East Timor Medical Elective - Week 2 (Part 5 / 5)

HEALTHCARE SHORTAGE IN EAST TIMOR

I started buying the local newspaper (“Timor Post”) and have been amused + appalled at the shortages within their public hospitals (food and medication, will attach photos in the future).

It saddens me that the public hospitals are underfunded even though they have the money to fund it properly (from the oil/gas revenues) due to significant corruption by politicians. I've read that they only have 10-15 years' of oil left, which is extremely scary given that their GDP is supposedly ~90% dependent on oil. An East Timorese person told me that ALL of the oil money is already gone (!!!!!), and that those research papers were just being overly optimistic... : (

 

I also wondered when I get back to Australia, I'll get jaded/absolutely fed up with patient complaints that are relatively minor in comparison. I worry that I might find Clinical Medicine in Australia less fulfilling for various reasons.

Will the Australian patients (esp. in GP setting) seem like “whiny losers” after my East Timor experiences? Will I start resenting the majority of Australian patients for their “lack of perspective”, and their taking for granted of the Australian public health system, which by world standards is very high class and accessible? And what about the stereotypical Australian drug-seeking patients on disability pensions from Centrelink for “questionable” conditions, who demand extra scripts of Morphine / Oxycodone for abuse or diversion (to get extra $$$), even though such drugs are in extremely short supply in East Timor, to the point where Palliative patients in severe pain can only receive Codeine or Tramadol at the best?

I know that my East Timor experiences will forever remain with me (until I die or get memory loss), but I'm not sure if I'll be able to deal with the “Reverse Culture Shock” in the long-term. It may be “heart-breaking” to see the contrast of “feast vs famine” in terms of Medical Resources, but I hope that if this is the case, that it'll push me towards pursuing Pathology Training permanently, 100%, ***LOCKED-IN***. Maybe it might be a blessing in disguise, in helping to clarify career goals and altruistic aspirations?

CUBA HELPS EAST TIMOR MORE THAN PORTUGAL?!

I started watching the main East Timorese TV Channel at night, which apparently only has native programs for ~ 3 hrs / day, the remaining being Portuguese programs direct from RTL International. 

 

The exposure to Portuguese people and lifestyles on TV (soap operas, festivals, talk shows) is blatantly obvious. I wondered if East Timorese people grow resentful of the Portuguese for the relative lack of help in their nation's development, apart from “forcing” students to learn Portuguese instead of Indonesian. Just look at the other ex-Portuguese colonies like Angola and Mozambique.

I was baffled as to why Portugal has barely sent any doctors to help East Timor. My impression was that they needed to rely on Cuban doctors, plus the fact that Cuba (not Portugal) offered medical scholarships to train East Timorese doctors.

Even in spite of Portugal's relative poverty in Europe, it's far wealthier to East Timor by comparison, yet has seemingly done little to help in healthcare apart from establishing a colonial presence.

TETUM LANGUAGE DIFFICULTIES

I thought that the huge lack of vocabulary of Tetum compared to English was one facet of the relative “simple-mindedness” and “purity” of East Timorese people, but have actually found it harder than I initially thought due to the extra reliance on context, to compensate for the greater percentage of words having multiple meanings.

This week, I was looking at the website of a Leprosy Organization in East Timor with a girl and said “Hau hadomi nia.” at a photo of a young man with Leprosy, thinking that I said “I pity him”, but she interpreted it as “I love him” and was very shocked, like I suddenly disclosed my sexual orientation.

I explained myself, and then she then said that although the dictionary says that “hadomi” can mean “pity”, it's more common to use the word “hanoin”, but then that can also mean “think” and “opinion”. 

 

I'm starting to worry that when I say one thing, the East Timorese will misinterpret me, even if I thought the context was clear. I personally like to have 1 word for 1 meaning, and am doing my research for Tetum words (especially the Portuguese loans) that match 1-on-1 with English.

I'm getting humbled by their language, and have been deceived by its superficial simplicity. I'm frustrated that the words I say in Tetum may have less "Ooooomph" (emphasis/power) due to the semantic uncertainty (being dependent on Context), but the East Timorese people have been coping with this for a long time,being able to share with each other their deepest, rawest feelings and thoughts with perfect comprehension when the "time calls for it".

Perhaps it's due to their superior intuition (maybe even more so than a non-East Timorese NT) and context-analyzing abilities, that they're able to communicate adequately with fewer words, even if they don't use the Portuguese loans. Not only do I have to work on the language itself, but my (mechanical) intuition...

East Timor Medical Elective - Week 2 (Part 4 / 5)

HELPING EAST TIMORESE PATIENTS VIA PATHOLOGY?

