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					Medical/Health Presentation
Health care values compared
       “Ours”                                                “Others”
Make it better                                         Accept with grace
Control over nature                                    Balance/Harmony with
Do something                                             nature
Intervene now                                          Wait and See
Strong Measures                                        Cautious Deliberation
Plan Ahead-Recent is                                   Gentle Approach
   better                                              Take life as it comes-
Standardize-treat                                        ”time honored”
   everyone the same                                   Individualize-recognize
http://hr.healthcare.ucla.edu/Download/Cultural%20Di
      versity%20and%20Health%20Care.ppt                  differences
Values continued…
Money               Group orientation
Privacy             Surrounded by family
Independence          and friends
Individualism       Defers decision making
                      to group
                    Expects others to take
                      total care of them
                      during sick phase.



www.ggalanti.com
        Community Profiles
Chinese                Hmong
Many will avoid saying ”No”      Many have not had formal
  because they consider it          education, so careful
  impolite.                         explanation on what is
Food, illness, and meds are         happening is important.
  classified, according to the   Traditional belief is that ill
  perceived effects on the          health may be the result
  body-“hot”/”cold”                 of the soul wandering
Many take on a sick role,           from the body and unable
  when ill or pregnant, in          to find its way home.
  which they depend heavily      A soul calling ceremony may
  on others for assistance.         be required to cure the
                                    sick person.

                                 http://www.health.qld.gov.au/multicultural/health_workers
                                       /cultdiver_guide.asp
           Interesting to
          ponder… The
       following world
        views and their
  impact on health care.
          Rationalism Empiricism
Existentialism Postmodernism
Healthcare in Thailand-Strengths
• Competent-Many of the doctors have
  studied abroad
• Doctors’ English generally good
• Inexpensive by Western standards
• Attentive
• Relatively quick
    Thailand is at the
 moment becoming a
destination for health
          treatment -
    http://www.thaiwebsites.com/
                  healthcare.asp
 Healthcare in Thailand-some challenges
1) “There is no established primary
health care system”
 • “Doctors in Thailand are mostly specialists,
   so you will not find a good reliable all
   around physician at the corner of your
   street for your minor ailments.”
 • Dr. Greer, Family Medicine MD
   13th floor Sriphat 9 – 12 M,W,F
   053-946700 (English speaking)
Doctors practicing family medicine
• Dr. Kriengsak, Pediatrics
  Kriengsak clinic, on Changkran Rd.
  cell phone 089-554-1624

• Dr. Sharin, people use as family practice
  but his speciality is cardiology.
  Sharin/Savitri clinic - close to DK bookstore
  on East outside moat road.
2) “Most Thai doctors working in
hospitals do not do so fulltime”
• “Physicians and surgeons have working schedules
  in different hospitals and go from one place to
  another to do their clinics and perform medical
  procedures (like surgery).”
• “Besides working in hospitals, they are also likely
  to have a private clinic somewhere. They work
  long hours, often into the evening.”
• “Another result is that you will not see your doctor
  that often while you stay in the hospital, and he or
  she will turn up at unusual hours, after doing his
  clinics (at various places).”
 3) “There are no adequate emergency
 transport facilities.”

