Valuing health workers

Part of VSO's global strategy for health is valuing health workers. Recent research carried out by VSO in Cambodia found that health workers here say what most health workers around the world would probably say about their job.

It found that Cambodian health care workers go into health because they want to help people, someone was sick in their family & they thought if they were a doctor or a nurse they could have cured them, they want to be respected in society, they want high status & a secure income.

They complain that they don't get paid enough, they work too hard & have long antisocial hours, the patients & relatives are demanding & don't respect them. No one appreciates the good work they do.

If this study was from the UK, I could relate to the interviewees & agree with their complaints but here in Cambodia I find it very hard to match the findings of this survey with the reality of my observations at the hospital I volunteer in. The small hospital on the border I go to once a month perhaps does mirror this research but in my main placement - where I have spent the last 20 months, I can't make that correlation.

Discussing this research with the VSO volunteer who is writing the report resulted in a major epiphany for me - of course valuing health workers is important, in fact you could say if you don't value somebody how can you capacity build them. And I'm afraid I just don't value the health workers I work with.

A wise Cambodian NGO doctor once told me - If you want to change someone you must first change yourself. I think I have a lot of changing to do.

But before I try to work out how I can change for the last 4 months of my placement I think its only fair  for me to give an example of why I find it so hard to value health workers in the first place.

S was born at 32 weeks gestation weighing only 1.7kg. It is most probable that because staff told his parents that he wouldn't survive he was abandoned at the hospital on day 3 by his parents. J saw him in an incubator on the Friday (day 2) & asked why he wasn't being NG fed, this request was repeated by me on the following Monday & Tuesday. Although the official line the staff gave was that the baby could suck, I'm pretty sure that they have all had training by more than one NGO about nutrition in premature babies & knew he needed NG feeding. The reluctance to NG feed was much more likely due to laziness. Nurses in Cambodia don't nurse patients - that is what relatives are for. J also asked the staff if there was an NGO that could support this baby in the absence of his birth parents and was categorically told there were no NGOs that would take a baby so small.

S was losing weight, drowsy & dehydrated.

On Wednesday two paediatric nurses from New Zealand were being shown around the hospital by J when they noticed one of the twin babies next to S had stopped breathing. Trying to get anyone - trained nurse, student nurse or doctor - engaged in this twins care was near damn impossible. The kiwi nurses bagged & suctioned for over one hour. When I questioned the twins mother she told me that her baby had been having apnoeas (intermittently stops breathing) for 36 hours but the nursing staff had told her with twins one always dies & so they had neglected to treat him. He was septic & just needed oxygen, IV fluids & IV antibiotics - all available at this hospital. The reason we couldn't generate enthusiasm for his resuscitation was because the staff had already decided he was going to die.

I tried to explain that both the twin & S were curable - they both needed very simple interventions which the hospital was more than capable of providing. I'm always told that the reason care is poor is because of lack of resources but this was just another good example of the staff's attitude quite literally killing patients. I asked once more for an NG tube & feeding for S & if they could transfer the twin to an NGO hospital.

The twin was transferred later that day.

S remained hungry but did have an IV for fluid. Still no NG tube.

Thursday I tried to ask the duty staff why the baby didn't have a NG tube & I was told he didn't need it as he could suck. I asked to see his feeding chart & daily weights - proof of his ability to suck & adequate intake. The medical assistant shouted at me the baby could suck & said they had done daily weights but as they were normal they hadn't recorded them. To call this medical assistant a liar is too mild but lets try to keep it polite.

I was fuming, I don't mind the staff not caring or being lazy or ignorant but being lied to makes me angry.

The head of service got an earful & said he would speak to his staff.

Friday J asked if the baby could be transferred to an NGO hospital, the hospital director refused to talk to her (he could see her on Monday!) & the paeds ward staff refused to do so without his permission. J bought clothes, a mattress, bottles & a mosquito net for S and was told the staff would buy some formula from a whip round they had. Maybe things were improving after all. The staff even admitted to having never weighed the baby & when it was done found he had lost 200g. They put down an NG tube. They said he pulled it out - a baby too weak to suck had pulled out his NG feeding tube - forgive me for being cynical. It was never replaced.

Over the weekend other mothers tried to feed S but he is small, premature & cold (they had taken him out of the incubator in Friday - day 9) so physically couldn't take in the volume of milk he required.

On Monday (day 12) I went to attempt to see if they would transfer him to an NGO hospital where he would receive proper care. There was a woman with S who said she wanted adopt him & had been looking after him over the weekend. She had fed him one fluid ounce at a time, as often as he would take it. He hadn't put on weight but he wasn't dehydrated either. His IV had tissued & he had a big, angry red lump on the back of his hand - in danger of becoming infected.

I tried to talk to the staff about who was going to adopt S so I could advise them to take him to the children's hospital in Siem Reap. The staff said that the woman who wanted to adopt was too poor & had too many children already - she had 2 children & a job. I tried to explain that maybe they were talking about another women to me but I just got shouted at. Why don't I take the baby I was told. At this point it was rapidly becoming plan B. Plan A was for the staff to actually do their job.

S continued to starve.

Some investigation from R who was getting really fed up about J & mine insistence to try to get this baby fed, found out the birth parents had signed the necessary papers for adoption & it was just a matter of the couple that had signed the adoption papers to come to the hospital & take him - this was not the woman who had been caring for him all over weekend that I had spoken to.

I suggested he wasn't medically fit for discharge & if he left now he would most likely die - the staff scoffed. As long as it got rid of me & J nagging them they didn't care what happened to him.

Tuesday -  smaller, hungrier, lighter but S was hanging in there.

An upturned bottle full of formula milk was wedged between him & his sleeping form. R joked that not only could he suck but he would feed himself as well. Clever baby.

I got really upset by the whole situation & started seriously considering adopting him.

A young nurse took R to one side & gave him the phone number of an NGO that had agreed to take S a week ago but was waiting for him to get stronger. Of course the staff had probably lied to J when she asked if there was an organisation that could help. If they had told us it would have reduced their chances of getting money from us. Cynical but probably true. The young male nurse had taken pity on me & broken the code of silence. He probably will get into trouble for this.

I value one health worker in this story.

I rang the number & it turns out that the NGO, which usually provides homes for HIV positive children, had agreed to take him in. Of course they hadn't heard of VSO or URC being involved in S's care. They had named him, bought formula & were planning to take him when the doctors said they could.

I explained in no uncertain terms that the longer S stayed in this hospital the greater the chances of him dying of sepsis, malnutrition, dehydration & neglect. I said I thought he needed admission to a proper neonatal care unit, where he could be put back in to an incubator, NG fed & treated if he became septic.

That afternoon someone from the NGO came in to complete the paperwork & the next day he was taken to the NGO hospital in Siem Reap for a better chance of survival. They are hopeful that with just some very basic care he should survive.

I went back to the ward to ask why they hadn't told us before about the NGO adopting him, there were claims of ignorance all around. Then I started to try to broach the more general subject of feeding in premature babies. The head of service starting shouting at me - "if you cared so much then you should feed the baby yourself, that baby can suck, I SAY IT CAN. It is not my staff's responsibility to care for that baby. He is poor & has no parents. Who cares!?"

That's the head of Paediatrics at a CPA 3 hospital saying he doesn't care if a baby dies under his care because the baby's poor and confirming that he doesn't believe that caring & nursing a premature baby is his or his staff's responsibility.

