Internal Medicine Continuing Medical Education

I am home from the 2 day IM CME conference. This is the 8th annual IM CME in Laos, and a number of improvements have been made over the years. For example, this year’s conference is on Friday and Saturday. They used to be held during the middle of the week, so that no one’s weekend was infringed on (even if they had travel days on either end), but we now acknowledge that it’s cool to learn on the weekend too. There was also minimal debate in the planning stages about whether boxed lunches would be OK - in the past much attention has been given to the quality of the buffet, but recently the quality of the lectures has taken precedence. The conference is still funded in part by pharmaceutical companies, but to be fair a lot of American CME is too.

I arrived just after the official start time, 8:30, and we actually started only 10 or 15 minutes later. The opening ceremony involved several of the head doctors in IM plus some ministers giving speeches. I had a moment of sheer terror when the WHO representative was asked to speak and I realized that I didn’t know if I was going to be asked to contribute to this. (Fortunately, I wasn’t.) In America, this would be a brief welcome formality, but in Lao the opening and closing ceremonies are important parts of the conference. So important that there are usually multiple camera men, and today, 2 videographers. I have to be very careful not to make faces during the opening ceremonies, because the videographers seem to particularly enjoy recording the one Falang in the room.

At the end of the opening ceremony, the Minister of something related to health gave a long speech that involved frequent use of the Lao word for child, and I watched the other dignitaries and attendees expressions of alarm and then amusement as we all realized he had no idea what kind of conference he was at. Bor Pben Yang, at least he knew it was about doctors and patients.



The dignitaries at the opening ceremony.

The first talk was a series of studies on patient satisfaction on one of the inpatient and outpatient wards at Mahosot. Interestingly, despite what would be considered sub-standard facilities (one one of the nicest, newest wards in Lao), 100% of the inpatients and more than 60% of outpatients thought the quality was “Good.” The other options were moderate or poor. Generally, positive answers were in the 85-100% range on all the subsets of the surveys, which were conducted twice several years apart. I don’t suppose there’s any way to figure out whether the patients really are that satisfied, they fear if they answer negatively their care will be affected, or they are just being polite non-complainers. I can’t imagine finding a group of American patients who would answer a similar survey the same way, however.

At the first coffee break, I tried a banana-leaf wrapped snack. I was skeptical, because several times in the past week the banana leaf has been filled with pork, sticky rice, and bean paste which I don’t actually like that much, but eat because it’s usually offered as part of some ritual event. This was sweetened coconut sticky rice, egg paste, and a pudding that i think was made of tapioca, though, and it was delicious. The rest of the morning was Thai doctors and the Lao endocrine fellow introducing them and the topics. It is nice to see Vasana, one of the graduates of the first residency class and now a HF sponsored fellowship grad, in a leadership/teaching role now.


Dr. Vasana introducing topics and her Thai colleagues. Isn't she beautiful?

I ate lunch in the VIP room, with the Lao senior teachers. Alounxay, a recent residency graduate and staff on the Cardio ward, served the most senior teachers lunch - as in, opened their boxed lunches and set things out for them - and then made coffee and tea for everyone as they finished their food. That’s a job you won’t find any American staff doctors doing. . . cultural differences. The box lunches were pretty good - pork and beans and white rice with a few slices of fried mekong fish or fried rice and soup - so I’m glad they saved money on a buffet.

After lunch, I went downstairs to peruse the pharma shopping area. It was interesting, especially when I realized the book stand was run by one of our residents - a second year who is not super motivated on the wards. The residents had mentioned something about his driving to Thailand for books in the past, which I thought was odd, but didn’t question further. I guess he’s running an import business now. He was doing brisk business with residents, staff, and medical students. I can’t really begrudge this - he is giving access to resources that they otherwise might find harder to get - and I think his mark up was only a dollar or two per book. Maybe he should have become a businessman, not a doctor. I bought a copy of the mass general handbook of internal medicine “Pocket Medicine” - it’s smaller than the real thing, has a beautiful pink cover, and was 6$. American MSRP - 60$. I probably should have owned one in residency, but better late than never, eh?

Afternoon was mostly Thai doctors - Movement disorders, chronic kidney disease, spondyloarthropathy - before the coffee break. At the end of each session, awards were presented to all the speakers - wrapped presents in boxes for the Thai visitors and envelopes for the Lao speakers. One of the senior doctors, or if present dignitaries, is called to the front of the room where a lovely young woman holds a silver bowl with the present or envelope in it. The presenter takes it out and hands it to the speaker while the audience claps rhythmically. Then they hold the pose of giving/receiving until the pictures are taken.


