Thursday, June 24, 2010

It Takes A Village to Heal A Child - At Least In Isaan

It has been a few days since my last blog. The lack of blogs has not been due to a lack of subjects but because we have been very busy. Much of our time has been spent at the hospital in Kumphawapi. Our grandson, Peelawat, has been hospitalized for three days.

Peelawat has been been living in Tahsang Village with his mother at his Great-Grandmother's home. In Tahsang Village, he spends a great deal of his time playing with his two and one half year old cousin, Kwan, and three year old neighbor, Tay. Like all other 16 month old children in Isaan, Peelawat's play involves walking around bare foot, playing in the dirt, running after chickens and puppies. All the toddlers carry evidence of their play on their ankles, legs and arms. Nicks, scrapes, and scabs bear testament to the fun that they have been having on these hot and humid days in Isaan.

Monday morning, we received a phone call from Duang's daughter saying that Peelawat was sick. He had a fever and had experienced a couple seizures. Previously when he had fevers, Peelawat had experienced seizures. At first this was extremely concerning to us but after researching I determined that these seizures are somewhat common in young children. Later I found out that Duang as well as her two children had the same experience with fevers when they were young. This made me somewhat more relaxed but I still had concerns about epilepsy or some other serious condition. Duang's daughter had a cousin take them to a clinic in Khumphawapi to see a doctor. Peelawat had a seizure at the clinic. He received treatment and returned to Tahsang Village.

Later that evening we received another, more stressful, call from Duang's daughter saying that Peelawat was running a fever, had additional seizures, and was being hospitalized. Peelawat and his parents had been taken to the hospital in Kumphawapi by one of the uncles in Tahsang Village who had a pickup truck. Most people in Isaan have motorbikes but out in the villages few people have trucks and even fewer have cars. People with vehicles are often called upon to help out in emergencies. With the emergency notification, Duang, her son, and I headed off to Kumphawapi.

We arrived at the hospital and found Peelawat in the Emergency Room. He seemed so small and defenseless laying on the gurney swathed in a blanket with an oxygen mask on. He was very feverish and in that quasi conscious state that a high fever induces. After a while, he was transported to the Pediatric Building of the hospital. Since the NICU is located on the second floor and there is no elevator, I had to carry him up the two flights of stairs to the NICU.

Although the sign above the entrance to the ward said "NICU" (Natal Intensive Care Unit), the room was more of a children's ward than what we expect to find as a Intensive Care Unit in the USA. The room was very similar to other hospital wards here in Isaan. It was a large room divided in two sections by a five foot high block wall. Each section contained 16 beds. A couple of ceiling fans provided ventilation for each of the sections. At the end of the room there was a large area that had several shower stalls and toilet stalls. Just to the left of the entrance to the bathroom area, there were a couple of large steel cabinets with hospital linens. There was a fairly large Nurse's Office, which was air conditioned, at the middle and front of the ward. Approximately 4 nurses were in and out of the office.

Here in Isaan, the Nurses handle taking vital signs, and giving medicine. They do not provide care for the patients such as bathing, dressing, changing bedding, feeding, or assisting in the personal hygiene of the patients. The family and friends of the patient provide patient care. Since there are such large families and such a strong sense of community here, the hospital wards are always filled with people. In addition there are many people congregated outside of the wards - eating, resting, and socializing while they await their turn to give care and comfort to the sick. While this may be reassuring during times of normal sickness, I fear the consequences of this behavior if the fears of a SARS, H1N51, or some other horrible epidemic become reality. Containment will not be possible.

The ward was filled with patients from two weeks old to about 12 years old. Each patient had two to four people attending to them. Surprisingly, many of the adults caring for the little patients were men. Lao Loum men are very involved in the raising of their children. Uncles are also involved in helping to care for their nephews and nieces. Peelawat had his grandfather, grandmother, mother, father, uncle, a couple of great aunts, a great uncle, and two cousins - a couple more attendants than typical that night. The ward was filled with the sounds of babies crying out of fear and from pain.

