Say it with Bananas

L, my VA (left in the above photo) was informed by admin staff - PPF (punch provoking face - named by VA number 3) that a woman had come into the administration block asking for me. She had left her phone number and was eager that I got in touch.

L called her & found out that she was the mother of the patient with meningitis (x-ref "how not to capacity build...") and wanted to see me to ask some questions about her daughters recovery. L arranged for her to come to the hospital when she knew I was available.

I was walking to ICU medicine last Friday morning in an attempt to find a doctor to discuss the interesting management of a patient with acute coronary syndrome who was on treatment for Asthma instead, when I was intercepted by a smiling woman bearing fruit. I instantly remembered her as the mother of the patient who had heard my whole conversation with the ICU medicine staff about the lack of treatment of her daughter, calling them 'lazy, corrupt, murderers of patients' - it had resulted in her daughter finally getting the correct treatment but many faces being lost including mine.

She had brought a bag of medications (that she is holding in the above photo) which her daughter had been given since by a private clinic & via L I was able to advise her to stop most of them as they were utterly useless & a waste of her money. I explained to her that her daughter was recovering from meningitis that hadn't been treated properly for 5 days & it would take time for a full convalescence.

She then gave me a bag of 'ply mean' (a lychee type fruit) grown from her farm to say thank you - I was suitably touched & humbled. I hadn't completely destroyed my relationship with the ICU staff for fruit I'd done it because I genuinely cared about the patient but the fruit was a acknowledgement of this & it meant an awful lot to me.

The mother then rushed off telling me to wait where I stood. Half a minute later a tuk tuk driver came bearing a large, heavy cardboard box on one shoulder. Inside were 6 huge bunches of home grown bananas - and I really mean huge.

Now I really was speechless. The mother smiled, said thank you & promptly left.

I didn't know what to do with over 100 bananas but R had the perfect solution - give them to the staff. I resisted as I didn't think they deserved any bananas but as I had a massive box of bananas & I couldn't take them home they had to go somewhere, so this is what I did;

Bunch #1 - to L who without her excellent interpersonal skills & translations there would have been no bananas
Bunch #2 - to the head nurse
Bunch #3 & 4 - to be shared by the 3 deputy directors - its all about hierarchy.
Bunch #5 & 6 - to be shared by the staff on ICU medicine.

I said to the staff in ICU - do you remember the woman with meningitis that you refused to treat as you were too 'busy', then you refused to treat unless she paid for equipment, then it took you 5 hours to give her the medication she needed & you shouted at me a lot, well her Mother has given me some fruit to say thank you & as you were the ones who actually treated her & saved her life I am giving them to you.

According to R this was the perfect thing for me to say, as he explained later. He told me that probably all of the staff - some of them working 20 years or more - will never have received a thank you gift from any patient. They will be really 'jealous' (his words) that I had but by sharing the bananas with them I had continued to role model compassionate & fair behaviour. He was right of course, I was reinforcing their good behaviour & demonstrating that refusing to treat unless a patient pays is not the only route that you can be rewarded.

Kindness, as well as corruption, pays.

A 'normal' weekend

The shape of my weekends has changed in the last few months. I have begun to teach R's daughter - P - & his nephew - Sy - weekend afternoon when I am at home. This has then led to various R's family gatherings & making friends with R's wife - Sb.

This weekend in the 'Bong went something like this.

Saturday 7 am - khmer lesson with my lovely khmer teacher - S - these are now a daily occurrence as I desperately try to improve my khmer despite the lack of any apparent natural ability. Normally I would go swimming after the lesson but the pool was closed for cleaning this weekend & so instead I cleaned my house in preparation for my friends imminent visit. 

Lunch - with J at the veggie place by paramount bus station which for months only opened for breakfast but now has enough staff to open all day again - yay! Even though J & I have spent the whole week together working away we still manage find plenty to talk about - well J is a very good listener.

1 30 - 5 pm - P & Sy come to my house & attempts are made to learn english/khmer. P is 8 years old & has been learning english for 11 months - her english is much better than my khmer which she never hesitates to correct. Sy is 12 years old & his english is similar to P's but he has a longer concentration span. I have discovered some great on-line phonics teaching tools. I am not a language teacher & I don't pretend to be, but I can, for the time being, just about speak english & as they haven't learnt phonics I thought that this was something useful I could do with them both. They both prefer to play on my iPhone, watch TV, eat & drink and draw me pictures (P) / make me wooden objects (Sy). I really do enjoy their company.

