It has been a while since I have properly put finger tips to keyboard. There are a multitude of reasons for this but PTC (primary trauma care) lends itself to a blog all to itself - it is an epic tale. It is a story of what I do here and of why so often this blog (to quote my friends husband) becomes a 'litany of despair' but it is also I hope a story of the reality of capacity building and the hard slog towards positive change.
It all started in May of this year when Sz an anaesthetist from Australia came to BTB to run an airway course. We got talking and before long she had recruited me to instruct on a PTC course she was planning in Siem Reap in September.
For the uninitiated, PTC is the developing worlds version of ATLS (Advanced Trauma Life Support) which in turn was created in the States after an orthopaedic surgeon crashed his plane with all his family in it and realized standards of care for trauma patients could probably bear some robust improvements. Cambodia's deaths due to trauma are double that of any other country in South East Asia so there is a strong argument for introducing PTC here.
The Course in Siem Reap was the first of its kind in Cambodia & the first 2 day course was instructed by Sz, me, another Australian Anaesthetist and a Filopino trauma surgeon. Then after a 1 day training the trainers course the second ever course was run by Cambodians - doctors and nurses that all work for the brilliant NGO hospital Angkor Hospital for Children and had been participants of the first course.
For a movement such as PTC to be incorporated into the medical culture it is important (I believe) for there to be ownership of the course my government hospital staff and to have their commitment - they after all will be treating the trauma patients, 17.8 per 10000 vehicles of which currently die. Because of this I asked if HS - the head surgeon of BTB Hospital; previously worked in NGO hospital and trained for 2 years as an orthopaedic surgeon in France - would be able to come on the Siem Reap course and then train as a trainer. This you would think would be an unremarkable feat - well I thought so, how wrong a girl can be.
So HS said he would come, he even at one point promised he would come. But I later learnt that a Cambodian promise is not quite the same thing as a european promise, actually I learnt this at 6 am whilst in PNH for my second language training. When I was told that Cambodia has an early culture I assumed it meant they came early for appointments (nothing could be further from the truth!), in fact it just means they are all just very early risers so phoning you, playing really loud music, banging very loud drums and delivering a huge bunch of bananas can all happen here before 6 am. HS in fairness to him only did the very former of this list of early morning activities, calling me with various excuses - one of which if I remember rightly was something to do with the dog eating his homework - for why he couldn't come to Siem Reap.
Having secured funding from URC for him to attend the PTC course to say I was mildly disappointed with him would be an understatement. In fact when I got back to BTB there was a 20 minute conversation with him which started with us eye to eye and ended with him slumped on his Moto dejected as I did a very good impersonation of a mother of a teenager. "I am very disappointed" was mentioned, "you've let me down, the hospital down but most of all yourself down" may have been a sentiment expressed by me also. All the NGO doctors and nurses had told me that government staff would not engage in training, they had bet me that HS would not attend the course. I told him so and that he had proved them all right, I believed he had potential to be a great instructor and improve trauma care in Cambodia but was lacking any proof.
HS delegated Dr V to go in his place but only for the first course as a candidate and then the training the trainers course. This would all work out fine because Dr V would have to be an 'instructor candidate' on one course and we could plan for that course to be here next time in BTB.
Three days before the course started in Siem Reap Dr H from the URC office called me - he had concerns about Dr V going on the course, as he holds the URC purse strings I needed his approval before Dr V could go. Dr H's case was that Dr V already taught with another trauma organization and perhaps it would be better for HS to go seeming as he was an orthopaedic surgeon and head of service - like I hadn't thought of that!
Dr V loved the PTC course, he was engaged with the subject matter and the style of teaching was novel, so completely different from previous methods he'd been exposed to, he could see its worth and regretted not being able to stay to teach on the 2nd ever Cambodian PTC. He was motivated and excited to deliver the course as an instructor candidate in BTB so we set a date for 4 months time - the end of the year - we wanted to keep the momentum going.
I picked the one week in December that Dr V was available to teach, I requested URC to financially support the training (VSO don't pay per diem & BTB staff won't get out of bed for anything less - that's a whole other blog!) and put it into the work-plan. I tried to book a room at the hospital but was told it was too early (forward planning isn't big in Cambodia). I confirmed with the directors that this week would be a good time for the hospital and that they supported the principle of PTC. I confirmed that Sz, Drs Ch & P, N (see favourite Cambodians list) from AHC were available to teach. I double checked that the timing was good for the hospital, I triple checked and then I emailed Sz confirming the second week in December as a date for the third PTC course in Cambodia.
