Its the little things....

Its the little things....

Day 4 & I employed a new strategy - avoid the wards at all costs.

This morning I didn't even go to the hospital but worked from the URC office. R came to find J & I.

Our initial morning conversation normally goes something like this;

Me "Arun Sua S'day, Soksa Bai tey?" Good morning how are you?
R (with glum expression)"Ot Sabai" Not so fine
Me "Oh dear - hat-ey?' Why? 
R - generally follows a list of complaints & worries, featuring a mixture of housing, children's health, marital relations, money, in-laws, "mental health problems" - I gave him the last label a while ago & he has ran with it ever since.

But this morning R smiled breezily & replied "Baat, Soksa Bai!" Yes, I'm fine!


Puzzled at the deviation from our normal morning conversation I asked him why. Then he explained he had been to the hospital already this morning & casually told me about the baby had died at 2 am. For as long as I live here I WILL NEVER understand Cambodians.

I tried to go back to the hospital in the afternoon but karmically I had a flat front tyre (again) so I walked to my favourite bicycle repair man near the hospital. He found the puncture & identified the culprit - a small slither of metal.

In my head I started to sing Paul Kelly's 'from little things, bigs things grow'.

After he repaired it I tried to give him money - he as always refused, there then followed the usual to-ing & throwing of reil notes that in reality only amounts to pence but it matters that I pay for his work and it seems to matter to him that I don't.

When he turned to put his tools away I hid some money in his pump machine, as I cycled off he chased after me & put the note into my bicycle basket. I will NEVER, EVER understand Cambodians. I can't understand why he won't let me pay him, I don't know what is the right thing to do in this situation.

WWJD? Well she says buy him a present when I leave.

But how do I repay the daily kindnesses of Cambodians & even more importantly how does one change the attitudes & behaviour of the less kind ones?

Day 3

Day 3 has continued along the same vein as days 1 & 2. I spent most of the day (sans VA) doing an audit of the death cases for ICU medicine, which is always guaranteed to whip me up into a state somewhere between agitation & despair. I was just about to call it a day & go to the office of the NGO that funds my placement to speak to the director when R got a call about a child on the paediatric ward.

As we walked over to assist, R somberly told me that in Buddhism we have to accept when someone dies, as this is their designated time. I responded that as a non-Buddhist, emergency physician, from the west my philosophy was to fight against this fatalism - especially in children, oh the hubris....

The 3 month old boy had been sick for 3 days with fever, runny nose, cough & difficulty breathing. When the parents had taken him to the local health centre he wasn't breathing - they were sent up to the big hospital. When the child arrived C - who works for an NGO hospital - started to resuscitate with CPR & ventilations. He gave him a bolus of IV fluids & after some oxygen & ventilations with a bag valve mask the baby had a pulse. After an hour of resuscitation he still wasn't breathing so C called R to give him a hand. I just happened to be with R when he got the call. Obviously as a paediatric emergency doctor I am not an appropriate person to call when a child needs resuscitating.

The student nurses in attendance (no doctor) were not giving effective ventilations so I proceeded to show them how to maintain an airway in a 3 month old & improve their ventilations. We also aspirated all the air that had been bagged into his stomach. We did this for a long time. The baby remained lifeless, pupils fixed & delated, cold peripheries. Things weren't looking good but he had a good pulse so following my medical culture we shouldn't give up.

C asked if I would intubate him - I, of course, said I would & wanted to know what the staff's plan was if we did this (they don't manage ventilated patients here). The parents were resigned to the fact that their only son was dead, they had no money to go to Siem Reap where the 2 nearest hospitals that can manage a ventilated child are & the staff said they had no one that could go with the baby on transfer. They couldn't find an appropriate size tube to intubate the child nor a laryngoscope. My Buddhist fatalism started to creep in.

We kept bagging the baby, the pulse remained strong.

CP - the paediatric 'all-star' showed up, came in to the paediatric ER, told me the baby was brain dead & walked out again.

A long series of conversations followed. I spoke with Dr P at an NGO hospital - because of the Dengue epidemic they had no ICU beds or ventilators, neither did the other hospital in Siem Reap. Was it really worth intubating the child & transferring him to Siem Reap only for all treatment to be withdrawn once he got there because there were no beds/ventilators/staff to treat? The parents did not even want him to be transferred but it was difficult with the language barrier to know whether this was solely based on financial concerns. CP clearly thought we should withdraw treatment but he wasn't the doctor on duty & he wanted the duty doctor to make that decision. C - paediatric nurse with NGO who had been there from the start of the resuscitation thought we should stop, he was confident that the child's down time would mean he would have significant hypoxic brain injury. V - trained nurse from BTB looking after the patient agreed. I am a westerner with western sensibilities & we don't give up on a child with a pulse - I was grappling with the medical culture gap. But as an advisor it wasn't (thankfully) my decision to make and I was beginning to understand the sense of hopelessness you often encounter when talking about seriously ill patients with Cambodian health workers.

