3 conversations

I have had 3 conversations today with various doctors at the referral hospital which basically sum up the very limited range of capacity building techniques I possess.

Conversation 1 - Semi-informal general chat with senior management doctor regarding my role and work plan. Style adopted - personable, informal & honest. The subject evolved on to how we can motivate, engage & train staff. There is always a lot of "I completely agree with you", "Can I be completely frank/honest with you?" from me and you don't have to have a degree in psychology to know that this is then often mirrored in return. He suggested to me that a technique for enabling co-operation from the staff would be to sack them if they don't do their job properly & engage in training. Oh how we laughed -  it's funny because in a system of patronage, hierarchy and corruption, people just don't get sacked for failing to meet their contractual requirements, breaking rules (what rules?) or even being completely incompetent & negligent. It was a wild flight of fantasy here yet in at home it would be normal working procedure. As far as relationship building goes these are the conversations that mean the most to me but are by far the hardest to have.

Conversation 2 - Any one who has ever worked with me will recognize this well used technique of communication -  the 'joking when you really mean every word' conversation. I am so well rehearsed at this technique that once whilst working in psychiatry my boss after asking me about something serious and listening to my response said to me "Esther - I think that humour is an incredibly sophisticated and intelligent defense mechanism but could you please just answer my original question?" Today when I saw one of the paediatric all stars I pretended to avoid him so he grabbed me by the hand, preventing my escape, then we had a long conversation about Vitamin A deficiency, team based learning modules & the paediatric ward renovations. When I suggested - smiling, laughing and leaning in a casual relaxed manner against the nearest wall - that the newly renovated clean, shiny & glazed Paediatric ER had remain empty for 2 weeks now not as he suggested because there had been no children sick enough to warrant it being occupied but more because "the patients were all too dirty and poor to put in to such a lovely new room" he may have got that I wasn't completely joking. He then told us he was on duty and had to go now to see some patients, J (the straight-man) added "so you can finally put some patients in your new ER" - much hilarity - oh how we all laughed (again - capacity building is just so much fun).


Conversation 3 - I like to call the final style of conversing - 'capacity building by flirtation' but I think the term 'prostituting ones-self' may also be used. This technique can only work with people who have initiated the flirtation that you can then reciprocate and use to your cunning capacity building intentions. After alienating myself from the whole surgical department for asking "whose patient is this?" (see 'why today my head hurts....') I had feared that this particular form of conversation was no longer available to me. But walking from conversation 2 to conversation 3 I did pretended to throw myself into the path of one of the surgeons driving his massive Lexus 4x4 to much waving & smiling (by both of us I hasten to add - if it had just been me doing the waving & smiling that would just be a bit odd) - so there was already hope that the thaw had began. My first day back I had barely received a nod of recognition from HS and then in khmer (he has more than reasonable english and french) he gruffly asked my VA "Has she come here because she wants to speak to me?", churlishly I had replied "No, non, o'tey!" But after the conversation 1 it had become apparent to me that HS was the person I really needed to speak to regarding a heading on my to-do list - 'surgery'.
So with B (URC nurse), as chaperone & not as it turned out translator, I went to the surgical changing room - the main stage for most of the important surgical conversations at the hospital. HS as you can imagine was hardly thrilled to see me but when I pulled my joker card that the Deputy Director had said I must speak with him he looked fairly resigned.
What ensued was a conversation regarding burns patients mismanagement, analgesia with dressing changes & trauma care. It was agreed that I would draw up a draft burns protocol, we would have further discussions regarding analgesia (I had previously succeeded in getting a post-operative analgesia protocol written by him using that little known technique 'reverse psychology'. I really hope that I'm not giving too many of my complexed and highly successful techniques away here) and there was even a forced/semi-genuine apology from him for giving me the 'cold shoulder' previously.
All this however required me to have my legs pinned in between one of his thighs & the table leg and having my hand held whilst B watched Karaoke on TV. Now as I have previously mentioned this physical contact is normal for a man-man interaction and my inclusion in this 'bromance' can mainly be put done to my curious 'half man-half woman' status as a foreign female doctor. The hair flicking (mine not theirs) is however just plain flirtation. B was impressed by the effectiveness of my type 3 conversation & quoted that all in all it had been "a very fruitful conversation".

I say - show me the fruit!

