Scabby Dog - an Allegorical tale

In our pre-daparture training, 27 months ago in a wintery Birmingham, a VSO nurse told us to NEVER touch animals whilst on our placement & warned against Rabies & vicious dog attacks. She never warned us about not being able to bare the way that animals are treated in our host countries or that we may fall in love with an animal & want it as our pet.

I've lived in the same house for 2 years now. The compound has 3 dogs that belong to my landlady & whose sole purpose is to keep away the ghosts. The 8 foot razor wired topped fence & locked gates deals with any potential human intruders. Yappy dog was disposed of after my neighbours complained about his barking. Snappy dog, true to his name, has bitten me & several visitors but no one seems to want to dispose of him & last but not least Tony - the landlady's deceased husband's big, ugly, white dog - who is a psychopath dog, I hate him. Even after 2 years he still barks & growls at me, not just when I enter or leave the compound but often even when I am INSIDE my house & he is stood on the other side of the closed door on my veranda or one storey below my window.

Kind, helpful people, who don't realise that I grew up with dogs, have repeatedly told me I should feed Tony then he will respect me as a pack leader. As Cesar the dog whisperer would say, Tony is the worst kind of dog to rehabilitate - he is an insecure, anxious dog. He barks & growls & snarls at me but when I go to feed him he runs away - still barking. I've tried everything but Tony is a dog that only deserves to be kidnappped & eaten at Pchum Ben, unfortunately due to the whole deceased husband situation this is very unlikely.

Up until recently the VSO nurse's advice to avoid all dogs wasn't that difficult to follow.

Scabby dog crept into the compound & the hearts of mine & the Landlady's daughters a few months ago. She just appeared one day - this hairless, scabby, emaciated, smelly, wretch - covered in encrusted dirt, mange & sores. But she had that quality for which I like dogs for, even in her weakened wretched state she would wag her tail when ever she saw me & say "LOVE ME, I LOVE YOU, PLEASE LOVE ME" with her a big, brown & the only part of her body that wasn't diseased, eyes.

She made me want to help her. I discussed her with R - often reviled & ridiculed by his own family for being kind to animals. He saved a puppy with one gammy eye & nursed him back to health. Tony - his dog, much nicer than my psycho Tony - is a barang dog. He is loved, fed & watered & understands english commands. R had some of Tony's medicine left over & reluctantly - I think he gets fed up with all the ridiculing from Cambodians - he agreed to help me treat scabby dog.

The first injection we gave, I held her down & he administered - she whimpered a little but after licking her injection site she then started following me about even more adoringly. I believed she could sense I was trying to help her & I spent silly money, for a volunteer, on dog treats & started feeding her every day.

2 weeks later she was a little less scabby & tufts of hair were growing back. She was still pretty smelly but also equally very loving. She could always be found laying on my welcome mat on my veranda & making the whole place smell disgusting. Encouraged by the improvement we gave her a second shot - much to the amusement of my landlady & her family.

Snappy dog started bullying her, adding bite marks to her mangy skin. I began to really hate the other dogs & became very protective of scabby dog - who because of her very sweet nature never fought back.

One day I came home from work & scabby dog rushed out the gate to greet me - she then saw a male american tourist walking into the hotel next door & went to him instead. I felt a little put out by her behaviour but my Australian friend pointed out that scabby dog was only doing what most people did - getting what she could from who ever would give it to her. I felt cheated & used, after all I was the one who fed her & gave her medicine. I had to keep reminding myself she was a dog.

I went away for 3 weeks & when I returned there was a startling transformation - scabby dog was plump & healthy looking. She had a full coat of fur, was happy & playing with snappy dog & Tony. I got the best welcome home greeting ever, in direct contravention of the VSO nurse's rules about touching dogs. She even would tell Tony to shut up when he started barking at me.

R thought she needed a third injection & also suggested given her a depot injection to prevent unwanted puppies. One day soon after this conversation I needed to get something from me home - dressings for a hotel receptionist's leg, another blog - so R gave me a lift from work on his moto. On arrival scabby dog was locked in doggy sex with the dog that lives across the street, it would appear that we were a little late in giving her depot contraception. She tried to wag & greet me but with a shaggy dog attached to her it was less easy for her to be welcoming.

