TB training - another epic tale

When I offered to help out the NGO I work closely with to deliver some TB in children training for them, in the small hospital on the border I go to once a month, I really couldn't have foreseen the consequences. 

In this epic tale of TB in children training, I managed to offend several Cambodians, reveal negligence & lies, have a radical change in my teaching style, finally get around to installing unicode (khmer font reader) on my laptop and become a TB champion.

It all started at the monthly meeting, of the NGO I work closely with, three months ago when it was noted that the budget for TB training at a border hospital had to be used by the end of year 4 of the project. So far it had been cancelled 3 times because the doctor who should have done was too busy to leave his NGO hospital due to the Dengue epidemic. I innocently offered to help out - I am by no means a TB specialist but if I could do it would that be better than nothing? - error number one.

It was agreed at the PNH office I could do this. A couple of weeks of silence. I emailed PNH office asking if they could send me the training materials. The reply was they were in the drop box. In the drop box were 6 lectures all in khmer in a font my computer can not read. I tried to get them printed so I could read the english rendered unreadable by the unreadable & distorted khmer font on my laptop, but was told by the NGO co-ordinator of that hospital it wasn't in the budget - he was as helpful as ever. My VA spent 2 weeks translating them for me & we installed all fonts on my computer just in case but I still did not have 'limon', which is what the training material was typed in. When I could finally read the content I realized that there were some pretty fundamental areas missing e.g. treatment of TB so I sent another email asking for a lesson plan & agenda - not with the training material in dropbox. The lesson plan did not exist, the agenda included 8 further lectures I did not have. I emailed again & was told they were in the drop box - they weren't! I emailed again & finally got the 8 further lectures sent to me, all in khmer - limon font. My VA was busy for a further week. It became apparent to me that the lectures were very poor quality - no learning objectives, confusing slides with too much information on them, irritating animations, no summary slides and no accompanying lesson plan. I voiced my concerns to the PNH office & was told this was MoH material & it could not be changed. A week before I was due to give the training a member of staff from the NGO I was helping out my delivering this training sent me the MoH guidelines on TB in english, which was the reference material for all the teaching slides - better late than never hey!

I was regretting offering to help & then I received an email from the doctor whose job it was to teach the material in the first place, it was the weekend before the training and he was asking me to do some clinician assessments for him whilst I was there. I was put out as last time I checked I am not his skivvy - I would have wrote that in my email reply but I'm pretty sure he wouldn't have understood what I was saying. Instead I wrote a very polite email - J screened it - saying I wouldn't have time & that I was surprised to see on the work-plan that he was going to another small hospital (the week I was training TB) when the only reason I was doing this training was because I had been told he was too busy to leave his base hospital because of the Dengue epidemic. I thought that was slightly odd - my innocent query resulted in him taking great offense. In his response he told me, "I don't know why this activity of mine surprised you, and I went there it did not mean that I did not take responsibility in my job. Please reconsider before talking things that might hurt other's feeling...I asked you for help with that activity and if you could not, just say no, don't say that because I want to avoid my responsibility."

I responded that I hadn't meant offense, I was simply asking the question why was I doing the training when I am a volunteer, its not in my work plan or my scope of expertise, I am not khmer & can't read or deliver the training material effectively & it will take me three times as long to deliver - surely it would have been better if he now had time to do it? Nowhere in my email had I said he was shirking responsibility but I guess sometimes the truth hurts.

The day before the training R & I went through the treatment lecture - R noticed some errors in translation so contacted the PNH office who replied we had the wrong lecture. They sent the correct one - all in khmer & limon font - telling me it wasn't a problem as all the drugs were in english. It was a problem as the treatment regimens & explanations were all in khmer & completely different from the MoH document or my translated lecture. I pointed out to the PNH office that I am an idiot mono-linguist so this was a problem, I never received a reply to that email. I am guessing their silence was assent.

Day one of the training one MA turned up, waited 5 minutes, got a call from someone & left with the handout. No one else came, it rained heavily, the room leaked - this wasn't a failure, it was just meeting our low expectations about the training.

Day two after a telling off from the director 20 nurses & 2 MAs attended the training, we only had 5 hours to cover a 3 day programme - the pre & post test went out the window - the training was designed for doctors I tried to modify the material for a mainly nurse & MA audience. The pre & post test was confusing & covering material I had chosen not to cover in detail as it was too complexed. 

I concentrated on training about diagnosing TB - the importance of history including contact of TB in EVERY patient. The symptoms (general signs are night sweats, weight loss or failure to thrive, fever, low energy, etc.) & physical signs of TB, how to diagnose & get samples for investigation and confirmation. This took me all morning. At one point they were talking among themselves & answering their phones, this is when I completely lost it - I told them if they weren't going to listen to me then I was just wasting my time & should leave, I explained I wasn't doing this for me, it was so that they could recognize & treat more children with TB, I asked if they didn't care about children & doing a better job they could just leave now, as I wasn't interested in wasting my time or theirs - they shut up.

As we were leaving for lunch one of the MAs brought her sister in law to the hospital for me to see. She had a 5 year history of right knee pain & intermittent swelling, haemorrhoids and maybe some kind of ovary or hip problem - translation was less than clear. Her question was - was this TB? So although they will continue to neglect their poor patients, at least they will have an unnecessary & needless high index of suspicion of TB in their relatives. That's Cambodia for you.

In the afternoon they all joked that they were in trouble with the teacher that morning, they were taking the piss out of me but they still shut up when I opened my mouth. This is not my normal teaching style but I could get used to it. R went through treatment, surveillance & prevention of TB - this was a lot quicker as translation from english to khmer does add a significantly long time to any training. This meant we also had time to go over pulmonary TB but not to go over the 7 individual lectures on extra pulmonary TB or to do the test.

At the end I asked them what were the keys points to make a diagnosis - silence. What in the history is suggestive of the general symptoms of TB? Their answer - an enlarged lymph node in the neck - I knew then that I had been unsuccessful in training them on TB!

