Shake a spear

My lovely assistant - L - had to write a poem for her English class. She doesn't really like khmer poems or literature she told me. I had to concede that writing poems was hard enough for a native speaker let alone in a second language. I went through some of Shakespeare's sonnets with her because my understanding of khmer poetry is that it has a very similar structure. 

I showed her Sonnet 116, which I read at my friends' wedding.

Let me not to the marriage of true minds

Admit impediments. Love is not love

Which alters when it alteration finds,

Or bends with the remover to remove:

O no! It is an ever-fixèd mark

That looks on tempests and is never shaken;

It is the star to every wandering bark,

Whose worth's unknown, although his height be taken.

Love's not Time's fool, though rosy lips and cheeks

Within his bending sickle's compass come:

Love alters not with his brief hours and weeks,

But bears it out even to the edge of doom.

If this be error and upon me proved,

I never writ, nor no man ever loved.

My friend died 15 years ago this February & reading it even now still makes me weep a little. I tried to explain the meaning to L, why these words touch me so much, & its message of the eternity of true love. The line, "Whose worth unknown, although his height be taken." & the meaning I derive from it particularly touches me. 

This sonnet just made L feel frustrated because Shakespeare says "If this be error and upon me proved, I never writ, nor no man ever loved." - typical arrogant man she exclaimed! 

After our discussion & hearing a song her sister played her L wrote this piece - which I think for a first attempt, from a non-native speaker who hates poetry, is pretty bloody awesome.

Whilst I was with you………….

Whilst it is heavy raining, I have an umbrella.

Whilst it is very sunny, I have wind.

Whilst it is very dark, I have light.

Whilst I was walking with you, my legs became stronger.

Whilst I was studying with you, my brain became more intelligent.

Whilst I was eating with you, my stomach became well-functioning.

Whilst I was drinking with you, my throat became clearer.

Whilst I was talking with you, my lip and ears became more skillful.

Whilst I was in hard time with you, my face always has more smiles.

Whilst I was digging the stone with you, my hands became more active.

Whilst I was with you, all great bodies come to me.

Whilst I was with you, my time seems so short.

Whilst you are gone, my time seems so long, my eyes tearing.

Whilst you are flying, my best friend, my blessings are given to you every minute, every breath I’ve taken.

Thanks my best friend for coming. Love you as my brain and breath are working.

Khmer text

One of the real joys I have found since living in Cambodia is receiving text messages from non-native English speakers. My first phone disappeared so I lost a lot of the classic text messages I'd collected which was far more upsetting than losing the hardware. Now my second phone's inbox is already full with many more great messages from my cambodian friends & work colleagues. I love the testing & use of newly learnt vocabulary, the openness & sometimes emotional rawness & often just the sheer bizarreness of them. So to share just a few of them with you, they really make me smile & are very precious to me.....

The text that inspired this blog, a review by a friends 3 year old daughter of a film I lent them - "Lion king made A cry because she pitied the lion's baby whe his dad died and the hiana willing to kill him. That's blasted cartoon. Maybe I'll need more of them. X good night."

When I texted my friend to say a man was trying to break into my hotel room - "I think you should tell him that: it is not enough space for him and I am feeling tiredness. I wanna sleep without any distraction. Maybe another time! What do you thing about my advice?"

After sending a text to my 'suicidal' friend, their response was - "I don't care about mine but I do care about you. I'd like to see you fine. We will talk later. Could you give me an advice about what cause and effect poverty? Thanks in advance! I don't wanna die anymore because I'd prefer to see you beforehand. Cheer up please!:);)!" Or another time - "I'll endeavor to be good and againsting with my mental breakdown. X." Or a particular favourite - "I do not feel good to do. Because I am depressive and have stigma feeling."And finally after my suggestion that maybe they will feel better soon - "Sorry maybe not because it is congenital." When I showed my good friend some of the depressive text messages they have sent me over the last year they read silently & then smiled proudly & said - I never realised that my English is so clear, this makes me very happy. So we are focusing on the quality of the expression of emotion rather than the psychology that lies beneath!

