Bruises

My last weekend in Cambodia  I had a massage that left me with a series of bruises down my leg. It was actually a really good massage & it hadn't hurt anywhere as near as others I've had here.  But There is certainly a lack of gentleness here, which extends far beyond massages. A common way of showing affection is often done by pinching, slapping or punching, not dissimilar to what you'd see in a primary school playground. Little babies will get smacked forcefully on their bottoms by their family & it's not done out of anger, a malevolent act or even punitive, it's just pure love.

So today - my last day in Cambodia - I look down at the fading blue fingerprint tattoos on my leg & I'm aware of the constant dull, almost unbearable, aching in my heart & I'm reminded that here if they love you they will bruise you.

Parting is such sweet sorrow

On Wednesday I left the place that has been my home for over the last 2 & a half years. It wasn't easy but it  also taught me that I am very lucky to feel so sad & have such an awful, overwhelming sense of loss because it means that I have loved & cared about people here. I'm happy that I've made so many emotional ties with Cambodians & that the tears have not just been all mine this week.

So I should feel glad that I am so sad to leave S - my Cambodian mother - who is keeping some of my things safe for me so I can collect them when I come back to visit her. She brought around hot bread at 6 30am for breakfast on my last day before I left for Phnom Penh. She cooked me, J (who I had been staying with) & J's husband a huge lunch that same day of fried & grilled fish, mango chilli salad, crab, prawn and pickled cabbage. She washed up & tidied busying herself whilst I waited for my Taxi resisting my attempts at hugs because she didn't want to cry. I told her I would have no khmer lesson that day, she replied she would see me tomorrow. We both cried. That evening she called me in my hotel room in Phnom Penh to tell me to sleep well & that I must "be happy" because if I was happy then she would be happy. I couldn't speak back to her without my voice breaking. 

I am very grateful that I met my lovely assistant - L - whose strength in adversity, wit & wisdom far surpass her years. Saying good bye to her on our last day of work together was tough, I could barely get out the words to thank her or tell her I couldn't have done the last year of work without her. She wiped away my tears before her own. When I replied to a text she sent whilst I was traveling down to Phnom Penh that I was feeling very sad to leave this was her response - I know that. But u will come to see us again. U r always presented in our heart n brain. So u r not leaving us - this didn't help much to stop my 'tears drop down'.

I feel overwhelmed by the kindness of C & her barang husband P, whose hotel (my spiritual home) we went to for one final drink on my last night. He had arranged bar food on the house, a bottle of Champagne & also bought me a G&T for the road. C booked a taxi & came down to Phnom Penh with me explaining to the bemused taxi driver that I was her Bong S'rey (big sister) & the constant sobbing was because I was sad to leave my Cambodian family. C told me stories of her life - bombings, gunfire, sweat shop factories, bad fathers, bad ex-husbands, bad brothers, divorce & being a single parent, a Cambodian woman's struggles. We went out for a Chinese meal that evening with her regular tuk tuk driver - who impressed me by accurately estimating the weight of my luggage - and she insisted on paying for my meal & a medicinal large bottle of Angkor beer. When I got tired & emotional, asking her why she has always been so kind & generous towards me, she reminded me of the first day we met - happy hour at the hotel bar, after just a short conversation I gave her my phone number, sincerely telling her to call me if her, her children or her family ever needed medical help - you were so friendly & kind & you didn't even know me then - she told me, I daren't tell her it was probably just the long island iced tea talking! Karma cuts both ways.

And finally I feel nothing but sweet sorrow for leaving behind my best friend, R whose daughter broke my heart by doing a drawing for me & writing in her best English & Khmer -"I love Esther & Esther loves me". His family - the village people - had a leaving party for me on my final evening with all our favourite Khmer food including 'dirty meat' & 'shake fruit' in memory of all the times J, R & I had the very same at the forest. Saying goodbye to his wife was the starting point of all my tears this week, then his daughter P held me very tight, sobbing, whilst I told her she must continue to be strong, clever & brave although she should try be good, sometimes it would be better to not obey always her parents! As I sobbed on the back of R's moto as he took me to P & C's hotel, he told me earnestly - I'm just going to drop you off now, I am not going to say goodbye to you - But the next day he wasn't true to his word & came to the house to see me off. Against khmer convention he asked me for a hug. There are some people in life that you never want to let go of, I am very lucky to have met so many of them here.

C was right - I have left behind a Cambodian family & the parting was such sweet sorrow.

My work here is definitely not done

With only 6 days left in Cambodia everything has become about 'lasts'. Today was my last visit to a CPA 1 Hospital near my base work place where we go to follow up TB in children screening & Severe acute malnutrition (SAM) training. The hospital has less resources than others because is has no health equity fund. I'm told that it was left without a health insurance programme so that it could act as a control to compare with other similar sized hospitals in the area that had equity funds introduced.

Although they don't have a lot the staff especially the younger nurses try really hard to following any change in practice that training advocates. On my last visit I hoped to follow up TB screening there but instead I got a stark reminder that there is still a lot more work that needs to be done here before health care is even half decent.

J & R were visiting to do nursing process follow up so went over to the emergency ward to talk to the nurse there who had attended training, whilst L & I went over to OPD. There were no staff in OPD & a few patients waiting but no children so instead we wondered over to the TB ward but that was empty, finally we ended up at the paediatric ward. Every child had been screened &had a TB contact history documented, one child had been diagnosed & transferred with SAM but that wasn't what caught my focus of attention. Sat on the bench next to the nurses table was a woman with her baby in her arms. The older male nurse told me that the child had a reaction to recent immunization. Further questioning revealed that vaccination had been 11 days ago & the child had been unwell since. The nurse was actually sat 3 metres away from the child & mother and clearly had not examined the baby as if he had we wouldn't have been chatting about whether the child at 9 months old was too young to have the immunisation. I went to check on the baby & found that it had an obstructed airway, was pale & completely unresponsive. L has no medical training but could see the little girl was in serious trouble.

I opened the airway & after the very briefest of assessments I told the male nurse that the patient was in coma & needed urgent treatment - where was customary to resuscitate severely unwell children at this hospital? I queried, having only ever done follow up & no ER work here before.

"Reanimation" he shrugged - still making no attempt to get up to see the child or even do a basic set of observations on the comatosed child. Sometimes the inaction & lassitude of health workers needs to be circumvented in a non-culturally sensitive way & this I judged was one such occasion so I took the child's uncompleted notes & their yellow book from the mother & instructed her to "follow me".

