Happy International Children's Day!

I am a member of a google group for Battambang. Its a useful forum for advertising, sharing ideas & asking for advice. There are some members whose dry wit & deep seated sense of irony really cheer me up & put a smile on my face. Below is an example of my favourite poster - I've never met him but I know it would be an interesting conversation over a beer if I ever did.


"As this Friday is International Children's Day, please take note of
the following:

THE BAMBOO TRAIN BRICK FACTORY WILL BE CLOSED
THERE WILL BE NO URCHINS COLLECTING TIN CANS OR PLASTIC BOTTLES FROM
THE STREET
BLIND BEGGARS WILL BE USING DOGS TO GUIDE THEM AROUND THE STREETS
NO BOOKS OR POSTCARDS WILL BE ON SALE IN SIEM REAP

Thanks for your understanding, exploitation and child labour will
resume normal service on Saturday, 2 June"

10 000 days

http://www.nytimes.com/2012/06/01/opinion/10000-days-of-hun-sen.html

http://www.bbc.co.uk/news/world-asia-18093818


This weekend is election time in Cambodia. I was informed last night that Hun Sen has decreed that the 3 days (Friday is International Children's day) will be alcohol free to facilitate a 'smooth' democratic process.

The last few weeks have been dominated by the white & blue uniforms of the CPP (Cambodian People Party) - convoys of SUVs, Motos, tractors pulling trailers of people all loyally wearing their CCP caps block the roads. The election propaganda blares out from loud speakers, traffic is brought to a halt & the thin veneer of democracy is translucent.

To have any job within the public sector in Cambodia one must be a paying member of the CPP. A large proportion of the Cambodia population are under 25 years old - the emerging new hope.

Talking with the younger generation of Cambodians I've been asking them who they will be voting for in the up coming elections. They fall into three categories;

1) They will not discuss

2) They will not vote - what is the point, their vote 'doesn't count'

3) They will vote for any party other than CPP in an attempt to practice their democratic right & will encourage friends & family to do the same.

Given the history of this country surprisingly few are category 1), understandably some are 2) but the majority are 3) - one person is having their marriage license withheld by their commune chief unless they vote CPP in there home district but they refuse to be intimidated.

The links above say more than I can say here.

Psychosclerosis

A while ago now, in-between the many public holidays that punctuate this time of year, I was in the hospital showing a short term volunteer from the Microbiology lab around the ICU medicine ward. She - R - was keen to talk to the doctors & nurses on ICU medicine about sending more samples for microbiology testing. The lab has been established for almost a year but changing health workers habits, whether that is requesting investigations or prescribing, readers of this blog will appreciate, is rather challenging. R wanted to 'remind' them that they could send blood cultures, CSF, urine, wound swabs etc. They were all sat around, looking very relaxed, watching karaoke so I'm not sure how much was absorbed.

R then requested to look around the ICU ward, before we even got to the first room I could see that this was not a good time for sight-seeing. Through the crack in the door I could see a man Cheyne-stoking (the last breaths of a dying man) with his wife crying over him. The 2 other patients & their relatives were looking on mutely. The nurses & doctors you will recall were sat watching television in the staff room. I expressed that this wasn't a good time to intrude on a dying man's last moment but my non-medical VA & the non-clinical R thought it was fine, she couldn't accept that there was anything seriously wrong with the patient because to her he looked perfectly well.

I went to find Dr L to find out why a man was dying & being ignored by all the staff who were all still sat in the staff room watching bad Cambodian TV. Apparently he had Hepatitis B, liver failure & encephalopathy which would explain why he was jaundiced & in a coma. The wife wanted her children who were 2 hours away to come & be with their dying father but it seemed that this wasn't going to be possible - money & time were both limited.

I went back to explain the situation to R but I found her crying with the inconsolable wife. The man started to vomit blood - I called for some help & without gloves or an apron I rolled the man over by myself to hold him on his side. One could argue this was a pointless intervention but I really can't bear to see an obstructed airway, even in a dying man. My VA has an aversion to body fluids, R & the wife were both paralysed by sobbing & the rest of the relatives passively looked on.

Two student nurses arrived - they saw me trying to help the man to have a semi-dignified death & just started giggling joining the audience mounting now in the door way & ward window consisting of various patients, relatives & monks.

The man died.

The wife became hysterical with grief. R started taking photos of the whole spectacle. It was truly one of the most surreal deaths I have ever been witness to, although it probably will make me sound like a terrible doctor, I have been present at quite a few. R wanted to take photos of the wife with her dead husband & for my VA to take photos of R with the wife & dead husband AND me with them also. My english reserve & sensibilities kicked in. The bereaved wife seemed to be buying it all though so who was I to judge. (R later went & got the photos printed out for the wife to take back to her village, for her & her children.)

Then the wife ran off to cry outside very loudly & telephone her children. Generally here people take pain, suffering & death quietly, it is quite unnerving & so it was a relief to have a physical & auditory response for a change. When she returned R had organised for her to clean & prepare her husband's body. This is something that in the UK would be done by the nursing staff but his widow, me & a short term microbiology volunteer managed to do a reasonable job.

R was crying as much as the wife - her face wet with tears & snot, the wife was clinging to me sobbing onto my shoulder, making my top wet with her tears. The other relatives in the ward even had tears in their eyes by this point & I found myself dry eyed,  stood grimly thinking, 'am I emotionally closer to the ICU staff who are still just sat watching TV & snacking in a room 6 metres away?' Surely what was happening in this room was much better than any Korean soap opera could offer them?