• “Very few hospitals run a good
  emergency service. You will have to
  get to the emergency room by
  yourself if possible.”
• “Cars do not even give way easily, if
  you happen to be transported by an
  ambulance.”
   4) “Money is very important”
• “Fortunately, most Westerners will have
  obligatory insurance, or will be assumed to
  have a medical insurance.”
• “Still, you better have the cash or credit card
  ready, or at least pertinent medical insurance
  documents.”
• It is advisable during a hospital stay to inquire
  about your bill so that you can verify charges
  and know how much money you will need to
  pay when released.
      5) Language Issues
• “While some of the well known hospitals clearly have a
  policy of catering to foreigners, and Thailand is actually
  promoting itself as a place to go for reasonably priced
  medical treatment, this remains an important issue.”
• “When you have to communicate properly, because you
  are incapacitated and need to be moved around in a
  certain way, it is very difficult to have things done
  properly, because most of the nursing staff has only
  basic English command.”
• “Even communicating with doctors can be a drag,
  possibly also because they are 'busy', and do not really
  take a lot of time to have a little chat with their
  patients.”
    6)”Pitfalls of being assertive:”
• “Possibly because you are a foreigner, the staff
  tends to take your objections and opinions too
  much into account. That is, if you do not want a
  certain medicine for whatever reason, they will
  not give it to you. You can almost bargain the
  whole time how you want to be treated. This
  attitude is not always beneficial to the patient.”
• “The staff at Thai hospitals may just give in to
  your wishes, just because you are a foreigner,
  and they apparently want to please you this
  way. Medically speaking, this is not always
  optimal.”
7) “Over-prescribing”
• “Whereas doctors in the West will only prescribe
  the medications you cannot obtain over the
  counter, doctors in Thailand will prescribe
  everything you might need, including Tylenol,
  Ibuprofen and antacids. If you don’t ask about
  the prescription before going to the cashier you
  will find yourself with several medications you
  probably already own.”
• Ask the doctor the names and reasons for the
  drugs. Some people end up taking too much
  paracetamol or other anti inflammatory meds
  because they didn’t know the pill was already a
  part of their pills prescribed by the doctor.
8. “Tendency to have limited nursing staff and
reliance on family assistance for patients.”

• “It is very common for Thai patients, and
  also apparently for Middle Eastern patients,
  to have one or more family members stay
  overnight to help out.”
• “If necessary, services are available to hire
  a nurse for the night (at a high fee) and the
  hospital can probably arrange for that.”
9. Medical Reports
• “Some major hospitals are computerized
  and have reports available showing your
  history at that hospital but many are not.”
• “Overall written health reports are rare
  because the Thai system doesn’t utilize a
  primary health system with a family doctor
  or general practice MD.”
• Keep detailed records yourself and ask for
  copies from different doctors so that you
  can have some health history available for
  doctors who ask for it.
Tips on going to the doctor
• Ask friends for recommendations
• Educate yourself before going
   – CDC.org, WebMD, Mayo Clinic website,
     wrongdiagnosis.com, drugs.com
• Don’t be afraid to ask questions. If you find
  the doctor seems unwilling or frustrated with
  your questions – go somewhere else.
• Be sure to get full information on
  prescriptions: when to take it, how long to
  take it, how many times per day, how many
  milligrams, side effects, etc.
Tips on going to the pharmacy
• Many medicines are over the counter here.
• If you have a routine prescription med from
  home, write the name (generic), dosage and
  number of pills, etc that you need on a piece of
  paper and give it to the person at the pharmacy.
• Dara Pharmacy across from Dara School and
  down from McCormick Hospital is
  recommended.
• Almost all chain pharmacies have pharmacists
  who speak English and are helpful. Prices vary
  and are generally more expensive in the
  hospitals.
• Most of the time, writing down what you want
  whether medicine or equipment will result in
  getting the item more quickly.
Chiangmai Ram 1
Chiangmai Ram 1
• Chiangmai Ram 1 is located right next to
  Central on the moat.
• Many chose this hospital for quick care of
  minor emergencies i.e. stitches, x-rays for
  possible broken bones, etc.
• In-house dental clinic, lab, MRI, X-ray &
  Pharmacy
• User-friendly
• Centrally located
Chiangmai Ram 1 - Shortcomings
• Not all the doctors at CM Ram are the best,
  though most are competent
• Tends to be on the higher end of cost
• Doctors are quick to admit and prescribe
Seeking medical care at CMR1

• DO NOT go to the Emergency Department
  unless it is a true emergency.
• Check in before seeking the doctor or clinic
• Registration staff will direct you to the
  proper specialty.
• 053-262-200
Registration
Klaimor Hospital
• The closest hospital to Grace Int’l School
• Klaimor Hospital has a convenient clinic for
  obtaining health certificates
• People report dried blood and lack of
  cleanliness in general.
Sriphat Hospital:
Special Medical Service Center
•   Where most CM Univ. professors practice
•   13th floor clinic 8am-8pm 053-946-905
•   Car park several blocks down from hospital
•   Head nurse of Mother/Baby unit at Sriphat
    is Australian trained and is very supportive
    of breastfeeding.
McCormick Hospital

