Recently myself & another VSO health volunteer undertook a health facility review. We visited various hospitals & clinics in Phnom Penh & Siem Reap trying to assess what was the most appropriate pathway to send volunteers with health problems down. I had even tried to write a draft algorithm based on the most common presentations - the overwhelming complaints are good old reliable gastroenteritis & upper respiratory tract infections - no need for an air ambulance for these.
Of course if the health service in Cambodia was adequate we wouldn't be here as health volunteers, so ultimately all serious ill & injured volunteers are medically evacuated to Bangkok. As a doctor, who gets a pretty constant stream of medical advice calls, since being in country I've been a little anxious about what would happen to a volunteer out in the provinces who was seriously ill or injured whilst they waited for the cogs of medical evacuation to turn. Last weekend I found out first hand.
I don't get lie ins, this is mainly because I live next door to a Wat but also because at the weekend I have early morning khmer lessons. So at 7 30 am last Saturday I was sat in my nightie (underwearless - this will become relevant soon) with my teacher for the momentous occasion of starting the grade 2 book. My phone started to ring with a mystery number but as it is normal practice here to buy a SIM card on a deal & use up the credit then move on to a new SIM, I have got into the habit of answering all calls from strange numbers.
It was D my favourite Tuk Tuk driver - I was confused. He seemed to be telling me he was outside my house & there had been an accident. It was only last week that we hit the moto coming back from the circus - perhaps that is what he was referring to. Then he mentioned another volunteer's name, E, & told me she had been in an accident. Concerned but mainly curious (This is not E's first dalliance with accidents) I went down to see after pulling on a pair of shorts - so I am now sporting a nightie-short combo. D met me anxious & agitated - my curiosity shifted to full concern. Outside my house E was slumped in D's Tuk Tuk grey, clammy, barely conscious & with an obvious broken leg. It was at this point that I thought that a nightie-short-underwearless combo was probably not going to serve me too well today.
I was later able to piece together that E had been turning left on her bicycle on the way to the market & a moto coming the other direction had hit her. Someone from the college she volunteers in recognised her & soon many people she knew were there trying to help her. D drove past & recognised her to, so put her into his Tuk Tuk & then because of the incident last week he knew to take her straight to Emergency Hospital - an NGO Hospital with by far the best Trauma care in Cambodia - we are extremely lucky here in Battambang. On the way there they drove past my house & E in her shock & pain still had the good sense to ask D to stop & ring me. She also very smart to be wearing a cycle helmet so that her injury was limited to an isolated limb.
Now I was running back to my house to get money & phone, to my teachers bemusement. People just don't run here, especially in the hot season.
The tuk tuk ride was a little bumpy & probably not the most appropriate form of transportation for a person with a unstable limb fracture but here tuk tuks are the main form of pre-hospital transport, along with unconscious patients being wedged between a moto driver & another pillion. My PTC brain is thinking perhaps we should be training basic trauma care to tuk tuk drivers & in the communities.
Getting E out of the tuk tuk & onto the trolly once we arrived at Emergency Hospital was a challenge. The ER staff came out (better than when I came with the unconscious moto driver but I'm guessing an injured barang has more curiosity pull) & it started off well with them putting on a temporary splint on E's injured leg. When lifting her to transfer onto to a trolly the head, body & injured leg were all coming in the right direction but her good leg was left behind causing her to come the closest to doing the splits in her adult life. She recalled later it reminded her of skiing.
Inside there wasn't much ABC action going on but I was happy that E had an airway (she was screaming at them every time they touched her leg), was breathing & had a good circulation. Every one seemed fixated on the obviously swollen & fracture leg - this is a common issue in trauma care. In fact they were keen to put on a permanent splint - I very assertively had to suggest that perhaps they do a set of observations & put in an IV & give her analgesia & THEN splint her leg. This involved me having to physically obstruct access to E's bad leg & raise my voice.
I've spent the last 13 months being gentle in my suggestions & not taking over patient care in an attempt to capacity build. Sometimes its frustrating for me (I've blogged numerous examples) to watch complete strangers suffer & receive inadequate care, lacking in compassion or what I consider competence, but when it is a close friend I simply couldn't bare it. They wouldn't put in a line until the doctor 'ordered' it & the doctor was in a meeting. After much haranguing a nurse attempted to find a vein, at this point E informed me she has useless veins. I tried to direct the nurse to a good vein on the back of her hand to cannulate. He spent a good 2 minutes rooting around in the back of E's hand with E demonstrating her airway was still open. Then I just took over, put a line in the other hand (the first in 15 months), then put up fluids, gave her Tramadol (the doctor had come by now & prescribed analgesia & requested a X-ray) & then was also was nominated to give her IM Diclofenac. Then I let them put on a splint - they by now had worked out I wasn't a physiotherapist that was visiting Battambang but was in fact an Emergency Physician who worked at the referral hospital - they were all resigned to the fact I wasn't going anywhere & wasn't going to make their lives easy.