R thought it was hilarious especially because of my reaction. I was disappointed, having spent the last few months nurturing her back to health, feeding her, gaining her trust & confidence so that in return she was going to get herself knocked up by first dog that came along. Who would look after the puppies hey? I'm sure the neighbourhood stud had promised to respect her & take responsibility for any puppies but he looked like just another dirty dog misogynist from where I was standing.

R got an english lesson in conditional & unconditional love.

I seemed to be taking it all very personally.

R used his buddhist card when I asked about performing a doggy abortion.

The stud followed scabby dog around for 3 days - she didn't look like it was completely unsolicited attention but equally she was looking a bit bored by his relentless attention. They would sleep on my steps or veranda & whenever I came or went scabby dog would wag her tail & stud would growl at me. I started throwing water over stud & calling him a dirty dog misogynist twat. I appeared to be harbouring a lot of unresolved rage.

I oddly felt as if scabby dog was throwing all my help & care back in my face - rather than her in actual fact only doing what all dogs do. R had a theory that I was jealous of scabby dog. R is a Cambodian male so you should take his theory from his cultural perspective & with a pinch of MSG. R also thinks that all women are lazy, stupid & weak as well as jealous.

The stud has now left the compound - good riddance, so I have to find a new object to channel my rage at. Scabby dog is getting even plumper.

After a week in SLN I came back to find that scabby dog is scabby again, she has open, bleeding sores and is loosing weight & as well as hair.

For the last 4 months I have tried to help her but she needs constant support & supervision that I can only give her for the time I am here. She is currently dependent on the kindness of the landladies daughters & R's medicine. I don't want her to be dependent on me but don't like to think of someone else looking after her either. My intervention changed her life but it wasn't sustainable & now she needs more. In return for my efforts I just get a waggy greeting every day & a smelly veranda.

Tony continues to growls & bark at me.

I'm sure there is a lesson in here somewhere.......

The great yeast extract tasting test...

Since coming to Cambodia my palate has adapted. Now I enjoy noodle soup for breakfast with offal & plenty of chilli. I have to eat rice at least once a day or I don't feel quite right, I LOVE Bor Bor - rice porridge. 

My tooth has become sweeter - I suck condensed milk through a straw with a splash of chocolaty nutty flavoured Khmer coffee & I drink evap milk with syrup as a treat. Snacks have to involve rice, banana or bean, coconut & be deep fried. 

I was feeling very jaded recently & before going on the long bus journey back home I went to the restaurant across the road from the bus station & ate rice with pork, pickles & a bowl of soup at 6 30 am & it was the best bloody hangover cure I have ever had. 

I am yet to eat spiders, crickets or fertilised eggs but it is just a matter of time - I do love one year fermented rotten fish paste (Prohok) after all.

So I have adapted to the Khmer diet & tastes but can Cambodians try something from my mother palate? Where ever I am in the world I can always be found with a pot of marmite. I have an ongoing debate with my Australian friend Kristy about which yeast extract is superior - my mate Marmite or the Australian alternative Vegemite. She mistakenly believes that the bitter, saltier, foul tasting Australian version is better. On a recent visit to Cambodian, after a Facebook induced debate & stand off, Kristy bought vegemite, marmite & another generic yeast extract product with her so that we could use our old translator & his girlfriend as our judges for the ultimate taste test.

Below is a photographic record of the results of giving yeast extract to virgin palates. It would seem in Cambodia with yeast extract, you either hate it or you hate it a little bit less!

Moments before the first tasting - Vegemite

Moments later -  taste buds are assaulted 

Generic yeast extract

Its getting all too much 

Kristy's antipodean biased response to Marmite!

Struggling to be a demure Cambodian female in the face of Vegemite

Kristy is happy that the taste challenge has been such a success

Kristy's vote

Under duress the best of a bad bunch

The sweetest tasting one

Marmite to the left of me, Vegemite to the right - here I am stuck in the middle with you

Just call me the grim reaper

I had a cheery Christmas on the Thai border, the Boxing Day afternoon in the ER was particularly cheerful, as is the rule which states that sad & terrible things always happen at Christmas time in Emergency departments.

A patient was admitted Christmas night with breathlessness & collapse. She was 33 years old & 4 days before had delivered twins. The MA on duty had recognized that she was seriously unwell & had wanted to transfer her to the provincial hospital but the director would not give permission so she was kept in the ER over night on oxygen.

