Assumption is the mother of all f*** ups

Communication is always important yet miscommunication seems inevitable.

Living in a different culture, communicating in a different language or through translator is fraught with communication errors. Then there is the communication with people who have the same language or culture as you, which is sometimes more susceptible to problems, probably due to the assumption that you will understand each other. Never assume - is makes an ass out of 'u' & 'me'!

Barangs often make communication with Cambodians more difficult by shortening the language & sacrificing grammar, this just makes things worse. Examples of this are "we go now" - does this mean "Shall we go now?" or is it meant as a statement "We are going now"? Who knows - I'm a native speaker & I'm confused. Equally perplexing is a statement like "We healing" - if only native english speakers could just communicate clearly & with clarity it would really help matters.

I have a sample of some of the case studies of communication breakdowns from various South East Asian countries.

Case study 1 - Laos


On Jean & my recent trip to Laos we stayed in Luang Prabang where we enjoyed a variety of breads & pastries, thankful for French imperialism. We found ourselves the only customers one particular morning in a cafe for breakfast - the customer to staff ratio was 1:4. I wanted it all & Jean who gets bad food envy ordered the same - a set breakfast "breakfast Americano' with many choices. Bread or toast? Tea or Coffee? Fruit shake or Juice? Eggs - scrambled, boiled or fried? So many choices but thankfully the fruit salad, cheese & bacon were fixed. To be honest it was all about the cheese & bacon for me.
When the breakfast feast arrived there was an absence of cheese or bacon - so I asked the waiter who looked dazed & confused, then brought us a menu. We pointed out the set breakfast we had ordered & I was fully prepared to hear there was no cheese or bacon - this is a common experience here if you order something they don't have you aren't told rather there is just a failure for it ever to materialise. In Asia one never really knows what will be on their plate when eating out. But this morning there was a new variation. Apparently as we had pointed to the set menu & verbalised our choices but not spoken the words 'cheese & bacon', he had assumed that we didn't want them.
Jean correctly predicted that a one inch slice of bacon & a processed cheese slice would be presented 5 minutes later - when this came to fruition Jean got a complete fit of the hysterical laughter. At one point when the tears were running down her cheeks & her whole body was shaking I was a unable to tell if this was still hysterical fits of laughter or if she had crossed over onto the other side into sobbing with despair.

Case study 2 - Laos


Still in Luang Prabang, Jean & I decided to go on a boat trip on the Mekong after being offered one every morning on multiple occasions for 4 days by the same persistent captain - persistence it would appear does pay.
When given the options we were told we could have a 2 hour trip for a ridiculous price or 1 hour for half the ridiculous price. We foolishly did not ask what the difference was because we assumed that for double the price & time we would be going twice as far. Assumption really is the mother of all f*** ups. We ended up going on a 2 hour boat ride which turned out to be the same distance as the 1 hour trip but just at half the speed. We could have swam faster & that would have almost certainly been cooler. Chugging along at a quarter of a knot doesn't generate any real air movement of note and in the hot season air movement (or even better AC) is all that is really necessary. We roasted for 2 long hours noting this down to another lesson in communication errors.

Case Study 3 - Cambodia


Kristy's last day in Battambang was all planned - lunch at noodle shop, Bambu for happy hour, a trip to the Circus followed by dinner at the Indian. What could possibly go wrong. I even checked online to see which show was on at the circus - there is one show that is inspired by the khmer rouge which tends to be less than cheerful. I called D my favourite tuk tuk driver who wasn't free but arranged for his younger brother to pick us up from the Bambu to go to the Circus. The Circus is a few kms out of town in the middle of a commune, there are no other nearby attractions or places worthy of visit - this will become relevant shortly.
So at 6 30 pm everything was going according to plan as we piled into a tuk tuk to go & see semi-clad cambodians throw themselves about. On arriving at the Circus there was an absence of other tuk tuks, people & general activity which did not bode well. "Oh!" said D's brother, "there is no Circus this evening - it has been cancelled because of Khmer New Year tomorrow". "Oh!" said I, "If you knew that then why did you not tell us this before?". "Because," I was told, "I didn't realise you wanted to see the Circus I thought you just wanted to visit where it was". Classic Cambodian response AND he then expected us to pay him the rate for the driver staying and waiting all evening to take you back home. At this point irritation crept in - I believe I communicated it quite clearly.

