Lao Friends Hospital For Children

                                    https://fwab.org/laos/

   I’m starting my second week working at the Lao Friends Hospital for Children. Above is a link to their website so you can read more about it but in a nutshell it’s a pediatric hospital that provides Outpatient, Inpatient, NICU, Physical Therapy, Outreach, Pharmacy, Developmental Clinic, Nutrition Clinic, Radiology and Surgical services free of charge to any child that shows up at the doorstep. The hospital opened in 2015 with the goal of becoming self sustaining in 10 years at which time it will be handed over to Provincial Hospital next door.  There is a sister hospital in Siem Reap, Cambodia that opened in 1999 and became an independent self managed hospital in 2013. My job and that of the other volunteer nurses, doctors, pharmacists, lab techs, physical therapists and occupational therapists is to support patient care and train Lao staff in pediatric medicine. 

   Maybe the best way to understand what we do is to take you through a “typical” day although with the warning that anything can throw a wrench into the schedule and usually does.

0630- Get on my bike and ride 4km across town to the hospital.

0700- Handoff with the night volunteer where we do a quick rounds on the patients in the Inpatient Department (IPD) with a little report of what happened in the night. (From my experience the patient population can change very quickly. Patients are discharged at all hours of night and new ones show up. Sometimes a family will make the decision to leave and won’t tell anyone. You’ll just notice that the bed is empty.) Lao nurses pick their assignments. If I’m lucky I have a shift leader who is an experienced Lao nurse who will make sure that the assignments are appropriate and help with checking meds and bed assignments.

0730- I touch base with the Lao nurses. I might make suggestions about what to look for and focus on with their patients. For instance- “please make sure you do very accurate fluid balance  (I&O) records on this patient with renal failure.” We might have a little teaching session about why this is important.  From what I’ve been told and observed, the Lao nurses are very task oriented and they are very good with putting in IVs, mixing meds etc so we are helping them develop critical thinking skills.

0800- I check charts and make note of medication times and look at vital signs, fluid balance, weights. Write down any concerns or questions I might have during ward rounds.

0900- Ward rounds with the volunteer doc and Lao docs. There is always one volunteer nurse and doc on every shift. The Lao nurses attend rounds on their patients. I round on all patients. During rounds the Lao doc presents information about each patient and then we discuss pathophysiology, medications, labs, diagnostics. There is a lot of teaching done by the volunteer doc. As a team we’ll come up with a plan for treatment for that day. The plan can change every day, mostly due to the fact that we are very limited in our resources. 

     For instance- a kid might come in with what we think is some bacterial illness but we can’t test for it so we treat as if it is Typhoid but if they don’t respond we might switch gears and question if it’s something different- maybe Rickettsia- which (guess what?) we also can’t test. It just is what it is. We do the best we can with what we have. We had one patient that we thought was bleeding somewhere and I asked if we could do a stool guaiac  (looks for blood in the stool) and a medical student I work with said “if you can see or smell it we pretty much don’t test  for it.” It really makes you change your way of thinking. We can’t just do a bunch of tests because either it’s not available or it’s a waste of limited resources. We do have x-ray and ultrasound but to get a CT scan we have to take the patient to Provincial Hospital next door—where we have to pay for it—so its carefully considered by the medical director as to whether its warranted. Any money we give to Provincial for services takes away from what we can provide free to our Lao patients.

    Back to rounds. It goes on for hours depending on how many patients we have. The longest I’ve attended was 4 hours. It’s very comprehensive and educational and has been a great refresher course in pathophysiology and pharmacology. After the inpatient department rounds we head to the NICU to do rounds.  On day shift there is a volunteer nurse working with a Lao nurse (thank goodness!! I’m terrified of those tiny babies!) On night shift there is no volunteer but always two experienced Lao nurses. So far it’s been fine but there is a panic button that the NICU nurses can hit if they need help that sounds an alarm. I live in fear of that alarm.

    During rounds or really at any time during the shift I get pulled away to double check med doses, open the narc box, assign a bed for a patient that has come through emergency or the operating theatre (OT) or oversee any type of emergency that is happening. I also need to touch base with NICU now and then to make sure they’re doing OK.

1400-1700-ish- Make sure everyone gets their breaks, meds are given, help with treatments, admit and discharge many patients, teach about disease processes and medication. Also the Lao nurses are scheduled for English classes and might take off for special training. They also attend classes on body systems, pathophysiology etc. This last month they were learning about the renal system which was good since we had our first dialysis patient in the last couple of weeks (sent to Provincial Hospital for treatment.) While this is all happening in the IPD there is an outpatient clinic that sees dozens and dozens of patients a day plus an emergency department that sees many patients too. The other day I checked the patient tally on the board at the Outpatient Department and they had seen 78 patients thus far- all by 2:00 or 3:00pm. Also a developmental clinic and PT and OT upstairs. When I show up to work in the morning there will be dozens of families camped out everywhere waiting to be seen.