We walked the length of the hospital grounds to the emergency ward which as its only asset is a cylinder of oxygen I will refrain from calling a ER. On arrival J & R looked surprised to see that our TB follow up had led me to present to the emergency ward with a pale, obstructed airway, shocked, comatosed 9 month old girl.

The first thing that became apparent to me was that the emergency ward had one oxygen cylinder connected to one dirty nasal prongs & tubing and that was pretty much what distinguished it from any other ward of the hospital. The child was so unconscious that her breathing was far from adequate - did they have anything to assist ventilation? I begged, whilst R suggested that nasal oxygen through dirty tubing at 2 litres a minutes was probably better than nothing at all.

A midwife went off in search of a bag valve mask that they keep on the maternity ward. The on duty medical assistant (MA) arrived at the same time as the box with the mask & a stethoscope in it. He, the midwife & nurse all stood staring helplessly at the child. I looked at R & wordlessly asked for permission to lead this resuscitation, he nodded his encouragement.

R placed a towel under the childs shoulders & explained to the staff that even if you didn't have airway adjuncts you could still do manoeuvers to open the airway. They gave oxygen. I listened to the chest & asked the MA what he could hear. I felt the femoral pulse whilst R suggested a temperature.

The child was pale, cold & tachycardic - shocked. R rolled up his shirt sleeves & then suggested they put in an IV whilst trying really hard not to do it himself. I think its fair to say that we both miss emergency clinical work & getting our hands metaphorically dirty.

Trying to get a clear history from the mother was challenging - she seemed to think the child had been deeply unconscious for 11 days yet the child had been still breast feeding & eating until the previous day. She could really tell me when the child stopped feeding, when she last passed urine or about the seizures she had. She was of course obviously very upset but this inability to give a clear history is a commonly recurring theme here.

It became clear to me that MA didn't know what to do so I talked through the ABCs of resuscitation & started to suggest a fluid bolus, some dextrose & antibiotics. After the dextrose the girl started to groan & whimper, she remained flaccid & floppy on the right but had increased tone & neck stiffness. The MA & I agreed on meningoencephalitis as a most probable differential diagnosis.

We reviewed the ABCD approach, I reinforced that good, correct management had been given & then we went on to discuss transfer to a higher level Hospital. R wanted me to explain to the Mother what was wrong with her child but I thought that it would be more appropriate if the MA could do this. After some discussion R turned round to me & told me that the MA didn't know what to tell the mother. I draw the line at thinking I am better than a Cambodian at talking to a parent in khmer about their seriously ill child. The MA was persuaded to do this whilst the nurse organized an ambulance to transfer the child.

The Hospital has no triage system or way to prioritize patients hence the child lay unconscious on her mother lap for an hour before I noticed how sick she was.

The Hospital has limited equipment & resources to properly deliver the care it needs to the poor rural community it serves.

The health workers have low knowledge & are poorly trained, they are on meager salaries. But when they have someone to lead & advise then they have the technical skills to good deliver care

The patients are mainly illiterate & uneducated and can barely give an account of themselves. Health education is not poor but absent.

So many times it has been demonstrated to me over the last 33 months that what is missing here is confident clinical leadership. On the job training with Cambodian health workers to help sick patients receive better care & build their confidence is absolutely what I love to do but sometimes the enormity of the deficit here is overwhelming and as a finisher completer it is clear to me that my work here is definitely not now, nor will it ever be, done.

What I don't blog about...

With a week left in Cambodia I suppose it is too late to right the balance now but I'll try.

This blog which started out as a way to communicate with people about what I was doing as a volunteer in a new Country, fast became a sounding board for my observations & frustrations, a form of writing therapy. So people who haven't spoken to me for a while will be forgiven for thinking after reading my blog that I must be truly ecstatic to be finally escaping the craziness of Cambodia - nothing could be further from the truth.

It is much easier to write about the big things that confront me here or challenge my cultural norms but its the little things about Cambodia that have a vice like grip on my heart which I find a lot harder to articulate, but here goes...

One lunch time my bicycle chain fell off, luckily I was near the office so I pushed it there. My bike has a chain guard that I needed a phillips screw driver to remove so I asked one of the drivers - Mr S -who was in the office if he had one in the tool kit in the car. He did so went to get it for me but then proceeded to remove the cover himself, he flipped the chain back on, discovered there was a problem with the back wheel, went to get his wrench to adjust the back wheel, put the cover back on again, then discovered that there was a problem with the cover and finally banged out an indent which had been rubbing on the chain. By this point he was covered in oil & dirt, as he got up to wash his hands J came out of the office to tell me that Mr S was actually on an annual leave day & had only come into the office to sign his time sheet. I felt terrible, Mr S just shrugged & smiled and told me "ot ay tey" - its not a problem. I don't write about this kindness of Cambodians enough.

This week my khmer teacher & Cambodian mother - S - tried to give me her ruby ear rings, that I have always admire on her. She originally had wanted to buy me some diamond ear rings but I had managed to persuade her that she should save her money instead, so giving me the precious stones from her own ear lobes was for her next logical step. I got upset - I am very emotional at the moment - and told her I should be buying her something to thank her for everything she has done for me. She looked at me earnestly, tears welling up in her eyes, pointed to the grade 5 book we are learning from & said "Doctor you have given me this, you don't need to give me anything else because you have given me knowledge"

Last week whilst staying away from home I texted my friend to see how he was doing working away from home also but with food poisoning "How you doing wonder boy?"

I got a characteristically honest & frank Cambodian response "Still on the bed waiting for a shit. I have 28time. X and you?"

This really made me laugh & distracted me from the grimness of my own salubrious guest house room with a beetle infestation, blood on the towels & a glob of vomit wiped on the curtain. I replied "Sounds like you had some very bad sea food! I hope it stops soon & you get some sleep."
Then I thought some more about the way his text had been worded as if to ask about the state of my intestines & laughed some more before adding an additional text, "And to answer your question to me, I have only had one shit today so far thanks for asking but that could all change! ;-)"

His response made me really laugh, "That's good to here that you ok. Otherwise i won't be able to sleep because I'm worried about you. It is ok for me this is my strength. Take care!"

I shot back with "You are really making me laugh. Not sure you are trying to but you are!"

Then is occurred to me that perhaps he really wasn't trying to make me laugh when I received his reply, "No that is my special feeling in my mind to you. I'm not kidding. X"

Communicating feelings through the medium of the Bristol Stool chart...only in Cambodia!

I have a very hard week ahead of me; in life generally its the little things that matter the most, which are the things I don't often blog about...

