to learn them in another language too.

Last Friday I watched one quarter of the Australian football semifinals. Australian football turns out to be way cooler than american football - it requires actual athletic skill; both cardiovascular fitness and coordination to kick and run with the ball. And it is not interrupted every 30 seconds for some esoteric rule. I hope to watch the grand finals with Amy tomorrow - Chris is leaving tonight at 9 and flying home for the game, because his team is playing and he won a free ticket in the lottery. He has never seen them win a grand final (though he has been to two grand final games) and his whole family are die hard fans and members of the athletic club the game is being played at. Given that his team won the semi-finals game by a margin of 60 points, (and only because they relaxed somewhat for the last quarter, which they started with a lead of about 80 points) I am hopeful that he will get to watch them win this year. And also that he gets there on time - he only has 3 hours from the time his plane is scheduled to land until the game starts!

I never thought, after all those months on the medicine firms at the U, that I would wish I could have more patients who got ERCPs. But I do. This week, I have seen 3 patients that have common bile duct stones and none have had anything done about it. The surgeons said they would operate on the first one, but then they waited over last weekend and monday he was septic so they transferred him back to medicine. As the intern was writing orders to start antibiotics for ascending cholangitis, his family was trying to decide whether they should take him home now, because it would be hard to get him home if he died in the hospital, or to let him stay and start antibiotics. On one hand, he did have elevated AFP levels and likely cirrhosis, so he might die in the next months - year anyway, but on the other, he had a very treatable problem which would likely be fatal if he doesn’t get IV antibiotics and ultimately have the stone removed. I really wished that he had gotten his surgery on friday. The second patient came with a month of right upper quadrant pain, not one but 2 ultrasounds confirming a CBD stone and dilation, and had been refused surgery because he was septic 2 weeks ago at his second presentation. He was treated for ascending cholangitis and discharged to home with plans for an elective cholecystectomy in a few weeks. He came back, still on antibiotics, no longer febrile, and with ongoing pain and was refused surgery because he had elevated liver function tests. Gee, I wonder if that could be due to the bile backing up into his liver and irritating it? A third ultrasound confirmed that the stone was still there, causing trouble. My resident and I agreed that if after being offered a second chance to surgerize him at Setta he was not accepted he would be sent to Mahosot, where there is a GI specialist that can do some ERCP, and/or maybe (Hopefully?) has a good relationship with a surgeon. The third was a similar story - a woman with a CBD stone and fever, who was initially refused surgery due to sepsis, and then the surgeons wanted to send her home for a couple weeks before operating. I didn’t anticipate running into the age-old medicine vs. surgery debate here as quickly and throughly as I have, and I feel somewhat adrift as to what to do. At home, I would try to talk to the surgeons personally, (Or have my staff call their staff) but here I’m pretty sure that would be inappropriate, plus I don’t speak Lao, so I actually can’t talk to them. And there is clearly a pattern of decision making emerging, so I don’t want to ask my residents to confront or try to explain to them, knowing that they probably need to preserve good relationships with their surgery colleagues for the benefit of future patients. So I’m pretty much left encouraging the patients to go to the “GI hospital” if they get discharged and have recurrence of symptoms (which they almost certainly will) and praying that some of those stones magically work their way out on there own. I’m not an optimist, or good at not being in control, so these are not great options for me.

Wat?

Buddhist temples are called wats. They are all over Vientiane. Literally, like every 3 blocks. I’ve only been in a couple, but if I wanted to go to one a week for the next year, I feel confident that I would not have to go back anywhere. The day I arrived, Christine took me to a wat near our house and showed me some monkeys she can hear at night. (I haven’t heard them, or haven’t recognized them as monkey sounds.) They were pretty cute, but unfortunately, I was so tired and disoriented from the 29 hour journey, that I have no idea which of the 3 wats within a 2 block walk of our house (one north, one south, and one east) they live in. In fact, I’ve found that while Christine showed me many useful places (the department store, the DVD store, and the book store amongst others) that afternoon, I have been unable to return to an of them without getting directions again. It was still a nice tour, though, and a good way to stay awake until sunset, so I didn’t have major jet lag. (I slept till 5AM the day after I arrived, which was a new record for sleeping in according to Christine)

(The monkey!)