When I saw her the next morning I was concerned about her & after discussion managed to persuade them to transfer her. J & R went to discuss nursing training with the head nurse whilst I stayed in the ER to keep an eye on her whilst I worked on my laptop - I had a bad feeling about her. The hospital ambulance took over 2 hours to mobilize & just before it finally arrived to take her she cried out & arrested.

I called for help, no one but me was in the ER. This actually required phoning R to come back. For the next hour 2 nurses, a Medical Assistant (MA), a student nurse, R, J & I tried to resuscitate her. I showed them how to do effective chest compression, they intubated her. We used up their supply of adrenaline & we got a return of spontaneous circulation. From her history it was most likely that she had a massive pulmonary embolus but I was worried that if she had a pericardial effusion, which was tamponading, this was something I could do something to reverse. Whilst she was still arrested I asked for a spinal needle & was preparing to do a pericardiocentesis when we got an output. I wasn't so keen about sticking a needle into her chest, without USS, if she wasn't arrested.

On a previous visit to the maternity ward I remembered seeing an USS machine locked in a cupboard. I asked if I could use it to do an ECHO on this patient. If I'd been at the provincial hospital they would have been resistant or said it wasn't possible but I was here so a student nurse rushed off to get it. The ECHO showed she didn't have a pericardial effusion but did have right heart strain making the most likely diagnosis a PE. She then arrested again. This time I was able to show the effect of adrenaline on her heart & why we give it as an inotrope. The staff were beginning to see you can do a lot more than scan a pregnant woman with this machine.

She was now dependent on adrenaline to maintain a cardiac output & wasn't self ventilating. The decision was made that there was no point in transferring her as she wouldn't probably survive the 2 - 3 hour journey.

She had a 4 year old daughter which J suggested should come & see her mum before we withdraw treatment. R got very angry with us & walked off. J was confused, normally R is so caring - neither of us knew what we'd done but concluded it must have been something really culturally insensitive.

She died 10 minutes later. That afternoon we were all a bit subdued. I sat with R & asked what we had done to upset/offend him. Nothing as it turned out, it was actually a lot worse than that. The daughter was from a previous marriage. R had heard the patient's relative discussing how the stepfather was an alcoholic & they couldn't afford to keep & feed the twins - which will now no doubt die without their mother - they were sure that the daughters fate was equally grim, perhaps she would be sold to Thailand, perhaps she would be abused. R heard all of this & just felt overwhelmed with hopelessness at being unable to save the mother. He didn't want to cry infront of the staff.

Now J & I were feeling even more upset about the events of the morning.  We worked in silence in the now empty ER all afternoon. It was getting late when a man rushed in with a 19 year old girl in his arms - she was dead. She had started coughing up blood 30 minutes before, choked & collapsed.

The second resuscitation of the day started, apart from this time, as it was 5 pm, there was no doctor - just me, 2 nurses & 2 student nurses as well as a depressed J & R. We did our best but there was an electricity cut so no suction, no light to see what we were doing.  We managed to get in 2 large IVs and give her 3 litres of saline. Intubation without suction was more of a challenge. Having exhausted the ER's adrenaline supply that morning we started on the medicine wards expired ampoules. After 30 minutes of resuscitation & in the half light we stopped.

We found out that she was from the south of Cambodia but was working here to send money back to her family 400 kms away. She was here all alone with no close relatives. She had been diagnosed with TB 2 weeks previously & had been commenced on treatment & discharged only 2 days previously. It was profoundly sad.

One of the nurses was crying. I suddenly felt a great connection with her. We had both tried & failed to save the lives of two young women. It felt so tragic & hopeless I wanted to cry too. I mentioned to R how upset the nurse was & how unusual it was to see this in Cambodian health workers. "Esther" he told me witheringly "she's crying because she's just found out the girl had TB & she's told me that she is worried that she will now catch it."

One Boxing Day, a few years ago now, I was working a run of six nights in paediatric ICU. Two children died of meningococcal sepsis, the day doctor didn't turn up to relieve me so I had to stay on until 11 am to do the ward round. When I went to my car, it had been broken in to, causing £150 worth of damage - the thief had taken just a packet of wine gums & some loose change.

Reflecting on the ghosts of Christmas past, my run of nights in PICU was beginning to seem like one of the happier ones. Writers block followed.