Reverse culture shock

Back in the sweatiness of the tropics I'm able now to reflect on my unexpected trip home & what was expected, what surprised me and what was one big shock.

Butt's has specifically requested a blog mention - so it was truly lovely to see all my family and a handful of friends (not enough time to catch up with all & not really the purpose of the trip) and to tick off (nearly) all of the 'missing you already' wish list. As I sit and write I am listening to the newly pilfered music from my sister's CD collection and trying to remember how cold I felt for that walk in Cirencester park or sated after lunch at the Bell in Sapperton.

Of course there were some reverse culture shocks - everything costing 10 times the price of what it does here in Cambodia, the overwhelming rudeness and unfriendliness of the Brits (in stark comparison to my host country), the obscene and full on capitalism and consumerism. I am left with an inexplicable desire for an iPad despite lacking any funds for said item - however when I voiced this today to a room of Cambodians expressing the same desire for the same Apple product, Ry quite rightly told me that I earned lots of money in the UK in the past and would again so I could buy them all one if I wanted to - I forgot voicing my financial worries is a pursuit for a developed country only!

Perhaps the thing I missed the most about Cambodia (after the obvious people & heat) was the absence of something. In fact I think I failed to fully appreciate this whist I was in the UK and only finally realized when I was woken on my first morning back to a wall of sound at 6 am. SILENCE - jeez it really is golden! As I roused to the sound of the Wat chanting, the extended Chinese New year drums (it was 6 days ago guys!), the chorus of howling dogs, the roosters crowing, the birdsong so loud it sounded as if they were in my room (they were as it turned out, having built a nest in my absence) - I groaned and recalled the absence of this assault on my ears which I enjoyed but failed to fully appreciate every single morning of my stay in the U of K.

I knew I was back in Asia when on the plane the packets of snack peanuts had little dried up whole fish in them as well.

Jet lag is wrecking my body & soul - I never recall skipping time zones being this tough previously, perhaps it is my advancing age. However today I was given a big shock whose subsequent adrenaline rush kept me awake for the rest of my first day back at work.

There is a long story about ALS (advanced life support) preceding this but luckily for you I am lacking the attention or will to recount it now. Suffice to say I found myself in ICU medicine today with their newly donated Defibrillator machine and an over enthusiastic Cambodian 'Cardiologist' - in conclusion I'm lucky to be here typing this now.

As we walked over to see the fabled machine I was proudly told how he had showed all the staff how to operate it but they were still "scared" to use it. The 'Cardiologist' then proceeded to switch on the defibrillator machine, charge the paddles to 200 volts, take them out of their cradles and wave the charged paddles in my face (whilst I cringed away in terror) shouting at me "don't be scared - its perfectly safe!"

I found myself slipping into ALS instructor mode - coldly and calmly ordering him to put the paddles back in their cradles and step away from the defib machine. He then got a 10 minute lecture about there only being two places for paddles - in the machine or on the chest of a patient (preferably arrested or peri-arrest) AND it was most definitely not safe to wave fully charged paddles in mine or anyone elses face (no matter how much they were annoying you) and the reason I was scared is from where I had been standing it looked as if he was trying to kill me.

Then the realization struck that this was the 'safe defibrillator practice' he had taught all the doctors and nurses in ICU. With more than 1 mg of Adrenaline coursing through my system and improving my cerebral blood flow I attempted to balance the dread with a hope (for once!) that the staff would not do anything & were still too scared to use the machine. Then as my heart rate hit 150 beats per minute it hit me with perfect clarity - all the hospital staff totally disregard any advice, training or information I offer, mainly I suspect based on my lack of a penis and a Y-chromosome.

We are all doomed to an epidemic of iatrogenic electrocutions - patients, relatives and staff alike.

That's reverse culture shock for you I suppose......

Be careful what you wish for...

Recently I blogged in a post festive, peri-new year pensive mood about all the things that I was missing from the UK. As Stephen Sonheim once lyrically put it :-

 Careful the wish you make 
Wishes are childrenCareful the path they takeWishes come true, not freeCareful the spell you castNot just on childrenSometimes the spell may lastPast what you can seeAnd turn against youCareful the tale you tellThat is the spell
So with the soundtrack of 'into the woods' in my head, I find myself seeing my family, wearing my down jacket & knitwear, eating cheese, drinking wine & tap water (the latter really should have been included in the 'missing you already' blog), sleeping under a duvet & orange blankie and had an emotional moment in Waitrose.
This however is because my Grandmother has died & I have come back for the funeral - to try to be a good daughter, sister, grand daughter, Auntie & if time permits friend. 
And because I am contrary I'm now missing Cambodia, Battambang, the hospital and work - there really is no pleasing some people.
So my advice is be careful what you wish for, they might come true past what you can see...