Case Study 4 - Vietnam


This is a borrowed story from Katie who last year visited her cousins in Ho Chi Min & found herself going to the hairdressers as they thought it would be 'fun' for her to have something done. Katie clearly stated that she would consent to 'hair straightening' but no colouring or cutting. This was reiterated on several occasions. When a huge, stinking pot of ammonia smelling paste was brought out, Katie got anxious & once again requested that there was no colouring. Smiles all round - of course no colouring - then paralysed by a fear of conflict & an over developed sense of politeness Katie sat petrified whilst they began to smear the foul smelling paste on her hair. It is for curls - she was reassured whilst hacking away at her fringe - 8 months later & she still has great kissing curls - it was at this point that the cold realisation that she was getting a perm hit her. Its easy done, she assumed she had been clear, she assumed that she was just having her hair straightened, she assumed they wouldn't do anything she hadn't consented to - we all know what assumption is the mother of!

A simple case of hair straightening - clearly

In Laos there was a strange censoring technique on the TV that not only erased 'bad words' by bleeps but also blurred out 'bad things' - for example a harpoon killing a man, a gun being fired or someone being punched in the stomach - all blurred out like over zealous soft focus. When I first saw it I thought it was my middle age heralding floaters getting worse but no need to book an optician appointment, it would appear that if you can't hear or see evil then it doesn't exist.

Oddly when they want to people can communicate very effectively - one weekend in March a group of us went to Siem Reap & for Lou's Birthday she wanted us all to dress up in traditional Cambodian wedding outfits. Cambodian's are all size zero, I - despite 14 months in a developing country & 5 serious episodes of gastro - remain a solid size 18. The likelihood of me finding a Cambodian wedding outfit to fit me seemed quite unlikely. Lou reassured me that Americans went to this photographic studio & I mustn't fret as nothing bad would happen.

On walking up the stairs to where the lady-boy makeup artist was waiting, Lou & I were 'greeted' by him standing up in disgust, pointing in horror at me, exclaiming that I was "Twot maintain!" - extremely fat - & then proceeding to do the dismissive hand flapping thing that is so commonly done here, before flouncing off in refusal to deal with me.

Sometimes communication can be very cutting.

Emotional/financial

One of the documents that URC is working with the MoH is a nursing assessment form.

I was shown a draft of it by Miss J, BTB Hospital co-ordinator for URC & 'she that keeps me sane' as all my other emotional props have left or are leaving imminently.

It initially looked pretty standard to me, subheadings of 'respiratory', 'cardiovascular', 'gastrointestinal' & 'Skin' for example. When nursing a patient you need to know how to position them in bed to facilitate breathing, if they require oxygen, what their exercise tolerance is, are they allowed out of bed to walk, what diet are they on, how are their pressure areas etc etc etc. It was looking very similar so far to nursing paperwork we had in the UK.

Then I came across an interesting subheading combination. 'Emotional' I'm sure we would all agree is another important area to assess when forming a nursing plan for an individual patient. I was slightly bemused to see what the emotional assessment of a patient had been paired with & realised that this simple pairing spoke volumes about the social situation, health system & Cambodian culture.

The subheading's full title was 'emotional/financial'. In the developing world I'm sure the two are inseparable. In the developed world we say that money doesn't bring you happiness but perhaps that's because we don't know what it is like to live on only $2 a day. 

BTB Emergency Medic

Last night Jean & I went to the Circus, "Five Styles" - it was good, less traumatic than "Rouge".

On the way home however we had our own personal trauma.

D, my regular tuk tuk driver had also brought an older Finnish woman to the circus, so we all got a lift back together having the innocuous "where are you from? What do you do?" conversation. We never got as far as what I did but that, all too soon, became apparent.

Everyday I cycle a particularly hazardous intersection between the middle bridge & a busy road on the way to work. As we chugged across at tuk tuk speed (often one can get places faster by walking) a girl on a moto came at speed and in classic slow motion crashed into the side of the tuk tuk. Jean (sat opposite to me) saw it all coming just from the look of horror on my face & a certain overused expletive. I still marvel at the slow motion speed that her crash helmet (sensible girl) was knocked from her.