Boundaries & limits

The day after discussing with the head nurse, Mr S, about staff stealing special food bars (BP-100) meant for malnourished children, I went back to the paediatric ward to check on a child with SAM (severe acute malnutrition) & take some photos of her clinical signs (skin & hair changes, foot oedema) for training purposes.

On approaching the ward it became clear they were having a cleaning day - all the beds & mattresses were wet & glistening outside, drying in the sun. The nurse who had stolen the BP-100 was washing her car & the cleaners son was running around it giggling, having fun splashing in the puddles & being occasionally sprayed with water from the hose.

It was a great scene but before I could get out my camera the nurse looked up, saw us, stopped cleaning, then apologized in english to me & L. She was just washing her car & there are no patients to be seen, she said, looking very contrite.

I'm not even sure if Mr S had spoken to the staff about the BP-100 but I was puzzled as to how the same staff that steal medicines, without a hint of remorse or guilt, in front of me, now think that washing a car is a shameful act. I know that it is maybe not the best use of work time but surely it is not worse than stealing from starving children. Is their moral compass really that skewed? Maybe they don't even think in terms of what is moral or immoral, maybe for them it is about what they can get & have.

It got me thinking of how children need boundaries & limits, morality is nurtured. I wondered if the same was true of the staff - their leadership is corrupt & role models are lacking. There needs to be some explanation of what is expected of health workers, what is appropriate & inappropriate. If good behaviour was rewarded then maybe they wouldn't reward themselves, by stealing & taking bribes, to supplement their low salaries. The introduction of the naughty step may be a step too far but some enforcement of fair rules & regulations is definitely needed here. Two thirds of the budget for medications in Cambodia not being 'skimmed off' before it reaches the patients may be a good place to start.

I went inside to take the SAM photos. The child was in respiratory distress, grey, clammy & looked like she was about to die. It was a Friday and I had broken the cardinal rule which is 'NEVER visit the paeds ward on a Friday' - no good ever comes of it.

Speaking with the mother & examining the child it seemed quite clear that she had aspirated on her NG feeds.

I tried to speak with the staff, who were about to give insulin for high blood sugar & absolutely refused to accept that it was an NG tube problem. Which was odd because when we arrived they were actually in the process of changing the NG tube. They also refused to admit that the blood sugar machine could ever be wrong & would not send a second sample to the lab to double check. I quote 'the machine is NEVER wrong'. And when I tried to explain that if this child had aspirated she was going to get even sicker & we should act preemptively by referring her to the NGO hospital in Siem Reap with an ICU, where they could intubate & ventilate, sooner rather than later - they shrugged & said "the child is sick, they will die".

Iced coffee has become my valium.

Whilst sucking up condensed milk I called Dr Ch who works at the NGO hospital. Puzzled he agreed with my assessment & management plan for the child, why was I calling him for advice?

I explained to him that after 2 years of being ignored & at best treated with disbelief & disrespect, you begin to really doubt myself. Sometimes its useful to hear that there are other doctors who would do the same as you - that you both have the same boundaries.

Dr Ch was happy to have the child transferred to his ICU. Whether the staff did this I don't know because I can only advise and this medical advisor had reached her limit.



The post script to this story is - the day before I had been advising on relactation for the same baby. The mother, my VA, the doctor & the nurses all refused to believe that the mother could relactate after a period of 6 months of not breast feeding the child (she was working in Thailand). I referred them to the SAM clinical practice guideline and the technique of suckling whilst giving tube feeds to stimulate production of maternal breast milk. They were skeptical & L was sure they wouldn't do it. I could understand that - sometime you need to see to believe. The nest day when I was asking the mother about the child's breathing problem, she told me it got worse after choking on an NG feed which is why the staff had changed the tube. It was only after leaving the ward that L pointed out I'd missed something, they had actually been attempting relactation. The mother had explained that the baby was suckling on her breast whilst being tube fed when she choked. You have to look hard for it but sometimes there is a positive.

When in Rome...

I'm currently helping to develop a Severe acute malnutrition (SAM) training package - my session is on the stabilisation phase, steps 1-6 -  and so found myself in the paediatric ward asking if  I could take some photos of the medication they have for SAM patients. One of the nurses always brings her 4 year old daughter to work & after 2 years she's become bold with me. Chatting away to me in english & khmer. "Hello" she says, "Sok-saa-bai?" I ask "Fine thank you" she replies, "Nyam bai howee?" I ask and the khmer conversation circle has been completed. She has stopped asking me where I come from after 18 months & she doesn't seem so interested as to where I might be going.