They then kindly confirmed this by mismanaging a patient on the medical ward despite training that week & me having conversations with 3 different MAs and the head nurse about him. The patient in question was a 56 year old man with a 6 month history of fever, night sweats, weight loss, cough, chest pain & haemoptysis. One MA had asked me to examine him - role modeling as always I took a full history first, which is the only reason I knew the history above as well as the history of a TB contact, none of this appeared in his medical notes. I listened to his chest & he had bronchial breathing at his right apex. The MA had written in the notes that his chest was clear. I managed to convince her to go back to listen again - she wasn't convinced I was right but as I always use the cheap, crappy stethoscopes in MoH hospitals rather than my Littman, they can't accuse me of having superior equipment which can hear things they can't. The following day when he had his chest X-ray (below), I spoke with her & another MA that with the history & now X-ray changes (a right upper lobe opacity with right upper lobe collapse) we needed to exclude TB. He would need to provide 3 sputum samples which should be sent to look for the characteristic acid fast bacilli of TB. I used his case as an example for the TB training, then I told the MA on medicine ward that he needed sputum samples sent just to make sure my advice was clear & consistent.

By the end of the week & after the TB training, where the whole algorithm of management for pulmonary TB was reiterated, they had still failed to take any sputum samples. On the Friday before leaving I sat with him & explained that we needed sputum samples & we needed to exclude TB which may take some time. He hadn't been asked for sputum samples & was keen to self discharge as nothing was happening at the hospital - it really wasn't. I spoke with the head nurse & explained that rather than letting the patient go home on amoxicillin as he was planning - there were no doctors in the hospital for 48 hours - it would be better to get the 3 sputum samples as I had already suggested to 3 separate MAs previously. I left convinced he would never receive the investigations or the treatment he needed & deserves.

Right upper lobe consolidation & collapseospital has also had this TB training and also there seems to be a completely lack of retention of information or change of behaviour in the management of suspected TB.

The Hospital I mainly work at also had these TB training delivered by an NGO. Below is an ECHO of a women that presented to ICU medicine in "heart failure" - she was started on frusemide & had an ECG with some abnormal T waves, I was just shocked it had been done. Me & a fellow from a US university - B - who was visiting for a fortnight, convinced ICU to get a chest X-ray. It showed a enlarged cardiac shadow but there was no sign of pulmonary oedema. B was keen to use the ultrasound machine in OPD to do an ECHO. I have suggested this on many occasions previously but it has only when B asked that it occurred to me the reason that they have always refused is to do with conflicting interests, the private ECHO clinic would lose out on money - ECHO is not available at the government hospital. 

Dr ON, who will be head of the the Emergency room if it ever opens, already does some ultrasound in OPD and also had been to Singapore the week before on an USS course and had arranged for them to come to BTB and donate equipment. B persuaded him to let him use the OPD USS to do an ECHO, we both convinced him that it's an important skill for him to learn - he bought this.

The USS machine in OPD gives surprisingly clear images & Dr ON picked up the technique of doing ECHO views quickly. What the ECHO showed was that there was a large pericardial effusion with right heart strain & after a week of frusemide she was intravascularly depleted. I asked her if she had a TB contact. Her son was being treated for lymph node TB. Children aren't usually infectious especially if they have lymph node TB but if they have TB then one of their care givers will have TB. Every child with TB should therefore have the source of their infection traced - this had not happened with her son. There was a 99% chance that her pericardial effusion & impending cardiac tamponade was due to TB. 

Dr ON & the ICU doctors wanted us to do a pericardiocentesis (drain the excess fluid from the sac around the heart), luckily B repeated my earlier explanation (from a similar case 6 months ago) that as emergency physicians we were happy to do this procedure if the patient was about to die with tamponade, but not if she is stable because the risks of the procedure far out way the benefits. We explained that if she was started on TB drugs the effusion would improve but by just draining the effusion it would just come back without TB treatment. We also explained the frusemide would kill her & it should be stopped, what she actually needed was fluids NOT diuretics.

A week later she was still on frusemide & had not been commenced on TB treatment, so we attempted again to explain to the ICU doctors what her diagnosis was. Obviously it wasn't their fault but they told us we should speak to the TB ward ourselves. We did, the doctor there agreed that the patient needed TB treatment & prescribed it. We tried to explain to ICU medicine that she would also need steroids & an HIV test. Last time I checked this hadn't happened. I suppose I should just be thankful that after a week she was finally started on TB medication & hope that her effusion doesn't get worse before it gets better.

Finally there is the case of negligence & lies. A 10 year old girl from the border came in with a 5 day history of fever, headache & left hemiplegia. She had been started on IV antibiotics for meningitis by the CPA 1 hospital but the MA on duty thought it was Dengue. I tried to explain to her that she should be investigating for meningitis & malaria but my advice, as usual, fell on deaf ears - she stopped the antibiotics. The following morning one of the paediatric all stars had spotted the gross mismanagement of the now comatosed child & done the necessary tests including attempting to do an LP. Admittedly I would have been more cautious about doing an LP on a unconscious child with localizing signs but I think we have established by now I am a crap doctor that no one respects or listens to.

However when the doctor & nurse both failed to successfully obtain CSF from an LP I helped much to the amazement of the hospital staff who I am sure don't even realize that I am a doctor. I got two tubes of clear coulourless CSF with a green needle & non-sterile gloves. Dr M had also referred the child to the TB ward where, without even seeing the patient, the TB doctor had prescribed TB medications. This meant that a CSF sample for microscopy & culture was even more important as otherwise how would we ever know if the child needed just 2 weeks of antibiotic or 6 months of TB treatment. The paediatric staff seemed less concerned about this diagnostic & management conundrum. 

At the end of the day I went to check what the LP result was - I saw one of the lab staff writing the form so I left reassured it was all in hand. I am an idiot.

The next day the result was surprising. The White cells were low, the protein was normal & the glucose high. It wasn't really consistent with the clinical picture, so I went in search of some answers. The patient was still comatosed. 

Fortunately WHO lab staff were visiting the micro lab when I went to check how the culture was going. What culture? I was asked - they had never received the sample. But it has had a gram stain, I had seen the report. I was told that it was not possible to do a gram stain without a sample being sent to the mirco lab, there was no record or evidence of this so it must have been done in a private clinic. I was able to disabuse them of this theory by revealing I had seen a member of staff from the main lab effectively making up the gram stain result. I'm not sure if this was due to ignorance or laziness but I know that the outcome is negligence. I checked with the TB lab, they didn't have a sample either - they had never received it - so the TB staining negative result was a fallacy also. The samples had now been discarded.