I was immediately out of the tuk tuk but before I could get to her there were already 10 bystanders dragging her from under her moto & generally breaking every trauma rule. I tried to explain to them that "Chea Kroo Peit" - I'm a doctor & to "Pror Yatt" - Be careful & "choop" - stop but hysteria had taken hold. They were pulling her about like a rag doll, she was unconscious & her head was rolling around, C-spine control was obviously not their priority.

She had an airway, was breathing & had a pulse - there I go again with the ABCs - just not fashionable here.

When about 30 cambodians had surrounded us - all pushing & pulling her and performing sternal rubs (apparently my VA tells me it is important to wake people up, D before ABC - I am so out of touch) Jean felt compelled to shout "NO!" No one of course took any notice of either of us.

She then was unceremoniously carried to the back of D's tuk tuk where she was dumped in a heap, spinal protection - non-existent.

D was all up for taking her to the hospital, I suggested the Emergency Hospital (NGO) as it is a) free & b) better. Free is important as D will be carrying the financial burden of any medical costs, compensation & bribes. Even then however no one would listen to my directions of how to get to Emergency & we ended up doing 3 sides of a square. Half way D turned around (still slightly shocked) & asked "Where is the old lady?" - whoops!

On the journey I also managed to communicate with her boyfriend (& pillion passenger) that I was a doctor who worked in emergency medicine & that it was important to protect her neck, keep her airway open & stop doing sternal rubs.

By the time we carried her onto a trolley outside the ER at Emergency Hospital she was regaining consciousness & I had regained control of her C-spine. She could move all her limbs, I tried to tell them the mechanism of injury but I was shooed out. I guess that is how I must have treated paramedics & in true buddhist style that this was my karmic revenge.

Then followed a lot of waiting. There was a protracted conversation in khmer between D, a moto driver in a striped shirt & a smiley woman. Then the police arrived so we sat down expectantly for lengthy negotiation only to be told by D he would take us home now.

Returning to the scene of the accident there was no sign of the Finnish lady - double whoops!

It was reassuring for me to know that even outside of my work place, people still fail to heed me & all my efforts to help are futile.

I've witnessed & attended various accidents in the UK - as soon as you declare your profession people tend to step back & afford you some professional respect. As with most things here in Cambodia, it is different. They probably were all thinking 'why is she doing nothing - she needs to rub that girl's sternum really hard and throw her about like a rag doll.' There is a lot to be said about the public health education aspect of programmes such Holby City & Casualty.

Today I went to Emergency to check on her, she wasn't even admitted over night. So she was sensible to wear a helmet even if driving into the side of a tuk tuk isn't to be recommended.

What do I take from this - I miss emergency medicine but perhaps not enough to go around making work for myself.

Not getting it, but getting it...

The sign above was in our hotel room in Laos. It is not an unfamiliar site here in Asia. It elicits a particular response in me 1) Jean & I only ever stay in the most salubrious places & 2) Men all over the world can't seem to keep it in their pants.

I should start with a conversation I had only yesterday with my lovely VA, he is young but very wise.

Me - V how do you feel when you see a barang* man with young Cambodian woman?

VA - I think it is a kind of sex tourism.

Me - So do you think that it is all just sex tourism?

VA - No, you can not say that 100% of it is sex tourism but mostly it is. In fact it is very rare to see a true love match without a financial gain also being involved.

And that is why he is my lovely VA - his ability to put into words, of his second language, concepts & realities that I struggle, with my irritability, to even express & which sometimes even keep me up at night.

A similar conversation, with the lovely R, was regarding a westerner who has a khmer girlfriend - his conclusion "She is only with him for his money - Esther!"

This whole situation really depresses me for some reason. To be in the 21st century and women are still a commodity that are bought & sold makes me very angry (6 on the VAS for anger!). Are all women really just chattels?

Then I've had this conversation with barang males, they think its ok to have sex with Cambodians as long as you don't pay for it - as if the physical transaction of giving someone dollar notes is the only power play in that particular equation. The naivety or ignorance of this makes me want to scream.