Evening - this weekend's Saturday evening was out of the ordinary as S's son is visiting from France with five of his friends, so J & G organised a party at their house (which they rent from S). J & G provided the venue, music & a crate of beer, G made a variety of salads - of which the coleslaw went down least well with the Cambodians, S & her son brought fish & squid for the BBQ, the french friends brought beers & I brought a bottle of Gin & cans of tonic - which it would turn out was a grave mistake. Sb collected P & Sy from mine & with A (little sister of P - 2 years old) we all went to the party. Conversations in various degrees of english, khmer & french were had, there was delicious food, a lot of alcohol consumed, singing (Sb has a great voice), guitar playing (Sy is very musical hence G's name for him 'drummer boy') & dancing (mainly by me which for anyone who knows me will give you an indication of how much I had to drink). My normal bedtime is 10 pm - the Wat next door necessitates it if I am to get 6 hours sleep. I got in this Saturday at 1 am.

Sunday 7 am - Khmer lesson with S - anticipating the state I would be in she came bearing bread to dip in coffee. Despite paracetamol & Royal D I was seriously flagging but S isn't a quitter so we got through 3 pages of my grade 2 khmer book. I'm not sure how effective my adult learning was though. 

At 8 30 am when S left  I retreated to my sofa to nurse the mother of all hangovers - I must have been their for 30 seconds before "Esther!" was called through my screen door. Sb despite a hangover of her own was on time for our previously arranged khmer cooking lesson. P, A & Sy all settled down to watch TV & help themselves to the contents of my fridge whilst Sb took me to the market. On the first attempt at leaving the house I remembered my crash helmet but forgot my shoes. I really wasn't feeling myself.

I should go to the market more often with Sb - I always suspected that as a barang I pay double for food but this weekend I learnt it was nearer to triple. I have to say that watching the fish we later ate make an attempt to escape from its bowl onto the floor, be recaptured, get pithed, gutted & de-scaled wasn't the best cure for my hangover. 

From 9 - 11 am the khmer cooking master class was conducted. I was ashamed at my inability to skin unknown vegetables, my lack of essential ingredients in my cupboard & the dirtiness of my kitchen (and that was after me cleaning the day before). Sb has no english but reassured me in khmer that I worked so couldn't possibly be expected to clean, know how to peel mystery vegetables or cook for myself. I pointed out to her that she also worked (looking after her daughters, husband & home) - all without running water, modern appliances or until very recently electricity. Sb told me even R (her husband) knows how to cook & reassured me that I would learn quickly - my complete lack of any essential Cambodian domestic skills did not phase her. Have I mentioned recently the kindness of Cambodians?

G & J came around for lunch - G stayed most of the afternoon on the hammock on my veranda nursing his own bigger hangover. J was wearing dark glasses & I think she would have opted for a Thai floor cushions but she had a lesson at 2 pm with S.

From 1 30 - 5 pm I appreciated those on-line teaching tools. 

From 5 - 7 pm it rained very hard, hence no moto pick up as normal. P & Sy depleted my iPhone of battery power & moved on to watching olympic diving & inappropriately violent films. I think we have established I would make a terrible wife & mother - even my credentials as a doctor are currently in question. R arrived just as P was flagging & told me she was hungry - perfect timing.

So however much I may struggle with my work at the hospital, weekends like this one are the reason I don't ever want to leave here.

But I think it will be an early night for me tonight......

A portrait of me - apparently!

Sy made this wooden cigarette box

Step one of the fish soup - fry the fish. It was at this point that Sb realised I didn't even own an apron & probably why I don't have a husband. Ever resourceful she turned her cardigan inside out & wore it back to front.

Soup - water, a mixture of aromatic herbs& something that looks suspiciously like ginger but was reassured wasn't, the cut veg, some fried garlic, fish sauce & the fried fish - boil until delicious 

One of the reasons I don't tend to cook with meat here. Sb was very proficient with a cleaver & laughed when I told her I wouldn't want to make her angry.

A starting early with reading - these are khmer books for grade one, according to A the book is about G buying her a bicycle & J taking her swimming

The week before & the week after

The week before I demonstrated how not to capacity build the ICU medicine staff I actually had quite a good week. There were moments when I even felt that the staff were listening to me & altering the management of patients as a result.

