TB training - another perspective

Once again my lovely VA hits the nail on the head....

Reflection in case of Training

Event Description

On the second week of September, my boss, Mrs. J, Mr.R, and I went to a small hospital near border. We were going to stay there for four days for lecturing TB and following up Triage. I was very excited to visit there. 

On the first day - Triage revision in the afternoon, there were no participants, according to Dr.Esther’s speech.  She spent the whole evening on computer work and waited for them. But there was no one appears. This made me very angry and disappointed after hearing this. I just wonder why they did not join the triage lessons even though they did not really understand it. I thought that maybe they were lazy to get the training as nurses and doctors in the hospital. I really concerned what would happen the next day for my TB training translation.

On the second day in the morning, we followed up the Triage process at OPD.  The process was very slow. The nurses were very difficult to recognize what kind of patient they would put in triage form. These because they could not read triage books or even ask patients ‘symptoms. They could not define what the worst compliance patients had. In this process, they spent long hours to know patient is red or yellow or green.  Mr. R tried to explain them about triage. He pointed out the right direction to read and get quick on this form. But it did not work out. So it meant that the triage training was unsuccessful. Also, in this morning, I saw the interesting cases for triage. One young girl who had sore throat and high fever was informed orange patient, for they misread in oxygen amount in oximeter. It was upside down reading. It turned out that they were unable to read properly in oximeter result. So they would like to get training on this. Another patient- a little baby who was diagnosed that she had hand and foot mouth disease was gotten incorrect treatment as pined out by Dr.Esther. Dr.Eshter asked to change the prescription to only Para Cetamol use because she had slightly fever and not serious. By the way, one a little girl was incorrect diagnosis patient who doctor though that she had pneumonia. But indeed, she had asthma. It demonstrated doctor here is not good at treating patient.  In end of the morning, there was one man who came with fractured hand was admitted straight to surgery ward without triage. We realized that he who is a police and brother in law of Golden teeth was considered in priority after asking the nurses at OPD. It is the way of Cambodians to be corruption.  Furthermore, one interesting patient came. This patient who hanged himself was in coma. Dr. Eshter asked bag-mask oxygen for resuscitating this man. But they did not have that material. Mrs. J and I run to find it in surgery ward and maternity ward. Only surgery ward had it. Unfortunately, there was no adult air way tube. Mrs. J hurried to take it in car. At the end, we got the bag- mask oxygen. Nevertheless, our material did not use to revive him.  They applied Oxygen concentrator. Anyway, it helped the patient. I noticed that Doctor at this ward listened to Dr. Esther by using sleep medicine to help him and neck x-ray to check whether he had neck fracture or not. It was good for hanged man but that was a very bad morning for triage result. Anyway, in the afternoon, there was TB training. Unbelievable, there was only one doctor came. In seven minute, he got the TB handout and received a phone call; then he left quickly. We waited for another people. However, there was no one attended as we had expected in the first day. I felt very frustrating with this. I just did not why most of Cambodian nurses or doctors are not eager to learn more. I felt that they do not want to improve their capacity because they think they already knew it. It made me very upset to see my nationality in danger in future. This second day story let me down so much.