Atherosclerosis is hardening of the arteries & as one of my moodscope emails recently told me psychosclerosis is hardening of the attitude. This I believe is definitely an issue here and some times I worry that it may even be contagious.

For the past 6 weeks, since but not directly related to this event, I have cried at least once a day - so I think my tentative self diagnosis of psychosclerosis was premature but I'm willing to accept 'burn-out' instead!

De-skilling or Up-skilling

It took me 14 years of schooling - 11 of them of which I knew I wanted to be a doctor. Then 5 years spent as an undergraduate at Medical School, 1 year as a house officer (intern/foundation year 1 - what ever they're calling it now), 3 years as a SHO (senior house officer) before going to work in Australia as a registrar for 2 years (with a couple of expedition medic outings on the way), another year of being an SHO before a year as a middle grade in emergency medicine (slipping in a diploma in tropical medicine & hygiene & my Membership exams). Finally I got a training number for emergency medicine for 5 years & came out with my fellowship exam & sub-speciality training in paediatric emergency medicine, a diploma in child health & very nearly a MSc in child health (dissertation pending). I worked for 14 months as a consultant in the NHS & it took me precisely 11 months in Cambodia before on a bus journey down to Phnom Penh I turned to J & came out with the classic freudian slip, "When I was a doctor..."

I have spent almost my whole life wanting, studying, training & working to be a doctor but in less than a year I had reached the point where I don't even consider myself to be one any more. This is what I like to call 'de-skilling'.

How, I hear you cry, can 21 years of medical education & training be lost in less than a year? Well the grand canyon was worn away by just water & the dripping tap of mistrust & disbelief has been eroding away at my self confidence over the last 15 months. Admittedly quicker than the formation of the grand canyon, I have now reached the point where I doubt myself over the most basic medical knowledge.

Example: at a recent ECG workshop following an ECG lecture, given by a delegation from a famous American University, my group were debating the tricky concept of QRS length & what is normal. I told them it was less than 3 small squares which represents 0.12 seconds. The 6 male Cambodian doctors in the group refused to believe me - I double checked with the lecture because I've only been teaching ECGs in ALS for 9 years now.

"You are wrong!" I was confidently told by a doctor whose hospital does not have & has never owned an ECG machine. ON (my deputy director) finally got to the root of the problem - I had been referring to small & large 'squares' where as the Americans had called them 'boxes' in the lecture. This it would appear had put my whole credibility to read ECGs into disrepute. I thought it was a little pedantic to point out that a 'box' is a 3-dimensional shape where as a 'square' more accurately describes the grid pattern of ECG paper. Instead I went for the more rational approach of asserting it was less than 0.12 seconds but again I was dismissed. The lecture quite clearly stated it was less than 120 milliseconds - this it would appear is completely different & I am therefore just a semi-literate & semi-numerate fool. It was at this point I gave up.

Which is odd as what usually happens to a lot of people in development is more, what someone I respect very much calls, 'up-skilling'. Non-medical people become medics, nurses become doctors, GPs become neurosurgeons etc. etc. etc.... you get the idea?

And I'd be lying if I said that this hadn't from time to time also happened to me, but I hope I have the self awareness & insight to recognize & moderate it. So for example since being here I have been deemed an expert in children with disabilities. A couple of volunteers have asked me to go out into the community to see children, it gets me out the hospital. Although I can manage an acutely sick child I wouldn't say I knew an awful lot about chronic problems, but I side step this by referring on to NGOs & hospitals that I know are experts or at least can help the children more than I can.

At a recent clinical case review of a child with Dengue recently, when I was asked for my opinion on the management, I deferred to the local doctors who have treated more cases of Dengue than I have had hot dinners.

Last Friday J & I found ourselves on the Paediatric ward advising a young mother, with her severely malnourished 2 month old, on re-lactation & breast feeding. J's last job in the UK was working as a ward manager of an adult medical ward, neither of us are midwives or breast feeding experts (J at least has done it once!). We both could see the funny side of stood in the middle of a ward squeezing our breasts & embarrassing R (Cambodian & male) who was translating for us. The first time mother from a village on the Thai border had stopped breast feeding after one month because of a breast infection & had fed her baby on soya milk & water. J & R found the child being treated for pneumonia at the CPA 2 hospital they visit once a month & had pointed out to the staff there that baby also had severe kwashiorkor & required transferring to Battambang - J isn't a paediatric nurse either but sometimes up-skilling comes out of necessity.

Guns don't kill people.....

One of the arguments that the NFA in the USA uses to support their belief that every citizen has the right to bear arms is the statement "guns don't kill people, people kill people."

This week a visiting delegation from the states has turned this argument on its head from a medical perspective. Hence I have learnt that it isn't health care professionals that save patients lives - it a automated external defibrillator (AED).

This is awkward as for the last year I have been explaining to my hospital that in the UK only 20% of in hospital cardiac arrest are a 'shockable' rhythm (no one knows what the figures for Cambodia are) & that with out adequate post resuscitation care the chain of survival is still weak. I've argued for capacity building basic & essential emergency care - basic airway management, importance of vital observations, good history taking, following evidence based protocols etc. etc. etc.