I rang the VSO emergency phone to explain that there had been an accident & that I anticipated we would need to medically evacuate E.
E was comfortable, less grey & her observation were stable, I was told I could push her to X-ray. 15 months as an anaesthetist has put me a good shape for trolley pushing. The radiologist was the same man that had X-rayed my ankle & who I had spent Christmas eve with at the Bambu so things started to go a lot more smoothly. Can I see the X-ray? I asked, Why not! came the reply. It was in deed broken & required a CT scan & operation. I rang back VSO emergency phone to confirm the wheels of medically evacuation needed turning.
The doctor came to tell us that if we didn't trust Cambodian health professionals he wouldn't be offended if E was transferred. I explained that we were thousands of miles from our family & friends & when we were sick we needed to be in our own culture & surrounded by people to support us. I don't think he bought it.
It was just after this I got a text from another volunteer saying that a programme office staff member had rang her thinking it was her who had been in an accident to see if she was OK. Communicating in a second language with poor mobile phone reception is fraught with difficulties & confidentiality is not a concept embraced here in Cambodia.
By now there was half of E's college in the ER with us & E was flying on the Tramadol. I called up K - my new roomie - & asked her to make up an bag for E to go to Bangkok with. All this is complicated by two things. 1) E was due to leave Battambang & finish her placement in 48 hours & her house was half packed up 2) E was having a leaving party that evening & had bought half a pig. At this point she was keen to get up as she was feeling better & carry on preparing for the party. I strongly advised against this. Instead I began ringing people to cancel the party.
Then the day-long, long distance, telephone conversation with Danny from AXA began. Considering it was 3 am in the UK he seemed like a pleasant young man.
Whilst they plastered E's leg, after I'd insisted they gave her more analgesia & I'd lectured on giving opiates until the patient is pain free & still breathing rather than a homeopathic doses every 6 hours, I spoke with the AXA doctor. She wanted to know what E's baseline Haemoglobin was - I explained this was Cambodia - I'm used to this being explanation enough but on this occasion I needed to expand.
Danny asked me if E was under the influence of alcohol - I flippantly replied that she was Irish & it was 7 30 in the morning so I'd check. "I most certainly WAS NOT!" came her indignant reply. Things were looking more normal. Danny also asked if we had a police report to which I replied less flippantly - this is Cambodia you can get whatever police report you pay for. E appreciated that comment. She had already been asked if she wanted to press charges & have compensation - she had declined.
Next an emotional khmer girl rushed in - sobbing & clutching E's good leg. Who is she? E asked, it soon became apparent that she was in fact the moto driver that had broken her leg. Because E had declined any 'compensation' the girl was so grateful she wanted to come & cry over E for a while. E gave her a lecture on driving too fast & looking where she is going, E is, after all, a teacher.
E's VA arrived with a packed bag but had forgotten the essential tooth brush charger & E also needed money so happy that she was stable & sleepy with Tramadol I slipped off to a) Shower & get out of my nightie-shorts combo b) have breakfast (it was 11 30) c) go to E's house to retrieve tooth brush charger (& observe that the place seemed to me less than half packed - at least I knew what I'd be doing for half of the next week!) & d) go to the ATM to get $$$. We also established that L who was traveling to BTB for the party (& is conveniently a nurse) was happy to travel with E to Bangkok. My passport was locked in the bowels of the Ministry of immigration waiting for a visa renewal. L's was at the programme office in Phnom Penh & could be sent up to Siem Reap where E would be flown out from.
K & I then went back to see the patient. By this time the various college staff, hysterical, careless moto driver, VA, landlady et al had left & E was in a blissful opiate induced sleep. Whilst K kept E entertained, I chatted with the ER staff. They seemed OK with me completely taking over before - one even asked if I could come & work at Emergency so he could learn more from me! The matron - a bloody marvelous woman - was very concerned about E staying on a trolley waiting for an ambulance. At this point it was 1 pm & my blossoming relationship with Danny from AXA hadn't enlightened us to when an ambulance would materialize. E was moved to ICU to a comfortable bed & we were sent off to find food for the hungry patient.