On third day for TB training, there were some nurses and a doctor participated. We lectured them about TB in children. Dr.Eshter tried to define them about local sign and general sign of TB of extra-pulmonary TB and pulmonary TB very clear. But they still did not get them even though I translated them several times. I did not know why they did not understand it- whether it was because of my interpreting or they did not have basic knowledge in TB in children. I tried to find the way to get them easy to take in this lecture. However, they did not pay attention in this. They turned their deaf ear to this explanation and talked on phone, instead. I was so sad and very dismayed that those people not listen to us. It showed that my translation was useless for them although I did my best on translation. I felt so bad to them. If they can aware of TB in children, the patient will not die due good treatment. Until in  the evening, Dr. Esther told me the TB training was not achieved because they did know nothing about our training when she asked them  about general sign and local sign of TB while she accompany by Mr.R taught them Regimen including other TB.  After getting this information, I felt very frustrating. We had done our best, but they just did not want to accept it.  Then, we walked around the ward to see patients. When we arrived in pediatric ward, we saw asthma girl whom we had seen on second day. Dr. Esther asked her aunt “what did Doctor told you about her?” She replied that “she had pneumonia”, but in fact she was suffered from asthma, according to Dr.Esther diagnose. Suddenly, little girl defensed quickly” I do not have pneumonia but I only have a cold”. Dr.Eshter was very surprise to hear what she said. She was brighter than Doctor to know what her illness was. We really appreciated this. Until in the evening, there was one patient who came with gastric hemorrhage. He was really sick and sent directly to ICU ward. Unluckily, there were no doctors around the hospital because they were all on commission. This was not appropriate for hospital not having doctors in hospital which could kill patients. Immediately, a male nurse asked Dr.Esther to see this patient as well as suggested her to role as doctor position today. He very concerned about the patient. Dr. Esther examined him quickly. She gave him on bolus serum and advised his wife how to take care her husband. This was an important point that I really excited. The nurses were very nice to patient even though they were unprofessional. They had compassion and sympathy to patient which differ from nurses in Battambang referral hospital. They behaved nicely to patients. I think if they are more trained, they will treat the patient professionally and compassionately. This good sight on nurses has changed my mind to them. I appreciated their jobs as they had those kindnesses. All of these really cheered me up although I had the bad result of TB training. 

On the final day, in the morning we lectured nurses about triage again. Dr. Esther gradually described it by giving the examples which I was acted as simple.  She concentrated in second section in triage form, most of them did not understand even in reading as well as defining what kind patient should be put.  As the same in Battambang referral hospital, they neither listen nor paid attention in this lecture although they did not make out.  Some of them were busy at texting or talking on phone. And others were talking together. They thought they already got it. This was common reaction of Cambodian nurses as I have believed that there was no point for us to give them more- at this really irritating me.  Moreover in this training, most of male nurses often played around me as in case of study. One male nurse was really shy at me. And it was made the teaching become worse.  I just could not believe that. They were rather shy than open minded to new people or knowledge. It really annoyed me. As result, only one midwife and one nurse could grasp this lesson. This was end of training day. In afternoon, we walked around the ward and checked patients up- G hemorrhage and hanged man in ICU ward. The G hemorrhage was getting better. For the hanged man, he was self-discharged   from hospital even though nurses tried to explain him to stay in hospital. But I felt glade that he was better. However, one thing caught my interest was that nurses ask Dr. Esther about one patient with complaining persisted chest pain for several days who she had seen before. She told him to take two specimens to test TB because she thought he could have TB or cancer according the illness history including chest x-ray- collapsed lung. She said that she had tried to tell this to doctor before but he did not followed at all. It maybe he had not been trained before we gave the lecture or he just ignored which made the patient want to leave because he did not improve instead he getting worse on chest pain. Dr. Esther came to explain him about his illness and the treatment we will take. She said that” you are probably have TB according to your chest x-ray, in TB treatment it will take  long time - it could be six months or more depending on your situation.” She continued that” we will take your sputum to test and find out whether you get TB or not. I ask you to stay in hospital better than stay at home which not good for your health”. This really made patient understand his illness and willing to stay in hospital. It was good to tell patients about their sickness which causes patient trust in doctor treatment as I noticed. After finishing this, we left this hospital. We hoped this patient will get correct treatment. 

Thoughts and feelings

For the first day, I felt very frustrating with their absent in Triage training. They were not interesting in learning something again though they did not understand about the process in triage. They thought that they were enough and did not need someone to train. This idea blocked them from build their knowledge up. 

On the second day, I was more irritating when they could not access triage and kept disappearing in training-TB training. For triage, they could not identify red, yellow, orange, or green patient in this form because they were trouble in defining the worst complication or in reading triage book. They spent too long to admit one patient-probably 15 minutes. It wasted a lot of times. I though this because they did not attend in training or they did not listen while teaching. After I saw Mr. R explain them, I found out that they were not really intelligence at all. They knew nothing. They just knew how play around with patient. And for power patient, police man –the brother in law of golden teeth, was transferred without triage. This told us powerful patient is more important than others. To be ministry official has advantage in all of facility. This was really try me hot. I thought this   because they had money and powerful face. So money face would make triage quickly. Anyway, doctor and nurses were unskillful. They could not diagnose correctly and treated well. I could say they lacked of skill.  But they were nice to patient as well as guest and listened to Dr. Esther in some kinds, such as sleep medicine, next x-ray. I felt they were a little opened to learn. I felt less negative to them than Doctors and nurses in Battambang referral hospital.  Instead of feeling a little positive sight on their mind, I could see they did not have enough emergency material in ICU medicine as in case of hanged man. When they needed mask-bag oxygen, they had to run to Surgery ward. It took long times to get this stuff. The patient could be died while they were running. But fortunately, he was revived on the next day although they struggled with this. I was happy to see that. 

