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.)

Amazing Day

The past couple days, I have been lucky to be able to attend the Oxford Tropica Network annual meeting. It is usually closed, but Paul did some finagling and local NGOs were allowed to send a representative. I don’t understand a lot of the research presented, but it is really cool to see how hard some really smart people are working on malaria, dengue, TB, and other diseases that disproportionately affect poor countries. Last night after a dinner for one of the Lao teachers, who has been promoted to the Ministry of Health, I was able to see them jamming together as well at their annual musical review. Scientists and musicians - a talented bunch of people.

This morning I went to the last session of the meeting, as I had a lunch meeting but not the truck, and no way to reliably get back from Setta in time. I’m glad I did (though I missed seeing the residents again this week) because it was again interesting. Talks on antibiotic resistance, new drugs for malaria etc were interesting. But the best was a talk on a neonatal unit in Thailand - basically a hut - but where good training in identifying at-risk babies and treating them quickly and correctly is saving many lives - of preterm and term infants - and all for 200$/month for the sickest. It was really interesting. I also really enjoyed the last talk - about giant crocodiles in a remote part of Papua New Guinea. Mostly because it reminded me of the book Dingley loaned me on crocks and how scary they are. Which made me miss the pub quiz.

Lunch was at our office, signing a “MOU” Memorandum of Understanding with an Australian / Chinese mining executive to pay for pediatric CME for the next 5 years. He told us about how they are helping the Lao government learn about sustainable, environmentally friendly mining practices - they took them to a reclaimed mine site in Indonesia that is now a stunning national park - and will visit Tasmania, which has some examples of bad mining practices and their long lasting effects. It was really nice to know that there are some companies that are trying to use sustainable, environmentally appropriate business practices, and even in a place like Laos where with some well placed bribes and pay-offs to the government, they could certainly get away with doing whatever they wanted and leaving the mess for the Lao people. As a child of the American West, it’s easy to assume no one has learned the lessons from our mine messes.

Then this evening I went with Yannick (our computer repair specialist), Dr. Leatherman, and some conference attendees to the Lao-Taipei soccer match. It started before we thought it did, and it was a long drive, so by the time we arrived it was half-time. (Or whatever we call that in soccer.) The second half was interesting - there were 8 or 9 pauses while players were carried off the field on stretchers - all of them to get up on their own power within a minute and most to cheerfully return to play - so it was all theatrics. The Brits we were with reported that the quality of play was not great, but it was still fun to watch. The crowd dynamics were much the same as an American sporting event - chanting go go go! counting when the players were down, and one crazy guy with a flag running up and down encouraging and leading cheering. After the 7 additional minutes added on to make up for the stretcher-related delays, the game was still tied, but Taipei won the previous night, so unfortunately Lao lost the series.

Dinner at La Terrace with Cindy (former IM coordinator) joining us late - one last camembert salad and pasta binge before I go off to the hinterlands - and tiramisu for desert, and then home to finish some e-mails and pack. Now, at 2 AM I will go to bed, for about 4 hours of sleep. At 6:30, we take a tuk tuk to the bus station, where we get a bus to Xieng Kuang to visit a pediatric grad there. 2 of my IM residents currently are from Xieng Kuang, so I’m interested to see it. Then I will go on alone to Sam Neua, where I will visit another former IM grad. I hope to also have time to see the Vieng Xay caves, where the Pathet Lao lived during the revolution.

Commence radio silence! (likely no safe internets where I am going, and I know you guys don’t want me spamming you after my passwords are stolen)

My Funny Valentine’s Day

I’m going to try blogging shorter snippets for a while and see how that goes.

Today I rounded at Setta for the first time in 9 or 10 days, because of scheduling conflicts in my or the resident’s schedules. It was nice to be back with them. When I arrived, of course we discussed Valentines day. There were some english logistics questions around exchanging gifts, and then of course whether I had plans to celebrate. When I told them I did not, the senior resident instructed the intern to take me out dancing “all night long” he blushed and very apologetically explained that he was on duty, so he would not be able to take me dancing. It was cute. (Actually, I had a full schedule this evening, but none of it was Valentines related.) Then we got on to the patient care, where I was able to help the residents thing through a musculoskeletal problem a bit more (thought they had a pretty good differential diagnosis, and they were on the right track of investigation for the most part.) The next patient, with an alarmingly high white blood cell count of 44 and anemia, I encouraged them to get a smear (morphology here) on, and the third they were again pretty much on the right track, with maybe a few small adjustments. Khamvay, the other 3rd year resident, is a short, shy woman who actually does decent patient presentations in English, but spends a great deal of time apologizing for not having perfect English. It is a real pleasure to work with her because she is so genuinely interested and learning and doing the best thing for her patients.