One of the deputy directors talking to R about the situation explained that the staff in the hospital only treat patients with a good chance of survival & the rest are left to die, he didn't think this was ideal but then said he didn't care what happened with patients because he was retiring soon.

My Khmer teacher told me that in France & England she knows that we care for anyone regardless of their status, age or wealth. But in Cambodia one should only care for oneself & close family. She tells me it is just different - neither way is right or wrong. No money, no life. I've heard that before.

I thought all doctors took a hippocratic oath but it turns out obviously in Cambodia they don't. I can't bring myself to change my morality & ethics or to not view such blatant disregard for a new human life as wrong. Although I can do it intellectually, emotionally I still struggle to put these attitudes into the context of culture, recent history, poverty & corruption. This lack of care, this shocking neglect, this absence of any humanity, even after 20 months here, profoundly disturbs me.

And that is why currently I can't bring myself to value some health workers & why I must be failing to capacity build them too.

Cambodian exceptionalism

Visiting a friend in Washington a few years ago now I was first introduced to the concept of American exceptionalism. What I didn't realise is that this same concept can be applied to any country - including Cambodia.

What makes someone or a whole nation feel that they are exceptional? Imperialism, insecurity, positive affirmations, ignorance?

As previously blogged about before "This is Cambodia!" is a common response to any suggestion of deviation from the status quo.

The best example of this that I can think of is the time I was training a group of nurses about sepsis & what was considered an abnormal temperature. One of the parameters that can define Sepsis is a temperature above 38 ˚C or below 36˚C - the whole room shook their head in disagreement. They didn't consider these the normal parameters - Barangs I was told have a lower body temperature because they live an a cooler climate. I tried to explain the concept of homeostasis & homeotherms but Cambodians are different & have a higher temperature than other nationalities.

Another favourite is midwives will also tell you that Cambodian women's perineum is tougher & thicker than other nationalities so they all require episiotomy at all deliveries.

Cambodian doctors can't spend any time taking a history - it takes too long.

Cambodian nurses can't be expected to perform basic hygiene for patients - they are too busy.

etc. etc. etc........

The list of exceptions is a long one, after all - This is Cambodia!

A well needed break

I'd say this is the 2013 WPC shortlist but after another year of not even a special commendation for my entry, my hopes are not high.

Myanmar was beautiful though & below is a little taster of my well needed break......

Yangon - Shwedagon sunset

Irrawady view 

Irrawady Sunset

Bagon Temple

Restoration at Bagon Temple

Bagon sunset

Monk teacher at Golden Palace

Monks enjoying the view from Mandalay Hill

Amarapura teak bridge

Amarapura Boats

Amarapura agriculture 

Amarapura ploughing 

Monk at Amarapura Monastery 

Inle Lake 

Bamboo shed

Inle lake

WPW - part 3

M is 17 year old girl that lives in a village one hour away from Battambang. Her family, like 70% of Cambodians, is poor & lives a rural existence. Her father can no longer work after an injury sustained working in a factory. He now, with her mother, farms their small piece of land. Her older sister works in a garment factory in Phnom Penh. M was working illegally in Thailand in construction when she developed her tachy-arrhythmia that I have written about previously ('WPW - what patients want'& 'The best thank you'). Her family could not afford the medication she needs for one week let alone her life time.

F had told me about a Cambodian cardiologist - Dr C - that could do an ablation which would prevent the same life threatening arrhythmia happening again. I emailed him & he told me the procedure would cost $1000 but I anticipated there would be many hidden costs. Rather than organise it over email or phone I arranged to meet him face to face where he is based, the next time I was in Phnom Penh.

Of course when I arrived at the specified date & time at the hospital he wasn't expecting me but looked at her ECG & told me to bring the girl to him immediately & he would do. I tried to explain to him that she was very poor & still at home. I needed to have an idea of cost as I would have to fund raise that amount. He told me I could just pay for it afterwards & he was happy to defer payment to do it as soon as possible - he said it was urgent. I could tell that as I was barang he thought that I could easily cover the cost (currently I can barely afford to cover my mortgage in the UK!) and he didn't even acknowledge that I was a doctor, drawing a child-like diagram of the heart & talking in condescending tones. Even when he asked me what I did & I explained I was an emergency medicine specialist the tone remained. Perhaps it was my gender or/& my volunteer status. Maybe it was just him.

Either way I set about arranging for M to come down to Phnom Penh the next day for pre-op work up & to have the procedure the following day. The day after that I was flying to Myanmar for a well needed (if not deserved) holiday. Thanks to D (URC office BTB) & lovely L (my VA) after numerous phone calls they had booked M & her Mother on the first bus to Phnom Penh the following morning. Daneth paid for the tickets (I still need to pay her back) & we had to negotiate only one family member accompanying her. Initially they couldn't get the early bus as the family doesn't own a moto and have to rely on a neighbour to take them into the bus station. After some to-ing & fro-ing we worked out that she lives on the route to Phnom Penh but as they had never used a bus (too expensive) they didn't realise the bus could stop & pick them up on the way. She needed to get down to Phnom Penh in order to see Dr C in the afternoon.

I spoke with URC's health equity fund (HEF - health insurance for poor patients) about covering transport & food costs - they arranged for someone to meet me at the hospital to help organise payment. For user fee & treatment costs this was not covered as the hospital does not have an agreement with the HEF, I managed to secure donations (I am really not a natural fundraiser) from a friend of mine from medical school, my old friend's sister, J's oldest friend & a few others that wish to remain anonymous.

A very BIG thank you to Ruth, Hannah, Elaine (and anon +) - you really have restored my faith in human nature & your generosity astounds me.

The following day there was an anxious wait & a few more phone calls to ensure that the bus driver stopped & they were on the bus. I thought this would be the biggest hurdle - I was very wrong.

L & I had to leave our VSO workshop to meet them off the bus & take them to the hospital. They wanted lunch but I just wanted to get them there first to make sure Dr C's promise was good. Dr C was there but seemed only interested in showing me a powerpoint presentation of all the ablations & research he has done. He didn't even look at M or say hello to her & her mother - well she is poor after all!

Whilst she had an ECG & bloods taken I went with L to get water & some food for their predicted 2 day stay. I also gave them a little bit of money for buying more food but I planned to come again tomorrow as I didn't want them to have too much money on them. If they didn't have money then they couldn't pay the bribes.

A person from the health equity fund came to meet me so we could discuss payment with administration. The admin people were rude & arrogant - this is a mild description of their behaviour & attitude. They refused to allow deferred payment at first despite me insisting that this is what Dr C had agreed. Eventually after emptying my cambodian bank account so I could pay the user fee - initially quoted as double what it actually should be until I bartered it down - I left with the understanding that treatment, investigation & other costs could be deferred 48 hours until I had sufficient funds to pay on Saturday morning. After the 40 minutes of negotiation I was given a pack for M of toothbrush, soap, comb & flannel - I hoped it would be worth it.

I felt really uneasy about leaving her & her mother alone there - my instinct was accurate.

The following day L called M who said they wouldn't do the procedure as the staff were waiting for me to come in to pay first. I rang Dr C & he assured me that he would do the ablation at 10 am & I needed to arrange with admin deferred payment. I explained I had already paid the user fee & arranged deferred payment with admin so surely it was all systems go.....errr no actually.  At 9 50 am Dr C called me saying "you come here now & pay $1000 or I will not do at 10 am and she will lose her slot. I will keep her in hospital for a very long time which will mean you will have to pay a  much bigger bill at the end". I calmly pointed out that this was slightly different to the promise a day earlier that he would do without payment & was happy to defer or the arrangement I had already made with admin.

