Calm Assertive

Recently I have been told that I am not authoritative or convincing enough. The person in question suggested I read Cesar Millan's book 'Cesar's Way' - the mexican american bloke who is the 'dog whisperer' on TV - I scoffed. I was told that I should be "calm assertive" and people, like dogs, would respond to me better. I passively aggressively told him where to go.

Then I spent a rainy weekend in Siem reap in a hotel room, watching re-runs of The Dog Whisperer on Animal Planet. I learnt some pretty pertinent stuff,  that dominant & aggressive dogs are easier to rehabilitate & behaviour change than an insecure & anxious dog.

Now considering that I am meant to be capacity building, which in turn is all about behaviour change suddenly Cesar Millan seemed to be talking a lot of sense. I hadn't really thought of the doctors I work with as anxious but arrogance is very often only hiding a deep seated insecurity.

The trouble is that although I am quite good at passive aggressive, calm assertive energy seems to allude me. I continue to strive to find this higher ground & to be more convincing whilst I am at it....

My New Friend - she is one of the hospital dogs, friendly & playful, takes food from your hand very gently, barks politely, lies patiently at your feet awaiting scraps & follows me all around the hospital despite being threatened with violence by the Cambodian staff - my calm assertive aura is finally working on someone at the hospital at least!

It's not a failure, its just meeting our low expectations

As a postscript to a previous blog regarding life being a series of disappointments, I thought it may be useful to explore my own coping strategy for disappointment.

An effective way I have found to deal with this phenomena has been to simply lower my expectations - the question is "How low should I go?"

So I accept now that most of the male Cambodians I know will go to Karaoke, buy beer girls & have girlfriends as well as wives & children, but that still didn't prepare me for seeing them bring prostitutes back to the hotel or when they get karaoke girls pregnant.

Or I know that most health workers take bribes but does that mean I should expect them not to treat poor patients who can't afford bribes?

And I expect 3 months of drum & gong banging at 4 am every morning in the rainy season, I've actually found that NOT wearing ear plugs helps as the expectation to not hear anything at all is eliminated, but the progressive rock pumping out of the speakers at 3 am today exceeded my expectations of the usual plinky plonky music. Perhaps I really have become 'comfortably numb'.

When only one person attended TB training on day one but then left after 5 minutes, I told J "it's not a failure it's just meeting our already low expectations."

When a Cambodian colleague recently text me to apologized for "letting you down", I replied he hadn't let me down as I hadn't expected anything from him in the first place.

But if you expect nothing then you will get nothing, so in truth I still expect an awful lot & I am constantly feeling frustrated &/or angry with disappointment.

It would appear that some Cambodians have kept their expectations much greater than mine. At the end of the cardiogenic shock protocol that I have been editing recently there was a suggestion that if drug therapy wasn't working to insert an "intra-aortic balloon pump" - appropriate but not really available or realistic in Cambodia. However the suggested treatment for irreversible cardiogenic shock that followed the intra-aortic balloon pump (I like to think this was one Cambodian doctor's very high expectations rather than just plain stupidity) was "Cardiac Transplantation". I laughed until I cried, whether this was through mirth or despair was less clear to me.

Gender Studies

I have been asked to do a session at the new volunteers in-country training on Gender - its a shame that there are no gender issues here, I've been finding it difficult to think of any examples. Surely sarcasm isn't the lowest form of wit?

My VA was telling me about a class she attended at her university - she had been told that women are the weaker sex & they are only made to have babies & stay at home. I clarified that this was a gender studies class & that surely these were points for debate. Apparently not, this statement was from a psychology class she takes & were delivered as fact by the lecturer. Cambodians hey? No actually - Barang!

I was intrigued to see if this really was a factual lesson or was meant as ideas for discussion in class. Today she brought in the handout for me to see - it was a lesson on evolutionary psychology & I just couldn't resist this opportunity to share some of the 'facts' with you. Here goes......

