For the last two years I have been going to ICU medicine ward most working days in my role as a medical advisor with VSO. Whilst there I have been ignored, shouted at, mocked, told to leave & experienced many hostile exchanges or aggression; I have seen countless patients suffer & die whilst I have stood by seemingly powerless to change the outcome. I've blogged about it, I've talked about it & it has filled me with a slow burning rage that I now can't seem to extinguish. Since finishing my placement with VSO I have not been back there. It's a hateful place that has almost certainly shortened my life expectancy.
Over the last 2 years I have received various feedback from people working in health here; some say that I shouldn't care so much, that I am a bad capacity builder because I judge the health workers, that I should just leave if I don't like it, that I blame others for my own inadequacies, I don't respect cambodian culture, one person even reported that I am "never at work" & ineffective in my job - the list of criticism from people is endless, people are very generous when it comes to criticism.
Interestingly one day last week when I couldn't face the hospital so instead worked from home the head nurse said - Is Esther OK? I miss her. I know that working with Cambodians is very difficult. I hope she is OK.
I have also received some ill informed advice from NGO workers in other sectors. I want to be clear here, although I came to Cambodia as an 'advisor' I tried to only ever advise about things within my remit - I know nothing about education, livelihoods or governance so I refrained from the arrogance of assuming I knew how people in those sectors could do their jobs better.
People who are not here have always given me very positive feedback - but they are not here, so how can they really know whether what I do is any good or even worthwhile?
The result has been that I now doubt my own knowledge, credibility & worth. I've internalised the last 2 years of my failure & inadequacy. I don't go to ICU anymore because I believe it is me that is useless & ineffective because I have failed to effect change.
This week I was away training but J stayed at the hospital. J has been in Cambodia twice as long as me & as I have mentioned countless times in this blog is one of God's better people & someone whose opinion & experience I respect greatly.
J goes to ICU rarely as its not part of her role, but this week she went to audit oral & IV medication administration & vital signs there. This week J had a taste of what I have experienced every working day for the last 2 years. It left her raw & doubting herself also. Although I would never, ever wish ICU on anyone. her experience has helped me to realise that I am not alone. It has strengthened my resolve never to go back to that ward. It has made me realise I need to adapt how I process my experiences here & redirect my energy. It isn't just me & it may even actually be them!
I want to tell J's story as proof that its not just because I am judgemental, absent, useless, over sensitive or any of the other criticisms that are thrown at my feet, that I have struggled for 2 years on ICU. The reality of this place is that its an extremely difficult environment & to survive it one has to compromise one's self a little with every interaction.
Below is J's recounting of the incident.
"I visited ICU Medicine with L (Esther’s translator) and found a patient who had just been admitted. The patient was a young male prisoner. He was chained to bed by both of his ankles. He was on the veranda and had the sun shining on him. The nurse said he was admitted with a stroke. The patient was agitated, incontinent and lying face down on the wooden bed with his left arm trapped under his body. The patient was sweating profusely and had secretions draining from his mouth. His head was getting stuck between the bed head and the side of the bed. He had removed his IV line and was bleeding from the puncture site; the nurses hadn’t dressed his hand. He had no caretakers with him, only a young police officer who was guarding him but not able to give him care.
Over the last 2 years I have received various feedback from people working in health here; some say that I shouldn't care so much, that I am a bad capacity builder because I judge the health workers, that I should just leave if I don't like it, that I blame others for my own inadequacies, I don't respect cambodian culture, one person even reported that I am "never at work" & ineffective in my job - the list of criticism from people is endless, people are very generous when it comes to criticism.
Interestingly one day last week when I couldn't face the hospital so instead worked from home the head nurse said - Is Esther OK? I miss her. I know that working with Cambodians is very difficult. I hope she is OK.
I have also received some ill informed advice from NGO workers in other sectors. I want to be clear here, although I came to Cambodia as an 'advisor' I tried to only ever advise about things within my remit - I know nothing about education, livelihoods or governance so I refrained from the arrogance of assuming I knew how people in those sectors could do their jobs better.
People who are not here have always given me very positive feedback - but they are not here, so how can they really know whether what I do is any good or even worthwhile?
The result has been that I now doubt my own knowledge, credibility & worth. I've internalised the last 2 years of my failure & inadequacy. I don't go to ICU anymore because I believe it is me that is useless & ineffective because I have failed to effect change.
This week I was away training but J stayed at the hospital. J has been in Cambodia twice as long as me & as I have mentioned countless times in this blog is one of God's better people & someone whose opinion & experience I respect greatly.
J goes to ICU rarely as its not part of her role, but this week she went to audit oral & IV medication administration & vital signs there. This week J had a taste of what I have experienced every working day for the last 2 years. It left her raw & doubting herself also. Although I would never, ever wish ICU on anyone. her experience has helped me to realise that I am not alone. It has strengthened my resolve never to go back to that ward. It has made me realise I need to adapt how I process my experiences here & redirect my energy. It isn't just me & it may even actually be them!
