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.