When I was in Phnom Penh for a disastrous meeting at the MoH, my work colleague back in the town I'm based at sent me this mid morning, coffee break time, message - "Come on Dr. E, we are waiting for you at cafeteria. No you no fun."

In the same week one work colleague was "not so fine" because a rat had eaten all his ducklings I also received this text - "Sorry for replying you late because I was waiting for killing cat which has eaten my chicken and I left my phone in my back. Maybe see tomorrow. Enjoy your work."

On finding out my annual meeting with the hospital had been cancelled, for a third time - "What! It cancelled again? But u r so important for patients. They really treasure u as their angel. They love u. Happy victory day! Have a nice holiday! X"

From my lovely assistant - "Because we r familiar. We r both angry birds;-). X" So true...

On telling my assistant about someone else's annoying behaviour - "Ah... Maybe he wanted yr reaction. He likes yr reaction,especially when u r angry ;-). X" So wise....

Medical advice - "I went to see S's father. S and Him probably misunderstood my education or tended not to listen. I told her to clean the wound with soap and water first then anticeptc but they cleaned Alcohol 96% so the wound a bit swollen by burning of Alcohol. That's amazing thing."

During a rough patch at the hospital when any training was aggressively rejected, my assistant demonstrates my terrible influence on her vocabulary - "Hope this cheers u up while u r teaching the bloody doctors. X" When I then responded it was not going very well again - "I also bother to hear this. They don listen to us not at all. I think because we women. By the way, snack can help u ;). X" She knows me so well!

The first & only text I have ever received from my Cambodian mother - "dear esther happy birthday I hope that ynu have had avery good day I miss you very much love from S"

From a work collegue running late - "Sorry 5 minute late ok. Because Cambodian."

Setting a dinner date - "Good Evening my Dr. Sorry for being to reply to you late. Hope you are not irritating. What time is good for you to go for dinner at the forest tonight? I'm looking forward to seeing your text. ;-(." Or "So could you wait for me a minute. You are a person who try me eat more food. Thanks!" And "Yes, i did. Why didn't you have? You should have dinner, otherwise you will definitely not have any energy. Am I right? Don't be destroyed your health. ;-)"

Capacity building in motion - "Sorry no karaoke because I must respect to all females."
Or when I joked in a text about betting how late a meetng would happen - "Know I don't because I promiss with you to stop buying lottery so even bet I'd rather include as well. See you soon at contin. X"

About scabby dog - "I cannot make a good communication with human too but dog I can stop her having sex either male or female. First injection and second castration. Any way I wanna cheer you as I am stupid person that irritated you yesterday so I promiss to treat her as your suggestion"

After another great day at the office my assistant felt the need to send this - "u r terrible for doctors here but u r lovely n nice to patients :-)"

Asking how english class went which I had helped with the prep - "It went very well because yours. Thanks! But if you came to talk, it would be best. ;-)!"

Pertaining to my landlady - "I think so. She said that she is woman, she doesn't have skill n energy as man. These works are for men. That is just excuse. Not appreciate with her!"

On a technical note - "Good morning Dr. Est. I hope you had a nice weekend. I'm really sorry in letting you know this information because I'm feeling guilty. I took your phone's memory to the phone shop to mimic them for you but unfortunately those picture's gone. Even thought, they tried to find it many time. I'm sorry in making your photograph are lost. Seriously! ;-("

Or for reassurance - "good night. Glade to see you smile. I'm vex irritable when I see you up set. Most of Cambodian doctors are stupidity. Don't be mind" Or "If i know whatever in your head but i still trust you are not idiot." Or "I will try. That is good to hear that u meet some nice men. I know when m very upset worry, i always think of u. U always make me feel strong n positive to myself. Thanks. I do love u. Take care n sleep well! X"

In work - "I'm very sorry Dr Est. The child has temperature 38, RR 38 and BP 60 over 40? Please forgive me."

