When it rains it pours...

   Last week was a bit rough...

   Before I get to that, I should say that things have generally been going very well in the hospital.  We have seen some very sick children that our Lao and expat volunteer doctors have managed brilliantly.  There were a few patients in heart failure from infantile beriberi who probably wouldn't have lived if they had been just a few hours slower in getting to the hospital.  But, they arrived in time...  Our nurses triaged them quickly, our doctors identified the problem and gave the proper treatment, and within hours they brought the patients from heart failure with low oxygen levels and respiratory distress to nearly normal.  Such cases are extremely rewarding.  Beriberi has now replaced diabetic ketoacidosis as my favorite condition to treat.  In both cases, you can guide a patient from critically ill to stable over the course of hours, all while seeing the physiology respond to treatment in front of your eyes.

   The staff are also doing a great job of managing traumas.  Under the guidance of our new executive director, Simon, they have re-aligned some displaced fractures (a little ketamine, a little tension, a little pressure, and a cast).  Our new director of medical education, Christine, is moving forward with the neonatal training we need to open our newborn unit.  And, our nursing director, Becky, is preparing the nurses for neonatal and surgical nursing - not to mention experimenting in the kitchen to prepare "plumpy nut" (ready to eat therapeutic food) in a way that Lao kids won't spit it out.  There is a lot of progress being made.

   Despite the successes, we sadly had 2 children die last week.  Considering how sick many of our patients are, it is surprisingly not that common that one of our patients dies in the hospital.  Two deaths in one week has been hard on all of us.

   I have to be careful discussing details out of respect and privacy, but I can share some information.  One of the cases was a toddler who came to us after having seizures continuously for nearly 24 hours.  The child arrived with dangerously low oxygen levels (for who knows how long at that point).  He also had very elevated blood acid levels, undetectably low blood sugar, and was in acute kidney failure when he arrived.  We were able to stop the seizures using three anti seizure medicines, quickly correct the blood sugar, and slowly resolve the acidosis, but the damage to brain and other organs was too much at that point, and he succumbed to his illness.

   It was heart-breaking to see the family suffer through this loss, especially since they had recently lost another child.  On the other hand, it was  inspiring to see the support of their extended family who, within an hour, had already sewn a beautiful little black funerary outfit for the child.  Family and community are especially powerful at times like these.  One of our Lao staff sat with the family, comforting them and simply being there.  She did an amazing job, but was pretty shaken.  A few hours later, I asked how she was doing.  "Not good, Dr. Greg. I cried. I am not strong enough yet."  I told her that every one of us in that room cried.  Crying is not weakness; it showed the family that she cared.  If there ever comes a day that I stop feeling grief at the loss of any child, then I should stop being a pediatrician.

   On top of all of this, one of our staff had to leave urgently because a family member suffered a severe accident with uncertain prognosis...

   As I said, it was a rough week.

   Fortunately the weekend has been therapeutic.  Many of the staff got together for a little fun at a karaoke club on Friday night - there was a private room with a few microphones, a few disco globes, a few cases of BeerLao (sweet iced tea for the abstainers), a big screen TV,  an eclectic selection of English, Lao, and Thai songs, and mercifully some VERY powerful air conditioning.  There were some great singers, and there were a few who sang like me...  Nobody cared, and nobody was particularly self-conscious.  It was all innocent fun and a well-deserved release of tension.

Bad picture, good fun.

   Yesterday the medical leadership team met with Amy Gray, an Australian pediatrician who has been working in Laos for years.  She also traveled with a few pediatric fellows who are working with her in Vientiane.  They were able to share insights about the past, current, and potential future state of pediatrics in the country... and the best part is no conference rooms were involved!  We talked over breakfast at a Le Banneton, an open-air French bakery/cafe', soaked away the afternoon in the swimming pool at La Pistoche (which is filled with Lao kids by day, and foreign tourists by night), and enjoyed a delicious dinner at Kaiphaen, a "social enterprise" restaurant that reinvests all profits into training programs for its student-employees.  The food was outstanding. all. day. long.  So good that I even passed on dessert.

