Wednesday, September 4, 2013

Bangkok, Thiland

Rounds at King Chulalongkorn Hospital
Bangkok, Thiland

By: Ben Gray

In July of my chief year, I traveled to Bangkok, Thailand for my international elective. Having taken off at 10AM on Saturday morning, I finally landed around midnight Sunday night losing roughly half a day to the time change. I was greeted by the staggering heat and humidity of the monsoon season and would only find out later that these temperatures paled in comparison to their “hot season” in April. When I told the surgeons at the hospital that I walked to work on the first day, they asked if I brought two shirts. I quickly learned the vast size of the city. Roughly 14 million people live within the metropolitan area of Bangkok. Of these, 98% are Buddhist in religion.

 I spent my two weeks working at the King Chulalongkorn Hospital, which is a public hospital that is run by the Thai Red Cross. I was fortunate enough to be hosted by Dr. Noppachart Limpaphayom who completed his pediatric orthopedic fellowship at St. Louis Children’s Hospital with Drs. Dobbs, Schoenecker, Gordon, and Luhmann. His practice in Thailand is a combination of pediatrics as well as general orthopedics. While the Department of Orthopedics at the hospital is robust with several departments, he has inherited all of his previous mentors patients on top of his new patients. Thus, he will perform revision joint arthroplasties and adult spinal fusions in addition to his treatment of pediatric foot conditions.

Administration building, King Chulalongkorn
Hospital, Bangkok, Thiland
The hospital was primarily open air but with air-conditioned operating rooms and clinic rooms. They are transitioning from a multitude of smaller subspecialty buildings (GI, orthopedics, cardiology) to a massive, multicenter facility that should be completed in the next several years. Patient rooms vary from the open wards with 8-12 patients to the private floor dedicated entirely to the Queen of Thailand. If patients do not have private insurance or government insurance, the Thai Red Cross will cover their expenses. The medical training in Thailand is quite different from the United States. Students take a national exam in high school that determines their profession more or less. The highest scores are eligible to apply for medicine. They then complete 6 years of medical school followed by 3 years of obligatory public service in which they serve as a primary care physician in a rural community. They then apply for a residency program, which for orthopedics is 4 years. Whereas in the United States all residents are paid by the hospital in which they are working, this made up only a minority of the residents. Most of the residents were being paid during their residency by a hospital that they had promised to return to practice upon completion. Likewise, they would need sponsors to complete fellowships beyond their residency training. Another contrast was that their third year residents served as their chief resident. They were responsible for calling patients, scheduling cases, and running the services. The fourth year was dedicated to reading and learning the finer points of operating.

 In Thailand, the feet are considered very lowly and you would never touch anyone else with your feet. Your toes thus are never supposed to point at the Buddha as it would be disrespectful. I found out that this is one reason that their hand surgeons do not perform pollicization of the toes for children with congenital hand deformities. Families would not want their children to have toes on their hands as it would be disrespectful. They would however do transfers of the proximal phalanxes from the toes to the hand for lengthening purposes. Somehow this was considered different. In the operating room, infection control was very important. If you entered a room with an infected wound or an open fracture, you were required to change your scrubs, hat, mask…and sandals before entering another operating room. It was striking to me that shoes were not allowed. When you entered the locker room, there was a wall of sandals that you would change in to. I quickly learned that there were separate sandals for the bathroom as well.

One of the interesting cases that I saw was of a young boy with a myelomeningocele and neuromuscular clubfeet. It was explained to me that families traveled a great distance to come to the hospital and most wanted one surgery to fix their child’s problem rather than returning for multiple casting or multiple procedures. Thus, they have adopted the practice of performing talectomies in order to accomplish the correction with one surgery. In the clinics, I was able to see a plethora of diseases that we rarely see in the United States. The residents explained that tuberculosis always has to be in their differential as it can be an atypical presentation of joint pain. Likewise, they are seeing a resurgence of polio. I was surprised to see a large number of patients with osteogenesis imperfecta. I greatly enjoyed interacting with the residents and attendings, discussing the varying ways in which we would treat cases in the United States. English is fortunately taught starting in elementary school and thus they were all quite proficient.

During my time in Thailand, I was able to explore the city and saw several of the beautiful Wats (temples) and experience the amazing food that Thailand has to offer. Dr. Noppochart as well as other residents treated me to several excellent meals and helped me find my way around the city. Overall it was an incredible experience to see a world that is far different from my own. I am extremely grateful to the department for allowing me this opportunity to see how orthopedic surgery is conducted in Thailand.