Final update from IM resident Joe Messana during international rotation in Chang Mai, Thailand

This week’s clinical responsibilities were unfortunately abbreviated secondary to illness. A learning point from my own case of bacterial gastroenteritis deals with the antibiotic recommendations that we are instructed to follow in America. We are told that due to give azithromycin as Campylobater resistance to fluoroquinolones is 20% in the US and is likely higher when infections are acquired during travel abroad. However, physicians in Chiang Mai typically still start with ciprofloxacin for traveller’s diarrhea initially and may give azithromycin if there is no clinical response. I had two days of azithromycin treatment without clinical improvement, but my fever broke 6 hours after ciprofloxacin. Notably, there were two formulations of ciprofloxacin I could take which were available at the local pharmacy without need for prescription. One was cheap, had higher rate of GI side effects, and was less potent, while the other cost 90 baht a pill (~@$3) and was much more reliable. My course also drew my attention back to how remarkable antibiotics are. I think I may have forgotten this fact as we prescribe them routinely, but my disease was controlled in a matter of hours. They are such powerful tools when used appropriately. It also harkens back to the talk I gave the weeks before regarding antibiotic resistance, and how that prospect is so frightening. 

In clinic, I’ve been participating long enough to start seeing patients for follow-up, which is rather gratifying. One repeat patient is seropositive with Hep B coinfection, and she came back for follow-up and vaccinations prior to her leaving for an extended trip in the US. It was interesting to think about this case from the opposite side of the ocean – thinking about people traveling to the States as opposed to the VFR that I see in my continuity clinic back in Minneapolis that are leaving the US for a period of time. 

Working with Dr. Parichat in outpatient clinic, I saw 3 AOID patients in just one day! This phenomenon is so intriguing. I’m eager to do more research about it. Apparently it is also prevalent in Taiwan.

This week marks actually marks the end of my infectious disease exposure at Maharaj Hospital. I start a stint in nephrology next until I leave for the states. Time is so relative, and just unceasingly seems to fly forward. It feels like I just arrived here a week or two ago. Being in this community where Buddhism is so prominent, you could definitely feel the increased “tone” of mindfulness in the general population. Hopefully this exposure left a long-lasting imprint that I will take back with me to the states.

Update #5 from IM resident Joe Messana during international rotation in Chang Mai, Thailand

Recently we’ve seen some fascinating cases, both things that are common in Thailand but also diagnostic dilemmas that reveal the intellectual prowess of the faculty here. 

This week we also saw 3 cases of synergistic gangrene. This is a post-surgical infection where the patient can have multiple expanding gangrenous lesions caused by either bacteria or fungus. Swabs of the skin lesions are taken and the patient is treated based on these culture results. Cultures are specifically used to determine if there is reason for antifungals or MRSA coverage. These patients require a long course of antibiotics, and the consequence of nontreatment is certainly very grave.

Working in Chiang Mai is a special place to practice ID because they it’s catchment area brings in the very rural diseases in the context of a functional university hospital system. It just makes one think, that our careers are so dependent on the clinical environments on which we are borne, and for obvious reasons. But by extension, I think ID would be a much more sought after specialty if the case load in the US was similar to that of Chiang Mai.

Update #4 from IM resident Joe Messana during international rotation in Chang Mai, Thailand

(apologies for the delay in posting)

This week is Kristina’s final week, and marks my half-way point of my Thailand immersion. I’d just like to say she has been a wonderful travel companion: kind, supportive, energetic, curious, and fun. It’s been a wonderful month acclimating/assimilating into Thai culture with her and she will certainly be missed!