Presenting thank you presents.

After the coffee break, we had a really great presentation from a Lao MD/epidemiologist about causes of fever in 2 distant provinces - one far north and one far south - that was impressive in reminding me of the quality of research that’s being done here with limited resources. And how much it can help them with treatment, like choosing antibiotics that the common local pathogens are susceptible. Brent would be please to see how frequently this means Doxycycline rather than ofloxicin, azithro, or ceftriaxone. Then we had some case presentations, one of ITP treated with cyclophosphamide which prompted a lot of discussion and I’m pretty sure there’s no evidence for, but since I didn’t completely understand the presentation, I kept my mouth shut. (I had just given a talk on thrombocytopenia thursday to the residents, so I’m a little worried they are getting mixed messages, but I think the discussion was heated enough to let them know that’s certainly not a well-accepted first line treatment.)


Thai visiting doctors and their current and former fellows and a few of the senior Lao doctors who have made fellowship possible by building the program.

The second day of CME featured: a Lao Nephrology fellow who will be returning from Bangkok soon talking about Rhabdomyolysis - (seems particularly relevant given all the earthquakes recently including one on the Lao/Myanmar border), our senior GI physician talking about GI cancers, another Thai physician discussing the interaction between PPIs and Plavix and the development of H Pylori resistance in Thailand and the interaction between PPI metabolism and H pylori eradication, several case presentations, and discussions of dialysis access and bronchoscopy in Laos. It all seemed useful and relevant, not to simple or too complicated to be useful here. And the PPI metabolism was new to me too - interesting! The first coffee break featured wafer-like, crispy cookies and small green jelly/coconut/mysterious centered treats wrapped in saran wrap, as well as the usual eclairs and cake. Lunch was fried rice and soup or pork and beans and breaded chicken with white rice. I opted for the fried rice. The second coffee break was fruit and very sturdy jello-like heart shaped pudding treats both days. Oh, and powdered soy milk in hot water - I liked the hot powdered milk drink in tanzania, and I found this tasty too (of course it has sugar added), although after a day of sitting and listening to lectures with breaks for food, I certainly didn’t need the calories. I tried to replicate the powdered milk drink in america, but was unsuccessful. There’s something about the texture of the milk powder that makes ours not work.

So overall, although I don’t fully understand most of the content, CME was positive. It was organized entirely by the Lao doctors, seemed relevant, and certainly showcased some HF grads in leadership roles (in addition to the lecturers, many of the people instrumental in planning are our former residents.) I wore 2 beautiful new sins an got many compliments including the ultimate one - “If you changed your hair color, you would be like a Lao woman.” (I challenge you to find a more gracious and complementary group of people than the Lao, so I know it’s not personal, but it’s still nice.) The residents looked engaged in the lectures, the residency grads and even a couple residents asked questions, a good sign that they are both paying attention and learning, and not afraid to speak up. Pharma paid for part of it, but didn’t seem to have any impact on the lectures themselves, and was not given time to speak, just space downstairs to sell the attendees stuff (and give them pens and hand outs, of course.)



The beautiful ladies of IM - Residents Payvanh, Khamvay, Libby, Velouvanh (Fellow at KKU) and Phouthasone. Phouthasone was unhappy about being in the sun. Notice my beautiful woven silk Sam-Neua style sin; This is what gets the compliments, not actually me.:)

Hits and Misses

Wednesday, after I had seen patients with all 3 residents at Setta, the intern asked me if I wanted to see one more quick case. Sure, why not? I usually stay until it’s clear they are finished with me, unless I have an appointment or meeting at lunch. The ‘quick’ case was a 22 year old woman who had been transferred from another hospital after a wrist abscess was lanced the preceding day. Before being admitted there, she had had a transient episode of loss of vision (without change in consciousness, dizziness, lightheadedness, palpations, etc.) Within a few hours of the lancing, she had sudden, complete loss of vision. The intern tells me this story as between 5 and 10 eager medical students crowd around the bed. I check her eyes - she has pupillary reflexes, but the are sluggish. We do not have an opthalmoscope, but even if we did, she has photophobia and I’m not good enough with one to see anything in a patient who’s not extra cooperative. She has tenderness of her sinuses above and below the eyes, but no swelling, redness, or warmth. She also has a particularly tender area under her jaw on the left, and maybe a slightly big L tonsil but nothing too exciting inside her mouth, and supposedly no tooth pain recently. I listen to her heart and lungs. She’s a bit tachy, but I don’t hear anything else unusual, of course, she is moaning occasionally, so it’s not the easiest cardiac exam. (She's not morbidly obese, though, so it's not the hardest either.:) ) I usually start my exam with the patient’s hands, because it’s less personal and confrontational than the face, but with a crowd of 10 observing, my routine is off. I will later learn that this was a mistake. . .