This afternoon, I was luck to be able to attend part of the Oxford Tropical Network annual conference, which is in Vientiane for the first time. The OTN is a network of labs doing research in tropical disease and supported in large part by the Welcome trust, and this is their annual global meeting to make sure everyone is up to date on the research and progress taking place elsewhere. My favorite session was the “Speed dating for scientists” - 16 2 minute talks (one power point slide/presenter) with 2 minutes for questions and 1 minute in between. You could tell we were all pretty type A, rule driven, people when one woman clicked on to a second slide. There was an audible gasp of disapproval from at least 3/4 of the audience. (Including me.) However, we uncomfortably sat through that slide and the third one that followed. Miraculously, this session ended up taking less than the scheduled time, though some presenters went over their allotted 2 minutes of explanation. The highlight was Cindy, a former HF IM coordinator who gave a great, brief but coherent talk about her Malaria research on the Thai-Burma border. She managed to explain why the research was important, how it was done, and what the results were, all coherently in such a short time. I hope I grow up to be like her. . .

After the meeting finished, we all headed over to the Lane Xane hotel where we had Lao food for dinner, and a Lao music show including a man who did an imitation of several birds and then a dying pig (including miming killing the pig), followed by skits/musical numbers by lab groups from Thailand, Vietnam, Cambodia, and Kenya. And then more Lao dancing. It was a good (if odd) way to spend Valentines Day; with a conference room full of people who have devoted their lives to tropical disease, though most of them could be earning more money or accumulating more prestige doing other types of research.

Funny conversations from the past few weeks

When asked how their new english teachers were (two Australian medical students who volunteered)
Resident: Nayang has palpitations.
Libby: Oh really?
R: Yes, because the new English teachers are very beautiful. He has sinus tachycardia.
Next week: L: Nayang, do you have tachycardia again?
Nayang: No, I premedicated with propranolol.

After a second new english teacher:
L: How do you like your new english teacher?
R: She is big and strong, like a man (Makes body building pose with arms)
L: Please don’t tell her that. . .

Thai Doctor, explaining how the university has only one staff dermatologist: “We say that dermatologists are a mystery. We train them and then they disappear.”

A win and a loss

My non-medical readers may want to skip this post. I will post a non-medical one soon, I promise.

Just before new years, the residents asked me to see a patient who had been admitted to the hospital for hiccoughs. When I saw him, the story was a bit more complicated, and included a motor vehicle accident with head trauma 10 years ago, and had been told that he had a hematoma but then had no follow up. He had a left sided daily headache for 2-3 years, pain around (but not inside) the left ear for several days, bleeding from the left ear for one day, and one day of subjective fever within the week prior to admission. At the end of the encounter, they mentioned that he had Hepatitis B and had been treated with interferon for 15 weeks several years ago. His headache was variable, not always in the morning, and didn’t fit migraine or cluster headache patterns either. It had improved with paracetamol, and his hiccoughs (his original presenting complaint) had been present for a week prior to admission, and had improved but not completely resolved over several days with metoclopramide. (He came on Friday and I saw him on Monday or Tuesday.) I think the residents had already decided to do a head CT, and I encouraged them with that plan, explaining that Hiccoughs can come from the brain/nerves or the diaphragm, and I was hopeful that his were from the diaphragm, but his story was worrisome that they might be from the brain.

The next day, I was asked to look at his head CT. He had multiple lesions, including an area on the right side that looked like an old stroke or hematoma - mostly empty space where there should have been brain - an 2 spots that light up homogeneously with contrast - one near the left ear, and one on the right, at the very front of the brain near the pituitary gland and optic nerves. And it looked like maybe he had an old fracture in his right sinuses that had not completely healed. The enhancing lesions looked most like tumor - they were very regular - but I was praying for infection (or something else we could treat.) Either way, it was clear he needed an MRI and a neurologist, so the residents sent him home with plans to see Lao’s only neurologist (and a HF internal medicine residency grad) after his MRI in Thailand. A week and a half or so later, he returned to Setta with his MRI read. 11 pages of images in a 5x6 grid. The residents asked me to interpret it for them, because there was no read.

