How not to capacity build....

This week on ICU medicine there was a woman in her 20's with a high fever. Her mother asked me if I could help - this happens a lot more now that I have a female VA - L. I think that the female relatives, who do the main care giving for patients here, feel more comfortable asking L for help than they did with my 3 previous male VAs. This is good but as it turned out can also be bad, or more specifically it makes me bad. When a mother is in tears begging me to help her it makes it very difficult for me to remain detached & professional in the face of laziness, negligence & corruption.

The first time I was asked to help her I noticed that despite coming from a malaria area she hadn't had a malaria test so I 'advised' to the doctor she might need one. She had been on a combination of antibiotics for 4 days which should have covered most bacterial illnesses so we needed to exclude malaria.

The following day when I went back she was still febrile & no better and her malaria screen was negative. The mother was in tears because none of the staff were bothering with her daughter whose condition was getting worse & she was beside herself with worry. I went to speak with Dr V - the doctor on duty. I 'advised' that perhaps she needed a change in antibiotics - she had symptoms consistent with meningitis so a LP (lumbar puncture) was clinically indicated. On admission she had not had a full blood count (FBC) or blood culture & was given IV glucose as an IV fluid. These are some of my pet hates, as they are common errors that despite discussion & training ad nauseum & in the face of reason the doctors still stubbornly refuse to change. 

When I questioned Dr V about these management decisions I couldn't hide the irritation or frustration in my voice - this is not how one should capacity build but as I was soon to discover I was actually at breaking point. He defensively told me that you didn't need a FBC in all patients, apparently a fever of 40˚C, a pulse of 100/min, a respiratory rate of 22/min and a BP of 90/40 didn't warrant this (wrong). Secondly blood cultures are not to be done immediately but only after a patient has been on antibiotics for at least a week (wrong) & finally IV glucose IS an IV fluid which can be used for resuscitation especially when you have run out of Normal Saline (wrong & they had plenty of Normal saline in the ward's emergency drug stock).

So what about changing the IV antibiotics? I asked - already done by Dr L, I was told by Dr V (a lie - when I went to check later Dr V added the new Antibiotic prescription after his conversation with me). But we could agree that an LP was indicated in a patient with a fever, headache, neck pain, vomiting & photophobia.

I suspected that perhaps the reason it hadn't been done sooner was the doctors ability to do an LP is limited. So I offered to support him doing it if he thought that would be helpful, which he looked quite relieved about. I then asked when would it be done, at this point nurse P looked up & started shouting at me telling me how busy she was. I don't know whether it was 17 months of daily similar hostility towards me, the mother crying on my shoulder before, the unprovoked aggression (I had simply asked the doctor what time he planned to do the LP?), the fact she was lying (she had been sat for at least 30 minutes watching TV before she said she was "too busy" to help do an LP) or just the fact that the start of the rainy season meant the monks now wake me up at 4 am every morning - but for whatever reason I completely lost it - saw red - hit 9 on the VAS for anger.

That is just an excuse I told her, not a reason. She wasn't busy, just lazy, paper work & watching TV is not as important as patient care & her priority should be the patients. L would have preferred to have translated "I can see you are really busy but how can I help you?" but as I explained later I've tried that approach for the last year & a half almost & in my view it just reinforces their behaviour. I have had enough of witnessing & tolerating behaviour that quite literally kills people. Obviously telling nurse P, however politely, that she wasn't doing her job properly escalated the situation to yelling, pointing & abuse (the staff) and me leaving the ward before I said anything else that I regretted.

But then Dr V slipped out after me (despite being on duty) to go to his private clinic, leaving the patient's management unresolved & I really saw red. I re-traced my steps & intercepted him. I told him that because the staff were too lazy to do their job this patient would die & that just because she was poor it didn't mean she wasn't entitled to basic health care. I said that the actions of the staff resulted in patients dying. I did all of this whilst resisting the urge to grab him by the lapels & shake him - I was as I may have previously intimated VERY ANGRY.

I went to my office & cried for a bit - tears of anger & frustration not sadness.