Of course the hospital want state of the art, shiny, new medical equipment & I don't debate that they deserve it, but like Maslow's pyramid - heirachy of needs in humans there is, I believe, the same principle to providing adequate emergency medical care. There is no point having a defib machine when nurses fabricate observations & there is no real nursing care or doctors can't manage basic airways or follow a simple Asthma protocol etc. etc. etc. This concept is sometimes hard to convey in a country where it is all about status & money.

So ON my deputy director gave me physical goose bumps & caused me to be culturally inappropriate when unprompted he agreed with me. We were both at an emergency seminar where the resurrection abilities of the AED were being lauded.

Preparing myself for a very long conversation about AED I sidled up & asked him what he thought. "Well Esther - an AED is very expensive & we have many things to buy for the new ER with very limited budget. I don't think an AED is first our priority - we need to sit down & prioritize equipment based on need & cost, lets meet Friday after this course."

I hugged him.

Angry Bird or Going Troppo part 2

Mr S - the head nurse at my hospital has started to call me 'Angry Bird' - he says it with affection & it is usually accompanied with a statement such as "Thank you for staying Esther, I know we frustrate you but I want you to know that I appreciate you." Shortly following this he will then ask me to do something for him, I will say 'yes', it works every time.

Angry Birds - a merchandise sensation here in Asia - is in fact a very fitting term of endearment for me because currently I am angry most of the time (although as a feminist I would usually object to being called a bird - it makes me angry!). I've been hoping that this is all down to the heat & 'going troppo' will vanish with the rains but I fear that there is a deeper rooted cause that a drop in ˚C is not going to address.

You will only have to read my previous blogs to get a general idea about what kind of things cause me to become frustrated & angry. My development of a visual analogue scale probably is a good indicator as to how much time I have been feeling this way recently.

Last month I under took a health facility review, for VSO, of a group of counsellors in Phnom Penh. 60% of their clients are Cambodian, mainly presenting with post traumatic stress & anxiety disorders. When I asked what the 40% ex-pats common complaints were, the answer was Culture Shock. This can present with many symptoms - poor appetite, sleep disorder (but that could be Wat related!), anxiety, depression, irritability.... Then I tentatively asked "Anger?" - apparently yes!

However I don't think that I am culture shocked, I don't believe I am going troppo, what I am experiencing is just a normal reaction to current life events. From  Cambodia to UK, work to home, professional to personal, regional politics & gender issues to bad driving - everything is driving me crazy.

But who I'm really angry with the most is myself & my failure to shake this angry bird trap. So if someone could please catapult a bird in my direction, release me from this cage & get a bonus pineapple for your troubles, it would be very much appreciated.

The worst boss or job in the world?

It's fair to say at the moment I am feeling a bit of a failure - both professionally & personally - so it came as a surprise that I managed to see my latest setback in a positive light. My VA has handed in his notice. Afterwards I cycled home thinking about the massive problem this poses for me (I currently don't have a work-plan for the coming year & now no VA to negotiate or translate a plan or time in the next month to recruit a new one) it occurred to me - surely I must hold the record for the volunteer who has had the most VAs in a single placement (I am in search now for my 4th). I may be a failure - but I am a record breaking failure.

I don't blame the boy for leaving, he recently lost the best bit about his job which was working the other half of his time with the lovely Kristy. She left a month ago, back to sunny Australia & he has been pretty gloomy since (To be fair so have I). Working with Kristy half the time he got to sit in a AC lab - translating documents with not much verbal interpretation & translation, he got on with the lab staff - especially the pretty, young ones.

With me his job is slightly different. We walk the length & breadth of the hospital in search of staff to capacity build. He soon learnt that his smart, metrosexual shoes gave him blisters from all the walking he does with me so for the half days he is with me he now wears flip flops.

When we find staff - they are often mean & hostile to us. He tends not to translate what they are saying if it is very bad, but only a small part of communication is verbal, so I usually get the message. I make him say challenging things to the staff, I sometimes disagree with their management, I make more work for them with my suggestions, I question the status quo, I rock the boat - he absolutely hates translating for me. Part of the problem is that he is not from a medical background so can not always understand the medical khmer which is used. Also he is young (21) &  an english/management student who has a very limited biological/sciences background. Then there is the added complication of doctors half talking & writing in french. It renders most of the conversations (especially in meetings) impossible for my (ex)VA to translate. Imagine how unintelligible an average English doctor can be when they are on a medical jargon roll, then put that to the power 10 & that is my VAs nightmare.

When I do training even the URC nurses & doctors that I work with sometimes struggle to translate some of the concepts into Khmer from my English. I'm beginning to lose the ability to communicate in simple English & unfortunately it hasn't been replaced by Khmer or French. Without adequate communication I am nothing.

Then if that wasn't enough with his blistered feet, injured feelings & bruised language skills, I then drag him to see bleeding, dying, suffering, distressed, seriously ill patients in smelly, dirty, appalling wards. And when the staff don't listen & are rude, and when the patients die needlessly and when it is all too much for me, I ask him "why?", because he isn't just my translator he is also my cultural guide. He doesn't have the answers & as he has written in this blog previously he feels the same way as me.

He does all this for $120 a month (part time). He tells me his new job is his "dream job". Unspoken in that statement is that this one is his absolute worst!

So you see I can completely understand why he is leaving - if I wasn't so stubborn & not a quitter I'd be right behind him.

So I am looking for a cheerful, resilient Cambodian - preferably from a medical background, with good English & medical French, who is confident, can put up with a lot of hassle from hospital staff & me, has good interpersonal skills & doesn't mind the worst boss in the world or doing the worst job in the world for a modest salary. Comfortable shoes are essential. All applicants will be considered.