On Third day of training, I felt very blue and angry with health staff there when they did not pay attention in our lecture although we tried to our best to explain them. They just ignored it, I believed. They tried to ask the same questions which wasted our time a lot because some of them did not listen at all while someone asking. This annoyed me so much. As the result, our training was not successful. I told myself that there was no point for us to give them more, but I felt better after I saw the nurses here was very kind to patients. They were very warm and worried about the patients. This removed my negative feeling to them; instead I really wanted to go and do trainings with them because if they concern patients, they will treat patient well once day after they get training. So I decided to I will try over again if I have chance to visit there.

On final day, in Triage retraining, I was so frustrating with their attitude in training and toward to me. They were playing around in class including me who presented as example of patient while Dr. Esther explaining. They were just dying to go for lunch or home, not care how hard we tried them to process triage well by spending our time to give them lecture again. They would never give their ear to us unless we do bring food or pay them, I reckoned. I started to have more negative again in my brain. All in this morning I was sick and tired of this. But in evening, I very impressed with Dr. Esther work. She gave good demonstration to the patient and nurses. She told nurses about patient diagnoses as well as pointed out how to examine this patient. The nurse really listened to her. For the patient was willing to stay in hospital. I was really happy to see this. However, I still concerned about nurses here on the way back home. I hesitated whether they follow or not because mostly they just listen but don’t practice. If they don’t do as Dr. Esther has told, the patient will take risk in his life. So I pray to Buddha to bless him.

Evaluation & Analysis

Good done:

-To revive the hanged man: Doctor did good job on resuscitating hanged man. He gave good care to this patient. He examined his neck through neck x-ray as he did listen to Dr. Esther.  I could see doctors really good at traumatic injury as well as interesting in learning new in some kind as this case. So we can work with them once day.

-To feel compassionate and sympathy: Some nurses there were nice to patient. They behaved well. They treated patient in some kind as their family. They spoke gently to patients as they gave medication to them. They did care the patients’ lives; for example, nurses in ICU medicine run to ask Dr. Esther to see the patient when there were no doctors around ward due to commission. They suggested her to role as doctor and to prescribe the treatment in doctor note which they could use it at night after Dr. Esther left. Also they asked her how to treat as well as examination one patient who suspected either TB or cancer according Dr. Esther. These told me that they had compassion and sympathy to the patient. It was good for patient to have those kind nurses and for us provide them more training because they eager to offer good service to their patients.

-To consult the TB patient: Dr. Esther explained to the patient who wanted to discharge from hospital when he did not improve his chest pain about his illness including what we would do for him. She told him about diagnose as well treatment we will take. He really understood his disease and reconsidered to stay in hospital. This consultation inspired the patient willing to stay to get treatment. So the nurses should tell every patient about their illness and treatment in order to get trusted from patient who won’t reluctant to stay in hospital for long times.

Bad done:

-insufficient emergency equipment: When we needed mask-bag oxygen to revive hanged man in ICU medicine, they did not have this material. So we had to run to find it in surgery ward which took us a long minute to bring it.  Unfortunately, they did not have adult air way tube. J was rushed to take it in car.  I could see they really lacked of emergency equipment. They should have this as they are ICU ward where every serious sick patient comes. But I could not blame them because this hospital is poor. There is no point for us to blame anyone when they do not have anything.

-Inability doctors& nurses: Doctor there could not diagnose patient correctly including treatment.  They incorrectly treated EV-71 baby and asthma girl. They did not really look into patient symptoms. They did it just as their habit. They should have examined patients carefully. I could say they lack of knowledge in this because they have been trained little. Therefore, they need more training to build their capacity up.  For nurses, they did not access triage very well. It took a long minute to get one patient flow. The reason was that difficult to define what color would they put patient in this form. They could not recognize the worst complaints of patients and read oximeter result. It showed us that they did have basic knowledge. They really need to be trained again.