I was angry. The paediatric doctors were amused. Everyone knows you can't trust results coming from the lab, you always just treat based on clinical findings. But they are liars & negligent! I exclaimed whilst ranting to Dr CP (head paediatrican) about the case. In khmer he told me I should talk quietly about these things. 'Its wrong' I tell him '& when something is wrong I will say it loudly & clearly'. He laughed - I am not sure which kind of khmer laugh it is, probably annoyance.

The 10 year old girl is getting better, she is obeying commands & is getting movement back in her left arm & leg. We will however never know whether she has TB or just a normal bacterial meningoencephalitis. She will be on the full course of TB medications & is still getting her Ceftriazone for another week.WHO will bring up the fraudulent CSF result with the head of lab & hospital director.

I am just grateful she didn't cone when I helped do her LP. 

Cutting for Stone

When I was a medical student I did an elective in South Africa - in a small mission hospital on the Mozambique border. I met many inspirational people there, including a nurse who lived in a converted ablution block in the grounds of the hospital, walked the 6 km to her township clinic after a early morning swim in the hospital reservoir & was kind to a bewildered english medical student. She introduced me to Cat Stevens, Johnny Clegg & long distance study. She was re-reading Illusions by Richard Bach and pencilled in the margins of her well thumbed copy were notes from many previous readings of the same book at different stages of her life & nursing career. Each time she would find new paragraphs that related to her current situation. I loved the idea of recording how you felt by highlighting what resonated at any particular time & place in your life.

When the previous VSO health programme manager left Cambodia in May she gave me a book of hers, with a hand written inscription on the inside cover - ensuring me that I would find some way to use my medical skills again (maybe just not in Cambodia!). The book was Cutting for Stone by Abraham Verghese and it was a perfect parting gift from her. It resonated with me like a bell and from chapter one I began to make a note of certain sentences that I related to or touched me, sometimes inexplicably. Certain chapters had be sobbing - I really loved reading this book, it has distracted & comforted me this month.

Below is a selection of some of these quotes, piece them together & you may get a better picture of my current mental state - in this particular time and place...

"Life is like that, you live it forward & understand it backward."

"In the hierarchy of her emotions, anger was always trumps."

"Ignorance was just as dynamic as knowledge, and it grew in the same proportion."

"When we cannot cure or save a life, our patients at least feel cared for. It should be a basic human right."

"She had nothing to put on the table but the truth."

"Departure or imminent death will force you to define your true tastes."

"Tizitash zeweter wide ene eye metah - I can't help thinking about you."

"The past recedes from the traveller."

"You had to exert yourself to see this world. But if you did, if you had that kind of curiosity, if you had an innate interest in the welfare of your fellow human beings, and if you went through that door, a strange thing happened; you left your petty troubles on the threshold. It could be addictive."

"A childhood at missing imparted lessons on resilience, about fortitude, and about the fragility of life."

"He had so many ways of climbing into the tree house in his head, escaping the madness below. And pulling the ladder up behind him; I was envious."

"Not only our actions, but also our omissions, become our destiny."

"Without Genet as a witness, nothing I did was meaningful."

"Life is full of signs, the trick is to know how to read them."

"Travel expands the mind and loosens the bowels."

"But you reach a point where after trying and trying you say, patience be damned. Let then suffer their distorted worldview. Your job is to preserve yourself, not to descend into their hole. It's a relief when you arrive at this place, the point of absurdity, because then you are free, you know you owe them nothing."

"I don't think you can be a physician and not see yourself in your patients illness."

"The mind was fragile, fickle but the human body resilient."

"The immersion of blood, pus, and tears - the fluids in which one dissolved all traces of self."

"The mood in the room went from the joy of reunion to profound sadness, as if those two emotions were invariably linked."

"I had nothing more to give, and nothing to fear."

A wish & a prayer

Sometimes someone else's blog just has to be plagiarized, so here it is from http://stuffexpataidworkerslike.com/

The Expat aid worker's prayer

"submitted by Molly (who blogs at Molly In Monrovia) and Alex

Dear Lord,

Today, aid me in my otherwise mundane tasks, that they shall not
result in gangrene or identity theft.

By Your grace, cancel the flight of our donor, so that I might have 24
more hours to shiny up our anecdotal success stories with pictures of
children

May the M&E consultant be amenable to case studies, or at least
receptive to my sexual advances

May the Internet, like Your mercy, flow abundantly, so that I might
watch that new Rihanna video on Youtube.

Please Lord, give me the serenity to accept the dangers of salads
the courage to eat the unidentifiable bits of meat
and the wisdom to know the difference between the proper course of
self-medication for the results of each

Fill me with Your glorious knowledge of the nationality of the person
that I am greeting, and how many cheek kisses are required; because
otherwise, Lord, it is always kind of awkward.

Grant me the patience to sit through yet another tale of Central Asia
in the early ‘90s, that lo this elderly consultant may one day, acting
in Your name, offer me a job, for only You know when the funding for my
current position may dry up

Lord, may the DJ always play Toto, for I am drunk, and THAT IS MY JAM

Forgive me for saying I was “working from home” the morning after karaoke,
as I forgive the still unsubmitted financial reports of our local partners.

And in Thy wisdom, let today be a public holiday in honor of a former
dictator’s birthday

But failing that, may I not receive too many marriage proposals on my
walk to work, for it shall make me indignant (…but just a couple would
not hurt).

And lead us not into open sewer pits, but deliver us to air
conditioned offices in white land rovers.

AMEN"

Golden Anniversary

Today is my parents 50th wedding anniversary. I find myself 7000 miles away from all my family on this day, volunteering as a medical advisor in Cambodia. I'm here because my parents have always supported & encouraged me. There is a sad irony that the unconditional love of the people closest to me has resulted in me being half a world away from them on their special day.

When I was a child & my Grandfather had a stroke, I was more fascinated by the other patients on his ward - with their various tubes, scars & diseases - than visiting him. It was then that I decided that I wanted to be a doctor. My parents have never deviated from supporting me.

My Mother took me to her work in the summer holidays when I was 9 years old & paid me a wage so I could save to buy some roller skates, which unintentionally increased my exposure to medical services & my desire to be a doctor.

My Father would 'help' me with my maths & physics homework - I use the word 'help' here loosely and it should really read 'became increasingly exasperated & frustrated by my stupidity'.

They bought me a Gray's Anatomy text book during A'levels when they could see my resolve to be a doctor was weakening.