This is Cambodia. No money, no life.

I asked L later - In Cambodia do you go to a restaurant & pay for the fried rice then eat it after?!

I called Jn, from URC, who arranged for health equity to go & pay as admin were now requesting - they paid for the user fee again plus treatment. By this time however she had missed her slot but after further phone calls it was established she would have the 1 pm, which didn't actually fit with the earlier threat from Dr C. Funny how money talks & what it says, here in Cambodia. This makes me sick - quite literally - I get palpitations & chest pain still thinking about this whole incident - I'll be the one needing an ablation next!

At 4 pm Liong told me that M's mum had called and "She has not had it done yet!" - I went ballistic. As we were in the middle of the VSO workshop I took  outside to get further details. Translation error - I had to explain to L that "She has not had it done yet" is not the same meaning as "She isn't out of surgery yet"! We both anxiously waited to here how it had gone.

After the workshop L & I hurried over to be greeted by an anxious mother - 5 hours & still no sign of her daughter. This could mean one of two things; 1) the procedure was technically too difficult for Dr C to do or 2) there had been a complication (as a doctor I am including death as a complication). I was being increasingly aware that the more time I spent at the hospital the higher the final bill would be. I texted Dr C who I presumed was busy in theatre with M. We waited with M's Mum - I tried to be reassuring. I rang J & ranted down the phone at her about the Cambodian health service until my credit ran out.

I received a text from Dr C - he could not successfully do the procedure it had turned out to be too difficult but he assured me that in February an American cardiologist was visiting and would do it then for free - but there is no such thing as free health care in Cambodia I have learned.

Before going to the airport the following morning I went early to the hospital to visit M & check on her well being, also I wanted to make sure they had enough money for food & transport home. The first thing I was presented with was a bill for investigations that I thought had been paid the day before, a little bit like the user fee. I was beginning to feel like a walking $ bill. No one had spoken to her about the result of the procedure, future treatment plans or asked her how she was feeling, so I did that too. Regarding payment they had been previously told by the HEF that they should not 'bother me'. Regarding payment I suggested they called HEF & just to be sure got L to do it before I left for the airport. I also called Dr C who said she needed to stay another day as she had pressure bandages on both femoral arteries - ker-ching!

I met a friend at the airport, who the evening before had been visiting the same hospital & had mentioned to a member of staff there that she knew me - "Oh! Is that the doctor from England that pays for treatment out of her own money?!" had been their response. Neither true or what I really want people to think about me.

Whilst we had breakfast together & caught up - concluding that our destiny was to grow old, remaining single & childless, meeting to discuss international health in unlikely places all around the world - I received a call from HEF saying that I needed to come to the hospital & pay another $1000. By this time I was very close to the edge of my patience with the whole rotten, corrupt, crappy situation but managed to defer him to Jn, who had calmly reassured me earlier she would sort out any further payment issues & we could settle later after I was back from my fortnights holiday & was a little less stressed!

I think L has developed a stomach ulcer during the whole debacle, I had to give her the last of my Omeprazole as I feel responsible for her work stress related illness!

M was actually kept in for a further 2 days, for what medical reason I am still not clear. She has been told to go back for a 'check-up' soon. Not sure how they expect a family that lives on $2 a day to afford the journey down & back for a clinic check-up appointment. If it is for a repeat ECG & medication then obviously as a female volunteer I am clearly totally incapable of reading an ECG or reviewing her medications.

Luckily I have enough donations now to cover the 3 months of medication she requires until the repeat surgery in February. The $1000 treatment cost ended up being $1500 & with no positive result or cure, one can only guess what the 'free' treatment will end up costing next February.

I really tried to do what I thought was the best for M but as is so common here it just came back to bite me, turning out not to be the best thing to do at all. What is left now is the hope that she will make it to February in good health & that the corrupt, flagging health care system won't fail her then.

Anyone who dares to complain to me about the NHS at the moment will have ignited the blue touch paper & should just stand well clear!

You know you need a holiday when....

Last time I came down to Phnom Penh it took me 9 & half hours by bus. This was because there was an ASEAN meeting & a certain re-elected north american president & "leader of the free world" was in town so they had shut ALL roads.

The journey hadn't started well with the discovery that my headphones were broken (the fifth set to die here) & I was therefore unable to drown out the karaoke & violent chinese films. Cambodia has not been kind to my electronic equipment, as well as the headphones I have been through 3 iPods, 2 cameras, one phone, one kindle, and had the whole bottom part of my laptop (bar the hard drive) replaced.  I am feeling slightly more buddhist about material possessions - especially electronics.

I was sat next to a man - who was actually sat in my window sit but I didn't have the energy to challenge him - who must have extraordinary enormous testicles as he was sitting with his legs so far apart he was occupying both his (really mine) & my (really his) seat. He also seemed quite insecure about his testicles too, as he had to keep checking they were still there. On the other side of the aisle was a man who was coughing, hawking & spitting into a bag for the whole 9 & a half hour journey. I think he may have TB - after this journey I suspect I may have TB too.

When R called me to say that he had left one &a  half hours before me but was now stuck at the edge of Phnom Penh because all the roads were shut for security I knew skipping lunch & not weeing at the last bus stop were both grave errors.

Apparently the knowledge that Mr President was flying in to town & that all the roads were closed had been received but not processed by the transport companies - hundreds of vehicles ground to a halt on the perimeter of Phnom Penh, there was no plan B.

R wanted to know if our gridlocked buses were close to each other so perhaps we would share a tuk tuk but there was a lot of traffic in between 10 30 am when he left & my midday departure. My mobile phone battery died. I switched to my UK mobile.

Moto drivers were asking for $10 to take passengers the last 5 km into the city, my well endowed neighbour muttered in khmer that for that price you could get the bus from Battambang to Phnom Penh AND back again. Supply & demand - the laws of capitalism.

Every hour or so we would move to a different place at which to remain stationary. I would say this  was in order to change the scenery except that it was pitch black by this point. It was during this long 3 hours that J let me know that the room I had booked at the guest house was not available & I had no room to stay in. I wasn't too concerned as it looked like we would all be sleeping on the bus at this rate.

Then an extraordinary thing happened - the bus driver had an idea. It was a good one but would have been an even better one if he had it 3 hours earlier & shared it with the hundreds of other buses also waiting for miles along the main roads into PNH. The idea was as the best ideas usually are very simple - lets go the other way around!

So we did just that which made 3 and half hours of unnecessary waiting even more annoying. My UK mobile died. This meant not only was I unable to share R's annoyance at his fellow countrymen's incompetence but I was also unable to broadcast my annoyance to various friends scattered around the planet.

I arrived at my guest house & J kindly shared her room & bed with me. The following morning we flapped around trying to find the lost room key, which J eventually found hanging from the key hole on the outside of the door. It would appear that I wasn't the only one in need of a holiday.

I walked to the office that morning as all the main boulevards were intermittently shut for various motorcades related to the ASEAN meeting. At the intersection between street 214 (where the URC office is) & Norodom the road was closed for a motorcade. A convoy of police motorbikes & cars sped by followed by black limousines. The cambodian police - a vision in khaki with round, shiny, tin hats & the ASEAN volunteers - who looked like boy scouts with little red flags, indicated to the stopped traffic that they could go just as the second half of the motorcade sped towards the intersection.

