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WHA Day 4 - "Sayar" means Doctor & Teacher

Today we went to the clinic in Naung Shwe, Shan state. Like the day before, hundreds of patients were waiting for our arrival in the bare courtyard of red dirt with a few trees. I thought I saw a Plumeria tree in full bloom? A group of women in lovely traditional costumes and colorful headpieces was lining up to greet us.

I once again had my own room as I needed an exam bed to do pelvis exam. I was assigned two nurses and an interpreter. From the window of my exam, I could see the little courtyard where a dog was resting lazily by a door. An elderly man with severe osteoporosis was going back and forth with a water bucket in his hand. It seems as if people of all ages have to work here, doing their part of the labor to sustain their livelihood.

Shortly after the clinic started, a 31 year old woman in a turmeric yellow dress entered my office with the chief complaint of edema in her extremities . She looked a little lethargic like most of the patients here, as if the hot sun has sucked up most of their energy. I had never seen such swollen feet! The edema uniformly extended throughout her lower extremities and it looked as if her knees and ankles had become a wide piece of shiny, dark ivory wood. " do you have a headache?" I asked her as the interpreter looked on, she rubbed her forehead and nodded . Her skin was fairly dark and with the only dim light coming from the small window, I couldn't decide if I saw edema on her face or around her eyes. Peri orbital edema is not a good sign in pregnancy.I immediately asked the nurse to check her blood pressure. It's not automatic here that the vital signs and urinalysis are checked by nurses

Her blood pressure was 150/110!

We didn't have a way to check her urine for protein so I sent her to Dr. Sophie Richard area for an U/A. It was 3+. She has severe preeclampsia! She needed to be delivered immediately! According to her expectant due date, she was to be 32 weeks. Her uterus, however, measured only 24 cm. She most likely had severe preeclampsia with growth restriction, a very serious condition in high risk obstetrics.

Her baby's heart rate was normal and strong. How could I have told her to enjoy that moment, that it probably was the first and the last time for her to hear her first baby's heart beats? The border of life and death in this area of Myanmar probably is very narrow. The NICU here probably won't be able to save this precious life.

"She needs to go to the hospital now to have an emergency cesarean section! " I told the interpreter. As we Americans would call it, the ball started rolling, with multiple people started hollering in Burmese and the clinic doctor in charge loudly explained the situation to the patient. She started crying quietly . There was an exchange of more words and more hollering before the medical officer, my interpreter, explained to me how the patient wanted to wait for her family. Don't we all want to wait for our family? Who want to be alone witnessing the birth and death of our first child?

Another interesting case was a 47 year old patient with cervicitis (cervical inflammation) resulted in a total abdominal hysterectomy and removal of both ovaries several years ago, a totally unnecessary procedure for her. What would I have done with her cervicitis? Probably nothing except for yearly Pap smear. How did the surgeon explain why she needed the procedure? There is no good follow up and he can't be sure if her cervix would get worse in the future. You gotta do what you gotta do in a limited environment! In a big city, her uterus and ovaries might have been saved.

This patient now has an increase risk for heart and bone diseases as her estrogen was cut off early. She was in the clinic for hot flashes. I told her how to relieve her hot flashes in the natural way. She was instructed to exercise frequently to reduce her risk of heart disease.

Another good day for me today as I was able to see all who showed up for me while the medical team had to turn away quite a few patients at the end of the day. I did have to skip lunch but had a trail mixed bar I brought from home. I gave a bar each to my interpreter and the two nurses who were examining them carefully and spoke to each other . They were examining every thing I brought in from the plastic speculum to my fetal Doppler to my Castile soap hand wipes.

The medical officer, my interpreter, was listening to how I counseled our patients so closely that by the end of the day, she was able to show the patients how to do Kegel's exercise or what kind of diet they should follow during pregnancy. Knowledge is a powerful and necessary tool for progress.

The most funny moment I had in the clinic was when I was teaching a patient with neck pain and lower back pain how to exercise her neck and lower back, as the nurses, interpreter and 4 women from the NGO were watching us. As I squatted down to show how she should pick up a heavy object, everybody was squatting down with me including the NGO ladies. As I was doing my neck exercises, all necks in the room were rotating left and right . It could have been a Hollywood moment!

Among the most simple but important teaching points was to cough into one's elbow or sleeve instead of one's hand. The nurse mimicked my motion as she spoke in Burmese to instruct the patient, before she herself had to cough and you probably have guessed how she was coughing? Oh well, it's not easy to break an old habit ! Maybe next time…

-Dr. Thu Tran, Obstetrician

Patients are My Teachers

In Burmese, the word "sayar" means doctor and teacher. In medicine, my patients are my best teachers. The people in Myanmar whom we are serving has reminded me that presence and human connections are the foundation of healing.

On this mission, I'm part of the Primary Care team along with two talented Canadian doctors and a Physician Assistant. While in the remote Naung Shwe area of Shan State, many of my patients, mostly women are farmers. Due to years of hard labor under unforgiving tropical sun, my patients appear several decades older than their stated biological age. They frequently present with several years history of back and/or shoulders pain. After a normal musculoskeletal exam, I reassured them that their pain is related to their occupation and taught them proper lifting procedures and instructed them on basic stretching exercises. Although a very simple encounter, inevitably, my patients, would beam with joy at my assessment and "prescription" and would reach for my hands to hold theirs and bow "kyay zuu tin par dawe" (thank you)! Similar to my patients back home in the U.S., my patients in Myanmar appreciate presence and connections with their doctors.

In medicine, we learn about human physiology and body mechanics from textbooks and professors. But patients are our best teachers for they remind us that true healing begins with connection of the hearts. I look forward to another day of learning from my favorite "sayar" patients.

(on a side note: Dr. Huynh also leads a yoga class for the team at 5am to help us mentally and physically prepare for the day)

-Dr. Mylene Huynh, MD Family Medicine

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