Medical Day...

I spent the entire day out at the medical clinic yesterday.  It was an exhausting but fascinating day.  Most of the kids and infants who are brought in by their parents just have the common cold.  They've become pretty easy to spot.  Slight runny nose, mild fatigue, mild fever and cough.  Questioning confirms that all the kids in the family have the same problem.  There seems to be a mini-epidemic of common cold in SE Asia right now, as I've come across many adults who have been complaining of a cold too.  But things got interesting just before noon.  

At about 11:30, Dr. Sokunthea went on her lunch break somewhere back in Siem Reap.  As I was packing up my bag to go find someplace to eat as well, a young man shyly shuffled into the room. I looked up and his problem was immediately obvious.  The skin of his left arm was about 50% rubbed off.  Another large abrasion above his mouth on the left side.  And a huge 6 cm gaping wound above his mouth on the right side.   The wounds were purulent and covered in the red colored dirt that is everywhere here.  Holy crap.  "Umm...Docta Hahn...you wememba me?"  Until he asked, I hadn't.  But then I realized this was one of the three kids that caught a short ride with me in the tuk tuk back to the orphanage on Friday as I headed out from the school.  Sehar was his name.  Sehar went on to explain that he got into a scooter accident on Friday night at about 11:30 pm.  He came to the clinic, but Dr. Sokunthea's assistant was the only person around.  He pointed to some small bottles of clear fluid in the cabinet.  That was what she had handed to him.  I looked at the label, but it was written in Vietnamese and there was only one English word I recognized - "OXY".  Hydrogen peroxide, maybe???  So there we were, on Monday morning, and his wounds were still pretty much untouched from Friday night.  Luckily, I had brought two big bottles of saline with me.  Dorothy a volunteer from Canada, came in to help me.  The next hour and and a half went by as I washed all the wounds, applied antibiotic cream, covered them with a non-stick gauze pads.  Let me just say for the record that this kid's tolerance for pain was superhuman.  There was no lidocaine to be found in the cabinets.  Tears streamed down his face as I cleaned the wounds, but he kept insisting that he was okay.  Then Dorothy raised a good question - "Do you think the inside of his mouth okay?"  Lifting up his upper lip, there it was - a small puncture oozing a little pus, just opposite the large gaping wound on the outside.  Did I say holy crap before?  Holy crap.  Rolling up some gauze with a little antibiotic ointment, I packed it into area.  Not ideal, but the best I could do.  He's coming back today to see me so I can check over everything.  On the plus side, it has been 3 days and I couldn't see any signs of infection.  I found out later what had happened.  He and his buddies were out and had a few beers.  As he was driving his scooter home with his two friends on the back, he came across a pothole but couldn't react in time.  I'm guessing the gaping wound was a result of his face hitting some part of the scooter.  The other two friends got away with minor cuts and bruises.

In the afternoon, an older man came in.  Complaint was abdominal pain - right upper quadrant - that came on after eating.  No swollen belly, soft liver, but *really* enlarged spleen.  Yellow eyes.  Possible gallstones?  Confirmed that he had spiking fevers for the last 3 days.  Also has a history of malaria - P. vivax.  I did a finger prick for some blood.  When I put the blood drop hit the slide, it spread out quickly like blood tinged water.  Clear sign of anemia.  His urine dipstick was positive for urobilinogen and bilirubin.  It all added up to some kind of hemolytic anemia.  Given his history of malaria, I am highly suspicious for it, but could not confirm it by microscopic exam. Not leukemia or lymphoma, but I can't rule out other causes for hemolysis.  Autoimmune?  Hereditary?  As good as the microscope is, I couldn't make out the red blood cells very well.  It may be due to poor prep technique which I will have to try to improve.  Won't be able to do anything about the gallstones and surgery is just not an option unless there's some way to get him free treatment.  But my priority is to treat the cause of the anemia which is pretty severe given the thinness of his blood.  Did some research last night and will treat him today presumptively with anti-malarials.  For those of you interested in medicine, check out Artemisinin.  Not available in the U.S. but widely used effectively everywhere else in the world.

The other patients in the afternoon included a possible pellagra case (Vitamin B3 deficiency) presenting with white patchy skin spots on sun exposed areas, and a congestive heart failure case presenting with dyspnea alleviated by lying down.  Amazing first full day in the clinic.  I was so tired last night, I finally got my first night of more than five hours of sleep.  Let's see what's in store for today...