I don't know whether it was the "NOOOOOOOOOOOOoooooooooooo........." of the police, the frantic whistle blowing & flag waving of the boy scouts, the high speed, 'forward-wind' quality to the swerving & weaving of the motos as they tried to continue to cross the intersection regardless or the astonished expression on the motorcade's european cargo but at this point I just completely lost it.

I was crying with laughter in the street, sobbing silently & struggling to breath with all my hysteria. The tuk tuk drivers who hang outside the office & only ever say "you want tuk tuk lady?"to me, even asked me if I was alright. Only a person in need of a holiday would find a near-miss multi-vehicle pandemonium that hysterical. I still have a little chuckle & smile to myself thinking about it now.

It was just so beautifully, incompetently, chaotically Cambodian.

Unfortunately the week got worse before I got my much needed break, but that's another blog....

Pchum Ben

Pchum Ben is a 15 day Buddhist festival for the ancestors, who simplistically all get the opportunity each year to leave purgatory through the gate's of hell and eat rice offered by their descendants. Cambodians go to the Pagodas where their ancestors will be to give offerings to the monks. It is preceded by a 3 month lent-type period which involves banging very loud drums at 4 am every morning, which intensifies for the 15 day festival with the added joy of chanting & plinky plonky music - I may have mentioned it before. This occurs after the full moon in September but I have been in a post-dengue fugue since that time.

I know a little bit more about this festival as there is a reading exercise about it at the very end of the grade 2 khmer text book. Soyeth - my khmer teacher - was rushing me through the last pages, finishing words off for me, ignoring my mistakes more than usual when I realised it was because she wanted me to finish grade 2 before Pchum Ben so I could learn all abut it in khmer. 

With all the fun & games I had read about at the Pagoda I thought maybe I should go and see it for myself. After all my local Pagoda has been a reliable early morning alarm for over 3 months - I should probably go to see what all the noise at the Wat is about. Soyeth was simply delighted when I asked her if I could go with her.

So one weekend after my khmer lesson I went to Soyeth's local Pagoda with her. We had to go to the market first to by a ready made 'offering' to the monks - including such delights as fish sauce & washing powder as well as flowers for offering to Buddha. 

I had been instructed to wear a white shirt & Sompot (khmer skirt) but had been let off the Sompot as I had to cycle across town to Soyeth's. Soyeth lent me a scarf which is meant to act as a sash across ones torso but caused logistical issues as my torso is the equivalent of 3 cambodian torsos.

The routine goes something like this;

• give flowers to Buddha & 'corrup' three times - place your palms together whilst sitting & then bow down & touch the floor with your palms
• light incense
• get multiple burns to your hands from the cheap incense
• take incense outside & leave in a big pot with a prayer to Buddha (another one - the big one in the big part of the Pagoda)
• go back in & offer gift to monk
• get a very nice 'thank you' in english from said monk
• put one spoonful of rice in a row of bowls for monks
• have problems keeping your scarf in place (see photo below)
• don't forget to save a bit of rice to place in the scraps bowl with your fingers - significance of this still unclear to me
• bump into your deputy director & get introduced to his entire family who are buying food for all the people at the Pagoda - a yearly tradition for the wealthier families in the community

The following month I received an email ominously entitled 'photo of you' - ON my deputy director had sneakily taken a photo on his iPad of me.

In between times I had spent Pchum Ben down in Sihanoukville, then fallen off my perch with Dengue Fever. At the time it felt like going to the Pagoda was a good thing to do, especially as I was worried about the health of the 17 year old girl with the tachyarrhythmia. Giving blood the same week felt like surely good karma would now come my way. 

As we left the Pagoda Soyeth was muttering something under her breath - when I paid attention I realised she was talking to Buddha. She was telling him about me, she was saying "she is kind, she is intelligent, she has a good heart" - I'm not sure Buddha believed her or perhaps the coming weeks were just to remind me that life is, after all, suffering.

Soyeth with my $3 offering for the Monks - I got a nice Thank you in english for them

My Deputy Director sent me this photo he took - Soyeth thinks she looks old & her face is too thin. I think it is quite worrying just how much concentration I clearly require to simply spoon rice into bowls!

The best thank you

I had the mother of a patient I tried to help intercept me in the hospital to say thank you the other day - this is becoming a regular occurrence thanks to L my lovely, approachable VA.

The mother in question had given up hope on her daughter, mainly because she had been told her daughters condition was hopeless by the less than caring hospital staff. In desperation she had told me if I could help her daughter she would give her to me - L & I both had a tear in our eye when this happened. She had brought her daughter back to hospital to see me as I had been ill with Dengue when she was discharged.

I hope what we did for her showed the staff that there is sometimes hope beyond their knowledge, skills or attitude - all be it costing $40 for medicine from Phnom Penh. I continue now to try to help her by attempting to arrange a procedure that would cure her completely. This requires me going down to Phnom Penh Cardiac centre next week to speak to a cardiologist who can do the surgery. Treatment will cost $1000 he has estimated, this doesn't include travel for her & a relative to go down to Phnom Penh, living costs for the week whilst they are there & the biggest hidden cost - bribes. She can't even afford to buy the medications to prevent her having another life threatening episode, which the surgery at Phnom Penh cardiac centre would prevent. 

So it would cost roughly $1000 for a life. It really is all about money here. "No money, no life" - as R would tell me when I complain about the incessant talk by Cambodians about 'louy'.

Her mother apologised that she hadn't brought me a gift to say thank you. I felt her daughters pulse - slow, steady & strong - and told her, for me, this was the best thank you. Better than bananas!

Now I need to find $1000 from somewhere..........

Save a Life, Give blood

A few weeks ago a VSO colleague & I visited the national blood bank in Phnom Penh as part of a general health facility review we have undertaken. So inspired were we that we donated a pint each, right there & then....little did I realise that I probably should have held on to mine.

The need for donated blood in Cambodia increases with a Dengue epidemic, which effects mainly children, such as the one we are just at the tail end of. It seems ironic then that a week after donating blood I came down with Dengue fever - so much for good karma.

It started with me feeling particularly 'ordinary' over Pchum Ben holiday. Whilst in a hotel in Phnom Penh in transit back to Battambang I began to feel really rather 'average' & it took me half the night to realise I was having rigors & chills. Morning brought a sustained fever of 40˚C despite paracetamol & a really bad back ache. Against good advice to stay in Phnom Penh, my homing instinct was so strong I dragged myself to the bus to endured the worst 7 hour journey of my life. Traveling by bus in Cambodia is challenging enough & its hard enough to tolerate very loud karaoke & violent chinese martial arts videos without having Dengue.

Despite thinking I never would, I finally arrive home & went to bed were I stayed for most of the next 10 days with a fever of above 39˚C - it wasn't very nice.

emedicine states the symptoms of Dengue are as follows;

"Many patients experience a prodrome of chills, erythematous mottling of the skin, and facial flushing (a sensitive and specific indicator of dengue fever). The prodrome may last for 2-3 days. Classic dengue fever begins with sudden onset of fever, chills, and severe (termed breakbone) aching of the head, back, and extremities, as well as other symptoms. The fever lasts 2-7 days and may reach 41°C. Fever that lasts longer than 10 days is probably not due to dengue.

Pain and other accompanying symptoms may include any of the following:

Headache
Retro-orbital pain
General body pain (arthralgias, myalgias)
Nausea and vomiting (however, diarrhea is rare)
Rash
Weakness
Altered taste sensation
Anorexia
Sore throat
Mild hemorrhagic manifestations (eg, petechiae, bleeding gums, epistaxis, menorrhagia, hematuria)
Lymphadenopathy
Rash in dengue fever is a maculopapular or macular confluent rash over the face, thorax, and flexor surfaces, with islands of skin sparing. The rash typically begins on day 3 and persists 2-3 days."

