Bruises

My last weekend in Cambodia  I had a massage that left me with a series of bruises down my leg. It was actually a really good massage & it hadn't hurt anywhere as near as others I've had here.  But There is certainly a lack of gentleness here, which extends far beyond massages. A common way of showing affection is often done by pinching, slapping or punching, not dissimilar to what you'd see in a primary school playground. Little babies will get smacked forcefully on their bottoms by their family & it's not done out of anger, a malevolent act or even punitive, it's just pure love.

So today - my last day in Cambodia - I look down at the fading blue fingerprint tattoos on my leg & I'm aware of the constant dull, almost unbearable, aching in my heart & I'm reminded that here if they love you they will bruise you.

Parting is such sweet sorrow

On Wednesday I left the place that has been my home for over the last 2 & a half years. It wasn't easy but it  also taught me that I am very lucky to feel so sad & have such an awful, overwhelming sense of loss because it means that I have loved & cared about people here. I'm happy that I've made so many emotional ties with Cambodians & that the tears have not just been all mine this week.

So I should feel glad that I am so sad to leave S - my Cambodian mother - who is keeping some of my things safe for me so I can collect them when I come back to visit her. She brought around hot bread at 6 30am for breakfast on my last day before I left for Phnom Penh. She cooked me, J (who I had been staying with) & J's husband a huge lunch that same day of fried & grilled fish, mango chilli salad, crab, prawn and pickled cabbage. She washed up & tidied busying herself whilst I waited for my Taxi resisting my attempts at hugs because she didn't want to cry. I told her I would have no khmer lesson that day, she replied she would see me tomorrow. We both cried. That evening she called me in my hotel room in Phnom Penh to tell me to sleep well & that I must "be happy" because if I was happy then she would be happy. I couldn't speak back to her without my voice breaking. 

I am very grateful that I met my lovely assistant - L - whose strength in adversity, wit & wisdom far surpass her years. Saying good bye to her on our last day of work together was tough, I could barely get out the words to thank her or tell her I couldn't have done the last year of work without her. She wiped away my tears before her own. When I replied to a text she sent whilst I was traveling down to Phnom Penh that I was feeling very sad to leave this was her response - I know that. But u will come to see us again. U r always presented in our heart n brain. So u r not leaving us - this didn't help much to stop my 'tears drop down'.

I feel overwhelmed by the kindness of C & her barang husband P, whose hotel (my spiritual home) we went to for one final drink on my last night. He had arranged bar food on the house, a bottle of Champagne & also bought me a G&T for the road. C booked a taxi & came down to Phnom Penh with me explaining to the bemused taxi driver that I was her Bong S'rey (big sister) & the constant sobbing was because I was sad to leave my Cambodian family. C told me stories of her life - bombings, gunfire, sweat shop factories, bad fathers, bad ex-husbands, bad brothers, divorce & being a single parent, a Cambodian woman's struggles. We went out for a Chinese meal that evening with her regular tuk tuk driver - who impressed me by accurately estimating the weight of my luggage - and she insisted on paying for my meal & a medicinal large bottle of Angkor beer. When I got tired & emotional, asking her why she has always been so kind & generous towards me, she reminded me of the first day we met - happy hour at the hotel bar, after just a short conversation I gave her my phone number, sincerely telling her to call me if her, her children or her family ever needed medical help - you were so friendly & kind & you didn't even know me then - she told me, I daren't tell her it was probably just the long island iced tea talking! Karma cuts both ways.

And finally I feel nothing but sweet sorrow for leaving behind my best friend, R whose daughter broke my heart by doing a drawing for me & writing in her best English & Khmer -"I love Esther & Esther loves me". His family - the village people - had a leaving party for me on my final evening with all our favourite Khmer food including 'dirty meat' & 'shake fruit' in memory of all the times J, R & I had the very same at the forest. Saying goodbye to his wife was the starting point of all my tears this week, then his daughter P held me very tight, sobbing, whilst I told her she must continue to be strong, clever & brave although she should try be good, sometimes it would be better to not obey always her parents! As I sobbed on the back of R's moto as he took me to P & C's hotel, he told me earnestly - I'm just going to drop you off now, I am not going to say goodbye to you - But the next day he wasn't true to his word & came to the house to see me off. Against khmer convention he asked me for a hug. There are some people in life that you never want to let go of, I am very lucky to have met so many of them here.