I want to tell J's story as proof that its not just because I am judgemental, absent, useless, over sensitive or any of the other criticisms that are thrown at my feet, that I have struggled for 2 years on ICU. The reality of this place is that its an extremely difficult environment & to survive it one has to compromise one's self a little with every interaction.
Below is J's recounting of the incident.
"I visited ICU Medicine with L (Esther’s translator) and found a patient who had just been admitted. The patient was a young male prisoner. He was chained to bed by both of his ankles. He was on the veranda and had the sun shining on him. The nurse said he was admitted with a stroke. The patient was agitated, incontinent and lying face down on the wooden bed with his left arm trapped under his body. The patient was sweating profusely and had secretions draining from his mouth. His head was getting stuck between the bed head and the side of the bed. He had removed his IV line and was bleeding from the puncture site; the nurses hadn’t dressed his hand. He had no caretakers with him, only a young police officer who was guarding him but not able to give him care.
I asked the nurses if they could
re-position the patient as he was at risk of strangling himself and obstructing
his airway. The trained nurse refused to help so I asked if the students could
help me move the patient, again the trained nurse refused. The trained nurse said the police officer was
responsible for the patients care. The
police officer confirmed to me that he was only there to guard the patient.
The doctor arrived on the ward
and asked the nurse to dress the patients hand as he was bleeding (the nurse
ignored this request). The doctor did
not examine the patient but observed him as he walked past. When I persisted in asking the nurse to help
the patient he refused and said the doctor would see him. The doctor wrote in a patient’s notes and
then left the ward without seeing the patient.
I asked the nurse for some gloves
so I could re-position the patient to maintain his airway; he refused to give
me any gloves and told us to leave the ward and not to interfere with the
patient. When we went back to the
patient he was cheyne stoking and died.
We informed the nurse but he didn’t go to see the patient, so there was
no attempt at resuscitation. L and I
put the screens around the patient as no nursing staff went out to check him.
The nurse was rude and hostile to
us and told us to leave the ward on more than one occasion.
As it was a public holiday there was
no senior medical or nursing staff on duty to call for assistance."
J's story of this excludes some salient points. Firstly she had taken photographic evidence of the state of the patient to show the staff before confronting them. Next when the nurses refused to give her gloves she had told them "I am worried that if someone sees this patient in this state - there are two English doctors visiting the hospital today taking publicity shots for a fund raising video - they may take these photos to the press & then there would be serious trouble." This veiled threat provoked further aggression & hostility but unsurprisingly did not motivate the nurses to get off their seats where they were sat watching TV. J was worried about this but I later reassured her that at least she hadn't grabbed a doctor's lapel & called him a murderer - one of my less fine moments where the accusation of judgemental & poor impulse control could be fairly levelled at me. In my case it did however result in the patient getting the correct care & her Mother bringing in a box of bananas to thank me.
Finally J was walking back to her office to get gloves to move the patient by herself when she discovered he had died. She can't shake the feeling that there was more that she should have done & she is some how responsible. As I have told her since - this patient was in a living hell that he has now been thankfully released from, we however are still living in our living hell!
When I returned later that same day to the hospital I found J sat with L having an iced coffee - my very own diazepam alternative frequently taken after my attempts to intervene with patient care on ICU. J was angry, shaken, upset & funnily enough I not once felt it was appropriate to tell her she was being judgemental or over sensitive or if she didn't like it could just go home.
That afternoon we had our monthly meeting & J discussed this case & showed the photos to a group of male Cambodian NGO Doctors & Nurses. Dr H - the Bong - who has the best poker face I have ever seen - looked opening shocked & appalled. If expressing emotion was on a scale with latino at one end Cambodians would definitely be at the other end of the scale. Smiling & laughing is the set response in any situation here. I have never seen Dr H visibly effected like he was on hearing the story & seeing the photos. That in itself was quite powerful. He started taking photos of the photos off J's computer screen & when J offered to email them to him he quickly said not to. It was at this point I advised J to tell Dr H about her threat to the ICU staff about going to the press. Dr H's poker face returned.
"What should I have done?" J implored - strange for me to hear as I am a big WWJD? advocate & this is the question I am always asking her.
Dr H said she had done the right thing & he would discuss this case with the hospital director.
One of my favourite Cambodians said this about the whole sickening affair. Even if the patient had murdered someone it can't be morally any worse than what the staff failed to do for him - their job - resulting in his death. The worse thing is that this happens every day here.
Facing these morally bankrupt people is it any wonder that J & I are incensed into calling them murderers or threatening to go to the press - this place can make good people mad.
I'm not saying this represents all of Cambodian health care, I'm not even saying it represents all staff on ICU, it's just this is the part of Cambodian health care I am unfortunately very familiar with. And writing it out, trying to make sense of it, sharing it with who ever wants to read about it - that's my therapy.
This - without cigarettes & alcohol due to my post dengue abstinence - is the only thing that is currently keeping me sane, this is my defence mechanism.
This - without cigarettes & alcohol due to my post dengue abstinence - is the only thing that is currently keeping me sane, this is my defence mechanism.
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