Lets just say I ticked all the boxes.

There are several people without whom I would have not survived those uncharacteristically ten long days of fever, cabin fever & the ensuing week plus of post-Dengue weirdness - a post viral exhaustion & mental bluntness best described as 'blah'.

In no particular order I'd like to thank & express my deep heart felt appreciation to

• Soerb who came to my house most days and stayed for hours trying to force feed me bor bor - rice gruel (against my will), mopping my fever brow & giving me bed baths, sweeping my floor, cleaning my house, doing my washing, her 2 children were angels & even put the TV volume down when I asked them to. She didn't once try to coin me or burn me with incense - traditional khmer medicine, for that I am forever grateful. I also had a constant supply of fresh coconuts from her garden.

• Soyeth - my Khmer teacher - who also visited daily & not once tried to teach me khmer. She too force fed me bor bor with dried meat - I was laying in bed with a fever of 41˚C and she was spooning it down me as I was too weak to fight her off. After this I refused all further bor bor feeding attempts. She brought me tinned milk & fresh coconuts. She also gave me bed baths & massaged me when my neck went into spasm but like Soerb resisted coining me although I could see her hand twitching towards the lid of the Tiger balm. When I fainted in the kitchen one night coming back from the bathroom she brought around a chamber pot - she cycled in the dark to do that, as I'm post-dengue & over-emotional this act alone brings tears to my eyes.

• Liong - my amazing VA - who visited me daily & made me fresh orange juice - and disapproved of all the fresh coconuts as they are bad for fever - & when I could eat (day 7!) brought me chinese soup for breakfast with offal (I know that sounds awful but she knows it is my favourite breakfast & obviously bor bor was no longer an option) & when she didn't visit she would text me - above & beyond the call of duty. She also omitted to tell me the whole truth about the follow up of the tachyarrhythmia patient as she knew I'd get agitated. She conveyed get well messages from the mother of the tachyarryhthmia patient - the irony of which was not lost even in my febrile state.

• Rady - qualified nurse - who told me I had a bad cold because adults don't get Dengue but changed his mind after I started bleeding & collapsed in my Kitchen, he took me twice to Laboratories to check my bloods (low white blood cells & platelets - typical of Dengue).  Once on board with the diagnosis he didn't think there was much he could do as I was the doctor & he is just a nurse - physician heal thyself and all that. He did however cook me a meal which Soerb bought over. I was skeptical that he had cooked it as he is, after all, a Cambodian man but Soerb (in khmer) & Panha - his 8 year old daughter - (in english) confirmed it was indeed the truth. I was still at my anorexic, altered taste stage but despite all that the Cambodian male can cook. He told me the other day he is glad I am feeling better now because when I was ill I was "really grumpy"!

• Geordie who brought me take out food once my appetite returned - he knew that mashed potato was what I needed NOT bloody bor bor, took me on the back of his moto - after 10 days in bed and my cabin fever had me at breaking point - for an outing to the Bambu hotel. He also endured 3 days of me in PNH when I couldn't walk far, sit up for too long or generally hold a coherent conversation. He would probably argue that this is no different from normal.

• And last but definitely not least Janice, who insisted on sleeping at my house because the first evening she offered & I declined, I then proceeded to faint in the night - she was really cross about that. She brought me take out food, milk shakes, cakes - when your appetite returns after dengue it really returns. She took me out on little trips to local cafes when I was going crazy with cabin fever. She lent me money, internet credit & bought me bus tickets taking me down to Phnom Penh with her to convalesce once the fever broke. She is a qualified nurse but as I was being assertively nursed by three amazing Cambodian women (whose roles are also my teacher, assistant & friend) Janice did more than just nurse - she was a brilliant friend to me and a complete rock.

The kindness of Cambodians confounds me & Dengue brain is making me a little emotional.

Anyone who knows me will know that I don't like to feel indebted to people but that's tough because I am eternally indebted to these people for all their care & friendship as well as all the friends & family who texted, whatsapped, facebooked, skyped & emailed me. 

emedicine says that occasionally the dengue rash can desquamate - in other words all my skin has now started to peel off & I look like a Zombie.  Pass me the DEET, I don't want this again.........

Feeling all warm & fuzzy  -  thinking it was due to a good deed but not realising it was probably the prodrome to Dengue Fever!

We made light work of the amazing post donation snacks - boiled egg, pasty, cake, 3 bananas & water plus 7up! Oh and can I have my pint of blood back - I am going to need it?

TB training - another perspective

Once again my lovely VA hits the nail on the head....

Reflection in case of Training

Event Description

On the second week of September, my boss, Mrs. J, Mr.R, and I went to a small hospital near border. We were going to stay there for four days for lecturing TB and following up Triage. I was very excited to visit there. 

On the first day - Triage revision in the afternoon, there were no participants, according to Dr.Esther’s speech.  She spent the whole evening on computer work and waited for them. But there was no one appears. This made me very angry and disappointed after hearing this. I just wonder why they did not join the triage lessons even though they did not really understand it. I thought that maybe they were lazy to get the training as nurses and doctors in the hospital. I really concerned what would happen the next day for my TB training translation.

On the second day in the morning, we followed up the Triage process at OPD.  The process was very slow. The nurses were very difficult to recognize what kind of patient they would put in triage form. These because they could not read triage books or even ask patients ‘symptoms. They could not define what the worst compliance patients had. In this process, they spent long hours to know patient is red or yellow or green.  Mr. R tried to explain them about triage. He pointed out the right direction to read and get quick on this form. But it did not work out. So it meant that the triage training was unsuccessful. Also, in this morning, I saw the interesting cases for triage. One young girl who had sore throat and high fever was informed orange patient, for they misread in oxygen amount in oximeter. It was upside down reading. It turned out that they were unable to read properly in oximeter result. So they would like to get training on this. Another patient- a little baby who was diagnosed that she had hand and foot mouth disease was gotten incorrect treatment as pined out by Dr.Esther. Dr.Eshter asked to change the prescription to only Para Cetamol use because she had slightly fever and not serious. By the way, one a little girl was incorrect diagnosis patient who doctor though that she had pneumonia. But indeed, she had asthma. It demonstrated doctor here is not good at treating patient.  In end of the morning, there was one man who came with fractured hand was admitted straight to surgery ward without triage. We realized that he who is a police and brother in law of Golden teeth was considered in priority after asking the nurses at OPD. It is the way of Cambodians to be corruption.  Furthermore, one interesting patient came. This patient who hanged himself was in coma. Dr. Eshter asked bag-mask oxygen for resuscitating this man. But they did not have that material. Mrs. J and I run to find it in surgery ward and maternity ward. Only surgery ward had it. Unfortunately, there was no adult air way tube. Mrs. J hurried to take it in car. At the end, we got the bag- mask oxygen. Nevertheless, our material did not use to revive him.  They applied Oxygen concentrator. Anyway, it helped the patient. I noticed that Doctor at this ward listened to Dr. Esther by using sleep medicine to help him and neck x-ray to check whether he had neck fracture or not. It was good for hanged man but that was a very bad morning for triage result. Anyway, in the afternoon, there was TB training. Unbelievable, there was only one doctor came. In seven minute, he got the TB handout and received a phone call; then he left quickly. We waited for another people. However, there was no one attended as we had expected in the first day. I felt very frustrating with this. I just did not why most of Cambodian nurses or doctors are not eager to learn more. I felt that they do not want to improve their capacity because they think they already knew it. It made me very upset to see my nationality in danger in future. This second day story let me down so much.