By the 6th or 7th page I was pretty discouraged. I couldn’t tell what kind of lesion the biggest, most worrisome one was, at the R front of the brain. It didn’t look like an abscess or a tumor to me, but I’m also not really trained to read brain MRIs. I’m not a neuro-radiologist, a neurosurgeon, or a neurologist, and while I occasionally look at brain MRIs, I usually do so with a detailed explanation of the results in front of me. I’d like to think I could see acute ischemia or a tumor or parasites on an MRI, but subtle differentiations are certainly beyond me. Fortunately for me, page 9 revealed a possible answer. The malformation lit up with IV contrast too - A LOT - like a blood vessel, not a tumor. Page 11 was the MRA and it clearly showed lots of blood flowing to the area and contrast filling the veins much quicker on the R. Maybe it wasn’t tumor but a crazy big aneurism or AVM? Would that be good or bad for my patient in a country with one neurologist and limited neurosurgeons, maybe none who specialize in vascular problems? I decided it was better than tumor, and explained my theory to the residents with multiple disclaimers about my lack of qualification to interpret MRIs, and they agreed to send the images on to the neurologist. The next day we got the official read from Thailand - he did, in fact, have a large abnormal vascular malformation in the R parasellar region. The neurologist tells me he and the surgeons will discus whether it can be repaired in Lao or he needs to go to Thailand. (And hopefully someone has figured out what the abnormality is on the Left side of the brain -that one wasn’t in the read we got.) But I left the hospital that day feeling proud of my deductive reasoning skills, if not my MRI reading ones. And while the patient isn’t “fixed” yet, he did have appropriate diagnostic testing in a timely fashion, and is being directed to the people who can decide when and how to fix him. :) That’s often as close as we get to a win in Laos.
At around the same time, a 15 year old girl was admitted to the inpatient medicine wards. It’s ok for my residents to take care of kids sometimes, because when they go home to their districts they may be the only competent doctor, and they will certainly be expected to care for everyone who shows up in the ER when they’re on call. However, I really do not feel qualified supervising them in the care of pediatric patients, particularly here in Lao; not only am I not trained in peds in america, I know nothing about the diseases that are more common here, or specific to SE asia, in children. However, the residents reported that they had asked the pediatricians if they’d like to take over the care of the patient and they weren’t interested. And she was looking pretty sick. She had had more than 3 months of abdominal pain, diarrhea, and weight loss. She now had anasarca and had had an albumin that was too low to measure (less than 2.7) on a check several months ago and again on admission. My resident really wanted it to be nephrotic syndrome (which is pretty common in SE asia) but she had multiple UAs that showed no protein. He was worried that it might be Capillaria philippinensis. This did not make a little light bulb appear over my head. Maybe we talked about it in global health class, but if we did I wasn’t remembering it. However, she did have Opisthorchis, a parasite that you get from eating raw fish, in her stool, and we determined that she had not been treated for this during her previous stay in the hospital. (No one had asked this, or reviewed the chart to see if treatment was prescribed.) So we agreed that we would repeat the few labs that hadn’t been ordered in the ER and treat the parasite we knew she had.

I went home and read about Capillaria philippinensis. It turns out that you get it the same way - eating raw fish - and it is one of the rare parasites that will actually kill you without treatment. It causes chronic diarrhea, abdominal pain, and protein loosing enteropathy. (All of the symptoms our patient had.) And it can be hard to find on stool exams. And almost all patients who have it have other parasites as well. And there have been cases in Lao. All of this was adding up to make me very worried about this patient. I e-mailed our beloved ID doc who agreed that the story was worrisome but suggested we also consider beri-beri (thiamine deficiency.) Another condition I have never actually seen in America. I reported this back to the residents. We discussed how she didn’t have the parasites on another stool exam, but we knew she had one parasite, which made others more likely. We discussed how clinically, the picture was compatible, and how these particular parasites can be hard to find on stool exam. We discussed how not treating capillariasis is deadly. We discussed the risk / benefit of possibly giving anti-parasite drugs she doesn’t need (side effects/toxicities) vs. the risk of not treating the infection (death.) The residents reported that they agreed with me but the teachers said they couldn’t give albendazole, the medicine for capillariasis. They did give some thiamine.

Over the next week, her anasarca improved and her fatigue improved a bit. She looked more like a chronically ill patient, but not one on the verge of death, the way she had the first day or two. She started eating a little, sitting up, and interacting with the doctors. Maybe she had just had thiamine deficiency, but probably not, because thiamine deficiency doesn’t cause abdominal pain, and it usually does cause other symptoms / exam findings that she did not have. I had the same discussion about likelihood of infection (Unknown, but certainly non-zero), and risk/benefit of treatment vs not treating several more times with the residents, and one time with the IM teachers and ID team there. They all sort of nodded their heads, but every day she still hadn’t been put on albendazole. This monday, I came in to the hospital and she was gone. She was discharged over the weekend, having never been given albendazole. The residents reported they would have liked to give it, but the teachers kept saying no. I can only hope that if she gets worse again (which she will do if she has untreated infection with this particular parasite) she comes back to Setta, either to the IM ward where I can try again, or to the peds ward where the docs can at least look at all the recent notes saying ?capillariasis and consider it as a diagnosis. But I feel like we failed a young woman with a lot of potential life left ahead of her, and that is discouraging.

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. . .