A Farang Doctor in Mae Sai

[DrB0b]

Interesting article from The Lancet, written by a young Doctor who went to Mae Sai to gain work experience.

An Elective in Thailand’s Corner of the Golden Triangle

The most northerly town in Thailand, Mae Sai, is adjoined to the Burmese town of Tachilek. These two small yet busy market towns, until quite recently acted as a major trafficking route for the Golden Triangle’s illicit export; opium. The area is now slowly starting to redevelop, but events in Myanmar are forcing many previously nomadic Hill Tribes to settle on the mountains just inside the Thai border. It was here that I was to spend my six week elective living and working in the most northerly hospital in Thailand.



Tim Baker and staff from Mae Sai Hospital

Mae Sai Hospital has 3 wards (one each for men, women and children) with a total of 100 beds, an outpatients department, a labour room, an A&E, two operating rooms and a clinic for HIV and TB. There are 3 consultants, 3 junior doctors and plenty of nurses. On an average day the wards will be full; most patients suffering with the manifestations of infective gastroenteritis, road traffic accidents, chronic obstructive pulmonary disease, ischaemic heart disease, chronic kidney disease, TB and/or HIV/AIDS. The emergency room will see and repair minor injuries; treat and admit illnesses if treatments are available in the hospital, or make referrals to the nearest major hospital. This was about 35 minutes away. I discovered, when asking for the rapid transfer of an 8 year old with a decreasing GCS and strong suspicion of an intracranial haemorrhage that 35 minutes, meant only if the ambulance – an old converted minibus or pick up truck – was on site and had a good engine.


Road traffic accidents were a very common problem

Forty percent of the patients in Mai Sai Hospital came from Burma despite Tachilek Hospital being just a short cycle-ride away. Wanting to understand why this was, I set off on my bicycle to find out and the answer was immediately apparent. The image of the wards in the third world, we have all seen on television, but nothing prepared me for the eerie quiet, the smell of unwashed patients and an overwhelming feeling of guilt. My desire to help was useless and compounded by a misguided perception, that a white doctor is somehow better trained than the highly experienced, fantastically trained local physicians. Walking through the overcrowded wards of rusting metal beds with wooden mattresses I was watched by desperate, hopefully expectant, eyes. Without basic equipment or medications the doctors struggled to cope; they had, however, managed to persuade the local government to fund antiretrovirals for 100 of the 300, known, HIV positive patients. Making decisions like these is an everyday occurrence. Frustratingly, a new, fully equipped, hospital had been built by a monk just minutes away, yet its official approval had been removed shortly after completion. It now sits decaying.

Before I left for Mae Sai, I was told I would learn more in my six week elective than I would in a year in the NHS and after only one day I began to believe this. The first patient I saw was having trouble with his sight; he was HIV positive and had recently started on antiretrovirals. I was clueless. Having had one week’s intensive lectures on HIV, I was desperately trying to remember the side effects of the medications. As a formality, but mostly to buy time to think, I looked at his retina. As I peered in, I saw what could only be (and is classically) described as a mozzarella pizza – suddenly from the murky depths the diagnosis appeared; CMV retinitis. An array of textbook late presentations followed throughout the day. As I was walking back to my apartment that evening, I passed a 23 year old girl on a trolley in the A&E. She had come off her moped and appeared to have landed face first. This could make for a very entertaining story if it weren’t for the blood pooling on the floor, her lack of consciousness and a very white, yet tanned, complexion. I could feel the blood draining from my own head as I realised there was no doctor around. Tensing and relaxing my legs – this I have always believed will prevent fainting – I rapidly replaced the lost fluid, arranged x-rays and a referral to the nearest hospital capable of dealing with her multiple skull fractures. This was daunting enough but made substantially more difficult by our language differences.

In the Golden Triangle, the region in which Burma, Laos and Thailand meet, language is often a problem. Migration between these three countries is relatively common and each of these countries has cultural subgroups and various Hill Tribes each with their own language. Most will speak a little Thai, and so I set about to do the same.


One of the many Hill Tribe villages in the mountains of northern Thailand

Linguistics is not a skill that comes naturally to me. By the end of my first week all I could manage was “very delicious”, “good” and “beautiful” (often a lie). This I learnt from the Laotian doctor I was living with; his only English was “beautiful lady” which he shouted enthusiastically most nights at around 3am whilst watching television. He taught me many words he felt important: “Thai boxing”, “fried insects”, “ladyboy” and “Chelsea”. I bought a phrasebook. By the end of my six weeks, I could hold very basic conversations around the weather, food or medicine. The most important word I learnt was “jeb” meaning pain.

Ever since an appointment at my school infirmary to have a (long) suture removed, I have considered pain management an essential part of medical care. In resource limited Mai Sae, pain management comes second to essential care. Women give birth without analgesia, which is a surprisingly quiet affair. If they decide they don’t want to go through this ordeal again, they can sign up for the Wednesday sterilisation list in the operating theatre. There is no anaesthetist so the tying of fallopian tubes is conducted by very skilled nurses who infuse local anaesthetics to prevent pain – if the patient is too noisy or moves too much a dose of ketamine will calm her down. About twice a day, children (and the occasional adult) will walk into the A&E with a large abscess that needs to be incised and drained. An eight year old boy who presented with four of them needed three strong porters to hold him still. The quality of his lungs was not in question. I could tell a hundred similar stories before I started on the patients who couldn’t afford treatment.