Yesterday, I visited the That Luang, (Stupa Yellow) which is the national emblem of Lao and has a Wat on either side of it. The that is a tower that rises 45 meters and is painted gold. It is actually a temple as well, and the distances and heights are symbolic in Buddhism, as are the numbers of things (a certain type of stones, lotus petals on top of the walls, etc. There are also 4 prayer halls, one facing north, south, east and west. I got there at about midmorning and it was threatening to rain so there were lots of interesting lighting and cloud changes during my visit. My favorite part was the Naga, or giant snake, which seems to be a common theme, and aside from flat walls, there was pretty not many things that didn’t have a naga - stairs, roofs, etc.

(The That Luang)

Just as I was leaving the That Luang (which cost 5000 kip, or 62 cents to get into) it started to sprinkle, and it looked like soon it would be down-pouring. So I popped across the street to the wat to the south of the monument, where I took of my shoes and sat in the main temple building under the roof for 15 or 20 minutes while it rained. This wat had a high, steeply arched roof with wide overhangs, but only one side had a wall. So it was kind of like sitting in the rain, without getting wet. The wat compound had many other buildings - smaller, enclosed temples, a giant Budda statue on the second floor of an open walled pavilion-like structure below, several other pavilions with many buddha lined up sitting and standing, and some enclosed buildings that must be housing for the monks. (In fact, one of our residents is living at a temple, so I know there is housing in the compound.) Inside the main wat, there are beautiful paintings on the ceiling, which presumably depict stories from the life of Buddha. I will have to read more about that, so I can understand them better. In the middle of the one enclosed wall is and alter, and to one side is a sort of pulpit, though this one appeared to be used for storage currently. At least 2 other groups of falang joined me to wait out the rain, and we all sat in silent reflection, which was nice. After if stopped raining, I spent some time wandering around the temple complex and then over to the wat to the north of the That Luang. That one is enclosed, more like a traditional church or temple that I would think of, and I did not try the doors. There were some young hooligans setting off fireworks in a pop bottle, so I spent less time at the second compound.

On the way back to the bike parking, I detoured past a monument at the other end of the parking lot. It was a white pillar with friezes around the bottom, and a big bouquet of roses form the president of India (who I later learned is in town.) The friezes seemed to depict the history of Lao, including pre-industrial times, the civil war, and the new, communist state of harmony. It was pretty cool, but it was looking like rain again, so I got back on my bike and pedaled down the hill to the Swedish baking company, which serves the best pizza in town. I really need to get on their delivery map. I went past the market on the way home, succeeded in buying 2 pair of shoes, and felt like I had accomplished quite a bit.

Free Right Turn

I still can’t decide if I approve or disapprove of “Free Right Turn.” It’s actually kind of nice when you’re turning right, but it can be pretty annoying when you’re going straight. This week was my first real week alone. Last week Christine let me manage things alone, but she was still here to answer questions. Now, she is gone. Things went well Monday through Thursday morning.

(If you’re a non-doctor an annoyed by doctorly discussions, skip the next 2 paragraphs.)

Monday through Thursday mornings, I went out to Setta and rounded with the two residents out there. They are both quite good, and I am lucky they both have decent English skills, so they can present in English. I still saw some disturbing patients. I saw at least 2 young women that were septic by vitals criteria (including pretty severe tachypnea), one on no antibiotics and the other on 2 antibiotics for 4 days (clearly, not the right ones.) One went to the ICU and the other was better the next day after being treated for Rickettsia. The ICU is apparently not a good place to go, (It is not staffed by Medicine residency grads) and last I checked, no one knew what had happened to that patient. The part that was disturbing, though, was that there is really not a sense of urgency. I look at a 27 year old woman with a fever and respiratory rate of 35 and want something to happen right away (blood cultures, antibiotics, etc.) The Lao doctors may have the right plan, but not in the appropriate timeline. To be fair to our residents, I think it is an endemic problem, and even if they really tried hard to do things quickly, I think the staff supervising them, the nurses, the radiologists, pharmacists, etc would make it impossible. Still, it’s frustrating to see young, previously healthy patients with treatable problems not being treated. I also saw a 2 week old hemorrhagic stroke. The patient had sudden onset of R sided HA 2 weeks ago, which as constant, and some L sided weakness on exam. We saw him wednesday and the resident got a CT (with and w/o contrast!) which showed fairly extensive R sided intraparenchymal bleed. I realized I’ve never diagnosed a hemorrhagic stroke because in America, people get stat CTs in the ED and go to neurosurgery if they have a bleed. The residents were planning to refer him to Mittaphab where they have neurosurgeons, but they weren’t sure he was going to go on Thursday. Fortunately, his exam was stable.