They stopped ventilating the baby & he started making gasps. J wanted the mother to hold her child but CP was more concerned about emptying the baby's bladder by pressing on it. I left.

I went to sit outside on a bench & ask myself what was the right thing to do? Or WWJD?

J answered the second question by shooing away the gathering crowd of rubber neckers from the window of the ER. CP had moved his attentions away from bladder evacuations & gave the baby vitamin B1. Then the baby was wrapped up & given to his mother to hold.

J, R, C & I left the ward.

Reflecting on the whole 2 hours we had spent on the ward I came up with some positives. We had capacity built student nurses' airway skills, we had taught about the importance of NG tubes in sick children to decompress stomachs & improve ventilation. We had role modeled compassion & caring. I had convinced myself & everyone there that I can still to manage a paediatric airway.

I was still feeling pretty shit about the whole experience despite my attempts at positive thinking.

I broke my self enforced sobriety after my little knock to the head & went for a beer. There were no other doctors or nurses around so I couldn't debrief, instead I just sat pensively looking into my 50 cents glass of beer. And the refrain is - what is the right thing to do here?

Then my phone rang - it was CP, he called to let me know that the baby was breathing a little better. It was 6 30 pm. I don't know how long the baby went without oxygen, I don't know what degree of hypoxic brain injury there will be, he may not even survive the night but CP had called me to tell me about his condition.

That means something, I'm still trying to work out what exactly.

Here we treat every patient as if they were our own family (that is of course only if you are actually one of us)....

Second day back at the hospital & there doesn't appear to be enough syrup & evap milk to soften the blow.

There was a lot of activity at ICU medicine first thing - crowds of people & two of the deputy directors were over there, one of them had a stethoscope around his neck. Curious I joined the crowds. A doctor from the hospital was sick, literally dozens of doctors, nurses & midwifes milled around them - there was a lot of shouting, fussing, an awful lot of arm & leg squeezing but no one had taken blood cultures, done an ECG or thought about requesting an chest X-ray.

ON was talking about shock index (thanks to the recent Emergency training by an american delegation - I of course have been talking about the treatment of shock for 15 months but as we are all well aware by now, I clearly know nothing about anything) & he was agonizing over giving the patient more than 10 drops a minute of normal saline for fear of overloading them (the pulse was 130 but we didn't know what the rhythm was because everybody was ignoring my suggestion that we do an ECG). The patient had been given their own private room. Obviously every other patient in the hospital was being ignored - business as usual then....

J joked with ON that perhaps if the nurses treated all patients as if they were members of staff it would improve patient care. I chipped in that it could also be the hospital motto "Here we treat every patient as if they were one of our own family". Oh, how we laughed.

J, R & I then went to the paediatric ward which is currently heaving with children with dengue fever. Not the mild clinical syndrome that expats get & are admitted to private clinics for IV fluids & the clinics profit. This is the much more serious Dengue haemorrhagic fever & shock from which many Cambodian children will die as a result - this years epidemic is a bad one. Visiting the paediatric ward is not a very cheering thing to do right now.

In the NICU was a premature new born. Two student nurses stood, like statues, over the baby holding a bag valve mask 10 cm away from its mouth. We asked them what they would do if the baby stopped breathing, their response "Chest compressions". We asked them what instructions the trained staff had given them, their response "None". We asked the trained staff why a newborn premature baby with respiratory distress had been left with two year 2 student nurses unsupervised. We were told they were only able to record vital signs. It didn't really feel like the answer to our question.

We went for lunch at the new hospital canteen, work commenced on it 3 months ago. The ER still remains unfinished, work commenced on that before I even arrived here. Good to know that everyone has their priorities straight.

After lunch there were more throngs of people outside ICU, this time an Ambulance was taking the same staff member down to Calmette Hospital in Phnom Penh. Again every staff member it seemed in the whole hospital was there to shout & fuss & limb squeeze.

It was only after the ambulance had pulled away & the crowd had dispersed that I noticed the dead young man laid out on a stretcher outside of ICU - not on the porch but on the path, uncovered in the mid day sun. As I am suffering from concussion & a dose of psychosclerosis as we walked past him  I mentioned to J how it was nice they were leaving corpses outside fully exposed now.