On third day for TB training, there were some nurses and a doctor participated. We lectured them about TB in children. Dr.Eshter tried to define them about local sign and general sign of TB of extra-pulmonary TB and pulmonary TB very clear. But they still did not get them even though I translated them several times. I did not know why they did not understand it- whether it was because of my interpreting or they did not have basic knowledge in TB in children. I tried to find the way to get them easy to take in this lecture. However, they did not pay attention in this. They turned their deaf ear to this explanation and talked on phone, instead. I was so sad and very dismayed that those people not listen to us. It showed that my translation was useless for them although I did my best on translation. I felt so bad to them. If they can aware of TB in children, the patient will not die due good treatment. Until in  the evening, Dr. Esther told me the TB training was not achieved because they did know nothing about our training when she asked them  about general sign and local sign of TB while she accompany by Mr.R taught them Regimen including other TB.  After getting this information, I felt very frustrating. We had done our best, but they just did not want to accept it.  Then, we walked around the ward to see patients. When we arrived in pediatric ward, we saw asthma girl whom we had seen on second day. Dr. Esther asked her aunt “what did Doctor told you about her?” She replied that “she had pneumonia”, but in fact she was suffered from asthma, according to Dr.Esther diagnose. Suddenly, little girl defensed quickly” I do not have pneumonia but I only have a cold”. Dr.Eshter was very surprise to hear what she said. She was brighter than Doctor to know what her illness was. We really appreciated this. Until in the evening, there was one patient who came with gastric hemorrhage. He was really sick and sent directly to ICU ward. Unluckily, there were no doctors around the hospital because they were all on commission. This was not appropriate for hospital not having doctors in hospital which could kill patients. Immediately, a male nurse asked Dr.Esther to see this patient as well as suggested her to role as doctor position today. He very concerned about the patient. Dr. Esther examined him quickly. She gave him on bolus serum and advised his wife how to take care her husband. This was an important point that I really excited. The nurses were very nice to patient even though they were unprofessional. They had compassion and sympathy to patient which differ from nurses in Battambang referral hospital. They behaved nicely to patients. I think if they are more trained, they will treat the patient professionally and compassionately. This good sight on nurses has changed my mind to them. I appreciated their jobs as they had those kindnesses. All of these really cheered me up although I had the bad result of TB training. 

On the final day, in the morning we lectured nurses about triage again. Dr. Esther gradually described it by giving the examples which I was acted as simple.  She concentrated in second section in triage form, most of them did not understand even in reading as well as defining what kind patient should be put.  As the same in Battambang referral hospital, they neither listen nor paid attention in this lecture although they did not make out.  Some of them were busy at texting or talking on phone. And others were talking together. They thought they already got it. This was common reaction of Cambodian nurses as I have believed that there was no point for us to give them more- at this really irritating me.  Moreover in this training, most of male nurses often played around me as in case of study. One male nurse was really shy at me. And it was made the teaching become worse.  I just could not believe that. They were rather shy than open minded to new people or knowledge. It really annoyed me. As result, only one midwife and one nurse could grasp this lesson. This was end of training day. In afternoon, we walked around the ward and checked patients up- G hemorrhage and hanged man in ICU ward. The G hemorrhage was getting better. For the hanged man, he was self-discharged   from hospital even though nurses tried to explain him to stay in hospital. But I felt glade that he was better. However, one thing caught my interest was that nurses ask Dr. Esther about one patient with complaining persisted chest pain for several days who she had seen before. She told him to take two specimens to test TB because she thought he could have TB or cancer according the illness history including chest x-ray- collapsed lung. She said that she had tried to tell this to doctor before but he did not followed at all. It maybe he had not been trained before we gave the lecture or he just ignored which made the patient want to leave because he did not improve instead he getting worse on chest pain. Dr. Esther came to explain him about his illness and the treatment we will take. She said that” you are probably have TB according to your chest x-ray, in TB treatment it will take  long time - it could be six months or more depending on your situation.” She continued that” we will take your sputum to test and find out whether you get TB or not. I ask you to stay in hospital better than stay at home which not good for your health”. This really made patient understand his illness and willing to stay in hospital. It was good to tell patients about their sickness which causes patient trust in doctor treatment as I noticed. After finishing this, we left this hospital. We hoped this patient will get correct treatment. 

Thoughts and feelings

For the first day, I felt very frustrating with their absent in Triage training. They were not interesting in learning something again though they did not understand about the process in triage. They thought that they were enough and did not need someone to train. This idea blocked them from build their knowledge up. 

On the second day, I was more irritating when they could not access triage and kept disappearing in training-TB training. For triage, they could not identify red, yellow, orange, or green patient in this form because they were trouble in defining the worst complication or in reading triage book. They spent too long to admit one patient-probably 15 minutes. It wasted a lot of times. I though this because they did not attend in training or they did not listen while teaching. After I saw Mr. R explain them, I found out that they were not really intelligence at all. They knew nothing. They just knew how play around with patient. And for power patient, police man –the brother in law of golden teeth, was transferred without triage. This told us powerful patient is more important than others. To be ministry official has advantage in all of facility. This was really try me hot. I thought this   because they had money and powerful face. So money face would make triage quickly. Anyway, doctor and nurses were unskillful. They could not diagnose correctly and treated well. I could say they lacked of skill.  But they were nice to patient as well as guest and listened to Dr. Esther in some kinds, such as sleep medicine, next x-ray. I felt they were a little opened to learn. I felt less negative to them than Doctors and nurses in Battambang referral hospital.  Instead of feeling a little positive sight on their mind, I could see they did not have enough emergency material in ICU medicine as in case of hanged man. When they needed mask-bag oxygen, they had to run to Surgery ward. It took long times to get this stuff. The patient could be died while they were running. But fortunately, he was revived on the next day although they struggled with this. I was happy to see that. 

On Third day of training, I felt very blue and angry with health staff there when they did not pay attention in our lecture although we tried to our best to explain them. They just ignored it, I believed. They tried to ask the same questions which wasted our time a lot because some of them did not listen at all while someone asking. This annoyed me so much. As the result, our training was not successful. I told myself that there was no point for us to give them more, but I felt better after I saw the nurses here was very kind to patients. They were very warm and worried about the patients. This removed my negative feeling to them; instead I really wanted to go and do trainings with them because if they concern patients, they will treat patient well once day after they get training. So I decided to I will try over again if I have chance to visit there.

On final day, in Triage retraining, I was so frustrating with their attitude in training and toward to me. They were playing around in class including me who presented as example of patient while Dr. Esther explaining. They were just dying to go for lunch or home, not care how hard we tried them to process triage well by spending our time to give them lecture again. They would never give their ear to us unless we do bring food or pay them, I reckoned. I started to have more negative again in my brain. All in this morning I was sick and tired of this. But in evening, I very impressed with Dr. Esther work. She gave good demonstration to the patient and nurses. She told nurses about patient diagnoses as well as pointed out how to examine this patient. The nurse really listened to her. For the patient was willing to stay in hospital. I was really happy to see this. However, I still concerned about nurses here on the way back home. I hesitated whether they follow or not because mostly they just listen but don’t practice. If they don’t do as Dr. Esther has told, the patient will take risk in his life. So I pray to Buddha to bless him.