It was at this point that L text us to say that her passport had been mistakingly sent to Battambang but someone from VSO was quite literally chasing it.
Whilst waiting for take out food to be prepared at the old faithful Bamboo Train Cafe the heavens opened & despite taking a tuk tuk back to the hospital Katie & I arrived at ICU soaked through to the bone. That's what I love about the tropics you can be beside yourself with heat & blinded by sweat yet 30 minutes later you are quite literally hypothermic - shivering with goose-bumps.
L had arrived with Gin, marshmallows & Reeses peanut butter cups, so the bed picnic began. The ICU staff were attentive & kind & just re-affirmed why emergency hospital is the best of its kind in Cambodia. E was getting cranky as she wanted a cigarette so they wheeled her out to the veranda where a patient with half his hand missing, bound in bandages, reprimanded her & pointed to the no smoking sign. There she was, full leg back slab, leg elevated, hair disheveled, sign above her bed mis-spelling her name 'Eun Soner', mystery pink towel draped across her midrift & fag in hand being told off by a fellow patient - I wish I had my camera but I hope I have painted the picture well enough.
I rang AXA - still no news on an ETA for the ambulance. Then the hospital in Siem Reap that would house E whilst she waited for the air ambulance called to get details - their ETA 6 30pm. So L, K & I left E to sleep whilst we went to grab a drink & some food before L set off on her own incredible journey with E.
We arrived back at 6 35pm to the shocking sight of blue flashing lights - it is not often in this country that when someone says a time, that is the time they mean, unless of course we are talking about parties - I am reliably informed.
E was looking a little worried as the ambulance crew were putting a bright orange vacuum splint on her leg. I tried to explain to them that as she already had a full leg back slab splint there was no need for a pre-hospital vacuum splint BUT they were following their protocol so my words fell on deaf ears. This as it turned out was to cause E a lot of pain & worsen her fracture blisters - being female & not old enough really is a liability here.
So we loaded E & L with all there bags onto the ambulance and at 7 pm (12 hours after her accident) they disappeared into the night. K & I went to have a very big G&T.
E & L's adventures had only just begun......
And in case you are wondering where this blog sits with my medical code of conduct & confidentiality, E has read this from her hospital bed in Bangkok & her only edit was to make me add in the comment about cycle helmets & how everyone should wear one. Its the law in Australia - perhaps those australians aren't half as bad as I think!
Of course if the health service in Cambodia was adequate we wouldn't be here as health volunteers, so ultimately all serious ill & injured volunteers are medically evacuated to Bangkok. As a doctor, who gets a pretty constant stream of medical advice calls, since being in country I've been a little anxious about what would happen to a volunteer out in the provinces who was seriously ill or injured whilst they waited for the cogs of medical evacuation to turn. Last weekend I found out first hand.
I don't get lie ins, this is mainly because I live next door to a Wat but also because at the weekend I have early morning khmer lessons. So at 7 30 am last Saturday I was sat in my nightie (underwearless - this will become relevant soon) with my teacher for the momentous occasion of starting the grade 2 book. My phone started to ring with a mystery number but as it is normal practice here to buy a SIM card on a deal & use up the credit then move on to a new SIM, I have got into the habit of answering all calls from strange numbers.
It was D my favourite Tuk Tuk driver - I was confused. He seemed to be telling me he was outside my house & there had been an accident. It was only last week that we hit the moto coming back from the circus - perhaps that is what he was referring to. Then he mentioned another volunteer's name, E, & told me she had been in an accident. Concerned but mainly curious (This is not E's first dalliance with accidents) I went down to see after pulling on a pair of shorts - so I am now sporting a nightie-short combo. D met me anxious & agitated - my curiosity shifted to full concern. Outside my house E was slumped in D's Tuk Tuk grey, clammy, barely conscious & with an obvious broken leg. It was at this point that I thought that a nightie-short-underwearless combo was probably not going to serve me too well today.
I was later able to piece together that E had been turning left on her bicycle on the way to the market & a moto coming the other direction had hit her. Someone from the college she volunteers in recognised her & soon many people she knew were there trying to help her. D drove past & recognised her to, so put her into his Tuk Tuk & then because of the incident last week he knew to take her straight to Emergency Hospital - an NGO Hospital with by far the best Trauma care in Cambodia - we are extremely lucky here in Battambang. On the way there they drove past my house & E in her shock & pain still had the good sense to ask D to stop & ring me. She also very smart to be wearing a cycle helmet so that her injury was limited to an isolated limb.
