Outreach Clinics

I can't believe it's only the second day! This morning we were both at the hospital clinic, I did a few fillings and the beginning of a root canal treatment to start with, and Jessye had all the extractions. I was then trying to help Bora decide what dose of diazepam should be used for oral sedation in children, as he had never used it before....so after introducing him to the bnf online, which said diazepam should not be used for Dental treatment on kids, we decided another drug should be used. I find it interesting that they are so confident using materials and drugs that they have never/rarely used. As the dentists here say: 'no choice' - they have to use what they've got to help the kids.

I had the most horrific experience with my next patient: a scared little four year old boy. He was whimpering as he got put in the chair, but I really felt like the bad guy in a horror movie when giving him local anaesthetic...he shrieked and screamed and balled his eyes out, thrashing his body about like he was in pain, but it was just because he didn't want the treatment. It was horrible. I almost cried. But the tooth just needed to come out as quickly as possible. And after it did, he was fine (although probably traumatised for life) A LOT of the children at the hospital are like that every day :-(

The afternoon was more pleasant, I went on outreach to a school about an hours drive away from the hospital. It was exactly what I had imagined a third world outreach programme to be like- the dental team (Dr Naren, two dental nurses and me) set up a clinic in a dark dingy classroom. We had one portable dental chair which Dr Naren and I used, and the nurses used a couple of school desks for their makeshift dental unit. (Dental nurses do everything the dentists do here.) There were no lights in the classroom, so a handheld torch provided our tiny glimmer of light. They do have enough clean instruments to use for each patient which was good to see!
School children who are in pain come to the outreach clinic, the nurse then quickly examines them and confirms which teeth need extracting, we then rattled through the patients (18 altogether today) within an hour. I feel much more confident with extractions from outreach alone. These kids are much more cooperative than at the hospital and don't cry so much, because they actually want the treatment, to get out of pain. In fact when the last patient was told to get up and leave because they were being uncooperative and not accepting an injection, they immediately lay back down and opened their mouth as they really wanted the teeth out.

They are then all given a toothbrush and toothpaste. The kids were all really sweet and liked having their photos taken....watch this space  for uploaded photos coming soon...

First day

Wow, what a day! It has been non-stop. From getting up a little later than we should have, eating breakfast on the tuk-tuk to the hospital, having a guided tour of the hospital (and it is VERY different from anything I've seen in the west!). We expected to be shadowing the dentists at the dental clinic for the first week, before being allowed to do any treatment. But after watching the first patient, we were thrown into the deep end, and I ended up with 4 extractions on my first child. I was very fortunate that this child was cooperative and did not scream or cry, which seemed to be the general background music to the clinic throughout the day. Here, it is the norm for the parent to hold the child's hands and body down by pretty much lying on top of them, and an assistant to restrain the child's head. This is so the child cannot wriggle about ferociously (which is what they tend to do - and they are very strong!) and therefore needle sticks and other injuries can be prevented. I didn't see a single child who didn't need an extraction, there are a lot of rotten teeth over here.....and they don't take pre-op X-rays, which is different from BDH, who advocate an X-ray for every extraction! Their X-ray developing room is in the toilet!

The dental surgery

Treatment is very fast moving and the clinic sees a lot of kids in one day, there are four dental chairs altogether but only three were really in full time use. There are two dentists, Dr Naren and Bora. Bora has recently graduated and has been working at the hospital for one year, I was working with him today. We are supervised by a dentist at all times, and they nurse for us, which is really nice of them-they must enjoy teaching, and they are very good at it. He also asked me some questions he genuinely didn't know, for example if fluoride completely arrests caries or if the caries would recur, at first I thought he was testing  me but it turned out he actually didn't know. He was also concerned about using Duraphat which had expired and asked for our advice-they don't have a choice though, as the materials they use are donated so what they do have, they must make use of, if it would benefit the child. Obviously if it was something like LA, they would know not to use it if out of date, but fluoride varnish would probably just be less effective as opposed to harmful.

Infection control is a bit different too, they do have separate bins for clinical and domestic waste and sharps. But they sterilise and reuse their burs, only wipe down the hand pieces between patients, and use old clothes rags and disinfectant spray to wipe down the dental unit.

So after a long hot working day, we chilled in the pool for a bit with a piña colada, before going into town for dinner - I'm keen to try new foods so had some fresh spring rolls and a banana leaf salad (which tasted lovely - very fragrant!)

Quite tired now though, so off to bed for an early start tomorrow morning!

We've arrived!

Sua s'day! After a door to door journey of just over 24hours, we've finally arrived in Cambodia! We're staying in a lovely little family run guesthouse - the owner and his wife are very friendly, Jessye knows them from previous visits to Cambodia which is nice. He was telling us how Doctors in Vietnam don't talk to patients and sometimes give patients the wrong drugs and injections, as they mix things up!! (Eg his father, who's not diabetic, had someone's insulin injection, and the diabetic had to miss that days injection!) We told him we'd get struck off for that in England, and he hopes one day that strategy would reach south east asia, but for now they can't complain.....treatment isn't free for them and they are grateful for any help.
Jessye's mum is also staying in siem reap, which is lovely, so we visited her hotel and had dinner by the pool. We then walked around the night street markets and had a pedicure for a dollar.....
We start work at 8am this morning for an orientation guide of the hospital. Normally clinics start at 7am, so apparently this is a lie-in!! So jet lagged last night, we both slept well and it was nice to lie down in a bed, as opposed to an airplane chair!!
Better get up and get to the hospital for a busy day ahead.......