Tuesday I went for case review and topic review (prepared by the residents.) They reported there was a visiting Cardiologist, so this had been cancelled. I went to see what the cardiologist was teaching on. The topics were good - HTN, Ischemia, anticoagulants, anti-arrythmics. (They start digoxin here for clinical heart failure, regardless of EF, without any monitoring. Luckily, most patients probably don’t stay on it longs since they’re paying for their own meds.) The lectures were in french with Lao translation. Tuesday happened to be anticoagulation, and while the info presented seemed to be factually accurate (Turns out medical french isn’t that different from medical English, so I could understand quite a bit from reading the slides); I am not sure how relevant it was to practice here. There was discussion of the various parinuxes and irudins, none of which are available here. There was discussion of indications for warfarin, which I know the residents already know because last week they asked me how they could dose it for a-fib without INR monitoring. Oh, right, there’s no INR monitoring. Not really necessary to teach about warfarin in depth then, eh? Maybe the other days were better, though. I did my english teaching as usual, but my thursday lecture was cancelled - there was poor attendance and the residents who did come were looking a bit glazed from the 3 hours of cardiology lecture each of the 4 previous afternoons. I can’t say I blame them.

Friday was Khon Kaen Grand rounds. We were fortunate to have a lovely young geriatrician from Thailand come and talk to the residents about delirium and dementia in the elderly. I don’t think there is any structured geriatrics teaching in Lao. (Indeed, there are no geriatricians yet.) So it was a good exposure for them. Unfortunately, it was also a lot of organization for me. I had to get the handouts printed before Friday, drive to the border Friday morning, then drive back and take the visiting MD to Mahosot to round, then host lunch (Ning cooked) and then bring her to the lecture room. Of course I forgot to check the gas tank (I fill it so infrequently on Gordon it didn’t even occur to me to look) and noticed just as we were getting back to town from the border that it was on E. So we didn’t have very much time to round, and the poor Thai doctor got an exciting trip to the Shell station as part of her visit. Then I forgot the handouts when we went to the lecture hall, so had to come back and get them. Fortunately, she was very patient with my deficient hosting skills, and hopefully by next month I will be more settled and capable.

I had my first Lao lesson Monday. My teacher seems very good, but unfortunately the Friday lesson was cancelled. I shall practice my flash cards this weekend. I went out for Indian food Friday night with Amy and Chris. It was delicious, and 68,000 kip (<10 dollars) for all three of us. I lowered the seat on Christine’s mountain bike so I can ride it, and aside from some difficulty adjusting to a man’s frame, that is going well. I rode up the river 15 minutes earlier this week, and then to the That Luang today. After having a basket incident that required repair, I have returned to the one speed bike for around town errands - it has a basket which is more convenient and I am really not sure how Christine was getting on the mountain bike in her sin (Lao skirt) but I am not confident enough to try yet. The one speed seems to be the perfect speed for in town riding anyway. I have worn 3 of my 4 new Sin and gotten positive comments on them from the Lao. “Teacher, you are very beautiful today, you look like Lao.” I’m not sure whether to be frustrated by the reluctance to acknowledge foreign or different things as potentially beautiful, or impressed by the lack of eager and universal conformity to western (and quickly becoming global, sadly) ideals of beauty.

New Experiences

Maybe my favorite moment of many good ones this week was when I was too tall to be in the front row for our group photo with the senior Lao doctors at Christine’s going away dinner. Not only was I too tall to stand in front of any of the attendees without obstructing their view, but I may not have been the shortest person there. Maybe I’m more sensitive about my height than I think I am. . .