What's your opinion?

Katie - my new & short term roomie, is teaching english five evenings a week. She is trying to develop her classes critical thinking skills - how they argue & form written opinion. She asked three key questions that she hoped would give some insight into Cambodian culture. The questions are also questions I have been asking myself recently - generally, personally, flippantly & sometimes simultaneously.
Below are three of the best examples transcribed faithfully without Katie's corrections. There is a lot of interesting use of english but between I think you'll find there is the wisdom of teenagers - some real gems.

Should both men & women remain faithful in a relationship? (written by 16 year old khmer girl from Katie's english class)

It is depend on the time, and the people. For example, a men and a women love each other but they are not husband, or wife that means they can not respond it. On the other they are married and made the family. Of course, they really remain faithful. For the men, I don't believe they have faithful. But there is some men have because he had a good family. In my opinion, I think both men and woman should remain faithful because it still have in our traditional long time. When both of them don't trust each other it means the reasons maybe they have another person between them. It always happen in our society now. For the person come to another relationship is a bad person and jealous or revenge in their heart. I believe that if everybody dont have faithful in their heart, they can not find their own happiness in the whole life.


Is it OK, if a person chooses to commit suicide? (written by a 17 year old boy from same class)

If a person chooses to commit suicide it's really the bad idea. there are several ideas to tell that its a bad idea. First they think that they had a terrible life and they disappointed at themself. Sometimes, they want to kill themself. For example: In the real society, especially cambodian girls when she loves the boy that her parents disagree, she tries to kill herself by knife or takes a lot of bad medicines. Because, she dont think clearly so what happened after she died, how about her parents. Secondly, the person has trouble with morale because at their family never take care their children. In fact, I noticed that a lot of teenagers in some countries are disappointed at their parents. They want to be warm. That teenagers always change their behaviour from happy, honest to very bad, cruel and they can use some cocaines to kill themself. Thirdly, they think that they don't have a good life like everybody around they. You need to think each person always had problem that they face today, but they can solve it. and succeed it. So, you can do like that. At the end, I want them to try to grow up themself. don't disappointed about themself and try to think more. So.please do not kill yourself because it's really the bad idea.

Is killing always wrong? (written by a 16 year old girl from the same class again)

Yes, it is because a lot of people always make many mistake and the life of people are very important. they don't want die, they want right all time, but mistake always have all time. Examples one person have people to make angry, so she/he want to kill who make her/his. Sometime she/he have a lot of mistake in her/he life, so when she/he see people she/he wants kill. But sometime killing are right because some people always stil money another people, so the people's money catch the robber and killing the robber out. Sometime some people have very very mistake, so the police kill them.

The yearly cycle of inefficiency & ineffectiveness

Apparently the Royal Ploughing ceremony (May 9th) heralds the end of the hot season in Cambodia & the start of the Rainy season.  Which is good because it has been really quite hot here - if sweating was an olympic sport I would be sure of a place on the podium.

The hot season is littered with various public holidays - cynically I believe they have been created because it is simply too hot to do anything else but sit in a hammock. We have Khmer New Year which on paper is a 3 day holiday invariably making a 5 day weekend, but in reality means people (by this I mean doctors, nurses, teachers etc. - you know the non-essential people in society) are all away for weeks & I really do mean weeks. Also the over charging on public transport occurs for a good week beforehand & at least two weeks after the holiday.

Other holidays in the hot season include - International Women's day, International Labour day, Visak Bochea day & 3 days for the Kings birthday - another exceptionally long weekend. All in all, productivity is significantly reduced for the 3 months of the hot season. It is too hot, it is too humid, people are too hot, people are too sweaty, people can not sleep too well so get tired & irritable (or go troppo) - so what with the numerous public holidays & general lassitude it is not the best time to get things done here in Cambodia. Unless you want to get married - then this is the perfect time to do a wedding, lots of guests will come, the rain won't keep those envelopes stuffed with $$$ away. Yep, the only thing that does happen in the hot season is weddings (& funerals), pretty sure there must be a dip in birth rate in December to February though - it is far too hot for any of that funny business currently.

Then it starts to rain - roads become treacherous, things go mouldy, dust turns to mud, things generally leak. Getting around can be difficult in the rainy season, plans can be disrupted by an unplanned violent tropical storm, roads become unpassable - its all very wet (but verdant & beautiful and there are less bloody weddings). Last year a large area of Cambodia was under flood water, this made anything other than surviving quite challenging for the thousands of Cambodians who lost there homes & rice crops.

The Rainy season has its own fair share of public holidays - two less than the hot season but over a longer period of time. International Children's day, Queen's Birthday, Constitution day, King's Birthday (father & son both get a public holiday), Coronation day & the the pinnacle of the rainy season public holiday - like our August bank holiday - guaranteed to be the wettest days of the entire year we have Phchum Bank, 3 days holiday, in reality a fortnight of rice balls being thrown in Pagados at the ancestors & a hell of a lot of drum banging for the 3 month run up. Wet & noisy - my favourite combination.

What with the flooding & the mud & the drum-induced lack of sleep the Rainy season also poses quite an obstacle to achieving anything.

Then the rain stops, it is cooler & then the rice harvest begins. People can't work because they need to be on their land getting the rice crop in, food/money for the coming year. So it cool, not so muddy, not so dusty, one can sleep at night (with out a fan & sometimes with a blanket), one can get around on the roads BUT ABSOLUTELY NO ONE is actually in their workplace or school. Of course I exaggerate some people show up - maybe the same as when it is incredibly hot or when it is dangerously wet.

