30 April 2000
Greetings once again!
It is hard to believe that another 2 weeks have flown past again. The past two weeks have been unbelievably busy for Eric and somewhat more restful for Jennifier since Dr. McDaniel and Melodie were gone with Melba on a family vacation for the majority of the time. As a consequence, I, Eric, will write this entire update.
In Dr. McDaniel's absence, I took primary responsibility for our inpatients. Dr. Sakda, the Thai doctor, has had a lot on his mind recently (getting married in 6 days and then leaving for a 4-year general surgery residency in Bangkok a couple of weeks later) so he was quite relieved to not have to add Dr. McDaniel's patients to his census. In addition to the inpatients, I saw about a third of the outpatients (Dr. Sakda is faster than me because he has about 3 years of experience here a KRCH and because he doesn't have to get the medical history through a translator) and over the course of the 2 weeks I admitted close to 10 patients and discharged about as many. In short it was an unparalleled experience for me and yet very humbling at the same time.
Two days after Dr. McDaniel left, the mother of one of our nurse aides was brought to the hospital in complete cardiopulmonary arrest (not breathing and no heartbeat). Dr. Sakda and I "coded" her for almost an hour as her daughter (who was working in the lab at the time) looked on, wailing louder than I've ever heard. The whole experience was very surreal -- in the States, of course, there would rarely be an audience for a code, especially not family members, but around here, the whole concept of privacy is pretty foreign. So, the daughter and about 40 other random people who heard the commotion watched our unsuccessful attempt to resuscitate her. Given our level of training and our limited available resources, I believe that Dr. Sakda and I did everything we could. We successfully intubated and "lined" her within a few minutes of her arrival. But without a heart monitor, defibrillator, etc, there was little else for us to do after pharmacologic resuscitation failed. The following evening Jennifier and I joined a group from the hospital in attending a Buddhist memorial service for her (the daughter who works in the hospital is the only Christian in the family). The service was quite sad, devoid of any sense of hope -- at least none that we could identify. But we're confident that the Christian daughter appreciated our support.The following day I made the new diagnosis of HIV in a patient with esophageal candidiasis (testing for HIV is one of the things we can do here). For the first time, I had to explain to a patient that they had a uniformly terminal disease about which I could do nothing other than treat "secondary" infections. In this part of Thailand, HIV treatment is cost prohibitive, so care is supportive in nature. In some ways I think it may be easier (for the doctor) to break bad news to a patient through a translator. Somehow you get this false sense that you're not really the one telling the patient. I was quite thankful that she was receptive to speaking with the hospital chaplain, Meechai, who became a good friend when I was here 5 years ago.
Saturday (a week ago) was a great day . . . at first. In the morning I did an "I & D" (incision and drainage) on a Karen man who had been beaten up by some Burmese soldiers two months before and consequently developed an abscess (collection of pus -- sort of a giant zit) in his left gluteal region (his butt). In the afternoon I successfully performed my first unsupervised spinal anesthesia and knee exploration to remove the gentamicin beads from the woman that I spoke of in the last update. Praise God, everything went perfectly! . . . But then in the evening three really sick folks arrived -- two went to Dr. Sakda, one to me. Mine was a 13-year-old Karen boy from Burma who was living in a nearby refugee camp. He had had fever for 3 weeks and abdominal pain for 1 week. That was about all the history we could get because he and his 14-year-old brother (the only family member with him) spoke a strange dialect of the Karen language that no one in the hospital could understand very well. His fever was high (> 105 F), his heart was racing, and his belly was more tender than I have ever seen (clear peritonitis). His history was consistent with Typhoid fever (which there is a lot of around here) with a ruptured typhoid ulcer of the gut. It could have been a lot of other things too, but it was clear that he needed an operation. I certainly couldn't do it and Dr. Sakda, who only does hernias, appendectomies, c-sections, and lumps and bumps, really didn't want to do it either. Though Dr. Sakda and I had many long, late-night talks throughout the week debating whether or not we should change our minds and take him to the O.R., we opted for "conservative" management in the end. I put in a central line to "feed" him through (TPN), and tanked him full of fluid and antibiotics. By the end of the week his peritonitis was all but gone and, more importantly, he had survived until Dr. McDaniel's return. Dr. McDaniel and I operated on him yesterday and drained a large abdominal abscess. Today he is looking much improved and has his appetite back. I praise God for keeping him alive! Unfortunately the other two "sick folks" died -- the first, a 9-month-old baby, died of pneumonia (we have no ventilators here); the second, a 30-year-old lady with a ruptured appendix, coded and then died an hour after I assisted Dr. Sakda with her surgery (we're still not sure what she died of). In both of these latter cases I am tortured by the fact that had these patients had fully trained doctors in state-of-the-art hospitals, they probably would have lived. I can only take some sort of strange comfort in knowing that this is not an option for poor Karen refugees who don't even have access to the Thai government medical system -- if we hadn't helped, no one else would have.
Last Wednesday afternoon, Petak (my primary translator who speaks 4 languages) took Jennifier and me to visit the nearby Karen refugee camp just on this side of the Thai-Burma border and the Mon (another Hill tribe group) camp just on the other side of the border. The border police seem to let any truckload of unarmed "farangs" (Caucasian foreigners) cross the border at will, and since Petak knows many of the soldiers from his days as an employee of the American Refugee Commission, he doesn't get hassled either. Any description that I could come up with could not do justice to the plight of the people living in these camps. I only hope that the pictures we took will turn out. These refugee camps provide what is necessary for basic human survival -- nothing more.
On a lighter note, today I played an arrangement of "Mansions Over The Hilltop" for 2 violins and guitar in church. It brought glory to God, I believe, and was great fun. The other violinist (the only resident violinist in the village) plays on a violin made in Burma. To be honest, it is a wonder that he gets any sound out of the instrument at all. But he doesn't care -- he feels fortunate simply to have a violin to play. Musical instruments are in very short supply here and too expensive for the Karen people anyway. There are about 5 guitars in the village (each worth about $25 in my estimation) that are shared among roughly 10-15 guitarists.
I was asked to speak at the hospital's morning worship last week. I hope and pray that my message on Jesus as our intimate teacher was understood and taken to heart by at least one. Jenn has spent the past two weeks doing a number of "odd jobs" around the hospital complex. She alphabetized a bunch of patient records, did some data entry for both the hospital and the McDaniels, did some cleaning, and did some much appreciated (by me) baking.
That's all for now. I must send this before the power goes out again.
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