 

I've already been humbled and privileged to meet East Timorese Patients, who have so far been very generous and patient (in spite of their poverty) to let me develop my clinical skills (after forgetting so much in my Gap Year) via clerking and physically examining them, with virtually no complaints or rejections so far. This week, I made a promise to myself, that if I pass internship next year, I'll try to return to BPC some time in the future to volunteer for 3 – 6 months as a way of repaying the East Timorese people.

 

But this re-opened my “Medical Careers” crossroads: pursuing Pathology vs GP training. The medical graduate oversupply means that any extra time taken off (beyond a Gap Year between Med School and Internship) would put you at even more disadvantage for applying to Training Programs. At the end of Med School, I considered GP training as a 2^nd option to Pathology coz I really enjoyed my rural GP rotation as a student, but then scrapped that idea about halfway through my Gap Year because of all the news and research I witnessed, which will essentially screw Australian GPs even further in both remuneration, working conditions, and medico-legal protection. 

 

GP Training is statistically much easier to get into than Pathology Training, and there are far more jobs available after completing training, especially in rural areas. This is in contrast to Pathology, where you're predominantly restricted to a handful of public hospital and private pathology labs in large cities, and setting up your own business would be nearly impossible unless you were already a billionaire, in which case you could just quit Medicine and pursue whatever you wanted!!! 

The increasing competition, and the seemingly much higher job security of working as a GP seemed appealing, but is that enough to sustain me in the long-term? Is being a GP (ie Family Physician, like Dr. Dan), the only practical way to help lots of East Timorese patients without pursuing even more grueling exams in Clinical Medicine (ie Physician's Training → Infectious Diseases / Respiratory Medicine etc)?

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This week, I started pondering the necessity & viability of Genetics Testing in East Timor.

I witnessed a few children with Haematological issues that weren't resolving. One of them has his DNA analyzed by Mater Lab in Queensland, and was found to have Alpha-Thalassaemia.

Genetics Testing in East Timor may be academically interesting due to their collectivist society (higher risk of inbreeding?). I'm also curious as to how the element of Portuguese ancestry influences them physiologically (apart from looks), and if there are any East Timorese people who have innately increased resistance to TB infection.

But realistically, how beneficial would it be to have Genetic Services set up here, when the public hospitals themselves are already heavily under-resourced in the basics (including medication)? Plus the fact that a lot of people outside of Dili live in the mountain/hill villages and have difficulty accessing the hospitals in the first place? The country roads outside of Dili are apparently full of potholes.

Yes, BPC has a TB-PCR machine that tests patients' sputum for DNA from M. tuberculosis (ironically in spite of not being able to perform Blood Cultures), but apart from that, Pathology testing as a whole is incredibly lacking here. An X-Ray machine for BPC (instead of having to constantly beg the Radiology Department at GVNH with their sole “public” X-Ray Machine in Dili) would be far more practical in the short-term, but even that apparently costs $250K.

Was this my “Ego” talking about wanting to help them in the future as a potential Pathologist?

There are probably even more sacrifices involved by working here, on top of infrastructural barriers that need to be overcome prior to establishing “proper Pathology”, as I've yet to perceive.

Apart from the above factors, I'm also aware that Abortion (apart from Ectopic Pregnancies) is still illegal here, plus life expectancy hasn't gone high enough for cancer prevalence (other than Lung Cancer, but that's more from smoking) to increase significantly + shortage of chemotherapy.

Even if a child was found to have a Genetic Condition such as Alpha-Thalassaemia, is it really going to change Management given the lack of Resources? Is there much help in being diagnosed with Cystic Fibrosis if your family doesn't have regular access to Treatments to help clear your airways and address other complications? I imagine that nearly all (if not 100%) of children with Cystic Fibrosis would've died before age 18 with the current resources.

Plus the whole of East Timor has a population of slightly above 1 million. In Dili alone, there are nearly 200,000 people. A lot of people don't visit Doctors or Hospitals until they feel sick. Many can't afford the $5 Doctors Fees (at private clinics), and just line up at the 2 “free” places (BPC and GVNH). In Australia, even with vastly greater access to GPs, a city of this size isn't large enough to merit a “proper” Genetics Lab. In Victoria state, my understanding was that Paediatric Genetics Testing is all funneled to Melbourne.

The life expectancy of East Timorese people can be increased from improved access to food, clean water, sanitation and certain vaccinations. I suspect they'll need to aim for this before considering advanced / super-specialized health services such as Genetics.

 

Maybe I'm just fantasizing and being unrealistic? I'll need to re-assess in the future...

