Little, tiny, baby steps...

Louise came to visit last weekend. She had spent 2 weeks in her village - the only barang - and as she works in health to, with the same delightful challenges, she was in need of some respite. So we pledged to have 48 hours of not being volunteers, it went something like this.

Louise arrives and hires a bicycle that actual moves forwards when you peddle. This was a fascinating insight for a us & confirmed our fears that VSO bicycles are in deed completely crap. We then cycled to the Gecko Cafe - Louise in one rotation of her peddles, Katie and I madly peddling away just to propel ourselves an inch forward.

Now the Gecko cafe is set on 1st floor level in a typical french colonial building where you sit out to eat on the veranda. The food is good but as meals are $4-6 us VSO-ers/Battambangers would never dream of going there - far too expensive. But this weekend we WERE NOT volunteers so we tucked into a 3 course meal.

Then off to the market to get our nails done before cocktails at Maddison's. There was a 'beach party' theme weekend which involved a lot of sand on the floor and deck chairs. There was a paddling pool where you could magnetic fish and have a 'lucky dip' prize. The staff there were insistent that I go for mickey mouse which after intense concentration and lack of any natural manual dexterity (I blame the cervical cord compression) I managed to hook mickey mouse AKA a free beer - the top prize - bless the staff for failing to understand the basis principle of a lucky dip.

The day was finished off in Battambang's one and only indian restaurant - it opened last month to much excitement but with the average meal costing $5+ its another no go area to volunteers. The food is fabulous and very authentic so thank god we weren't volunteers for this weekend. Although Katie did save half her meal to take home and have the next day which is a bit volunteer-esque.

The following day we were too full to eat breakfast and spent the morning on my veranda drinking coffee and talking about the joys of volunteering in health, capacity building in a developing country. So this was being a volunteer but as its completely necessary to de-brief and share experiences this one is allowed.

Then it was off to the pool at the Khemera hotel - which we had virtually to ourselves - and half a day of complete relaxation and minimal swimming. Then for some reason I got it into my head that what we needed was a hot stone massage, after all Cambodia isn't really hot enough already. I am not exaggerating when I say that it was quite simply the most terrifying, painful and 'hot' massage I have EVER had. Facebook friends will have seen the photo of the burn over my right scapula as a result of the 'really quite hot' stones. The masseuses could barely hold the stones, doing a comedy hot potato routine each time they picked one up, you could feel the radiant heat from the flannel they used from over 1 metre away - I exaggerate not! Still we rationalized this is what non-volunteers do- right?

Burnt, crippled and a little scarred for life we headed to the Bambu Hotel for happy hour, check it out (http://www.bambuhotel.com), it is where my sister, brother-in-law and nieces will be staying for Christmas this year & because they are kind, lovely and generous people, so will I. It turned out to be a happy 4 hours with free cocktails from the manager (it pays to hang out with two beautiful young women!) and as we were not volunteers for the night and were a little bit intoxicated we actual found ourselves declining free drinks from the guests who were offering.

Payment of the bill involved scrapping together every last 100 riel note to make the total after Lou assured us she had enough money to lend us before realising she had spent most of it. We then weaved our way home on our bikes, laughing hysterically at the fact that Katie paid $3.75 for chips and felt glad about it, the 5 cocktails clearly having no effect on our sense of humour or ability to cycle straight.

Packing Lou on the early Siem Reap bus early the next day, feeling the burden of monday morning, I had no idea how therapeutic the last 48 hours would prove to be.

I have started charting my mood on a website called moodscope, I heard about it on a podcast & thought it would be an interesting exercise to undertake whilst volunteering. Surprisingly first thing on Monday morning I reached an all time low of 40% but as the week went on it crept up until it was 75% by Friday.  Two main factors I think have contributed to this - the first is of course the un-volunteer weekend, this was a turbo charged morale boost. The second however is much more subtle and is the little, tiny, baby steps that have been made this week in work.

It is hard to explain but they include Dr L agreeing for me to use a case from his ward to teach URC staff to do a proper M&M (morbidity & mortality review), I quote "If it's for you, of course" - for me anything!