Two good examples of this were on the Paediatric & ICU medicine wards respectively.

There is currently in Cambodia a Dengue epidemic & the Paediatric ward is bursting to the seams with Dengue patients - easy to identify due to the big blocks of ice on their abdomens & the characteristic look in their eyes - its the look of a child with a very bad headache & high fever. Whilst walking around the ward one day L was stopped by a concerned Mother (I may have mentioned before that having a female VA - volunteers assistant - has opened up a whole new world to me). The mother was concerned because although her son had Dengue, he also had a lump on his neck for the last month. She had asked the staff on the ward about it, who had told her that her son was in for Dengue fever & that was all they would treat him for. L called me back to talk with the mother. I asked her what she was worried about. She told me that her father, who she lived with, had been treated for TB recently & had just stopped his 6 month treatment - she was worried that her son had TB also, I thought this was a reasonable concern to have. I explained to her that the staff at the hospital didn't listen to me much either but I would try to ask them to refer her son for TB testing. I explained to her that if I wasn't successful the best thing to do would be to go to her health centre when her son was discharged, as TB was generally managed in the community here so the staff there would have training & be able to help her.

I went in search of the head of service - Dr CP - one of the paediatric all stars. He was having coffee at the hospital canteen, previously doctors left the hospital for coffee but now you know where you can go to find them - its progress of sorts. He was sat with one of the URC doctors & invited me to join them. I asked "what would you do if a child had a 1 month history of an enlarged lymph node & a close TB contact?" - he knows me well so his response was "which room is the patient in?" To which I responded "I am just talking generally!" He laughed & asked "Generally which room is the patient in?!"

We went over to see the patient together. The mother surprised me by being quite assertive when Dr CP asked her what the problem was - her response "I've already told 3 of your staff & they have ignored me". Dr CP was quite taken back - here in Cambodian patients & relatives don't speak to doctors like that. He then went on to show me the notes & the absence of his hand writing in them - "I have never seen this patient!" he exclaimed "If I had I would have organised TB testing". I laughed (in a saving face kind of way) "I know" I reassured, "and that is why I asked you as I know you will do the right thing. Perhaps now you, as head of service, need to tell the rest of the staff to behave in the same way?"

And the following week, after my first run in with ICU medicine, Dr CP with Dr M are the people who comfort me with coffee & kind words - this is why they are the paediatric all stars.

The other case from the week before was a case of Tetanus on ICU medicine. I have learnt about tetanus, I have seen videos of the spasms but I have never seen a case before. I found it hard to control the nerdy medic in me who just wanted to take videos & was very excited despite the suffering of the poor man. He was 29 years old, so when he was a baby & his immunisations for tetanus were due there was a little civil war going on in Cambodia along the border with Thailand which was the Khmer Rouge strong hold against the occupying Vietnamese & hence despite any history of a particular wound, he had developed fever & the classical symptoms of tetanus. He had been correctly diagnosed - although Dr O told me it wasn't that common in Cambodia either any more these days - and had been started on the correct antibiotics, was on a diazepam infusion (of sorts) & had been put in a separate quiet room with the shutters drawn -  stimulus such as noise or light can exacerbate the spams. However despite being in for over 24 hours & having 'lock jaw' so being unable to swallow he had no IV fluids prescribed. I explained to the staff he needed IV fluids also & was told that he was on an IV already  - I tried to explain that 5% glucose with 60mg of diazepam given over a 24 hour period was not IV fluids but sedation. I left thinking my message was clear but the next day when I went to check on him he still had no IV fluids up. This time I went straight to the boss, Dr L, who I was expecting the same old resistance & the usual hostility from (x-ref any medical blog involving ICU medicine) but the conversation went something like this.

Me: Dr L, I wonder if I could discuss the management of the man with Tetanus?

Dr L: Yes - what is it?

Me: I am very interested to see him as I have never seen a case of tetanus before. His medical management has been excellent, he looks like he will survive but I wonder if he might benefit from IV fluids as well - Normal saline or Ringers Lactate - as he can not swallow & the 5% dextrose used for the sedation infusion is not enough?

Dr L: Yes of course.

Me: He will need another cannula & at least 2 litres a day.

Dr L: Yes, I know, I will do that.

And the strangest thing happened, when I went back that afternoon he had!

The patient survived & went home after an uneventful recovery. Maybe this is why the following week in ICU hit me so hard - my expectations had been raised.

