Sefanit Mekuria – Project Angkor

Written by Sefanit Mekuria, PGY 4 at Kasier Permanente Oakland Pediatric Residency Program on global health rotation with Project Angkor in Cambodia.

We made it to the airport on December 28, 2014 with our luggage and large boxes that contained medications and medical supplies, which was sent to us from the Project Angkor staff. I was excited to begin our trip and knew that we would be working in a clinic set up by project Angkor, but I was unsure what to expect from the experience. After a long flight we finally made it to Siem Reap, Cambodia and headed to Sisophon province (Serey Sophon). The drive was 2 hours long from Siem Reap and filled with views that captured the rural area: open fields, mountains in the distant, and shallow areas of water where people were fishing.  Once we arrived in Serey Sophon we checked into our hotel. The city was a small city surrounded by a very rural area. It had everything you would expect in a city- small shops, markets, a city center, and restaurants.

The next day we were able explore Serey Sophon and Siem Reap, which gave us a better understanding of the area. For New Years Eve the Governor of the Serey Sophon invited us to a dinner and a party that took place in the city center. It was nice to see Cambodian culture, but most of the volunteers did not make it till midnight due to jetlag. The next day we arrived to the location of our clinic early in order to set up for the week. For the past several years Project Angkor has been traveling to different areas of Cambodia, teaming up with a local provincial hospital in order to use their space for the clinic they set up. The Serei Sophon Referral Hospital usually has a small clinic and a very small inpatient service that handles only simple conditions.  For the week Project Angkor took over the clinic, expanded it by setting up tents in order to see a large number of patients, and brought in medical supplies and medication in order to run the clinic. We spent the first day setting up for the clinic, arranging the pharmacy that we made for the trip, and deciding the location of each clinic.  The other pediatric residents and myself were placed in the pediatric clinic with the rest of the pediatric team. The pediatric clinic was located in the building that usually has inpatients. The left half continued to have inpatient pediatric patients, which the local Cambodian doctors continued to care for. On average during the week we saw 1-2 patients that were in these pediatric inpatient areas. The rest of the building was used as our clinic. Each of us just had a cot that the patient and their families sat on, triage was located in the front by the doors, and the pharmacy was behind triage.

Clinic started the next day after a brief opening ceremony. Our clinic ran pretty smoothly. Patients were triaged, waited to be seen, then sent to the pharmacy if medications were needed.  Many children had severe dental decay and sent to the dentist for removal or other procedures.  The dentists were also part of the Project Angkor team and essentially brought a dentist office with them, including a machine allowing them to do dental xrays. The first day for the pediatric clinic was slow, but by the second day things picked up. Clinic was 8am to 5pm everyday and we took turns going to lunch, in order to keep the clinic open all day. We averaged seeing about 150-172 families a day, but many of these families consisted of 2-3 children, so likely about 200-300 pediatric patients came through the clinic each day. The Cambodian children and parents were always so grateful and patient- waiting all day to be seen. We had basic labs and xray capacity that were available for small fees, so we mostly used clinical judgment and got other tests if really needed.  Our pharmacy had the basic antibiotics, antifungal, GI medications, vitamins, deworm treatments, scabies treatment, medications for hypertension, and few other medications. For the most part it had everything we needed for basic pediatric care, but for common issues such as tinea capitis, we had to research other treatment options using what our pharmacy had.

In general we saw similar common pediatric complaints during clinic: viral syndrome and URI- it’s that time of year in Cambodia, ear infections, superficial skin infections, Tinea capitis, and urinary tract infection. We also saw disease processes that were new for the residents such as cataract in a teenager, no red reflex in infant suggesting cataracts or retinoblastoma. Children came in with conditions that we would usually run more test or have them admitted for further work-up, but we had to use the resources that were available to use.  For example, a 1 month old presented in respiratory distress, which was present for the past 3 weeks with no weight gain since birth. This did not seem consistent with RSV or another viral cause, but instead suggested a heart condition or metabolic condition. We had an old ultrasound machine and an ED doctor was able to see an ASD or VSD using it. Given the amount of respiratory distress that this baby was in. it was decided to transport the kid to the children’s hospital in Siem Reap for further care and work up. In Siem Reap there are two children’s hospitals with specialists that provide free care for patients. The project paid for transport and a doctor went with this baby for the two-hour ride. Once the family arrived, the hospital refused to admit him since the Cardiologist does not work on the weekends (it was a Saturday) and they would not do anything for the infant during the weekend. The family was set up in a tent by the hospital to wait for the Cardiologist on Monday. Another case that would be have been admitted for further work up and evaluation was in a 6 year old female who presented to the clinic with abdominal distention and pain. In a long discussion with the family, and documents that they had from Thailand, it was discovered that she had rhabdomyosarcoma diagnosed 1-2 weeks earlier.  She was sent back to Cambodia for chemotherapy, but the parents had used all their money on getting her to Thailand and care once there. Due to the lack of finances and their fears of the next steps, they had not been able to come to a clinic in Cambodia.  She had worsening pain and increasing abdominal distention in the past week, so they can into our clinic. We were able to transport and refer her to the children’s hospital in Siem Reap, but the hospital did not do chemotherapy for rhabdomyosarcoma. She was sent home from the children’s hospital on palliative care with pain medications. Although her presentation was late and palliative care may have been the best option, she did not get any other options or investigation on prognosis due to the limited resources.

Overall clinic was busy and at times overwhelming with the volume of patients and the limited ability of what care we could offer, even after referral to the bigger hospitals. Although the clinic experience was 1 week and went by very fast, it taught me to be efficient, honed my clinic skills, and expanded my knowledge on how to practice medicine in a location with limited resources. By the end of the week everyone was exhausted, but the work felt rewarding with the ability to help so many patients. I think the experience would have been more rewarding if it was more sustainable for the community and Cambodian people. Although we were able to refer several families for needed care, follow up or care was not guaranteed and left me thinking that any project would benefit from deeper integration of the local medical system to continue the work once the team has gone.