He had been there the whole time that the throngs of people had been transferring the staff member into the ambulance - ignored by everyone. R had already been informed by the hospital main gate security guard (AKA triage) that a patient had come a while ago with an electrocution. He had probably been dead on arrival.

His family then arrived & the father afforded his son the dignity in death that none of the staff had considered to do, he covered him with a sarong. He then held him & wailed.

Its days like these that really put things in to perspective.

Back home with a bump

I arrived back to Cambodia from China after a mammoth 30 hour journey of planes, cars, buses, motos & tuk tuks and was met by J&G. They could see exactly what I needed so took me straight to happy hour at Eden & then to the noodle shop for dumplings.
The following day they came around to take me for breakfast knowing that I would be in an acute 'roomie' withdrawal state, their main purpose was to keep me occupied & the 'post-time-away-from-Cambodia-blues' slump at bay.
My bicycle back tyre was, as is normal after a week away, completely flat so I took full opportunity of the new moto repair place that has just set up business near my house. Foolishly, as I was there, I thought it would be reasonable to top up air in the front tyre as well. Error number one as it would subsequently turn out. The not so nice new bicycle repair man proceeded to screw up my front tyre valve & render my bicycle unrideable. His response was to demand 200 R for the privilege of breaking my bicycle, laugh, smile sheepishly & then shoo me away with the classic Cambodian dismissive hand flap (my all time favourite). To say I was less than impressed would be a mild understatement, but resigned I began pushing/dragging my useless bicycle towards the breakfast rendez vous in the increasing mid-morning heat.
After 10 minutes walking I came across another road side moto repair stop where the proprietor cheerfully told me he would replace my valve for $4, as I am quite confident that the whole bicycle wasn't worth much more I began to think about telling him what he could do with his valve when the price immediately reduced by half but I was already stomping off down the road - muttering about getting on the next plane out of here; the amazing, inspiring, reaffirming time in China erased by just another normal day of Cambodian frustrations.
After a further 10 minutes - now sweaty, thirsty & very irritable I stopped at one of my regular eating places & asked in khmer where the nearest bicycle repair shop was - I was given a menu & asked what I wanted to order for take out!
Finally I found a repair stall - the little old woman flapped her hand at me - I suppressed the urge to rip her arm off. I don't know why but the flappy, dismissive hand gesture really gets to me even when I haven't been walking with an incompetence induced flat tyre for half an hour in the tropics. But the flappy hand was deceptive - wordlessly & in seconds she replaced my valve, inflated my tyre & charged me 50 cents. If J&G hadn't been waiting for me at our breakfast destination I would have back tracked & told $4 man what a rip off merchant he was. Instead I recognised that most of my irritation & frustration was down to thirst & hunger so I headed for fried rice & a khmer coffee - it was the right choice.
We spent the afternoon with R's family at the swimming pool & eating ice cream, things seemed a little better.
The next day I headed to a hospital on the Thai border. The staff there are receptive & open, the syrup & evap milk has remarkable restorative effects & being the only barang (apart from J) had the strangely soothing & relaxing result that it also had in China. I swear living within an ex-pat community is often the biggest challenge to volunteering. Feeling odd, different, strange & an outsider is much easier when you at least look & speak differently.
Coming back home at the end of the week & interviewing for a new VA gave me a 4 day migraine that rendered me bed-sofa bound for the weekend when I should have been day tripping it to PNH for a leaving do. Just when the vice on my head was starting to ease I slipped on my wet kitchen floor & gave myself the first head injury I've had since I was 3 years old. I was bleeding, I was alone - I thought to myself WWJD? - so I called her & she came around with a bag of dressings, coals to Newcastle. Her & G sat with me for an hour whilst I became less grey & stopped bleeding - J reassured me that the Emergency hospital performed burr holes, I settled for doing my own neurological observations & taking my own head injury advice.
Using the universal medical measurement system of fruit for lump size - I now have a walnut on my right temple,
Today I have had post-concussion syndrome; my head hurts to think, all my thoughts are painfully slow, writing this make me giddy, I feel totally detached & very strange.
Today was also my first day back at the hospital for 3 weeks, it was very lucky that I was concussed as when I received the stroppy call from HS demanding to know where I was for 'the' meeting, I had never arranged, I was able to keep calm. Smashing my head on the cold, hard concrete & tiles of my kitchen wasn't as painful as my deputy director telling me that HS had arranged this meeting & if he said I knew about it then he must be right. I smiled sweetly, explained I had been in China & SLN for the last 3 weeks so couldn't have arranged this meeting with him, reasoned that I don't have a translator so wouldn't have arranged any meetings in this hiatus, apologised for any inconvenience caused, suggested that perhaps a more urgent meeting was that of agreeing on my work-plan, which incidentally they had all stood me up for before China. I then walked away from them all in a concussive fog.
I was fuming but I just couldn't quite connect my brain with my adrenal glands.
So it seems I am back home with a bump & unlike last weekend when I just wanted to get on the next plane out of here - now my refrain is 'get me to the border', if for nothing else for the syrup & evap milk which certainly eases the pain of the landing.