This week - the week after - the MoH have visited whilst I have been away, they were on an infection control (IC) inspection. When they went to ICU medicine it was scored a zero, when they tried to tell the staff about their incorrect IC practice the staff were hostile & verbally abusive. For some reason it makes me very happy that they are now in the dog house & in serious trouble, despite the fact that improving IC is part of my role here. But the MoH staff got a taste of what I get on a daily basis & they are high status, Cambodian males - so this means I can take last week less personally.

I went to ICU today & apologized to Dr V for being rude & inappropriate last week, I explained I was upset because I cared about the outcome of the patient. I knew it was wrong & I knew it was unCambodian. He accepted my apology, listened to my advice about doing an ECG on a patient who had been in for 3 days already with chest pain & shortness of breath. He listened to me whilst I went through the ECG with him (fast atrial fibrillation with ischaemia, secondary to pneumonia probably, that he then independently requested a CXR to confirm). He requested a full blood count when I begged him to, instead of the usual white blood cell count & then he meekly explained he couldn't stop the Digoxin on the pre-eclamptic women (yes, I know - why was she not in maternity & what the hell was she on Digoxin for when she had a sinus tachycardia due to sepsis & having an haemoglobin of 4?!!) because his boss started it so as he is junior/lower status, he couldn't change it.

Nurse P is not talking to me, but as she was the member of staff that was abusive & rude to MoH officials, I think perhaps she has been spoken to about her attitude.

And the woman with meningitis - she made a full recovery & went home this Thursday. Her mother told my VA to pass on her thanks to me, for all my help. That alone makes that week, the one in the middle of the week before & the week after, worth it.

It's all in a splint

IV cannulas in children often need a splint especially if over a joint, to prevent the plastic tube kinking & obstructing flow of IV fluids & drugs. They also help secure the line in place as especially when children feel better they can be more mobile & pull out their IV.

In the UK we use single use plastic splints with padding - here in Cambodia this is not an option so the health workers have to get resourceful & use their imagination.

There are many differences between the two hospitals I work in. One is a CPA 3 referral hospital (has many specialities & is the highest level of referral - one in nearly every province), 260 beds, 38 doctors & is one of the largest provincial hospital in Cambodia.

The other is a CPA 2 (can do c-sections & some surgery but they have no specialities available),  it only has 5 Medical assistants & one doctor, 50 beds,  is on the Thai border & is an ex-khmer Rouge hospital.

One due to its size & level of under the table payments has a reasonable amount of cash flow. The other is small & resource poor, relative to other facilities in Cambodia.

Above are examples of splints from these two hospitals in  Cambodia - both children are toddlers with Dengue haemorrhagic fever. The second example is clearly the superior splint - fashioned from cardboard & tape. I wonder if you can guess which is from which hospital?

Its only a splint but sometimes a splint can say a thousand words.......

The gift that keeps on giving.....

On Christmas eve my camera was taken by a moto driver when it fell out of my bag & with it all the photos from the epic PTC course & my sister's family visit. It was a little annoying but clearly not the end of the world.

When I went back to the UK the following month for my Grandmother's funeral my Parents bought me a new camera for my birthday (the third since coming to Cambodia) & like VAs I wonder how long this one will last. 

But because I am blessed with good friends & family - my oldest friend's husband (by this I mean the friend I have known longer than any other - she's not that old!), after reading my blog about having my camera stolen, looked out the first digital camera he ever bought to give it to me. I already had my early birthday present by this time so explained I no longer needed it. But he insisted that he no longer needed it either & perhaps I could find a better use for it than sitting in his garage - the resting place of many of his discarded gadgets. 

Simon is definitely an early adopter - always at the front of the curve for purchasing new technology. The camera has less mega-pixels than my current telephone but in its day, if know Simon as well as I think I do, I'm pretty sure it would have been top of the range & state of the art. 

So I packed it along with another 20kgs worth of presents I had acquired & took it back to Cambodia. I mentioned to G - husband of WWJD? & photographer - that I had a second camera & he could think of exactly what would be a better use for it.

He volunteers once a week with a school for children affected by HIV, teaching then photography with three of his SLR cameras & he thought that an extra camera would be great to give the children more opportunity to practice, learn & take more photos.

Below are some of G's photos of the children using the camera & some of the photos taken by the children using the camera.

I'm sure you all have things packed away in garages & lofts which you don't use or need anymore. These things instead of gathering dust could be making a difference to other peoples lives.

