Remember to chew...

Today is blog action day and the topic is food, hence I am spoilt for choice as to what to write about.
I could discuss all the food that I love here and how long the gratification lasts after consuming certain comfort food stuffs (for the record dumplings from the noodle shop are pretty high up the gratification scale lasting a good 7 hours at least and thats with out the garlic repeating).
Equally I could talk about all the food that I crave or have fantasies about, better still the welfare packages I have received from home (and Australia) that even reminded me of things I had forgotten to miss (dorset cereal, tim tams, peppermint tea, green & black Maya Gold chocolate - the list is endless).
There is at least a whole blog on cooking with just a wok and a skillet with no sharp knives at your disposal.
I could discuss the recent floods in Cambodia and the destroyed rice harvest and threatened food shortage. Or the malnourishment wing of the paediatric ward and the shock of seeing a severe marasmus infant. Or how you feed yourself on less than $2 a day (not very well but two thirds of Cambodians have no choice).
But I am going to keep it short, sweet, tenuously connected to food and of course medical.....
Every morning there is a hospital meeting where new patient admissions, deaths and any other current management problems are discussed. Occasionally something is brought up that reminds you why you attend these meetings, despite the hours of 'ot mean' - 'don't have' conversations you have had to sit through.
Last Friday was one of those days, there had been a death on one of the wards and as my new VA translated the conversation I realized that going back to basics was going to need to be a lot more basic than I had bargained for.
The patient admitted to the ward the previous afternoon had choked to death on their evening meal; none of the nurses had known what to do, the doctor had taken 30 minutes to arrive by which time the patient had asphyxiated.
So I was left considering this scenario - you are Cambodian, you get sick, the traditional khmer medicine doesn't work, you are able to afford transport to the local hospital, you either can pay the user fee or have a letter to prove that you are poor so can have the UF paid for you, you are well enough that you don't die waiting for some kind of medical attention, you survive whatever medical attention or inattention you receive and you can either afford to buy food or receive the rice soup provided by the hospital. But then when you choke on your food in hospital nobody knows what to do. The irony of it is you will have probably spent most of your life hungry or working all day every day just to put some food in your belly so that one day it will go down the wrong tube and no-one will have any of the training or skills to help you.
This week I go to a fellow VSO volunteer's hospital to conduct some emergency triage assessment and treatment training, the week after we have a basic life support course in my hospital - both involve choking algorithms. It seems so basic but then again it is the simple things that save lives.
Capacity building is an expensive and slow process but ultimately I still believe it to be the most sustainable way of improving peoples lives and in the words of Student Community Action's motto (circa 1990s) "If you are not part of the solution, you are part of the problem". Although I'm learning it is possible you can be both!
Happy world food day - remember to chew......

Patience is a virtue...

A conversation I had with a Cambodian colleague resonated with me after certain events this week.

Dr C (x-ref 'suffering doesn't have to be fun bit it helps') works for an NGO hospital and also trains government staff at a hospital which he affectionately refers to as a 'hot spot'. Dr C is an excellent physician, would have preferred to studied english literature & be a teacher and is Cambodian. Sharing the common ground of us both being doctors that 'advise' in government hospital 'hot spots' I find myself looking to him for guidance to navigate these stormy waters.

The last time we met, a few weeks ago, I asked him how is was going at his 'hot spot' - he grimaced and told me it had been going quite well but 3 months ago something had happened to rock the boat. One of the nurses from the government hospital had applied for and got a job at the NGO hospital Dr C works for. This had caused a degree of consternation among the staff at 'hot spot' and one person in particular who felt that the NGO were deliberately poaching their good staff.

Now Dr C had been given fore-warning of this impending mutiny so the next time he visited 'hot spot' he was prepared. He told me that just looking at the disgruntled government doctors face and could tell that he still was angry at him & the NGO - so he did what any self respecting Cambodian would do - he saved face and ignored it.

My western sensibilities twitched at this - surely if someone had an issue with you, you would address it, confront them, put matters right, straighten out any misunderstanding, not allow matters to spiral out of control, fix the problem, find the solution etc. etc. etc........

Dr C went on to tell me that on returning the following month he found that the disgruntled individual was still angry with him and continued to ignore him. However other staff were still receptive so he carried on his course and continued saving face.