1700-1900- touch base with the Lao nurses about charting, make sure meds are caught up and they understand the plan so they can report off to the next nurse. Basically try to straighten everything up for the next shift. After about 6pm we don’t have access to lab, pharmacy  or x-ray until the next morning so we try to make sure any lab tests, diagnostics or meds we might need are taken care of. Sometimes if it’s been particularly chaotic we’ll do a mini rounds on everyone to make sure we haven’t missed anything.

1900- Handoff to the night nurse.

1930- Ride home. Eat. Sleep. Repeat.

I am on the night shift at least once or twice a week. It’s pretty much the same routine except we have no lab, pharmacy, x-ray etc. That really can change how we treat an emergency. We have to do the best we can and guess what is happening instead of being able to rely on labs or x-rays. Also the Lao nurses and docs take sleep breaks. I suppose I could put the volunteer doc in charge and sneak off for a short nap but I don’t. I like to be around to keep an eye on things and I think I would wake up sleepier than before. So I just tough it out.

Right now we’re short on volunteer nurses so I worked four shifts last week and I work four this week. After this week it’s back to the regular schedule of 3 shifts/week. They always bundle your days so you have at least 3 or 4 days off in a row and in the middle of March I have almost a week off.

We do have some typical patients. 

-Gastroenteritis, dehydration and lots of malnutrition and worms. Every kid (inpatient or outpatient) gets a dose of vitamins and albenzadole for worms. 

-Beriberi- thiamine deficiency in babies because mom is following the taboo diet during the postpartum period, meaning she has food restrictions because of cultural beliefs. The rice in her diet is polished and washed over and over and the B vitamin is stripped away so baby doesn’t get it in the breast milk. It can be very debilitating but baby makes great progress with a dose of thiamine and mom is given some too and sent home with it. Outreach is working on education in the villages. 

-Preventable diseases due to lack of vaccination. Outreach is also working on this. 

-Thalassemia, an inherited anemia requiring frequent blood transfusions. We have a thalassemia clinic every Thursday with kids coming in for transfusions. There is a huge need for blood here. They run frequent blood drives. I haven’t been able to donate in the US for years because of our exotic travels but they don’t care here. Plus I’m O neg so very much in demand. I’ll donate on my next day off. Mike’s already done his duty. 

-Traumas, any and every thing you can think of. It’s very common to see whole families on a scooter with only dad wearing a helmet. I’m especially sensitive to this now. On my day off as I ride around town I find myself cringing at potential accidents. Lots of orthopedic surgeries. There is a huge problem in this country with UXO (unexploded ordinance- land mines and unexploded shells from the Vietnam War.) I know it’s a bigger problem southeast of here so I haven’t seen any patients who have injuries from that- yet.

As a rule we follow guidelines from the World Health Organization for treating these conditions. I just found out that our Medical Director is considered the leading expert on severe malnutrition in resource limited areas. His research has changed the way malnutrition is treated in the world.

Families are very loving, attentive and sweet with their children. There’s always one family member with every kid and the rest of the family is usually camped out in the family area outside. They take turns coming in and providing care- bathing, helping with toileting, feeding. There is no food provided by the hospital so they either cook in the communal kitchen or buy food from the canteen during the day. Besides the cooking area, we provide bathrooms, showers and mats for sleeping. During the night there are patients and their families sprawled all over the ward or outside. As a rule these people are very poor and come from villages far away from here. They might travel up to 8 hours for care. Often  parents use the local shaman for medical treatment before they come to us so sometimes a kid comes in and we’re not sure what they’ve taken as far as medication/toxins/treatments. But they really do mean the best for their kids- they are in no way negligent, just don’t know any better. They’re receptive to our care and seem very appreciative. The people are really shy, stoic and somewhat reserved but quick to smile.

Any child can come for treatment and many times a western kid will come through with some illness. We don’t require any payment but ask for a donation for services (for instance a CT scan is 800,00Kip (about $100) a unit of blood is 80,000Kip ($10.)  They are always grateful and happy to pay.

We have 22 beds in the IPD and 10 beds in NICU but we won’t turn anyone away so sometimes the halls, ED and treatment rooms are filled with patients too. Thursday I had a bed with two patients in it- sisters both getting transfusions for Thalassemia. A couple of days ago we had 24 In the IPD, 12 in the NICU and 2 in the ED. We always find room for more. The Lao nurses and doctors stay very calm and cool during emergencies and through all the chaos. They understand we can only do what we can do. I try to take a breath and stay calm because it's true.  Acuity is very high. We’ve had a couple of kids die just in the last week. It’s been a very intense, emotional and rewarding experience.