East Timor Medical Elective - Week 2 (Part 3 / 5)

EAST TIMORESE PATIENTS (OBSERVATIONS SO FAR - Week 2)

The East Timorese patients (at BPC at least) seem a lot less “medicalized” (in the Modern Western sense), and are more “innocent”. This is clearly in part due to less exposure to health information. For example, not everyone has heard of Diabetes or Anaemia. A lot of them understand the concept of blood/urine tests, X-rays, and measuring blood pressure, but consider the other investigations (including ECGs) to be rather “alien/exotic”.

Sometimes they give unusual responses to medical questions. I asked a lady with shortness of breath, “Do you exercise?”, and she said “Yes”, and when asked to clarify she said she “works at the market selling fruits and vegetables”. I said “that's not really exercise, I was thinking of activities like running, swimming and basketball.” 

              - Given the high prevalence of poverty and malnutrition, I suspect obtaining regular exercise isn't a high priority for her and many others, especially when they're not getting enough food to begin with, and are often scraping by to make a living with little free time at the end of the day.

Another example, there was a patient who had ?Delirium, and I was trying to screen his level of consciousness by asking “what day is it today?” “what month is it now?”, but his friend initially answered those 2 questions without realizing my intention. I had to tell him to stop answering for him.

There's also some interference from traditional folk medicine (“Aimoruk Timor/Tradisional”), like one of the patients putting hot garlic on her forehead for a headache, but creating a light burn instead. I'm more concerned about any traditional Timorese herbs that can interfere with metabolism of other drugs, like the St. John's Wort that a handful of Australians use for mild depression.

A lot of them view the physical exams with curiosity, and seem to be most amused by the Neurological Exams. Every time I physically examine a patient, most of the other patients and families inside the room start staring at us (if not already so during the history-taking process), like I'm doing a magic trick. Occasionally it gets to the point where I had to use the portable partitions on a man for even a non-sexual physical exam, simply because he was embarrassed by others looking in our direction.

"Lucinda"

"Lucinda" was the patient I most fondly remember that week, who was still depressed/really upset over father's death, and claimed to feel limb weakness after a headache. I wasn't sure if she was “somatizating” (expressing mental/psychiatric discomfort via physical symptoms etc), but was worried she had a Subarachnoid Haemorrhage etc, and did a Neuro assessment. 

When I proceeded to the Cranial Nerve Exam, I asked her to stick her tongue out and move it left and right. She did it for a short while but then smiled/blushed and stopped after other people in the room quickly started laughing out of amusement.

I felt good being able to make an unhappy person smile, but I find that I can't force people to laugh if I try, but have to just continue behaving like my normal self and let them “find” the funny bits in my behaviour (if they find it “funny”). I've noticed that the things that I do naturally, that some find funny, is often annoying to others.

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The “Medical Innocence” of East Timorese people seemed “refreshing” to me. Hardly any of the patients here take antidepressants, even if they have access to it. The Clinical Medicine at BPC is overwhelmingly for organic conditions. It's not “holistic” under the biopsychosocial model, but the patients all seem grateful and respectful towards the doctors and nurses. I haven't seen a single "Code-Grey"-like incident (patient aggression) so far.

I wondered if East Timorese society would overall become unhappier and more demanding as their health literacy (esp. awareness of all the diseases and risk factors) improves over time. Given the urgency of dealing with their TB and HIV/AIDS crisis in East Timor, it would probably be selfish for me to say this, but being exposed to the Australian system, I briefly felt like “ignorance is bliss".

East Timor Medical Elective - Week 2 (Part 2 / 5)

"OVER-PROTOCOLIZATION" + DOING THINGS OUT OF CONTEXT

I intellectually knew that Clinical Medicine in East Timor had to be different from Australia due to a different case-mix, and vastly less diagnostic and treatment modalities, along with worse under-staffing than even in a rural Australian Hospital. But in my 2^nd week, I made several blunders that demonstrated my rigidity at the time, and obsession with following protocols/algorithms, as I rely on for social interactions with NTs. It also doesn't help that the Australian medical environment is now very rules-obsessed secondary to an increasingly litigious culture, thanks to following America.

"Carlos"
Carlos was a patient in the TB Ward who just commenced TB medications. When clerking him, I immediately focused on his first presenting complaint which was a headache that started about 1 month ago. I became very anal and tried to systematically rule out the dangerous causes of Headaches (eg Bacterial Meningitis, and Subarachnoid Haemorrhage), instead of asking about other more recent medical issues, ie his collapse in bed a few hours ago.

I should've realized that Carlos' headache was unlikely to be something urgent if it started 1 month ago, and should've inquired at the start if he had any other medical issues that needed investigation and/or treatment.