We both prepared discussions this week that supplanted the fellow’s monthly lectures. Kristina talked about medicine and the media. She focused on how providers can better navigate this relationship and underscored the importance of doing so. She also gave instructions on how to speak to the media with about 10 recommended rules to follow. I gave a case presentation on lamivudine toxicity causing rhabdomyolysis with a short discussion about the differential for rhabdo afterwards. Then I gave a thorough review of HAART medication side effects in the major drug classes. In preparation for the discussion we had to buy a thumbdrive. We had an encounter with a saleswoman that just again underscores the generosity of the Thai people. She owns a small store at the corner of our soi (road/street), and sells several knick-knacks, but apparently not thumb drives. She has seen us walking back and forth daily and recognized us when we asked. She went to the back of the store and brought her own thumb drive and said we could use it as long as we needed! We were just overcome with her kindness. We couldn’t take hers, but now always say hello to her as we pass her corner.

Additionally, we were invited to be a part of a multidisciplinary international discussion panel for a course given by One Health at a satellite campus of Chaing Mai University. The night before we met with Deb Olson, Will Hueston, and other representatives from the group, to discuss the details of our role and the program. The panel of which we would be apart had representatives from nursing, medical research, agricultural industry, and physicians (us). The topic of the discussion was antibiotic resistance, the obstacles to overcome it, the risks of not doing so, and ways of troubleshooting and improving the issue. The panelists were convened to share their experience and give more insight to the people in the course on the topic and also practice in facilitating a panel discussion. Panelists were questioned by members of the class and then participated in several exercises to detail the problem further in small groups. The individual from the research field was German, and he had some fantastic insight into the problem in terms of monitoring and control of antibiotic use. IT was a pleasure to be involved with the course and contribute to the One Health movement. 

On rounds this week we saw a patient with SX linked Hypogammaglobulinemia leading to a cardiac abscess and grade I heart block who had negative blood cultures. We also saw aeromonas peritonitis and two cases of penicillosis!

Update #3 from IM resident Joe Messana during international rotation in Chang Mai, Thailand

(apologies for its delay in posting)

Our clinical work continues to reveal compelling cases, some similar to the “U style” patient in complexity (transplant patients, cancer patients, etc), while others are compelling based on the low prevalence of their disease in the US. 

We’ve been consulted on several similar AML patients which neutropenic fever in the hospital, however, in clinic we see a large population of seropositive patients. Recently we saw a case of pythiosis that required a left AKA. We see many cases of seropositive patients for biannual checkups regarding their medications and checking for toxicities. We see a lot of lipodystrophy with older HAART medications (as we transition from stavudine to tenofovir). There were 3-5 cases of disseminated aspergillosis with abscesses intra-abdominally, all occurring in a seropositive background. The burden of HIV was quoted to be 5% for Thailand but was recently increased to 8% by rough estimates. However, the attendings believe the prevalence to be closer to 15%. The discrepancy is probably due to underreporting/people not regularly seeing the medical system. 

We also have seen more and more cases of an interesting entity called Adult Onset Immunodeficiency  (AOID). These patients are typically from rural northeastern Thailand, present at middle age, and have antibodies to IFN-gamma. They present with recurrent infections equivalent to what would be seen in an immunocompromised/HIV population. 

We’ve been consulted on several cases of candidemia, though they mostly see Candida tropicalis in their hospital, unless they are post-surgical at which point it is usually Candida krucei. 

We have two excellent residents working with us: Jack and Fern. Jack a third year, is in an accelerated program, and Fern worked in a rural community hospital for about 3 years before ceding to come back and complete a residency. Their energy and laughter are infectious, and are always smiling throughout the day. Their English is very good, which allows them to present in English during rounds for our benefit and their practice. We realize however this is a time drain on their work flow and appreciate their effort. 

There was a visiting lecturer on seizure disorders from Texas, I believe Texas A&M. Kristina and I attended the lecture that began with two cases including an extended discussion on pseudoseizures. Thereafter he plunged into the nuances of different anti-epileptics and their interactions/side effects. Visiting lecturers are considered a special event and our attendance was encouraged.

There have been a steady amount of consults on patients injured from motorcycle accidents, which is in-line with MVAs being the most common health issue for travelers. We had one patient whose abdomen was punctured and required an emergent ex-lap. We were consulted later as he contracted acinetobacter meningitis! His condition was thankfully improving.