At this point in the conversation I expressed my desire that if I was him I would have to sort out the problem directly. He frowned at me then smiled pitifully. "Esther" he reassured me, "If this month there is still a problem I will talk to the hospital director and arrange a meeting."

"But it already been 3 months!" I exclaimed impatiently.

This is when I was educated in the virtue of patience. Dr C explained to me that if a person is angry the best thing to do is to just wait until they had calmed down, have had time to reflect and came to their own conclusion that it wasn't Dr C's fault the nurse had left. Addressing the problem head on would only lead to cross words which then can't be retracted. Dr C knows that he isn't responsible for the nurse leaving and with the disgruntled person in such a state of anger any conversation about it would just be fruitless.

"Sometimes Esther the best action is inaction - you should be patient." I was wisely told.

So this week after a rocky start I have decided to take Dr C's advice. I am going to sit back, keep my mouth shut, wait to see what happens, float rudderless and just try to be patient.....


n.b all boat references are subconscious and most likely due to Battambang's water festival.

The unbearable lightness of volunteering

The pinnacle of good emergency medicine & post resuscitation care -  ICU - my goal!

So I have reached the 6 month mark of my time here (8 months in Cambodia in total) and now is about the time that it is anticipated for volunteers to experience the "6 month dip." If my current mood is anything to go by I think that the 'dip' they refer to is probably born out of an overwhelming sense of futility, bubbling up of 6 months worth of frustration and the dawning realization that volunteerism is not valued or worse still completely worthless.

Now most people (not all) come out the other side of this dip and have long and fulfilled lives in international development but whilst I am in it I think it is probably worth exploring why it happens and what it means about us (as volunteers) and them (the reluctant recipients of our capacity building).

I came to the conclusion that people do not value things that are for free at about exactly the same time that a friend messaged me words of encouragement and support. It was powerfully well timed, his response to my exclamation of futility clarified I think the root of the problem. 

He works in Africa and empathized with my experience of not feeling valued by doctors or nurses that we  work with. He wisely told me to concentrate on the patients - the small child or parent - who are more likely to see the value of a competent, trained and caring health care professional. It got me thinking, we had worked together in the NHS -universal free health care - how the fact that something is free impacts on it's perceived worth. Patients do not directly pay for their health care in the UK and there is a high expectation of the right to have free health care and often a failure to value or see the true worth of something as precious as the NHS. As a salaried doctor in the NHS, although I believed in a patient centered approach and got much of my job satisfaction from my interactions with patients, many of my feelings of value or worth around my job came from the committed team of hospital staff that I worked with. The patients and relatives were why we were all there but their taxes paid my (overpaid) wages as they often like to remind us and I had to get accustomed to frequently failing to meet their expectations. The dynamics of private health care are of course different, when you are paying directly (not through taxes) for health care you value it more because it has a tangible worth. Having worked in countries where there is not free health care it always frustrates me how undervalued the NHS is and how the better something is the less people seem to appreciate it.

So value & worth - how do you get it? From my limited experience here it would seem that you have to earn lots of money overseas and then come out on short visits only. This way you are seen as a revered expert and very much valued. If you can not speak the language, make no attempt to understand the culture or context and ignore local experts this seems to be even more effective. 

Giving up a well paid job to come here for 26 months as a volunteer - well that's just madness and at best deserves sympathy and at worst contempt. My favourite piece of advice was from a colleague who works for my partner NGO - he told me not long into my placement here sincerely and with no malice intended, "Thank you for coming Esther, we really appreciate it, but there is absolutely nothing you can do here."

I sometimes think that if my hospital had to contribute to my living allowance, as they do in other countries, perhaps they would value me a little more. I'm not saying that they would listen to me or even take any of my advice but maybe there would be a sense of ownership and they may even consider letting me into the room. Currently I am left standing out in the rain wondering whether the plans for the new Emergency Room will ever be shared with me or if being a specialist in emergency medicine means anything at all because the moment I gave up my job in the NHS it appears I was rendered completely useless. 

And as for the reluctant recipients of my capacity building - they would just like lots of money and resources and not to have their knowledge challenged by training or for me to ask any difficult or awkward questions.

So why do I even need to feel there is a sense of value or worth to what I do? Maybe I'll leave that one as a rhetorical question for you.... 

The reality of Emergency Medicine in Cambodia - my starting point!