Pulling Teeth in Cambodia

Hello all. Let me once again thank all of you for the nice emails I have been receiving. The pace is glacial in the internet world over here, so I apologize for not returning so many of your emails. Waiting five minutes for my email account to open is maddening enough. Let me also give a big shout out to my comments writers namely Nilbog (Chris D), Mike O., and Cliff. Chris, your commentaries have grown both in length and depth over the month. And no, there was no happy ending to my massage. Thanks for your concern my good man.

I decided to start out my post with a downer and then work my way towards the lighter material instead of my usual pattern. I tell you all this story not because it's any different than anything I've seen before in DC or Providence, but because I find it somewhat therapeutic to put it down in words.

So one of the best things about working in medicine is getting to meet all kinds of people and having the opportunity to make some kind of impact, big or small, on their day, or their week or their life. I'm a people person, no one can deny that so although I've been here less than a month it's been nice to get to know some of the kids and their families.

I met a really nice girl in clinic last week, she'll turn 15 next month. Her grandmother brought her in because for the last month she has had painful swelling on both sides of her neck. I was the first doctor she had ever seen in her life. Let me repeat that for effect. This girl, nay woman, had never seen a doctor in her life prior to last Thursday. She is an only child and lives with her grandmother because both of her parents died of AIDS two years ago (ed note: greater than 1% of Cambodia's population is HIV +). In my mind, I had surmised that her neck swelling was either due to a bacterial infection or tuberculosis, but was most concerned about her risk of having congenital HIV. So I talked it over with one of the head Cambodian docs and he agreed with my differential diagnosis and plan, but didn't feel that HIV testing at this time was necessary. I knew what he was saying, he truly made sense, but part of me (a big part) felt that regardless of whether or not she was ill, she deserves to know her status. So I placed a PPD (TB test) and discussed with her and her grandmother that maybe HIV testing in the near future was a good idea.

So the weekend passes and I think that the girl entered my mind once or twice, but I didn't dwell on the case. I just think I thought it sucked that she was an only child and her parents were dead. She reappeared in the chair across from me Monday morning with 15mm of induration on her right forearm - in the biz, we call that a positve PPD - thus Doctor Mike made the right call ("thank you, thank you"). As I was looking up the correct doses for her four different TB medications, her grandmother asked the interpreter to ask me about HIV testing. I was so happy she asked but scared at some level of finding out the result. I sent her to the HIV counselor for pretest counseling and then on to get the test done. She then told me that she would wait the requisite two hours for the result to come back which she would receive from the HIV counselors.

So I get back from lunch about 30 minutes early stalking the lab for the result(I think you all know where this is going). I start sifting through the completed labs and there it is - POSITIVE. Both screening and confirmatory tests. Are you f&*king kidding me? This is insane on several levels, mainly because she's lived for nearly 15 years with this virus and been, until she developed TB, asymptomatic. But any medical interest this case creates is trumped by how sad I am for this kid. Again, this kind of shit happens every day in Providence and DC and London and Berlin and Capetown and SIEM REAP, so take it down a notch Spaeder! Well, that feels a little better now.

As I mentioned getting to know kids and their families earlier, it finally came in really handy the other day. For any of you who have traveled through the developing world you have likely experienced the joy of the marketplace. It's a place of bargaining and it's also a place with absolutely no pricetags. I don't like bargaining...at all. I am the absolute worst person to have with at a garage sale or flea market. My only response to a unreasonable price is to make a joke, which never helps me lower said price. So my performance up to now in Cambodia has been poor. I spent $2 on fruit that afterward everyone said should have only cost $1 - for the record it was a lot of fruit and if I tried to buy the same fruit in the States I, a.) wouldn't be able to because it doesn't exist there and b.) if it did exist I could only find it at Fresh Fields where I would have literally paid $10-$15. So, I went to the Central Market looking for something nice for the Mrs. when all of a sudden, amid the cat calls of the market workers, I am grabbed by a woman who recognizes me from the hospital. I treated her child last week and she owns a stall at the market! What ensued was insane to say the least, as she and her sister showed me every goddamn thing they had for sale - trying things on I might add. I don't know if I got a good deal but I felt like I was getting one. And really, isn't that all that matters.

Back to my adventures with Paul the British Dentist. So he continues to be hours of entertainment for us. He has really inspired me to work on my dry humor. He also inspired me to ask him if he would show me how to pull out teeth. I've never had the slightest interest in Dentistry, but when else I am going to have the opportunity to pull teeth. So, he was all for it and had me jump right in. The first kid had a bad molar and I got almost all the way out before the pliers slipped off the tooth, so he finished that one off for me. As I was yanking out the front tooth of my second victim, the tooth was so rotten that it just broke into pieces. Not a stellar start to say the least.

So Paul, pleased that I was at least giving it the old college try invited me to go with him and his two dental assistants to a health clinic about 15km outside of town (which of course took 40 minutes, cause the roads SUCK). On a certain date, at a certain time, the people of these little "towns" know to show up at the health center if they have a tooth that needs to be pulled - let's just say for the record that any tooth in Cambodia has a greater than 50% chance of needing to be pulled. I was more than excited to go - a chance to see a little more of the countryside, learn a little dentisty - because who really is better equipped to teach me about bad teeth than a British dentist. We arrive at the health center and the young and old of the town requiring extraction were there waiting with baded breath. What ensued was an amazing display of dental prowess as Paul rid this town of tooth decay - incisors gone, canines gone, molars g-o-n-e gone! I stood in awe, silently taking all of the extraction knowledge he was imparting on me and storing it in an important place - my cerebral cortex. Thursday morning he has invited me back to the dental clinic to get my extraction on - I'll let you know how it goes.

Ed. note: I intended to end the post with the above musing on my teeth pulling exploits but as I often write the post at night and wait to publish in the AM, I had the opportunity to run into the young woman who I told you about several paragraphs above. She was coming out of the HIV office and we saw each other. She gave me a huge smile and a wave. It was the first time I ever saw her smile during this whole ordeal. Maybe she felt like a weight was lifted. I don't know.