They both paid my way through medical school, my Mother staying on at her work & then immediately retiring the moment I graduated. So for the first 23 years of my life they put a roof over my head, fed & watered me & totally financially supported me. This meant that the money I earned from my various summer & weekend jobs (newspaper delivery, burger bar attendant, bakery assistant, nursing axillary), as well as my student loans & overdraft could be solely spent on beer, holidays, festivals & LPs!

They continue to financial support me - as my father likes to tell me, 'Fathers are nature's bankers"

My Father has always believed & reassured me that if things don't work out in medicine that I could be a Bakery manager.

My Mother has always believed in me & put curses on people who dare to upset me!

When I came back from working in Australia - financially broke - they boarded & lodged me for 6 months & tolerated my 30 year old tantrums & regression into a teenage state.

They recorded & watched every episode of Emergency Medics even though my Father is squeamish & can't stand the sight of blood.

My Father has tested my Diploma of Tropical Medicine knowledge on more than one occasion. Once I passed - tick bite fever. Once I was less successful - the flu was actually malaria and he ended up on CCU for a week.

My Mother has tested my surgical & trauma skills with her various falls (its the Pinner in her!) & a hernia.

They both test my mediation & conflict resolution skills regularly!

They are better letting agents than my real letting agents.

They are trouble shooters & problem solvers in all areas of my life.

Their house has provided me with free storage through out the years - the ceilings bow from all my possessions in their attic.

My Mother provides me with knitwear.

My Father provides me with wooden furniture.

They both provide me with a shoulder to cry on & a ear to listen but most importantly they always provide wine.

Since I left home they have provided long distance emotional support whether it be by phone, letter, email, text or skype.

My Father says 'a ton of sympathy is worth an ounce of help.'

My Mother is an extremely empathic, caring & sympathetic person!

They are the best travel companions a daughter could wish for - from long weekends in Exmoor during the madness of my finals, meeting me in Namibia after I'd been an expedition medic, visiting me when I was living & working in Australia, to staying in my wooden house next to the extremely noisy Pagoda here in Battambang - they are adventurous, warm, open, funny, generous, friendly to strangers & of course they always pay for me!

I wouldn't be here if it wasn't for them & I can't be there today because of them.

They have instilled me with a sense of justice, they have made me stubborn (more than strong) and as the old saying goes - they have given their child two things, "roots & wings".

So I am really sorry that I can't be there today but..........

Ann & Geoff Wilson - Happy Golden Wedding Anniversary!

......I'll see you in Burma. xxx

The skies of Sampov Lun

Once a month for a week I go to Sampov Lun - a small town on the border with Thailand. It only has a commercial border crossing, the road to it terrible, the only other barangs we ever see are missionaries & the hospital has its own special set of challenges but the scenery & skies are stunning.

Below are a small collection of the photos I have taken over the last 6 months from the guest house we stay in, the tuk-a-luc shop & the hospital.

I really love it there...

101 reasons not to do an ECG....

Although this patient's diagnosis was Cardiogenic shock & this was their ECG when they presented with chest pain & shortness of breath the patient continued to receive treatment for infective exacerbation of Asthma only, revealing the real reason why ECGs are rarely done.......

When I was a doctor (in the UK!) working in emergency medicine, I used to keep a mental note of all the reasons people presenting with a 'Boxer's fracture' (the clue is in the title) - strangely getting drunk, angry & punching someone was rarely the history offered.

Now that I am not a doctor, volunteering in Cambodia, I have another favourite pass-time, what is the reason for not doing an ECG?

So far on ICU medicine I have these reasons/excuses;

1) The patient was too sick

2) The patient was a 'hopeless case' so they didn't bother to do anything

3) The patient was too sweaty - they use suction for the leads & not stickers so this one is really quite ridiculous

4) The patient was too agitated - this is commonly used for patients that when I go to assess are either unconscious or sitting calmly

5) An ECG is not indicated - these are commonly patients with a) Tachy/brady cardia b) Chest pain c) Breathlessness d) Loss of consciousness

6) The patient had a nose bleed - my favourite excuse!

7) Nurses who can not do an ECG - instructions are on the machine/I have shown them how

8) Doctor can not do the ECG- instructions are on the machine/I have shown them how AND they are taught how to do them at medical school but forget because they never do them in practice

9) The ECG machine has no paper

10) The ECG machine has no ink

11) There was no electricity to do it/battery was flat - oddly the AC in the directors office always works even when there is a power cut

12) The staff were "too busy" to do one

13) I think my VA may have stubbled across the real reason ECGs are rarely done & if performed NEVER acted upon, Dr V took her to one side last week & explained to her "I don't know how to read an ECG"

“Growth begins when we begin to accept our weaknesses.” ~Jean Vanier

Common sense

Someone wise once said "There is nothing more uncommon than common sense". This particular phrase resonates with me more & more, as my stay in Cambodia lengthens.

There often appears to me to be an absence of common sense or perhaps better put an absence of any good sense. After trying to explain to my VA & R that when the staff on medical population ward record every patient's vital signs as the same, they are not even using their 'common sense' (as well as lying & being lazy) because not every one can possibly have exactly the same observations all the time. R & my VA looked blankly at me at the use of the phrase 'common sense', so I showed them the translation from my iPhone khmer dictionary App, they both responded with "We don't use that word in Khmer!'

And I wonder why.....?

Below are a few examples from my experience & also those of fellow NGO workers in health;

Whilst reviewing & editing the nursing protocols J read this extract out to me "Thermometer could stimulate the vagus nerve in the rectum & cause cardiac arrhythmia". There we were thinking the vagus nerve is a cranial nerve. The same set of nursing protocols also instructs that a 3 ml syringe measuring 6 cm in length needs to be inserted 12.5 cm into the rectum. Leading J & I to wonder if this was a veterinary nursing protocol we were reading. Although, the endemic lack of common sense is accommodated for in the previous paragraph of the same rectal medication protocol with this instruction "remove needle from syringe before inserting in anus."

After introducing a sepsis protocol to a group of surgeons, which clearly stated the normal parameters of temperature, pulse, blood pressure & respiratory rate, the deviation from which with infection indicates sepsis, a doctor then asked me this question "How do you know that a patient is getting better & has recovered?" My VA chose not to translate this for me at the time but handled the question herself. She is a 21 year english literature student, with a more than average quota of good sense.