-poor human resource management: There is very crucial to have doctors in the ward all the time. They should not allow all doctors to leave the ward even though they were on hospital commission. Without doctors could kill patients, especially sever sick patients because they could not get treatment quickly as they need. So they should have keep some the most important doctors in the most emergency wards such as ICU ward, pediatric ward, etc. They should have put patient in priority. So they could have both advantages- keep patient and get on training.

-not eager to improve knowledge:   Nurses did not pay attention in both training – TB & Triage. They just came as followed the director order. They were dying to have lunch or to go home. While we were teaching, they were talking, playing around, phoning, etc. They really did not care what we were trying to explain them to get easily on triage and aware of TB in children. It turned out they were not very interesting in this because they just ignored them. They should have grasped this training, for those trainings are fundamental knowledge for them. They can have a lot advantages on this if they acknowledge them.  So in order to let them pay attention, we should warn them about what we are going to do if they do not take in these lessons, such as if you want to work and open ER soon, you need to understand this; otherwise, ER will not be opened. We need to talk to both director and staff here. I think they will listen to us because they really want ER.

-Not present in training: They did not appear for first& second day of training.  They really dismayed us and wasted our time.  They should participant our training, for they did not understand about it at all. It may be they lazy or busy. So in order to avoiding this again, we need to inform director of hospital often beforehand. Also give him the warning sign like I would never give lecture or help you again if you still keep this. It is good way to make red card to them because human will follow up if they see the red card.

Future Action:

As role as translator, what I can do is trying to translate effectively in lecturing through asking them often whether they have question or not and giving them a short summarize in each parts in training. My repeating sometimes can get their interesting or remember because they hear it several times. I hope this will work out.

WPW - what patients want....

I think I should be clear that when I write these clinical blogs its not for sympathy nor out of despair, I write them so that people can have a clearer idea of what it is like trying to capacity build in health in Cambodia. If you find them too depressing or distressing then I suggest you stop reading this blog, because it is more of the same I am afraid.

For a fortnight I worked with a doctor from a famous US university hospital at my hospital. He is an emergency physician (like I used to be!) & it was good to have him inject some inspiration back into my work. After his departure I went on a study tour & when I came back I went to see if the woman with pericardial TB was improving (she is) & I saw Dr L with an ECG but when he saw me he scuttled off, hiding it from me. I didn't have the energy to pursue it.

The next day (Thursday) I stumbled across a very worrying looking ECG on the desk whilst looking for another patient's notes - it was the same ECG that Dr L had been concealing from me. B had conducted a 2 day ECG workshop whilst he was here but the doctors will not ask me for help reading ECGs. I am not sure if this is arrogance or shyness or hostility but it invariably makes my job of capacity building very difficult.

The ECG had been done 2 days before and showed a wide complexed tachycardia. I went to see the patient. She was a 17 year old girl who had been working illegally in Thailand until 2 weeks previously when she developed palpitations and then swelling in her legs (pitting oedema), breathlessness & felt 'exhausted' all the time. She came back to BTB where the doctor 2 days previously had failed to diagnose her as having a life threatening tachyarrythmia so had started her on Dopamine for her low blood pressure & Digoxin. Dopamine is a powerful drug that is used to make the heart beat stronger & faster, the reason this girl had a very low blood pressure was because she had a heart rate of over 200/min - the last thing she needed was her heart racing any faster. Digoxin is an anti-arrhythmic that can be fatal if used in certain kinds of tachyarrhythmia - in short she was being mismanaged.

Dr S, who is a 'specialist' in cardiology, was on the ward - not one of the usual ICU doctors but one who often covers the odd shift there. I showed him the 'interesting' ECG - he immediately asked to see the patient. He had been on duty for the last 24 hours but apparently a 17 year old girl with an extremely fast heart rate & respiratory rate and no palpable radial pulse wasn't cause for concern enough for any of the nurses to mention her to him. He, of course, could have rounded - there are only 12 patients on ICU.