WWJD? What would Janice drink???

On Algorithms... (warning this blog contains explicit language of an Anglo-Saxon origin)

Recently, during one of my frequent rocky patches, a very good friend whatsapp'ed to me an image of a greeting card. The image (below) struck a chord & had almost been, word for word, what I was thinking most of that day.

I shared it with J who also appreciated the underlying sentiment & message. Then because she is a genius (x-ref WWJD?) she suggested something very funny.

Recently I have been tasked by many Cambodians to create algorithms & job aids. The MoH has been updating CPGs (clinical practice guidelines - last written in 1999) but the hospital doctors want them simplified into Algorithms that can be made into a posters, which can in turn be stuck on the walls of clinical areas. Below is an example from an ER 'rescue room' I visited on my recent trip to China.

Now I don't object to Algorithms in principle, it just sometimes feels that I am only ever being asked to write them here because people are too lazy to read & try to understand the full protocol themselves or just to keep me away from the wards & anything remotely close to 'proper' capacity building.

I have started to visit for one week a month a small hospital on the Thai border, the director there asked me to do some training on Organophosphate poisoning, a common presentation here in Cambodia. One of the NGO staff I work closely with suggested that, as well as a training package, I should also develop a treatment algorithm, the CPG (written in french) is less than clear & straight forward. This, I thought, was actually a very good idea so below is my attempt of simplifying the national guidelines for the treatment of patients that take an overdose of insecticide. The text boxes, autoshapes & my mouse pad on my laptop, have been really testing my patience to the very limit.

I've become, it is fair to say, a little over burdened with text boxes & arrows in the last few weeks, so J's genius suggestion was for me to write an algorithm to simplify the inspirational whatsapp message from my good friend. In a free lunch hour I therefore gladly obliged.....

Tomorrow I'll start work on the algorithms & job aids for the paediatric CPGs......

Nystagmus of the head

To the uninitiated, Nystagmus is a medical term used to describe "fast, uncontrollable movements of the eyes".

Whilst I was in China I coined a new term 'nystagmus of the head' because either I have become stunningly attractive & a very rare beauty over night (unlikely) or white people are an unusual sight in Zhangye city (much more likely). 

Suzi had a different problem, as 2 of her Grandparents are chinese, locals were constantly chatting away to her in chinese & becoming increasingly perplexed & frustrated that she didn't answer or appear to understand them. I failed to capture on film the very specific expression on their faces when they realised she wasn't being rude but simply couldn't speak their lingo.

I however made children cry, men nearly fall of there bicycles, & stopped old ladies in their tracks.

One day whilst out on our 'morning exercise' I went back to the hotel early by myself & a miraculous thing occurred. People started saying "Good Morning" & asking "How are you?" - they smiled at me, they held open doors for me. It would appear being on my own had given them the courage to practice their english. Having an asian companion it would seem inhibited all friendly behaviour from the locals.

Now I am back home in Battambang & have rarely turned a head even once, let alone in a fast, repeated & uncontrollable way. Back to mediocracy, *sigh*.........

And Suzi said "How can I be putting on weight when all I am eating is vegetables & dumplings?!"

I remember once visiting my paternal grandmother & seeing that all of her 9 grandchildren had sent her postcards from their various summer holidays which she had proudly displayed on her mantle piece. When I read them a common theme soon became apparent; there was mention of cream teas in Devon, delicious street food in Morocco, lack of decent food on a camping trip, lovely pub lunches walking in the lakes, expensive michelin star food from fancy hotels, Sunday lunch with the in-laws etc. etc. etc....

There are many potential blogs from my recent China trip but as I am a true Wilson family member I'll start with the food.

