Will Cleek, MS4
February 2017
Thailand Reflection Paper
Both clinically and culturally my time in Thailand is something that I will always look back on fondly.For my clinical work I spent two weeks with the CT Surgery Department and two weeks with Trauma Surgery. As the biggest and most highly regarded hospital in the country, complex cases from around the country were funneled into Siriraj, which definitely made for an interesting learning environment. On both of these rotations I spent the majority of my time in the operating room bouncing from case to case. While the operating room is not usually my favorite place to be in the hospital, I very much enjoyed my time with both of these services. The residents and attendings were always welcoming, great about translating the daily rounds into English for me, and making sure I was aware of what was going on with each of our patients.
On the CT Surgery service I saw a large variety of patients that came to Siriraj from across Southeast Asia for the treatment of various cardiac problems: heart failure, coronary artery disease, congenital heart malformations, aortic dissection, aortic dilation secondary to Marfan’s syndrome, abdominal aortic aneurism, ect. My most profound clinical experience in Thailand involved a 35yo pregnant female (18 weeks) with mitral stenosis secondary to rheumatic heart disease that decompensated during her pregnancy and subsequently coded. I was with the CT Surgery resident that received the call from the obstetrical floor shortly after the code blue was initiated. By the time we arrived on the floor the patient had been successfully resuscitated, however, she still required an emergency valve replacement surgery. During this operation I learned that the patient was Cambodian and was informed that she was very lucky to have been in Thailand for this incident. According to the attending running the surgery there are not any hospitals capable of performing open-heart surgery in Cambodia so it would have been very difficult for her to get the care she urgently needed if she were back home. This experience really highlighted the differences in care that exist and change suddenly depending on which side of an international boundary one happens to be on. The outcome for this patient could have been drastically different is this patient was a mere 200miles east.
During both my two-weeks on CT Surgery and Trauma Surgery I took time to speak with two attending about healthcare challenges that are of unique/disproportionate concern in Thailand and how this impacted the care they administer. On my CT surgery rotation the attending stressed the troubles that Thailand has with diabetes and the health affects that stem from it. He brought to my attention the high carbohydrate content of a lot of the foods that Thai people eat on a daily basis (noodles, smoothies, numerous food/drinks made with sweetened condensed milk, ect.). This point was further emphasized in my Thai cooking class when the “big three” ingredients said to make up Thai food were fish sauce, chilies, and sugar. Additionally, there is a high incidence of heart problems caused by infectious disease (Rheumatic heart disease, TB myocarditis/endocarditis) that lead to high rates of valvular repairs in Thailand. The effects of diabetes and infectious disease induced cardiac problems place stress on the Thai healthcare system that offers universal coverage to its citizens. To partially combat these costs, the CT Surgeons at Siriraj continue to rely on mechanical valves, which have a longer lifespan, rather than tissue valves, which are common in the US, to reduce the number of patients requiring reoperation after their initial valve replacement operations.
Dr. Roeksomtawin, a trauma surgeon at Siriraj, spoke at length to me about the high volumes of patients with severe burns and patients injured in motorcycle crashes that his department treats on a daily basis. The problems with motorcycle injuries are a problem nationwide, but are particularly bad in Bangkok, a sprawling city of over eight million people with a traffic problem almost equally as large. Dr. Roeksomtawin and one of his residents (present for the interview) recalled their own struggles with Bangkok traffic, the resident sharing that during high school it took him a total of 4 hours a day to travel to and from his school due to the intense traffic. To combat this problem, large numbers of Thai travel using motorbikes which are able to cut through the traffic. While saving on driving time, these vehicles are also much more dangerous and lead to higher rates of bad traumas. Burns are also a big issue for the trauma department at Siriraj. As there are only “two or three” hospitals in Thailand with the ability to treat extensive burns, the patients that present to Siriraj often present late or arrive septic from the poor wound care they’ve received in other parts of the country. These burns mostly arise from occupational hazards and while the quality of care provided at Siriraj is high for these patients, no everyone can easily get to a healthcare center that provides them with the care that they require.
Both my travel in Thailand and especially my prior international travel experience through KUMC in India have shown me the impact that health disparities have on populations across the globe. While Thailand has adopted a universal healthcare system and the healthcare provided at public facilities was miles ahead of the public healthcare I saw being delivered in India, specialty healthcare services (cardiac care, burn care, ect.) are not as widely available and accessible as they need to be in settings outside of a few public hospitals like Siriraj. This problem isn’t unique to India and Thailand.Rural healthcare in the United States has similar problems related with access to specialty services. My time in Thailand reminds of my ongoing desire to set aside time in my future practice to do my part to address the health disparities that exist both in the US and abroad, both through work at local community outreach facilities and global health missions.
A lot of the profound cultural experience(s)I had during my time in Thailand stemmed from the recent death of Rama the IX, the former king of Thailand and longest serving monarch in history. As a result of his death the country is currently in the middle of a yearlong period of mourning. As I walked around the city I was never far removed from the omnipresent image of the king, in fact, a memorial or image of him was almost always somewhere in site. Coming from a country that is currently bitterly divided from a political standpoint, the uniformity with which the Thai people participated in this “year in mourning” struck me as a bit odd and perhaps a bit forced. Thai people were expected to wear black every day and visit the memorial to the king at least once during this period, a visit that required one to wake up before dawn and stand in line for hours in the heat. On top of this, Rama the IX’s son who is expected to take over as the new king is widely reported to be a divisive figure in the foreign press. Knowing this, I attempted to broach this subject in private settings with two Thai friends that I made on the trip, both of whom were uncomfortable talking about the subject even in private for fear of being overheard. Traveling during this mourning period and immediately following the heated 2016 US election definitely made the political contrasts between Thailand the United States very obvious.
Outside of my clinical work and time in Bangkok I was able to travel to different parts of Thailand on the weekends. Additionally at the end of my clinical responsibilities I spent a week each in Kuala Lumpur and in Sydney. During my entire trip I jotted thoughts and observations in a journal that I kept with me, excerpts of which I will be posting to my blog in the near future now that I have returned from my extended journey.