He agreed with me that this patient needed a DC cardioversion (electrical shock) & failing that a chemical cardioversion with an IV drug. Neither were available. The defibrillator that the same doctor had tried to shock me with, 6 months ago, now had a flat battery, otherwise I would have DC cardioverted her myself right there & then - no discussion.

Instead he started her on an oral version of the ideal IV drug - less than ideal because when a patient is hypotensive the gastrointestinal tract is one of the first areas to get reduced blood flow which is re-directed to more vital organs. This means that oral medications are not absorbed very well, if at all. He stopped the digoxin but was reluctant to stop the Dopamine as Dr L had started it & he didn't want an "argument" with him. After much insistence from me he promised he would come back in the afternoon to check on the patient & discuss the case with Dr L.

I repeated the ECG - there was no change from 2 days previously. She had not had any bloods taken as she had 'difficult veins' so I offered to show the staff how to do a femoral stab. One MA came with me - the rest of the nurses & doctors sat in the staff room watching TV. The bloods showed that she had renal impairment - 2 weeks of having a heart rate of over 200/min will do that to you.

After we had left the ward L (my VA) told me that SP - the same nurse that we have previously had run ins with - had said to Dr S, when he asked for her to stop the digoxin, "Do what you like, I don't care, she can die for all I care, I am only interested in money". What patients want? That kind of attitude from the staff looking after them!

The following day she was still on Dopamine & no better, there were no doctors on the ward so I went straight to the deputy director, Dr ON. I showed him the ECGs & explained that dopamine was bad and we went to the ward together. Dr L was there but told me to write my recommendations in the notes, rather than talk directly to him, which I duly did. He wasn't interested in my explanation or clinical reasoning. Dr ON however was keen to understand how he could tell if shock was due to tachycardia or if shock was causing the tachycardia. There was another young girl with sepsis with a sinus tachycardia on ICU so I was able to show him the difference between a sinus tachycardia & a tachyarrhymia. At least someone wanted to learn.

I spoke to the Head nurse about the nursing staff's attitude on ICU. I said although their behaviour revealed that all they cared about was money & they didn't care if patients died, it was probably not very professional to voice this in a room with 4 student nurses, 3 trained nurses, 3 Cambodian doctors and a barang doctor with her very shocked VA.

I called the local NGO hospital to see if they had either IV Amiodarone or a defibrillator that worked - no such luck. No pharmacists in town stocked IV Amiodarone - it is only available in Phnom Penh. The only other option was for her to go to the cardiac centre in Phnom Penh but as a poor card holder only her transport would be paid for & her parents did not have the money to go with her. In Calmette she would need her family there to deliver her basic nursing care & would not receive treatment with out giving significant amounts of "tea money".

I decided to wait & see if stopping the dopamine & another 24 hours of oral Amiodarone would improve her condition. On Saturday I went to check on her - without the Dopamine her pulse was stronger but still rapid. Her mother told me that if her daughter survived she would 'give her' to me. This made me feel profoundly sad.

Then I lost my phone. I bought a new one & replaced my SIM.

I rang a doctor from another NGO for her advice. She suggested a NGO Children's hospital in Siem Reap but the girl was too old. We both knew that she needed DC cardioversion & IV Amiodarone but like most of Cambodia her & her family were too poor to afford the healthcare she really required.

On Sunday I went to the Pagoda with my Khmer teacher - I found myself praying to Buddha. When I checked on her at the hospital afterwards she was worse. Her urine production was low, her breathing faster. J noticed that the dose of Amiodarone was too low (being an idiot I had misread the prescription chart) so we spoke to the duty doctor & increased the oral dose. In my heart I knew it was hopeless.

On Monday J went down to Phnom Penh for meetings - I waited for a miracle, it didn't happen.

Tuesday we had planned for J to buy 8 ampoules of Amiodarone ($40) & send them up by Taxi. The girl had been in a wide complexed tachycardia for 3 weeks by now.

I went to the ward first thing to find that the girl's parents had been told to take her home to die, as she was a hopeless case. I explained to the mother that we were arranging for medicine to be sent up & if she stayed in hospital we could give it to her daughter that evening. I went to tell the staff not to send her home & 'the lovely nurse' (as my VA now calls her) was there & shouted that she had been told to go home & that's what should happen. I tried to explain that we were buying the medicine she needed but SP's malignant presence meant my words fell on deaf ears.