L has a lot of examples of common sense failure in her work place - most of the photos below are hers. She was delivering CPR training in a health centre & asked the staff how long they would feel for a pulse in a collapsed patient. The directors response "5 minutes" - any hope that this was a confusion was down to translation error was destroyed when a nurse then asked, "When we get a return of circulation, can we send them home?"

Another time, L's ER was transferring a patient from her hospital to the provincial hospital, before the ambulance left she noticed that the oxygen cylinder gauge was on red (nearly empty), she pointed this out to the ambulance driver & staff going on the transfer, who told her that there was still oxygen in the cylinder & refused to change it. They ran out of oxygen on route & the patient died. Actually this story may be less about common sense & more about straight forward negligence.

Where the builders at L's hospital thought it would be the best place to put a pile of bricks - the entrance to the emergency room

So then L goes out to discover the sand & gravel for the building work has been put in an even better place - obstructing the entrance to the entire hospital.

During recent triage training a well looking patient presented to OPD with a sore throat. She was confidently triaged as a 'red' until I rechecked her Sats (recorded as 86%) only to  point out that they were reading the machine upside down

Also at my L's  hospital - the material thought best to use for privacy & dignity of all patients

My hotel room in SLN - the shower holder wouldn't hold the shower head until I realised that was because someone had screwed the holder up side down -

The three questions that I always ask myself now when faced with another episode of common sense failure are as follows;

1) Does it really matter? Usually no as long as its not work related.

2) Is anyone dead? Unfortunately, not always no.

3) Has anyone gone insane? I'm getting there!

When you're a stranger, people look strange......

This Friday when I went to my Khmer teacher's house (Do you remember anything I teach you? she implored of me today - other people's disappointment really can sting) she was full of tales of a magical bed with an engine that cures all ails. Despite our colourful combination of pigeon english, khmer & charades I couldn't really understand what she was talking about, exasperated - a common emotion she has with me - she ordered me to bring a sheet to my lesson with her on Saturday morning & she would show me at 11 am - it is free even for Barangs she reassured me.

The following morning I dutifully turned up with a sheet & my khmer grade 2 text book. After my lesson where yet again I demonstrated that after a year I still can't read khmer, we went on a little walk to a local private clinic.

At the door was a man giving out laminated cards with numbers on them. My teacher & her neighbour, who was joining us on this explanatory journey, insisted on having cards 1, 2 & 3 which was odd as given that this is Cambodia & the order of numbers doesn't denote anything & certainly wouldn't guarantee that we would be secured a place on a magic bed first, second & third. It seems strange that I've lived here only 18 months & I know this, yet Sy has been here 60 years & still believes a Deli counter like numbered ticket system will work here. This was not the strangest thing to happen that morning however.

So in we go to a room that is packed with 50 people or more - at the front is a Japanese man & a khmer translator. What is he saying? I ask S as we sit down on the little plastic stools so ubiquitous here in Asia & for which I live in fear I will break if I sit on. Listen - she snapped - he is speaking in English. I was pretty sure it was Japanese but I've learnt a long time ago not to argue with her. 

By now I am attracting attention from the 50 plus Cambodians sat listening to the Japanese man preaching the magical properties & virtues of the electric bed, as well as the 30 Cambodians strapped to the magical beds with their BYO sheets & blankets. Who is she they all murmur some near Sy ask her directly - my student she replies. A Japanese man from the magical bed marketing team comes up to me & asks me if I am "an American lady?" He may as well of said what he was really thinking  'my, you are very obese! Are you sure that little blue plastic stool can take your weight?' Primly I replied I was english - but in khmer because for some reason this made me feel better about being the unwilling receiver of a lot of Cambodia attention.

The talk ended & there some chanting, call & response & punching of the air, which was all very confusing & bewildering. The magical bed users started to remove their electrodes & the man at the front - the Cambodian translator - shouted down the microphone repeatedly "HELLO BARANG!"

I was the only Barang in the room so pretending I hadn't heard & disappearing into the floor wasn't an option. I waved politely & smiled back secretly believing that Sy had orchestrated this whole scenario to punish me for being such a bad student.

There was then a great push forwards for the next 30 people to try (for free!) the magical beds with its incredible healing properties. Shockingly our laminated cards with 1, 2 & 3 on did not secure us a bed in the next sitting. Sy rushed to the front to try & push in, for someone so small she is really rather fierce & forceful, whilst I was restrained from following her by the toothless lady to my left who clearly had English queuing sensibilities. 

Everyone stared at the strange, fat barang. I said in khmer to Sy that I had to go home because P & S were due round for there English lesson so I didn't have time to wait another 40 minutes - all the time that is needed for the magical bed to work its magic. It was with deep satisfaction that I noted that the gawping masses had understood my spoken khmer but were also looking at me as if I had gone from being an obese american lady to a talking dog. 

I made a sharp exit.

The next day Sy was full of tales of the magical bed - she had waited an hour for a bed. It cures diabetes, joint problems, intestinal conditions & headaches. Sy could detect my cynicism. I spent half my khmer lesson explaining to her what a randomised controlled double blind trail was but I was talking to a woman who believes in ghosts, ancestral spirits, lucky phone numbers, traditional medicine & laminated numbered cards work in Asia for queuing.

When you're a stranger - everything is strange.....................

Activity

This week J & I have been in the border hospital but instead of just being with R - our normal dynamic trio, there have also been 3 other Cambodian males from the NGO J works for. As a result it has been the usual Cambodian misogyny-fest of exclusion from meals/Karaoke & work conversations because we are 'just' women. This came to a head on Wednesday morning when R & B who we were meant to be triage training with, rocked up to work 50 minutes late all smiles, without even a phone call or text warning. J is normally pretty laid back but was very angry with them so gave them both (as their supervisor) a good talking to. They didn't seem very contrite so I waded in afterwards but was a little more personal talking about the misogyny of Cambodian men, not respecting J as their boss & how their behaviour all this week has been deeply offensive to Janice & me. Capacity building doesn't have to just be about clinical skills, I'll have a stab at work ethic, professionalism & gender inequality given half the chance.

R is actually a very good friend of J's - like her son in fact & also one of my favourite Cambodians (along with his wife & 2 lovely daughters). For the rest of the day he was pretty withdrawn & distracted, that afternoon he composed for me the piece of writing below & emailed it along with his usual English writing homework he sends me for checking with the message "Dear Dr could you please see these files and correct my stupid writing. thanks!"

