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.