Swimming at La Pistoche

   Overnight and into the morning on Sunday, we had the kind of house-shaking thunderstorm I remember fondly from childhood storms in the Midwestern US.  The rain mercifully brought the temperature down a few notches so I did a little walking around town, and the day left plenty of free time (and functioning internet!) to do a little websurfing, a little work via e-mail, FaceTime with the family, and Skype with a prospective volunteer.

   I finished the weekend with even more great food and conversation.  First came dinner at a newly opened Chinese restaurant with perhaps my favorite Szechuan dish 酸菜鱼 - spicy pickled veggies with fresh fish.  The owner gave me dinner for free after I helped him post his business to google maps.  I also chatted with his sister-in-law at length about educating kids while living abroad.  She sent her 6 year old back to China to live with the grandparents so he could learn Chinese characters and not fall behind in the demanding Chinese school system.  She is still struggling over that decision.

So delicious.

   Finally, I wandered back to the guesthouse where I exchanged Lao and English language tips and cultural insights with some of the young staff over a plate of sliced mangoes and rambutans.  I think I am ready for another week.

Novice monk resting, with frangipani in the foreground. 

When you hear hoofbeats...

   There is a commonly-repeated aphorism in medicine: "When you hear hoofbeats, think of horses, not zebras." This was coined in the 1940's by Dr. Theodore Woodward, who encouraged his medical interns to consider common illnesses (horses) as the cause of a patients symptoms, before immediately leaping to the rare diseases (zebras) which tend to capture our imaginations.

We saw these guys in 2007 in South Africa (where zebras may be more common than horses...).

   I don't fault trainees for thinking of exotic zebras before commonplace horses. It is partly human nature, and partly a by-product of our medical education which uses rare illnesses to illustrate broader principles.  This is because much of what we learn about how our bodies work comes from studying uncommon situations where these systems go haywire.

   For example, we know about vitamin C because we wanted to understand why sailors got scurvy - a nasty condition characterized by bleeding gums, non-healing wounds, and eventually neurological problems and death.  For several centuries there were various theories about the cause of scurvy, as well as various cures prescribed - some of which worked, and some didn't. It wasn't until the 1930s that we had the conclusive answer, when it was demonstrated that giving Vitamin C to guinea pigs who were otherwise fed a grain-only diet would cure them of scurvy.  Vitamin C's current name of ascorbic acid (or "anti-scurvy acid") was given because of those studies.  Through studying scurvy, we learned about the myriad processes in our bodies which depend on Vitamin C.  We also learned that humans (and fortuitously enough for science, guinea pigs) are sort of freaks in the animal world.  Most other animals can synthesize their own Vitamin C.  Humans, along with many other primates, just happened to inherit a faulty Vitamin C gene, which doesn't cause us any problems, unless we have a very imbalanced diet.

   Every medical student learns about vitamin C and scurvy, but few physicians today have ever seen a case (myself included).  That said, every time I hear "bleeding gums", the diagnosis of scurvy immediately pops into my mind, even though gingivitis (or an anticoagulant medication, or a host of other causes) is much more likely to be the culprit.  At least Dr Woodward's aphorism reassures me that I am not the only person guilty of thinking of zebras before horses.

I'm not worried about scurvy in Laos. Mangoes have way more Vit C than oranges. 

  As a third-year medical student, I remember rounding on a 40-year old man who was recovering from a relatively minor illness.  He was improving nicely, and was very anxious to get home to attend to his business.  As per routine, we asked how he was feeling that morning.  He casually mentioned he had a bit of a headache - a feeling of tightness around his head.  Another medical student asked him if it was the worst headache of his life, to which patient responded "As a matter of fact, I suppose it is worse than the headache I usually get".  When our supervising physician asked my colleague about the cause of the headache, he replied uncertainly, "Morning headache, worst of his life - possibly a brain tumor?".  It was, actually nothing more than a simple tension/stress headache, which a brief exam and a few questions revealed pretty conclusively.