•   The hospital that many Thais use
•   Quite cheap, yet has a decent reputation
•   Quite busy, you may find yourself waiting
•   Some unpleasant reports from patients
•   The place to use if you’re very short on cash
Lanna Hospital
• Birth packages about 10% more than Ram1
• Most foreigners who use this hospital go for
  Dr. Udom, an OB.
Pediatrics
• Dr. Sompong at Pediatric Expertise
  – Monday/Thursday evenings from 5-8
  – Saturday/Sunday 9-12
  – Does consulting at CM Ram 1

• Dr. Watcharee at Pediatric Expertise
  – Works out of Suan Dok/Sriphat
  – Monday/Wednesday evenings from 5-8
  – Saturday/Sunday 9-12
OB/Gyn
• Dr. Supreeya
• Located at a row of hongtaews on the
  Superhighway just before Airport Plaza
  and at Kullapant Clinic not far from Lanna
  Polytech college
• M-W-F 5:30-7:30/Thurs 5:30-7:30
• Practices at Sriphat and at CM Ram 1
Dr. Udom
• Practices everyday at Lanna Hospital
• Lack of accountability structures
• Low-tech/questions about ultrasound
  trustworthiness
• Lanna is not the place to go for any
  complications
• Some have reported that nurses speak
  limited English or not at all
Orthopedics
•   Dr. Sudhee
•   Very experienced
•   Excellent surgeon
•   Private Clinic – 053-214-139
•   M, T, Th 5 pm/ Sundays 9 am
Dermatology



• Ram – Dr. Wachiraporn, 4th floor

• Sirphat – pediatric dermatologist available
Other specialties at CM Ram 1
•   Ophthalmology       •   Rheumatology
•   Allergy & Chest     •   Ped. Cardiology
•   Cardiology          •   Ped. Endocrinology
•   Dermatology         •   Ped. Hematology
•   Endocrinology       •   Neonatology
•   Gastroenterology    •   Ped. Nephrology
•   Hematology          •   Neurosurgery
•   Nephrology          •   Surgery
•   Neurology           •   Plastic Surgery
•   Internal Medicine   •   Urology
  Special Medical Service Center
  • Faculty of Medicine CMU
  • 053-946-905

•Pediatric Allergy     •Ped. Orthopedics
•Infectious Diseases   •Ped. Pulmonology
•Cardiology            •Colorectal Surgery
•Dermatology           •Ped. Surgery
•Chest/Heart Surgery   •Neonatology
•Ped. Dermatology
For a JCIA hospital…




         Bumrungrad Hospital, Bangkok
             www.bumrungrad.com
      A handful of BKK hospitals have JCIA.
Vaccinations
• Be up-to-date on all the usual vaccines
• For information visit
  http://www.cdc.gov/nip/recs/child-
  schedule.htm#Printable
• The CDC website also has numerous fact
  sheets about individual vaccinations
Vaccine schedule
Typhoid: inj–every 3 yrs; oral-every 5 yrs
Hep A: booster may be needed
Hep B: booster may be needed
Tetnus: every 10 years
MMR: You should have had a booster in your
  teens
Japanese Encephalitis: up to 4 shots/2 shots
Rabies: every time bitten by a unvaccinated*
  dog/cat, some shots are given.
Special Vaccines for Thailand

