One of the things that I really struggle with here is not being believed, taken seriously or even listened to, ever. People have told me (including Cambodians themselves) that Cambodians, generally speaking, will reject anything new immediately out of hand - its a force of habit. But what annoys me isn't skepticism, which I actually encourage, nor stubbornness, which I too am afflicted with, but rather the complete lack of an enquiring mind this is a symptom of.
If someone tells me something which I haven't heard about before or is different from what I believe to be true e.g. my cambodian male work colleague who has 'eye disease' told me that breast milk can cure viral conjunctivitis; I will ask - Why? How do you know that? Show me the evidence? Where is your proof? For this example I thought maybe it as something to do with IgA in breast milk & a google search revealed many mother & baby websites that confirmed this old wives tale, less so when I did a proper literature search.
Here when I say something contrary to popularly held Cambodia opinion the standard response is "NO! That is not right, you are wrong, that won't work - this is Cambodia!" often even before I have finished my sentence or its been translated into khmer.
This closed mindedness, this narrowness of vision, this lack of curiosity or acceptance of new ideas or conflicting opinions literally drives me to tears, despite knowing & appreciating the roots of it - a poor education system, civil war, PTSD, an oppressive regime to name but a few.
It used to be only in clinical environments when people were suffering or dying as a result of my advice being ignored that I would be crying tears of frustration but recently I have found that the chronic exposure to rejection of my statements without any question is actually shortening my life expectancy significantly.
One recent weekend I had bought some bread & went to put it in the freezer (I was going away but my friend was arriving to stay at mine the next day) when my khmer teacher screamed at me "NOOOOOOOO!" I thought maybe there was a deadly snake or scorpion I was about to step on but apparently it was just to stop me putting the bread in my freezer. Now maybe there is new research that shows that frozen food causes cancer but my khmer teacher didn't use this in her argument, she just repeatedly told me "No, you can not do". Eventually, brandishing reason & rational argument, which is always a little tricky here, I asked her had she ever owed or used a freezer. Silence then a muted "no" - So I challenged her on what evidence was she telling me I couldn't put bread in the freezer. Turns out there was absolutely none whats so ever, she just had never seen it done before & therefore felt in a position to tell me what to do, despite having no prior knowledge, exposure or experience of freezers & bread.
This happens A LOT to me here.
A beautiful Pagoda moment was spoilt by me casually saying to my Cambodian friend, who was playing with a lotus flower - pulling on a thread from the stem - that in Burma they use the lotus flower stem to make silk. "NOOOOOOOO" came the response in stereo from her & my Cambodian mother - This was wrong - I did not know what I was talking about. It took me 24 hours to calm down enough to show them both my holiday photos before they would believe me. They didn't ask for this proof, it was forced upon them.
It worries me that even the brightest & the best here still have a tendency to reject things initially but if you spend time to show them the evidence or proof they will eventually - often weeks later - concede you may have a point.
Rarely in work am I asked why do you think/say that? what is your proof? Yet if I am asked it is usually used as a delaying tactic, if I show proof it too is often rejected without even being considered. The biggest problem of this lazy thinking clinically is that if a patient doesn't die it is believed that treatment that was used is correct, it is very hard to persuade health workers using critical or evidence based thinking.
Snakebites are a really good example of this. 70% of people bitten by a snake won't actually be envenomated & hence what ever you do to them they will survive. So 70 times out of a hundred if you go to a traditional healer & they spit on the bite or cut it out or put a poultice on it or say a prayer or throw some bones you will still survive & would have survived even without all the spit & incantations.
Equally if you go to a hospital in Cambodia many doctors including the NGO ones I work with believe that Chinese herbal tablets are effective for snake bite. When you try to explain the odds of envenomation & why it would appear that they work when evidence shows they are useless they shake their heads & say - you are wrong, I have seen them work, this is Cambodia. It is a little like homeopathy but if you have actually been envenomated by a king cobra you tend to die, pretty quickly.
A health NGO worker (not a clinician) once told me that he "couldn't see the harm in the traditional snake healer" in his village - as he wasn't a clinician he obviously hadn't seen one of the 30% that die, like the 7 year old girl who was bitten in her mosquito net & was taken by her parents to the traditional healer first so was already in respiratory arrest when they arrived at hospital. DOA - No harm done hey? Lazy thinking like this I have come to tolerate from Cambodians but it is unforgivable coming from a barang.