When stars align

I went to another border town & another hospital this week to train another ER how to use their newly donated ECG machine & monitor. It seemed a futile mission as one solitary visit was hardly going to make them confident & able to read a monitor or 12 lead ECG but the Bong had promised the hospital director a training session & so I went with only a couple of weeks left in country.

I conducted 2 training sessions that covered basic rhythm recognition & then common brady & tachycardias they may see. I also went to the ER & demonstrated how to use the ECG monitor & did a 12 lead ECG on a patient who has Hyperthyroidism so takes B-blockers which had induced a first degree heart block.

The ER doctors seemed interested & eager to learn but told me they really needed a lot more supervision & support before they felt confident to use & diagnose. I could understand this. It took me 10 years before I could tell the difference between a VT & a SVT with aberrant conduction. Maybe this was because I am very dense but despite my cognitive struggles I still think that reading ECGs takes a lot of practice, training, time & you need to see hundreds to establish good, reliable pattern recognition. Like a lot of things in medicine it is both an art & a science.

I tried to comfort myself with the knowledge that maybe the 5 part training package I had developed which is soon to be filmed to make a training DVD, which hopefully the TV obsessed Cambodians health care workers will watch, will actually be useful & help hospitals to benefit from all the donated equipment they receive.

The 2 packets of ECG dots I bought them in Phnom Penh hardly solves the problem of consumables nor will the basic job aids I've developed be a substitute for the English language user manuals & maintenance guides. But I am trying to be positive about my 33 months here.

The morning before we left, the Bong & I went to the ER where the young ER doctor showed me an ECG of a SVT. A woman had come in with palpitations so the doctor had connected her to the monitor. She had seen the fast rate so went on to do her first ever 12 lead ECG. From my training & handouts she was able to recognize that the patient had an SVT. She was currently in the process of arranging transfer to a larger hospital after some failed vagal maneuvers. She had diagnosed the woman as thyrotoxic due to her goitre & history. Words can't describe how happy this incident made me.

It doesn't happen often, in fact it is extremely rare, but once in a while in capacity building the stars align. 

9 days to go

After spending 33 months in Cambodia capacity building, I was told, having just delivered some training on ECG rhythm recognition, by the Doctor translating for me that he had similar training on this subject many times by various NGOs & overseas doctors but he still couldn't read an ECG because "You barangs are all the same, you come here, give just a little then go back to your own country taking all your knowledge back with you. You leave us with nothing". I was surprised & a little hurt that a local NGO worker, who knows me, had interpreted my actions & motives in this way.

I have observed in Cambodia that people with any training or education tend to guard it very closely to exert power & influence over others, most importantly they can use it to earn money with their unique & unshared knowledge. It is generally accepted that this is the culture of knowledge & education here, which can make cascade training a bit of a challenge. Of course this jealous guarding of information & knowledge extends far beyond Khmer culture but I can honestly say that as a volunteer & then as a consultant I hadn't consciously thought I had ever behaved in this way.

I have a good friend here who we frequently share the joke that I am just deliberately making him dependent on me by helping him so that when I leave he won't be able to manage without me but now, after this most recent character assassination, I am beginning to doubt my own motives when trying to help others.

Every day since being here I have persistently tried to share my knowledge & expertise with others. Every day I have been met with an overwhelming wall of resistance to change or lack of motivation to engage with or respect me. I have spent hours developing training materials that will never be used because the hospital did not have time to accommodate the training they asked for. I have turned myself inside out trying to present things in a way that is culturally palatable to some of the most arrogant, ignorant & difficult people I have ever worked with.

Had I known that it was expected that I would just keep all my knowledge, education, training, skills & experience to myself & then leave without doing anything meaningful or of any use, I could have saved myself an awful lot of time, money, effort & emotional energy.

Still I have 9 days to enjoy this feeling of liberation, knowing that the reason no one ever took any of my advice was because I was only expected to hold on to it, really tightly.

Trust me I'm a doctor...honest!

I've written about 'up-skilling' before & it is not just the expats that have a problem with this. This week I discovered one of the nurses who works for the same NGO as I do has also been at it.

The very first time I met this particular character he introduced himself as follows - Hello, my name is M & I have a masters in public health. He has been heard to say that knows more than any Cambodian doctor, he told my friend that he knows better than all Barang Doctors too. I have only ever seen him demonstrate ignorance & arrogance - but I think we have already established time & time again that what the hell would I know about medicine?

When being constantly ignored & diminished I have found that an effective coping strategy is avoidance so I have skillfully managed to minimise the time that me & M spend in the same room. Its not difficult as he is busy chasing American doctors that visit once in a while, whose gifts of pens & tie pins he treasures & idolizes. From a distance I can even find his behaviour amusing.

This week I visited another hospital which M had also been to the day before. On the way the Cambodia Doctor I was working with - the Bong - told me that M had diagnosed a patient with a pericardial effusion with the new ECG monitor. I looked disbelievingly at the Bong & his lips twitched imperceptibly upwards. I eye rolled & the Bong said ruefully - I think it is important that people work within their roles, if you are a nurse then you should nurse the patient.

There are certain people here who love touching my blue paper, I don't think that the Bong is one of them. In fact he doesn't even like my character, it was him who told me recently I should try to be more Cambodian - but it appeared on this occasion that he was deliberately trying to wind me up.

After we had delivered some training at the hospital, we went to ER to show them how to use their new equipment. We discussed a case from the day before, an overdose of diazepam. The young female ER doctor wanted to know my opinion on gastric lavage. I know here that it is expected by relatives of any patient that has taken an overdose, the same as every patient regardless of their complaint must receive an IV of 5% dextrose - but I also know it is rarely clinically indicated & has a risk of aspiration as a complication. They knew this but found it hard to convince patients & their relatives which I appreciated from many similar conversations. Pick your battles is my mantra - and gastric lavage is by no means the biggest barrier to effective emergency medical care here.

The ER doctor then turned to the Bong & started to talking to him in khmer about what had happened yesterday to spark this conversation. Now my khmer is terrible but given context & a clear speaker I can sometimes get the gist so after she finished I asked her who had M made so very angry. She looked a little surprised & the Bong explained to her, in khmer, that she should be careful as I understood some khmer.

I could see that the ER doctor was weighing up the situation before finally deciding to continue the conversation in English. She explained that they had been doing the lavage outside the entrance of their new emergency room & M had openly criticized them, shouting at them that they were wrong in front of the patient, his relatives & all the other patients & relatives in the ER. She earnestly told me that this was extremely rude & inappropriate in Cambodia.