Making new connections - "Hey Esther.sorry i'm late reply back to u. How are u?i'm happy when u know my phone number.ok i really happy when i know ur phone to.thank u see u soon.goodlucky" followed by "Okay i can go to ur house tomorrow. But can u change time for me. Maybe u free or not. Because i need wasthy God at chuchr. If u agree or not.reply back i hope"

On telling my assistant about some other NGO workers - "what! They r such a super rude people"

After my khmer teacher coined me it elicited this message - "Hi! I saw your post on face book. How is your feeling now? I felt so surprised that you did coining. It is so painful. Hope u are better. Take care! X"

My feelings of inadequacy & failure are contagious - "I don't feel happy too. I don't know why they are very idiot and stupid like this. Why they don't ever do a reflection on their treatment right or wrong or follow your advice. And it is because I'm not a good translator. ;-( sorry!!!" or "Ok I'll try as your support and trust to me. I'll do all my best. You don't make me up sad. I just hate my self. See you on Monday. Xs!" These are not text written by me but it is scary how close they are to being something I may write!

Expanding vocabulary - "I don't understand the word boundaries. So don't understand your text."
Or occasionally also helping me with my limited vocabulary - "Could you order baycha with chilli and what I always like please. Sorry i can't live without eating. X" - knowing full well that it is about the only dish I can order in Khmer! Sometimes its easier to just give up when it all gets too difficult - "So why i don't really like doing text or email because it can make confusing as my English is very poor."


I have no idea what this text is even about but it pretty much sums up my time trying to communicate here - "How terrible it is? What we should have but can't get it. It will make we up set like me never cheer up."

4 stages of anger

My deputy director, ON,  told me today that there are 4 stages of anger. He is a psychiatrist & this is his take on anger.

Stage 1 - Anger
A week ago the paediatric doctor was at this stage with me. He completely lost it with me although I'm still unclear what I did to provoke him, breathing possibly. He was yelling at me, spitting in my face whilst he shouted personal insults at me in front of patients, their families & other staff. I asked him not to behave like this as it was unprofessional so he physical removed me & then banned me from his ward. I really quite enjoyed it because if they're not shouting at you, then you are probably doing something wrong.

Stage 2 - Rumination/irritability 
Today we had a ward meeting with the deputy directors to try & resolve these difficulties. The doctor wasn't shouting or spitting anymore but he wouldn't look at me, jabbed his finger aggressively at me once or twice & was still openly hostile. Annoyingly he wouldn't let us (me, J & R) answer any of his questions or accusations towards us. So I read the BBC website on my laptop to detach myself from it all but I still managed to understand when he said in khmer that he hates us. When I spoke to ON about the meeting afterwards he asked me had I ever heard of the 4 stages of Anger. In a very Cambodian, round about way, he was telling me The Angry doctor was at stage 2. Give him time, he was advising, maybe next week we could meet together again & then have the opportunity to answer all his complaints about us.

Stage 3 - Calm contemplation
Eventually, I was told, people calm down & can then start to think rationally about the situation. This is when discussion & reconciliation can begin. That's where I am! - I proudly beamed at my deputy director who smiled placatingly back at me. As a psychiatrist he can spot a delusional person from a 100 paces.

Stage 4 - Acceptance 
What about the 4th stage? I enquired. Acceptance, ON replied sagely.
Ahhhhhh acceptance I nodded - I will never know it......

I'm now tempted to show ON my own VAS for anger

Crumbs from the table of joy

"Sometimes a crumb falls

From the tables of joy

Sometimes a bone

Is flung

To some people

Love is given

To others

Only heaven."

Every once in a while here I am thrown a crumb of hope. Some weeks I have even been known to get two.

Before I went back to the UK I attended a hospital clinical case review (CCR) that was chaired by the deputy director, ON - my only friend at the hospital, or as he would put it "not just her friend but her psychiatrist too!" He is of course correct.