The following morning R looked exhausted - he'd had a sleepless night. He told J & I  in detail about the nightmare/anxiety dream he'd had that night about being late for work because his trailer's wheel was broken, he couldn't get a moto dob, it was raining & he couldn't think of what to say when he rang to tell J the reason for his being late for work - J was horrified her telling off had induced nightmares & a bad nights sleep. He also has been practicing using his new words, 'misogynist', 'hurt feelings' & 'offensive' in sentences all day.

He is really is a very hard person to remain angry with for long....

"Activity

Last night after working time, I hung out with my colleagues and hospital director to the three shadow restaurant. First of all, we all had a lovely dinner with many foods specifically, fried chicken, chicken soup and fried a long fish. I had much food and soft drink because the foods were very delicious and the price is reasonable, we only paid 5$ in each. Then the rain came very hard came down quickly so we asked the seller for the bill and we walked to get on the car for coming back to the guest house. When I arrived the guest house I had a shower and got on the bed fell as sleep till the morning. At 6:30 I got up and had a bath and put on cloth. After that I received a message from my boss that wrote about the breakfast location and I also replied her quickly, I would go to have breakfast at Thailand. After eating I went round the market with a few people were joining a trip the I looked at the time it is nearly 8:30 then I talked to Mr. B that we’d get blame from our boss because we were too late. When I came in to the meeting room, she asked me: when is the working time and would I do like this if J or P were here? My answer was not, but in my feeling I must be honest and responsibility not just respect to someone in front. Then Dr. Es also asked me a very good question, why did not I send or call her for telling that I would be came late? Why? That I could not give the answer to her, because I made a mistake yet and I don’t want to rule out my messing up."

Triage Training in an emergency care vacuum

This week I have been at the small hospital I go to on the Thai border (with the great splints), introducing a new Triage tool developed by an American University & supported by the NGO I work closely with. Today something happened that highlighted to me the futility of triage alone when there co-exists a complete lack of emergency care knowledge or skills. Sorry folks, it's another frustrating clinical story, please change channels if you have heard enough of them from me already.

This morning we (R, B, J & me) were doing 'on the job' training in OPD with the new triage tool when a mother walked up with a fitting child in her arms. The 2 nurses sat at the OPD desk instantly recognized that this was a triage category 'RED' patient & therefore should go straight to the ER.

The ER is actually the old lab that still needs renovating - quotes this week were three times the price as those for similar work in the Pursat hospital due to lack of competition, good capitalistic principles. So there is no ER at the moment & currently patients go straight to the ward - OPD has no room or resus equipment, OPD is just a porch with 2 tables & a few benches.

The 2 nurses didn't get up to see the patient or talk to the mother, so I went to her & directed her, walking with her & the fitting child, to the paediatric ward. We were greeted, when we got there, by one of the MAs (Medical assistants) & an older nurse (both ex-khmer rouge). The MA recognized that the child was fitting & then said he was very busy with a delivery in maternity (which is odd as he had been sat chatting to the nurse on our approach) & left saying I should look after this patient. In the 18 months I have been here I have advised, coached & even run the odd cardiac arrest. I have never seen patients without being with or discussing them after with their doctor or MA - this is because my job title is "medical advisor". Something clicked in my head when that MA left me with this fitting child, for 18 months I may have felt responsible for patients but I have known that I am not really their doctor. This morning I was that 4 year old girl's doctor & I found a whole new level of frustration & anger that was yet to be explored.

So first of all I asked for some oxygen & suction (there I go with my ABCs again!) - this took an awfully long time, inexplicably but eventually they administered 2 litres/minute of nasal speculum oxygen from an oxygen concentrator. When I pointed to the oxygen cylinder for high flow oxygen I was told it was empty. Before leaving the MA had prescribed diazepam to stop the fitting. I asked where it was but again this took an inexplicably long time to come. I asked about rectal diazepam - quicker - 'ot mean', did not have. Then I asked R (who had the unenviable job of being my translator) if they could put an IV line in rather than give it IM. I was earnestly told by the nurse - lets call her 'gold teeth' - that IM didn't cause respiratory depression as did IV diazepam & there was no way they would ever give a fitting child IV. There are national as well as international guidelines of course that contradict this but 'this is Cambodia!'

By this time the child had been fitting for well over 20 minutes so by definition was in status epilepticus so I could see that a discussion on the pharmokinetics of benzodiazepams was probably not appropriate at this time neither would it have been very successful. "What should I tell them?" asked R - "Just tell them to give the bloody diazepam which ever way they want to BUT DO IT AS SOON AS POSSIBLE!" I snapped. The lack of urgency & second guessing of me was beginning to wear thin.

Apparently, I found out later that 'gold teeth' disagreed that the child was fitting. She actually knew that the symptoms were that of a paracetamol overdose & the little girl just needed glucose, because she had seen this many times before. Meanwhile, silly me had bothered to take a history from the mother which told me the child either had meningitis, malaria or an atypical febrile convulsion & had already been given an appropriate dose of paracetamol by the health centre before being referred to hospital.

IM diazepam was delivered despite another nurse securing an IV line before hand to put up a bag of  5% dextrose - by this point the child had been on the ward more than 15 minutes. 'Gold teeth' went to give 10mls of 50% dextrose just at the time that I noticed the child had stopped breathing. As I went to open the airway & assess breathing 'gold teeth' tried to push me out the way. Through R I tried to explain that no airway & breathing was more important to address & could she please stop pushing me away from the child & if she wanted to be useful could I have a bag valve mask to ventilate the child.

The child was taking very shallow breaths - maybe 4/minute. I waited for an bag valve mask. Everyone stood around, R was silent, I asked again for a bag valve mask. Eventually J showed up & went to find what the delay was. The bag valve mask was encrusted with dirt & dust so one of the nurses was meticulously & painstakingly cleaning it. Meanwhile the child continued not to breath very much. With out the advantage of a translator to explain to the nurse that cleaning the mask was less important than me having the mask so I could bag the patient, J just snatched it off the nurse & brought it to me.