On this occasion she was sat on the table in the staff room stuffing oranges into her mouth & looking the picture of a well nourished & healthy Cambodian child. Her mother lazily got up, on one of the paediatric all star's request, to unlock the room for me where all the malnutrition medication is kept. F-75 & F-100 a special formula, ReSomal for dehydration & BP-100 a special food supplement bar.

Whilst I was taking photos of the packets of medications - because that is what they are, special medication for children who have severe malnutrition - the nurses daughter came in & started pulling at a box on the floor. Her mother went to the box & got out a vacuum packed packet of BP-100, I smiled & said politely "Do the children with malnutrition like to eat this?" just as the nurse started to open the seal. Before I had the chance to construct a sentence in khmer saying I didn't need it opened she wordlessly gave the bar to her 4 year old child who started shoving it into her mouth, like a child who had been asking for the bars that she always gets when ever she is in work with her mother.

Sadly I was not that shocked or surprised, after all this is the same nurse I've seen sat watching TV, eating snacks, laughing, whilst children die without medical intervention only 5 metres away. It doesn't surprise me at all that she may see nothing wrong in quite literally stealing food from the mouths of children who are starving to death. All in a days work.

What upset me was my response & the conversations I had afterwards about this incident.

Walking for a well needed iced coffee break afterwards with L, I asked if she thought it was wrong to take BP-100 & give it to well children? - yes. And had I done the right thing? - yes. As my translator she has a vested interest in me not upsetting people as it is, after all,  her that gets it in the neck.

I then spoke with the Cambodian NGO worker I share an office with when I got back there. He laughed - this is normal for Cambodia. Was it wrong? - yes, but it was still normal for Cambodia. What would he have done? nothing or maybe made a joke.

I spoke with R - he shrugged, this is Cambodia, I do not understand why this is upsetting you. He told me to put it into perspective. With all the huge corrupt practices & the money skimmed off at ministry level why was I so concerned about a single bar of BP-100.

From little things big things grow.

I went for my khmer lesson, S & I had a long conversation about this. Apparently I am in Cambodia - I require reminding of this fact at least 4 times a day. She told me a great proverb which although involving a lake & country side basically means the same as 'when in Rome, do as the Romans do'. What do you think I did? I asked her. You must say nothing & keep silent she implored me - like any one who lived through the khmer rouge would tell you this is the only survival strategy here. Slowly & calmly in khmer I asked her - I do not want to know what you think I SHOULD have done, I want to know what you think I ACTUALLY did? She smiled at me knowingly & said - you stayed silent.

She was right. I knew that saying something in that time, that place, was just pointless.

When in a lake do as the country people do!

I was feeling pretty depressed by this. Have I lost my fight? Is it time for me to leave?

I discussed with R, S & L again about the morality of what happened. I gave them 2 scenarios. The first is a health worker who has a headache or fever whilst at work so takes paracetamol from the drug cupboard so they can then carry on with their shift. The second story, some what emotively, involved stealing medicine from the mouths of starving babies.

What's the same about these stories? Well they are both stealing so therefore morally wrong.

So why is story 1 more palatable, more acceptable?

They all answered the same, and I also agree, which is that although in story 1 the health worker is stealing, they are self medicating & staying at work to do their job & care for patients. They could go home, they could leave work to buy medication or they could stay & be ill & not as effective in their work. What they choose is not the worst option for the patients. Their motivation & intent is not completely morally wrong.

Thankfully they all agreed that Story 2 was wrong & felt more wrong as the child is eating a medication for malnourished children when she is in fact perfectly well nourished. Also they all know that often the hospital runs out of medication & this is the reason is why. S is a retired teacher & she knows this is the case - its common knowledge.

I know this happens everyday. I know it is a normal part of Cambodian culture. I know that it is wrong.

What I don't know is why I didn't think it was right say something at the time or why all the people I work with don't seem as upset & disturbed by it as I am when their job is the same as mine - to cspscity build & improve health care.

The following day I was waiting to speak to the head nurse about it - knowing full well he would never act on my complaint - when I had a call from Jn my future boss.

She wanted to ask about cellulitis but the conversation quickly came around to malnutrition & the nurse. I told her how useless I felt, I said I was actually sat writing my final report for VSO when she rang & it was making me realise I have achieved nothing & I am a waste of space.