Flight Day

It's not often I wake up at 6.30am without an alarm.....perhaps only on these occasions, when my body knows I have to be somewhere out of the ordinary. Our flight is this afternoon, Dad is giving us a lift to heathrow from Bristol. So it's an early start for all.
Yesterday was very busy, as well as having a full day at uni with back to back patients, we managed to aquire what seems like thousands of toothpaste samples from clinics at BDH, (probably nearer the hundreds mark ;-)) which is a bit of a relief as we were worried about turning up empty handed.
I spent ages unpacking-packing-unpacking-rearranging-packing-finding out I had packed all my clothes and had nothing to wear for today-repacking...last night until eventually settling on some sort of organised backpack! Just remember, all you need is your passport!!
Right-o see you in Cambodia!

Checked in

Only one day to go! We fly out to Cambodia tomorrow!!! It's come around so quickly and these last couple of weeks have been a manic fest of trying to arrange our travel itinerary and get last minute supplies. It would be a bit less stressful if we didn't have a full week of uni this week.....so much root canal treatment in three days that I've tried to get finished before I go away......and a full day of uni yet to come today too.
GSK haven't delivered their donations yet, despite us contacting them in good time. So we have to go race round the clinics at uni today to see if Bristol Dental Hospital (BDH) have anything to offer.
As for our travel plans, to cut a long story short, we are planning on visiting just one country afterwards and spending longer there, either Thailand or Malaysia. The problem we have with Malaysia is that we will be travelling during Ramadan so there's a high possibility that things will be shut down and travelling will be difficult. But we may just have to arrange our flights and things when we get to Cambodia.....
We checked in online last night but there's still lots of last minute packing to do....so better get on with today, and in a few patients time I hope to have a chance to get everything sorted(!)

Planning planning planning

The good thing is I managed to get the Hep A/Typhoid vaccination at my home Drs last week. The bad (and annoying) thing is that it's given me a stinking cold/flu, which just seems to be lingering and getting worse......

Anyway, today we managed to get a few things sorted for our elective - we contacted the airline and managed to get some extra luggage allowance for the supplies we're taking over for the hospital. GSK are very kindly donating some toothbrushes, toothpaste and mouthwash and in return want some photos of our elective. We've also contacted other companies such as Dentsply, 3M and Septodont to see if they can donate any equipment. AHC have a long wish list of supplies that they use on a high consumption basis, or which they find difficult to get hold of in Cambodia. As they are a non-governmental/charity organisation, they rely on the generosity of donations.
We also ordered our prescription of HIV PEP (post exposure prophylaxis) today. [Something which you need to take if you are exposed to HIV infected bodily fluids, for example through a needlestick injury]. Cambodia has the highest HIV infection rate in all of Asia (~2%). AHC is the only centre outside Phnom Penh which provides antiretroviral treatment for Cambodian children with HIV/AIDS. So AHC really is a valuable centre for all Cambodians.

We also started planning our travel itinery for after our elective. At the moment, we want to visit the islands off of Southern Thailand's Gulf Coast: Ko Tao and Ko Pha Ngan in particular. I'm also really keen to see The Perhentian islands off the coast of Malaysia. <See google images> The trouble we're having is planning how to get there, as the FCO (foreign and commonwealth office) website advise against all but essential travel through parts of the the Thai-Malaysia border, due to terrorism. Which means we can't get the train to the part of Malaysia that we were hoping to. So we need another plan, maybe take the longer route around and then catch a bus? It's starting to look like 12 days isn't long at all to get from Siem Reap to Singapore and see some islands on the way!!

Lots more planning still needs to be done.....only just over two weeks to go!!

Intro to dental clinic protocol

Looks like the typhoid vaccination is popular at the moment: the student health service have run out! Hopefully I'll be able to get it at my family doctors when I go home....

But now for an update...we recently had an email from a paediatric Dentist (Dr. S) who's worked at AHC in the past. He's the key liaison with the dental volunteers and was telling us about the protocol for the dental clinic, as we only have a few weeks there so will need to get to grips with the way things are run pretty quickly.

The dental clinic has two dentists and three dental nurses. The dental nurses perform all procedures: injections, extractions, fillings, everything the dentist does! And apparently they are very good at it. This is a great example of how the Cambodians are utilizing the skills of all staff at AHC to provide decent dental treatment in large quantities for all the children who visit the hospital. (Over 600 children are treated in the dental clinic every month).

The guidelines for the dental clinic aim to make the best use of the volunteers' time to help the children in the most effective way. Dr. S has advised the staff to carry out quadrant dentistry (this is where you fix all the teeth in one particular 'quadrant' of the mouth at the same visit, as well as the problem tooth). The children who visit AHC often come in pain and have travelled for long distances to get there, missing a day of school/work. They most likely don't have enough money to keep coming back to the hospital, so the more work that can be done at their appointment, the better. Obviously this also depends on the cooperation of the child and how much treatment they can manage in one go. 

Some of the guidelines include: 

• take care of the adjacent tooth to the problem tooth, as this will already be numb....and it's better to treat it sooner, as you don't know what it'll be like in the future.
• extract all root tips even if they're in a different quadrant, as retained roots can deflect the eruption of permanent teeth and lead to crowding and periodontal problems.
• try to save the teeth by placing fillings, crowns or carrying out pulpotomies, instead of extracting as this then gives the kids teeth to chew with.

I've read a few accounts of students' dental elective experiences, and remember someone saying how they thought they were going to make a massive difference and change everyones lives etc, but found themselves disappointed afterwards as it was such an unreasonable expectation. This has stuck with me and I don't expect to have a HUGE impact but I do hope and pray that I'd make a small positive difference and that the children and the hospital would benefit from me volunteering there. 

As Dr. S puts it: ".....know that you have really helped the children of Cambodia. One tooth at a time. One mouth at a time. One child at a time."