There are in fact 2 polyvalent anti-venoms for use in Cambodia & distributed by the MoH. One is for snakes that cause clotting problems "heamo" such as the green pit viper & the other is for snakes - like cobras - that cause neurological problems "neuro". Staff have had training on this.
We arrived at the border hospital this week to find a 18 year old boy who had stepped on & been bitten by a cobra - it had been killed & brought in with him. The staff had decided to give him antivenom after demonstrating that although his blood clotted he had a pulse of 52/minute & felt sleepy, which they felt represented a problem due to the cobra venom. Now this decision is debatable as he had no other neurology but as I wasn't there when they made it I have to accept their clinical decision.
However I did feel I could question their decision to give the 'haemo' antivenom for a boy who was confirmed to be bitten by a cobra - a neurotoxic snake & who had no symptoms of a coagulation problem. But when I broached this I was told that there was only one antivenom for all snake bites in Cambodia.
The antivenom comes from Thailand & the instructions are in Thai & English. I showed them the bottle that clearly stated it was 'Haemo' antivenom & the instructions which clearly talked about 2 different kinds of antivenom but at this point even my work colleague wouldn't believe me. I showed them the powerpoint presentation & video produced by an american university that works with my NGO in Cambodia - rejected as foreign & therefore not respectful or knowledgeable of the Cambodian context.
I showed them a WHO document about snakebite in Cambodia which states that doctors have poor knowledge & are known to not use the 2 antivenoms appropriately. There is only one antivenom in Cambodia I was repeatedly told. YOU ARE WRONG.
I started to doubt myself - this is also very common. I think maybe 20 years ago perhaps there was only one type of antivenom available.
Luckily the boy was fine, ambulatory, asymptomatic & as he was fit & healthy his pulse of 52/minute was just a normal sinus bradycardia for him. I decided that as the boy seemed not to be envenomated & had no adverse effects from the antivenom - such as anaphylaxis or death - best just to drop it. Life here has really taught me how to pick my battles.
The next day he was discharged, "See!" my work colleague beamed, "the antivenom was the right type & now he is cured. "
He was deliberately goading me of course but equally he was reflecting the thought processes of the MoH hospital staff here. The boy survived so they were right & I am wrong.
If I DC shock a 17 year old girl out of her life threatening SVT this inarguably provides immediate proof that my clinical knowledge & skills are correct but often the changes needed to improve medical practice here, such as something as simple as washing hands between patients, can take time to prove & if people don't want to see that proof, well then they just won't see it.
Meanwhile I continue to make self doubt a fine art......
If someone tells me something which I haven't heard about before or is different from what I believe to be true e.g. my cambodian male work colleague who has 'eye disease' told me that breast milk can cure viral conjunctivitis; I will ask - Why? How do you know that? Show me the evidence? Where is your proof? For this example I thought maybe it as something to do with IgA in breast milk & a google search revealed many mother & baby websites that confirmed this old wives tale, less so when I did a proper literature search.
Here when I say something contrary to popularly held Cambodia opinion the standard response is "NO! That is not right, you are wrong, that won't work - this is Cambodia!" often even before I have finished my sentence or its been translated into khmer.
This closed mindedness, this narrowness of vision, this lack of curiosity or acceptance of new ideas or conflicting opinions literally drives me to tears, despite knowing & appreciating the roots of it - a poor education system, civil war, PTSD, an oppressive regime to name but a few.
It used to be only in clinical environments when people were suffering or dying as a result of my advice being ignored that I would be crying tears of frustration but recently I have found that the chronic exposure to rejection of my statements without any question is actually shortening my life expectancy significantly.
One recent weekend I had bought some bread & went to put it in the freezer (I was going away but my friend was arriving to stay at mine the next day) when my khmer teacher screamed at me "NOOOOOOOO!" I thought maybe there was a deadly snake or scorpion I was about to step on but apparently it was just to stop me putting the bread in my freezer. Now maybe there is new research that shows that frozen food causes cancer but my khmer teacher didn't use this in her argument, she just repeatedly told me "No, you can not do". Eventually, brandishing reason & rational argument, which is always a little tricky here, I asked her had she ever owed or used a freezer. Silence then a muted "no" - So I challenged her on what evidence was she telling me I couldn't put bread in the freezer. Turns out there was absolutely none whats so ever, she just had never seen it done before & therefore felt in a position to tell me what to do, despite having no prior knowledge, exposure or experience of freezers & bread.
This happens A LOT to me here.