The young patients were placed in full sized hospital beds. The beds had been modified for young patients by the addition of smooth nylon string in a lattice pattern to reduce the spaces on the pop up rails on the side of the bed. Very young patients sleep with their mother in the hospital bed. Older patients mothers or fathers sleep under the hospital bed or on the balcony outside of the ward - if they get to sleep at all.

Duang and her daughter kept busy wiping Peelawat down with tepid water to break his fever. I occupied myself trying to comfort him. Peelawat was confused about the situation. One thing that he was sure of as well as adamant about - he wanted out of the hospital. He remembered the way into the ward and he was constantly pointing toward the entrance indicating that he wanted OUT and expected me to take him out.

Sadly just about every time that Peelawat calmed down a little bit and started to get some much needed sleep, a Nurse came by to check his temperature, collect blood, or give him a shot. After awhile, the Nurses decided to connect Peelawat to an IV. Just about every other patient on the ward was hooked up to an IV. One of the younger Nurses tried to put a needle into his foot. She tried and tried to no avail. Peelawat very quickly understood what was going to happen when the piece of surgical tubing was wrapped around his arm or leg. After about 5 minutes of stabbing and jabbing Peelawat to connect an IV, I said "Enough. No More, she doesn't know what she is doing. Get someone else to try". Thankfully, whether they understood me or not, another Nurse took over. Three nurses moved Peelawat's bed over to be in better light to assist in finding a vein. In the end it took a third nurse to finally connect the IV.

A Doctor was not available to examine Peelawat or any of the other patients until the next morning. I tried to determine what medicine Peelawat was getting - fighting against the language barrier as well as the cultural barrier. Medicine in Isaan is similar to the type of medicine practiced in the USA 50 years ago and longer ago in the USA - The Doctor is always right, the Doctor has no obligation to explain treatments, the patient is just to take the medicine given to them, and the Doctor is infallible. After some time I learned that Peelawat had been given an antibiotic. This seemed reasonable to me and reassuring. I was also satisfied that blood as well as urine samples had been collected. After four hours we left the hospital and returned home.

The next morning, we were back at the hospital at 8:00 A.M. I noticed that Peelawat's ankle was swollen, very hot, as well as surrounded by a black band. It was obvious that there were several red ant, weaver ant, bite marks on that leg - not an unusual sight on village children in Isaan. I pointed this out to Duang and she told me that some people in Tahsang Village had the same thing only higher on their body and they had died. This was not comforting news. Duang informed me that some of the old people in the village know what to do. She added that they make medicine and blow it onto the affected area. I asked what kind of medicine and she disturbed me once again - "same same Momma chew" Betel nut? I asked her to make sure that the Doctor took a good look at that area. I was suspicious that Peelwat had what is often commonly referred to, in accurately, as "Blood Poisoning". The actual condition is "Bacteremia", bacterial infection of the blood. The Doctor had not arrived at the ward by Noon when I left. The Doctor had been delayed because of so many adult patients in the other building. Duang called the Village to arrange for one of the older villagers to be brought to the hospital to treat Peelawat. When Duang returned home she informed me that the Doctor had not seen Peelawat but he had authorized more antibiotics for Peelawat. She also told me that a man from the village had visited and given Peelawat the first of his three "treatments"

Duang returned to the hospital the next morning to help her daughter to care for Peelawat. Her daughter and son-in-law had spent two mostly sleepless nights at the hospital. The good news was that Peelawat was feeling better. He had been chasing the same stray cat out the ward that I had chased the night before. The hospital has several stray cats that have run of most of the facilities. The cats eat the uneaten food off of the metal trays that are placed at the end of the corridor awaiting pick up at some time. I suspect that the cat's diet is also supplemented by rodents since I have not seen any around.