This I know because I have spent the last nigh on 3 years tip toeing around cultural norms, saving face culture & often delicate egos to try & advocate for half decent medical care. I would never openly even advise in front of a patient as I learnt early on this does not improve patient care & only serves to increase clinician hostility & resistance.

I explained to the doctor that I try really hard not to offend people but have recently managed to completely alienate myself from the paediatric ward of my base hospital.

No, no - she assured me - you have been fine, most doctors that visit are fine. They advise how we should do things but respect that it is our decision to change. It was only that doctor yesterday that was aggressive with us, was disrespectful & too forceful.

Doctor? - I confirmed with a raised eyebrow shot in the Bong's direction.

Yes - she nodded - that Doctor was very rude!

Walking back to the shiny white, AC, 4x4 I couldn't help but remind the Bong that he had no reservations telling me to "change your character to be more Cambodian" yet he wasn't even prepared to correct the false assumption that one of his fellow staff members was a Doctor when they were in actual fact a nurse.

It seems that a male Cambodian who trained as a nurse & did a masters in public health in Cambodia that both aren't recognized internationally and can just as easily be bought without a minutes study for a price, can think & let health staff also believe that he is a doctor, dispensing all kinds of false or dangerous advice is perfectly acceptable. However I am still being ignored & provoked extreme hostility for suggesting a bottle ban on the Malnutrition unit & encouragement of relactation to improve SAM treatment - I guess my internationally recognized medical education & specialist registration plus my higher education counts for nothing because it turns out that saving face, being an arrogant & delusional are what actually counts.

So the old adage 'Trust me I'm a doctor' is redundant here because trust doesn't even enter in to the equation & any one can be what ever their money & status allows.

9 days to go & counting......

Sim pee

One evening at the border town I visit once a month J, R & I were sat waiting for our evening meal at our local eating spot - the corner restaurant. Two women who work there were sat on the table next to us with a their children - a pre-school girl & maybe in grade one boy - it was obviously going to be a long wait for food because they were all preoccupied with a stag beetle they had found.

I was directly facing them so watched as they captured the beetle & tormented the 3 year old girl by attaching it to her clothes & laughing at her whilst she screamed & became frozen with fear. This kept them entertained for a fair few minutes. Then they directed their focus of attention to the restaurant dog whose nose they attached the beetle to - he also freaked out, yelping & whining & running around in circles - distressed trying to remove the latched on hissing beetle. This caused enormous hilarity amongst the adults & children, even the recently tormented young girl.

Then the boy captured the beetle & began picking off its legs & piercing the beetle with tooth picks, whilst the adults sat laughing & encouraging him, the little girl played with her scooter & the dog slunk under a table that was safe kicking distance away. J & I exchanged a knowing, pained glances. I turned to R & asked him what he thought J & I were feeling right now.

Disgusted? - he responded.

But how do you feel about it? I queried.

Nothing - he shrugged.

The threshold for macabre acts is a lot higher here for obvious & previously stated reasons.

I understand & accept that my idea of animal cruelty, child neglect & emotional abuse, acceptable behaviour towards woman and health care worker's compassion & professionalism are different from R's due to a myriad of socio-cultural-economic factors but I was curious to know what does actually upset or disgusted R.

Nothing - he continued to watch the TV.

The great thing about having a cross cultural friendship, I have learnt, is you get to question incessantly, harass, mock, provocate, tease, doubt, challenge, be completely insufferable & generally over step boundaries all under the flag of exploring cultural differences. To clarify - this is a two way street with R. So as is fitting with our friendship I continued to push R for an answer.

There must be something that you see here that disgusts you? - I insisted.

No.

To be fair I have seen R not flinch at pretty much most things, he actively enjoys the diaster porn that is Cambodian media or the ultra violent Chinese movies shown on buses, as a nurse in a heavily land mined country he has seen his fair share of trauma, as a child & young adult he lived through a violent & bloody civil war, social injustice continues to be common place here.

You are devoid of all disgust? Everything you see & hear is palatable? - I persisted.

R is not stupid & could tell I wasn't going to give up & let him watch TV until he had given me an answer.

Sim pee - he eventually replied whilst still fixated on the news coverage of a hanging with graphic footage. In Cambodia phones with 2 SIM cards are common - SIM pee (pee is Khmer for 2) - it is also the slang for a homosexual male.

Luckily our meal then finally arrived & I was left to ponder over my rice whether my best Cambodian friend is really homophobic or just knows exactly how to provoke, incense & ignite my blue touch paper. Both are equally probable. I think I'm going to miss the continual uncertainly & challenge of living in a completely different culture. I know I will miss R.

Bong

As my time in Cambodia rapidly approaches its end, it seems like every day & hour is now observed by me more acutely than before. So things I previously learnt & have grown accustomed to are suddenly more remarkable.

For example today I was sat with my assistant in the NGO office when one of the staff members - D - asked my assistant in khmer how 'nursing process' was translated in to khmer. I intervened to suggest she ask a nurse I work with as he is a nursing process trainer where as my assistant & I aren't really  involved in this. The Bong of the office - H - over heard this conversation & went over to a near by book shelf to take a folder of 'Nursing protocols' to give it to D.

But that's not the Nursing process book - I told D & him - The nursing protocols are in that folder which included how to take a blood pressure or giving an IV etc., but the nursing process is a different from this & has its own book.

D flat ignored me then went back to her office with the folder.

I turned to my assistant & wordlessly implored my common refrain - why won't anyone listen to me?

After nearly 3 years here she obviously thinks I shouldn't need to ask this question anymore.

H is the Bong - she explained later - you are lower status than him, D can't listen to you when you are correcting or contradicting H. This is Cambodia.

Simple as that. Sometimes I am so stupid. Sometimes this place is so annoying.

I went to D's office with the nursing process book later to show her the correct translation of 'Nursing process'. She seemed grateful. Working within a hierarchy & saving face culture as well as navigating the translation errors can make writing even a simple invitation letter for nursing process training much harder than it ever really needs to be.

No photos please, we're British

One of the many things that I have struggled with here culturally is the diaster porn that is the Cambodian excuse for the media. TV & printed journalism frequently will show the mangled bodies of RTA victims laying dead on the tarmac or patients supine on dirty hospital trolleys covered in their own blood, in obvious pain. They reported with relish the story of a man that raped & murdered his stepdaughter & then beheaded his wife, who himself was then beaten to death by a angry mob of 50 villagers. They have no reservations about showing the slain bodies of murder or the victims of rape. As an emergency doctor it is not as if I haven't seen my fair share of major trauma & death, I just get perturbed when it is shared publicly without anyone here even batting an eyelid.

