Hola Desde Chile!

Perlita and I arrived in Santiago, Chile safely and are currently staying in our hostel located in the central part of downtown in Providencia. When we arrived to our hostel, we were immediately welcomed by a friendly staff member who helped us carry our luggage up to our bedroom. It is a quaint and small bedroom, but in this 90 degree weather, the humidity can be somewhat uncomfortable.

We decided to unpack partially, have dinner, and explore the surrounding area a little more. It wasn’t in our best interest to go out at night. Many places were closed and there weren’t too many people walking in the neighboring streets. Before we met with our preceptor, we had the opportunity to sight see. There were many old and historical buildings that are preserved in downtown. We are walking distance to the metro station which is very convenient to get to and from the Instituo de Nutricion y Tecnologia de los Alimentos (INTA) where we will be conducting our research. Our nearest metro station is located in the city’s main plaza called Plazas de Armas. The plaza used to be the center for political and cultural activities and is still bustling with a wide range of people. There are public concerts, comedians, preachers, chess players, and artists. We even got to see the national dance of Chile called, the “Cueca” in the Plaza de Armas.


Today, we had our first meeting with our preceptor, Dr. Camila Corvalan at INTA. Her colleague, Dr. Maria Luisa, introduced herself while Dr. Corvalan was in a meeting with the Director of INTA. Dr. Maria Luisa is also a physician who studies and researches chronic diseases such as obesity, cancer, and cardiovascular diseases. Much of their work involves working with the low-middle income population and collecting quantitative data. For the purpose of our research, we are collaborating with the Chilean Ministry of Health (MINSAL) to provide technical support for implementing the new law that regulates the publicity and labeling of foods. The law basically states that any food that contains high sodium and/or fat content will have warning messages on its food packages. They have decided not to follow the UK system’s concept of traffic color coding. For example, green represents a healthy food choice while red represents an unhealthy one. Instead, we will be developing another alternative that alerts and helps consumers distinguish between healthy and unhealthy food products through warning messages. Since, there’s not enough evidence to suggest these alternatives, Perlita and I will be collecting data through focus groups.

In our focus group, we want to understand how people, particularly mothers, understand nutritional labeling by checking, reading, interpreting it; and whether they find this useful. The second part of the focus group will be dedicated towards displaying these warning messages to our participants. Since a majority of food publicity is focused on low-middle income families, Dr. Corvalan suggested that our focus groups should be based on our participant’s educational background. Once we find that our messages are appropriate and understood by the participants, we will present the findings to MINSAL and suggest the alternatives that were based on the feedback we obtained from our focus group discussion.

This week, we will be focusing on the logistics (i.e. contacting participants, development of warning messages) so that we can begin on Monday with the focus groups discussion. We will be meeting with an expert who has experience in marketing of foods and labeling. She will be providing recommendations of the messages that will be presented on the food packages. We will also be meeting with dieticians at the office.

We are excited to be part of this team and we look forward to the progression of our study!

Giving Thanks for an Amazing Trip

I've had some time to decompress after my trip from Cambodia and there's a lot of people that I wanted to give thanks to for making this trip happen.  These sorts of events don't happen in a vacuum and if it wasn't for the support that I got from everyone I know that my winter break would have been much less eventful.

Project Summary

I haven't talk about my project much. Therefore, I am going to write a summary about my whole experience in this blog.

What is my project about?

The incidence of infectious diseases occurs in many tourist destinations and is increasingly imported by tourists due to increase in global travel. For example, dengue disease is the most common arboviral (insect-borne) disease in travelers (Other than the fact that mosquito can carry diseases, they are the most annoying thing in Thailand too). However, with the lack of intervention and research focusing on tourists, the infection rate of dengue and infectious diseases among tourists remains high and is growing (A lot of people thought dengue is transmitted by food and water. Some people thought there is a vaccine against dengue). The purpose of this study is to assess the knowledge and behavior of tourists about disease and prevention. The study will be conducted through cross-sectional survey of tourists using one stage cluster sampling in the area of Ko Chang, Trat, Thailand, where dengue is endemic. Through Likert-scale, multiple-choice and open-ended questions, I will assess disease prevention knowledge, perceived disease susceptibility and severity, level of compliance, and the knowledge of dengue specific information, including, means of transmission, signs and symptoms, prevention methods and their level of compliance. I will attempt to survey 500 tourists that enter the island of Ko Chang with a milieu of tourists from various parts of the world. Inclusion criteria will be those who are over 18, speak English or Thai, mentally stable, and can give verbal consent. Those who are under 18, cannot understand English or Thai, mentally altered and are unable to give consent will be excluded (I ended up with 400+ surveys. I had to throw out 50+ surveys because it was not complete). The results of this study can potentially inform intervention strategies and health policy change for disease prevention among global travelers.