C was right - I have left behind a Cambodian family & the parting was such sweet sorrow.

My work here is definitely not done

With only 6 days left in Cambodia everything has become about 'lasts'. Today was my last visit to a CPA 1 Hospital near my base work place where we go to follow up TB in children screening & Severe acute malnutrition (SAM) training. The hospital has less resources than others because is has no health equity fund. I'm told that it was left without a health insurance programme so that it could act as a control to compare with other similar sized hospitals in the area that had equity funds introduced.

Although they don't have a lot the staff especially the younger nurses try really hard to following any change in practice that training advocates. On my last visit I hoped to follow up TB screening there but instead I got a stark reminder that there is still a lot more work that needs to be done here before health care is even half decent.

J & R were visiting to do nursing process follow up so went over to the emergency ward to talk to the nurse there who had attended training, whilst L & I went over to OPD. There were no staff in OPD & a few patients waiting but no children so instead we wondered over to the TB ward but that was empty, finally we ended up at the paediatric ward. Every child had been screened &had a TB contact history documented, one child had been diagnosed & transferred with SAM but that wasn't what caught my focus of attention. Sat on the bench next to the nurses table was a woman with her baby in her arms. The older male nurse told me that the child had a reaction to recent immunization. Further questioning revealed that vaccination had been 11 days ago & the child had been unwell since. The nurse was actually sat 3 metres away from the child & mother and clearly had not examined the baby as if he had we wouldn't have been chatting about whether the child at 9 months old was too young to have the immunisation. I went to check on the baby & found that it had an obstructed airway, was pale & completely unresponsive. L has no medical training but could see the little girl was in serious trouble.

I opened the airway & after the very briefest of assessments I told the male nurse that the patient was in coma & needed urgent treatment - where was customary to resuscitate severely unwell children at this hospital? I queried, having only ever done follow up & no ER work here before.

"Reanimation" he shrugged - still making no attempt to get up to see the child or even do a basic set of observations on the comatosed child. Sometimes the inaction & lassitude of health workers needs to be circumvented in a non-culturally sensitive way & this I judged was one such occasion so I took the child's uncompleted notes & their yellow book from the mother & instructed her to "follow me".

We walked the length of the hospital grounds to the emergency ward which as its only asset is a cylinder of oxygen I will refrain from calling a ER. On arrival J & R looked surprised to see that our TB follow up had led me to present to the emergency ward with a pale, obstructed airway, shocked, comatosed 9 month old girl.

The first thing that became apparent to me was that the emergency ward had one oxygen cylinder connected to one dirty nasal prongs & tubing and that was pretty much what distinguished it from any other ward of the hospital. The child was so unconscious that her breathing was far from adequate - did they have anything to assist ventilation? I begged, whilst R suggested that nasal oxygen through dirty tubing at 2 litres a minutes was probably better than nothing at all.

A midwife went off in search of a bag valve mask that they keep on the maternity ward. The on duty medical assistant (MA) arrived at the same time as the box with the mask & a stethoscope in it. He, the midwife & nurse all stood staring helplessly at the child. I looked at R & wordlessly asked for permission to lead this resuscitation, he nodded his encouragement.

R placed a towel under the childs shoulders & explained to the staff that even if you didn't have airway adjuncts you could still do manoeuvers to open the airway. They gave oxygen. I listened to the chest & asked the MA what he could hear. I felt the femoral pulse whilst R suggested a temperature.

The child was pale, cold & tachycardic - shocked. R rolled up his shirt sleeves & then suggested they put in an IV whilst trying really hard not to do it himself. I think its fair to say that we both miss emergency clinical work & getting our hands metaphorically dirty.

Trying to get a clear history from the mother was challenging - she seemed to think the child had been deeply unconscious for 11 days yet the child had been still breast feeding & eating until the previous day. She could really tell me when the child stopped feeding, when she last passed urine or about the seizures she had. She was of course obviously very upset but this inability to give a clear history is a commonly recurring theme here.

It became clear to me that MA didn't know what to do so I talked through the ABCs of resuscitation & started to suggest a fluid bolus, some dextrose & antibiotics. After the dextrose the girl started to groan & whimper, she remained flaccid & floppy on the right but had increased tone & neck stiffness. The MA & I agreed on meningoencephalitis as a most probable differential diagnosis.