Extracts from "Innate (genetic) male-female differences in bodies, psychology, roles, and brain"

• Females have wide hips and legs that turn in at the knee, to bear the weight of a baby, especially one with a big brain. These physical features restrict their mobility. Females, cannot run, jump, and throw well. They are designed instead to have babies.
• Males also have twice as much testosterone as females, which gives them a high sex drive and an aggressive personality.
• Men are psychologically disposed by evolution to like each other and to get along - "the male bond" Men enjoy being with large groups of other men - "running with the pack" Women, on the other hand, even when quite young, form small, family-sized groups. They are very close & supportive with others in these small groups, often they are mean to other girl who aren't in their group.
• Women control men while allowing the men to think that they are in control (for example, it is women who decide how to spend almost all the money) Women have two intellectual advantages over men. First, they can easily "multi-task" This makes them seem silly & illogical to men. Second women have a mental faculty called intuition that men lack. She knows what children, men, and animals are feeling and thinking. These mental abilities evolved as part of a women's role in keeping her husband, guarding her children, and holding the family together. Men don't have a clue.
• When a man is jealous, he becomes angry and violent. When a woman is jealous, she tries to make herself prettier. 
• For a man, any discussion with a woman can be exhausting, because she can't stay on a logical track and talks about many different things that aren't related to the problem you are discussing. Men get tired of this, and conclude that women aren't logical and can't think. There is some truth to this. There has never been an outstanding mathematician. Men can concentrate on one thing or one problem, if necessary for hours, days, months, or years. Women can't. 
• Women don't respect a man's 'space' and can't leave their man alone 'nagging' - the man will become angry.
• If a women becomes so frustrated with a man because he won't do what she wants and she gets out of control, she will shout at a man non-stop for an hour without even taking a drink of water. When a woman shouts at a man for an hour, he feels bullied and defenseless because he doesn't have the same verbal abilities she does and can't shout back at her for such a long time. Under those circumstances a man will raise their fist.
• Men want to have sex with many different women. A man will lie to a woman about his love and commitment, so that she'll let him have sex. After marriage most men are not sexually faithful to their wives. Women will tease men by making them wait and by requiring them to write poems and take them out to dinner in order to show that the man is serious.
• Psychologically diseases of modernity - harmful & extravagant attempts to attract love & attention: anorexia & bulimia in women; When a man & his wife both work, children don't get the attention they need; If a women stays at home with her small children all day she resents them and becomes violent and angry with them.

I am going to leave if there - you will have to guess the gender, age & nationality of the lecturer.

I'm off with my enormous hips & knock knees to try & make myself prettier, then concentrate my little brain on how to help my VA get a more balanced education, free from sexual harassment. If only I had a man that would lie to me to get sex & who I could starve myself for & nag for an hour without taking water, maybe then I'd be lucky enough to get a fist raised in my direction......

Cambodian Triage

A nurse I met with at the weekend who was first time visiting Cambodia with a NGO gave me a great idea for how triage could work here.

The triage system that we are introducing & training on, in my two hospitals, is as follows;

RED Unstable patients with a life threatening conditions that need to be seen immediately e.g airway obstruction, severe asthma, septic shock, fitting

ORANGE Emergency patients that need to be seen very quickly (within 10 minutes) e.g. Heart failure, uncontrolled bleeding, snake bite

YELLOW Priority/Urgent patients that need to be seen by a doctor but can wait an hour for two e.g. Early appendicitis, early malaria, moderate dehydration 

GREEN Stable, non-urgent patients that can wait to be seen or go to OPD for consultation

I've been struggling to inspire a sense of urgency for the whole process of recognizing & managing a sick patient. Currently triaging one patient can take up to 15 minutes, it should be a 2 minute process!

The nurse I met with has only been in country a week but came up with a very good method for instilling a sense of urgency & potentially getting sick patients seen in a timely manner. The method was inspired by a system of triage in mass casualties situations & some beers. 

It goes something like this;

RED Place a $20 note on the patients forehead

ORANGE Place a $10 note on the patients forehead 

YELLOW Place a $5 note on the patients forehead 

GREEN Place a $1 note on the patients forehead


Show me the money............

TB training - another epic tale

When I offered to help out the NGO I work closely with to deliver some TB in children training for them, in the small hospital on the border I go to once a month, I really couldn't have foreseen the consequences. 

In this epic tale of TB in children training, I managed to offend several Cambodians, reveal negligence & lies, have a radical change in my teaching style, finally get around to installing unicode (khmer font reader) on my laptop and become a TB champion.

It all started at the monthly meeting, of the NGO I work closely with, three months ago when it was noted that the budget for TB training at a border hospital had to be used by the end of year 4 of the project. So far it had been cancelled 3 times because the doctor who should have done was too busy to leave his NGO hospital due to the Dengue epidemic. I innocently offered to help out - I am by no means a TB specialist but if I could do it would that be better than nothing? - error number one.