Thank you Simon & Kirsa - you gave the perfect gift, 'the gift that keeps on giving'.........

How not to capacity build....

This week on ICU medicine there was a woman in her 20's with a high fever. Her mother asked me if I could help - this happens a lot more now that I have a female VA - L. I think that the female relatives, who do the main care giving for patients here, feel more comfortable asking L for help than they did with my 3 previous male VAs. This is good but as it turned out can also be bad, or more specifically it makes me bad. When a mother is in tears begging me to help her it makes it very difficult for me to remain detached & professional in the face of laziness, negligence & corruption.

The first time I was asked to help her I noticed that despite coming from a malaria area she hadn't had a malaria test so I 'advised' to the doctor she might need one. She had been on a combination of antibiotics for 4 days which should have covered most bacterial illnesses so we needed to exclude malaria.

The following day when I went back she was still febrile & no better and her malaria screen was negative. The mother was in tears because none of the staff were bothering with her daughter whose condition was getting worse & she was beside herself with worry. I went to speak with Dr V - the doctor on duty. I 'advised' that perhaps she needed a change in antibiotics - she had symptoms consistent with meningitis so a LP (lumbar puncture) was clinically indicated. On admission she had not had a full blood count (FBC) or blood culture & was given IV glucose as an IV fluid. These are some of my pet hates, as they are common errors that despite discussion & training ad nauseum & in the face of reason the doctors still stubbornly refuse to change. 

When I questioned Dr V about these management decisions I couldn't hide the irritation or frustration in my voice - this is not how one should capacity build but as I was soon to discover I was actually at breaking point. He defensively told me that you didn't need a FBC in all patients, apparently a fever of 40˚C, a pulse of 100/min, a respiratory rate of 22/min and a BP of 90/40 didn't warrant this (wrong). Secondly blood cultures are not to be done immediately but only after a patient has been on antibiotics for at least a week (wrong) & finally IV glucose IS an IV fluid which can be used for resuscitation especially when you have run out of Normal Saline (wrong & they had plenty of Normal saline in the ward's emergency drug stock).

So what about changing the IV antibiotics? I asked - already done by Dr L, I was told by Dr V (a lie - when I went to check later Dr V added the new Antibiotic prescription after his conversation with me). But we could agree that an LP was indicated in a patient with a fever, headache, neck pain, vomiting & photophobia.

I suspected that perhaps the reason it hadn't been done sooner was the doctors ability to do an LP is limited. So I offered to support him doing it if he thought that would be helpful, which he looked quite relieved about. I then asked when would it be done, at this point nurse P looked up & started shouting at me telling me how busy she was. I don't know whether it was 17 months of daily similar hostility towards me, the mother crying on my shoulder before, the unprovoked aggression (I had simply asked the doctor what time he planned to do the LP?), the fact she was lying (she had been sat for at least 30 minutes watching TV before she said she was "too busy" to help do an LP) or just the fact that the start of the rainy season meant the monks now wake me up at 4 am every morning - but for whatever reason I completely lost it - saw red - hit 9 on the VAS for anger.

That is just an excuse I told her, not a reason. She wasn't busy, just lazy, paper work & watching TV is not as important as patient care & her priority should be the patients. L would have preferred to have translated "I can see you are really busy but how can I help you?" but as I explained later I've tried that approach for the last year & a half almost & in my view it just reinforces their behaviour. I have had enough of witnessing & tolerating behaviour that quite literally kills people. Obviously telling nurse P, however politely, that she wasn't doing her job properly escalated the situation to yelling, pointing & abuse (the staff) and me leaving the ward before I said anything else that I regretted.

But then Dr V slipped out after me (despite being on duty) to go to his private clinic, leaving the patient's management unresolved & I really saw red. I re-traced my steps & intercepted him. I told him that because the staff were too lazy to do their job this patient would die & that just because she was poor it didn't mean she wasn't entitled to basic health care. I said that the actions of the staff resulted in patients dying. I did all of this whilst resisting the urge to grab him by the lapels & shake him - I was as I may have previously intimated VERY ANGRY.

I went to my office & cried for a bit - tears of anger & frustration not sadness.