• http://www.cdc.gov/travel/
seasia.htm#vaccines
Hepatitis A
• Transmission of hepatitis A virus can occur
  through direct person-to-person contact;
  through exposure to contaminated water,
  ice, or shellfish harvested in contaminated
  water; or from fruits, vegetables, or other
  foods that are eaten uncooked and that
  were contaminated during harvesting or
  subsequent handling.
– Highly recommended
Hepatitis B
• Hepatitis B vaccine is now recommended for all
  infants. It is recommended for all people living in
  Asia.
• Hepatitis B is endemic in Southeast Asia and many
  are carriers and have no idea that they can
  spread it.
• The virus is virulent and can last at least 7 days in
  dried blood or body discharges.
• Some people require boosters to keep immunity.
  Check blood tests – Anti-HBs
– highly recommended
Japanese Encephalitis
• This is a routine immunization for people
  who live in Chiang Mai.
• A series of 3 shots with a possible 4th
  booster; it is available in most clinics and at
  the hospitals.
• A new 2 shot series is available now.
• Sriphat is reported to have less expensive
  vaccines (4 shot series) than Ram.
Typhoid
• Typhoid fever can be contracted through
  contaminated drinking water or food, or by
  eating food or drinking beverages that have been
  handled by a person who is infected. Large
  outbreaks are most often related to fecal
  contamination of water supplies or foods sold by
  street vendors.
• Oral pills (5 yrs) are available from McCormick.
• The injection (2-3 yrs) is available at most
  hospitals.
Rabies
• If you might have extensive unprotected
  outdoor exposure in rural areas, such as
  might occur during camping, hiking, or
  bicycling, or engaging in certain
  occupational activities.
• If you can get to a hospital within 1 hour of
  being bitten, there is no need for a rabies
  vaccine.
Malaria
• Resistant forms of malaria exist along the
  borders with Laos and Burma.
• Malaria prophylaxis offers little or no
  protection in these areas.
• Malaria is not a problem in Chiang Mai.
         Unique
Health Problems
      Leptospirosis & Schistosomias

• Usually caught by wading or swimming in fresh
  water. The latter is carried by water snails and
  the former is transferred by the urine of wild &
  domesticated animals. If you have to wade
  through water, wearing boots will prevent these
  diseases.
• Leptospirosis can also be transferred through soil
  because of pets. Pets should be vaccinated. This
  has been on the rise in Thailand.
TB
• TB is endemic here and will continue to be a
  problem because of the number of people
  with HIV/AIDS.
• It is recommended that you have a yearly
  skin test to catch and treat latent infections
  which can cause many serious problems.
• Dr. Kriengsak will do testing. PPD skin tests
  are not part of routine care for most Thais.
Dengue Fever

• Dengue Fever is transmitted by the bite of a
  day biting mosquito.
• Only Tylenol/paracetamol should be used
  for Dengue pain relief so use Tylenol for
  fevers of unknown cause.
• The number of people with Dengue
  dramatically increased this past rainy
  season throughout Asia.
Trichinosis
• This is a parasite you get from
  inadequately cooked pork.
• Pork should not be pink when you eat it.
• Chiang Mai has the highest number of cases
  in all of Thailand!
Another parasite…
• Pinworms
• Spread through dirt primarily from pets, etc but
  also through sheets, shared bath water, bath
  towels, blankets, etc.
• S/S: Difficulty sleeping, huge appetite, girls:
  bladder control problems, itching around anal
  area.
• Mebendazole – for children 2 years and up.
  Use no more than 2 x’s/yr. 100 mg followed by
  100mg 2 weeks later. Only available in
  200/400 mg tablets here.
• Benedryl is useful to help the child and the
  worms sleep. Thick diaper ointment or vaseline
  can also help relieve the itching.
          And other
general health topics
Lead Poisoning