I drove to Setta by myself 4 times this week. The first time I missed the last turn and on Thursday I went right at the first round about on the way home, but given the absence of street signs, I think I did pretty well. I also learned 2 new things about driving. The first is that a turn signal on a motor scooter is actually less helpful than nothing. The baseline status of motor scooters here is that they could turn left or right at any time. If you drive based on that assumption things seem to go well. When a motor scooter has their turn signal on it either means that they have recently turned or that they might at some point in the future turn. So basically, it means nothing but if you mistake it for meaning something, you may be wrong. (Like, that right turn signal means that they will be turning right, and then they turn left right in front of you.) The second thing I learned is that red lights only apply at moderate-high traffic times. Red lights during low traffic times are uniformly ignored. Sometimes people have the courtesy to flash their lights before running them. And they usually slow down, but not always. Exciting!

In Lao, your nick name might be “fatty” (Dtui) if you’re very skinny. The Lao are not generally a particularly bulky group of people, so there are quite a few people nicknamed Dtui. One of our residents is nicknamed Dtui, but because he is actually pretty giant compared to his colleagues. Tall, and what would be considered overweight in America, but is obese by Lao standards. On Thursday night, my lecture was “Introduction to Dr. Libby,” and then I had the residents introduce themselves to me. Too get a little bit of a sense of who they were, and as an ice breaker, I asked them what their favorite foods were and what they liked to do on Saturday night. I picked directed questions because when Christine came, she asked them to write down one thing that no one in the room knew about them. She got a lot of “I love medicine” and a lot of “I have no secrets” but not a lot of personal info. So I directed them while still trying to encourage them to express themselves. It sort of worked. Almost everyone said their favorite food was Lao food, but about half of them expanded on this with a dish or two (Fish, chicken, and papaya salad were popular.) One of the interns who is quite skinny reported that he only drinks milk, which is why he is so skinny. I’m almost certain he was kidding. And then there was Dtui. His response started “ I like Lao food.” He then followed with “I like Japan food, I like Korean food, I like Falang food. . .” and so on. (Falang means white people.) It was funny. Many of them reported that they like to study on Saturday, but no one claimed that was the only thing they did on Saturday - some of them work (at pharmacies or small shops they own / manage), many like Karaoke, picnics, hiking, sports, watching TV, and of course shopping for the female residents. It was a good introduction.

We had two teachers meetings last week - the first with the chief residents (2nd and 3rd years elected by their classmates) and assistant director of resident education, and one with all the major Lao teachers and administrators. Most of the meeting both times was conducted in Lao, which is good because it means the Lao teachers are taking more responsibility for decision making and teaching. Since the ultimate goal is for the programs to be independent and sustainable without outside leadership or support, that is great. However, between two meetings mostly in Lao, rounding on the wards where presentations to me are in english, but communication with patients and colleagues is in Lao, and resident topic review and case presentation (which is in English on the screen but in Lao verbally) my ‘sincere’ active listening skills are getting a work out. The decision from the two teachers meetings was to go back to a monthly focus curriculum. This month is neurology month, so I’m preparing a talk on bacterial meningitis for this week.

I finally got some fruit. I succumbed and purchased at 17,000 kip mango at the Falang grocery store that is 1.5 blocks from home. That’s just over 2 dollars, which is what I would pay for a mango in Minnesota, but this was a giant, ripe, delicious mango, so I’ve reconciled it with myself. In fact, after the first one, I got a two pack the second time. They are yellow mangoes, more like the ataulfo mango sold at the coop than the orange ones I ate in Africa. I also tried pomello, which is like grapefruit but bigger, with bigger grains of fruit, and sweeter and milder. It is delicious, but somewhat hard to prepare. I also ate at “Nudle”, the new noodle take away that is 2-3 blocks from our house, and conveniently on the way home from the hospital after late lectures. Apparently, they have a giant noodle box costume that someone has been wearing to advertise the grand opening, though I have not been fortunate enough to witness this. Amy saw a smallish person manning the costume somewhat clumsily with a large British man tailing him/her and saying “take it slow. . .” last weekend. I am too hot in a skirt and t-shirt, so I don’t even want to think what it would be like inside a noodle box costume. But the noodles are good and the price is right ($2.25 for a box which is enough for at least 2 meals) so I anticipate I will become a regular, and one day will get to see the giant noodle box.

Arrival/Orientation : Home.

My house is the Health Frontiers office. The office is downstairs, with a room for the files, printers, etc, and where our administrative assistant Novalinh works. There is a shared bathroom, kitchen, living room, and Dining / meeting room on the first level as well. The TV cabinet is well stocked with bootleg DVDs, so I will not have the opportunity to miss american media. Right now Christine and Amy are watching Glee and How I Met Your Mother, both of which were on my netflix queue at home. (Amy is the Pediatrics coordinator, here from Australia with her husband, Chris.)