I wrote in the notes a prescription for IV Amiodarone & tried to explain to the nursing staff how to give. SP shouted at me to just go & talk to pharmacy, she wouldn't do anything as she did not trust my translator's translation. I calmly & assertively told her it was none of her business - she wasn't on duty.

L & I went to cool down & have a coffee, when we came back to the ward. SP AKA 'the lovely nurse'  had left & suddenly every nurse was very receptive to learn how to deliver a loading dose & then maintenance infusion of Amiodarone. Dr L was the doctor on duty - I tried to explain to him that giving IV Amiodarone in a shocked patient was less than ideal but she was going to die if we didn't try. He wasn't particularly interested in listening to anything I had to say.

I waited for the package from Phnom Penh to arrive.

At 5 30 pm my VA picked up the package & I met her at the hospital (interrupting my khmer lesson with S). We gave the 8 ampoules to the nurse on the ward & I called J who with was in a meeting with the head nurse who in turn called the ward to check that they would give as I had prescribed.

Out of courtesy & concern I called Dr L to inform him that the Amiodarone had arrived. His response - "I am busy" (at his private clinic) "You do" (I had taken a history, examined her, diagnosed the patient, taken bloods, repeated an ECG, stopped the life threatening drugs he had prescribed, checked on her everyday, rang around trying to get the right treatment for her, arranged for IV Amiodarone to be sent up, stopped her from being sent home to die as a hopeless case - WHAT EXACTLY DID HE WANT ME TO DO?!) and then finally the one that really felt like a punch in the solar plexus "Why are you telling me, it is not my problem - it is not my responsibility" (He is the head of service for ICU medicine and was the doctor on duty that night).

That night I woke with a start after a vivid dream where the girl died because of the Amiodarone loading dose. It was 4 am. As I was drifting back to sleep my phone rang. S - my khmer teacher - was calling me but in my semiconscious state it felt like I was back in the UK on call & I knew the call was about the girl. S was agitated - she was insisting I went to the hospital to check on the patient, she couldn't sleep, GO NOW she kept imploring me. I looked at the clock - it was 4 20 am. I whatsappe'd J to tell her what happened & that I was a little freaked out, fully expecting her not to get the message until the morning. She responded immediately that she couldn't sleep either & had also been thinking about the girl. I was even more freaked out.

I waited for a reasonable hour to go to the hospital. I reminded myself that this is why I chose emergency medicine over ward medicine.

I went at 6 30 am to the hospital. She was still alive, I considered converting to Buddhism.

The nurses were agitated & looked worried - they were telling me that she had reacted badly to the medicine. Not surprisingly the Amiodarone had reduced her blood pressure further before it had converted her back to a normal sinus rhythm. Whilst J, S & I had fretted & tossed & turned all night, the patient had her first decent nights sleep in 3 weeks in normal sinus rhythm. The mother looked like a different woman - she had slept well too & when I told her we hadn't slept as we were so worried, she just laughed & gave me a big hug.

I repeated the ECG and this showed that the patient had Wolf-Parkinson-White Syndrome - WPW. I explained to the patient & her relatives what was wrong, what she could do if it happened again & what needed to happen next. The mother didn't want me to leave (she had seen me come to the hospital with a rucksack) and asked what would happen without me to be her daughters advocate. I explained that the staff had told her to go home to die as they did not have the knowledge & skills to know any better -  that's why I am here, its my job to capacity build them. It was a minor epiphany.

Dr S came to check on her. He had been to the hospital technical committee meeting the afternoon before to say that drugs like IV Amiodarone are necessary & if a 'poor card' patient needs them they should be bought my the hospital & not by Barangs. He thought it was best if the patient was transferred to his medical ward for further management now she had a blood pressure & a palpable pulse. This gave me hope.

I then had to go to Phnom Penh later that day but the next day L emailed me;

"This morning i visited the young patient in POP. She is getting better. She is on Glucose IV now.
Her abdomen is less swollen, and her breathing is better. She has appetite to food and drink.
I can say she looks better.  Oh! her mom asked me to say" thanks you! how are you?" to you.
She said you save her daughter life and thanks for your kindness.She is very thankful to you.