I was moved to write to my boss to tell her about it because ON did such a great job that it gave me hope. He picked a case that was an excellent example of common system errors with possible action points that could be achievable & realistic. He went through the notes before asking to talk to me about it, he had picked out already all the points for improvement I would have done too. He asked for a template powerpoint so I gave him a sample presentation I had developed for CCR training, which he went on to use.

The CCR case was a pregnant woman who had initially been seen by the surgeons before being passed on to the obstetricians,who finally turfed her to ICU medicine, where after further neglect she eventually died. There had been no collaboration between specialities, there was late recognition of sepsis, no blood cultures had been taken, inadequate fluid resuscitation was used & there was inappropriate use of antibiotics & inotropes in this case. Just another normal day in my Cambodian hospital workplace.

ON asked me to attend the meeting, I went despite having no translator so just sat quietly at the back, out of the way, but the hospital director came to sit right next to me. The staff got angry & animated at certain points but ON chaired the meeting really well, allowing everyone to have their say whilst making sure the salient points were communicated. At one point the hospital director got up & shouted at them all for never listening to anyone, ignoring others training & advice. Not exactly in keeping with the CCR philosophy but I could hardly blame him for it - I often feel like doing the same but as a mere visitor & low status female I am prohibited.

After the CCR meeting I wanted to feedback to ON how well I thought it had gone, to ask him for translation & summary of the meeting, to make sure I had followed the important themes & to give some suggestions on how to take the CCR to the next step by developing action points that individuals are responsible & accountable for with actual deadlines. However there was a pre-election CCP meeting directly after the CCR meeting so I was ushered out & then didn't see ON for the next month.

When we finally had a chance to meet up it was after I had been banned from the paediatric ward. Mr S ,the head nurse, was particularly delighted by all my trouble making with the doctors. He enjoys someone else, other than him, being on the receiving end of their normal foul behaviour - especially when that person is a bolshy barang.

ON was less delighted by my collaborative working fail, more resigned that I would never be able to endure his colleagues poor behaviour towards me. He told me to just stop going to the wards & only work with him because he wanted & needed me. What did it matter if all the other doctors hate me, he wanted me!? Crumb number one.

He went on to tell me that USAID on a recent visit had interviewed him & asked him what would he prefer to have, equipment for the hospital or an overseas expert. He told them he would rather have me. I really do think he was being completely sincere. Crumb two.

I finally had the opportunity to feed back to him about the CCR he had chaired & it turned out I had understood most of what was said plus ON realised they had not formulated any action plans but we both recognised how hard accountability is to practice here.

Then he threw me an unprecedented third crumb. Earlier in the month whilst I had been at the border hospital he had contacted me asking if I could help him with a patient. I had to explain that I was away from the hospital & wouldn't be back for 3 days, which I absolutely hated doing because if people ask for help I want to give it & here if you fail to give the help they have requested then they can hold it against you forever. I have learnt this bitter lesson on numerous occasions, failing to meet people's unrealistic expectations here is a common occurrence for me.

ON got out his smart phone to show me a photo.

He explained that whilst I had been away a trauma patient had been transferred from Thailand who still required ventilation. He had called me because he wanted help to set up a high care area on the surgical ward.

For the last 2 & a half years I have been advocating for a high care area in the hospital (whilst patiently waiting for the ER to open) this advice has of course been persistently ignored.

On ON's request I had managed to find a portable ventilator which was donated by an NGO for the ER, which as it is not yet opened ON had used in this newly created high care area. There was a monitor & bed from a donation from France, but for me the most exciting thing was a drip stand. This photo surpassed my wildest dreams of what a high care area could look like in this hospital during the time I have been here.

I was so happy that ON had the same vision as me that I posted this photo on facebook & to my dismay people congratulated me for this, I was horrified to think that they all thought I was just blowing my own trumpet. In fact I wasn't in anyway feeling self congratulatory, the reason I was happy was for ON's success in changing the system. I genuinely don't believe I can take any, even a small amount, of credit for this. If any thing I have failed to capacity build or inspire change during my time here but ON and a small handful of Cambodians I know have shown me their huge potential & capacity for change and I have just tried to help them in what ever way I can.