It was agreed at the PNH office I could do this. A couple of weeks of silence. I emailed PNH office asking if they could send me the training materials. The reply was they were in the drop box. In the drop box were 6 lectures all in khmer in a font my computer can not read. I tried to get them printed so I could read the english rendered unreadable by the unreadable & distorted khmer font on my laptop, but was told by the NGO co-ordinator of that hospital it wasn't in the budget - he was as helpful as ever. My VA spent 2 weeks translating them for me & we installed all fonts on my computer just in case but I still did not have 'limon', which is what the training material was typed in. When I could finally read the content I realized that there were some pretty fundamental areas missing e.g. treatment of TB so I sent another email asking for a lesson plan & agenda - not with the training material in dropbox. The lesson plan did not exist, the agenda included 8 further lectures I did not have. I emailed again & was told they were in the drop box - they weren't! I emailed again & finally got the 8 further lectures sent to me, all in khmer - limon font. My VA was busy for a further week. It became apparent to me that the lectures were very poor quality - no learning objectives, confusing slides with too much information on them, irritating animations, no summary slides and no accompanying lesson plan. I voiced my concerns to the PNH office & was told this was MoH material & it could not be changed. A week before I was due to give the training a member of staff from the NGO I was helping out my delivering this training sent me the MoH guidelines on TB in english, which was the reference material for all the teaching slides - better late than never hey!

I was regretting offering to help & then I received an email from the doctor whose job it was to teach the material in the first place, it was the weekend before the training and he was asking me to do some clinician assessments for him whilst I was there. I was put out as last time I checked I am not his skivvy - I would have wrote that in my email reply but I'm pretty sure he wouldn't have understood what I was saying. Instead I wrote a very polite email - J screened it - saying I wouldn't have time & that I was surprised to see on the work-plan that he was going to another small hospital (the week I was training TB) when the only reason I was doing this training was because I had been told he was too busy to leave his base hospital because of the Dengue epidemic. I thought that was slightly odd - my innocent query resulted in him taking great offense. In his response he told me, "I don't know why this activity of mine surprised you, and I went there it did not mean that I did not take responsibility in my job. Please reconsider before talking things that might hurt other's feeling...I asked you for help with that activity and if you could not, just say no, don't say that because I want to avoid my responsibility."

I responded that I hadn't meant offense, I was simply asking the question why was I doing the training when I am a volunteer, its not in my work plan or my scope of expertise, I am not khmer & can't read or deliver the training material effectively & it will take me three times as long to deliver - surely it would have been better if he now had time to do it? Nowhere in my email had I said he was shirking responsibility but I guess sometimes the truth hurts.

The day before the training R & I went through the treatment lecture - R noticed some errors in translation so contacted the PNH office who replied we had the wrong lecture. They sent the correct one - all in khmer & limon font - telling me it wasn't a problem as all the drugs were in english. It was a problem as the treatment regimens & explanations were all in khmer & completely different from the MoH document or my translated lecture. I pointed out to the PNH office that I am an idiot mono-linguist so this was a problem, I never received a reply to that email. I am guessing their silence was assent.

Day one of the training one MA turned up, waited 5 minutes, got a call from someone & left with the handout. No one else came, it rained heavily, the room leaked - this wasn't a failure, it was just meeting our low expectations about the training.

Day two after a telling off from the director 20 nurses & 2 MAs attended the training, we only had 5 hours to cover a 3 day programme - the pre & post test went out the window - the training was designed for doctors I tried to modify the material for a mainly nurse & MA audience. The pre & post test was confusing & covering material I had chosen not to cover in detail as it was too complexed. 

I concentrated on training about diagnosing TB - the importance of history including contact of TB in EVERY patient. The symptoms (general signs are night sweats, weight loss or failure to thrive, fever, low energy, etc.) & physical signs of TB, how to diagnose & get samples for investigation and confirmation. This took me all morning. At one point they were talking among themselves & answering their phones, this is when I completely lost it - I told them if they weren't going to listen to me then I was just wasting my time & should leave, I explained I wasn't doing this for me, it was so that they could recognize & treat more children with TB, I asked if they didn't care about children & doing a better job they could just leave now, as I wasn't interested in wasting my time or theirs - they shut up.