During this mass country-wide rice harvest there are several more public holidays. Independence day, International Human Rights day (*cough*), International New Year day, Victory over Genocide, Meak Bochea day & another 3 day (i.e. 2 week) extravaganza - Water Festival Ceremony.

Then end of February, beginning of March it begins to hot up again, on go the air fans, here come the power cuts & the yearly cycle of inefficiency & ineffectiveness continues.

And I wonder if this is why most of the high income countries are in the temperate zone & most of the low/middle income countries are in the tropics?

Another day (& a half) in the 'Bang

Recently myself & another VSO health volunteer undertook a health facility review. We visited various hospitals & clinics in Phnom Penh & Siem Reap trying to assess what was the most appropriate pathway to send volunteers with health problems down. I had even tried to write a draft algorithm based on the most common presentations - the overwhelming complaints are good old reliable gastroenteritis & upper respiratory tract infections - no need for an air ambulance for these.

Of course if the health service in Cambodia was adequate we wouldn't be here as health volunteers, so ultimately all serious ill & injured volunteers are medically evacuated to Bangkok. As a doctor, who gets a pretty constant stream of medical advice calls, since being in country I've been a little anxious about what would happen to a volunteer out in the provinces who was seriously ill or injured whilst they waited for the cogs of medical evacuation to turn. Last weekend I found out first hand.

I don't get lie ins, this is mainly because I live next door to a Wat but also because at the weekend I have early morning khmer lessons. So at 7 30 am last Saturday I was sat in my nightie (underwearless - this will become relevant soon) with my teacher for the momentous occasion of starting the grade 2 book. My phone started to ring with a mystery number but as it is normal practice here to buy a SIM card on a deal & use up the credit then move on to a new SIM, I have got into the habit of answering all calls from strange numbers.

It was D my favourite Tuk Tuk driver - I was confused. He seemed to be telling me he was outside my house & there had been an accident. It was only last week that we hit the moto coming back from the circus - perhaps that is what he was referring to. Then he mentioned another volunteer's name, E, & told me she had been in an accident. Concerned but mainly curious (This is not E's first dalliance with accidents) I went down to see after pulling on a pair of shorts - so I am now sporting a nightie-short combo. D met me anxious & agitated - my curiosity shifted to full concern. Outside my house E was slumped in D's Tuk Tuk grey, clammy, barely conscious & with an obvious broken leg. It was at this point that I thought that a nightie-short-underwearless combo was probably not going to serve me too well today.

I was later able to piece together that E had been turning left on her bicycle on the way to the market & a moto coming the other direction had hit her. Someone from the college she volunteers in recognised her & soon many people she knew were there trying to help her. D drove past & recognised her to, so put her into his Tuk Tuk & then because of the incident last week he knew to take her straight to Emergency Hospital - an NGO Hospital with by far the best Trauma care in Cambodia - we are extremely lucky here in Battambang. On the way there they drove past my house & E in her shock & pain still had the good sense to ask D to stop & ring me. She also very smart to be wearing a cycle helmet so that her injury was limited to an isolated limb.

Now I was running back to my house to get money & phone, to my teachers bemusement. People just don't run here, especially in the hot season.

The tuk tuk ride was a little bumpy & probably not the most appropriate form of transportation for a person with a unstable limb fracture but here tuk tuks are the main form of pre-hospital transport, along with unconscious patients being wedged between a moto driver & another pillion. My PTC brain is thinking perhaps we should be training basic trauma care to tuk tuk drivers & in the communities.

Getting E out of the tuk tuk & onto the trolly once we arrived at Emergency Hospital was a challenge. The ER staff came out (better than when I came with the unconscious moto driver but I'm guessing an injured barang has more curiosity pull) & it started off well with them putting on a temporary splint on E's injured leg. When lifting her to transfer onto to a trolly the head, body & injured leg were all coming in the right direction but her good leg was left behind causing her to come the closest to doing the splits in her adult life. She recalled later it reminded her of skiing.

Inside there wasn't much ABC action going on but I was happy that E had an airway (she was screaming at them every time they touched her leg), was breathing & had a good circulation. Every one seemed fixated on the obviously swollen & fracture leg - this is a common issue in trauma care. In fact they were keen to put on a permanent splint - I very assertively had to suggest that perhaps they do a set of observations & put in an IV & give her analgesia & THEN splint her leg. This involved me having to physically obstruct access to E's bad leg & raise my voice.

I've spent the last 13 months being gentle in my suggestions & not taking over patient care in an attempt to capacity build. Sometimes its frustrating for me (I've blogged numerous examples) to watch complete strangers suffer & receive inadequate care, lacking in compassion or what I consider competence, but when it is a close friend I simply couldn't bare it. They wouldn't put in a line until the doctor 'ordered' it & the doctor was in a meeting. After much haranguing a nurse attempted to find a vein, at this point E informed me she has useless veins. I tried to direct the nurse to a good vein on the back of her hand to cannulate. He spent a good 2 minutes rooting around in the back of E's hand with E demonstrating her airway was still open. Then I just took over, put a line in the other hand (the first in 15 months), then put up fluids, gave her Tramadol (the doctor had come by now & prescribed analgesia & requested a X-ray) & then was also was nominated to give her IM Diclofenac. Then I let them put on a splint - they by now had worked out I wasn't a physiotherapist that was visiting Battambang but was in fact an Emergency Physician who worked at the referral hospital - they were all resigned to the fact I wasn't going anywhere & wasn't going to make their lives easy.