Jn told me something that pulled me out of my nose dive. She said this "Esther you have had conversations with people about the morality of stealing. If you weren't here they would not even think about whether the nurse taking the BP-100 was right or wrong. They would just accept that this is the way that things are here in Cambodia. Every day you challenge & question them. Even if you don't change their attitude or behaviour you have introduced them to another point of view. That is what capacity building is. That's what I want to see written in your final report!"

It really is exhausting constantly challenging others received wisdom, constantly doubting your own morality or motivation or reason. But that's my job, my choice.

Today I will discuss this case with Mr S, the head nurse. Today I will be a Roman even though I am in actual fact living in Cambodia.

WPW - the saga that will never end.....

So the last time I blogged about M - the 17 year old girl with WPW syndrome - she had a third & finally successful ablation on my Birthday. I then went to Borneo for a holiday & she went home unmedicated to start the rest of her life without any further life threatening arrhythmia's.

Life is - as I have discovered here - a series of disappointments.

The Sunday that I arrived back in BTB I got a text from L - my VA - saying that M had not eaten rice for 4 days & was very sick. I told her to come to the referral hospital on Monday so I could see her. I had a very sleepless night. They hadn't come earlier I later found out, despite me telling them to seek medical advice early, because they couldn't afford the transport, they didn't like how they were treated at the hospital when I am not there & they hoped it would get better by itself - after all they had been told she was cured.

On Monday M arrived at OPD looking swollen, pale & jaundiced. Her heart rate was 240/min. My heart sank. I went to tell ICU about her admission & was told - we don't have any ECG paper. I asked if they had requested any replacement ECG paper. They flapped their hands in my face & told me to go away they were busy - ask Dr ON, the deputy director, if its so important to you. By 'busy', they were sat watching TV, writing paper work.

We got an ECG at OPD which confirmed the diagnosis of an broad complex tachycardia - her WPW -  & so I called Jn in PNH to organise for Amiodarone to be sent up. Jn had her own fun trying to find IVAmiodarone and finally could only find 2 boxes of ampoules that were 3 months expired. I joked with her that the nurses would probably refuse to give it. In the past 2 years I have never once seen them even check expiration dates on medications.

Meanwhile despite a very low BP, M was walked over from OPD to ICU and was left standing in the corridor until I kicked up a fuss. The staff remained in the staff room. My post holiday glow had evaporated.

Now that I have a contact in the states - the cardiologist that did ablations 2 & 3 - I emailed him & asked for his advice. He replied almost immediately saying he knew a friend who worked at the NGO trauma hospital in town - Handa - and had skyped her. They had a defib machine there. Previously, in September I had been told it was old & had never been used so had discounted it as an option but apparently it was now available, it was still untested as never used.

I went to see it & it did seem to be working - it charged very slowly, as if the little men inside on their bicycles peddling up the charge were as exhausted as I feel currently. As M was stable (IV fluids had treated her dehydration from 4 days of not eating) and Amiodarone had worked for her last time, I opted to keep her at the referral hospital & load her with Amiodarone but if she deteriorated we could transfer her for a DC cardioversion. It felt good to have options for a change.

The Amiodarone didn't arrive until late as although J got it on a Taxi by 1pm in PNH, the taxi then waited another 4 hours to fill up with passengers.

The following morning the nursing staff refused to give the Amiodarone as it had expired - is this my hubris? After a lot of discussion & explanation they started the loading dose - M's BP dropped, her respiratory rate increased, she looked dreadful. I wanted to transfer her to Handa Emergency Hospital but the hospital management team were not happy with this & would not allow use of a hospital ambulance to transfer her, however she was hardly in a fit state for a tuk tuk or moto.

They showed me 3 defib machines the hospital had - none of which I knew about, none of which worked anyway - and I convinced them that the only hope for this 17 year old girl was a synchronized shock. They agreed if I could find a method to privately transport her they would sign her out as self discharged.

Handa arranged for an ambulance to come pick her up that afternoon.

M's renal function wasn't so good, she wasn't really producing urine, she had bilateral pleural effusions & was becoming increasingly oedematous. I had poisoned her.

When the ambulance arrived the staff from Handa wanted her to walk to the ambulance. I had to explain that she had no blood pressure, a heart rate of 240/min and was in heart, renal & impending liver failure. They still wanted her to walk! R & I got a trolley & transferred her ourselves.