There was no oxygen cylinder so I ventilated on air, 'gold teeth' kept (at least 5 times) removing the nasal speculum despite every time me telling her no & putting them back on. Later I learnt that no one other than me & J actually had recognized that the child had stopped breathing but when I started bagging 'gold teeth' told everyone it was because the child had not been fitting so hadn't needed diazepam. By this time the child was no longer fitting but was cerebrally agitated, extended all limbs to pain & had up going plantar reflexes - before she had been having a complex partial seizure which as it wasn't all limbs twitching was not acknowledged as a seizure here in Cambodia.

So as I ventilated with air & tried to reassure the mother I did actually know what I was doing - I have long since given up trying to convince Cambodian health staff of the same - I asked for a normal saline bolus 20ml/kg - the child was tachycardic with a pulse of 160/min & peripherally shut down & Ceftriaxone - meningitis as a diagnosis was a high probability.

'Gold teeth' refused to do either. The child was already on 5% dextrose & that is resuscitation fluid (WRONG!!!) & Ceftriaxone was not indicated as her temperature was only 36˚C. The child's history was fever, vomiting & lethargy for 12 hours, she has been given paracetamol & an oral antibiotic at the health centre, she had been fitting for maybe over an hour - no one had spoken to the mother but me (through R of course) & no one had read the health centre referral slip. My patience was wearing thin.

"But tell her that the MA said this was my patient now & this is what I am prescribing!" - "No" said R "She is refusing to do it".

J marched off to maternity to drag the MA from the delivery & brought him back just as I turned around to discover that for the entire time another MA has been sat at the desk not engaging with me or the patient, not doing her job at all. The child started to breath, now I could focus my attention on the staff.

I started with a rant to R,  "I do in fact know what I am doing you know!!!" I exclaimed "Why won't they listen to me?" Because I was told 'gold teeth' says she is "experienced" & doesn't need to read protocols or have any training she just knows everything from past experience. She didn't think the child was fitting - she was. She failed to act with any urgency to stop the seizure. She refused to give the diazepam by the route I requested - she didn't as she thought actually know best. She failed to realize the child had stopped breathing - the child really had. She thought cleaning a mask was more important than delivering ventilations - it really isn't. And now not only did she think that a fluid bolus & Ceftriaxone would kill the patient - when it would of course save her - her next plan was to catheterize the patient, the only time she had touched the patient so far was to palpate for a bladder. I was beginning to doubt the validity of her 'experience'.

I looked to J & asked myself, silently, WWJD?

I grabbed R & went to where MA 1 & 2 & 'gold teeth' were huddled together, probably muttering about how Ceftriaxone could kill this poor afebrile child.

Calmly & slowly with R translating I went through the ABCD approach to seriously ill child. I talked about airway opening & suction, I talked about oxygen & supporting ventilation. I pointed out that she still had a circulation problem & required fluids as she was septic. I explained about how fitting can look different to generalized tonic clonic seizures, I tried to explain about the pharmokinetics of benzodiazepams, I talked about the importance of giving 10% glucose if a bedside blood test wasn't available in all unconscious or fitting children. I gave my differential diagnosis & explained why I wanted to give Ceftriaxone & then I begged, I implored & politely requested they did what I asked.

They did.

After lunch the child was more alert, remained afebrile & after 2 fluid boluses she was no longer tachycardic.

After the vital signs protocol training where 'gold teeth' was the most verbal participant sharing all her 'experience' that afternoon J & I went back to check on the child,  she was febrile & mysteriously 'gold teeth' had performed hourly observations (that were stable) recorded for all of today from early this morning even though she only came in at 10 30 am & also a few observations for tomorrow too.

Triage in an emergency care vacuum - what is the point?

How not to capacity build - a second perspective

In 'how not to capacity build', 'the week before & the week after' & 'say it with bananas' I described one incident with the staff on ICU medicine & its ramifications, but below is my lovely VAs interpretation of the events. Sometimes it's really good to have an ally. 

Reflection in case of Meningitis patient

Description of the event

On Wednesday my boss and I went to check up patients in ICU Medicine ward as usual as around 9o’clock in the morning. We always visited interesting patients each room. But when we arrived in the room 6, we noticed there is a remarkable young female patient who is around 25 years old with suspected meningitis was a back-bend patient. After questing with her mother about her history of illness and complaints, we learned that this miserable girl, who had been treated as the typhoid fever in health center and not yet improved, was referred from the health center far away where she lives. Also, she had been staying in the hospital for five days. She still got the high temperature including abdominal pain as before. Suddenly, my boss examined her throat and abdominal. She thought that maybe she had malaria because she lives in the malaria place. Then she went to check the doctor document and knew that there is no malaria test in blood test which they need to diagnose it when patients come from the malaria location. So my boss asked Dr.V to do blood test with the malaria test again. For the result, we had to wait until tomorrow.

On Thursday at 9 am, we went to ICU Medicine ward to see the result. The result showed there is negative for malaria. Immediately, my boss went to check up the patient. She examined her throat, abdominal and took pulse. Then she thought that this girl probably has meningitis. After examination, she told Dr. V about her ideas and recommended him to change specific antibiotic early as well as do the LP test for making sure that she has meningitis because the previous antibiotic was not respond to her daughter disease for five days, according to her mother. He agreed her decision and would change it later. That sounded so great that he listen to us. However, Doctor asked a nurse whose name is P to do it. But she yelled at us that “I was pretty busy with my paper works- the medicine papers and I didn’t have time to do it”. And I wouldn’t do it until I completed this.My boss and I felt very frustrating to get that response which is not appropriate for being nurse. She said to her that “in role as a nurse, you need to put patient first not your paper work. You need to change to specific antibiotic early as soon as possible, otherwise patient would be died soon because you’re carless and laziness-you are not busy. You kill patient“.  As a translator, I had to interpret it in diplomatic way by changing that” you didn’t have time to do it, so can you ask someone to do instead of you?” Dr. V suggested the new qualified doctor to do LP test. However, thing did not happened due to this nasty nurse. She said that she did not have time to prepare the LP equipment for new doctor and told him not to do it. We told the qualified doctor that “when you do LP test, we can help you.” After that, we left the ward to calm our emotion down; then we went again and something came up with interesting. We saw invoice on the patient’s bed. The invoice was about two compress steroids purchase. The doctor asked the patient to buy because they run out of compress in their medicine store. But it is not right for patient with PFD. Immediately; we came to Sry P to confirm about that. She really shouted at us and said that it was out of stock. We decided to see pharmacy to make sure whether it is true or not. Exactly, it was no more inn pharmacy, according to medicine workers. Then we told the sub-director M about and asked him about PFD patient (patient has equity card) problems. Dr. M said that he would solve this problem himself in order to avoid the conflict between staff and u. He went straight to ICU Medicine ward and worked that out. After this, we went to see doctor to make sure that the antibiotic has change. Nevertheless, a nurse told us that there is no antibiotic in their medicine store; hence they couldn’t do it today. There was nothing being done on that day until tomorrow.