"Josefina"
I clerked Josefina on the same day soon after Carlos, but forgot to address the immediate circumstances by being too focused on history taking and physical exam. She was in respiratory difficulty, but I just skipped the history taking bit due to her shortness of breath, and proceeded to physical exam of her lungs, without realizing that she needed urgent treatment for relief. 

When I presented her to one of the two visiting Specialists (“Julie”), she immediately asked Josefina if she has Asthma, in which she said “no”. Nevertheless, she was commenced on nebulized Salbutamol and Oxygen with immediate relief. 

I felt really guilty that night, and apologized to Julie the next morning as I had partially delayed Josefina's immediate treatment. 

From then on I decided to update my internal algorithm, to do a quick “ABC” (Airways / Breathing / Circulation) scan if patient is in distress before they're able to continue talking etc.

I feel like I'm so dependent on Algorithms to the point where I'm just a human “robot / computer program”. At least if I place ABC at the very start of my clerking algorithm, it'll somehow resemble the “common sense” and “1^st Principles” that NTs talk about.

"Jacinto"

Jacinto was the 3rd patient that I nearly “hurt” that week, who got admitted to the wards for polyuria and polydipsia (drinking lots of water), along with some weight loss. We all thought he had untreated Diabetes Mellitus (esp. Type 1), so did fasting sugars which were all normal. 

Our next differential was Diabetes Insipidus, which is basically a problem due to impaired functioning of a hormone called ADH (Anti-Diuretic Hormone), which helps concentrate urine. I was told by the other visiting Specialist (“Karl”) to help prepare and explain the diagnostic text to him, which according to my OHCM (Oxford Handbook of Clinical Medicine) was the “WATER DEPRIVATION TEST”. Essentially, this test involves not drinking any fluids for 24 hrs and measuring the patient's urine output during that period, to see if the Patient's still producing lots of dilute urine in the face of relative dehydration. I told the patient he wasn't allowed to drink any water for 24 hrs and documented this in the chart. 
 

About 30 minutes later, when Anjali was physically examining Jacinto, she noted my notes and told Karl. Karl then went to Jacinto's bed and corrected it to being ALLOWED to drink fluids during this 24 hr period, and then comparing fluid intake vs urine output, ie ***NOT*** water deprivation. Karl told me later that afternoon that it wasn't necessary to do the Water Deprivation Test immediately, but to do this “intermediate” test as a screen. I apologized to the 3 of them, and most especially to Jacinto, coz had that error not been checked, he would've been in even more unnecessary discomfort.

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From the above blunders, I hope that I'll eventually be able to more rapidly understand the context in which things are done, and also how to possibly be more flexible in a developing country setting. 

I think it'll take a few more days for me to drop my medico-legal "shackles" and just focus on Clinical Medicine in the purest, traditional sense, with minimal red-tape and litigation fears...

East Timor Medical Elective - Week 2 (Part 1 / 5)

Week 2 (8/9/14 – 12/9/14)

I can't believe that after seeing what I've seen so far, only 1 week has passed. I've been feeling so stimulated/aroused by the environment that I can actually skip my afternoon medication without feeling sleepy after lunch. Maybe it's the hot weather that's also irritating me and keeping me awake. I've started to get used to the “3rd-World” vibes, and suspect I'll get a “Reverse-Culture Shock” when I come back to Australia...

"SCOLIOSIS GIRL"

A medical student (“Anjali”) asked me to help be her mini-interpreter in Tetum, for a girl with Scoliosis, to perform a back exam. The girl was with her grandmother in the examination room, and was crying. I asked her grandmother why she (girl) was crying. She said that it was because she was worried she'll be admitted to BPC today, and have surgery done soon. I told Anjali this, and she gently hugged the girl, saying calmly in English that she doesn't have to worry about being admitted today, and that she'll go home, but will need to see Dr. Dan later in the week.

Obviously the girl didn't understand what Anjali was saying, but she quietened down immediately. It amazed me that someone who can't communicate in the other person's language was still able to calm them. My hypothesis was that her sense of touch (“hug”) and calm tone of voice was enough to comfort the girl for the time being. Anjali's response was a pure demonstration of how the universal emotions and non-verbal communication of humans can transgress language and cultural barriers. 