Post Script

As always there is someone who has written on a subject much more succinctly and eloquently than I ever could.

Jon Swain in his book 'River of Time' describes an incident of a bomb injuring a child in Phnom Penh. He went to help the child but couldn't get anyone else to assist on the street or in deed when he took the child to the nearest hospital.

He wrote in the 1990s - "Even today, after years of suffering, the Cambodians do not have a strong sense of caring for their fellow man. Medical staff, negligent and greedy, demand to be paid for drugs provided free of charge by the international aid agencies. Perhaps this is due to the Cambodians fatalistic perception of human life. For many, morality is a luxury to be disowned; survival and money are the ultimate objectives."

Fifteen years on and despite millions of dollars in aid, sadly it seems that this is still very much the case.

I am not quite sure what the cure for compassion fatigue is...

why today my head hurts....

I'm looking for some answers. I would like to know how I can motivate people, how to make them care and how to engender a sense of responsibility? Failing that I'm looking for permission to lapse on my new years resolution.

It's another clinical tale I'm afraid - but often writing it out helps me make sense of it, or at least try to, so sorry if the following bores you.

After the storming success of the PTC course I have started work on the surgical ward, observing trauma management and attempting to encourage the best practice demonstrated in PTC. This required much negotiation with the Director, deputy director and head of service (HS) but was finally agreed, people even signed a piece of paper - there were no photos or banners though.

So the first working day of 2012 I found myself with a man who had fallen from his moto 5 hours earlier. He had a large boggy haematoma on the side of his head, would only open his eyes to voice and was confused (I had to take the Cambodian staffs word for that as my khmer isn't that good yet) and was complaining of a severe headache.

Unfortunately as there is no CT scanner or neurosurgery the plan was just to wait & see. I felt it was probably quite likely that he had a intracranial bleed but in a world of hopeless cases sent home to die, 'no money - no surgery' and no specialist care I wasn't really surprised to not see him the next day. You'd think this case would be the cause of my own headache - not quite.

That same day I ventured on to the Surgical ICU ward - a hybrid of a recovery room (not like any room I'd want to even recover from a bad pedicure in) and a serious cases ward. In there was a young man in a hard neck collar. On further investigation - reading the notes, speaking with the patient and his mother, the staff are 'too busy' -  it became clear he was a construction worker who 4 days previously had fallen 3m onto his head and as a result had a headache, sore neck and couldn't move his arms or legs.

I asked if he had an X-ray taken and his mother produced a solitary AP (front to back) X-ray of his neck. A surgeon popped up to point out to me the crushed 7th cervical vertebrae (its been a while but even I could spot the difference) and when I asked for the other X-rays he just looked at me puzzled and I was told that any other views can not be done here in Cambodia and it wasn't his patient anyway. Now I've learnt a thing or two in my 9 months here and one of them is never, ever question or challenge a doctor directly ESPECIALLY not in front of patients, their relatives (the patient's or the doctor's), nurses, other doctors and occasionally even my own translator (the latter can be a real challenge). So I shrugged, smiled and demurely told the family I'd be back.

I wandered outside to the front of the surgical ward with my VA in tow in search of a surgeon (he gets nervous in these situations.)

I have a new years resolution - I am trying to be good. Note the use of the word 'try' - as long as I am trying it doesn't matter if I am achieving.

Three surgeons were stood outside chatting. I approached them - much arm clasping and slapping (them), hair flicking (me) ensued. In the most non-confrontational & non-threatening way possible I asked if I could ask a question about a patient. All smiles - go ahead, they really are such a friendly bunch as long as you aren't trying to capacity build them. Mind you if I had a personal trainer I would almost certainly react as they did when I asked them who the C7# patient (forgive me but I was conversing with surgeons) was being looked after by?

