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.