I went back to the ward to speak with the mother. She was clutching a piece of paper with a list of equipment required to do an LP given to her by the staff - she had a poor card so the health equity fund pay for the care but the staff had told her that if she didn't buy this equipment they would not treat her daughter. I didn't think I could have got any angrier but I was wrong. I went back to the staff & asked them what this meant. The chief of ward said he didn't have the stock & neither did pharmacy. I explained I would address this as it was morally wrong to refuse treatment on account of patients not having funds & anyway the PFD (poor family development) fund should pay for this. He shrugged & said he didn't care. I resisted the urge to punch him. I asked calmly that if the LP was delayed then the new antibiotics should not be delayed & needed to be given as soon as possible. Please don't delay treatment I begged. Nurse P came up to me & shouted at me about how busy she was - spitting in my face in her rage - but at least she had gotten out of her chair for the first time that morning.

Pharmacy said they didn't have the equipment but the next day I discovered they did but were lying to me. The Deputy director in charge of the technical committee & supplies refused to talk to me. The other deputy director listened to L tell the story of the morning's events & agreed that staff had no right to refuse treatment & make poor patients pay for equipment that the hospital should provide. The staff should have advised the mother to go to PFD to get money to buy the equipment but in fact they wanted the money themselves. It was just another case of good old fashioned corruption. The deputy director knew this was a delicate situation so he told me not to go back to the ward & he would sort it out i.e nothing would change & patients will continue to die if they can't afford bribes.

I went to have a coffee with L - apologizing for all my high expressed emotion. In Cambodia people keep a lid on their emotions & I knew that my anger & upset was making L feel intensely uncomfortable. The Paediatric all stars were also having coffee they took one look at me & knew I needed cheering. They told me that I should work more with them & their opinion of the ICU medicine staff was similar to mine. Dr M showed me a book that he got for his daughter from the library that was in both english & khmer - I read in khmer which he tried not to be impressed by. 

Despite the deputy director telling me not to go back to the ward there was the small matter of a patient who was seriously ill & required the correct treatment. L agreed we needed to go back if only to explain to the mother that the staff couldn't demand extra payments. We did this & then I noticed that after 2 & half hours the patient still hadn't received her antibiotics. 

Poor L followed me back into the staff room. I had regained my composure, the staff were all sat watching TV. I sat down with them & asked "If you had suspected meningitis how quickly would you like your antibiotics given?" Nurse P lost it with me - I calmly sat saying - just a question! She walked out. I asked the doctors (Dr V & a newly qualified Dr who is volunteering until he gets a permanent job) what they were taught at medical school about how quickly antibiotics should be administered. They both said as soon as possible but it wasn't their problem and then they too walked off.

L & I sat there until every other member of staff had left for lunch & it was just us & Nurse S - a very quiet & good nurse. He asked me "what is it you want me to do for the patient?" - I love him for this question.

I explained that she needed the antibiotics that she had been prescribed ASAP. He explained that she had already had different antibiotics at 6 am that morning and so why ASAP? surely we should wait until the next dose is due? I explained that the old antibiotics weren't effective & we should disregard them when planning a time to give the new one which was better for suspected meningitis. He understood this explanation so went to the emergency drug cupboard to give them before he also left for lunch. He returned with two used vials of antibiotic in his hand - "ot mean".

Silently & repeatedly I banged my head on the table. The emergency drug cupboard should be re-stocked everyday but obviously the staff had been 'too busy' to do this, there was no antibiotic to give. 

On reflection & even at the time, I knew that I obviously handled this whole situation completely wrongly. That afternoon I had a meeting with other volunteers working in livelihoods & education. They told me it is the same for them in their placements. But to me it just doesn't feel like its really the same - no one dies in their day jobs as a result of their inability to change people minds & behaviours. I seem to be collecting a large cohort of patients that I feel personally responsible for failing to save & when my frustration spills over into my interactions with staff it causes even more problems for the patients as a result. 

J hasn't been here for a fortnight to ask WWJD? R (one of my favourite Cambodians - along with his family) was away when this happened but I text him about it after the event. His response was this "Oh no. How awful! How can I help? You know I too sometimes hate the staff, especially the staff who are rich and show off even they are f*****g lazy." And that's when I knew it wasn't all hopeless because although I am failing to improve health care in Cambodia, I have at least taught one Cambodian to swear like a docker & to use anglo-saxon grammatically correctly.