Transcript Report on rotation in Vientiane, Lao PDR

Report on rotation in
Vientiane, Lao PDR
Renée Cassidy
Medicine-Pediatrics PGY 3
March 2003
Overview
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Introduction to Lao
Lao Health Care
My Lao Experience
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Living Arrangements and Schedule
Internal Medicine Experience
Pediatric Experience
Links
References
Laos
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Formally known as Lao People’s Democratic
Republic, or Lao PDR
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Informally “Lao,” as the S was mistakenly added by
the French
Landlocked nation bordering China, Vietnam,
Myanmar, Thailand, and Cambodia
Language is Lao, similar to Thai, a monosyllabic
tonal language
Many ethnicities populate Lao, including Lao
Loum, Lao Tai, Lao Theung, and Lao Sung
Lao
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Population is approximately 5 to 5.5 million
Government is single party, communist, with
much bureaucratic oversight and little economic
freedom on a policy level
Climate is tropical, generally from a low of 15 °C
(59 °F) to high of 38 °C (100 °F)
Economy is predominantly agricultural, with
considerable foreign aid from Thailand, the US,
Australia, Malaysia, and France
Lao
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About 70% of the land is mountainous and 50%
forested; the Mekong River runs through Laos
from China to Thailand
Public education is generally poor and private
education is expensive. School dropout rates
and literacy rates are each around 60 %.
Theravada Buddhism is the most common
religion
Culturally the Lao are known as laid-back,
hospitable, devout, and sociable
Health Care in Lao
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Life expectancy is about 54 years (US
around 77 years)
Infant mortality is 93/1000 (US about 7)
Child mortality is 137-153/1000 (US 7-9)
Health expenditures are 2-3% of the GDP
(US 13-14%)
No health insurance; most health care
expenses paid out-of-pocket
Health Care in Lao
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Majority of people see physicians only when ill
and often when illness is advanced
Hospitals are poorly staffed and equipped, with
restricted access to medicines, and are often far
from villagers
Approximately 24 physicians and 108 nurses per
100,000 population (compared to US 279
physicians and 972 nurses)
Many use traditional medicines and remedies
Medical Education in Lao
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After “high school” students enter directly into medical
school, a 5-7 year program encompassing premedical
studies and basic sciences
Little clinical learning is provided
Books and other resources are not widely available
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Very few Lao language materials exist, thus many books are
Thai, French, English, Russian
Physicians practice immediately after finishing medical
school, provided they can find a job
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Many express significant discomfort with their experience; “not
ready” to treat patients
Medical Education in Lao
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No structured residency training exists in the country
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Those with enough money or with scholarships trained in
France, Germany, Australia, Thailand, etc.
In the last decade or so, NGOs have assisted the
National University of Lao PDR Faculty of Medical
Sciences to create pediatrics and obstetrics/gynecology
residencies
An internal medicine residency was begun last year
Currently there are 6 positions per year for pediatric
residents and 6 for internal medicine.
Internal Medicine Experience
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Worked primarily in Mahosot Hospital but
also visited Hôpital de l’Amitié and
Setthathirat Hospital
Conferences, lectures, and bedside
teaching as well as time for reading and
research
Case presentation on syphilis and lecture
on hyponatremia
Internal Medicine Experience
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31 yo F from the provinces with several months
of worsening fatigue, irregular menstruation,
constipation who had mild thyromegaly on exam
20 yo M who presented pale and fatigued
30 yo F with inability to walk and headache who
had nystagmus, paraplegia of the lower
extremities, right weaker than left, and bilateral
Babinski signs
37 yo M from Vientiane with fever and bright red
blood per rectum
Interesting Cases– and Frustrations
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The 31 yo F with fatigue and thyromegaly was suspected
of having hypothyroidism due to iodine deficiency,
although Hashimoto’s thyroiditis is also relatively
common. She couldn’t afford the TSH and T4 ($20), and
when assistance was offered she declined anyway
because she and her husband needed to return home
and the lab only drew blood and ran the tests once daily.
20 yo M who presented pale and fatigued had a CBC of
WBCs 2.4, Hemoglobin 6, Hematocrit 19, and Platelets
85,000. Aplastic anemia is extremely common in Lao
and Northern Thailand with as yet no identified reason.
The 30 yo F with neurologic signs was unable to afford a
CT scan which was recommended ($65). Her family
wished to take her home although she was still unsteady
walking, even with assistance.
Interesting Cases– and Frustrations
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The 37 yo M with bright red blood per rectum was
obtunded in the ICU, BP 80/50, IVF at 50 ml/hr, H/H
4/12 awaiting a blood transfusion because the blood
bank had no blood. Someone went to Thailand to
request blood and an ambulance, which arrived just as
the local blood bank delivered 3 units donated for him.
He was transferred to a larger hospital in Thailand where
he underwent colonoscopy showing ulcerations in the
ileum and a Dieulafoy lesion in the cecum. He was
treated by epinephrine injection and cautery, received a
total of 17 units of blood, and survived. He was
suspected to have underlying S. typhi (Typhoid fever)
causing the ulcerations, fever, and other systemic signs.