On Facebook people create their own disaster porn from moto drivers with heads literally split open after colliding with Capitol buses to dead babies hanging out the windows of crushed shared taxis, taken on their smart phones & shared on social networks. This psychosclerosis or hardening of their attitudes towards graphic scenes of violence is symptomatic of a much darker psychological stain this country bears. But what concerns me is the total lack of respect this shows towards the victims & their families, the absence of confidentiality when the subject is actually a patient in a health care facility as well as the distraction & shift of focus from potentially more news worthy stories this results in.

And as is so often the case when I start to explore something deeper that relates to Cambodia, I then inevitably find certain parallels with my home country. The recent BBC coverage of Typhoon Haiyan had rather too many shots of distressed, orphaned children for my liking as well as among the ariel shots of the utter devastation of flattened buildings a cynically edited shot of two UN staff stood with their hands on their hips apparently doing nothing, before cutting back to a person being pulled out from under a tree. Maybe I have grown over sensitive to reporting bias & a state controlled media, perhaps there is no such thing as balanced reporting any more anyway.

Last week whilst on the Thai border we were walking with the hospital director to see the new equipment for theatre when we came across a crowd outside the surgical ward. In the centre was a 7 year old boy looking scared & upset with an enormous bandage on his head. Two men with cameras were taking photos of him.

It was explained to me that the boys parents were killed in a moto accident & he was now orphaned. Why are they taking photos of him? I asked, the boy was starting to look even more distressed as the large throng of strangers - patients & their relatives - crowded around to see what was happening.

They are journalists from the press - I was informed.

What about confidentiality or consent? I asked bemused.

A silent shrug....this is Cambodia - they can do as they please.

They started taking photos of me & my english work colleague at which point we both began to feel rather imposed upon. We imagined the headline - NGO Barangs in white 4x4 plough down & orphan Khmer child yet do nothing to help him.

After we tried to explain our western perspective to the hospital director, how would he feel if this was his orphaned son? etc. he finally tried to ask the journalists to not photograph us or the boy anymore as we didn't like it. They just stood there & lit up a cigarette.....which leads me very nicely onto my second Cambodian media story.

Just before I arrived my base hospital introduced a smoking ban. A Khmer nurse advisor from another NGO - Rt - was walking to conduct some student nurse training when he spotted two men smoking by the surgical ward. Rt went over to explain to them that this was a clinical area & was hence non-smoking. He got a tirade of verbal abuse along the lines of 'who the hell do you think you are? Do you know who you are speaking to? How dare you! Rt went on his way to his training session & thought nothing of one of the men taking his photo. Rt was only informing them of hospital policy & couldn't see what harm he had done.

The next day there was a half page spread in a national newspaper with a photo of Rt - identifying him as a cruel & terrible nurse who neglected patients to instead harass & abuse innocent bystanders.

This story may go some way to explaining why J & I were so camera shy last week - we knew enough about Cambodian 'journalism' to avoid getting on the wrong side of the camera lens.

No photos please, we're British!

Reciprocity

In Psychology the principle of reciprocity states that it is "The social expectation that people will respond to each other kindly by returning benefits for benefits, and respond with either indifference or hostility to harms."

J & I experienced it this weekend whilst shopping at the old market in Siem Reap.

J was looking for a gold Buddha pendant & necklace. The first stall we stopped at she was told it would be $55 - this is unusually cheap as a solid 18c Buddha is generally in excess of $100. She felt the pendant & it was also unusually heavy. Is it gold plate? she asked the seller who had relatively good English.

No, no, no she was emphatically assured this was a solid 18c gold pendant & for her she could do a special price of only $55. 

We were both skeptical. 

Whilst J continued to negotiate the authenticity & price of the suspiciously heavy & cheap Buddha I was distracted by the sellers young daughter playing with her friends near by the stall. I nudged J mid-haggle & pointed to the T-shirt the 7 year old child was wearing. J instinctively gasped & covered her mouth - the universal body language for embarrassment, so the seller asked her what the matter was.

J pointed to the girls T-shirt & asked the mother if she knew what it meant. The seller shrugged & said it was just a cheap T-shirt she had bought from the market & although she couldn't read English she knew that it had Siem reap written on it.

Tell her in khmer what it means - J asked me. I am an expert of Khmer swear words!

Its a very bad word - I explained to her in khmer - Con Doi.

It was then the seller & her sister's turn to gasp - both horrified.

She was very shocked & all flustered, immediately telling her confused daughter to remove the T-shirt.

She then turned around to us with a completely changed expression & countenance saying earnestly- to be completely honest with you, you were right, this is just gold plated Buddha - I can give it to you for $10. Sorry that I lie to you before. Thank you for telling me about my daughters T-shirt. If you really want a real gold Buddha you should go to that stall over there, but currently a pendant of this weight if it was solid gold would cost $160. 

So in the end J got her lucky gold plated Buddha, which if she is really lucky may even stay a gold colour until she leaves Cambodia in 3 months time, the seller got to know her daughter was playing in public with a anglo-saxon profanity for female genitalia emblazoned on her T-shirt & I got a good story to tell, as well as a bonus lesson in reciprocity.

Relaying the story to some friends in the pub later that same day one of them nonchalantly nodded & told us his friend actually produced these T-shirts & there was in fact a whole range of them available - english literacy clearly not necessary for purchase..........

The back of the T-shirt says - in here is a ****

J with her Reciprocity discounted gold plated Buddha - another happy customer!

Excel-lent

I think it is fair to say that forward planning isn't generally a common Cambodian characteristic.

The other day my Cambodian friend asked me to help him with a spreadsheet, he wanted to know how to generate a formula to add up the columns & rows. I showed him the Sum function on Excel & as he played about getting familiar with how it worked I read the headings to his columns. They were in Khmer but my grade 4 reading meant I could recognize 'School lessons', 'Food' & 'Petrol'.

Is this a work spreadsheet? I asked, curious.

No, its a monthly budget for my family - I was told.

I was slightly surprised by this revelation & also very impressed.

We went through the existing column titles & I suggested a few more to try & minimize the variability of the 'other' column.

This is really good - I exclaimed - it will really help you manage your families finances. Its a great idea! What made you think to do this?

You - He deadpanned.

Really? How? - now I was even more taken back.

You told me that if I budgeted I would be able to manage my money better & that I could use excel to make a spreadsheet to help me do this.

I have no recollection of this as a recent conversation so I asked - when did I tell you this?

Pause....

18 months or maybe even 2 years ago.