I will let you know if there is anything wrong."

And I so here I wait, wondering what else can go wrong & really hoping it doesn't.

Pitting oedema

'Bad' ECG

After chemical cardioversion, 'better' ECG revealed the diagnosis of WPW

IV Amiodarone - eventually!

Calm Assertive

Recently I have been told that I am not authoritative or convincing enough. The person in question suggested I read Cesar Millan's book 'Cesar's Way' - the mexican american bloke who is the 'dog whisperer' on TV - I scoffed. I was told that I should be "calm assertive" and people, like dogs, would respond to me better. I passively aggressively told him where to go.

Then I spent a rainy weekend in Siem reap in a hotel room, watching re-runs of The Dog Whisperer on Animal Planet. I learnt some pretty pertinent stuff,  that dominant & aggressive dogs are easier to rehabilitate & behaviour change than an insecure & anxious dog.

Now considering that I am meant to be capacity building, which in turn is all about behaviour change suddenly Cesar Millan seemed to be talking a lot of sense. I hadn't really thought of the doctors I work with as anxious but arrogance is very often only hiding a deep seated insecurity.

The trouble is that although I am quite good at passive aggressive, calm assertive energy seems to allude me. I continue to strive to find this higher ground & to be more convincing whilst I am at it....

My New Friend - she is one of the hospital dogs, friendly & playful, takes food from your hand very gently, barks politely, lies patiently at your feet awaiting scraps & follows me all around the hospital despite being threatened with violence by the Cambodian staff - my calm assertive aura is finally working on someone at the hospital at least!

It's not a failure, its just meeting our low expectations

As a postscript to a previous blog regarding life being a series of disappointments, I thought it may be useful to explore my own coping strategy for disappointment.

An effective way I have found to deal with this phenomena has been to simply lower my expectations - the question is "How low should I go?"

So I accept now that most of the male Cambodians I know will go to Karaoke, buy beer girls & have girlfriends as well as wives & children, but that still didn't prepare me for seeing them bring prostitutes back to the hotel or when they get karaoke girls pregnant.

Or I know that most health workers take bribes but does that mean I should expect them not to treat poor patients who can't afford bribes?

And I expect 3 months of drum & gong banging at 4 am every morning in the rainy season, I've actually found that NOT wearing ear plugs helps as the expectation to not hear anything at all is eliminated, but the progressive rock pumping out of the speakers at 3 am today exceeded my expectations of the usual plinky plonky music. Perhaps I really have become 'comfortably numb'.

When only one person attended TB training on day one but then left after 5 minutes, I told J "it's not a failure it's just meeting our already low expectations."

When a Cambodian colleague recently text me to apologized for "letting you down", I replied he hadn't let me down as I hadn't expected anything from him in the first place.

But if you expect nothing then you will get nothing, so in truth I still expect an awful lot & I am constantly feeling frustrated &/or angry with disappointment.

It would appear that some Cambodians have kept their expectations much greater than mine. At the end of the cardiogenic shock protocol that I have been editing recently there was a suggestion that if drug therapy wasn't working to insert an "intra-aortic balloon pump" - appropriate but not really available or realistic in Cambodia. However the suggested treatment for irreversible cardiogenic shock that followed the intra-aortic balloon pump (I like to think this was one Cambodian doctor's very high expectations rather than just plain stupidity) was "Cardiac Transplantation". I laughed until I cried, whether this was through mirth or despair was less clear to me.

Gender Studies

I have been asked to do a session at the new volunteers in-country training on Gender - its a shame that there are no gender issues here, I've been finding it difficult to think of any examples. Surely sarcasm isn't the lowest form of wit?

My VA was telling me about a class she attended at her university - she had been told that women are the weaker sex & they are only made to have babies & stay at home. I clarified that this was a gender studies class & that surely these were points for debate. Apparently not, this statement was from a psychology class she takes & were delivered as fact by the lecturer. Cambodians hey? No actually - Barang!

I was intrigued to see if this really was a factual lesson or was meant as ideas for discussion in class. Today she brought in the handout for me to see - it was a lesson on evolutionary psychology & I just couldn't resist this opportunity to share some of the 'facts' with you. Here goes......