On Friday at 8:00am, we checked up the patient and knew that the new antibiotic which had been changed since yesterday afternoon responded to her disease. We were so happy to see that. One week later, she was improved and discharged from hospital.

Two week later, the mother of meningitis girl came to meet us and gave us a lot of bunches of banana, and a bunch of Longan fruit for saving her daughter’s life. She was very thankful and grateful to us, especially my boss. We felt very happy to see and hear that. We think we have done the great job today. This is the great success for us.

Feelings and Thoughts

At beginning of the event, I felt very sad because doctors didn’t treat the patient correctly, as pointed out by Dr.Esther. They did not observed the patient whether she was improved or not with their treatment. Absolutely, they just did it to show that they already completed their duties. I thought they are definitely not doctors but they are killers. After seeing and arguing with the doctor and nurses, I felt more frustrating and upset what nurses did on patient. They didn’t put the patient first instead they thought their paper works were more important than patient’s life. It seemed that they did not know their basic duties or they were lazy to treat the poor patient because there was no bribe for them, so they did not look after the patient properly. For another thing that caused me felt more aggressive   and pity to patient is that they did not control well in medication as well as medicine store.  They should have kept all materials, especially antibiotics and compress all the time. If they don’t have that stuff, the patient will die because they delay treatment until they have it. It showed us that they are careless as well as laziness. However, at the end, I felt happy to see that patient get the correct treatment after this big argument. I think my boss did the great job and cheer the patient up by concentrating the doctor and nurses to do the right things. Her works was served the patient’s life. All in all, I feel very impressed with my boss’s work, but I feel very upset and frustrated with nurses and nurses due to their bad works and behavior.

Evaluation& Analysis

Through critical thinking, I can explore some good and bad experiences as description below:

·       Well done:

-       Patient and illness observation: Dr. Esther observed patient’s illness from day to day until get the correct treatment. This really helped her disease improve and get better from time to time.  As result, she recovered from the illness and discharged from hospital. So following up the patient is a key to obtain the right treatment.

-      Hard-working of Dr. Esther: Dr. Esther parts were really changed the situation more actives. And her work made the patient get the correct treatment and recover from meningitis. Patient felt very happy. So her assistance brought the new life to patient.

-      Struggling with nurses even in hard-time:  Even though Dr. Esther and I confronted with lots of problems such as verbal abuse, ignoring from them, etc., we still keep going on to see the doctor and nurses’ works to the patient. Also still continued to argue with them and recommended them to do correct treatment to the patient. This struggling made them more concentrated on the patient, so she could have proper care from them as the result showed. Therefore, our attention on the patient put the pressure to staff there.

-      Appropriate authority: When the Dr.M took part with those problems, we noticed that staff in ICU ward paid more attention and active in this patient. It means that his position is more powerful than us which can put more pressure on them. His present in this problem can give us more authorities because they might listen to Dr. Esther, the professional doctor in order to avoid another problems, otherwise they will get trouble with Dr. M who is sub-director of hospital later. This points out that when we have similar case, we should tell Dr. M in case that they are so stubborn with us.

-      Diplomatic interpretation: Diplomatic translation helped the argument get a little better. It assisted my boss speech to become slightly negative to staff when the staff felt very aggressive to us. So it could lead situation less tighten.

·       Bad done:

-Poor pharmacy management: Antibiotic and compress are very important in each ward, especially ICU medicine. They should have them in their store room all times, or they will kill patient who were waiting them because Ward has to delay treatment until they get them from Pharmacy. So pharmacy needs to check their inventory such as medicine, compress every week to know the inflow and outflow of these. They can control inventory flows and know the amount of inventory left. Therefore, all of medical equipment or medicine will be ready for ward needs.

-Poor ICU Medicine management: There were no the antibiotics and compress in their medicine store which are needed to be there all times, for they are ICU ward. They have to treat the patient in time, but they didn’t have one, so the patient was dying to get their service. Therefore, they should check it every day to make sure there is enough material for treatment.

- Doctor and nurses Ignorance:  Doctors and nurses didn’t observe the patient. The patient was not improved due to their ignorance. They thought she was a minor life that no needed to care. As the result, she got worse from day to day until the argument came. This made the patient feel very miserable and angry. They should have treated her early not waited until the argument took place, then started to concentrate on patient. So they have to treat the patient correctly as they are the health staff. Their caring to the patients will improve condition in ICU ward.

-Verbal abuse &-Laziness of nurse: Sry P, a nurse in ICU ward, did not behave well   to patient and us who cared the patient‘s life. She yelled loudly at us when we tried to tell her to do something for patients. She always said she was busy and did not willing to do it .In fact, she was not busy but she was definitely lazy. Her attitude made the patient feel very upset and scare to death. This is the cause of death rate in ICU increase from day to day. In role as a nurse, she must have looked after all patients and offered the good service all the same level. She must have put the patient priority –not do the paper work. This is the basic of nurse duty. Also she should behave well to patient and people who care patient and accept the good recommendation from Dr.Esther.

Conclusion

After observation this situation, I could see that the great help from big argument between us and staff. I also know how nurse should react to patient, how to treat patient correctly, and how to interpret in argument. The nurses and doctor should have treat patient correctly with their well- behave. This has taught me to how to get involved in the argument and how can I help poor patients. I could see that i can help them through my diplomatic translation in argument. Moreover, these problems have given me more power to confront with the bad health staff .So I have to ask my boss to see the patient often. This is what i can do as translator.

Action Plan

This is an action plan that I have to change myself to encounter this event against in the future in order to get the situation more successful:

-        To control my feeling when we have this argument again. I am not too aggressive, but I have to be calm down and try to find the way to talk to those people more effective in order to put them the pressure to do it.

-        To build up more strength to confront with those bad staff.