I went back to the ward to speak with the mother. She was clutching a piece of paper with a list of equipment required to do an LP given to her by the staff - she had a poor card so the health equity fund pay for the care but the staff had told her that if she didn't buy this equipment they would not treat her daughter. I didn't think I could have got any angrier but I was wrong. I went back to the staff & asked them what this meant. The chief of ward said he didn't have the stock & neither did pharmacy. I explained I would address this as it was morally wrong to refuse treatment on account of patients not having funds & anyway the PFD (poor family development) fund should pay for this. He shrugged & said he didn't care. I resisted the urge to punch him. I asked calmly that if the LP was delayed then the new antibiotics should not be delayed & needed to be given as soon as possible. Please don't delay treatment I begged. Nurse P came up to me & shouted at me about how busy she was - spitting in my face in her rage - but at least she had gotten out of her chair for the first time that morning.

Pharmacy said they didn't have the equipment but the next day I discovered they did but were lying to me. The Deputy director in charge of the technical committee & supplies refused to talk to me. The other deputy director listened to L tell the story of the morning's events & agreed that staff had no right to refuse treatment & make poor patients pay for equipment that the hospital should provide. The staff should have advised the mother to go to PFD to get money to buy the equipment but in fact they wanted the money themselves. It was just another case of good old fashioned corruption. The deputy director knew this was a delicate situation so he told me not to go back to the ward & he would sort it out i.e nothing would change & patients will continue to die if they can't afford bribes.

I went to have a coffee with L - apologizing for all my high expressed emotion. In Cambodia people keep a lid on their emotions & I knew that my anger & upset was making L feel intensely uncomfortable. The Paediatric all stars were also having coffee they took one look at me & knew I needed cheering. They told me that I should work more with them & their opinion of the ICU medicine staff was similar to mine. Dr M showed me a book that he got for his daughter from the library that was in both english & khmer - I read in khmer which he tried not to be impressed by. 

Despite the deputy director telling me not to go back to the ward there was the small matter of a patient who was seriously ill & required the correct treatment. L agreed we needed to go back if only to explain to the mother that the staff couldn't demand extra payments. We did this & then I noticed that after 2 & half hours the patient still hadn't received her antibiotics. 

Poor L followed me back into the staff room. I had regained my composure, the staff were all sat watching TV. I sat down with them & asked "If you had suspected meningitis how quickly would you like your antibiotics given?" Nurse P lost it with me - I calmly sat saying - just a question! She walked out. I asked the doctors (Dr V & a newly qualified Dr who is volunteering until he gets a permanent job) what they were taught at medical school about how quickly antibiotics should be administered. They both said as soon as possible but it wasn't their problem and then they too walked off.

L & I sat there until every other member of staff had left for lunch & it was just us & Nurse S - a very quiet & good nurse. He asked me "what is it you want me to do for the patient?" - I love him for this question.

I explained that she needed the antibiotics that she had been prescribed ASAP. He explained that she had already had different antibiotics at 6 am that morning and so why ASAP? surely we should wait until the next dose is due? I explained that the old antibiotics weren't effective & we should disregard them when planning a time to give the new one which was better for suspected meningitis. He understood this explanation so went to the emergency drug cupboard to give them before he also left for lunch. He returned with two used vials of antibiotic in his hand - "ot mean".

Silently & repeatedly I banged my head on the table. The emergency drug cupboard should be re-stocked everyday but obviously the staff had been 'too busy' to do this, there was no antibiotic to give. 

On reflection & even at the time, I knew that I obviously handled this whole situation completely wrongly. That afternoon I had a meeting with other volunteers working in livelihoods & education. They told me it is the same for them in their placements. But to me it just doesn't feel like its really the same - no one dies in their day jobs as a result of their inability to change people minds & behaviours. I seem to be collecting a large cohort of patients that I feel personally responsible for failing to save & when my frustration spills over into my interactions with staff it causes even more problems for the patients as a result. 

J hasn't been here for a fortnight to ask WWJD? R (one of my favourite Cambodians - along with his family) was away when this happened but I text him about it after the event. His response was this "Oh no. How awful! How can I help? You know I too sometimes hate the staff, especially the staff who are rich and show off even they are f*****g lazy." And that's when I knew it wasn't all hopeless because although I am failing to improve health care in Cambodia, I have at least taught one Cambodian to swear like a docker & to use anglo-saxon grammatically correctly.

Engaging with the locals

Having sworn of all weddings last year, my life has turned into a string of nuptials and last weekend I experienced my first Cambodian engagement ceremony. It started early as I am living in the land of early starts, if not early attendances.