Upstairs we have 2 guest bedrooms, another shared bath, and my room which is en-suite. I have an air conditioner, a fan, and a king sized bed, so I’m pretty much in the lap of western luxury. I do wish the ants would stop crawling into and out of my keyboard, and my mosquito screens aren’t 100% effective as one night I woke up with 2 mosquito bites, but other than those two things, my room could just as easily be in America.

We have a housekeeper, Ning, who works 5 days a week, and a night guard and gardener, Pa, who works 6 nights a week. He has a day job too, so I think he just sleeps in his hammock on the front porch most of the time, but our gate is so creaky that anything big trying to get in would wake him up.

Last week I ate breakfast with Christine at Kung’s every day. Kung’s is down a little side alley about 3 blocks from our house, and Christine eats breakfast there every day. They do make a mean cafe Lao yein (coffee Lao cold) and a delicious sticky rice pancake (pancake mix with rice in it) filled with a slice of mango. Other breakfast options are omelet and french bread or french toast, which is really more like a cross between texas toast and french toast served with syrup and banana. All of them are tasty, and at 1600-1800 kip with coffee (2-2.25$) the price is right, but after 7 days, I was ready for some corn flakes and more fruit, so I may save Kung’s for lunch and weekend breakfast and eat at home for weekday breakfasts.

Lunch is Kung’s or Ning will cook for $3 each, with leftovers for dinner. Dinner tends to be leftovers or bread, cheese, and some kind of veggie from the nearby falang (foreigner) supermarket, unless we go out. In addition to Kungs, we have eaten at La Terrace - affordable decent French, Sticky Fingers - Australian pub comfort foods, a Vietnamese restaurant near the medical school where I had a standard vermicelli salad, and BFE which is near home and serves big safe salads and Lao food. I haven’t had any sticky rice or spring rolls yet, but plan to correct that deficit tonight or tomorrow. Pomello is in season, but I was out too late after our meeting this afternoon to buy any. I will get some more fruit this week!

Transport is primarily by bike - currently I am riding a chinese one speed with fairly poor rear brakes, but I have a new helmet and just take things slow. Christine will leave me her mountain bike when she leaves, which will be faster and safer. Biking is pretty much the same here as in America - you have to watch out for the cars and ride defensively. There are no bike lanes, but since there really aren’t well respected car lanes, and many more bikes and motor bikes, it’s less of a problem. To go to Setta or Mittaphab I must drive, however.

I am learning how to drive; last Monday I gave Novalinh, our administrative assistant, two passport photos and a copy of my MN drivers license. On Thursday, I received a laminated card with my name and one of the photos, which is my Lao drivers license and is good for one year. There are only 2 cardinal rules in Lao driving: 1) You’re responsible for what’s in front of you on the road - your lane, other lanes, pulling out from parking without looking, and oncoming traffic is included. (This might include pedestrians or animals and will almost certainly include motorbikes, and cars of all sizes, plus some decent sized trucks.) 2) Try not to hit anything. Lanes are marked but often don’t make sense, and are pretty much uniformly ignored. People stop at stop lights for the most part, though there is a lot of extending of yellow lights. (I entered the intersection near our house at the end of the yellow left turn arrow this morning. Two more cars behind me turned as well.) There is also something called the “Free right turn” which means you can turn right anywhere, any time, even at a red light in front of oncoming traffic. There are traffic circles more frequently than lights and Lao tradition is that people entering the traffic circle have the right of way. This is fairly universally respected, even when it causes at jam. (Eventually, no one can exit.) Stop signs are respected when convenient, but when they’ve been waiting a long time, eventually people just pull out in front of oncoming traffic, particularly at certain intersections, so you really have to watch them at certain spots. My general approach is just to drive slowly and cautiously and this seems to be working and accepted. Christine says people are pretty patient here, though some drivers are starting to get faster and more likely to honk or pass you. Either way, as a foreigner, I’m responsible for any accident I’m involved in (eg: drunk motor-scooter broadsides me when I have right of way - my fault) so caution is the best approach. The good news is our car is big - a 93 Isuzu extended cab pickup - and slow, and a stick which I prefer, so there will be minimal temptation to start going faster when I get used to the crazy traffic here.