 

Is this considered empathy? I wouldn't intuitively know how to respond in such a situation unless I rote-memorized it like nearly all my other social situations. There are times that I can identify how the person is feeling, and know what the “correct” response is by Neurotypical standards, but when I execute it, it doesn't always have that “authentic” appearance even if I meant it. It can look authentic if I faked my body language and tone of voice really hard (instead of my usual flat affect and relative monotone), which would tire me out even more. I feel like the character Sheldon from the show “Big Bang Theory”, who in one episode, patted a woman on the shoulders saying “There, there...” when she was upset. It's not that I'm fake, it's just that I have to act a certain amount to avoid being seen as completely aloof or rude by NTs, even if I genuinely do care about some of them.

I became more aware of my deficiencies in intuitive socio-emotional processing of NTs, and at night got frustrated by the fact that for the rest of my life, I'll have to learn the majority of these things by brute study and intellectualization. Will I burn out and give up eventually, sheltering myself from the NTs after work like a “Hikikomori”? Will my analytical mind ever give way to intuition as I go older, or will I be permanently stuck in this state? There've been a handful of times where I automatically get “vibes” about a social situation, and have been correct, but I feel that they are flukes and dunno how it came to me. Alas this is the quandary of an Aspie...

East Timor Medical Elective - Week 1 (Part 5 / 5)

Thursday and Friday afternoons was when I got to clerk new Patients for the first time. Due to the language barrier, I was unable to ask everything I wanted to ask, so was quite dependent on supplementing my information from physical exam findings. Most of my questions in Tetum were “Yes-No” questions, similar to how I communicated to patients with Expressive Dysphasia. Except the rationale was to make it easier for ME to understand their answer, and not for them to express it.

I felt embarrassed when clerking in Tetum, coz the other Patients in the room and their families would frequently giggle after I said a sentence, and when I asked why, they said “Komik” (funny). Nevertheless I received a lot of compliments that my Tetum was “Diak” (good), although I digress. I ended up presenting my information to the Junior Doctor, and assisted with writing patient progress notes, but aren't allowed to prescribe medications (yet?). I initially got frustrated not being able to narrow down the differential diagnoses as much due to lack of resources, but was told you get used to it quickly.

The patients all seem remarkably easy to placate though, from what I've seen so far. They don't seem to complain when the Doctors state what treatments and investigations will be done. They are in more tightly-packed warm rooms (no air-conditioners, fans only), and sit/lie in non-luxurious beds quietly or talk to their relatives/friends. It's a far cry from Australia, where I've met quite a portion with a sense of entitlement (even when already receiving Centrelink welfare), or being dissatisfied with whatever services they receive (even though it's way ahead of Third-World standards). In my mind, I was wondering if it was coz the East Timorese are more resilient people (thanks to their extremely traumatic history from World War 2 onwards), and/or if it's because they have low expectations from not having access to, or knowing any better about modern Western healthcare. If East Timorese people as a whole became richer with improving qualities of life, will they also become more demanding and “spoilt”, taking more things (including healthcare) for granted?

I don't want to stereotype them as “Noble Savages”, but in some ways they superficially seem more “innocent” and “simple-minded”. This may be supported by the fact that Tetum's vocabulary is extremely small compared to English, and a lot of the Portuguese loans (of which their English equivalents would be known to laymen Anglophones such as “association”, “coordinator”, “investigation”) are actually considered advanced/high-level to them. Tetum also seemingly has an incredibly high proportion of “undifferentiated” words (given its vocabulary size) that would otherwise exist as different words in English.

• Their word “Uat” can mean “blood vessel”, “tendon” or “nerve”!!!
• “Ain” can mean “leg” or “foot”.
• “Fuan” can mean “heart” or “fruit”.
• “Moras” can mean “sick”, “pain”, “condition/illness”.

- The “Moras” word is frustrating when clerking, coz when a Patient says it, it's not immediately clear if they're referring to pain or a medical problem associated with that area.

I'm getting the impression that East Timorese are quite conservative with regards to sexual matters (towards males at least). I was clerking a patient with lower abdominal pain but refused to take her sexual / menstrual history. I asked Natalya to do so with an interpreter, and I said in Tetum that I didn't want to ask about “sex”.

The interpreter said “Sex? What is this?”

And I said “Hola Malu” (Tetum for sex).

And she was like “OHHHHHHH”

I found this really weird coz IIRC “Sex” in Indonesian/Malay is “Seks”, and given that virtually all East Timorese people can speak that language, to not recognize that word means that they've never discussed it with others in public (when Indonesian was forced onto them as the official language).

I'm becoming more aware of the disturbing shortages of medications as well. Morphine is quite rare to get, so for the palliative patients, Codeine or Tramadol is used. Ceftriaxone is quite expensive, so Chloramphenicol apparently is used as a cheap substitute for things like Bacterial Meningitis. It was unusual that although Antibiotics are available OTC here, they still don't seem to have a known problem with MRSA or VRE yet, unlike most Western countries. But as mentioned, Drug-Resistant TB is a problem due to incompleted monotherapy regimens (they shouldn't even be on monotherapy in the first place?!)...