I attempted to mend my broken capacity building relationship with HS.
Nearer the time I tried to book the large hospital meeting room for training again and this time was told by the admin man that I could not have the room for 2 days as there may be more important meetings which have not been arranged yet BUT could be arranged.
I lost it.
I went to the deputy directors office and lost it with them. I spelt out to them that PTC was an internationally recognized trauma course, they had the first ever Cambodian government staff instructor candidate on their staff, he had gone to Siem Reap on their approval so he could train the rest of BTB staff, all the equipment for the course would be provided by URC & AHC, instructors had already bought their tickets from Australia (Sz and her trauma surgeon mate Sp - they were coming in their own time and at their own expense). Despite not having to travel anywhere, stay overnight away from home or even leave their workplace they were still getting a per diem (this is a whole other topic for discussion - don't get me started) and ALL that I was asking for was one room. It would seem that this was just too much.
They were perturbed - they had seen frustrated Esther quite a lot already - but never incandescent with rage Esther, so they rang the Director at home. He said - give her a room!
I had a meeting with the hospital (they were rejecting my work-plan but again that is another story and don't get me started) - the issue of staff attending training was raised. It was suggested that perhaps if the management team attended courses this would improve 'discipline'. Another suggestion floated was training should be held in hotels. I calmly countered this with the argument that I am VSO and don't have money for a hotel room and more importantly clinical teaching is best delivered in a clinical environment. I said I would ask URC about getting a hotel room (it sounds so sordid) for PTC but I already knew the answer. Jn (Hospital Improvement Team Leader URC) didn't dignify my email with a reply.
When I told them the answer was no (or technically silence) the hospital seemed to take it pretty well. They told me that there was a meeting planned for the second week in December but as it was later in the week it wouldn't affect my PTC plans.
Three weeks to D-day and I was away in Anlong Veng when I received a phone call from my VA - he sounded very worried. "Try to keep calm boss" he implored me. The hospital in their wisdom had booked a meeting during the course so we had no venue now for training. I remained calm - it was after all not my VA's problem although as he sagely told me "your problem becomes my problem boss!".
I was having my own 'issues' in Anlong Veng (another story for another time) so rang J (URC BTB hospital co-ordinator) who went with Jn to speak with the deputy director. They seemed to think it was a genuine mistake rather than my cynical interpretation that was just a device for getting a hotel room. Thankfully URC came to the rescue and we changed the course venue to the meeting room at the BTB URC office - I believe thats what is called a compromise.
The next hurdle was obtaining a list from the hospital of 20 participants. I met with HS and asked if he could provide a list - he gave me 3 names. What followed was a 1 hour negotiation to increase that number to 10 staff from the surgical ward, at this point I was beginning to think PTC was NEVER going to happen. Once again URC provided one third of the solution by placing 6 of their staff on the course so they could then train as instructors. I applied VSO's volunteer dimensions and problem solved by being flexible - I invited OPD staff and the deputy directors. HS's name was not on the list but I invited him anyway.
I organized all the equipment needed for the course. This is a very short sentence that fails to convey the enormity of that task.
I spoke again with HS - I explained I had invited him because I needed his support. He promised me he would come, I pointed out that I had previous experience of what his promise means. I reset my expectation to 'none'.
Monday evening before the PTC course on the Tuesday I felt immense anticipation and a little bit of dread.
HS came, I owed all the faculty a drink as I had lost my bet that he wouldn't attend. The hospital staff surpassed my expectations which I suppose as I had 'none' is not that hard. They were engaged, they supported each other, their post-test scores were double the pre-test and although HS is still not instructor potential material the head nurse was good & has now done the instructor training with 7 other potential instructors from URC.
Dr V was a star.
The highlight for me was playing the role of a pregnant trauma patient and being log rolled. The surgical nurse doing the scenario tried to do a rectal exam on me, when I moved my head to object the person holding it clamped down on it like vice to protect my c-spine. It was all very real for them (& me!) and that is why scenario teaching is such a powerful teaching method!
Obviously I was a useless co-ordinator, I didn't get the certificates right, I hadn't bought gifts for everyone and I wasn't to be trusted with even the simplest task - but hey this is Cambodia and feedback is always only of the negative variety. They just haven't had the 'how to give feedback lecture' yet...