First day

I decided that recruiting people to complete a survey is not my favorite thing to do. However, it is the majority of work for this project. Initially, I interviewed the participants one by one. The process was too slow. At this rate, I would not finish the project on time. Also, the rejections was a bit of a shock for me. I realized that not everybody would complete the survey. I also know that I will get reject. Regardless, to get reject in a row was a sad situation. Later on, I learned to let go and did not take the rejection personally.

Later days

Later on, I developed a recruiting technique. The technique was a success. I finished 500 surveys as expected. Basically, I would pass the survey out before tourists walked into the boat (I asked for their consent first. Or else, it wouldn't pass the IRB, right?) Then I would give them incentive when they finished the survey (I walked around the ferry to collect the survey).

It was easier to survey people on their way back from the island than on their way to the island. My theory is that they are less excited about leaving. Therefore, they tend to have more time to complete the survey.

Something to keep in mind/interesting facts

- There are a lot of Russian tourists. However, they came in a big group and refused to speak English. Therefore, I could not get enough representatives from this group. To my surprise, they could speak perfect English when they hit on a girl(Maybe life is not so bad for global health women after all.) In order for the tour guide to identify the russians apart, they put a little round sticker on their shirt, which was also how I tell them apart. I would spend less time recruiting this group of people (i would first ask them if they speak English.)

- In the questionnaire design, I overlooked repeated traveler. They usually get vaccination for their previous trips. Therefore, for this particular trip, they do not get any vaccination. Something to keep in mind for my other project.

- I pre-tested the questionnaire with 10 people from the state before I came to Thailand. However, I realized now that pre-testing with the exact population I will be working with is important. Not only for questionnaire improvement but also for the recruiting technique. There are a few questions I would change, but it was too late to resubmit the IRB. So I decided to stick to the original questionnaire.

- Data input was a pain. Initially, I wanted to use iPad as a survey tool. So I wouldn't have to input the data by hand. However, the program was expensive. With iPad, I can only survey 1 person at a time. It would be impossible to complete 500 surveys in that amount of time. Therefore, I decided to go with a traditional (paper) method. (Also, the iPad survey program is extremely expensive.) Someone please develop a student version!! After inputting all the data, I have to recheck them again because there were a few errors....must be from looking at too many numbers for too long. Next time, I will hire someone to do it.....

To sum it up - - -

Ko Chang is not as underdeveloped as I expect it to be. However, Ko Chang is facing bigger problems many tourist destinations face in second and third world countries. The development is going up too fast without a good plan. There is no affordable clinic on the island, no sewage system, no clean water for the public, no trash management system, and no development plan. I think the whole island need to act quickly on these issues before this tropical paradise turns into another one of those ugly tourist spot in Thailand. I truly want to stay longer and work on those issues but my time here is up. I have to pack and get ready for my flight.

See you back in California...

Decoding in Chile

This is my first blog post for my project on the ¨Medical Analysis of the Chilean National Forensic Database from an Emergency Medicine Perspective.¨ Actually, this is my first blog post ever, so hopefully it´s good! First, I´m going to give a brief introduction on the project. Then I will describe the 10th revision of the International Classification of Disease (ICD-10) and its importance in my project.

The Chilean doctors involved in this project work at the Pontificial University Catholic University of Chile.









My research project is a descriptive study on mortality rates due to injuries in Greater Santiago using the Chilean National Forensic Database from 1997 till 2010. Over the past couple months I´ve been working with Emergency Medicine physicians from USC, Dr. William Mallon, and the Pontifical Catholic University of Chile (PUC), Dr. Pablo Aguilera, Dr. Oscar Navea, and Dr. Marcela Garrido, to develop the project. The database includes the external cause (motor vehicle, gunshot, poisoning, etc.); the victim´s age, gender, and alcohol level; the nature of the injury (fracture of skull, third degree burn of hand, traumatic pneumothorax, etc.), the commune of the victim´s residence and the commune where the incident occurred (commune is an administrative division--it is comparable to a county); the origin of the victim´s body (hospital, street, jail, etc.); and the date of the incident. Essentially, we are looking to create a statistical description of deaths in Santiago of who, when, where, and why. It may not seem like we are looking at a lot, but we are looking at nearly 25000 victims in the database.




Marcela (left) and Pablo (right) in the office after our first meeting in Chile.






The sections on external cause and nature of injury (in our case death--all the entries in the forensic database are mortalities) are coded using the 10th revision of the International Classification of Disease (ICD-10). More specifically, the external cause of injury is coded using Chapter 20 of ICD-10 and the nature of injury is coded using Chapter 19. The dataset we are using has 850 unique codes for external cause and 500 codes for the nature of injury (however, we are not interested in the nature of injury for this study). These codes are used to facilitate the comparison of disease statistics between different countries. As I already mentioned, I´m only interested in one chapter of ICD-10: chapter 20. The codes used in this chapter are broken down into several groups including: transport accidents (car accidents, airplane crashes, etc.), other types of accidents (Falls, poisoning, etc.), intentional self-harm, assault, legal intervention and operations of war, complications of medical and surgical care, and a few others. This database only includes codes from the first 4 groups. These groups are further broken down based on the type of transport accident, the type of non-transport accident, and the method of self-harm or assault.