More to come shortly!

Update #4 from Med/Peds Resident Ryan Fabrizius during international rotation in Arusha, Tanzania

Pole Jambo from Arusha!

Since last writing I have been rounding on the medicine ward, which has been quite a different experience compared with pediatrics. While malnutrition and respiratory infections malign the infants and children, HIV devastates the adult population. Surprisingly, non-communicable diseases are just as common, if not more so, than HIV and its complications. Diabetes, hypertension, and chronic obstructive lung disease (emphysema) are much more common that I expected, and, unfortunately, with the transition of local populations to urban lifestyles, they will likely become the major burden of disease in developing countries like Tanzania. Just as it is in the US, chronic disease is difficult for patients to understand and providers to feel like they can make a difference, but I have been impressed by the knowledge and compassion of the local doctors to not just treat but to educate their patients on how to manage chronic diseases. For example, in outpatient clinic this week, I sat with Christopher, the internal medicine registrar, as he took about 30 minutes of a busy clinic day to explain diabetes type 2 to a patient. The concept of disease occurring without symptoms and not having a one time solution is a difficult one to grasp, but Christopher patiently reached for common ground in understanding. Despite the myth that doctors in developing countries are "paternalistic," I have found that in this case and many others, doctors like Christopher strive to educate and empower patients and families to understand their condition and proactively participate in their own care.

For today's Swahili lesson, I wanted to introduce the word "pole." Just like "karibu," pole is a common and versatile word that enters into interaction several times per day. It is usually used here for "sorry," like when you bump into someone or walk on a clean floor with dirty shoes (I seem to leave a trail wherever I go). "Pole" also has some unique uses that we have observed. It is considerate to express "pole" when you see someone carrying a heavy load (we get a alot of "pole"s when we carry groceries home up the hill). Many people will say "pole la kazi" when they see people at work, whether working at the hospital, harvesting roadside crops, constructing/digging, etc... It means, literally, sorry about the work. It feels similar to the feeling of sympathy medical residents give each other during a busy night shift or after a difficult series of events. To me, it seems to be expressing, "I have been there and I feel your struggle, hope you get to finish work and rest soon". 

The most interesting use of "pole" for me has been with patients. When most local medical staff approach a patient on rounds or clinic, they usually begin with "pole bibi/babu/mama" (sorry grandma/grandpa/mother), which acknowledges the fact the patient is having a struggle. The usual response is "asante" (thank you), which feels like an expression of gratitude for recognizing the burden on the patient and family. As medical workers in the US, I think we do recognize the value of this sort of sympathy. Some useful expressions that I have learned from my teachers are "this seems like a difficult time for you" or "i'm sorry you have to go through this," but usually this comes up after a display of emotion from the patient or family that beckons validation. In clinical practice here, I find it most interesting that this validation and sympathy is the greeting, rather a phrase reserved for certain situations. It seems rooted in the community values here, that one person's burden is shared amongst others, not just friends and family, but all people that interact with them. Here in Tanzania, there are so many burdens that people carry, even in daily struggles for basic needs. It is frustrating for me, as someone that takes for granted that my daily needs are easily met, to see the barriers that people have to providing for themselves and their children. On top of that, the burden that HIV, chronic disease, and other medical conditions place on an already struggling people seem absolutely insurmountable. This, for me, stirs up feelings of injustice and unfairness, questions of why? and how?, and often results in frustration and fatalism. But for the people here, they bear with each other in these circumstances, supporting one another and carrying one another's burdens. Linguistically, I do not know if these words have a common root, but "pole pole" is another common expression that means "slowly" or "gradually". It is the unofficial mantra of climbing Mt. Kilimanjaro: gradually, one foot in front of the other. And such is seems with bearing one another's burdens. Sorry for your troubles, but slowly, together, we will carry it together.

Walking to Selian Hospital with Mount Meru in the background