I don't believe for one minute that having a high care area with donated equipment will automatically mean that patients will suddenly get much better nursing & medical care here, but I am happy that it is a step in the right direction & it was a step made by the hospital, on their own innovation.

I think the moment I actually start believing that I have personally or singlehandedly changed another person or situation is probably the same moment that my ego has overtaken good sense or reason, humility has been lost & I have started to fling bones at people instead of looking for the crumbs.

General Ignorance

It has been brought to my attention that I think that Cambodian health workers are stupid & therefore look down on them. I'm inclined to think that this is slightly unfair & perhaps it would be more accurate to say that I think Cambodian health workers have a very poor basic education & hence knowledge about health care which combined with endemic corruption, the hierarchical system & an obsession with money (over & above human life) means that I have witnessed some pretty horrific medical 'care' during my time here.

I discovered if anything after 2 years I still tend to overestimated the basic medical education of health workers & my underestimation of their general ignorance means I expect them to know an awful lot more than they actually do.

This was brought to my attention this week when training on the stabilisation of a severe acute malnourished (SAM) child in a small hospital. One of the key messages of the training was to check & treat hypoglycaemia (low blood sugar) in every child who presents with malnutrition. Sick children as a rule are susceptible to hypoglycaemia & hence a malnourished child is even more likely to be in need of sugar.

After the training one of the staff asked a question about hypoglycaemia & breast feeding. I thought it was a good question so gave a detailed answer including that breast feeding is a treatment & a prevention of hypoglycaemia in children which is why it is so important to re-establich breast feeding in children under 2 years old. My translator, R, shook his head & told me I hadn't answered the question. I explained I was trying to explain about hypoglycaemia generally as a learning point but what had I missed?

What is the difference between a child that is breast fed & one that is not breast fed when taking a blood sugar?

Hmmm - well as I had previously explained breast feeding reduces the risk of hypoglycaemia but SAM children are at risk, especially if they have an infection, which most do. So we should do a blood sugar on ALL SAM children regardless of whether they are breast fed to screen for hypoglycaemia.

Blank stares..... You still haven't answered their question I was told by R.

Oh! So can you repeat the question?

What is the normal range of blood glucose in a child? I was asked.

Similar to an adult, I replied.

Well in an adult we make sure they haven't eaten before doing a blood glucose, so what can we do to make sure the child hasn't eaten?

The penny then dropped for me.

I think I see the problem, I told them. There is some confusion here - I am talking about hypoglycaemia in malnourished children & you are talking about screening for a high blood sugar - diabetes - in adults, using a fasting blood glucose test.

Collective blank stares.... what is the difference? they shrugged.

Well...one is increased blood glucose due to a problem with insulin production or the bodies sensitivity to insulin & the other is the body not having enough stores or intake of energy resulting in a LOW blood glucose.

Further blank stares.

But if the child has had Bor Bor or been breast fed they will have a high blood sugar, they asserted.

Not necessarily, I explained. The human body does have a mechanism for regulating blood sugar so that it remains in a steady state. In diabetes this is broken because of the hormone insulin not working properly & diabetics patients will have a high blood glucose. In children as they have limited stores of sugar sometimes when they are sick they can become hypoglycaemic, which is why we should test every child with SAM.

Silence.

So what should we do if a child has fed already?

DO A BLOOD SUGAR ANYWAY- I said it much nicer than this but in my head is was in upper case & bold.

They all shook their heads & clearly thought that my advice was seriously flawed.

So it appears that all that I have successfully managed to do is to train staff to do a 'fasting' blood glucose in all SAM children, mainly because I had seriously underestimated the baseline knowledge of my audience.

It now becomes apparent that any of their bluster, shouting, accusations, arrogance & rudeness is clearly just a smoke screen for their general ignorance....