During my time at medical school I have often read the opinion that it is inappropriate to send western medical students to practise on patients from the developing world (1,2); I considered this a lot whilst I was there. I had passed my finals the day before I started my elective so had some experience of hospital medicine, yet it is well known that the day junior doctors arrive in hospitals is the most dangerous day to be a patient. This is a fact that is drummed into us and we fear it more than any patient could. Is it unethical to send medical students to be trained in the setting of a developing country? I found my answer one day as I stood in the A&E with only the two nurses on duty; in rushed simultaneously, the victim of a knife fight (multiple superficial lacerations to his torso and half a hand hanging off) and an unconscious woman who had overdosed, this was daunting enough and then I was handed a non-breathing newborn.


An x-ray of a patient who travelled for three days across Burma to reach Mae Sai Hospital only to return home because the surgery would have been too expensive.

There were times when I felt out of my depth but support was never far away. I have been trained to be one of Tomorrow’s Doctors and I heed the words of Hippocrates, I know my limitations and am honest about them. The doctors in Mae Sai did not allow me to perform procedures I wasn’t trained to do but were very happy to teach me. My time in Mae Sai has provided me with the confidence to know I can cope, whilst also showing me how much I still have to learn. I have been given a catalogue of experience, knowledge and fond memories.

All of this would not have been possible if it weren’t for the support of Christ’s Hospital School; the Judy Evans elective fund, the Benevolent Society of Blues and Michael Pugh who assisted me through Christ’s Hospital and medical school on behalf of the Society of Apothecaries. For all this support I am exceptionally grateful. I would also like to thank the Khom Loy Development Foundation in Thailand for their logistical assistance making my elective possible.

Tim Baker has just completed his final year of medicine at Barts and the London School of Medicine and Dentistry in the UK.
emailme[at]drtbaker.com

References

1. Bhat SB. Ethical coherency when medical students work abroad. Lancet 2008 Sep 27; 372(9644):1133-4.

2. Radstone SJJ. Practising on the poor? Healthcare workers’ beliefs about the role of medical students during their elective. J Med Ethics 2005;31:109-110.
http://www.thelancetstudent.com/2009...lden-triangle/

[KHUNDAN]

I am at a lost for words on this story as you have put it all so well.

Many foreigners only complain about Thailand and what it is like and how they cheat us etc. It is good to read a story like yours where we should just take a step back and realize how lucky we really are as foreigners.

My heart goes out to all these people who cannot afford or cannot get the basic medical needs in this world. If we had someone in our family in this situation then we would for sure change our outlook on life and become better neighbors and friends to others.

Just wanted to thank you for the story and I know you will never forget what you saw and experienced here in Thailand or in Burma. Their are things I saw as a U.S. Marine that I will never forget in some 3rd world areas.

Take care and gods speed.

Dan

[klongmaster]

Bobbie: this is excellent...why don't you post stuff like this more often and stay away from the mindless taunting which is currently the bane of TD...

[robuzo]

Thanks for posting this, DrB.

[DrB0b]

Bobbie: this is excellent...why don't you post stuff like this more often and stay away from the mindless taunting which is currently the bane of TD...

Eh? I post stuff like this all the time.

[blackgang]

Thanks again Dude..
and the Dr.'s here make shit for a wage upcountry and even then they are over worked.

[Michael]

And then we read the pathetic and fatuous comments on the rest of TD. A real wake-up call.

Why do we persist? Boredom on my part. I should change my lifestyle.

[Michael]

Unless we change TD. Afraid of popular opinion? Why should we be?

The stupid, ignorant and flippant can go elsewhere.

M

[Ramatender]

A great contribution which raises the bar for all of us
Perhaps less comfy expats whingeing and more observation and insights iinto real thailand away from Pattaya and Phuket sleaze will be as refreshing as it is unlikely
Well done best thing Ive read outside melvbots tips to net

[klongmaster]

Eh? I post stuff like this all the time.

No you don't...want some examples...this is the sort of nonsense that you normally post and really we can do without it all over the board...

Any of you cunts who make up the rules care to justify this one?

Just another example of the emptiness and ignorance that is Teakdoor

Any response, you hypocrite farang dirtbags?

thought you'd fekked off, kid. Can't you make your mind up?

[Wayne Kerr]

Great shivers up the spine stuff ... handed a non-breathing newborn ... bugger me with a rag man's bugle he won't forget that for a while!

F'n unique breed indeed guys like that ... thanks Bob

[NickA]

^is this the right thread to bring it up, Klong?

[klongmaster]

is this the right thread to bring it up, Klong?

well, this is the first time I've ever responded to one of his threads so thought I might mention why...

[Marmite the Dog]

Unless we change TD. Afraid of popular opinion?Why should we be?

The stupid, ignorant and flippant can go elsewhere.

TD was built by the stupid, ignorant and flippant.

[Michael]

Sorry, MD, no offence intended.

[friscofrankie]

Great read Dr. B
One of the more sane, less sensationalized impressions of Thailand from a visitor I've had the pleasure of reading in a long time.

[NickA]

TD was built by the stupid, ignorant and flippant.

TD's new moto

[DrAndy]

Unless we change TD. Afraid of popular opinion?Why should we be?

The stupid, ignorant and flippant can go elsewhere.

TD was built by the stupid, ignorant and flippant.

and supported and continued by them

anyway, good stuff DrBOb

most of that quoted crap is in MKP anyway

[Spyker]

Very nice read indeed , keep it coming OP .

[ossierob]

Enjoyed reading of the challenges....thanks