At work, I will be expected to adopt the traditional Lao skirt - “sin.” It’s basically a tube of cloth that is about 1.5-2 times as big around which you overlap using snaps or hooks an eyes and makes a wrap skirt. Christine reports they are comfortable for bike riding. I was feeling discouraged because the ones I see people wearing are all black backgrounds or very dark green, blue, purple, maroon etc. These are colors I rarely wear in America, and I brought mostly light blue, purple, and green shirts. (My preferred palate.) However, Christine took me shopping this weekend and I picked out 4 nice ones with lighter, brighter colors including light blue, medium purple, and some nice medium pink and blue. I suppose I still won’t look truly Lao, but I’ll be sort of traditional and much happier than I would be in all dark colors. This week we’ll try to get into a tailor to actually get the skirts made.

As far as entertainment / sports goes - I played badminton this weekend - a hot endeavor, but with a roof so it can be played in the rain. I hope to take up tennis, so I may not continue going to badminton or I’ll get my swings all confused. I will be able to bike when it’s not raining, and once my backside gets all adjusted to biking again. I could join a gym for 300-600$/year, but I think I’ll see how I do with outdoor social sports and yoga first. There is a pretty big community of French and Australian aid workers and entrepreneurs here, so I don’t think it will be too hard to find friends.

Arrival and Orientaton - Work:

I am starting my second week in Lao. I arrived last Sunday (one week ago yesterday) after 29 hours in transit - I flew Denver-LA, LA-Bangkok (17 hrs) and Bangkok-Vientiane with a long layover in Bangkok. I left at 6:30PM on Friday and arrived at noon on Sunday.

I spent the first week getting to know the people and places I will be working. There are 22 residents in the internal medicine program - 8 interns and 7 second and third years. They rotate at 3 hospitals - Mahosot, Settarthirath, (Setta) and Mittaphab. Mahosot is the closest to my home, where I will give lectures on Thursdays, and where I will teach beginning English on Tuesday and Thursdays. There is pretty good teaching on cardiology, GI (which is actually more general medicine) and Infectious disease wards there, so I will probably not do much rounding at Mahosot. However, it is home to the majority of the senior Lao doctors involved in the residency program, so I should get to know it well.

Setta is likely where I will round most days - there are few internal medicine graduates there currently, so there is a need for teaching rounds. Right now the three residents at Setta speak good English, so we were able to understand each other last week. It will be more interesting when the residents with less English proficiency rotate through. Christine (my predecessor) speaks enough Lao to do half or more of the presentations in Lao, so I will be a challenge for the residents.The residents will pick out a few cases to review with me each day. Last week we saw AML with tumor lysis syndrome (there is no chemo here and even if there were neutropenic fevers would be a nearly insurmountable risk,) fever which was not dengue or rickettsia (two of the more common causes of fever,) and likely temporal arteritis with no ability to do biopsy confirmation and an ESR that had been ordered but not drawn, but improved with steroids. Since they save the hard cases for teaching rounds, it will probably often be challenging for me to figure out what if any recommendations I can give.

Mittaphab is the newest of the three hospitals, but looks the oldest, and is undergoing renovations and new construction, so we spent several minutes wandering around the basement looking for administrators who’s offices had been moved from the (now empty) administrative ward. It has a fairly good teaching structure with 3 general and one cardiology and one ICU team, all of whom have staff doctors that are internal medicine grads and round with the residents daily. There was good teaching happening there when we visited last week, so I will likely not spend a great deal of time rounding there.

I met many people last week - IM teachers, hospital directors, University of Health Sciences staff doctors who oversee our program and the medical school, and many of the medicine and pediatrics residents. I am sure I will not remember all of them, but hopefully they will be forgiving when we meet again. I also (theoretically) learned how to get many places. I am certain I can get to Mahosot (a few blocks by bicycle) and to the Thai-Lao friendship bridge (where I will pick up doctors from Thailand for grand rounds), and pretty sure I can get to Mittaphab. Today I will try to make sure I can get to Setta, where Christine and I can follow up on the patients we saw last week.

This week, I will start Lao lessons, teach my first Beginner english class to the residents, and give my first Thursday lecture (luckily, I get to use the first week to introduce myself.)