Before going to China another VSO volunteer who had done a VSO placement there previously warned me the food would be really good, and by God she was right. The amazing food coupled with the exceptional hospitality meant that despite getting up at 6 am every day for ‘morning exercise’ it was still a squeeze to get into my plane seat on the return flight.

Suzi’s refrain was the title of this blog along with “but vegetables are 90% water!”

Below is just a small sample of the food & meals I munched my way through like a hungry caterpillar – Suzi I hasten to add was much more restrained.

The peak of the cherry tomato & cucumber glut

I'll start with cherry tomatoes & cucumbers as a snack & a hotel room gratuity. Odd but strangely effective. The additional plates of tomatoes & cucumbers as the week progressed in the hotel room was slightly alarming but reached a peak at 5 plates at which point the staff realised my tomato consumption couldn't keep up with their supply.

Next maybe it is appropriate to discuss the many dumpling options available in China.

or in soup.....

Then there were the noodles....

Flat...

short & round.....

and always very spicy!

Beef noodle soup with lashings of chilli oil was also a breakfast favourite which regrettably I also failed to capture on film - perhaps my breakfast priorities were more about eating the food rather than photographing it.

Lunches at the hospital were a kind in Chinese Thali affair and were duly recorded for prosperity. I soon learnt to not have eggs for breakfast!

And as if the massive lunch wasn't enough apart from the tomatoes, cucumbers & strange fruit there were always the strange chinese snacks.

Especially bought chrysanthemum tea for Suzi 

Salty & sweet

Possibly lemon flavour

Then there were the evening meals where to say there was excessive amounts of food would be an understatement.

A plethora of dipping sauces for Hot pot lunch on our 'rest' day

The last supper with all the big wigs of Zhangye Hospital - a feast

Each dish is a piece of art

Beautiful presentation of a meringue type thing

more enormous bowls of soupy goodness

Then there was the drinking opportunities & street food.

Local wine - surprisingly palatable 

After 5 minutes of miming & interpretive dance to communicate we wanted a beer we were presented with 2 milky, sweet, luke warm teas with beans which we duly paid for. 10 minutes later  a tray with a further 6 glasses of the same were brought out but this time we communicated our objection by shouting no & waving our palms in the air - we miss Miss Du!

Cookies

Street beer

Much toasting - apparently it is good luck to toast 3 times & down the whole glass. The final supper involved a lot of toasting & an awful lot of rice wine - not sure about luck but certainly felt merry.

Finally on one of our morning exploration walks & visits to one of the many 'exercise' parks I saw a lorry with this load below........

....so that evening we just had vegetables & dumplings!

WWJD - What would J***** do?

Lounging in my hammock before Khmer New Year,  I was planning with Jean our imminent trip to Laos.  She wanted to know if we would need malaria prophylaxis & I said no more than here in Cambodia. Jean looked doubtful then said "No offense Esther, but do you mind ringing & asking J what would she do?". I wasn't offended WWJD is something I ask myself here on a daily basis.

The mother that can't afford to bring her dead son's body home, the family with triplets that can't support themselves & the mother doesn't have enough food to breast feed successfully, the patient dying with only the cleaner looking after them as they have no relatives, the 18 month old critically ill child with no nursing care & the doctor absent at a wedding - all these clinical situations I have turned to J & asked her what would she do.

She is a nurse of many years experience, she is generous but not a complete door mat, she is kind but doesn't suffer fools lightly, she is compassionate & always seems to know what is the right thing to do. She has humanity, humility & cultural sensitivity.

Now this may well be down to that fact that she has been here 3 and a half years & listens to other people rather than thinking she always knows best as an "expert". However I suspect that she was equally thought of in a 'WWJD-way' in her old role as a NHS ward manager in the UK.

She has many Cambodian friends who I am sure have assisted in the WWJD phenomena. One of them, R, used to work at the hospital J was a VSO nursing advisor at for 2 years. He now works as her translator & a technical advisor at her current NGO. He is one of my favourite Cambodians (x-ref The Kindness of Cambodians). J will often ask R what should we do - he (like my lovely & soon to be ex-VA) is a her cultural guide. R & J's old VA have walked her through the intricacies of Cambodian culture & now she is better placed to navigate situations here as a result.

Recently the NGO she works for created a social network page, every employee had to fill out details about themselves including their "Famous Role model". Some people have written Cambodian pop-stars or actors, the more politically aware have written Hun Sen, one nurse wrote Florence Nightingale & an ex-pat wrote Jesus.

For his 'famous role model' R wrote 'J' - and why not? After all, when you're in a tough moral situation you could do a lot worse than ask yourself WWJD?