At 5:30 P.M. I returned to the hospital with Duang's son and his girl friend. As we pulled into the parking lot we saw a very good sight - Peelawat and Duang were sitting outside waiting for us. Peelawat had a shunt installed in his hand but other than that he looked excellent. His fever was gone and he had his energy back. He enjoyed having his photograph taken and had to see each picture on the camera's monitor after it was taken. He eagerly displayed his "Big Smile" more like a soundless lion's roar when asked.

We went back upstairs to the ward and let Peelawat play on the outside balcony. Peelawat still was pointing to the exit and now that he was mobile, he often took off for the stairway to leave the facilities. Peelawat amused himself by playing with the various shoes placed outside the doorway to the ward. Peelawat kept himself busy by trying on the various shoes. He wore mens as well as women's shoes irregardless of their size. He was very adapt at ensuring that he selected matching shoes. Later he started to play with a bed table that was stored on the balcony. He amused himself turning the crank on the table and pulling as well as pushing the table along the corridor. After awhile he indicated to me that he wanted to get on top of the table. Being a somewhat indulgent grandfather and somewhat bored, I placed him on the table. Peelawat lay on his stomach and had such a big smile as I pushed him down the corridor that I decided to share his pleasure with Duang. I wheeled him into the ward and quickly discovered that the nurses were not amused. Duang scolded me and Peelawat and I went back outside. We limited ourselves to the simple pleasure of sitting in a chair and kicking our feet back and forth while learning the English words for parts of our face.

After awhile, Duang's son returned from Tahsang Village with one of the village elders to give Peelawat his second treatment. The man had a small plastic bag with a green leaf, slices of Betel Nut, and some wood chips. He placed the items into a small brass mortar and ground them together with a small brass pestle. He sat next to Peelawat on a concrete bench on the outside balcony. Peelawat was not afraid at all and sat patiently next to the man. The man, a spiritual leader, chewed the ground up concoction and soon had a mouth full of red liquid. He examined Peelawat's infected leg, said some chants, and sprayed the red liquid on the infected portion of his leg three times. Peelawat observed the ritual with interest. The man also placed his hand on Peelawat's head and said some chants before blow air three times on the top of the head. Peelawat then pointed to a scab on his other leg to the shaman and said "Nee" (here). Somehow Peelawat inherently understood what the shaman was doing and he was pointing out to him another one of his injuries for special treatment. We all had a good laugh. Having been informed by Duang that Peelawat had received more intravenous antibotics at 6:00 P.M. and that the Doctor had scraped the skin on his leg while putting some medicine on it, I was not opposed to the traditional treatment.

After the man completed treating Peelawat, Peelawat thanked him by giving him a wai, the Thai gesture of respect which is similar to the Western prayer gesture. We left the hospital at 9:00 P.M. much relieved that Peelwat is well on his way to recovery. Peelawat will be released today from the hospital once the doctor has checked him.

Once again the differences between health care in Isaan and health care in the USA had been made very apparent. Here in Isaan health care is much more of a community effort. Family members as well as friends or neighbors are heavily involved in caring for the sick. The play on the old African proverb ("It takes a village to raise a child") - "It takes a village to cure a child" is not too far from the truth - at least here in Isaan.


  1. Debra Elkins DickeyJune 24, 2010 at 9:51 PM

    Really interesting post!I'm glad that all turned out well for Peelawat, and the family must be very relieved. I was wondering why you hadn't posted lately.

    Have you considered submitting this to The Day, or something like it? It was a terrific article on medical care in other countries, and cultural differences toward illness. I was amazed at how involved male relatives are with the children in Thailand.

  2. Thanks Debra - Yes we are all relieved to have Peelawat well once again. He is back playing in Tahsang Village with Tay and Kwan.

    I'll have to look into getting greater distribution of the blogs.

    Lao Loum men are good fathers but not necessarily "good" husbands. Most have girlfriends or other "wives"