Kep Hospital shadowing

Frustrating to know that they don't receive
The care or the skill or the service they need
To cure that which ails them or comfort their grief
But light in the darkness -- one does do a good deed

KEP, CAMBODIA

July 23, 2008

I like to think that I'm pretty laid back, and more of a Type B personality than a Type A. Sure, I've got my little things (as everyone does), and I think I'm quite an initiative-taker, but I'm pretty sure I'm less high strung than a true Type A. And as a result, unlike my classmates this year, I have not taken advantage of shadowing in clinics or anything like that.

That all being said, Cambodia is another story. The stuff we see here is different from what we see at home, and that's a reason to go shadowing. There. Justified. Still not a Type A.

Anyways, Wednesday TH and I went over to the Kep Referral Hospital to shadow the doctor there during his morning clinic (his name is Dr. Deena).


A bit of background for context: people don't like to use the public health system here, because they think that the quality is poor, and the facilities understaffed. They often don't have the drugs that are needed (G saw a kid who was bitten by a dog get sent home because they have no rabies vaccine), and the doctors, nurses, and midwives all prefer to open their own private clinics in their homes and charge people an arm and a leg.

(Aside: for anyone who thinks that a parallel public-private system is a good idea -- you're an idiot.)

So, health centres are understaffed, and villagers aren't supposed to come to the hospital before going to the local HC. But most of the time, there isn't anyone at the HC. So, if a poor villager spends the money to go to the HC one of two things happens: (1) He has to go back home because no one is there -- and there's no electricity or running water there either, so if it's night time, he's SOL; or (2) He just gets referred to the hospital anyways. So, now his transportation costs have doubled, and beyond that, he's a subsistence farmer, so taking even just the morning to do all this might mean that his kids don't eat for a day.

(I suppose there's the remote likelihood of (3) He is treated, but I haven't heard many good things about the HCs.)

Anyways, the public system has earned itself a bad reputation for poor quality, so villagers just go to private clinics, who are run by the same people who work in the public clinics (they just leave the public clinics at any which hour during the day), where prices are not regulated, licensure is a non-issue, meds are often fake, but...it's right next door, so no transport costs. They do this not realizing that the hospital is actually very inexpensive, and even though quite far, offers decent service.

Right. I digress. This is not an Op-Ed piece, this is a recounting of my day. My point is that people don't come to the hospital so we were only shadowing from 7:30 to about 11 am.


We saw quite a few run of the mill, sort of boring things: a cut leg from a moto accident, lots of constipation, abdominal pain. And we also saw a lot of interesting things: an ultrasound for a woman who is 7 months pregnant, pneumonia. And then, there were the really crazy things (all in-patients, whereas the others were outpatients) that were super interesting: tuberculosis (I am SO going to be testing positive for exposure when I get back...which means months of antibiotics), spinal TB, and a right-sided complete hemiplegia.

We looked at some chest x-rays of people with TB and learned how to look for cavitations (where the bacterial colonies apparently concentrate?), and learned to tell the difference between pneumonia and TB.

The spinal TB case was super interesting, but really very sad. I know nothing about spinal TB...but this poor patient had a vertebral fracture at L4-L5 in addition to whatever else spinal TB does, and was paralyzed from the legs down. The patient's legs were severely atrophic and the patient was incontinent as well. Really sad case, but Dr. Deena was doing everything that he could for her.

The hemiplegic was a bit of a medical mystery. This patient had gone to a traditional healer for something, and then started having problems on his right side. Not sure if it was caused by the traditional healer, or if there were problems before visiting the healer, or if that visit was unrelated. Anyways, the patient had no motor control of his entire right side, but sensory pathways were intact. (We got to see a Babinski test done on this guy too. But Dr. Deena uses a pen to ellicit a response, so the poor patient had pen marks all over the sole of his foot.) Dr. Deena doesn't know what the cause of the deficits is, and he has tried to get the family to send him to Calmette hospital in Phnom Penh, since they have imaging there, but they won't go. And so he has lain in the Kep hospital for the last 15 days, neither improving nor deteriorating. Where is the lesion, what is the lesion, huh? So much for all that.


Frustration again, because it's the same problems over and over and over again.

But that's where Dr. Deena comes in. We sat and chatted with him for about half an hour as we were waiting for some lab results on a patient. It was about 10 am, and we were done with all the patients, so we spoke about the Cambodian health system, about the Kep health system, about the public-private debate, and healthcare in Cambodia in general. This guy is one of the last few good ones. He earns $50 per month for working in the hospital, and works around the clock -- he actually lives at the hospital. Unlike his counterparts (there are four other doctors at Kep Hospital), he does not have a private clinic at home. Private clinic doctors earn upwards of $500 - 600 per month, but Dr. Deena prefers to work in the public system.

He talked to us about how he just wants to be a doctor, to practice medicine, and how in order for him to work at a big hospital in a big city, or move up in the Ministry of Health, he would have to get involved in politics, and that's something he is not interested in. He just does his job because he wants to.


In my med school interview over a year ago now, they asked me who my medical heroes were. I hadn't prepped for my interview, so this questions really took me off-guard. I answered (maybe a little stupidly, or cliche-like) that Dr. Henry Norman Bethune was my hero, partially because I didn't know anyone else famous, and partly because I had read about him in my Children's Canadian Encyclopedia probably about 18 years ago (thanks for those, Mommy) and thought he was a pretty cool guy. He still is, for me, a pretty cool guy. But...I've been impressed by Dr. Deena, and, well, I think Dr. Bethune has, for me, been replaced.