And this may just be a perfect example of how capacity building works & how long it can take to see any change however small.....

Be prepared

This week at the border hospital much to my surprise I was actually able to deliver all the training I had prepared, including the use of a their first ventilator. As usual the MAs were quite reserved to the point of being slightly disengaged but the 2 young nurses who are being trained up as nurse anaesthetists by the chief nurse anaesthetist were very enthusiastic & asked lots of questions.

At the end of the session the gentlest, most approachable MA smiled & said quietly that I should treat them all like children because that's the level they operate at - I couldn't argue. But then shouty khmer rouge MA suggested I should show them how to use the ventilator with a case in the OR to help them gain confidence with using the machine - I couldn't argue with him either.

The following day we were asked to help anaesthetise a woman for an elective caesarean section, using the new ventilator - spinal anaesthesia is not possible due to a lack of local anaesthesia, perhaps I could support this when I go back to the UK my Cambodian NGO colleague - R - suggested because I clearly haven't given enough so far. It was my first time in theatre here & the first C-section I'd attended for a while. In fact the last one was when I was visiting my friend in South Africa - we were mid Braai at his house when he got a call to help with a C-section at the rural hospital he worked & lived in. I went with him & ended up at the top end in my former role as an anaesthetist whilst Karl scrubbed up & helped deliver the breech baby whose bum was out & his head was still in the uterus - crying in a muffled, echoey, surreal way that I will never forget. It was a healthy baby boy who just need an extended surgical incision to help deliver his head safely. We then went back to our Braai & Boerewors. I relayed this story to R as we got changed into scrubs - he wasn't really impressed other than to know what pressor I had used to raise the South African's mother low BP.

The anaesthetic staff really impressed me, it oddly felt very much like an operating theatre from my previous short life as an anaesthetist, a long time ago in the UK. They had all the drugs they needed labelled & ready, all the equipment was laid out, there was BP & oxygen saturation monitoring but the patient was awake strapped to the operating table like a stainless steel crucifix, no one was talking to her or explaining what they were doing & the new ECG monitor was not being used, so things were just a little different than the UK.

Before I realised it they were doing a RSI intubation, without any cricoid pressure & then they were looking at me expectantly to attach the patient to the ventilator. The motivated, keen young nurse had already checked all the settings & the machine was happily ventilating a rubber lung so we transferred it over to the patient as the surgeons started to cut down through the abdominal layers.

Soon after the machine alarmed a low minute volume warning & the anaesthetic nurse immediately checked the patient, more from habit than my training the previous day I am quite sure. He found she had good air entry, normal chest movement, her pulse & oxygen saturations were all fine. So then without my prompting he started checking the machine & its tubing for any leaks, almost immediately he found a small hole in the tubing, which was then promptly sealed temporarily with tape.

Him & his fellow trainee asked lots of questions about mechanical ventilation - they had never seen a ventilator used before. However they always periodically went back to check the patient, give her top ups of IV anaesthetic or some Ketamine for pain. It was an attentiveness that I rarely see here.

Then the baby was delivered - grey, limp, not breathing - and the waiting midwife took the child to a cold stainless steel table. The table was bare, no towel for drying - just a paper sheet, no suction, no bag valve mask. These things were each asked for slowly, in turn, whilst the baby continued not to breath, losing heat from his wet skin in the aggressively air conditioned room.The Paediatrician in me itched to go over to cover & dry him with a towel whilst the OR staff were struggling to move one of the operating lights to act as a warming light.

The young male nurses & my work colleague continued to play with the machine, adjusting alarm parameters & fiddling with the humidifier. "Ermmm,"I tentatively asked, "Should we go & help the midwife?"

R shrugged & told me that they have had plenty of training on helping babies breath. In a sense he was right as the suction & rescue breathes, as well as towel, all did eventually arrive but just not as the rate that I would have carried it out at.

I agitated. "Be patient Dr Esther!"- I was instructed.

It puzzles me how in the same room for the same clinical case the quality of care can be so varied. The anaesthetic & surgical team were completely prepared for the case - medication, oxygen, monitoring, suction, surgical equipment all at the ready and yet when the baby was delivered there wasn't even a prepared area to resuscitate him. No towel, no warming light, no suction, no bag-valve mask, yet they were all available in the hospital. The midwife knew what to do, my collegue was right she had plenty of training but there was no preparedness, no forward planning, no sense of emergency.

If you had come to this hospital a year ago the ER had only just opened - it was brimming with newly purchased emergency equipment that no one really knew how to use. Today you would see that there is extension building work to accommodate for the increase in patient numbers, often there are patients sleeping on the ER veranda as the 2 trolleys inside are occupied by sicker patients requiring oxygen & monitoring. Nurses will do 'ABCs', they will monitor & record vital signs, the drug cabinet is neat & organised - checked & restocked very day, the whole area (apart from the building work) is clean & well maintained. This has been an excellent demonstration of how basic resources, space & preparedness has resulted in better patient care, which in turn increased patient attendance which improves Hospital income due to the user fee increase.

Whilst feeding back to the Hospital that afternoon on their yearly assessment R brought up the issue of preparedness - what I had witnessed with the neonatal resuscitation & how being ready for emergency cases will improve patient outcomes. Because he is Cambodian he failed to also feedback how impressed I was with the organisation of the anaesthetic & surgical team and how the development of their ER has been exemplary but he remembered to name & directly quote me for the less than positive feedback.

Today I went to see the mother & her baby boy - the first patient to ever have a ventilator used on them in the history of the hospital. She was a bit sore but the baby was doing well.

Today is my last day at this hospital. Words can't really describe how sad I feel about this, leaving just as improvement in patient care & positive change are gaining momentum here. The tail end of Tropical cyclone Haiylan's blustery, grey cloud laden skies & cold, persistent drizzle is a perfect match for my current mood.

Spidey Senses

Recently I was blind sided by my best Cambodian friend over lunch. He was sat in the corner restaurant where we go for lunch in the border town watching the TV. J had gone to shop in the market whilst we waited for lunch. I was creating a viciously hot dipping sauce from fish sauce, fresh red chillies, dried chillies & soy sauce when R innocently asked me "Is spider man real?"

Used to translation errors I asked him what he meant. He pointed to the TV & asked me again if spider man was a real person. "He comes from your country doesn't he?"

I looked over my shoulder & saw a dubbed version of Spiderman the film on the TV.

"Its fiction - this is just a film" I answered slightly bemused.

"Yes I know that," R persisted. "But is the film based on a real story? Where does he come from?"