• Due to pottery glazes or the lack thereof
• Ask about FDA approval for export.
Heat Stroke/Exhaustion
• Take it easy – this is the tropics!
• Drink lots of fluids. If you feel like you are
  dehydrated drink electrolyte fluid-readily
  available everywhere.
• Stay out of the sun, or at least wear a hat. The
  sun is the most dangerous from 10 – 4pm.
• If you succumb to heatstroke, you may have
  trouble with heat in the future.
• Macular Degeneration is very common now –
  wear approved eye protection.
The SUN!
• Use sunscreen, protective clothing, hats, and
  sunglasses to protect yourself against the effects
  of the tropical sun!
• Latest research seems to show that sunscreen
  doesn’t protect against melanoma. Clothes with
  dense fibers are the best protection.
• If a person has a blistering sunburn before the
  age of 19, their risk of skin cancer is dramatically
  increased.
• You can even get burned while under a shade
  tree here in Asia if you are fair skinned.
Dog Bites
• No leash laws mean that dogs roam free and are
  very territorial.
• You may want to take a stick/doggy treats with
  you when walking out of your “territory”.
• If you are bitten, try to contact the owner to find
  out if the dog has been vaccinated against rabies.
  *3 -5% of Thai dogs vaccinated still get rabies!
• Each time bitten, you will have to have some
  rabies shots.
Cuts & Scratches
• Cuts, scratches, and bug bites tend to be
  more easily infected here in Thailand.
• Wash immediately with drinking water and
  soap. Use betadine for puncture wounds.
• Apply antibiotic cream/ointment
• Have deep wounds stitched
• Cat bites/scratches almost always need to
  be treated with oral antibiotics.
Cuts and Scratches cont.
• Peroxide should not be used because it prevents
  the white blood cells from coming to the wound.
• Stitches are recommended for facial wounds
  after they have been cleaned thoroughly.
• A puncture wound, minor foot and hand
  wounds, and wounds with care delayed
  beyond 12 hours, cat/human bite wounds, and
  wounds of people with compromised immune
  systems should not be stitched because of
  infection problems.
• Deep wounds which involve tendons, joints,
  deep layers or blood vessels should be stitched
  by a plastic surgeon.
• Remember always use drinking water/sterile
  water to wash or soak a wound in.
Food & Water
• Food is generally clean
• Always drink bottled or filtered water – several
  companies provide water delivery
• Market veggies tend to be high on pesticides
• Imboom vegetables are reputed to be organic –
  Khun Jantip 053-823-223
• Doi Kam veggies are available at most grocery
  stores.
• Meat from Northern Farm products thought to be
  the best.
• Mango allergy possible if allergic to poison
  oak/ivy
Case Studies
Case Study #1


Jane was riding on a motorcycle with her
  friend and accidentally touched the tail
  pipe. She has a large burn on her right
  calf.
Treatment
• Immediately put in cold water for 15 min.
  for 1st and 2nd degree burns. (If a large portion of a
  person is burned do not put in water.) Or apply cold
  compresses or towels. Use large quantities of drinking
  water to cool the area.
• Take off the clothes, jewelry, etc on or around the
  wound. (If clothes are burned on the skin, do not
  remove. Take immediately to the hospital.)
• Apply antibiotic cream or burn ointment with a nonstick
  sterile gauze dressing. Do not apply ointment if you
  have a large burn and need to go to the doctor.
• Daily clean the area with drinking water and mild liquid
  soap; apply cold compresses several times/day to
  relieve pain; do not break the blister; cover with a non
  stick sterile dressing.
• Healing takes between 3-6 days(1st) to 2-3 weeks(2nd)
Burns cont.
• Make sure that you are up-to-date on Td
• Do not apply butter, oil, ice or ice water on the
  burn.
• Check the burn every day for signs of infection,
  such as increased pain, redness, swelling or pus.
  Draw around the outer edge of the redness with a
  permanent pen to help you distinguish if the
  redness is spreading from day to day. Go to the
  doctor if any of the above symptoms occur.
• Dermazin crèam has been recommended for burns
  here.
Case Study #2

 Your child was swinging and fell off the
 swing. She hit her head and is crying.
 You are able to calm her but now she
 appears to be dazed and not her normal
 self.
Treatment
The following require immediate medical care if they occur after a
   head injury.
    –   Loss of consciousness, confusion, or drowsiness
    –   Low breathing rate or drop in blood pressure
    –   Convulsions
    –   Fracture in the skull or face, facial bruising, swelling at the site of the
        injury, or scalp wound
    –   Fluid drainage from nose, mouth, or ears (may be clear or bloody)
    –   Severe headache
    –   Initial improvement followed by worsening symptoms
    –   Irritability (especially in children), personality changes, or unusual
        behavior
    –   Restlessness, clumsiness, lack of coordination
    –   Slurred speech or blurred vision
    –   Inability to move one or more limbs
    –   Stiff neck or vomiting
    –   Pupil changes
    –   Inability to hear, see, taste, or smell
Treatment cont…
• Apply ice to area for 20 min every 2-3 hrs.
• Watch for signs of a serious head injury.
• If a child throws up more than once, continues
  to “act abnormal”, complain of a severe
  headache, or have any of the problems listed in
  the previous slide – Take to the hospital.
• If a child starts to go about normal activities but
  wants to sleep – wake every 3 hours and ask
  questions.
• Paracetamol/tylenol are fine to give a child with
  a headache. Do not give aspirin.
Case Study #3

