Thailand Medical Adventure - 4 - Tha Muang Hospital Rotation Beginnings

I rapidly recovered and then was ready for my rotation.  Tip had set up a fluid busy schedule that involved outpatient clinics, emergency room, primary care unit, Chinese medicine clinic, Thai massage clinic, and added additional ward medicine and other experiences.

My experiences will be a mix since of little observations, experiences, with variable timing since I have been so busy that I have not had dedicated writing time.

A bit about the hospital structure of staffing.  When I am saying Intern doctor, it means something different here in Thailand.  After the 6 years of medical school training there is a big national lottery for government hospital training sites.  Everyone pics some sort of ping pong ball with a number on it.  Then you get to choose in order of what you want.  Sounds horribly stressful!  If you pick a high number you could be stuck down way south far away from family.  They tell me it is a 3 year commitment and you are referred to as an intern or general practitioner the whole time, so intern year 1 or 2 or 3.  The hospital has I believe 8 interns, and a handful of doctors, including ophthalmologist, a few pediatricians, one medicine doctor, an obstetrician and a surgeon will be coming.  So much of the inpatient and outpatient activities are run by the interns!  Talk about a lot of work!  They tell me they do not get formal vacation time either.  The incentive to go through the GP training is that at the end their 300,000 baht loans are dissolved.  For USD that is about 10,000$.  Amazing…  Here we have average debts in the 200,000 USD range.  But, in order to continue with specialization like medicine, surgery, radiology, you are required to complete a GP training.  This system pushes all their young doctors to get at least basic functioning at taking care of medical issues.  Technically GPs are also training in basic surgery, including to perform appendectomy's.  It is amazing how hard they are pushed.  The most amazing thing is that because of the intern heavy work load, staff supervision comes in self-initiated ways.  The second and third year interns are running their own show.  They have access to a couple specialists on site and at the larger hospital about 12km away via phone.  But otherwise, it’s just them.  It is kind of sad, because having the intern and resident dynamic in medicine and other fields I feel is a wonderful way to train.  This is a very independent learning structure for sure!

My first few days were just getting oriented and Dr. Tip took me to visit the administration.  I met the head of the entire hospital, and various directors.  Everyone was wearing festive Hawaiian style shirts for Songkran.  Everyone seemed interested in meeting this random farang doctor from California.  Luckily I had already learned the different ways to say hello.  When you put your hands together as if praying, it is part of hello and thank you.  But you vary the intensity whether you are directing toward an elder or a monk.  So by the sternum for most, then to chin and then forehead for monk. 

I made my way to the emergency room where I first met Dr. Kim.  Bear in mind, everyone has much longer names than Kim and Tan, but at birth Thai’s are given the long name plus a nick name.  So the whole country has all these cute names!  Yada, Noot, Nooh, Tom… more later on the intense cuteness of this culture =D.  Hello kitty… that is just the beginning, =D. Sorry, more later.  In the ER was a very relaxed group of nurses and varying degrees of drunk revelers from songkran =D.  Some amazing observations.  The nurses are training in suturing!  I was watching the nurse confidently sew up a young guys foot, amazing skill.  When it is one intern running the whole ER it is truly necessary.  I feel like I would be nervous as all heck running an ER on my own, but Dr. Kim just remained jovial and showed no obvious signs of stress.  I have a feeling they achieve and require a much higher level of confidence from this style of training.  Sink or swim out here I am guessing.  Sitting around the main desk were some young appearing Thai girls in what appeared to be street clothes.  I felt a little spray of water hit my arm, I turn around and the nurses are having a full on hello kitty water gun fight in the ER =D.  Whaa, so crazy.  This is not the last.. haha.  No one seemed to bat an eye at the activities.  Soon it made it outside, I guess they were ER nurses but with songkran uniforms protocol is quite lenient.  

I was so busy noting all the differences that I forgot many of the medical cases, but as they say here, no problem (or pompem… =D).    One of the patients was a 10 year old little monk.  His father brought him in for a URI.  He was wearing his orange robes and head shaven.  You don’t see that in Los Angeles!  Oh yeah, that morning there was actually a mass casualty called.  A double decker bus of songkran Thai revelers overturned on the highway nearby killing a handful and injuring many more.  The hospital activated their mass casualty triage protocol, but everything was calm by the time I arrived.  Apparently there are many double decker bus accidents in Thailand and the government was beginning the process of testing them for stability.  They are ridiculously tall compared to their width, so it is no surprising that they would topple over if a turn was taken too fast.  Car accidents during Songkran are a well-known issue.  You couple national holiday, copious drinking and partying, and driving/motorcycle riding (without helmets!!) and you have an issue.  Here are the final statistics found online Songkran 2014: 322 deaths, 3,225 injuries and 2,992 accidents craziness.  Taking care of these issues at Tha Muang can be an issue since, the hospital does not have ICU level care so many patients that require intubation or higher level care are rapidly shipped out to the larger kanchanaburi hospital.  It is very interesting to be at a hospital without the higher level care, since I am so used to being in tertiary and quaternary care medical facilities.  This is a true community hospital, doing the best they can to help their community with the financial limitations of governmental run health care.

The EMR (electronic medical record) situation is interesting.  They have a government medical records that is used with a paper version.  The company is Hosxp, it was created within their country by a pharmacist I believe, then picked up by the government.  It looks pretty slick with encounters, documentation, laboratory, outpatient RX abilities with refill.  The interns tell me it is province specific so you cannot see patients across all of Thailand. They have PACS and can view images on their computers which is great.  The patients keep their own little notebook that keeps track of vitals, visits and pertinent info to their planned OPD (outpatient department visits).  This was similar to rural Africa, where patients kept these little books which was essentially their entire medical record!  The nurses fill out the patients little books.  But in addition to the electronic chart there is a paper mini chart that is about 4inchx8inch folder with pertinent diagnosis, medications (printed in pharmacy I believe), labs, d/c summaries (pretty brief though… few sentences).  So all of this is used.  When patient is admitted they use a paper standard admit sheet that is a H and P note, and then a page with free hand writing orders for sending them upstairs.  Daily progress notes are in the form of a SOAP, and a few words/sentences suffice per patient.  Nurses can also document in the chart when labs or other important info comes up.  The daily vitals, I/O, medications are charted in what looks like an old ICU paper chart or anesthesia sheet.  It all seems to work for them.  Reminds me a bit of cview (our old UCLA EMR) with multiple systems, but there is no way Epic will be coming to Thailand anytime soon.  I think it would be 100s of billions of dollars to convert an entire country into Epic =D, it’s almost funny and painful to think about such a transition.  Either way, medicine is medicine, you still see the patient, write a note, order something, talk with patient, monitor patient, discharge, refill prescription… it’s amazing how western medicine has more similarities than differences from country to country.

One side note, I noticed on the charts the years were not 2014 but like 2555.  Turns out they use a Buddhist calendar!  So confusing.  They even have little charts to help convert the years!

One of the patients had cough so we reviewed the X-ray together, me and intern Dr. Kim.  Looked clear to me.  I asked, “so how long for the final radiology read.”  He laughed, “radiologist? I am the final read.”  They have access to radiology review but only by calling a larger hospital if there is an issue.  They also need to call for all MRI and CT scans since it involves a transfer and return.  Seeing this reminds me of how absolutely ridiculous we are with ordering radiologic studies!  It is truly madness.  We should at least exercise some amount of restraint with this, and just document why we did or did not order a test.  I think the ER staff might need a visit to a rural governmental hospital as well…  IM and ER both...