Another example was sitting preparing for the paediatric M&M on the paediatric ward & me suggesting perhaps rather than me & the other two NGO workers sat in one room writing a presentation whilst the two paediatricians sit huddled defensively around the notes of the M&M case in next room, we could all sit together. Then followed an hour of open & productive discussion; as I sat watching the only two paediatric doctors for the second largest hospital in Cambodia there seemed to be something strangely familiar about them. They both looked tired, harassed, wrinkles of concerned etched to their foreheads, large black rings of disturbed sleep under their eyes and their shoulders sagging a little. Dr M told me about his failed attempt to resuscitate the malnourished 21 month old with TB meningitis he would be presenting at the M&M, he had tears in his eyes. Then it hit me - they looked like most of the doctors I worked with in the NHS. These guys care, they work bloody hard, they come in on their days off to check up on their patients and significantly they are well supported by three separate NGOs, capacity building really can work.

My personal highlight of the week involved sitting in on the first meeting between maternity & paediatrics. Currently paediatricians don't attend any deliveries and their is little communication between the 2 departments. Unsurprisingly neonatal mortality rates (NMR) are high in Cambodia. But there I sat in a meeting watching the first lines of communication being made. J & I were the only barangs and we were staying out of things but I had a burning question I had to ask, "What is your neonatal mortality rate here?". They didn't know the answer. I suggested that if they knew what it was they could then have a baseline from which to measure the effectiveness of all the interventions they had been discussing for the last 2 hours, hell there could even be a publication in it for them. I thought this comment had been disregarded but 30 minutes later Dr M told me they were still discussing NMR data and how this could be used to monitor interventions. But the important thing was it was no longer my idea, they had taken ownership of it, it was now their idea and they were going to act on it (hopefully). Little, tiny, baby steps.

Bloody Hot Stone Massage burn

Beautiful Nails - works of art

What a difference a day makes.

24 hours after the shocking start to the week I was having meetings with chief of ward, head of ITU medicine, head nurse and then deputy directors and finally the hospital director. The common theme is "slowly, slowly", "be patient' and "this is Cambodia - that won't work here". In fact my favourite quote is from the Director who told me "I'm not sure VSO is any good here, you have no money, you can't buy us equipment, you are no use." A motivational speech if ever I've heard one.
So with herculean strength I am attempting patience, smiling through gritted teeth and trying not to take each patients death as a personal insult and, hardest of all to achieve, my responsibility.
48 hours after the shocking Monday, Gary & I went to the ward to find a strange and beautiful sight. The bays were single sex, the nursing staff were out of the back room, leaving their embroidery behind, to supervise the student nurses. The chief of ward was proudly spraying ICU on to two new oxygen cylinder holders and the observation charts had all been filled out for that day. The last one really threw me, I've been so used to observation charts (which also act as drug charts here) not being up to date that I was asking why drugs hadn't been given until Gary pointed out that the charts had todays date on them.
A new patient had been admitted overnight with a diagnosis of hypocalcaemia - its a common default diagnosis which drives me a little crazy - so I thought I'd have a chat (via VA) to the patient, to find out what had led the admitting doctor to come up with this over used diagnosis.
The man had been getting chest pain if he did too much lifting for a while, he'd had a transient loss of vision in his right eye 3 months ago, he had left leg weakness the week before and then 2 days previously he had collapsed and been breathless and sick with upper abdominal pain. He lives 60 km away from the Hospital and the local health centre couldn't help, so the local community had had a whip round for a taxi fare and after a day he was able to get a taxi. He was still complaining of epigastric pain and some pleuritic chest pain and breathless on exertion. His observation chart showed he was bradycardic (slow pulse). He smoked heavily, was an ex-drinker and his father had died of a stroke.
Bloods on admission had been done but were limited to white blood cell count only from the FBC, Haemoglobin is rarely done - maybe because everyone is anaemic so they think why bother.  His triglyceride had been requested and was elevated and he didn't have hepatitis B or C.
Now perhaps even the non-medical readers among you will be thinking - "hmm- this is sounding very cardiovascular", well I certainly was so I began searching the notes for an ECG (heart tracing). There was to my surprise an ECG but it had creatively been stapled into the back of the notes in such a way that it was completely impossible to read. It had been triple folded with the ECG facing in and then double stapled under a sheet of blood test results.
To the horror and irritation of the nursing staff I completely dissembled the notes to get to the mystery ECG. It was worth my troubles. The ECG was a perfect example of an inferior myocardial infarction. Unless hypocalcaemia is a code word for heart attack I suggested to the staff that they revise the diagnosis.
Then it happened; Dr L asked me what medications I thought we should start this man on?!!! Little old me - VSO medical advisor - was being asked for advice.
Gingerly, aware that rejection could just be around the corner, I suggested Aspirin, a ß-blocker, ACE inhibitor & a statin, and blow me down they only went and prescribed it. So perhaps, I suggested, we could use this patient for a case review to revise how to manage ischaemic heart disease? Steady on Est, don't run before you can walk. Remember the advice "slowly, slowly", "be patient", and "this is Cambodia - that won't work here."
I'm off to do my deep breathing exercises and positive affirmations - its been a very long week.