On the bright side (academically), this week I saw a case of Leprosy, a TB-Ulcer (!!!) and met a Woman with Patent Ductus Arteriosus. I've asked Dr. Dan to show me any Patients with Janeway Lesions & Osler's Nodes (from Infective Endocarditis), so hopefully he'll score one for me to see next time.

Phew, it's a lot I've typed. I'm sure I've still missed a lot of other things I wanted to say, but that's it for now.

East Timor Medical Elective - Week 1 (Part 4 / 5)

Thursday morning was when I got to skip the Ward Rounds and help accompany some patients to GVNH to have their X-Rays done (for ?TB). This is because GVNH has Dili's ONLY “free” X-Ray Machine, and the country's ONLY CT-Scanner (there's NO MRI)!!! I felt sorry for patients who have strokes outside of Dili, coz Doctors wouldn't be able to clarify if it was the Haemorrhagic or Thrombo-Embolic subtype to determine treatment...

The weird thing was that apparently GVNH didn't want the patients' medical details (HOPC and past medical history) as documented at BPC, and would assess them independently for eligibility.

I went with an intelligent pre-medical student (who starts Med School next year) called “Natalya” (not real name). It was quite a sight to arrive at the GVNH, long queues of people waiting outside in the courtyard, and we had to wait for ages just to get the patients registered for an X-Ray. Some of the patients actually didn't know their complete date of birth, so we had to get them to make it up. GVNH actually has a lot of Cuban Doctors due to an exchange program, but unfortunately I forgot to bring my camera to snap them. The patients were supposed to receive an X-Ray request form but even when I told the doctor that all these patients were coughing blood for > 1 year, he forgot to give us the form, and I had to beg another doctor to do so.

Natalya was accompanying the female patient who was at her Obstetrics outpatients appointment, so I ended up leading the other patients to the radiology department. The female Cuban Radiologist said that they were closed, and we had to come tomorrow morning, but it seemed a bit suspicious given that their official morning break was at 11 AM, and we came at about 10:30 AM. I got annoyed/frustrated, and said to the Radiographer in Tetum that they've been coughing blood for a long time and it's really important they have the X-Ray done to check for TB and that they weren't technically closed yet, but neither of them budged.

When Natalya finished the Obstetrics appointment after 11 AM, she came over and I explained the situation. She went up to the radiology counter and begged them in a soft “charismatic” manner, begging them in English, also mentioning how she loved Cuba and wanted to stay there for a holiday, and lo and behold, the Cuban Radiologist agreed and called the Radiographer to take the X-Rays.

I was simultaneously impressed and envious of Natalya, and pissed off at that Cuban Radiologist and Radiographer. Natalya said that you had to restrain your anger/frustration, and talk in a way that doesn't sound like you are demanding their services, because they'll think it sounds like you are “bigger than them”. I realized that I was disinhibited at the time due to being annoyed by them breaking the rules, and instead should've made myself seem “smaller” than them, as much as you had to “swallow your pride”.

I discussed this issue with one of the BPC staff, who agreed with my hypothesis that it was a “supply vs demand” issue, that because they were the only public radiology providers in Dili, that they have the ability to throw their weight around and act superior to those who need their services, ie to stroke their Egos by feeling needed. It was apparently less important to emphasize the patient's clinical history and indication for the X-Ray, but to emphasize how good and important (and “G-d-like”) they (radiology staff) were and that you needed their help really badly, all without sounding demanding.

“Ahhh you get it now!” she said.

I understood the situation in retrospect, but it really disgusted me that in the pursuit of getting one's Ego stroked, that it would come at the expense of patient care. Healthcare Systems in developing countries are already underfunded and under-resourced, it doesn't help that those who provide those limited services can possibly restrain it any further to make themselves feel superior over others. I imagine that medico-legally, this would be unacceptable in a Western Country as such actions can delay treatment.

It was a lesson learnt, but it left a sour “taste” in my mouth. I see now that it's important to have more “soft skills” to deal with various contexts. I didn't wish to go back to GVNH again for a while, so hopefully the next time I go to the radiology department, they might've forgotten my face.