   It wasn't my colleague's fault that in our first 2 years of med school we only learned about the more "sexy" causes of headaches - things like migraines, or increased pressure inside the skull (hence his guess of a brain tumor).  Tension headaches, were not something any of the classroom teachers found particularly interesting to discuss, since they didn't teach any obvious physiological principles.

   Once we began to work with patients, we quickly learned to shift focus.  We couldn't forget completely about the zebras that our education had emphasized, but now we needed to think first about horses.  Since then, and now that I have practiced as a generalist pediatrician for the past 10 years, it is very natural that hoofbeats first make me think of horses.  After all the majority of what I have seen day-to-day has been fairly common presentations of common conditions, with the occasional 1%er zebra to keep me from getting too complacent.  When I hear about a 6 year old's abdominal pain before getting on the school bus I first think about anxiety or constipation, rather than pancreatitis.  Horses, not zebras...

   Now that I am in Laos, however, I have had to change the filters through which I see the world.  Unlike Maryland, where Dr. Woodward encouraged his interns to consider horses, Laos doesn't have many horses (and probably not a single zebra for that matter), but there are plenty of water buffalo.  So, now when I hear hoofbeats, I think of water buffalo.

Water buffalo walking up a bank of the mekong.

   In America, a profoundly anemic toddler is probably drinking too much cows milk (a horse), or maybe has a severe occult bleed, or something worrisome like leukemia, or bone marrow suppression. In Laos, a profoundly anemic toddler almost certainly has thalassemia (a water buffalo).

This young girl has such a pale thumbnail bed, due to anemia from thalassemia. Her total volume of circulating red blood cell mass was only 1/6 of normal.

   In America, a two month old presenting in acute heart failure probably has a congenital heart condition.  In Laos, that same presentation probably means beriberi, aka thiamine deficiency. In fact, in Laos we assume any infant with fussiness, weakness, heart failure, weak cry, stridor, decreased reflexes, signs of meningitis, or a whole host of other symptoms, probably has beriberi, perhaps the biggest pediatric water buffalo of them all.  We don't forget to think of other diagnoses, but they all get a shot of thiamine in their thighs, because assuming that this particular water buffalo is a horse could quickly result in death.

Adding to the list of our common water buffalo are typhoid/enteric fever, dengue fever, Japanese encephalitis, infantile staphylococcal scalded skin syndrome, and chickenpox - which has gone from being one of the most common of horses in the US to one of the rarest of zebras. In fact, chickenpox is such a common water buffalo in Laos that many cases of impetigo are misdiagnosed as chickenpox.  I guess we all have our biases when it comes to hoofbeats.

A River Runs Through It

Last night, I sat on the deck of the Villa Merry 1 Guesthouse deck sharing a *second* dinner with several of the local guesthouse staff.  VM1 sits perched on the bank of Laos’s muddy and usually languorous and shallow NamKhan river.  As we chatted over bowls of spicy noodles, our conversation was punctuated by loud splashes coming from the direction of the NamKhan.  My hosts explained that the river is flowing faster due to recent rainstorms.  There is also water being released from the hydroelectric dams that have been built to help satiate Laos’s neighbors’ thirst for electricity.  This increased flow dislodges chunks of the opposite river bank which slide into the water, where they are churned into silt, and are washed downstream.  We speculated on how much longer the seasonal bamboo pedestrian bridge would last, before it was also consumed by the muddy river, only to be rebuilt by hand with the coming of the next dry season. 

Seasonal bamboo bridge across the NamKhan river

As the NamKhan enters the town of Luang Prabang, it briefly parallels its big brother, the Mekong, before it finally makes a sharp turn and the NamKhan quietly empties into the Mekong. This meander creates a narrow peninsula of land between the two rivers, which forms the heart of Luang Prabang. It is the site of some of Lao Buddhism’s holiest temples, and the historic residence of the Lao monarch.  It is also the epicenter of the booming tourism business in Luang Prabang.  The peninsula hosts Lao and foreign restaurants, guesthouses catering to all budgets, French cafés brimming with breads and pastries, and a crowded night market bustling with Korean tourists and dreadlocked Western twenty-somethings on a gap year.  All haggle with the vendors over handicrafts or BeerLao t-shirts.