Evaluation & Analysis

Good done:

-To revive the hanged man: Doctor did good job on resuscitating hanged man. He gave good care to this patient. He examined his neck through neck x-ray as he did listen to Dr. Esther.  I could see doctors really good at traumatic injury as well as interesting in learning new in some kind as this case. So we can work with them once day.

-To feel compassionate and sympathy: Some nurses there were nice to patient. They behaved well. They treated patient in some kind as their family. They spoke gently to patients as they gave medication to them. They did care the patients’ lives; for example, nurses in ICU medicine run to ask Dr. Esther to see the patient when there were no doctors around ward due to commission. They suggested her to role as doctor and to prescribe the treatment in doctor note which they could use it at night after Dr. Esther left. Also they asked her how to treat as well as examination one patient who suspected either TB or cancer according Dr. Esther. These told me that they had compassion and sympathy to the patient. It was good for patient to have those kind nurses and for us provide them more training because they eager to offer good service to their patients.

-To consult the TB patient: Dr. Esther explained to the patient who wanted to discharge from hospital when he did not improve his chest pain about his illness including what we would do for him. She told him about diagnose as well treatment we will take. He really understood his disease and reconsidered to stay in hospital. This consultation inspired the patient willing to stay to get treatment. So the nurses should tell every patient about their illness and treatment in order to get trusted from patient who won’t reluctant to stay in hospital for long times.

Bad done:

-insufficient emergency equipment: When we needed mask-bag oxygen to revive hanged man in ICU medicine, they did not have this material. So we had to run to find it in surgery ward which took us a long minute to bring it.  Unfortunately, they did not have adult air way tube. J was rushed to take it in car.  I could see they really lacked of emergency equipment. They should have this as they are ICU ward where every serious sick patient comes. But I could not blame them because this hospital is poor. There is no point for us to blame anyone when they do not have anything.

-Inability doctors& nurses: Doctor there could not diagnose patient correctly including treatment.  They incorrectly treated EV-71 baby and asthma girl. They did not really look into patient symptoms. They did it just as their habit. They should have examined patients carefully. I could say they lack of knowledge in this because they have been trained little. Therefore, they need more training to build their capacity up.  For nurses, they did not access triage very well. It took a long minute to get one patient flow. The reason was that difficult to define what color would they put patient in this form. They could not recognize the worst complaints of patients and read oximeter result. It showed us that they did have basic knowledge. They really need to be trained again.

-poor human resource management: There is very crucial to have doctors in the ward all the time. They should not allow all doctors to leave the ward even though they were on hospital commission. Without doctors could kill patients, especially sever sick patients because they could not get treatment quickly as they need. So they should have keep some the most important doctors in the most emergency wards such as ICU ward, pediatric ward, etc. They should have put patient in priority. So they could have both advantages- keep patient and get on training.

-not eager to improve knowledge:   Nurses did not pay attention in both training – TB & Triage. They just came as followed the director order. They were dying to have lunch or to go home. While we were teaching, they were talking, playing around, phoning, etc. They really did not care what we were trying to explain them to get easily on triage and aware of TB in children. It turned out they were not very interesting in this because they just ignored them. They should have grasped this training, for those trainings are fundamental knowledge for them. They can have a lot advantages on this if they acknowledge them.  So in order to let them pay attention, we should warn them about what we are going to do if they do not take in these lessons, such as if you want to work and open ER soon, you need to understand this; otherwise, ER will not be opened. We need to talk to both director and staff here. I think they will listen to us because they really want ER.

-Not present in training: They did not appear for first& second day of training.  They really dismayed us and wasted our time.  They should participant our training, for they did not understand about it at all. It may be they lazy or busy. So in order to avoiding this again, we need to inform director of hospital often beforehand. Also give him the warning sign like I would never give lecture or help you again if you still keep this. It is good way to make red card to them because human will follow up if they see the red card.

Future Action:

As role as translator, what I can do is trying to translate effectively in lecturing through asking them often whether they have question or not and giving them a short summarize in each parts in training. My repeating sometimes can get their interesting or remember because they hear it several times. I hope this will work out.

WPW - what patients want....

I think I should be clear that when I write these clinical blogs its not for sympathy nor out of despair, I write them so that people can have a clearer idea of what it is like trying to capacity build in health in Cambodia. If you find them too depressing or distressing then I suggest you stop reading this blog, because it is more of the same I am afraid.

For a fortnight I worked with a doctor from a famous US university hospital at my hospital. He is an emergency physician (like I used to be!) & it was good to have him inject some inspiration back into my work. After his departure I went on a study tour & when I came back I went to see if the woman with pericardial TB was improving (she is) & I saw Dr L with an ECG but when he saw me he scuttled off, hiding it from me. I didn't have the energy to pursue it.

The next day (Thursday) I stumbled across a very worrying looking ECG on the desk whilst looking for another patient's notes - it was the same ECG that Dr L had been concealing from me. B had conducted a 2 day ECG workshop whilst he was here but the doctors will not ask me for help reading ECGs. I am not sure if this is arrogance or shyness or hostility but it invariably makes my job of capacity building very difficult.

The ECG had been done 2 days before and showed a wide complexed tachycardia. I went to see the patient. She was a 17 year old girl who had been working illegally in Thailand until 2 weeks previously when she developed palpitations and then swelling in her legs (pitting oedema), breathlessness & felt 'exhausted' all the time. She came back to BTB where the doctor 2 days previously had failed to diagnose her as having a life threatening tachyarrythmia so had started her on Dopamine for her low blood pressure & Digoxin. Dopamine is a powerful drug that is used to make the heart beat stronger & faster, the reason this girl had a very low blood pressure was because she had a heart rate of over 200/min - the last thing she needed was her heart racing any faster. Digoxin is an anti-arrhythmic that can be fatal if used in certain kinds of tachyarrhythmia - in short she was being mismanaged.

Dr S, who is a 'specialist' in cardiology, was on the ward - not one of the usual ICU doctors but one who often covers the odd shift there. I showed him the 'interesting' ECG - he immediately asked to see the patient. He had been on duty for the last 24 hours but apparently a 17 year old girl with an extremely fast heart rate & respiratory rate and no palpable radial pulse wasn't cause for concern enough for any of the nurses to mention her to him. He, of course, could have rounded - there are only 12 patients on ICU.

He agreed with me that this patient needed a DC cardioversion (electrical shock) & failing that a chemical cardioversion with an IV drug. Neither were available. The defibrillator that the same doctor had tried to shock me with, 6 months ago, now had a flat battery, otherwise I would have DC cardioverted her myself right there & then - no discussion.

Instead he started her on an oral version of the ideal IV drug - less than ideal because when a patient is hypotensive the gastrointestinal tract is one of the first areas to get reduced blood flow which is re-directed to more vital organs. This means that oral medications are not absorbed very well, if at all. He stopped the digoxin but was reluctant to stop the Dopamine as Dr L had started it & he didn't want an "argument" with him. After much insistence from me he promised he would come back in the afternoon to check on the patient & discuss the case with Dr L.

I repeated the ECG - there was no change from 2 days previously. She had not had any bloods taken as she had 'difficult veins' so I offered to show the staff how to do a femoral stab. One MA came with me - the rest of the nurses & doctors sat in the staff room watching TV. The bloods showed that she had renal impairment - 2 weeks of having a heart rate of over 200/min will do that to you.

After we had left the ward L (my VA) told me that SP - the same nurse that we have previously had run ins with - had said to Dr S, when he asked for her to stop the digoxin, "Do what you like, I don't care, she can die for all I care, I am only interested in money". What patients want? That kind of attitude from the staff looking after them!