As we were leaving for lunch one of the MAs brought her sister in law to the hospital for me to see. She had a 5 year history of right knee pain & intermittent swelling, haemorrhoids and maybe some kind of ovary or hip problem - translation was less than clear. Her question was - was this TB? So although they will continue to neglect their poor patients, at least they will have an unnecessary & needless high index of suspicion of TB in their relatives. That's Cambodia for you.

In the afternoon they all joked that they were in trouble with the teacher that morning, they were taking the piss out of me but they still shut up when I opened my mouth. This is not my normal teaching style but I could get used to it. R went through treatment, surveillance & prevention of TB - this was a lot quicker as translation from english to khmer does add a significantly long time to any training. This meant we also had time to go over pulmonary TB but not to go over the 7 individual lectures on extra pulmonary TB or to do the test.

At the end I asked them what were the keys points to make a diagnosis - silence. What in the history is suggestive of the general symptoms of TB? Their answer - an enlarged lymph node in the neck - I knew then that I had been unsuccessful in training them on TB!

They then kindly confirmed this by mismanaging a patient on the medical ward despite training that week & me having conversations with 3 different MAs and the head nurse about him. The patient in question was a 56 year old man with a 6 month history of fever, night sweats, weight loss, cough, chest pain & haemoptysis. One MA had asked me to examine him - role modeling as always I took a full history first, which is the only reason I knew the history above as well as the history of a TB contact, none of this appeared in his medical notes. I listened to his chest & he had bronchial breathing at his right apex. The MA had written in the notes that his chest was clear. I managed to convince her to go back to listen again - she wasn't convinced I was right but as I always use the cheap, crappy stethoscopes in MoH hospitals rather than my Littman, they can't accuse me of having superior equipment which can hear things they can't. The following day when he had his chest X-ray (below), I spoke with her & another MA that with the history & now X-ray changes (a right upper lobe opacity with right upper lobe collapse) we needed to exclude TB. He would need to provide 3 sputum samples which should be sent to look for the characteristic acid fast bacilli of TB. I used his case as an example for the TB training, then I told the MA on medicine ward that he needed sputum samples sent just to make sure my advice was clear & consistent.

By the end of the week & after the TB training, where the whole algorithm of management for pulmonary TB was reiterated, they had still failed to take any sputum samples. On the Friday before leaving I sat with him & explained that we needed sputum samples & we needed to exclude TB which may take some time. He hadn't been asked for sputum samples & was keen to self discharge as nothing was happening at the hospital - it really wasn't. I spoke with the head nurse & explained that rather than letting the patient go home on amoxicillin as he was planning - there were no doctors in the hospital for 48 hours - it would be better to get the 3 sputum samples as I had already suggested to 3 separate MAs previously. I left convinced he would never receive the investigations or the treatment he needed & deserves.

Right upper lobe consolidation & collapseospital has also had this TB training and also there seems to be a completely lack of retention of information or change of behaviour in the management of suspected TB.

The Hospital I mainly work at also had these TB training delivered by an NGO. Below is an ECHO of a women that presented to ICU medicine in "heart failure" - she was started on frusemide & had an ECG with some abnormal T waves, I was just shocked it had been done. Me & a fellow from a US university - B - who was visiting for a fortnight, convinced ICU to get a chest X-ray. It showed a enlarged cardiac shadow but there was no sign of pulmonary oedema. B was keen to use the ultrasound machine in OPD to do an ECHO. I have suggested this on many occasions previously but it has only when B asked that it occurred to me the reason that they have always refused is to do with conflicting interests, the private ECHO clinic would lose out on money - ECHO is not available at the government hospital. 

Dr ON, who will be head of the the Emergency room if it ever opens, already does some ultrasound in OPD and also had been to Singapore the week before on an USS course and had arranged for them to come to BTB and donate equipment. B persuaded him to let him use the OPD USS to do an ECHO, we both convinced him that it's an important skill for him to learn - he bought this.

The USS machine in OPD gives surprisingly clear images & Dr ON picked up the technique of doing ECHO views quickly. What the ECHO showed was that there was a large pericardial effusion with right heart strain & after a week of frusemide she was intravascularly depleted. I asked her if she had a TB contact. Her son was being treated for lymph node TB. Children aren't usually infectious especially if they have lymph node TB but if they have TB then one of their care givers will have TB. Every child with TB should therefore have the source of their infection traced - this had not happened with her son. There was a 99% chance that her pericardial effusion & impending cardiac tamponade was due to TB. 