I ask the residents what the wrist abscess looked like. It was red, warm, and swollen and drained puss when it was lanced. She only had fever for one day before coming to the hospital, according to the family. They haven’t actually seen it though, because no one has unwrapped it since her arrival at this hospital. Maybe the surgeons will look at it this afternoon. (She is actually on the surgery ward, the medicine team was just consulting.) I try to model good wound-observing practices, so we unwrap it. It’s surprisingly clean and benign looking - she writhes in pain every time we move the hand, but it’s not red or warm, and no pus comes out when I remove the pieces of what appears to be rubber glove that had been used to pack it. I’m beginning to think that she’s not a particularly stoic 22 year old. I re-bandage the wound. We talk about what could have possibly caused sudden, bilateral, complete, loss of vision in this 22 year old. We talk about how sudden loss of vision is an emergency (not a quick case.) I am worried about a retropharyngeal abscess with swelling affecting the optic chiasm, or some kind of spread to the sinuses with swelling, because I can’t figure out how else to put the clinical picture together. Either way, I’m pretty certain that she needs more than just cloxacillin, so I suggest we change to ceftriaxone and metronidazole, given the potential tooth/mouth involvement. Ceftraxone will cover meningitis if this is some kind of crazy manifestation of systemic spread from the wrist abscess. I also suggest we need a CT of her head somewhat urgently, and maybe and LP.

Thursday, I am told she is getting better (she is still in the surgery room) but has not had a CT. One of the french program interns suggests that this might be a psychogenic problem, as she tested a blink reflex and found it present, though the patient claimed not to see anything. Still, without a CT (and really, probably and MRI) we couldn’t rule out a physical cause, and I was worried about the tenderness I had found, so I again asked them to push for this. I did not see her, as I did have a lunch appointment and was just barely going to be on time.

Friday, she had been moved to one of our rooms. I had David, an Australian Oncologist here with his wife, Margie who is taking over the Peds coordinator job with me. Her vision was better, maybe even normal, and she was getting ceftriaxone and metronidazole. She still hadn’t had a CT. When I had gotten home Wednesday, I started to worry about eosinophilic meningitis - it can cause a lot of swelling and intraparenchymal hemorrhage - and severe headache, which she now had. Would a contrast head CT be bad, or terrible, in that case? No peripheral eosinophil on the CBC though, so we could put that worry lower on the list. She still had a lot of tenderness under her jaw as well. I again asked about getting a CT - preferably before the weekend started. And I gently chided the residents when I saw that the bandage I had put on on Wednesday was still there, just as I had left it. . . We headed on, but were called back to the bed. Someone had noticed lesions on her hands and feet. We went back to discover that she had classic Osler’s nodes on her right hand - the one without the abscess - and splinter hemorrhages and janeway lesions on her feet. Endocarditis would explain the multiple site of infectious involvement well - I listened to her heart again - now her heart rate was normal and I heard a soft systolic murmur. Was it new, or was my exam just harder on Wednesday? Had we missed these skin findings for 3 days? Or were these new despite antibiotics? We asked the family - they had been there since before she came to the hospital. Part of me was relieved, because it means she wasn’t failing treatment, but another part was mortified that we had all missed this evidence for 3 days. So we changed the plan - EKG, echo at Mahosot that afternoon, and talking to the family about a possible need to go to Thailand for valve replacement if she had a large lesion. We would add gentamycin if she got worse again. And someone would discretely ask her and her husband about “risk factors” (IE, not in the room with 7 other patients, 5-10 doctors/med students, and her whole family.) So that is how I missed, and then (probably) found, my first classic case of bacterial endocarditis. Needless to say, David was also impressed with the incredible pathology you can see here. I am hopeful and afraid about what I will find Wednesday when I return to Setta. (Today I had to take a visiting nephrologist out to Mittaphab for introductions, and tomorrow is Women’s day, a holiday, so the residents will do short rounds then go home.)