A beautiful Pagoda moment was spoilt by me casually saying to my Cambodian friend, who was playing with a lotus flower - pulling on a thread from the stem - that in Burma they use the lotus flower stem to make silk. "NOOOOOOOO" came the response in stereo from her & my Cambodian mother - This was wrong - I did not know what I was talking about. It took me 24 hours to calm down enough to show them both my holiday photos before they would believe me. They didn't ask for this proof, it was forced upon them.
It worries me that even the brightest & the best here still have a tendency to reject things initially but if you spend time to show them the evidence or proof they will eventually - often weeks later - concede you may have a point.
Rarely in work am I asked why do you think/say that? what is your proof? Yet if I am asked it is usually used as a delaying tactic, if I show proof it too is often rejected without even being considered. The biggest problem of this lazy thinking clinically is that if a patient doesn't die it is believed that treatment that was used is correct, it is very hard to persuade health workers using critical or evidence based thinking.
Snakebites are a really good example of this. 70% of people bitten by a snake won't actually be envenomated & hence what ever you do to them they will survive. So 70 times out of a hundred if you go to a traditional healer & they spit on the bite or cut it out or put a poultice on it or say a prayer or throw some bones you will still survive & would have survived even without all the spit & incantations.
Equally if you go to a hospital in Cambodia many doctors including the NGO ones I work with believe that Chinese herbal tablets are effective for snake bite. When you try to explain the odds of envenomation & why it would appear that they work when evidence shows they are useless they shake their heads & say - you are wrong, I have seen them work, this is Cambodia. It is a little like homeopathy but if you have actually been envenomated by a king cobra you tend to die, pretty quickly.
A health NGO worker (not a clinician) once told me that he "couldn't see the harm in the traditional snake healer" in his village - as he wasn't a clinician he obviously hadn't seen one of the 30% that die, like the 7 year old girl who was bitten in her mosquito net & was taken by her parents to the traditional healer first so was already in respiratory arrest when they arrived at hospital. DOA - No harm done hey? Lazy thinking like this I have come to tolerate from Cambodians but it is unforgivable coming from a barang.
There are in fact 2 polyvalent anti-venoms for use in Cambodia & distributed by the MoH. One is for snakes that cause clotting problems "heamo" such as the green pit viper & the other is for snakes - like cobras - that cause neurological problems "neuro". Staff have had training on this.
We arrived at the border hospital this week to find a 18 year old boy who had stepped on & been bitten by a cobra - it had been killed & brought in with him. The staff had decided to give him antivenom after demonstrating that although his blood clotted he had a pulse of 52/minute & felt sleepy, which they felt represented a problem due to the cobra venom. Now this decision is debatable as he had no other neurology but as I wasn't there when they made it I have to accept their clinical decision.
However I did feel I could question their decision to give the 'haemo' antivenom for a boy who was confirmed to be bitten by a cobra - a neurotoxic snake & who had no symptoms of a coagulation problem. But when I broached this I was told that there was only one antivenom for all snake bites in Cambodia.
The antivenom comes from Thailand & the instructions are in Thai & English. I showed them the bottle that clearly stated it was 'Haemo' antivenom & the instructions which clearly talked about 2 different kinds of antivenom but at this point even my work colleague wouldn't believe me. I showed them the powerpoint presentation & video produced by an american university that works with my NGO in Cambodia - rejected as foreign & therefore not respectful or knowledgeable of the Cambodian context.
I showed them a WHO document about snakebite in Cambodia which states that doctors have poor knowledge & are known to not use the 2 antivenoms appropriately. There is only one antivenom in Cambodia I was repeatedly told. YOU ARE WRONG.
I started to doubt myself - this is also very common. I think maybe 20 years ago perhaps there was only one type of antivenom available.
Luckily the boy was fine, ambulatory, asymptomatic & as he was fit & healthy his pulse of 52/minute was just a normal sinus bradycardia for him. I decided that as the boy seemed not to be envenomated & had no adverse effects from the antivenom - such as anaphylaxis or death - best just to drop it. Life here has really taught me how to pick my battles.
The next day he was discharged, "See!" my work colleague beamed, "the antivenom was the right type & now he is cured. "
He was deliberately goading me of course but equally he was reflecting the thought processes of the MoH hospital staff here. The boy survived so they were right & I am wrong.
If I DC shock a 17 year old girl out of her life threatening SVT this inarguably provides immediate proof that my clinical knowledge & skills are correct but often the changes needed to improve medical practice here, such as something as simple as washing hands between patients, can take time to prove & if people don't want to see that proof, well then they just won't see it.
Meanwhile I continue to make self doubt a fine art......
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