I often get told that going to Karaoke is just a bit of harmless fun - I'm sure the girls that work here who are paid to be groped & exploited by drunk men are also having lots of fun earning a living wage to support themselves & their families.

There is no doubt that even without foreign 'investment' the sex trade would still be going strong here in Asia. However it is the added dimension to this that the barang (mainly male) brings that vexes me because they, after all, are visitors & therefore have choices.

Remove the sex trade from the equation & there are still huge issues around a barang having a Cambodian girlfriend. There are many cultural differences that exist around sex before marriage, virtue, prospects of marriage, financial security, family bonds, respectability, reputation, status, standing in the community - the list goes on.

I am not denying that a beautiful, compliant, asian woman is, by far, a more attractive alternative than a middle aged, obese, opinionated european that won't iron your shirts. That is not my 'beef'. There is a power imbalance that disturbs me greatly.

Now of course I do know some barang males in relationships with Cambodian women who are aware of all the cultural differences & are sensitive to all these issues. They are aware that their actions have consequences. They, as V quite rightly stated, are rare.

One good friend of mine describes him & his girlfriend being in a cardboard box of cultural restraints which they slowly & gently push against to give themselves more space without smashing through. He is an extraordinary barang.

Most barangs however are not getting it - but perhaps that is because they are 'getting it'.

* Barang - Khmer for french but commonly used to refer to a foreigner.

Visual Analogue scale for Anger

As a medic I'm a little obsessed by trying to understand other people's subjective experiences of the world using a scale of 0 - 10 (based on the visual analogue scale (VAS) for pain). I even annoy myself with my relentless "On a scale of zero to ten where ten is on top of the world looking down on creation & zero is the very depths of despair - where are you?" etc, etc, etc - pain presents itself in many forms.

I've spent a little bit of time this weekend devising a visual analogue scale for Anger - there is currently a lot of anger in my life & I thought that quantifying & qualifying it would help me to make sense of things.

Every day I visit a website called moodscope, I think I've mentioned it before, which was introduced to me via a midweek podcast, the founder - Jon - was telling his story of setting up moodscope. It has been a useful exercise to answer 20 question 'cards' every day with one of four options 1) Very slightly or not at all 2) A little 3) Quite a bit 4) Extremely. There are ten positive 'cards' such as 'Strong', 'Determined' & 'Proud' - although the latter I always view as a negative trait & often score that one as 'not at all'.

The ten negative 'cards' include 'irritation' - always high scoring for me & 'hostility'. But after a week of fluctuating levels of irritability, hostility & anger (not an option on moodscope) I wondered if I could perhaps devise my own tool - with a little help from my friends whilst at the Victory swimming pool.

Just to talk you through the tool, as if it needs any explanation;

0) Obviously found to the far left of the line & depicts a state of complete calmness, inner peace & a sense of full well-being. I have never been there in the last 39 years so didn't feel the need to add it.

1) Annoyance - this can be mild, moderate or severe & is when a stimulant provokes an awareness but not a true emotional response to it. Mosquitos in your mosquito net are an annoyance, sweating in the hot season can be annoying, no water when you turn on the tap, toilets that don't flush, living next door to a Wat, dogs in my compound - are all an annoyance to some degree or another.

2) Frustration - this occurs after prolonged exposure to annoyance with an additional attempt to engage, change or modifying the annoyance unsuccessfully. Trying to get doctors to order a full blood count is frustrating, people saying 'yes' when they mean 'no', errors made in communication based on translation, people deliberately messing with your head, the sense of non-urgency & general pace of life - these can all be frustrating.

3) Agitation - after prolonged frustration comes agitation which is a physical manifestation of frustration. This can reveal in many ways; shouting, pacing, tearing ones hair out, not sleeping, not eating, eating too much, smoking, drinking alcohol, crying for no reason. It tends to be short lived & can be addressed my removing the source of the frustration.

4) Irritation - when there is prolonged frustration, annoyance & agitation or you have a mood disorder then the result is irritability and this can be low grade to a full on state of heightened irritation. Its pathological but sometimes I quite enjoy it. Every day in work is irritating, certain people are irritating, online banking, my flat situation, weddings/funerals/festivals here - all tick the irritation box.