 Ken has climbed a ladder to pick a
 papaya from the tree. The ladder
 collapses and he falls to the ground on
 his back – about 5 feet.
Treatment
• Ask if they are okay and if they hurt anywhere.
• If they are conscious and respond to you, allow
  them to move if they want to but monitor them
  closely and give them assistance.
• If they cannot move on their own: Stabilize
  their body by holding their head and neck in
  line with their body. Move as you would a log
  only if necessary for safety. Call for help.
• Look for any signs of bleeding or broken bones
  after you have made sure they are conscious
  and breathing. Stabilize a broken limb with a
  splint. Elevate a bleeding limb and apply
  pressure with a clean bandage or cloth.
Case Study #4

 Andrew, 5 years, has a fever and
 vomiting and diarrhea for the past few
 days. He will only drink liquids and lays
 around on the couch most of the day with
 naps throughout the day. He vomits
 almost any liquid a few minutes after he
 drinks it.
Treatment
• High Fevers (102/38.89 – 105/40.56) cause dehydration
  in a small child quickly. Treat with paracetamol/tylenol
  10 – 15 mg/kg of body weight every 4 hours. Use tepid
  baths and cool compresses.
• Diarrhea: more than 7 stools/day in a child/adult. If
  diarrhea is bloody, has mucus or pus, or is foul
  smelling, go to the doctor. Provide sports drinks –
  watered down or other forms of electrolytes to replace
  the loss.
• Vomiting: Use ice chips for chewing on. Keep trying to
  take small amounts of watered down electrolytes or
  sports drinks. If a child wants to eat, allow them to eat
  what they are hungry for but also encourage toast,
  pretzels, crackers, clear soup, rice, etc to help their
  stomach adjust.
• The behavior is normal for a child with these
  symptoms– but must be monitored carefully because
  dehydration can occur quickly in a small child.
Treatment
Diarrhea in adults without fever; blood, mucus or
  pus in their stool can be treated with immodium
  for up to 3 days.
Pepto bismal is also useful. It has been reported
  to have an antibiotic property which helps kill
  the problem bug. This shouldn’t be used in
  those under 18 years of age because of Reye’s
  syndrome.
Lactobacillus after a case of diarrhea may help
  your body restore the normal bacterial flora of
  your gut. Active culture yogurt is available at
  Rim Ping and the pills are available at most
  pharmacies.
Case Study #5
 Juanita is returning late at night after
 teaching an evening class for new parents.
 One of the class participants is catching a
 ride home with her. As they come around a
 curve in the middle of the canal road,
 Juanita has to swerve to miss a motorbike
 crashed in the middle of the road. The
 road has few lights but the lady with her
 said that she saw a body on the right side
 of the road. The road is quiet and no one
 else seems to be around.
      Some things to think about…
• Be prepared if you want to be able to stop and help people.
  Gloves, etc to protect against blood and body discharges are
  vital.
• Be aware that if you stop and help, you could be blamed for the
  problem and held liable for the costs. Sometimes the police just
  take your driver’s license while they work on it. Remember our
  cultural understanding of justice is much different than what is
  practiced here.
• If there are other people there and available vehicles, most
  likely your help is not needed.
• If you do plan to stop, park your car where it is obviously not a
  part of the wreck. But still be prepared to defend yourself in
  case someone starts blaming you.
• Always have on your person, emergency phone numbers of those
  who can help you or of people that could be called if you
  yourself are in an emergency. We don’t always have our cell
  phones, etc but we should always have some sort of ID and
  numbers so that people can be reached in times of emergency.

				
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