"From a comic book, a made up story"

"NO - I mean where did the writer of the comic hear about the story? When exactly did the real Spiderman exist?"

"He didn't hear a story about him, he made it up from his imagination."

The penny dropped as I realised that I had already had a similar conversation with my khmer teacher about the king of the monkeys tying clods of earth to his leg hair, flying & making mountains and whether this was a true story or not. I told R the same story & asked him if he remembered this grade 4 exercise. Yes he nodded, of course that story is completely true, he told me. 

I was just explaining what a fictional story was in shocked & yet increasingly animated way when J returned from the market. 

R thinks Spider man is a real person from history - I announced to her.

I was initially quite shocked to discover what I hadn't previously known about R but as time progressed I realised that it did actually explain a lot about both him & Cambodia. 

A long conversation about fiction, fact & belief systems followed. Ghosts exist, Muslims can cause illnesses, people from earth live on other planets, fortune tellers are always correct, Titanic the film was a true story with no artistic license, he doesn't watch the news or read books.

It soon became apparent that everything on TV was considered to be fact or based on fact or ancient history. A long time ago a boy was bitten by a radioactive spider & had special spidey senses as a result. Clearly this was a true & I am just a horrible cynic.

And yet here when I attempt to convey a rational, reasonable, evidenced based, logical argument or piece of advice, well then I am the only non-skeptic in the room.

Education through bad TV dramas seems to be the only way forward here.

Blue moon

Once in a blue moon a Cambodian doctor will be exceptionally nice or supportive to me.

At the border hospital this week I was asked to see the Pelvic X-ray of a child who had been involved in a moto accident. The pubic rami looked a bit fuzzy on one side, but as there was no left or right marker on the X-ray I couldn't tell you which. I asked if I could see the patient to see if I could match the X-ray to any symptoms she had.

I found her squatting outside the surgery ward where she leapt up from & walked over to us when the Hospital director beckoned her. No limp, not in any pain, fully weight bearing with a full range of movement in both hips. She is fine I pronounced confidently.

Her father - obviously wealthy & connected - insisted she needed a CT scan of her head also.

Was she knocked unconscious?

Had she had a seizure?

Had she vomited more than once?

Did she have double vision?

Any weakness?

Fluid leaking from her ears or nose?

Was she confused?

No to all of the above.

Well then perhaps, I suggested, a CT head was not clinically indicated & would increase her risk of cancer with absolutely no benefit to her. After a long pause I added - and it is a waste of money.

The father acquiesced on the CT head, I am sure the money argument won him over, but he then turned to the Director & said that the X-ray technician had told him her hip was fractured & that I was wrong.

Without waiting for my translator to convey what the father had just said, the hospital director told the father that as I was a highly qualified & experienced doctor from the UK who could read & diagnose X-rays better than any of the staff in his hospital, maybe I actually did know what I was talking about & he should respect my opinion.

As I said at the start, once in a blue moon someone will throw me a little bone.

Karma

My best friend here announced to me recently that I have bad luck. Oddly previously I had never really thought of it that way. Admittedly I don't ever seem to get what I want but I thought that this wasn't bad luck more misplaced expectations. Living in a house with intermittent electricity & water near to a noisy Pagoda & uninvited guests both non-human & human, having a VSO placement at a hospital where the ER never opened, staying on as a consultant on the promise that it would & then it still didn't, owning a bicycle that has a permanent slow puncture; these things I always thought were just my poor life choices rather than bad luck. My friend alerted me to the fact that I actually have bad karma.

My laptop's hard drive has a manufacturing fault which means the hard drive died this week losing with it 2 days of my work.

That same evening I found myself moaning to my Khmer teacher about my bad karma.

Why, when I have spent $500 fixing my old computer & giving it to my Cambodian friend so that his whole family could use it & benefit from it, was I now repaid with my brand new computer breaking? Where's was the cosmic justice in that? I asked her with more than a liberal dose of self pity.

S shook her head pityingly at me. I clearly didn't have the first clue about karma.

Karma isn't about laptops. It isn't about whether things are lost, broken or stolen. Karma is not concerned with material wealth or earthly possessions.

Sagely she told me - you have many people here who care about you very much. You have done many kind acts & you are loved. That's karma.

Sometimes its the most obvious truths that are the very hardest to recognise. 

Kathen - កឋិន

I scratched up another Buddhist ceremony last week as part of S - my khmer teacher - one woman attempt to convert me to Buddhism.

This one Kathen - កឋិន is a monk robe giving ceremony which happens once a year & gives the donor a better chance of a good life when reincarnated. The robes were $45 which is significantly more than any items of clothing I currently possess. The date was set for Wednesday so I agreed to meet S at 3 pm for an hour to do the ceremony.

On the day at 2 45 pm I received a frantic call from S to tell me that the ceremony was starting sooner than expected & I must come immediately. I started to pack my things up before cycling the 5 minutes to her Pagoda when I received a second even more frantic call from S telling me it had started already & she was going on with out me. It was 2 46 pm. This is Cambodia.

By the time I arrived at the Pagoda they were on the third & final lap of the pagoda. S was carrying the box of monk robes on her head & beaming like a happy buddhist, safe in the knowledge that a good next life was in the bag.

The thing that struck me about the large procession of people all looking for  better reincarnation was that they were predominantly women. Perhaps Cambodian women have, I mused, more reasons than men to improve their next life.

S found us a spot by the door where everyone coming in & out, as well as all around could stare & gawp at the only barang in the crowded Pagoda. A woman gave me a flier for something which I took smiling & then immediately gave to S. S started rooting around in her bag for Riel. The woman was asking for money for another Pagoda & spent the next 2 hours milking the crowd. "Give only a little" S hissed at me as she slipped a 500 Riel note into the flier & passed it back to me. Apparently you can't reach enlightenment in Cambodia without a lot of money being forked out first.

The master of ceremonies started to call out names & pairs of people picked their way through the packed Pagoda to offer the robes to the monks sat at the front beneath the huge gold Buddha.

Concerned I asked S - I won't have to go up there will I?

S smiled reassuringly back at me & shook her head & told me to wait.

I got given a bottle of water.

I made friends with a 2 year old boy eating dried banana who had a similar vocabulary to me. He enjoyed showing me his half masticated banana.

My legs went numb.

My back went in to spasm.

I marvelled at the callouses on the ankles of the old khmer women who have spent a life time sitting on hard floors with out the soles of their feet showing.

I admired the variation of the traditional Pagoda dress of sampot & white shirt. Some women had intricate sequinned lace tops, other beautiful embroidered cotton blouses. Some Sampots were traditional khmer silk, other Laos or burmese pattern. All were in their Sunday best.

