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©2010 Iris Ma, MD

I arrived in Cambodia ~midnight on Sunday, March 28 to be picked up by Sothat, a fluent English-speaker and self-described Cambodian "farmboy" who lives with his "[god]Dad," the famous Jon Morgan, an American and fearless leader of The Lake Clinic.

At the airport, Sothat was quite confused by my appearance as he clearly expected a fair-skinned Caucasian as opposed to a fast-talking Asian-American. All this was made somewhat more entertaining by the fact that my plane came from Seoul and was composed of mainly South Korean tourists.

My first impression of Siem Reap is that it is a bustling, touristy, well-outfitted city with a lot of dogs. These dogs are generally medium sized, but thin and generally non-aggressive but highly alarming. It's no wonder that rabies is a problem and this knowledge, combined with my general discomfort around canines makes me somewhat skittish on the streets.

Otherwise, I am happy to walk around taking in the sites and food. Everything is skinny here: skinny people, skinny dogs, skinny chickens, skinny cows. I wonder how a Cambodian would react to a day in Dallas, Texas.

©2010 Iris Ma, MD

I left for the lake on 3/29 with Dr. Sambun, Savann (nurse and team leader), Ally (excellent boatwoman, cook and former resident of Moat Klas, the largest of the floating villages) and the Chantriya (boatdriver). We traveled 1 hour by car to Kampong Khleang to board what the team jokingly calls "TLC Zero".

The lake is particularly low this dry season, measuring less than 1 meter in several areas and impeding travel significantly. The chocolate milk complexion of the water is alarming, especially knowing that is where all the people and animals defecate, urinate, bathe and drink.

Unfortunately, TLC One is too heavy to travel with the lake’s low water levels, so this week a small boat has been rented to make the journey through the narrow channels.

Like the Little Engine That Could, TLC Zero made it to Moat Klas (Tiger’s mouth) in a little over 5 hours, about twice as long as it usually takes, and continued for 6 hours until we reached Don Sdeung. There were several problems with the engine and getting stuck in the shallows.

©2010 Iris Ma, MD

Our intrepid boatdriver would frequently hop into the lake to push the boat. It was disheartening to see that at times he was only up to his knees or thighs. We made it to only two villages this week and were forced to cut out a clinic half-day due to long travel times.

The floating village residents are essentially all fishermen/women and not considered so poor as there are a lot of fish. However, Cambodians, particularly educated Cambodians, have no interest in living in these distant fishing communities with their backwards ways and really difficult access to the rest of the world.

The UN has several programs in the area and I believe the UNDP even built a clinic facility in Don Sdeung, one of the villages I went to, but they were unable to recruit a doctor to work there.

As you can imagine, the underserved of Cambodia put the underserved of the US to shame.

Elana Rosenthal, MD empathizing with a small patient.
©2010 Iris Ma, MD

At Don Sdeung, we acted in an acute and primary care clinic capacity. Most of our problems were similar to those in the US as far as acute illnesses go with a lot of URIS, way more gastroenteritis and some acute otitis media. However, the chronic problems were fewer as there are not many older people and no obesity.

There was no hypertension (every BP I measured was 90-120/60-80)! Certainly, arthritis and vision problems abounded in the older patients, and we had one untreated diabetic with a horrible foot wound.

The pharmacy is impressive with a wide range of antibiotics including ciprofloxacin, trimethoprim-sulfamethoxazole, amoxicillin, ampicillin, metronidazole, clindamycin among others.

©2010 The Lake Clinic Cambodia

I had fun opening up a perirectal abscess in a 3yo boy. I'm sure it was horribly painful, but the amount of pus that came out was very, very impressive.

I suspect he would have died if not for this clinic as he was a small (~5kg) child with a very large, deep abscess. Mom and baby were crying during lidocaine injection and then later as I squeezed out about 1.5cups of pus and broke loculations. However, mom in the end was very satisfied and thanked us with a very large fish.

That night we continued on to Peam Bang, worked from 7:30 AM the next morning through a similar set of problems and left by 9:30 AM to make it home before dark.

We saw 66 patients on day one and 41 on day two.

I wish I could capture and send smells because Cambodia is a fragrant country. In the morning as I make my city rounds, usually around 6:30-7 as it becomes intolerably hot by 1030, the aroma from the food stalls/shanties wafts onto the street. A mix of garlic and fish sauce in a cloud of steam may sound unappealing, but is rather a delicious smell.