East Timor Medical Elective - Week 1 (Part 3 / 5)

The traffic in Dili is so ***BUSY***, it just goes on and on and on, barely any lapses. The drivers and motorists take great liberties in the dearth of traffic lights. I thought that it wouldn't be so bad coz most of the locals can't afford cars, but there's a lot of Taxis, Motorcycles, “Mikrolets” (minibuses) and Jeeps (I presume for expatriates and the rich elite Timorese). Thankfully Taxis are quite cheap by Western standards ($2-5 / trip), so we could save the hassle of crossing roads, but for the occasions that we had to, it was really terrifying. I was really paranoid of crossing the roads, so I stockpiled on food to last at least 1 month before I have to go to a supermarket again. I was initially planning to travel outside of Dili on my days off for touristy stuff (eg visiting Mt. Ramelau, the tallest mountain in East Timor with the Mary Statue at the top), but scrapped that thought due to the poor quality of country roads (heaps of potholes). Maybe in the future...

There wasn't much beach area at the coast of Dili, but the scenery was still pretty nonetheless. And then we visited the Tais (traditional hand-woven cloth) market, and local fruit and vegetable markets. It was weird that East Timor doesn't really produce Durians even though they have similar climate to Malaysia and Indonesia. I was surprised that I haven't seen any beggars so far, or people begging us for money. I read somewhere that begging (“Ezmola”) is unacceptable in their culture, but would've thought that people would eventually get desperate.

The East Timorese children seem to like posing in photos even if they don't get to keep it. A boy asked me to snap him, and I showed him the photo, in which he was pleased. His Dad didn't seem to mind at all. This is so different from Australia, where an adult stranger taking photos of children in public is suspected of being a Paedophile. The irony was that statistically from previous readings, there is sadly a lot of child sexual abuse and incest in villages outside of Dili, much more so than in Australia. And this is supposed to be a Catholic country...

We visited the famous Cristo Rei which is the Jesus Christ statue standing on Earth a short drive's way from Dili. It was tiring climbing up the hill, but it was interesting to see the intermittent stone carvings along the footpaths depicting the scenes prior to Jesus' crucifixion. The scene from the top with the statue was wonderful, nice and windy. Funnily when I looked at the Australia part of the Earth bit, Tasmania was missing!

However due to the traffic issue, I'm extremely reticent to do any more sightseeing around Dili unless invited by others.

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Add: Laptop batteries are running out, I'll re-order and add captions to these photos next time!

East Timor Medical Elective - Week 1 (Part 2 / 5)

Re: Pathology diagnostics, I was absolutely shocked/gobsmacked at how limited BPC's resources were. In spite of having the TB-PCR machine, the only blood tests BPC's can analyze for are CBC (FBE), UEC, LFTs and Blood Smears (via Microscope for Malaria etc). They used to be able to test for Hepatitis B Ag, but the country's reagents have apparently been fully *depleted* for some months : (

Little area to collect blood tubes and stain slides.

Microscopes (covered) + stained slides for looking at Peripheral Blood Smears.

Beckman Coulter AC T-Diff2, a mini Haematology analyzer (FBE at least).

They DON'T even have Cardiac or Inflammatory Markers (Troponins, CK, CRP, ESR)!!! The pathology report will show the serum creatinine concentration, but not the eGFR, so you'd have to manually calculate it using the “Cockcroft-Gault” equation using the patient's age and weight. They can perform Urine Dipsticks but not Urine MC&S.

List of Blood Tests available at GVNH. I'm aware that they don't perform TFTs (Thyroid Function Tests), but the lack of Cardiac Markers on this poster is disturbing...

Blood Cultures aren't available, so BPC patients with suspected septicaemia are just given empirical antibiotics. In fact, the WHOLE COUNTRY (inc. GVNH) DOESN'T have any microbiology culture facilities!!!!!!

It made me realize how privileged we are in Australia to have a far larger array of pathology tests available, that IMHO many patients (especially non-compliant ones) take for granted. On the bright side, the lack of diagnostics here meant that the medical students and doctors would have numerous opportunities to hone their clinical skills to greater depth, and learn to manage patients by “First Principles” without having a number for everything. For example, we knew that one of the patients was in metabolic acidosis (without having ABGs available) because he was performing Kussmaul Breathing.

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On the ward rounds, I finally got to meet multiple patients with TB, which was incredibly refreshing given that I didn't see any during Med School. It was also refreshing that virtually none of the patients were obese, so their heart sounds were quite easy to hear. Their X-Rays showed a few granulomas. It was good that they were commenced on combination antibiotic therapy, and to be given a decent supply upon discharge, although I was appalled that in the past, some of them only received a single antibiotic for 1 or 2 weeks at a time (!!!!!) in their villages from the mobile clinics. Everyone had to wear facemasks in the TBC and RTB wards, but soon afterwards I decided to wear my mask the whole day at BPC due to “paranoia”. Multi-Drug Resistant TB is a growing problem in East Timor.