The following day she was still on Dopamine & no better, there were no doctors on the ward so I went straight to the deputy director, Dr ON. I showed him the ECGs & explained that dopamine was bad and we went to the ward together. Dr L was there but told me to write my recommendations in the notes, rather than talk directly to him, which I duly did. He wasn't interested in my explanation or clinical reasoning. Dr ON however was keen to understand how he could tell if shock was due to tachycardia or if shock was causing the tachycardia. There was another young girl with sepsis with a sinus tachycardia on ICU so I was able to show him the difference between a sinus tachycardia & a tachyarrhymia. At least someone wanted to learn.

I spoke to the Head nurse about the nursing staff's attitude on ICU. I said although their behaviour revealed that all they cared about was money & they didn't care if patients died, it was probably not very professional to voice this in a room with 4 student nurses, 3 trained nurses, 3 Cambodian doctors and a barang doctor with her very shocked VA.

I called the local NGO hospital to see if they had either IV Amiodarone or a defibrillator that worked - no such luck. No pharmacists in town stocked IV Amiodarone - it is only available in Phnom Penh. The only other option was for her to go to the cardiac centre in Phnom Penh but as a poor card holder only her transport would be paid for & her parents did not have the money to go with her. In Calmette she would need her family there to deliver her basic nursing care & would not receive treatment with out giving significant amounts of "tea money".

I decided to wait & see if stopping the dopamine & another 24 hours of oral Amiodarone would improve her condition. On Saturday I went to check on her - without the Dopamine her pulse was stronger but still rapid. Her mother told me that if her daughter survived she would 'give her' to me. This made me feel profoundly sad.

Then I lost my phone. I bought a new one & replaced my SIM.

I rang a doctor from another NGO for her advice. She suggested a NGO Children's hospital in Siem Reap but the girl was too old. We both knew that she needed DC cardioversion & IV Amiodarone but like most of Cambodia her & her family were too poor to afford the healthcare she really required.

On Sunday I went to the Pagoda with my Khmer teacher - I found myself praying to Buddha. When I checked on her at the hospital afterwards she was worse. Her urine production was low, her breathing faster. J noticed that the dose of Amiodarone was too low (being an idiot I had misread the prescription chart) so we spoke to the duty doctor & increased the oral dose. In my heart I knew it was hopeless.

On Monday J went down to Phnom Penh for meetings - I waited for a miracle, it didn't happen.

Tuesday we had planned for J to buy 8 ampoules of Amiodarone ($40) & send them up by Taxi. The girl had been in a wide complexed tachycardia for 3 weeks by now.

I went to the ward first thing to find that the girl's parents had been told to take her home to die, as she was a hopeless case. I explained to the mother that we were arranging for medicine to be sent up & if she stayed in hospital we could give it to her daughter that evening. I went to tell the staff not to send her home & 'the lovely nurse' (as my VA now calls her) was there & shouted that she had been told to go home & that's what should happen. I tried to explain that we were buying the medicine she needed but SP's malignant presence meant my words fell on deaf ears.

I wrote in the notes a prescription for IV Amiodarone & tried to explain to the nursing staff how to give. SP shouted at me to just go & talk to pharmacy, she wouldn't do anything as she did not trust my translator's translation. I calmly & assertively told her it was none of her business - she wasn't on duty.

L & I went to cool down & have a coffee, when we came back to the ward. SP AKA 'the lovely nurse'  had left & suddenly every nurse was very receptive to learn how to deliver a loading dose & then maintenance infusion of Amiodarone. Dr L was the doctor on duty - I tried to explain to him that giving IV Amiodarone in a shocked patient was less than ideal but she was going to die if we didn't try. He wasn't particularly interested in listening to anything I had to say.

I waited for the package from Phnom Penh to arrive.

At 5 30 pm my VA picked up the package & I met her at the hospital (interrupting my khmer lesson with S). We gave the 8 ampoules to the nurse on the ward & I called J who with was in a meeting with the head nurse who in turn called the ward to check that they would give as I had prescribed.

Out of courtesy & concern I called Dr L to inform him that the Amiodarone had arrived. His response - "I am busy" (at his private clinic) "You do" (I had taken a history, examined her, diagnosed the patient, taken bloods, repeated an ECG, stopped the life threatening drugs he had prescribed, checked on her everyday, rang around trying to get the right treatment for her, arranged for IV Amiodarone to be sent up, stopped her from being sent home to die as a hopeless case - WHAT EXACTLY DID HE WANT ME TO DO?!) and then finally the one that really felt like a punch in the solar plexus "Why are you telling me, it is not my problem - it is not my responsibility" (He is the head of service for ICU medicine and was the doctor on duty that night).

That night I woke with a start after a vivid dream where the girl died because of the Amiodarone loading dose. It was 4 am. As I was drifting back to sleep my phone rang. S - my khmer teacher - was calling me but in my semiconscious state it felt like I was back in the UK on call & I knew the call was about the girl. S was agitated - she was insisting I went to the hospital to check on the patient, she couldn't sleep, GO NOW she kept imploring me. I looked at the clock - it was 4 20 am. I whatsappe'd J to tell her what happened & that I was a little freaked out, fully expecting her not to get the message until the morning. She responded immediately that she couldn't sleep either & had also been thinking about the girl. I was even more freaked out.

I waited for a reasonable hour to go to the hospital. I reminded myself that this is why I chose emergency medicine over ward medicine.

I went at 6 30 am to the hospital. She was still alive, I considered converting to Buddhism.

The nurses were agitated & looked worried - they were telling me that she had reacted badly to the medicine. Not surprisingly the Amiodarone had reduced her blood pressure further before it had converted her back to a normal sinus rhythm. Whilst J, S & I had fretted & tossed & turned all night, the patient had her first decent nights sleep in 3 weeks in normal sinus rhythm. The mother looked like a different woman - she had slept well too & when I told her we hadn't slept as we were so worried, she just laughed & gave me a big hug.

I repeated the ECG and this showed that the patient had Wolf-Parkinson-White Syndrome - WPW. I explained to the patient & her relatives what was wrong, what she could do if it happened again & what needed to happen next. The mother didn't want me to leave (she had seen me come to the hospital with a rucksack) and asked what would happen without me to be her daughters advocate. I explained that the staff had told her to go home to die as they did not have the knowledge & skills to know any better -  that's why I am here, its my job to capacity build them. It was a minor epiphany.

Dr S came to check on her. He had been to the hospital technical committee meeting the afternoon before to say that drugs like IV Amiodarone are necessary & if a 'poor card' patient needs them they should be bought my the hospital & not by Barangs. He thought it was best if the patient was transferred to his medical ward for further management now she had a blood pressure & a palpable pulse. This gave me hope.

I then had to go to Phnom Penh later that day but the next day L emailed me;

"This morning i visited the young patient in POP. She is getting better. She is on Glucose IV now.
Her abdomen is less swollen, and her breathing is better. She has appetite to food and drink.
I can say she looks better.  Oh! her mom asked me to say" thanks you! how are you?" to you.
She said you save her daughter life and thanks for your kindness.She is very thankful to you.

I will let you know if there is anything wrong."

And I so here I wait, wondering what else can go wrong & really hoping it doesn't.

Pitting oedema

'Bad' ECG

After chemical cardioversion, 'better' ECG revealed the diagnosis of WPW

IV Amiodarone - eventually!