Pablo (left) and Osacr (right) with another doctor (middle) at the private Catholic Hospital. Oscar is my current host in Chile.

To give you a better idea of what information is included in the ICD-10 codes, and what I am doing for this research project, I´m going to take a few sample ICD-10 codes and decode them. Lets start with V03.12. The main code is ¨V03¨ while ¨12¨ is a subdivision. The ¨V¨ tells us that this was a transport accident. The other letters used in Chapter 20 include W, X, and Y. Our dataset only includes V´s and X´s (X´s can be used for non-transport accidents, intentional-self harm, and assault). For transport accidents, the first number also helps group the accidents: 0 refers to pedestrian victims, 1 refers to pedal cyclists, 2 refers to motorcyclists, etc. So, what does ¨V03¨ mean? It means that the victim was a pedestrian injured in a collision with a car, pick-up truck, or van.

Christmas Eve with David Acuña, a emergency medicine resident at PUC. I stayed with David´s family for my first week in Santiago.

Now you may remember what that the code was V03.12, so what about the .12? As I said before, the numbers following the decimal place are subdivisions (NOTE: from what I understand different countries and different sources can present the subdivision characters differently. They can present them following a decimal place, or they can present them separately). For transport accidents, the meaning of the first subdivision number varies depending on the first three characters (in this case V03). In our example, V03, the ¨1¨ means that it was a traffic accident (a ¨0¨ refers to non-traffic accidents while a ¨9¨ means that it was not specified if the accident was traffic or non-traffic). Let´s say that our code was V44.12. The first three characters, V44, refers to a car occupant injured in a collision with a heavy vehicle or bus. In this case, the fourth character, ¨1¨, indicates that the occupant was a passenger injured in a non-traffic accident. For all types of injures other than traffic accidents, the fourth character refers to the place of occurrence, which I´ll address later in our next example.

Finally, we have the 5th character. Remember our code is V03.12. Fortunately, the fifth character is the same for all types of injuries. It is the activity code and it tells us what the victim was doing when they were injured. A ¨2¨ means that the victim was injured while working for income (other codes include ¨0¨ for sports, ¨1¨ for leisure, etc.). So, in conclusion, V03.12 means that that victim was a pedestrian injured in a traffic accident involving a collision with a car, pick-up truck, or van while working for income.





New Year´s Day at parque los dominicos.




Let´s try one more code (because I know you are enjoying this so much). This time the code is X45.51. The X45 indicates that the victim suffered accidental poisoning by exposure to alcohol (it includes ethanol and other types). Meanwhile, the fourth character ¨5¨ means that the poisoning occurred in a trade or service area, such as an airport, restaurant, or supermarket. Finally, the fifth character ¨1¨ tells us that the accidental poisoning occurred during leisure activity.

Now if you are still awake, and if you enjoyed learning about disease coding, you can learn more about it at the WHO website, which includes an online version of ICD-10 and an online training program. http://www.who.int/classifications/icd/en/

A view of Santiago from Santa Lucia Hill with two emergency medicine residents: Catalina (left) and Valeria (right).

Wrapping up Cambodia

Happy New Year to everybody!  It's quickly approaching the end of my last full day in Cambodia and I must admit that I'm sad to be leaving so soon.  There's so much left to see and do in this country, but most importantly, there's so much that can still be done at Sihanouk Hospital.  Christian and I plan to keep working with the hospital in the future and we're really optimistic for the future.

Happy New Year!

Happy New Year!

It is finally 2012. It also means, the winter break is almost over.

WORK: I finally collected enough surveys (450 - my original goal was 300) from tourists. Majority of the tourists can speak English. They are mostly Eu

ropean from Sweden, Russia, Denmark, and the UK. I came to a conclusion that American prefers Bangkok civilization over this island (Ko Chang). I have to thank many people for helping me out with this project, without them I do not think I will be able to complete my project on time.

PLAY: I believe in "work hard, play hard" motto. Therefore, on Dec 31st and Jan 1st, I went out!

The picture above was taken during my snorkeling trip. The water was so clear and warm. Something I can never get in SoCal. I also fed sea monkeys (picture below/not the type that we grow in a jar of water).

Finishing touches

I finally had a chance to upload some pictures from my camera. So let's begin.

The first image is a glimpse of our "office" while at the hospital. We found a nice, breezy, thatched-roof loft on one of the buildings. The hallway connects to the hospital administration staff and the staircase leads right into the laboratory. Space in the laboratory was limited and so we managed to stay mobile wherever the work needed us to be.





The next two pictures showcase our work gear. We used a large role of butcher paper and post-its to track out progress. This helped us present information to our project team members versus having to use too many words--language was a slight barrier still. And since there was no shortage of work to be done, this helped us stay focus.


















I wish I could write more, but our driver is waiting for us as I wrap up this blog. Enjoy!