I rang the VSO emergency phone to explain that there had been an accident & that I anticipated we would need to medically evacuate E.

E was comfortable, less grey & her observation were stable, I was told I could push her to X-ray. 15 months as an anaesthetist has put me a good shape for trolley pushing. The radiologist was the same man that had X-rayed my ankle & who I had spent Christmas eve with at the Bambu so things started to go a lot more smoothly. Can I see the X-ray? I asked, Why not! came the reply. It was in deed broken & required a CT scan & operation. I rang back VSO emergency phone to confirm the wheels of medically evacuation needed turning.

The doctor came to tell us that if we didn't trust Cambodian health professionals he wouldn't be offended if E was transferred. I explained that we were thousands of miles from our family & friends & when we were sick we needed to be in our own culture & surrounded by people to support us. I don't think he bought it.

It was just after this I got a text from another volunteer saying that a programme office staff member had rang her thinking it was her who had been in an accident to see if she was OK. Communicating in a second language with poor mobile phone reception is fraught with difficulties & confidentiality is not a concept embraced here in Cambodia.

By now there was half of E's college in the ER with us & E was flying on the Tramadol. I called up K - my new roomie - & asked her to make up an bag for E to go to Bangkok with. All this is complicated by two things. 1) E was due to leave Battambang & finish her placement in 48 hours & her house was half packed up 2) E was having a leaving party that evening & had bought half a pig. At this point she was keen to get up as she was feeling better & carry on preparing for the party. I strongly advised against this. Instead I began ringing people to cancel the party.

Then the day-long, long distance, telephone conversation with Danny from AXA began. Considering it was 3 am in the UK he seemed like a pleasant young man.

Whilst they plastered E's leg, after I'd insisted they gave her more analgesia & I'd lectured on giving opiates until the patient is pain free & still breathing rather than a homeopathic doses every 6 hours, I spoke with the AXA doctor. She wanted to know what E's baseline Haemoglobin was - I explained this was Cambodia - I'm used to this being explanation enough but on this occasion I needed to expand.

Danny asked me if E was under the influence of alcohol - I flippantly replied that she was Irish & it was 7 30 in the morning so I'd check. "I most certainly WAS NOT!" came her indignant reply. Things were looking more normal. Danny also asked if we had a police report to which I replied less flippantly - this is Cambodia you can get whatever police report you pay for. E appreciated that comment. She had already been asked if she wanted to press charges & have compensation - she had declined.

Next an emotional khmer girl rushed in - sobbing & clutching E's good leg. Who is she? E asked, it soon became apparent that she was in fact the moto driver that had broken her leg. Because E had declined any 'compensation' the girl was so grateful she wanted to come & cry over E for a while. E gave her a lecture on driving too fast & looking where she is going, E is, after all, a teacher.

E's VA arrived with a packed bag but had forgotten the essential tooth brush charger & E also needed money so happy that she was stable & sleepy with Tramadol I slipped off to a) Shower & get out of my nightie-shorts combo b) have breakfast (it was 11 30) c) go to E's house to retrieve tooth brush charger (& observe that the place seemed to me less than half packed - at least I knew what I'd be doing for half of the next week!) & d) go to the ATM to get $$$. We also established that L who was traveling to BTB for the party (& is conveniently a nurse) was happy to travel with E to Bangkok. My passport was locked in the bowels of the Ministry of immigration waiting for a visa renewal. L's was at the programme office in Phnom Penh & could be sent up to Siem Reap where E would be flown out from.

K & I then went back to see the patient. By this time the various college staff, hysterical, careless moto driver, VA, landlady et al had left & E was in a blissful opiate induced sleep. Whilst K kept E entertained, I chatted with the ER staff. They seemed OK with me completely taking over before - one even asked if I could come & work at Emergency so he could learn more from me! The matron - a bloody marvelous woman - was very concerned about E staying on a trolley waiting for an ambulance. At this point it was 1 pm & my blossoming relationship with Danny from AXA hadn't enlightened us to when an ambulance would materialize. E was moved to ICU to a comfortable bed & we were sent off to find food for the hungry patient.

It was at this point that L text us to say that her passport had been mistakingly sent to Battambang but someone from VSO was quite literally chasing it.

Whilst waiting for take out food to be prepared at the old faithful Bamboo Train Cafe the heavens opened & despite taking a tuk tuk back to the hospital Katie & I arrived at ICU soaked through to the bone. That's what I love about the tropics you can be beside yourself with heat & blinded by sweat yet 30 minutes later you are quite literally hypothermic - shivering with goose-bumps.

L had arrived with Gin, marshmallows & Reeses peanut butter cups, so the bed picnic began. The ICU staff were attentive & kind & just re-affirmed why emergency hospital is the best of its kind in Cambodia. E was getting cranky as she wanted a cigarette so they wheeled her out to the veranda where a patient with half his hand missing, bound in bandages, reprimanded her & pointed to the no smoking sign. There she was, full leg back slab, leg elevated, hair disheveled, sign above her bed mis-spelling her name 'Eun Soner', mystery pink towel draped across her midrift & fag in hand being told off by a fellow patient - I wish I had my camera but I hope I have painted the picture well enough.