Continuing across the bridge over the Siem Reap River, I pass the Buddhist temples where monks light incense. The combination of incense and humidity is surprisingly potent. The smell is intense even at a distance, and suffocating within a 100-foot radius. Then there is the stench of the floating villages. It reminds me of the fish section of a Chinese supermarket served with a side of raw sewage. The villagers trade the cleanliness of isolation to live together.

I went to a real Khmer party! One of the doctors at Angkor Hospital for Children had a party - supposedly a birthday party for his 11-year-old-daughter, but there were about 5 children and about 80 adults. There were 5 courses of authentic Khmer food, a brief magic show, a cake and sparklers, some dancing, and a lot of Angkor beer.

Khmer dancing involved walking in a circle while waving one's hands gracefully and rhythmically (not so much in my case) in time to the music. For Apsara dancing (Khmer traditional dance), dancers are selected as children based on the elegance and flexibility of their hands.

Elana my closest friend and infectious disease expert-to-be arrived on Sunday. A brief bio: we were college roommates at Yale and she is soon to be an intern at Beth Israel Deaconess. Here in Cambodia, she's been going through the same transitions that I have - the 2am wakeups and adjusting to a slower pace. It’s great to have her here.

Back to the second week of The Lake Clinic. The main character this week is Sakhem, the dynamic leader of community development. He is 67 years old with completely white hair, completely buzzed except for a long tuft in the front - a stylish gentleman indeed.

In his earlier life, he was a parachuting captain and fought alongside the Americans against the Viet Cong. He continues to dress in military garb, but wears a dissonantly cheerful personality. His role with TLC is to supervise the Village Health Volunteers (VHVs).

Under Sakhem’s leadership, we made a dry season trip to recruit VHVs this week while the doctor and nurse/pharmacist/team leader are on vacation for the Khmer New Year. This was a bold decision as it is sweltering on the water this time of year even for the locals and the length of the journey twice as long as in the wet season.

So we went out on the boat again, this time to Pavoy and Moak La for Village Health Volunteer (VHV) selection and training. VHVs are elected representatives from the villages that TLC serves. They are responsible for helping with registration (getting people lined up and handing out numbers that determine the order in which people will be seen), disseminating basic medical information (antenatal care, birthing procedures, contraception, sanitation, diarrhea management), gathering feedback from the villagers to determine what TLC is doing well or needs to improve for future visits, and sometimes cooking for the TLC staff on the boat.

Sakhem and Ya, the kind midwife on our team, led elections in Pavoy. About 50 villagers appeared, including men, women, and children and 5 young, new VHVs joined the TLC team. Later in the year, they will travel to TLC headquarters in Siem Reap for more extensive training, and then they will be back to their village to improve health from the ground up. It is clear that VHVs are a critically important part of TLC. They increase the scope of TLC’s impact, place an appropriate emphasis on prevention, and provide invaluable feedback.

It was another struggle to travel to the villages, and we were forced to stay off the channels. We went to Pitchakray and Moak La, and saw over 150 patients. Again, we saw mainly viral infections interspersed with bacterial and fungal infections. We had a few chronic care patients, and a few emergencies.

There was a woman with a red, swollen hand with several areas of maceration and black streaking. Her hand had been caught in a boat propeller several weeks ago and her treatment had been antibiotics and bandages. Per our team, her hand looked notably improved from their previous visit. It must have looked awful before.

A 13-year-old boy was chopping wood and the axe glanced off the wood and lodged in his thigh. He was left with a fairly deep laceration, which I repaired in the chief’s house. It was a strange feeling to be operating on a wooden floor with an audience of young children. There were also unique distractions, for example, the chief’s grandson accidentally set fire to a napkin. All in all, our team worked as an efficient, effective unit and we were able to run smooth clinics.

My time at The Lake Clinic is over, but I will keep with me many special memories and important lessons. It has been a privilege to work with the talented, generous TLC staff. They taught me so much, and always with a smile. And I will miss the floating villages, the excitement of the clinic as the boats pulled up to the rickety schoolbuilding coopted as medical building and the din of children and families eager for medical care.

The villagers deserve to have better - improved clinic facilities, hospital access, and a wider range of medications that includes diabetes meds and a few more key antibiotics. I feel proud to have been part of TLC. Thank you.