Sharing of skills being actively resisted, changing lives (but not in a good way)...

VSO's tag line is "sharing skills, changing lives" but the title of this blog reveals a more realistic interpretation after todays events.
In my 2 and a half months working in a hospital I Cambodia I have had to let a lot of things slide not just for my mental health but also because Rome wasn't built in a day (I am told) and hence I was pretty clear from all our training that the changes (if any) will be small and like a glaciers their progress often imperceptible.
Now you will all, I'm sure, remember the maternal death blog and if not then I'll remind you that from the moment I walked into the room I knew there was nothing I could do for that poor 23 year old woman who had already gone past the point of no return. It still smarts.
However today I had a whole new experience of a 21 year old girl being sent home by the doctors to die despite my attempts to persuade them to treat her with antibiotics, this one hurt like hell.
So, I rock up to the ICU medicine ward for the ward round today as normal and in the corridor is a young girl surrounding by family and looking very unwell. It shames me to write it but I have got so used to seeing patients suffering that although I noticed her I didn't stop to find out more.
Her emaciated and unconscious form did however prompt me to ask the duty doctor what was the matter with her. He started to tell me that she had previously had a moto accident and serious head injury. She had been treated initially at the NGO emergency hospital but as she had a brain haemorrhage that needed neurosurgery her family had paid for her to be transferred to Vietnam for a evacuation of the clot and then she had required a VP shunt (a tube going from her brain to her abdomen) after she developed hydrocephalus (build up of pressure in the brain).
Duty doc didn't get too far with the history though as I noticed that a group of 6 student nurses were gathered around the girl performing what I can only describe as a half hearted attempt at CPR. Half hearted mainly due to the fact that they are 1st year students in their 2nd week of training and as most of the senior nurses and doctors in Cambodia are not ALS trained I'm pretty sure the same goes for student nurses.
I disengaged myself from the history to walk over to her and asked the nurses what they were doing. Now to try and be positive about the situation (believe me this is a monumental struggle currently) the students had obviously recognized that the girl was a very sick patient which I'm sure you will agree is a start. However I had to point out to them that she had 'signs of life' (i.e blinking, swallowing, moving her limbs), breathing and had a strong radial pulse so CPR on this occasion was not indicated. I congratulated them on recognizing that a respiratory rate of 6/min is a bit slow and then all via my VA (volunteers assistant) Chan, I explained to them that what is normally more appropriate when someone has a breathing problem is to give oxygen, support breathing with a bag valve mask and generally avoid cardiac massage when they do in fact have a cracking pulse.
How effective I was at getting this message across I will never know because at this point the duty doc (slightly miffed at me walking off halfway through his presentation of the patient) had arrived to see what was all the fuss the barang was making.
At this point it was becoming increasingly clear to me that the likely diagnosis for this patient was an infected +/- blocked shunt which would explain her coming in 6 hours earlier fitting with a fever of 40ºC. It also started to become clearer that at least some of her respiratory depression was due to the whacking dose of IV Diazepam she had been given (wasted and malnourished after 4 months of illness she must only weight 40kg) to stop her fitting.
I noticed that she hadn't been given any antibiotics, strange as all patients will get an IV with fluids and often antibiotics whether they need them or not.
When I asked the duty doc what the 'plan' was I was told that there was no 'plan'. I then had to explain to my VA that there is ALWAYS a 'plan' even if the plan is palliation. So I asked again what the management plan was for this patient and received the same answer - THERE IS NO PLAN.
I then had a 15 minute conversation where I explained to the duty doc that 21 year olds didn't have febrile convulsions (the current working diagnosis although written on her chart was hypocalcaemia!) and in this particular patients case her pyrexia and reduced level of consciousness was much more likely to be due to an infected+/- blocked shunt. It was a tough gig but I finally persuaded him to do some blood cultures (a new shiny innovation at the hospital and a luxury only enjoyed by 4 hospitals in the whole of Cambodia) and start some IV antibiotics. Just when I thought I was getting somewhere the head of ward rocked up and slipped passed me hoping like a small child that if he didn't get eye contact with me I wouldn't see him.
Regardless I joined him on the ward round and when he finally gets to the sickest patient in the ward he turns to me and says "you intubate her" I am omitting the '?' because it really was more of a demand than request. I explained to him that as they have no ventilator, no trained staff, no resources, no experience of managing intubated patients and had yet to decide on a definitive 'plan' for this patient that I didn't feel intubation was currently appropriate. Dr L - "But her breathing is only 6 a minute". Me "Yes she has had a huge dose of diazepam which is a respiratory depressant". Dr L "You Intubate her!". Me "err, no! But I can certainly bag her whilst you decide with the family if they can afford for her to be transferred to a neurosurgical ICU in Phnom Penh or Vietnam?"
Then he went up to the mother - red-blotchy faced from 4 months of worry and distress - and told her that her daughter was a lost cause and she should take her home to die as there was nothing he would do for her here.
The family's neighbour (a midwife) followed him into the staff room, imploring him to keep her there, to give her antibiotics to see if she would respond to treatment. He refused her request. I explained that the least we could do was give her IV antibiotics for her shunt infection - the same response.
I went to talk to the family, the patient's mother grabbed my hands and thanked me in Khmer for trying to help her daughter, she was sobbing and raw and at this point I could have joined her.
Often on the ward I will suggest something and it is rejected but if I go back a few hours later it has been done - it is all about saving face. So when I went back after lunchtime I was fully hoping to see a bag of Ceftriaxone dripping into her and a chance for the diazepam to be metabolized given.
Not so, her bed was empty. The only nurse I could find (asleep in the staff room) informed me "p'tair" - she had been taken home.
I can't even begin to describe how impotent and frustrated and angry and guilty and sick to the very pit of my stomach I feel about this whole episode.
A patient had laid on a bed in the corridor for 6 hours without a 'plan', I had tried to advocate for a 'plan' that was within the limits of the resource poor setting we were in, and it feels to me that because I thought it was inappropriate to intubate her she was then sent home with one 'plan' - to die without even being given some paracetamol for her fever.