We reviewed the ABCD approach, I reinforced that good, correct management had been given & then we went on to discuss transfer to a higher level Hospital. R wanted me to explain to the Mother what was wrong with her child but I thought that it would be more appropriate if the MA could do this. After some discussion R turned round to me & told me that the MA didn't know what to tell the mother. I draw the line at thinking I am better than a Cambodian at talking to a parent in khmer about their seriously ill child. The MA was persuaded to do this whilst the nurse organized an ambulance to transfer the child.

The Hospital has no triage system or way to prioritize patients hence the child lay unconscious on her mother lap for an hour before I noticed how sick she was.

The Hospital has limited equipment & resources to properly deliver the care it needs to the poor rural community it serves.

The health workers have low knowledge & are poorly trained, they are on meager salaries. But when they have someone to lead & advise then they have the technical skills to good deliver care

The patients are mainly illiterate & uneducated and can barely give an account of themselves. Health education is not poor but absent.

So many times it has been demonstrated to me over the last 33 months that what is missing here is confident clinical leadership. On the job training with Cambodian health workers to help sick patients receive better care & build their confidence is absolutely what I love to do but sometimes the enormity of the deficit here is overwhelming and as a finisher completer it is clear to me that my work here is definitely not now, nor will it ever be, done.

What I don't blog about...

With a week left in Cambodia I suppose it is too late to right the balance now but I'll try.

This blog which started out as a way to communicate with people about what I was doing as a volunteer in a new Country, fast became a sounding board for my observations & frustrations, a form of writing therapy. So people who haven't spoken to me for a while will be forgiven for thinking after reading my blog that I must be truly ecstatic to be finally escaping the craziness of Cambodia - nothing could be further from the truth.

It is much easier to write about the big things that confront me here or challenge my cultural norms but its the little things about Cambodia that have a vice like grip on my heart which I find a lot harder to articulate, but here goes...

One lunch time my bicycle chain fell off, luckily I was near the office so I pushed it there. My bike has a chain guard that I needed a phillips screw driver to remove so I asked one of the drivers - Mr S -who was in the office if he had one in the tool kit in the car. He did so went to get it for me but then proceeded to remove the cover himself, he flipped the chain back on, discovered there was a problem with the back wheel, went to get his wrench to adjust the back wheel, put the cover back on again, then discovered that there was a problem with the cover and finally banged out an indent which had been rubbing on the chain. By this point he was covered in oil & dirt, as he got up to wash his hands J came out of the office to tell me that Mr S was actually on an annual leave day & had only come into the office to sign his time sheet. I felt terrible, Mr S just shrugged & smiled and told me "ot ay tey" - its not a problem. I don't write about this kindness of Cambodians enough.

This week my khmer teacher & Cambodian mother - S - tried to give me her ruby ear rings, that I have always admire on her. She originally had wanted to buy me some diamond ear rings but I had managed to persuade her that she should save her money instead, so giving me the precious stones from her own ear lobes was for her next logical step. I got upset - I am very emotional at the moment - and told her I should be buying her something to thank her for everything she has done for me. She looked at me earnestly, tears welling up in her eyes, pointed to the grade 5 book we are learning from & said "Doctor you have given me this, you don't need to give me anything else because you have given me knowledge"

Last week whilst staying away from home I texted my friend to see how he was doing working away from home also but with food poisoning "How you doing wonder boy?"

I got a characteristically honest & frank Cambodian response "Still on the bed waiting for a shit. I have 28time. X and you?"

This really made me laugh & distracted me from the grimness of my own salubrious guest house room with a beetle infestation, blood on the towels & a glob of vomit wiped on the curtain. I replied "Sounds like you had some very bad sea food! I hope it stops soon & you get some sleep."
Then I thought some more about the way his text had been worded as if to ask about the state of my intestines & laughed some more before adding an additional text, "And to answer your question to me, I have only had one shit today so far thanks for asking but that could all change! ;-)"

His response made me really laugh, "That's good to here that you ok. Otherwise i won't be able to sleep because I'm worried about you. It is ok for me this is my strength. Take care!"

I shot back with "You are really making me laugh. Not sure you are trying to but you are!"