Extracts from "Innate (genetic) male-female differences in bodies, psychology, roles, and brain"

• Females have wide hips and legs that turn in at the knee, to bear the weight of a baby, especially one with a big brain. These physical features restrict their mobility. Females, cannot run, jump, and throw well. They are designed instead to have babies.
• Males also have twice as much testosterone as females, which gives them a high sex drive and an aggressive personality.
• Men are psychologically disposed by evolution to like each other and to get along - "the male bond" Men enjoy being with large groups of other men - "running with the pack" Women, on the other hand, even when quite young, form small, family-sized groups. They are very close & supportive with others in these small groups, often they are mean to other girl who aren't in their group.
• Women control men while allowing the men to think that they are in control (for example, it is women who decide how to spend almost all the money) Women have two intellectual advantages over men. First, they can easily "multi-task" This makes them seem silly & illogical to men. Second women have a mental faculty called intuition that men lack. She knows what children, men, and animals are feeling and thinking. These mental abilities evolved as part of a women's role in keeping her husband, guarding her children, and holding the family together. Men don't have a clue.
• When a man is jealous, he becomes angry and violent. When a woman is jealous, she tries to make herself prettier. 
• For a man, any discussion with a woman can be exhausting, because she can't stay on a logical track and talks about many different things that aren't related to the problem you are discussing. Men get tired of this, and conclude that women aren't logical and can't think. There is some truth to this. There has never been an outstanding mathematician. Men can concentrate on one thing or one problem, if necessary for hours, days, months, or years. Women can't. 
• Women don't respect a man's 'space' and can't leave their man alone 'nagging' - the man will become angry.
• If a women becomes so frustrated with a man because he won't do what she wants and she gets out of control, she will shout at a man non-stop for an hour without even taking a drink of water. When a woman shouts at a man for an hour, he feels bullied and defenseless because he doesn't have the same verbal abilities she does and can't shout back at her for such a long time. Under those circumstances a man will raise their fist.
• Men want to have sex with many different women. A man will lie to a woman about his love and commitment, so that she'll let him have sex. After marriage most men are not sexually faithful to their wives. Women will tease men by making them wait and by requiring them to write poems and take them out to dinner in order to show that the man is serious.
• Psychologically diseases of modernity - harmful & extravagant attempts to attract love & attention: anorexia & bulimia in women; When a man & his wife both work, children don't get the attention they need; If a women stays at home with her small children all day she resents them and becomes violent and angry with them.

I am going to leave if there - you will have to guess the gender, age & nationality of the lecturer.

I'm off with my enormous hips & knock knees to try & make myself prettier, then concentrate my little brain on how to help my VA get a more balanced education, free from sexual harassment. If only I had a man that would lie to me to get sex & who I could starve myself for & nag for an hour without taking water, maybe then I'd be lucky enough to get a fist raised in my direction......

Cambodian Triage

A nurse I met with at the weekend who was first time visiting Cambodia with a NGO gave me a great idea for how triage could work here.

The triage system that we are introducing & training on, in my two hospitals, is as follows;

RED Unstable patients with a life threatening conditions that need to be seen immediately e.g airway obstruction, severe asthma, septic shock, fitting

ORANGE Emergency patients that need to be seen very quickly (within 10 minutes) e.g. Heart failure, uncontrolled bleeding, snake bite

YELLOW Priority/Urgent patients that need to be seen by a doctor but can wait an hour for two e.g. Early appendicitis, early malaria, moderate dehydration 

GREEN Stable, non-urgent patients that can wait to be seen or go to OPD for consultation

I've been struggling to inspire a sense of urgency for the whole process of recognizing & managing a sick patient. Currently triaging one patient can take up to 15 minutes, it should be a 2 minute process!

The nurse I met with has only been in country a week but came up with a very good method for instilling a sense of urgency & potentially getting sick patients seen in a timely manner. The method was inspired by a system of triage in mass casualties situations & some beers. 

It goes something like this;

RED Place a $20 note on the patients forehead

ORANGE Place a $10 note on the patients forehead 

YELLOW Place a $5 note on the patients forehead 

GREEN Place a $1 note on the patients forehead


Show me the money............