I rang AXA - still no news on an ETA for the ambulance. Then the hospital in Siem Reap that would house E whilst she waited for the air ambulance called to get details - their ETA 6 30pm. So L, K & I left E to sleep whilst we went to grab a drink & some food before L set off on her own incredible journey with E.

We arrived back at 6 35pm to the shocking sight of blue flashing lights - it is not often in this country that when someone says a time, that is the time they mean, unless of course we are talking about parties - I am reliably informed.

E was looking a little worried as the ambulance crew were putting a bright orange vacuum splint on her leg. I tried to explain to them that as she already had a full leg back slab splint there was no need for a pre-hospital vacuum splint BUT they were following their protocol so my words fell on deaf ears. This as it turned out was to cause E a lot of pain & worsen her fracture blisters - being female & not old enough really is a liability here.

So we loaded E & L with all there bags onto the ambulance and at 7 pm (12 hours after her accident) they disappeared into the night. K & I went to have a very big G&T.

E & L's adventures had only just begun......

And in case you are wondering where this blog sits with my medical code of conduct & confidentiality, E has read this from her hospital bed in Bangkok & her only edit was to make me add in the comment about cycle helmets & how everyone should wear one. Its the law in Australia - perhaps those australians aren't half as bad as I think!

Laos - Cambodia; a comparative study

After mine & Jean's recent trip to Laos we constructed a table comparing & contrasting Cambodia with its northerly neighbour.

	Laos	Cambodia
Food	Great bread & pastries – thank heavens for French food imperialism, which seems to have stuck here more than Cambodia, Sticky rice.	A lot of cross over between Laos & Cambodian food. Both sandwiched between Vietnam & Thailand so rice & soup with a spicy/Chinese influence.
People	Very laid back & relaxed. Not much hassling, lots of laughter.	I think Cambodians are smiley-er & friendlier but Jean would say that I am bias & it helps I can try to communicate (not always successfully) in Khmer.
Transport/ roads	A lot more diversity of the makes of cars. Bus trip from Vang Vieng to Luang Prabang more diverse in pitch, roll & yaw – Jean’s worse bus journey of her life. Thai imported food at road stops with fridges that have magnums. There appears to be more order on the roads & rules that are followed. Less beeping of horns, less tarmac = bumpier roads.	Better roads, straighter with significantly less pitch, roll & yaw than Laos. There are distinct advantages to living in the Mekong basin – no mountains. Capitol bus company is the best. Great snacks at bus stops – crickets, spiders, fertilised ducks eggs – clearly superior snacks to magnums & Lays crisps.
Agriculture	Much greener, more trees, more slash & burn farming. Less rice more variety of other crops.	Rice, rice, rice. Rubber, Cassava cash crops. Very few trees.
Shopping	Great textiles – wider variety. Good crafts. The night market in Luang Prabang was the calmest place I have ever been to. The occasional “Sa Bai Dee” & rarely “You like, you look” but a total absence of hard sale. A delight – Jean left with a huge blanket, so much for travelling light with a 38-litre rucksack!	Great clothes – imported & made. Great shoes – beautiful but not always comfortable. Markets – hot, hard sale, hassle.
Environment	Quieter, they have functioning pavements. Cleaner – less plastic.	More of – dust, Wat noise pollution, traffic, Karaoke, dogs, chickens, chaos.
$$$	More expensive but we were on the tourist route.	Cheap – I live on £10/day.
Sex tourism	That is depressingly the same all over South East Asia.
New Year Celebrations	Wet & joyous	Wet & dangerous

 

Pineapple swans - part of an 'interesting' curry chicken & pineapple salad - disingenuously Thailand not Laos 

Not just Cambodia that could do with rationalizing its electricity wires

Laos new year - joyous, noisy & wet

Jean rejecting Beer Laos for a glass of wine

New Year water party - not sure what the bloke sat on the far right of the water tanker needs an assault rifle for!

Jean after a Laos guy - at least a foot shorter than her - picked her up & put her in a paddling pool. 

Wires!

Product placement meets buddhism

Vang Vieng

Boat Trip - drier & quicker than tubing

The quiet end of Vang Vieng

The lovely Luang Prabang

The man with his tripod & self timer than followed us around Laos

Frangipani shadow

The mighty Mekong

Another Mekong sunset

Smiling fools

Beers - completely lived up to all my expectations of what a bear should be

Love this waterfall

This place was idyllic & what you can't see in this photo is that it was actually heaving with people

Very precarious bamboo bridge

Assumption is the mother of all f*** ups

Communication is always important yet miscommunication seems inevitable.

Living in a different culture, communicating in a different language or through translator is fraught with communication errors. Then there is the communication with people who have the same language or culture as you, which is sometimes more susceptible to problems, probably due to the assumption that you will understand each other. Never assume - is makes an ass out of 'u' & 'me'!

Barangs often make communication with Cambodians more difficult by shortening the language & sacrificing grammar, this just makes things worse. Examples of this are "we go now" - does this mean "Shall we go now?" or is it meant as a statement "We are going now"? Who knows - I'm a native speaker & I'm confused. Equally perplexing is a statement like "We healing" - if only native english speakers could just communicate clearly & with clarity it would really help matters.

I have a sample of some of the case studies of communication breakdowns from various South East Asian countries.