Scabs & other habits

I've always had a tendency to be  a picker of scabs - its a guilty pleasure, although as a child I seemed to have more opportunities & scabs to pick. Something happens when you get older, I'm not sure it's necessarily acquiring better coordination, more likely less risk taking behavior resulting in less scab producing wounds.

So in adulthood I've developed other ways in which to create & pick metaphorical scabs. I seem to have developed an unhealthy habit of putting myself in situations that make me feel worse. This can be the only explanation for why I have spent the last 2 & a half years being worn away my the Cambodian health system & its workers, whilst steadfastly refusing to quit or to leave early.

Other people working in other hospitals here have achieved great things, developed great relationships with staff, left behind donated equipment & created training material. People with high flying clinical & academic careers drop in to deliver highly polished training programmes & command instant respect & awe.

Meanwhile I have failed quietly to do anything remotely successful & every day produces yet more evidence that I am clearly quite useless. Cambodia is good for cultivating uncertainty or for bolstering those with a highly developed inner critical voice. Especially if you are female because then you can always throw some misogyny into the delightful mix of self doubt & loathing.

I have learnt plenty of other stuff about myself whilst being here, not just that I'm a picker of literal & metaphorical scabs.

I have a rescuer personality trait, which is great when I'm in the emergency medic role but a little annoying when being a friend & especially aggravating for me when people reject my overtures of being rescued whether it be in the capacity building arena or elsewhere.

My anger is almost always just a manifestation of my anxiety.

I often give my time, affection, thoughts, energy & good will to people fairly undeserving of it. The people that really count I don't value enough.

My egalitarian values are not shared by everyone nor the value I attach to education, training & experience.

I had seriously underestimated how important having a penis was for commanding even the most minimal respect from most people in certain countries, above even internationally recognised qualifications.

I can cry without sobbing. I mean that the tears will now just roll down (or 'drop down' as a good friend says) my cheeks without me even trying. I have a friend who I was always amazed at her ability to just tear up & silently weep but now I too have also mastered this art.

If I cry everyday my face doesn't swell up like I am having an acute allergic reaction any more, so my Aunts advice "Don't cry, it will ruin your good looks" is no longer heeded.

I actually can suffer fools to a certain degree, those yearly assessments during my EM training were incorrect.

I can still cannulate, do an LP, intubate, run a resuscitation (in another language - a newly acquired skill) even though I say I have de-skilled.

My head & my heart seem to be on different agendas which explains why in the day time I think about booking the next flight out of here but at night I dream about getting on that flight & wake up choking back tears.

Each of us has the capacity to do good or bad & we choose which we do, circumstances & external factors influence this but the final decision is always our own. I have observed that it is not necessarily hard to do the right thing it is just much easier sometimes to do the wrong thing.

I (we all) have a huge capacity to change but I can't change anyone else but myself.

I didn't appreciate my weight bearing joints until it was too late......

Change

This week I was shouted off the paediatric ward for trying to follow up training on severe acute malnutrition in children & told that I had no right to tell people how to change patient care because I am low status & a woman, my credentials have been found lacking by the Cambodian health workers. After 2 & a half years of the same shit every day I have started to think it definitely must be my problem even if my problem is staying when clearly nobody wants me here. The Hospital director told me most of the staff don't like me, they clearly don't respect me. The former I can live with but without the latter how can I influence change here? I am so sick of being ignored & abused whilst negligence, ignorance & arrogance literally kill children (and adults). How can you help people change when they don't want to change? I lamented. Why am I here? I asked in a pit of existential angst.