5) Vexation - I love this word, it so very Jane Austin. I like to think of this as 'very cross' - a combination of irritation, agitation, frustration & annoyance. Being vexed with people is always a lot more polite than being bloody angry at them. Not getting your lunch when everyone else has, after no breakfast & you've had little sleep, a bumpy journey and you are already annoyed & agitated results in vexation. People giving you mixed messages - that can be extremely vexing. The bus company charging me a ridiculous amount of money because it is Khmer New Year then refusing to drop me off in the centre of BTB hence I had to walk in the midday sun - this caused me vexation.

6) Righteous Indignation - I am very familiar with this state, one perceives oneself to have been wronged in some way - implying that you are in the right - & you are very angry about this. It's often made worse by the person/thing that has made you angry not acknowledging that you are right/have a point/deserve some respect. I feel this most days of working in the Cambodian Health Care system. Read any clinical blog as an example of righteous indignation - perhaps PTC - an epic journey is a good start. Clearly righteous indignation is a barrier to effective capacity building.

7) Anger - a score of 7) or more on the VAS for pain denotes severe pain requiring an opiate - Anger AKA Wrath is the psychological equivalent. It needs what ever 'opiate' works to dull it - shouting, crying, violence towards oneself or others, smoking, drinking, using class A drugs, extreme sports, exercise, dangerous driving - everyone has there own coping mechanism. Humour as a defence is a common mechanism for me which doesn't work so well, when I'm angry people laughing at me seems just to make me angrier!

8) Slow Burning Rage - prolonged anger results in this state of persistent rage, it is not good for ones health. Last weekend I spent most of it 8) on the VAS for anger, hence the creation of the above scale. I felt like I had transcended annoyance, frustration, agitation, irritation, vexation, righteous indignation & anger. I had a true sense of calmness - much like the eye of a storm - my moodscope score was even 79%, the highest it had been in months. But that's only because I had focused all my negative energy on one thing then put it on the back burner. The peptic ulcer/BP are doing nicely, thank you for asking.

9) Fury/Red mist - slow burning rage isn't sustainable & one can either slip back down the scale or progress to fury. Thankfully seeing the 'red mist' is not a common experience for me, however I have it in my genes. Seeing 'red' tends to be a family trait, various members of my family or their loved ones have lived in fear of a 'Wilson' in a fury. Sleeping with a hardback coffee table book on ones chest in fear of being stabbed, hiding in your room/garage/place of safety/panic room, wordlessly handing over a large glass of whisky - these are all well used coping mechanisms for the recipients of this fury. I really don't do it half as much as I'd like to but you never know given the current circumstances I could be entering a new phase of my life & how I manage anger.

10) Acceptance/Depression - people have choices, one can either reach a level of acceptance about the source of one's anger or failing this develop a huge sense of helplessness & hopelessness heralding the onset of depression. I believe it is quite possible to cycle between the two depending on the amount of sleep/food/drink one has had, also it is dependent on environmental factors such as temperature & humidity, public holidays & visits to a swimming pool.

Being angry isn't healthy and as a fellow VSO-er pointed out to me the Buddhist scriptures advise "breath in love, out anger". My glib response was - well I'm very good at the anger part. Her text reply was - no esther, you have a lot of love. And she is right of course - it's holding on to it that is proving to be the tricky part.

It's not them, it's me...

As I sat in a meeting this week in Phnom Penh, being presented with the figures from the most recent hospital assessments showing an unbelievably high score for most things in the hospital I am based at, I had this epiphany - it's not them, it's me...

So much of the time when struggling to make sense of my job & how I can go about successfully capacity building I am told by others that it is just a hard placement, that the hospital is one of the toughest to work in, the staff the most resistant & stubborn. I am reassured that I am in fact doing just fine.

But when a relationship ends & you are told "It's not you, it's me" you can't help but wonder if it isn't really actually all just you.

Hope - an example

The drug chart of the severe asthmatic patient (x-ref Life is a Series of Disappointments) - after asking the staff every day to prescribe a non-homeopathic dose of salbutamol followed by my subsequent melt down with the deputy director on Friday - FINALLY over the weekend he received proper amounts of medication & today was sat up eating bor bor & smiling when I visited the ward this morning. Hope - do not leave me! Those that give me hope - the same...