Dieulafoy Lesions
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Dilated, tortuous submucosal vessel with an overlying small erosive
defect in the epithelium
Most commonly found in the upper half of the stomach but has
been described in all areas of the GI tract
Unclear etiology; may be related to ischemia, vascular
abnormalities, or other mucosal defects
Typically diagnosed by endoscopy but angiography may be useful
Endoscopic treatments include epinephrine injections,
electrocautery, hemoclipping, band ligation; typically epi is followed
by cautery
Surgical intervention may be required for lesions which rebleed or
are difficult to reach endoscopically
Rebleeding occurs in 10-40%, attributed to large underlying arteries
Typhoid Fever
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Systemic Salmonella infection caused by S. enterica
serotype typhi (S. typhi) or other similar Salmonella
serotypes
Estimated 16 million cases annually, with 600,000 deaths
– overwhelmingly in developing countries
Transmitted by contaminated food or water (feces or
urine) containing 1000-1,000,000 organisms; lower
infectious dose if gastric pH is high
Diagnosed by blood cultures which are positive in 6080%; bone marrow cultures, which are positive in 8095%; or by clinical suspicion in an endemic area
Initially the bacteria multiply in mesenteric lymph nodes,
then infect mononuclear phagocytes, then are released
into the bloodstream. Secondary bacteremia leads to
multiple organ infection, most commonly liver, spleen,
bone marrow, gallbladder, and GI tract
Clinical Features of Typhoid Fever
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Incubation is 7 to 20 days
Initial symptoms are malaise, headache, dry cough, low
grade fever (about 1 week)
Progresses in the second week to high sustained fever
(39-40 °C), transient rose spots (2-4 mm pinkish
blanching maculopapules), abdominal pain,
hepatosplenomegaly, apathy, toxic appearance
3rd and 4th weeks are characterized by significant toxicity,
neurologic signs, hemodynamic instability, complications,
and death
Where typhoid is endemic, it may be confused with
malaria, tuberculosis, amebic liver abscess, influenza,
dengue fever, leptospirosis, mononucleosis, endocarditis,
brucellosis, typhus, visceral leishmaniasis, toxoplasmosis,
neoplasia or connective tissue disease.
Clinical Features of Typhoid Fever
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Complications include GI bleeding or perforation,
often due to ulceration of Peyer’s patches in the
terminal ileum; encephalopathy; or myocarditis
Relapse occurs in 10-20% about 2-3 weeks after
the fever breaks; this is usually less serious than
the initial bout
Chronic carriage occurs in 1-5% and the
organism is shed in feces or occasionally in urine
(particularly in those with Schistosomiasis)
Most cases are managed as an outpatient with
oral antibiotics
Treatment and Prevention
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Fluoroquinolones (ofloxacin, ciprofloxacin, pefloxacin)
are very effective
3rd generation cephalosporins (ceftriaxone, cefotaxime)
are an alternative in severe disease
Resistance is found to chloramphenicol, ampicillin,
TMP/SMX, and often multiple drugs concurrently
Dexamethasone decreases mortality in severe disease
Treatment is for 5-7 days in mild disease and 10-14 days
in severe
Two vaccines are available: an oral, attenuated vaccine
lasting about 5 years and a parenteral vaccine lasting
about 2 years
Improved sanitation, water quality, and living conditions
would significantly reduce the transmission
Internal Medicine Experience
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Malaria
Dengue Fever
Typhoid Fever
Hypertension
Stroke
Jaundice
Aplastic Anemia
Opisthorchiasis
Pediatrics Experience
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Spent majority of time on Mahosot
Hospital wards and Diarrheal/Infectious
disease wards but also saw cases in the
outpatient department, NICU, and PICU.
Conferences, lectures, journal club, and
bedside teaching, pre-rounding and
rounding on patients as well as time for
reading and research
Pediatrics Experience
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Rheumatic fever and Rheumatic heart disease
Vomiting, diarrhea and dehydration
Typhoid fever
Tetanus
Measles
Pneumonia and pleural effusions
Malaria
Dengue Fever
Leukemia
Aplastic Anemia
Thalassemia
Sepsis
Links
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www.healthfrontiers.org – Health Frontiers is a non-profit organization
which currently administers the residencies in Lao and donates to the care
of the Lao people
www.theboatlanding.com – an excellent Lao website which has links to
many travel and tourism sites, recommendations for how to get the best
out of a trip to Lao, and information about the Lao people and Luang Nam
Tha
www.who.int/country/lao/en/ - World Health Organization information
about Lao
www.heritage.org/research/features/index/ - The Wall Street Journal /
Heritage Foundation annual ratings of individual countries’ economies
www.bryanwatt.com – Bryan is the husband of the current pediatric
residency coordinator and a professional photographer
www.gushurst.com – Jordan’s and my home page, soon with photos of the
trip to Lao and Viet Nam
References
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Cummings, Joe. Laos, 4th ed. Lonely Planet Publications, Australia: 2002.
Eddleston, M. and Pierini, S. Oxford Handbook of Tropical Medicine. Oxford
University Press, Oxford: 1999, pp 206-7.
Heritage Foundation and Wall Street Journal. Index of Economic Freedom 2003.
Hohmann, E. L. Pathogenesis of Typhoid Fever, Treatment of Typhoid Fever, and
Approach to the patient with Typhoid Fever. UpToDate version 11.1.
Mahosot Microbiology Review. Issue 2, April 2002.
Norton, I. D., et al. Management and long-term prognosis of Dieulafoy lesion.
Gastrointestinal Endoscopy 50(6): 762-7, 1999.
Parry, C. M., et al. Typhoid Fever. NEJM 347(22): 1770-81, 2002.
Schmulewitz, N., and Baillie, J. Dieulafoy Lesions: A review of 6 years of experience
at a tertiary referral center. American J Gastroenterology 96(6): 1688-94, 2001.
World Health Organization. Selected Health indicators for Lao People’s Democratic
Republic.