A rare uncrowded shot of the night market (from July 2015)

The tourist activity co-mingles surprisingly comfortably with the Luang Prabang's locals who carry on with their daily lives  – children attending primary school; saffron-robed monks and novices chanting, studying, and doing chores in the various temples; and market vendors selling everything from vegetables, to consumable insects and bamboo-woven kitchen items. 

Novice monks on the peninsula (July 2015)

The Mekong quietly flows past this activity.  Originating in Tibet, the Mekong is one of the world's great rivers, and is the traditional lifeblood of Southeast Asia.  It passes through China and Myanmar, forms much of the Lao-Thai border, then flows through, and supports the economies of Cambodia and Vietnam, before it spreads into the vast Mekong Delta and ultimately spills its muddy contents into the South China Sea.  In landlocked Laos, it is a major source of fish, and its brown waters conceal unique occupants like the Mekong giant catfish, which is the world’s largest true freshwater fish, as well as the critically endangered Irrawaddy river dolphin.  

Typical river scene from the NamOu River near NongKhiao (taken July 2015)

As the regional economies grow, the role of its rivers is changing.  Hydroelectric dams are obstructing their flow and blocking boat traffic, unique river animals are being endangered, and overland transport is supplanting boat traffic.  Dirt tracks are being replaced by sealed roads that support the flow of motorbikes, dusty trucks full of construction materials and consumer goods, and inter-city minivans and buses of all sizes.  There is even a plan for a high-speed rail line that is destined to link China, Laos, and Thailand.  It will be the central piece of a three-line network, with the additional lines from China passing through Myanmar and Vietnam.  These will all converge in Bangkok before continuing southward through the Malay peninsula to Singapore.  As a testament to the complexity of the project, an estimated 60%, of the line through Laos will be either bridges or tunnels due to Laos’s rugged terrain.

Proposed Lao Rail Lines. Source: Vientiane Times

Interestingly this rail idea originated with the British and French imperialists of the past two centuries.  Now with its re-emergence as a regional and global power, it is China, rather than the West, that is helping to bring this plan to fruition.  Some would argue that the imperial motivations are unchanged, however.  Most of the funding for the Lao line will come from China and is likely to include concessions of land around the stations to the funders, and will open Lao markets to additional Chinese imports.  The amount of debt Laos will carry may also be a drain on the Lao economy.

I am cautiously optimistic about the opportunities that economic growth brings for the people of Laos.  It remains one of the world’s poorest countries despite its recent growth rate of 8% annually.  Poor nutrition and lack of quality healthcare still contribute greatly to unnecessary death and disability.  But, I sense a degree of happiness and optimism among people here that I have not experienced in other developing countries.  The people of Laos seem accepting of the current state of things, but not resigned to it, which is refreshing.

Despite all of this activity and change, the pace of Lao life still seems more in tune with the tranquil waterways than the bustle of the emerging roads and rails.  Laos provides a quiet and gentle contrast to the more frantic activity of its neighbors in China, Vietnam, and even Thailand which have all more fully embraced the brash consumerism of corporate globalization.

Photo from my bike commute to work.

For now, I am still able to pedal to work on my bicycle at about the same speed as cars, motorbikes, and the rusting, dented blue tuk-tuks (a vehicular chimera consisting basically of a motorcycle in front and a covered pickup in back).  People I meet still make time for a greeting and ask if I have eaten.  They are almost always ready to engage in a conversation, share a laugh, and help me learn another word or two in Lao.

A tuk-tuk

As I watch the NamKhan’s flow eating away at its banks, I am aware that the increasing rush of modernity and economic forces are going to change the course of life for the Lao people, just as the dams are changing the flow of its rivers. I am hopeful, however, that the cultural foundations of Laos are strong enough to resist being eroded away like the banks of its rivers.