Dr ON & the ICU doctors wanted us to do a pericardiocentesis (drain the excess fluid from the sac around the heart), luckily B repeated my earlier explanation (from a similar case 6 months ago) that as emergency physicians we were happy to do this procedure if the patient was about to die with tamponade, but not if she is stable because the risks of the procedure far out way the benefits. We explained that if she was started on TB drugs the effusion would improve but by just draining the effusion it would just come back without TB treatment. We also explained the frusemide would kill her & it should be stopped, what she actually needed was fluids NOT diuretics.

A week later she was still on frusemide & had not been commenced on TB treatment, so we attempted again to explain to the ICU doctors what her diagnosis was. Obviously it wasn't their fault but they told us we should speak to the TB ward ourselves. We did, the doctor there agreed that the patient needed TB treatment & prescribed it. We tried to explain to ICU medicine that she would also need steroids & an HIV test. Last time I checked this hadn't happened. I suppose I should just be thankful that after a week she was finally started on TB medication & hope that her effusion doesn't get worse before it gets better.

Finally there is the case of negligence & lies. A 10 year old girl from the border came in with a 5 day history of fever, headache & left hemiplegia. She had been started on IV antibiotics for meningitis by the CPA 1 hospital but the MA on duty thought it was Dengue. I tried to explain to her that she should be investigating for meningitis & malaria but my advice, as usual, fell on deaf ears - she stopped the antibiotics. The following morning one of the paediatric all stars had spotted the gross mismanagement of the now comatosed child & done the necessary tests including attempting to do an LP. Admittedly I would have been more cautious about doing an LP on a unconscious child with localizing signs but I think we have established by now I am a crap doctor that no one respects or listens to.

However when the doctor & nurse both failed to successfully obtain CSF from an LP I helped much to the amazement of the hospital staff who I am sure don't even realize that I am a doctor. I got two tubes of clear coulourless CSF with a green needle & non-sterile gloves. Dr M had also referred the child to the TB ward where, without even seeing the patient, the TB doctor had prescribed TB medications. This meant that a CSF sample for microscopy & culture was even more important as otherwise how would we ever know if the child needed just 2 weeks of antibiotic or 6 months of TB treatment. The paediatric staff seemed less concerned about this diagnostic & management conundrum. 

At the end of the day I went to check what the LP result was - I saw one of the lab staff writing the form so I left reassured it was all in hand. I am an idiot.

The next day the result was surprising. The White cells were low, the protein was normal & the glucose high. It wasn't really consistent with the clinical picture, so I went in search of some answers. The patient was still comatosed. 

Fortunately WHO lab staff were visiting the micro lab when I went to check how the culture was going. What culture? I was asked - they had never received the sample. But it has had a gram stain, I had seen the report. I was told that it was not possible to do a gram stain without a sample being sent to the mirco lab, there was no record or evidence of this so it must have been done in a private clinic. I was able to disabuse them of this theory by revealing I had seen a member of staff from the main lab effectively making up the gram stain result. I'm not sure if this was due to ignorance or laziness but I know that the outcome is negligence. I checked with the TB lab, they didn't have a sample either - they had never received it - so the TB staining negative result was a fallacy also. The samples had now been discarded.

I was angry. The paediatric doctors were amused. Everyone knows you can't trust results coming from the lab, you always just treat based on clinical findings. But they are liars & negligent! I exclaimed whilst ranting to Dr CP (head paediatrican) about the case. In khmer he told me I should talk quietly about these things. 'Its wrong' I tell him '& when something is wrong I will say it loudly & clearly'. He laughed - I am not sure which kind of khmer laugh it is, probably annoyance.

The 10 year old girl is getting better, she is obeying commands & is getting movement back in her left arm & leg. We will however never know whether she has TB or just a normal bacterial meningoencephalitis. She will be on the full course of TB medications & is still getting her Ceftriazone for another week.WHO will bring up the fraudulent CSF result with the head of lab & hospital director.

I am just grateful she didn't cone when I helped do her LP. 

Cutting for Stone

When I was a medical student I did an elective in South Africa - in a small mission hospital on the Mozambique border. I met many inspirational people there, including a nurse who lived in a converted ablution block in the grounds of the hospital, walked the 6 km to her township clinic after a early morning swim in the hospital reservoir & was kind to a bewildered english medical student. She introduced me to Cat Stevens, Johnny Clegg & long distance study. She was re-reading Illusions by Richard Bach and pencilled in the margins of her well thumbed copy were notes from many previous readings of the same book at different stages of her life & nursing career. Each time she would find new paragraphs that related to her current situation. I loved the idea of recording how you felt by highlighting what resonated at any particular time & place in your life.