As we saw more patients during the ward round, I felt sadness and pity in my mind, that a lot of the patients were having medical issues that would be less severe had they been caught and managed earlier, perhaps in a primary-care setting, which is obviously lacking in East Timor. The lack of resources doesn't help either. My impression was that most patients only saw a doctor in a hospital or clinic when they were quite sick and didn't have routine monitoring or follow-up.

I watched the medical students try to do history and physical exams in Tetum (or with a translator) after ward rounds were done and went home. It was a lot to take in that day, and I decided to take Wednesday off to go sightseeing with my parents.

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Add: If I can take a photo of the TB-PCR machine, I'll add it here.

East Timor Medical Elective - Week 1 (Part 1 / 5)

Week 1 (1/9/14 – 5/9/14)

I arrived in Dili, East Timor on Monday 1^st September, 2014. In the week prior, I was getting very excited and nervous about my elective here, and wasn't entirely sure what to expect both in the city and at the Clinic. I already spent several months studying their main language Tetum (more specifically “Tetum Dili/Prasa, an Austronesian language with very heavy Portuguese influence) casually, but in retrospect should've just learnt Indonesian/Malay as pretty much all of the adults can speak it fluently due to previous Indonesian rule, plus the fact there are far more quality language resources for it in Australia. I suppose the nice thing about Tetum is that there are hordes of Portuguese loans that sound like English, making vocabulary acquisition relatively easy.

After arriving at the (lacklustre) airport in a sleep-deprived state, our family met up with a local BPC volunteer called “Rico” (not real name) who helped load our luggage onto the ambulance and dropped us off at the Motel.

  The back porch of the Motel in Dili.

                                               

The Papaya tree in the same back porch.

My Motel Room. Air Conditioner thankfully is working atm. The TV had Indonesian channels + 1 Portuguese channel. Strangely I was unable to find a TV Channel in Tetum. Can't drink tap water (too dirty) so you need to use either bottled water, or boil it / treat it with purification tablets in advance.

We slept in the morning and walked to the clinic in the afternoon for a tour. I must say when I first arrived, BPC looked rather...”run-down” (compared to an Australian hospital). I didn't even realize I was near the clinic until I saw the Red Cross symbol near the entrance.

 BPC's sign at the entrance.

Poster next to entrance showing signs of Leprosy.

 Main courtyard of BPC.

However, I'm not surprised given that this is a developing country, and BPC's funding is virtually dependent on donations, and they have very high patient-load (outpatients and inpatient-wise). Patients were already queuing up outside the main building 1 hr before Dr. Dan arrived for the morning ward rounds, even though they'd be seen in the afternoon.

 Waiting area outside Outpatients building. It looks quiet in the photo coz I accidentally came too early (misinterpretation due to time difference from Australia), but it gets crowded very quickly in the MORNING as patients and their families queue up to see Dr. Dan in the AFTERNOON (after he completes the morning Ward Rounds with the other doctors and medical students).

Rico showed us the different adult and paediatric wards. Adult Medicine, where I was going to spend most of my elective in, was split into “TBC” (TB), “RTB” (Suspected TB) and “Baixa” (Hospitalized, ie Gen Med).

TBC (TB) Room

RTB (Suspected TB) Room

Baixa (Hospitalized, ie Gen Med) Room

He went through some info about how BPC runs, and explained about East Timorese culture, eg dressing conservatively and being very careful re: sexual topics. I also had a chat with Dr. Dan and the Clinic Manager Ms. Fiona Oakes who both welcomed me to BPC and provided further information about its operation. There were at the time 2 medical and 2 pre-medical students who were doing their elective here, along with a British junior doctor and 2 Italian infectious diseases Specialists.

The next morning, I joined in on the morning ward rounds and watched Dr. Dan Murphy ask patients how they were going and providing medical advice. I could only understand some of his speech, but it was clear that he avoided using jargon to facilitate their comprehension. I was interested in the factoids that he gave us about how the medical conditions were managed and investigated for given the limited resources.

The wards looked quite primitive, with no curtains to separate the patients for privacy. Everyone could hear what the Doctors and medical students were saying. If a sensitive exam (Breast/Pelvic/Prostate) needed to be done, the patient would have to be escorted to an empty room, which was troublesome for those with mobility problems (especially the ones who already had a stroke).

The sink outside Baixa Room.

There were no sinks or toilets in the wards either, so if you didn't have alcohol gel, you'd had to get out of the building and wash your hands at the sink just outside the “Baixa” ward. There was a shortage of anticoagulants for DVT prophylaxis, so it was rationed out, and most bed-ridden patients were rotated hourly by nurses.