Meanwhile my good Cambodian friend, work colleague & fellow evictee from the paediatric ward, was given english homework to write a short piece on 'change', so as I am his proof reader he showed a draft to me. Initially he had thought about writing about his workplace but realised, after just a little thought, that this didn't really involve any change so instead he wrote this titled 'The change of place':

"Sometime the change brings more development to the country or place. In 1990, there weren't too many patient people who live in BTB province. many streets and pathway had destroyed by sivil [sic] war. Some of market had closed as the security was not good enough for doing a business. Most people were killed by mine and robbery and separated from their relative. After this situation had been finished, the people were able to do their own business. Most of the streets either in the town or remote area were also constructed. Especially in the town, was developed to be a model city. The other thing most people economic is improving a lot."

I can always rely on my PTSD afflicted Cambodian best friend to put things here in to perspective.

Undesirables

The town that I live in seems to have had an explosion in its population of undesirable expats. These mainly consist of older, male predators of children & young Cambodian women who spend the majority of their time sitting in bars, drinking copious amounts of draft beer for 50 cents a glass & chain smoking 25 cent packs of Cambodian cigarettes not to mention various narcotics. They tend to look down on volunteers & NGO workers because being an alcoholic, chain-smoking, sexual predator & paedophile is a much more honourable vocation.

One such expat was recently arrested after a combined surveillance operation by Cambodian police & a child protection NGO. The comments on the news report even alleged he may be HIV positive, as if preying on vulnerable street children with glue addictions wasn't bad enough.

I read a blog recently that although deliberately provoking gave 7 good reasons for expats not to move from Thailand to Cambodia. I wish more undesirables would heed this advice.

My good (desirable) friends got stung by one such expat con man recently who turned out to be very well known around these parts. There is a reason why people come to a country with a corrupt police force & alack of law & order, they are not always good ones. Being trusting & having a good heart won't always protect you.

26 things I know I will miss about Cambodia

Cambodia is compelling & confounding in equal measure. Before I went back to the UK for a short visit I had listed 20 things that frustrate me about the place. I'd been apprehensive about going back to the UK so this exercise had helped the transition. I was then blind sided by the reverse culture shock that manifested itself in a permanent & unshakeable feeling of anxiety whilst in the UK but I was also pleasantly surprised to discovered things, other than friends & family, which are very good about my mother country, being a Wilson I listed those as well.

Now I am back in Cambodia I thought it would only be fair to reciprocate. So in no particular order here are the things I know I will always miss when not here.

1) Heat - 24/7, 365 days a year - lovely, joint soothing, skin moisturising, muscle relaxing, all pervading heat.

2) Rice - it is just not the same anywhere else. First day back at work I had fried rice with beef, basil & chilli at the hospital canteen - I was complete.

3) Nothing is ever straight forward or simple - I know that I often complain about this, but in truth it means that life is never dull or boring. There is beauty in the over complicated mess that is life here, nothing is easy & every day throws up new challenges & tests. As an emergency physician I am not adverse to a little bit of chaos.

4) My Khmer lessons - which are a lot more than just learning to read a new script. S is my Cambodian mother, confidant, cultural advisor, friend, comforter, counsellor, Buddhism converter, coining therapist & is much, much more than just my language teacher. There isn't a scale to measure how much I will miss her.

5) My lovely assistant L - when she arrived one hour early for the interview for VSO volunteer's assistant I already knew I was on to a good thing. She is strong, clever, compassionate, patient, kind, has boundless potential & vision, she is my lion. I will miss her when we don't work together anymore but know she is destined for much greater things.

6) The village people - are my adopted extended family of brothers & sisters, nieces & nephews and in laws. They are joyful & fun. Sb & I can talk for hours in a language I have barely the most basic grasp of & yet we understand each other completely. Our topics of discussion far extend my limited vocabulary from language training & often deal with issues not even broached by my closest friends in English.

7) English lessons with P - most weekends P comes to my house for "English lessons", generally this involves a little bit of phonics, reading & writing and more of her mum (Sb) & I chatting whilst P plays on my iPhone or watches TV & eats barang food whilst A, her 3 year old sister, has a tantrum.