Then is occurred to me that perhaps he really wasn't trying to make me laugh when I received his reply, "No that is my special feeling in my mind to you. I'm not kidding. X"

Communicating feelings through the medium of the Bristol Stool chart...only in Cambodia!

I have a very hard week ahead of me; in life generally its the little things that matter the most, which are the things I don't often blog about...

When stars align

I went to another border town & another hospital this week to train another ER how to use their newly donated ECG machine & monitor. It seemed a futile mission as one solitary visit was hardly going to make them confident & able to read a monitor or 12 lead ECG but the Bong had promised the hospital director a training session & so I went with only a couple of weeks left in country.

I conducted 2 training sessions that covered basic rhythm recognition & then common brady & tachycardias they may see. I also went to the ER & demonstrated how to use the ECG monitor & did a 12 lead ECG on a patient who has Hyperthyroidism so takes B-blockers which had induced a first degree heart block.

The ER doctors seemed interested & eager to learn but told me they really needed a lot more supervision & support before they felt confident to use & diagnose. I could understand this. It took me 10 years before I could tell the difference between a VT & a SVT with aberrant conduction. Maybe this was because I am very dense but despite my cognitive struggles I still think that reading ECGs takes a lot of practice, training, time & you need to see hundreds to establish good, reliable pattern recognition. Like a lot of things in medicine it is both an art & a science.

I tried to comfort myself with the knowledge that maybe the 5 part training package I had developed which is soon to be filmed to make a training DVD, which hopefully the TV obsessed Cambodians health care workers will watch, will actually be useful & help hospitals to benefit from all the donated equipment they receive.

The 2 packets of ECG dots I bought them in Phnom Penh hardly solves the problem of consumables nor will the basic job aids I've developed be a substitute for the English language user manuals & maintenance guides. But I am trying to be positive about my 33 months here.

The morning before we left, the Bong & I went to the ER where the young ER doctor showed me an ECG of a SVT. A woman had come in with palpitations so the doctor had connected her to the monitor. She had seen the fast rate so went on to do her first ever 12 lead ECG. From my training & handouts she was able to recognize that the patient had an SVT. She was currently in the process of arranging transfer to a larger hospital after some failed vagal maneuvers. She had diagnosed the woman as thyrotoxic due to her goitre & history. Words can't describe how happy this incident made me.

It doesn't happen often, in fact it is extremely rare, but once in a while in capacity building the stars align. 

9 days to go

After spending 33 months in Cambodia capacity building, I was told, having just delivered some training on ECG rhythm recognition, by the Doctor translating for me that he had similar training on this subject many times by various NGOs & overseas doctors but he still couldn't read an ECG because "You barangs are all the same, you come here, give just a little then go back to your own country taking all your knowledge back with you. You leave us with nothing". I was surprised & a little hurt that a local NGO worker, who knows me, had interpreted my actions & motives in this way.

I have observed in Cambodia that people with any training or education tend to guard it very closely to exert power & influence over others, most importantly they can use it to earn money with their unique & unshared knowledge. It is generally accepted that this is the culture of knowledge & education here, which can make cascade training a bit of a challenge. Of course this jealous guarding of information & knowledge extends far beyond Khmer culture but I can honestly say that as a volunteer & then as a consultant I hadn't consciously thought I had ever behaved in this way.

I have a good friend here who we frequently share the joke that I am just deliberately making him dependent on me by helping him so that when I leave he won't be able to manage without me but now, after this most recent character assassination, I am beginning to doubt my own motives when trying to help others.

Every day since being here I have persistently tried to share my knowledge & expertise with others. Every day I have been met with an overwhelming wall of resistance to change or lack of motivation to engage with or respect me. I have spent hours developing training materials that will never be used because the hospital did not have time to accommodate the training they asked for. I have turned myself inside out trying to present things in a way that is culturally palatable to some of the most arrogant, ignorant & difficult people I have ever worked with.

Had I known that it was expected that I would just keep all my knowledge, education, training, skills & experience to myself & then leave without doing anything meaningful or of any use, I could have saved myself an awful lot of time, money, effort & emotional energy.

Still I have 9 days to enjoy this feeling of liberation, knowing that the reason no one ever took any of my advice was because I was only expected to hold on to it, really tightly.

Trust me I'm a doctor...honest!

