The day after discussing with the head nurse, Mr S, about staff stealing special food bars (BP-100) meant for malnourished children, I went back to the paediatric ward to check on a child with SAM (severe acute malnutrition) & take some photos of her clinical signs (skin & hair changes, foot oedema) for training purposes.
On approaching the ward it became clear they were having a cleaning day - all the beds & mattresses were wet & glistening outside, drying in the sun. The nurse who had stolen the BP-100 was washing her car & the cleaners son was running around it giggling, having fun splashing in the puddles & being occasionally sprayed with water from the hose.
It was a great scene but before I could get out my camera the nurse looked up, saw us, stopped cleaning, then apologized in english to me & L. She was just washing her car & there are no patients to be seen, she said, looking very contrite.
I'm not even sure if Mr S had spoken to the staff about the BP-100 but I was puzzled as to how the same staff that steal medicines, without a hint of remorse or guilt, in front of me, now think that washing a car is a shameful act. I know that it is maybe not the best use of work time but surely it is not worse than stealing from starving children. Is their moral compass really that skewed? Maybe they don't even think in terms of what is moral or immoral, maybe for them it is about what they can get & have.
It got me thinking of how children need boundaries & limits, morality is nurtured. I wondered if the same was true of the staff - their leadership is corrupt & role models are lacking. There needs to be some explanation of what is expected of health workers, what is appropriate & inappropriate. If good behaviour was rewarded then maybe they wouldn't reward themselves, by stealing & taking bribes, to supplement their low salaries. The introduction of the naughty step may be a step too far but some enforcement of fair rules & regulations is definitely needed here. Two thirds of the budget for medications in Cambodia not being 'skimmed off' before it reaches the patients may be a good place to start.
I went inside to take the SAM photos. The child was in respiratory distress, grey, clammy & looked like she was about to die. It was a Friday and I had broken the cardinal rule which is 'NEVER visit the paeds ward on a Friday' - no good ever comes of it.
Speaking with the mother & examining the child it seemed quite clear that she had aspirated on her NG feeds.
I tried to speak with the staff, who were about to give insulin for high blood sugar & absolutely refused to accept that it was an NG tube problem. Which was odd because when we arrived they were actually in the process of changing the NG tube. They also refused to admit that the blood sugar machine could ever be wrong & would not send a second sample to the lab to double check. I quote 'the machine is NEVER wrong'. And when I tried to explain that if this child had aspirated she was going to get even sicker & we should act preemptively by referring her to the NGO hospital in Siem Reap with an ICU, where they could intubate & ventilate, sooner rather than later - they shrugged & said "the child is sick, they will die".
Iced coffee has become my valium.
Whilst sucking up condensed milk I called Dr Ch who works at the NGO hospital. Puzzled he agreed with my assessment & management plan for the child, why was I calling him for advice?
I explained to him that after 2 years of being ignored & at best treated with disbelief & disrespect, you begin to really doubt myself. Sometimes its useful to hear that there are other doctors who would do the same as you - that you both have the same boundaries.
Dr Ch was happy to have the child transferred to his ICU. Whether the staff did this I don't know because I can only advise and this medical advisor had reached her limit.
The post script to this story is - the day before I had been advising on relactation for the same baby. The mother, my VA, the doctor & the nurses all refused to believe that the mother could relactate after a period of 6 months of not breast feeding the child (she was working in Thailand). I referred them to the SAM clinical practice guideline and the technique of suckling whilst giving tube feeds to stimulate production of maternal breast milk. They were skeptical & L was sure they wouldn't do it. I could understand that - sometime you need to see to believe. The nest day when I was asking the mother about the child's breathing problem, she told me it got worse after choking on an NG feed which is why the staff had changed the tube. It was only after leaving the ward that L pointed out I'd missed something, they had actually been attempting relactation. The mother had explained that the baby was suckling on her breast whilst being tube fed when she choked. You have to look hard for it but sometimes there is a positive.
On approaching the ward it became clear they were having a cleaning day - all the beds & mattresses were wet & glistening outside, drying in the sun. The nurse who had stolen the BP-100 was washing her car & the cleaners son was running around it giggling, having fun splashing in the puddles & being occasionally sprayed with water from the hose.
It was a great scene but before I could get out my camera the nurse looked up, saw us, stopped cleaning, then apologized in english to me & L. She was just washing her car & there are no patients to be seen, she said, looking very contrite.
I'm not even sure if Mr S had spoken to the staff about the BP-100 but I was puzzled as to how the same staff that steal medicines, without a hint of remorse or guilt, in front of me, now think that washing a car is a shameful act. I know that it is maybe not the best use of work time but surely it is not worse than stealing from starving children. Is their moral compass really that skewed? Maybe they don't even think in terms of what is moral or immoral, maybe for them it is about what they can get & have.
It got me thinking of how children need boundaries & limits, morality is nurtured. I wondered if the same was true of the staff - their leadership is corrupt & role models are lacking. There needs to be some explanation of what is expected of health workers, what is appropriate & inappropriate. If good behaviour was rewarded then maybe they wouldn't reward themselves, by stealing & taking bribes, to supplement their low salaries. The introduction of the naughty step may be a step too far but some enforcement of fair rules & regulations is definitely needed here. Two thirds of the budget for medications in Cambodia not being 'skimmed off' before it reaches the patients may be a good place to start.
I went inside to take the SAM photos. The child was in respiratory distress, grey, clammy & looked like she was about to die. It was a Friday and I had broken the cardinal rule which is 'NEVER visit the paeds ward on a Friday' - no good ever comes of it.
Speaking with the mother & examining the child it seemed quite clear that she had aspirated on her NG feeds.
I tried to speak with the staff, who were about to give insulin for high blood sugar & absolutely refused to accept that it was an NG tube problem. Which was odd because when we arrived they were actually in the process of changing the NG tube. They also refused to admit that the blood sugar machine could ever be wrong & would not send a second sample to the lab to double check. I quote 'the machine is NEVER wrong'. And when I tried to explain that if this child had aspirated she was going to get even sicker & we should act preemptively by referring her to the NGO hospital in Siem Reap with an ICU, where they could intubate & ventilate, sooner rather than later - they shrugged & said "the child is sick, they will die".
Iced coffee has become my valium.
Whilst sucking up condensed milk I called Dr Ch who works at the NGO hospital. Puzzled he agreed with my assessment & management plan for the child, why was I calling him for advice?
I explained to him that after 2 years of being ignored & at best treated with disbelief & disrespect, you begin to really doubt myself. Sometimes its useful to hear that there are other doctors who would do the same as you - that you both have the same boundaries.
Dr Ch was happy to have the child transferred to his ICU. Whether the staff did this I don't know because I can only advise and this medical advisor had reached her limit.
The post script to this story is - the day before I had been advising on relactation for the same baby. The mother, my VA, the doctor & the nurses all refused to believe that the mother could relactate after a period of 6 months of not breast feeding the child (she was working in Thailand). I referred them to the SAM clinical practice guideline and the technique of suckling whilst giving tube feeds to stimulate production of maternal breast milk. They were skeptical & L was sure they wouldn't do it. I could understand that - sometime you need to see to believe. The nest day when I was asking the mother about the child's breathing problem, she told me it got worse after choking on an NG feed which is why the staff had changed the tube. It was only after leaving the ward that L pointed out I'd missed something, they had actually been attempting relactation. The mother had explained that the baby was suckling on her breast whilst being tube fed when she choked. You have to look hard for it but sometimes there is a positive.
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