Out side the Yays gathered, drank tea, chewed betel nut & the fat.

I felt the familiar feeling of inner peace wash over me as I stared up at the intricate paintings of Buddha's life story on the ceiling, felt the cold tiles under my numb legs & inhaled the incense & talc ladened air.

"ESTHER WILSON" the man with the microphone shouted.

I snapped back to reality. S had already leapt up & was nimbly tip toeing toward the front of the Pagoda. I sat literally paralysed as it would take at least 5 minutes to get my legs working again.

"ESTHER WILSON" was called again.

The Yays all sat around me started to mutter - go Esther Wilson, go!

I looked imploringly at S - You said I didn't have to go up?

She smiled serenely & told me it didn't matter.

"ESTHER WILSON???"

The Yays all looked at me accusingly. "Tow - Go!"

"I am shy" - I replied

Ohhhhhh - they all nodded in agreement - Ean - they murmured. The barang is shy.

Meanwhile S got to give her monk robes & buy a few more future life credits.

There then was a long session of buddhist chanting which at one point sounded like an ambient track I once owned when I was at university. I felt awkward about recording it until I saw one of the monks get out his smart phone & film the proceedings.

The lab lady from the hospital saw me on the way out & amused asked S what I was doing there. Every one looked very happy, it must be nice to believe that you have secured yourself some good karma for the next reincarnation.

Why didn't you come up with me to give the robe? S asked me crossly when we got back to her house.

You said it was ok for me not to! I replied defensively, bewildered by her sudden change in mood.

I wanted to do it with you, next year you come back & we will feed the monks AND do monk robe ceremony together, both. Every year in this life so we will be together in the next life.

But I don't believe in any other life but this one, I deferred.

The sharp intake of breath from S was adequate reproach.

I gave her a kiss & apologised for being a constant source of disappointment & worry to her, she is after all my Cambodian mother.

Then I went back to work, safe in the knowledge that I would need an awful lot of ceremonies or Bon to ever be any where near a good person.

Very Superstitious, one more thing to say...

Just a post script about superstition & health in Cambodia. Follow the link…...

After the Flood

There has been bad flooding in Cambodia this rainy season which a couple of weeks ago resulted in a Dam near my home being breached to stop the reservoir bursting its banks. 

A Khmer blog said that the villagers that had lost their homes had said that "the authority told them that their houses are deliberately flooded because the land in this area has already given as a concession to the company and they company tried to evict them along time ago but the people refused to leave. Now they deliberately flooded their houses in order to evict them from the land." 

My friend went last week with a group of people to hand out tarpaulins & rice to the displaced villagers & help make temporary shelters for them. This weekend my assistant wanted to go to see the lake - it felt a little like disaster tourism but as we had lunch at an exorbitant price at least we gave back a little to the local economy. I have never visited the lake before - it is a 1 hour moto journey from my house - therefore I have nothing previous to compare what I saw to but suffice to say you don't need to have visited a place before to recognise devastation.

 Flooding all the way to the road we travel on once a month to the border hospital

Deep enough to necessitate the white 4 x 4 car we go in.

The lake still beautiful despite a UK-like grey overcast day & no longer threatening to burst its banks

The path the breached water flow took through a village taking with it over 50 dwellings

Life after the flood

The expensive lake monster we had for lunch - looking at the teeth on it we didn't really fancy a  post prandial swim 

Historian

At medical school we were always told that there is no such thing as a patient who is a poor historian just a poor history taker. With this doctrine still ringing in my ears in Cambodia I thought that it was just my extremely poor language skills & things getting lost in translation, which gave me the impression that Cambodian patients are really dreadful historians. I have recently had to revise this opinion.

My khmer teacher, S, who speaks reasonably good english & is an educated woman asked me for some medical advice. In khmer she told me she had a sore throat.

How long for? I enquired.

Since you left for Sampov Luon - came the reply. So this was about 6 days.

Where is it sore exactly?

THROAT! she shouted as me in khmer.

All over, one side, upper, lower???? Could she maybe point to the place? I persisted

Silence & a very blank stare. So I asked again but this time in khmer. Still a blank stare. So I demonstrated pointing to either side of the throat on the outside, then opened my mouth & pointed to my tonsils & finally pointing outside but lower down, by my sternal notch.

THROAT! she yelled at me in khmer again. It is not uncommon for patients to present with unspecified character of pain "choo" all over their entire body so I should perhaps have been grateful we had an area.

What brought the pain on? I asked her, changing tack slightly. Have you had a cough or fever with it? Can you swallow ok?

NO NO NO! she shouted back at me & then disappeared into my bathroom.

She came out a few minutes later & flipped her head back like a cartoon character, opening her mouth in such a way that all could I see was the roof of her mouth & her false teeth.

THROAT - she yelled in khmer at me whilst performing a semi-limbo for me to inspect her dentures. Well at least I could surmise she had an airway, was not hoarse & at 63 years of age was still very nibble.

I felt for swelling or lymph nodes in her neck - she shrugged me off - THROAT! she screamed at me.

Using another favourite history taking trick of mine & the very last of my patience I asked her what she thought the problem was?

"I ate some fish & the next day I had a sore throat, maybe I scratched my throat" she responded in perfect english.

Which side? I asked

She stared at me impassively.

Normally when you get a fish bone stuck or scratch the throat it will be sore in one particular place that people can point to from either in or out side.

THROAT! - she replied......

I have a theory that because in the UK even child birth is medicalised any woman having a baby will have some access to antenatal & prenatal clinics & medical care. Most children are immunised & there are scheduled follow ups for children with community health. Doctors used to go into schools. Dental & optician services used to be provided for free. All of this meant that even if you were a perfectly healthy individual you would still have some contact with free health care services & health surveillance programmes. This meant you became practiced in the questions health workers usually asked. There is health promotion & education in the media, medical dramas & documentaries on the TV all of which provide the language to communicate with health workers. Parents teach their offspring.

Doctors & nurses in the UK talk to patients & depend on their answers to help them make a diagnosis. If you speak to a doctor in my country or ask them a question generally they don't yell at you, tell you to leave there clinic & refuse to treat you again, generally not......

So although I do agree that it is up to a doctor to get a history from their patient there is also something within certain cultures that trains patients to be better historians. Mainly I believe that this is as a result of a decent & robust public health system & professional health workers.

S went to get coined the following day & now feels much better. She is still unable to pin point for me where exactly her pain was but since it has disappeared I thought it was best just to let that one drop.