8) Being frugal - Save, re-use, recycle, repair is my motto here. I like cycling everywhere, spending very little on necessities, making everything last as long as possible & generally not having very many possessions. I found the huge mass of wealth & 'things' in the UK incredibly overwhelming - especially supermarkets & all my junk in my parents loft. I have grown used to the frequent power cuts, always when I am fully soaped up in the shower, in the middle of a good trashy TV programme or when all my appliances need charging. I now always have a large bucket of water on stand by for when the water supply abruptly dries up - sometimes for days at a time.

9) Children - there are children like P & A, from the village people, who I know very well and consider part of my extended family. There are also other Cambodian children like my Landlady's nieces, the adopted baby from the noodle shop & the little girl from the bike shed at work who I see very day & have watched grow. From heavily pregnant mothers to nursing babies to toddlers. They have blown kisses, sam peah, waved, taken their first steps, called "bye bye" & with every developmental milestone wormed their way deeper into my heart. Nothing marks the passing of time better than a child - I will miss them & not knowing what they will grow up to be.

10) Eating out every day - cheap, delicious, affordable & sociable.

11) The outside lifestyle - in doors in the tropics without AC can be hot & oppressive, outside is much better. This often includes patients on the verandas of wards, as well as my house with no glass in the windows and little wooden huts on stilts for picnics in the rain.

12) Rural Cambodia - paddy fields, spiky lime stone 'mountains', awesome sunsets, coconut palms, red earth, flooded villages - all beautiful images that are burnt into my memory.

13) Having clothes made to measure & repaired for tuppence - although occasionally you get what you pay for.

14) Unregulated pharmaceuticals - in work it drives me crazy & fuels the huge problem with antibiotic resistance but personally you can bypass the middle man & self prescribe to your hearts content for much less than the NHS prescription fee. I am not talking controlled drugs here mind just more de-worming tablets & anti-protazoal medication.

15) Spontaneity - forward planning is not really practiced here at all & spontaneous decisions are easily accommodated. You can pretty much do anything at the very last minute - even board a plane.

16) Righteous anger - in the UK there seems to be an epidemic of over inflated sense of entitlement. People get outraged about things such as parking & mobile phone contracts. Here you can really let rip about a child being left to die uncared for by health workers or any number of other social injustices, its hard for anyone to argue that it is a first world problem.

17) Venting but no one being able to understand what I am saying - theres's nothing like a good rant with lots of swearing when no one else can understand the details but gets the general idea that you are not happy. See point 16)

18) The close proximity to many tropical beaches & islands - overland in Cambodia, Thailand, Vietnam & further afield by just a cheap air asia flight to Malaysia, Indonesia or the Philippines.

19) Bambu - my spiritual home. The Hotel staff, P & his wife C are very simply the best.

20) Scabby dog - she stinks to high heaven but I love that mutt.

21) Proper rain - not this pathetic UK drizzle or 'Liverpool rain' as one Cambodian who had studied there called it. Tropical rain is torrential, unforgiving & dumps several inches in a short space of time filling rivers until their banks are swollen & flooding your house if your roof happens to have a leak.

22) Tuk Tuk AC - there is no finer way to say cool than sat in a tuk tuk travelling through the countryside whilst silently sweating.

23) Cambodian food - 'dirty meat', Chinese soup, dumplings from the Chinese noodle shop, Chinese breakfast noodle soup, tropical fruit, deep fried 'snacks', Bor Bor, Tukraluk (fruit shake) - over shadowed by its neighbours cuisine it is harder to find a Cambodian restaurant than Thai, Chinese or Vietnamese outside of Cambodia which is a shame.

24) My old VSO bicycle with its brand new shiny bell - it cost me $13 to buy from VSO, it has a constant slow puncture despite numerous repairs & the brakes are really squeaky. After HUI its my most treasured transport related possession.

25) Kramas - I love Cambodian scarfs. It has become a small obsession.

26) Star world & HBO TV - the former is utter trash but what would we do with Beauty & the Geek? & the latter is worth the $2.50 I pay for cable TV a month.

And the list goes on & on & on.......