Pete, Edwin, Kim & myself presented to Neil's (future groom) Phnom Penh flat - his pseudo-brothers & sisters along with his real parents, where we all received a dowry offering to present to the Wattey's (future bride) family. The father of the groom & Neil carried the lychee-like fruit as they are a symbol of wealth. Pete & I carried apples, which was mildly disappointing as I had been hoping to replicate the Dirty Dancing classic line - "I carried a water melon" - alas it was not to be, they are too big for the basket & perhaps do don't represent any of the attributes required from a potential suitor here in Cambodia. Which to my knowledge seem to be three things, money, money & money!

Quite literally bearing fruit, we processed (after a short Taxi drive) to Whattey's waiting family where we all sat down in their living room for the ceremony. The Whattey family matriarch sat opposite us looking very hard to impress. Kim & I, as female foreigners, were allowed to cross our legs (in Cambodian society it is polite to sit with your legs to one side, soles of feet are highly offensive) but despite this, after an hour or more of engagement negotiation, I was still completely numb from the waist down. Meanwhile the Yay (grandmother) & Min (aunts) of the family all leapt up - agile & flexibility are in the Cambodian genes.

Chum Noon - a woman's worth measured in fresh produce

The ceremony itself was focused around the two sets of parents agreeing that their son & daughter were a good match. Birth date is important but luckily Whattey was born in the year of gold, in the month of silver & on the day of happiness. All Cambodian brides are born on this day apparently.

The parents drink tea & do something with a leaf & a fruit - I was lacking translation at this point - & then Neil is presented quietly sweating away in his silk traditional khmer jacket. Then Whattey was presented all demure & beautiful with not a bead of sweat on her. When she sat down infront of her parents her Mother was tugging at her sampot to cover a good half inch of still exposed ankle. She bowed deeply three times to both sets of parents - Neil was I think it is fair to say less elegant. They exchanged rings & then Neil tried to kiss Whattey who responded with every fibre of her being with this non-verbal message "NO! Not in front of my Yay & aunts you idiot!" This and the sampot tugging were my personal highlights of the ceremony.

Then followed a long lunch with beer, wine & whisky. Our table drank the wine & beer whilst 'the Uncles' sat on the table next to the 4 litre bottle of whisky (x2). The Uncles piled out of the house mid-afternoon (destination unknown), the women went to rest & change outfits whilst the barangs discussed anglo-irish relations rather than irish-cambodians relations.

The beer & wine drinking blended into more food & the Men of the family staggered back from destination unknown slightly worse for wear & requiring facilitation to walk. Then the music started & of course the dancing.

The dancing was lubricated by the Uncles drinking more whisky & the aunts playing a drinking game that required downing full glasses of wine. Neil's future mother-in-law came over to our table & filled his glass up to the rim & before he could thank her the mob of aunties were demanding he downed it in one. They then went around the table (three times) demanding we downed our drinks. We soon realised dancing was a safer option.

On the dance floor one of the Aunties showed me the steps to a complicated khmer modern dance which I obviously wasn't drunk enough to learn previously at the Hospital Khmer New Year Party this year. She held in her hand a glass of red wine with the paper from the bottle top stuck to its rim - when I asked her why she told me she had already had too much to drink so it was to stop people pouring her more. I have to be honest I don't think as a method it was very effective.

When the Uncles had finally had enough whisky & collapsed our taxis' were called. I think it is fair to say we had all put in a considerable effort to eat & drink & dance as much as possible & we were all extremely merry.

Kim dancing with the Father of the bride-to-be, whisky had been consumed

Mother of the bride-to-be - red wine had been consumed

Uncle of the bride-to-be - or the General as he is known

Aunt & Uncle of the bride-to-be with some intoxicated Barang

The happy engaged couple

The Fathers

Pete (pseudo-brother to Neil), Phillip (Father of Neil), Eleanor (Mother of Neil) & Kim (pseudo-sister to Neil)

Dowry - 'Cake', rice & pork wrapped in banana leaf

Yay - the boss & whose opinion really matters

Kim with Whattey's Big brother - he's 29 years old would you believe it?

Neil with his new in-law brother

Neil didn't want the evening to end so with a goodie bag of left over beers & a musical selection from Pete's iPad we found ourselves doing laps of Wat Phnom until finally giddy & replete went home to face our enormous hangovers the next day.

After the wedding I am booking into rehab......