That was the problem that faced me as I sat in my clinic room at M’Lop Tapang in Cambodia today. An easy question for a Paediatric Emergency Medicine doctor you would think except not so easy to deal with here in Cambodia – especially as the child had, apparently, been blue for the last seven years.
With the loudest murmurs and most striking cardiac signs I have seen for the last 13 years, and with no access to any imaging or ultrasound machine in the clinic, I only had my clinical history and examination skills to rely on to make a diagnosis. The history was, as is common here, somewhat limited as the patient attended alone, with only the clinic and education teams to help provide the information that parent(s) usually would have done.
With a likely diagnosis of Tetralogy of Fallot, the most difficult task of the day was to work out what supportive treatment can be given in Cambodia when if the same child had presented in the UK the diagnosis would have been very likely picked up antenatally on scans or, if not, very soon after birth and certainly not seven years later. The main treatment for this condition is cardiac surgery soon after birth, or in infancy, depending on the scale of the cardiac lesion.
I was thankful that M’Lop Tapang have a dedicated and empathetic health and social care team who can support this child (photo not shown to protect confidentiality) and their family from now on. The surgery that would have been carried out in the UK is simply not available here. I don’t think I need to go into detail here about what that means for this particular child in the future except to say that there are a very large number of acute and chronic conditions in childhood with a mortality rate here significantly higher than in the UK and for the children with very serious life limiting conditions one of the most important interventions is working out who can have treatment and for whom a supportive and palliative management plan is more appropriate or the only possible course of action.
The clinical team are superb to work with here at M’Lop Tapang. Efficiently run and spotlessly clean there has been a stream of patients queuing at the door to be seen today. Some were acute unselected cases and some were specifically brought back for me to review or provide a second opinion on:
Smiles all round during a consultation in clinic in Cambodia
It has been immensely satisfying to see a group of patients today who I last saw in May 2015. The intensive management plans that were put into place for the children with developmental delay have had striking results in under six months. From being unable to sit unsupported at the age of five years, one child can now weightbear and take a few steps with support. From having no head control and severe hypotonic at the age of eight years, another child can now sit by herself without support with independent head control. These amazing results, and a whole file of others, would not have been possible without intensive work from the Special Needs Team and Medical Team under the watchful eye of the Medical Team Manager – an Advanced Nurse Practitioner from Cambodia whom the University of Salford has recognised with the award of an Honorary Lecturer appointment.
The new guidelines for the management of acute and chronic asthma are going really well and will be further enhanced by the generous donation of some volumatic spacers by the Director of Nursing of our new charity, SicKids.
Senior Nurse Ra with one of the donated Volumatic Spacers
Work hasn’t stopped now the clinic is over; I’ve just had a quick dinner in the training restaurant and as soon as I’ve finished this update I’ve got to write some referral letters for the children I’ve seen in the clinic today who will need to travel up to the capital, Phnom Penh, or even further up to Siem Reap, for tertiary management of their conditions.
Except I won’t be able to do that until the lights come back on as we’ve just had a power cut and I’m now sat in complete darkness, with only my back-lit keyboard for light, waiting to see if the back-up generator kicks in. If not it will be a long evening…!
So for now, I’ll say រាត្រីសួស្តី.