When the previous VSO health programme manager left Cambodia in May she gave me a book of hers, with a hand written inscription on the inside cover - ensuring me that I would find some way to use my medical skills again (maybe just not in Cambodia!). The book was Cutting for Stone by Abraham Verghese and it was a perfect parting gift from her. It resonated with me like a bell and from chapter one I began to make a note of certain sentences that I related to or touched me, sometimes inexplicably. Certain chapters had be sobbing - I really loved reading this book, it has distracted & comforted me this month.

Below is a selection of some of these quotes, piece them together & you may get a better picture of my current mental state - in this particular time and place...

"Life is like that, you live it forward & understand it backward."

"In the hierarchy of her emotions, anger was always trumps."

"Ignorance was just as dynamic as knowledge, and it grew in the same proportion."

"When we cannot cure or save a life, our patients at least feel cared for. It should be a basic human right."

"She had nothing to put on the table but the truth."

"Departure or imminent death will force you to define your true tastes."

"Tizitash zeweter wide ene eye metah - I can't help thinking about you."

"The past recedes from the traveller."

"You had to exert yourself to see this world. But if you did, if you had that kind of curiosity, if you had an innate interest in the welfare of your fellow human beings, and if you went through that door, a strange thing happened; you left your petty troubles on the threshold. It could be addictive."

"A childhood at missing imparted lessons on resilience, about fortitude, and about the fragility of life."

"He had so many ways of climbing into the tree house in his head, escaping the madness below. And pulling the ladder up behind him; I was envious."

"Not only our actions, but also our omissions, become our destiny."

"Without Genet as a witness, nothing I did was meaningful."

"Life is full of signs, the trick is to know how to read them."

"Travel expands the mind and loosens the bowels."

"But you reach a point where after trying and trying you say, patience be damned. Let then suffer their distorted worldview. Your job is to preserve yourself, not to descend into their hole. It's a relief when you arrive at this place, the point of absurdity, because then you are free, you know you owe them nothing."

"I don't think you can be a physician and not see yourself in your patients illness."

"The mind was fragile, fickle but the human body resilient."

"The immersion of blood, pus, and tears - the fluids in which one dissolved all traces of self."

"The mood in the room went from the joy of reunion to profound sadness, as if those two emotions were invariably linked."

"I had nothing more to give, and nothing to fear."

A wish & a prayer

Sometimes someone else's blog just has to be plagiarized, so here it is from http://stuffexpataidworkerslike.com/

The Expat aid worker's prayer

"submitted by Molly (who blogs at Molly In Monrovia) and Alex

Dear Lord,

Today, aid me in my otherwise mundane tasks, that they shall not
result in gangrene or identity theft.

By Your grace, cancel the flight of our donor, so that I might have 24
more hours to shiny up our anecdotal success stories with pictures of
children

May the M&E consultant be amenable to case studies, or at least
receptive to my sexual advances

May the Internet, like Your mercy, flow abundantly, so that I might
watch that new Rihanna video on Youtube.

Please Lord, give me the serenity to accept the dangers of salads
the courage to eat the unidentifiable bits of meat
and the wisdom to know the difference between the proper course of
self-medication for the results of each

Fill me with Your glorious knowledge of the nationality of the person
that I am greeting, and how many cheek kisses are required; because
otherwise, Lord, it is always kind of awkward.

Grant me the patience to sit through yet another tale of Central Asia
in the early ‘90s, that lo this elderly consultant may one day, acting
in Your name, offer me a job, for only You know when the funding for my
current position may dry up

Lord, may the DJ always play Toto, for I am drunk, and THAT IS MY JAM

Forgive me for saying I was “working from home” the morning after karaoke,
as I forgive the still unsubmitted financial reports of our local partners.

And in Thy wisdom, let today be a public holiday in honor of a former
dictator’s birthday

But failing that, may I not receive too many marriage proposals on my
walk to work, for it shall make me indignant (…but just a couple would
not hurt).

And lead us not into open sewer pits, but deliver us to air
conditioned offices in white land rovers.

AMEN"