Case study 1 - Laos


On Jean & my recent trip to Laos we stayed in Luang Prabang where we enjoyed a variety of breads & pastries, thankful for French imperialism. We found ourselves the only customers one particular morning in a cafe for breakfast - the customer to staff ratio was 1:4. I wanted it all & Jean who gets bad food envy ordered the same - a set breakfast "breakfast Americano' with many choices. Bread or toast? Tea or Coffee? Fruit shake or Juice? Eggs - scrambled, boiled or fried? So many choices but thankfully the fruit salad, cheese & bacon were fixed. To be honest it was all about the cheese & bacon for me.
When the breakfast feast arrived there was an absence of cheese or bacon - so I asked the waiter who looked dazed & confused, then brought us a menu. We pointed out the set breakfast we had ordered & I was fully prepared to hear there was no cheese or bacon - this is a common experience here if you order something they don't have you aren't told rather there is just a failure for it ever to materialise. In Asia one never really knows what will be on their plate when eating out. But this morning there was a new variation. Apparently as we had pointed to the set menu & verbalised our choices but not spoken the words 'cheese & bacon', he had assumed that we didn't want them.
Jean correctly predicted that a one inch slice of bacon & a processed cheese slice would be presented 5 minutes later - when this came to fruition Jean got a complete fit of the hysterical laughter. At one point when the tears were running down her cheeks & her whole body was shaking I was a unable to tell if this was still hysterical fits of laughter or if she had crossed over onto the other side into sobbing with despair.

Case study 2 - Laos


Still in Luang Prabang, Jean & I decided to go on a boat trip on the Mekong after being offered one every morning on multiple occasions for 4 days by the same persistent captain - persistence it would appear does pay.
When given the options we were told we could have a 2 hour trip for a ridiculous price or 1 hour for half the ridiculous price. We foolishly did not ask what the difference was because we assumed that for double the price & time we would be going twice as far. Assumption really is the mother of all f*** ups. We ended up going on a 2 hour boat ride which turned out to be the same distance as the 1 hour trip but just at half the speed. We could have swam faster & that would have almost certainly been cooler. Chugging along at a quarter of a knot doesn't generate any real air movement of note and in the hot season air movement (or even better AC) is all that is really necessary. We roasted for 2 long hours noting this down to another lesson in communication errors.

Case Study 3 - Cambodia


Kristy's last day in Battambang was all planned - lunch at noodle shop, Bambu for happy hour, a trip to the Circus followed by dinner at the Indian. What could possibly go wrong. I even checked online to see which show was on at the circus - there is one show that is inspired by the khmer rouge which tends to be less than cheerful. I called D my favourite tuk tuk driver who wasn't free but arranged for his younger brother to pick us up from the Bambu to go to the Circus. The Circus is a few kms out of town in the middle of a commune, there are no other nearby attractions or places worthy of visit - this will become relevant shortly.
So at 6 30 pm everything was going according to plan as we piled into a tuk tuk to go & see semi-clad cambodians throw themselves about. On arriving at the Circus there was an absence of other tuk tuks, people & general activity which did not bode well. "Oh!" said D's brother, "there is no Circus this evening - it has been cancelled because of Khmer New Year tomorrow". "Oh!" said I, "If you knew that then why did you not tell us this before?". "Because," I was told, "I didn't realise you wanted to see the Circus I thought you just wanted to visit where it was". Classic Cambodian response AND he then expected us to pay him the rate for the driver staying and waiting all evening to take you back home. At this point irritation crept in - I believe I communicated it quite clearly.

Case Study 4 - Vietnam


This is a borrowed story from Katie who last year visited her cousins in Ho Chi Min & found herself going to the hairdressers as they thought it would be 'fun' for her to have something done. Katie clearly stated that she would consent to 'hair straightening' but no colouring or cutting. This was reiterated on several occasions. When a huge, stinking pot of ammonia smelling paste was brought out, Katie got anxious & once again requested that there was no colouring. Smiles all round - of course no colouring - then paralysed by a fear of conflict & an over developed sense of politeness Katie sat petrified whilst they began to smear the foul smelling paste on her hair. It is for curls - she was reassured whilst hacking away at her fringe - 8 months later & she still has great kissing curls - it was at this point that the cold realisation that she was getting a perm hit her. Its easy done, she assumed she had been clear, she assumed that she was just having her hair straightened, she assumed they wouldn't do anything she hadn't consented to - we all know what assumption is the mother of!

A simple case of hair straightening - clearly

In Laos there was a strange censoring technique on the TV that not only erased 'bad words' by bleeps but also blurred out 'bad things' - for example a harpoon killing a man, a gun being fired or someone being punched in the stomach - all blurred out like over zealous soft focus. When I first saw it I thought it was my middle age heralding floaters getting worse but no need to book an optician appointment, it would appear that if you can't hear or see evil then it doesn't exist.

Oddly when they want to people can communicate very effectively - one weekend in March a group of us went to Siem Reap & for Lou's Birthday she wanted us all to dress up in traditional Cambodian wedding outfits. Cambodian's are all size zero, I - despite 14 months in a developing country & 5 serious episodes of gastro - remain a solid size 18. The likelihood of me finding a Cambodian wedding outfit to fit me seemed quite unlikely. Lou reassured me that Americans went to this photographic studio & I mustn't fret as nothing bad would happen.

On walking up the stairs to where the lady-boy makeup artist was waiting, Lou & I were 'greeted' by him standing up in disgust, pointing in horror at me, exclaiming that I was "Twot maintain!" - extremely fat - & then proceeding to do the dismissive hand flapping thing that is so commonly done here, before flouncing off in refusal to deal with me.

Sometimes communication can be very cutting.