Welcome back to Cambodia

I am actually very glad to be back in Cambodia after my short medical visit to Thailand. It was great to walk across the border at Poipet into the dust bowl of this wild west border town where tumble weed wouldn't be out of place. Within seconds of having my passport stamped the attempts to extort money from me had begun.
Scam 1) moto driver asks me where I'm going then tells me that the bus is about to leave so I mustn't wait for the free bus station shuttle but must pay him 2000 reil to take me there immediately.
Scam 2) at bus station I am told that it will cost me $10 to catch a bus back to Battambang. The moto driver 'helpfully' buys me the ticket. Me "but it says here on this ticket that the price is only 12000 reil?" 'helpful' moto driver "where? Really? Oh? You not tourist? Oh? You pay me commission?!!!" we finally settled on a 50 cent commission mainly because by this time I'd lost the will to argue & thought he deserved something for trying! I did however drag him over to the bus & in Khmer confirm with them that it was a valid ticket and told 'helpful' moto driver that I did not trust him.
Scam 3) small child selling coke tried to charge me 12000 reil for a can of coke. After extensive questioning to see if he meant baht or thought I needed a crate of coke or perhaps I'd miss heard him we established that he to was just trying it on. "com kow kngyom" is a handy phrase here thats literal meaning is "don't shave me", it seemed relevant at this point in the conversation to throw it in.
So when the hospital director came out to greet me on my first day back at work with a big smile and hands in the air calling out to me "Esther - how are you?", I thought - how lovely to be welcomed and wanted. On some further introspection I've come to the conclusion he probably just wanted some cash!
I hope to collect my laptop up this weekend from Phnom Penh so if all goes to plan the short iphone blogs will soon be a thing of the past - fingers crossed.

No sitting, no Spitting

When the hotel dog is playing with a dead rat in the foyer,the excitement of AC shopping malls has lost it's shine, and the sleaze has started to not automatically turn your stomach, you know it's time to head back to the developing east.....safe in the knowledge that I have medical evidence that I am biologically old.