Notes from Thailand - January 2007

By Krupal Shah

It is hard to believe that it has only been a few months since I last corresponded. While this is a relief, since I have not magically produced any papers in the meantime, it is also surprising because I have come to view the semi-rural city of Ubon as my home, and one would think that this sort of acclimatization takes longer than ~100 days!

First things first, the project for which I arrived in Thailand (a prospective study of S. aureus bacteremia) is going much better than expected. While we had anticipated an enrollment of 100 patients over the course of twelve months based on a retrospective analysis of lab results from the 1990's, a rough count of our patient records last week showed that we already had more than 60 patients enrolled. This is because we have a fairly large number of patients with sterile site staph aureus infections (mostly surgical sites with cultures from pus), which could not have been estimated retrospectively from review of charts alone. Thus, I am now engaged in data entry every evening (less fun that data collection!) so that I will be able to write a preliminary report by the end of the year. As per standard clinical trial protocol, we are entering all the data twice, and then comparing our data sets for consistency, which means that both my ID-fellow and I suffer equally!

As there are only two of us on the project, in addition to our PI, there is an informal sharing of responsibilities for all aspects of data collection and administration. However, given my comparative lack of experience in clinical decision making (whether to include or exclude certain patients etc) I typically take charge of leading rounds for the day, with our list of follow-up visits for enrolled subjects who are not yet discharged, and our new list of prospective subjects from the hospital micro lab.

In terms of additional activities, I am also responsible for giving weekly talks (Tuesday) on ID topics that I occasionally see on the wards, but that our Staph-specific rounds are not geared towards. My Tuesday audience is small, usually only my ID-fellow, but the Q and A session following the talk usually leaves me with plenty of homework, which I present on Fridays. My talks schedule so far has focused on worms (cestodes, nematodes, filaria and trematodes) and I am now branching out to make sure that some of the big topics do not get overlooked (TB, malaria, typhoid, dengue, cholera, leishmaniasis, trypanosomiasis and leptospirosis for the next three months). I am also scheduled to spend a week in the larger Wellcome Unit lab at Mahidol University in Bangkok during February to learn basic culture techniques and speciation of organisms. Part of our study (which I may not be present for) involves antimicrobial susceptibility testing, and so this will be a good way to get some practical experience within my limited timeline.

As I have requested additional responsibilities when the wards are not terribly busy (like today, when only one patient was recruited), I am working with our Thai lab director on a project to analyze data collected on B. pseudomellei resistance to antimicrobials over the past two decades. It is a small project, just to get my feet wet in another area of knowledge that this lab specializes in. It also gives me some practice with statistical methods which I have trained in, but have not used since my masters degree thesis.

Lest I give you the impression I am never coming home, let me introduce you to some local residents that never tire of reminding me that I am an outsider. Before you conjure images of a xenophobic Thai mob, take a look at the picture (Pic 1) and notice that no people are present. The dogs on the street leading to my house, while harmless, will bark at any time of day or night if they catch sight of me (or scent, I guess). I have completed a series of rabies shots, just in case, and have also invested in a little ultrasonic device that gives me the ability to bark back with some advantage. All in all, the relationship is stable!

While I don't expect much of my routine to change in the next few months, I should have some interesting news to report from my time in the lab in Bangkok and also give you an update on my Melioid stats project. I don't expect any results from the staph study at that point, but I can at least tell you how large our sample has gotten.

Sincerely,
Krupal Shah, MS3

Pictures

PICTURE 1: The spotted lady in the front is usually quiet, while the two gentlemen in the back (the third one scrambling back to his designated lookout) are always vocal in their greetings and farewells.

Picture 2: This is the building where we rent space for the lab office. It is across the street (diagonally) from the hospital and has a dental clinic on the bottom floor that is always packed in the evenings. *An aside: The SUV in the foreground is a true representation of the cars you will usually see on the roads here (both in size and age i.e. most cars are new looking). The previous Thai government heavily taxed cars and left a loophole for trucks (and apparently SUVs) so that they are actually cheaper to own. In combination with the fact that gas is cheaper here than in the US (probably the only place in the world!) it has made the average vehicle owner inclined to buy big lumbering vehicles rather than anything remotely efficient.

Picture 3: This is the main entrance to Sappasithiprasong Hospital (named after a prince). It is a ~1,500 bed (depending on the # of beds in the hallways) regional tertiary care center. It is the largest hospital in NE Thailand and also serves a sig. population of people from Laos (given the proximity of the border).

Picture 4: This is another picture of the front of the hospital, panned slightly to the left. The new structure is the tallest in Ubon (they might keep going - I was surprised to see the top two stories after Dec break!). They are planning to start a medical school here at some point.

Picture 5: Same view as 3 and 4, panned to the right. This health center is HUGE! The building (new-looking) on the end is the Cardiac/Vascular surgery complex. The depth of these buildings is about half a city block (about the same as Duke or the VA, I think)