Now I was running back to my house to get money & phone, to my teachers bemusement. People just don't run here, especially in the hot season.
The tuk tuk ride was a little bumpy & probably not the most appropriate form of transportation for a person with a unstable limb fracture but here tuk tuks are the main form of pre-hospital transport, along with unconscious patients being wedged between a moto driver & another pillion. My PTC brain is thinking perhaps we should be training basic trauma care to tuk tuk drivers & in the communities.
Getting E out of the tuk tuk & onto the trolly once we arrived at Emergency Hospital was a challenge. The ER staff came out (better than when I came with the unconscious moto driver but I'm guessing an injured barang has more curiosity pull) & it started off well with them putting on a temporary splint on E's injured leg. When lifting her to transfer onto to a trolly the head, body & injured leg were all coming in the right direction but her good leg was left behind causing her to come the closest to doing the splits in her adult life. She recalled later it reminded her of skiing.
Inside there wasn't much ABC action going on but I was happy that E had an airway (she was screaming at them every time they touched her leg), was breathing & had a good circulation. Every one seemed fixated on the obviously swollen & fracture leg - this is a common issue in trauma care. In fact they were keen to put on a permanent splint - I very assertively had to suggest that perhaps they do a set of observations & put in an IV & give her analgesia & THEN splint her leg. This involved me having to physically obstruct access to E's bad leg & raise my voice.
I've spent the last 13 months being gentle in my suggestions & not taking over patient care in an attempt to capacity build. Sometimes its frustrating for me (I've blogged numerous examples) to watch complete strangers suffer & receive inadequate care, lacking in compassion or what I consider competence, but when it is a close friend I simply couldn't bare it. They wouldn't put in a line until the doctor 'ordered' it & the doctor was in a meeting. After much haranguing a nurse attempted to find a vein, at this point E informed me she has useless veins. I tried to direct the nurse to a good vein on the back of her hand to cannulate. He spent a good 2 minutes rooting around in the back of E's hand with E demonstrating her airway was still open. Then I just took over, put a line in the other hand (the first in 15 months), then put up fluids, gave her Tramadol (the doctor had come by now & prescribed analgesia & requested a X-ray) & then was also was nominated to give her IM Diclofenac. Then I let them put on a splint - they by now had worked out I wasn't a physiotherapist that was visiting Battambang but was in fact an Emergency Physician who worked at the referral hospital - they were all resigned to the fact I wasn't going anywhere & wasn't going to make their lives easy.
I rang the VSO emergency phone to explain that there had been an accident & that I anticipated we would need to medically evacuate E.
E was comfortable, less grey & her observation were stable, I was told I could push her to X-ray. 15 months as an anaesthetist has put me a good shape for trolley pushing. The radiologist was the same man that had X-rayed my ankle & who I had spent Christmas eve with at the Bambu so things started to go a lot more smoothly. Can I see the X-ray? I asked, Why not! came the reply. It was in deed broken & required a CT scan & operation. I rang back VSO emergency phone to confirm the wheels of medically evacuation needed turning.
The doctor came to tell us that if we didn't trust Cambodian health professionals he wouldn't be offended if E was transferred. I explained that we were thousands of miles from our family & friends & when we were sick we needed to be in our own culture & surrounded by people to support us. I don't think he bought it.
It was just after this I got a text from another volunteer saying that a programme office staff member had rang her thinking it was her who had been in an accident to see if she was OK. Communicating in a second language with poor mobile phone reception is fraught with difficulties & confidentiality is not a concept embraced here in Cambodia.
By now there was half of E's college in the ER with us & E was flying on the Tramadol. I called up K - my new roomie - & asked her to make up an bag for E to go to Bangkok with. All this is complicated by two things. 1) E was due to leave Battambang & finish her placement in 48 hours & her house was half packed up 2) E was having a leaving party that evening & had bought half a pig. At this point she was keen to get up as she was feeling better & carry on preparing for the party. I strongly advised against this. Instead I began ringing people to cancel the party.
Then the day-long, long distance, telephone conversation with Danny from AXA began. Considering it was 3 am in the UK he seemed like a pleasant young man.
Whilst they plastered E's leg, after I'd insisted they gave her more analgesia & I'd lectured on giving opiates until the patient is pain free & still breathing rather than a homeopathic doses every 6 hours, I spoke with the AXA doctor. She wanted to know what E's baseline Haemoglobin was - I explained this was Cambodia - I'm used to this being explanation enough but on this occasion I needed to expand.