I've written about 'up-skilling' before & it is not just the expats that have a problem with this. This week I discovered one of the nurses who works for the same NGO as I do has also been at it.

The very first time I met this particular character he introduced himself as follows - Hello, my name is M & I have a masters in public health. He has been heard to say that knows more than any Cambodian doctor, he told my friend that he knows better than all Barang Doctors too. I have only ever seen him demonstrate ignorance & arrogance - but I think we have already established time & time again that what the hell would I know about medicine?

When being constantly ignored & diminished I have found that an effective coping strategy is avoidance so I have skillfully managed to minimise the time that me & M spend in the same room. Its not difficult as he is busy chasing American doctors that visit once in a while, whose gifts of pens & tie pins he treasures & idolizes. From a distance I can even find his behaviour amusing.

This week I visited another hospital which M had also been to the day before. On the way the Cambodia Doctor I was working with - the Bong - told me that M had diagnosed a patient with a pericardial effusion with the new ECG monitor. I looked disbelievingly at the Bong & his lips twitched imperceptibly upwards. I eye rolled & the Bong said ruefully - I think it is important that people work within their roles, if you are a nurse then you should nurse the patient.

There are certain people here who love touching my blue paper, I don't think that the Bong is one of them. In fact he doesn't even like my character, it was him who told me recently I should try to be more Cambodian - but it appeared on this occasion that he was deliberately trying to wind me up.

After we had delivered some training at the hospital, we went to ER to show them how to use their new equipment. We discussed a case from the day before, an overdose of diazepam. The young female ER doctor wanted to know my opinion on gastric lavage. I know here that it is expected by relatives of any patient that has taken an overdose, the same as every patient regardless of their complaint must receive an IV of 5% dextrose - but I also know it is rarely clinically indicated & has a risk of aspiration as a complication. They knew this but found it hard to convince patients & their relatives which I appreciated from many similar conversations. Pick your battles is my mantra - and gastric lavage is by no means the biggest barrier to effective emergency medical care here.

The ER doctor then turned to the Bong & started to talking to him in khmer about what had happened yesterday to spark this conversation. Now my khmer is terrible but given context & a clear speaker I can sometimes get the gist so after she finished I asked her who had M made so very angry. She looked a little surprised & the Bong explained to her, in khmer, that she should be careful as I understood some khmer.

I could see that the ER doctor was weighing up the situation before finally deciding to continue the conversation in English. She explained that they had been doing the lavage outside the entrance of their new emergency room & M had openly criticized them, shouting at them that they were wrong in front of the patient, his relatives & all the other patients & relatives in the ER. She earnestly told me that this was extremely rude & inappropriate in Cambodia.

This I know because I have spent the last nigh on 3 years tip toeing around cultural norms, saving face culture & often delicate egos to try & advocate for half decent medical care. I would never openly even advise in front of a patient as I learnt early on this does not improve patient care & only serves to increase clinician hostility & resistance.

I explained to the doctor that I try really hard not to offend people but have recently managed to completely alienate myself from the paediatric ward of my base hospital.

No, no - she assured me - you have been fine, most doctors that visit are fine. They advise how we should do things but respect that it is our decision to change. It was only that doctor yesterday that was aggressive with us, was disrespectful & too forceful.

Doctor? - I confirmed with a raised eyebrow shot in the Bong's direction.

Yes - she nodded - that Doctor was very rude!

Walking back to the shiny white, AC, 4x4 I couldn't help but remind the Bong that he had no reservations telling me to "change your character to be more Cambodian" yet he wasn't even prepared to correct the false assumption that one of his fellow staff members was a Doctor when they were in actual fact a nurse.

It seems that a male Cambodian who trained as a nurse & did a masters in public health in Cambodia that both aren't recognized internationally and can just as easily be bought without a minutes study for a price, can think & let health staff also believe that he is a doctor, dispensing all kinds of false or dangerous advice is perfectly acceptable. However I am still being ignored & provoked extreme hostility for suggesting a bottle ban on the Malnutrition unit & encouragement of relactation to improve SAM treatment - I guess my internationally recognized medical education & specialist registration plus my higher education counts for nothing because it turns out that saving face, being an arrogant & delusional are what actually counts.

So the old adage 'Trust me I'm a doctor' is redundant here because trust doesn't even enter in to the equation & any one can be what ever their money & status allows.

9 days to go & counting......