After a very long conversation it was established that none of the 3 surgeons I was talking to were responsible for this young quadriplegic man's care. They then commandeered my VA and chewed his ear off for another 10 minutes about operation lists, the nurses not doing what they are told, how I had only been here 9 months imagine how they feel and if I had a problem I should speak to HS, he is responsible for all patients as head of service. At this point I had only asked who I could talk to about the patients management - I can only assume that they knew he had been mismanaged and this explained their defensive behaviour. That or their new years resolution was to be as obstructive and rude as possible - damn, I should have picked that one to, much more achievable.

When I smiled (as a good person would) and said I only wanted to log roll him (not documented as done on admission) to check he hadn't any further injuries (if you have one spinal fracture it significantly increases your chances of another) and I just wanted permission from his attending surgeon, then there was a queue to grant me consent.

The next challenge was to find people able to log roll him. Its not brain surgery (which is a good job because we can't do that here) but a log roll does require 4 people who know what they are all doing. There was a student nurse (always good log rolling fodder), a nurse who had been on the PTC course (reinforcing transportation workshop) and B from URC to take the head but we needed one more person. B and my VA being polite, respectful Cambodians didn't want to disturb the nurse writing her monthly report. I'm not Cambodian and thought it would be polite & respectful to the patient for him   to have a proper log roll so called out for "Kroo Peit moie tiet!" - another nurse came.

We log rolled him, he had no other spinal tenderness but a sacral pressure sore of a size and depth that you would expect of a newly quadriplegic man who had laid on a metal bed with no mattress for 4 days without being turned.

I'm trying to be a good person so I pointed out to the nurses what HS had written in the notes that morning about 2 hourly turns, checked that they knew now how to log roll and left.

I went in search of  HS, he unlike the rest of the department - who were still stood outside watching the construction of a restaurant (yes they can build a staff canteen but not complete the sodding ER building!) - was scrubbed in theatre all day.

The following day I checked on the patient - he hadn't been turned since we had done it last (a long 2 hours). I  caught up with HS - he wasn't in good humour. Staying up half the night doing a laparotomy will do that to you. I suggested perhaps I could come back another day - I knew where this encounter was heading, we've been here before. Despite my best smiling & trying to be a 'good person' and even after me saying "please don't get defensive I just want to talk generally about improving trauma care" - it all went a bit defensive.

Apparently HS was not responsible for the patient with the C7#, couldn't tell the nurses what to do and certainly wasn't responsible as the head surgeon for any of the other surgeons. He thought I should not work in the surgical ward and it would be best if I waited for the ER to open (or failing that the new hospital restaurant). I may have said some things I shouldn't - maybe not quite in keeping with my new years resolution. In khmer I know how to say 'lazy', 'arrogant' and 'closed minded' but he started it off by saying all the staff here were 'blind' and I just ran with it. None of this was a problem, as these are practically the only 3 words in khmer I use in work, he has heard it all before (sticks & stones) but when I told him (in english) that I thought the staff here didn't care - that appeared to hit home.

The staff in ICU pretended they couldn't understand what I was asking when I went without my VA to see if we could turn the patient and so that afternoon when I returned with my VA there was a student nurse and some tumble weed. HS had suggested the family log roll him, when this idea was mooted with the patient he said he would prefer people who knew what they were doing. I bit my tongue - I am trying!

URC staff log rolled the patient that afternoon.

Today after lunch I went to check up on C7#, we passed HS on the way who decided to give me the cold shoulder - this was an excellent opportunity for my VA to learn another idiom and also revealed that maybe staff do care, about what remains to be seen.

No surprises that the patient had not been turned since the last time we were there. We corralled a posse of log rollers and as I observed worsening bed sores and paralysis the futility of it all suddenly hit me. What was I doing? It certainly isn't sustainable. What was best for this 24 year old man anyway? Why the hell doesn't any of the staff care about his pressure areas, potential pneumonia and progressive neurological deficit?

I went in search of a surgeon who could tell me a plan so I could believe that someone had one and did actually care. I failed but in fairness did remain 'good' throughout. Even when a surgeon I hadn't even known was in the building came up to me whilst I was deep in conversation with the duty surgeon and shouted "I am busy and don't want to talk to you" - cue serene good person's smile.

None of the staff will take responsibility for, is motivated or seems to care about this (or any) patient. I don't know how to capacity build from this starting point.

So unless you have any answers to my original question can you please give me permission to lapse - the trying to be good is most definitely the hardest part.....