Danny asked me if E was under the influence of alcohol - I flippantly replied that she was Irish & it was 7 30 in the morning so I'd check. "I most certainly WAS NOT!" came her indignant reply. Things were looking more normal. Danny also asked if we had a police report to which I replied less flippantly - this is Cambodia you can get whatever police report you pay for. E appreciated that comment. She had already been asked if she wanted to press charges & have compensation - she had declined.
Next an emotional khmer girl rushed in - sobbing & clutching E's good leg. Who is she? E asked, it soon became apparent that she was in fact the moto driver that had broken her leg. Because E had declined any 'compensation' the girl was so grateful she wanted to come & cry over E for a while. E gave her a lecture on driving too fast & looking where she is going, E is, after all, a teacher.
E's VA arrived with a packed bag but had forgotten the essential tooth brush charger & E also needed money so happy that she was stable & sleepy with Tramadol I slipped off to a) Shower & get out of my nightie-shorts combo b) have breakfast (it was 11 30) c) go to E's house to retrieve tooth brush charger (& observe that the place seemed to me less than half packed - at least I knew what I'd be doing for half of the next week!) & d) go to the ATM to get $$$. We also established that L who was traveling to BTB for the party (& is conveniently a nurse) was happy to travel with E to Bangkok. My passport was locked in the bowels of the Ministry of immigration waiting for a visa renewal. L's was at the programme office in Phnom Penh & could be sent up to Siem Reap where E would be flown out from.
K & I then went back to see the patient. By this time the various college staff, hysterical, careless moto driver, VA, landlady et al had left & E was in a blissful opiate induced sleep. Whilst K kept E entertained, I chatted with the ER staff. They seemed OK with me completely taking over before - one even asked if I could come & work at Emergency so he could learn more from me! The matron - a bloody marvelous woman - was very concerned about E staying on a trolley waiting for an ambulance. At this point it was 1 pm & my blossoming relationship with Danny from AXA hadn't enlightened us to when an ambulance would materialize. E was moved to ICU to a comfortable bed & we were sent off to find food for the hungry patient.
It was at this point that L text us to say that her passport had been mistakingly sent to Battambang but someone from VSO was quite literally chasing it.
Whilst waiting for take out food to be prepared at the old faithful Bamboo Train Cafe the heavens opened & despite taking a tuk tuk back to the hospital Katie & I arrived at ICU soaked through to the bone. That's what I love about the tropics you can be beside yourself with heat & blinded by sweat yet 30 minutes later you are quite literally hypothermic - shivering with goose-bumps.
L had arrived with Gin, marshmallows & Reeses peanut butter cups, so the bed picnic began. The ICU staff were attentive & kind & just re-affirmed why emergency hospital is the best of its kind in Cambodia. E was getting cranky as she wanted a cigarette so they wheeled her out to the veranda where a patient with half his hand missing, bound in bandages, reprimanded her & pointed to the no smoking sign. There she was, full leg back slab, leg elevated, hair disheveled, sign above her bed mis-spelling her name 'Eun Soner', mystery pink towel draped across her midrift & fag in hand being told off by a fellow patient - I wish I had my camera but I hope I have painted the picture well enough.
I rang AXA - still no news on an ETA for the ambulance. Then the hospital in Siem Reap that would house E whilst she waited for the air ambulance called to get details - their ETA 6 30pm. So L, K & I left E to sleep whilst we went to grab a drink & some food before L set off on her own incredible journey with E.
We arrived back at 6 35pm to the shocking sight of blue flashing lights - it is not often in this country that when someone says a time, that is the time they mean, unless of course we are talking about parties - I am reliably informed.
E was looking a little worried as the ambulance crew were putting a bright orange vacuum splint on her leg. I tried to explain to them that as she already had a full leg back slab splint there was no need for a pre-hospital vacuum splint BUT they were following their protocol so my words fell on deaf ears. This as it turned out was to cause E a lot of pain & worsen her fracture blisters - being female & not old enough really is a liability here.
So we loaded E & L with all there bags onto the ambulance and at 7 pm (12 hours after her accident) they disappeared into the night. K & I went to have a very big G&T.
E & L's adventures had only just begun......
And in case you are wondering where this blog sits with my medical code of conduct & confidentiality, E has read this from her hospital bed in Bangkok & her only edit was to make me add in the comment about cycle helmets & how everyone should wear one. Its the law in Australia - perhaps those australians aren't half as bad as I think!
Crikey!
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