At Handa, Dr G took one look at M & felt as engaged in saving her as I have for the last 6 months, she has this effect on people. After a brief assessment in their OPD they transferred her to the Operating Theatre where I was shown the changing room & told as I was much more experienced in delivering DC cardioversion I should do it. Now in the 2 years I have been here no one has ever deferred to me or acknowledged any of my skills - it was quite intoxicating. You'd also think that after 2 years without doing a DC cardioversion I may feel a little rusty or apprehensive. In truth I was just concerned about whether they had scrubs that would fit me - thankfully they did.

She converted after a 100 joules shock - the longest part of the whole procedure was waiting for the machine to charge. Sedated with midazalam & fentanyl she woke up on delivery of the shock & murmured "that's better".

Later that evening Dr G called me to tell me she was back in a SVT but the rate was 140/min & she was stable. We decided to wait for the IV Amiodarone infusion to work but at midnight I got another call telling me she had dropped her BP so they were taking her back to theatre for another DC cardioversion. Another sleepless night.

Jn was coming up to BTB for a meeting & was bringing with her $200 worth of Flecainide tablets that would hopefully keep M in normal sinus rhythm when she went home.

Dr C in the states wanted her to also take a B-blocker. Both of these medications need to be taken twice a day & cost $60 a month.

M stayed for monitoring for 3 more days at Handa & will go home on medications for a review at Handa in 2 months time. She lives a long way away & has no money which makes her follow up a difficult balance between cost & well being. The last of the donations friends gave me has been spent on Handa's inpatient bill of over $200.

M receives free (if inadequate) medical care at the referral hospital because she has a poor card so her care is paid for by a health equity fund, however Handa as an NGO hospital does not have government system & its own poor patient fund is currently empty.

Dr C wants to have a 4th attempt at doing an ablation either next year in Phnom Penh or to bring M to Korea or USA where there is better equipment. I'm not sure how M & her family would manage an overseas trip but it may well come to that is the technology is not available in Cambodia.

Dr CM the Cambodian Cardiologist who did her first ablation wants her to come to PNH when a French team of Cardiologists come for them to have an attempt at a successful ablation.

In the mean time M needs medication & regular check ups to ensure that she remains in a normal rhythm & doesn't die waiting for a cure.

All of this costs money. After 26 months volunteering that isn't something I have an awful lot of.

I have struggled with the morality & ethics of spending so much money on one individual in a country so wanting & full of need. But all I can reason is that without mine & others intervention, M - an otherwise bright & healthy 17 year old girl with her whole life ahead of her - would be dead. Her Mum has come to the same conclusion & told me so yesterday, right after she had told me that she will give me her daughter if I can fix her. This makes me & L very upset to hear such abject despair.

There's no other way to say it than here - no money, no life. M needs money so that she can stay alive & then she needs money for her cure. I am committed to achieving this for her but could really do with a little support. If any one would like to help me to help M please let me know.

Thank you.

I'm a celebrity, get me out of here!

There's a lot of things that I do which aren't strictly in my placement job description & yet are, I consider, capacity building.

This afternoon over coffee break I was doing one such extra-curricula capacity building activity with R - his english home work. Now R has pretty good English but he isn't very confident, so wanted me to check his homework exercise answers.

The format was very similar to my grade 3 khmer text book. Read a piece of writing & then answer questions, match boxes or feel in the gaps. A few sentences where he had to fill in the gaps made me smile, as I said to him he, they could have easily replaced the fictional name with mine.

Examples of this were;

Bob is upset in his work place, he finds it very frustrating.

John is an angry person, during a discussion he can get very aggressive.

Wordlessly R opened his text book to an earlier home work exercise, the task had been 'Write a paragraph about a celebrity of your choice.'

He showed the following writing to me.

"Dr Wilson is a celebrity, nearly almost two years I work with Dr Wilson. So I find that she's a famous person in my mind. She's a very, very good skill and talent in saving patients lives who face a serious problem. She's also got a top score in emergency resuscitation class and she provide excellent medical practice to many country around the world. Specifically many medical practice are provided by her in emergency department. She is very kind and doesn't discriminate to anyone around her. She's also provided all her knowledge and skill on emergency patients resuscitation to all facility which involving to be improved health quality care in Cambodia and other country so needed. So I believe that she's a celebrity."

A little embarrassed he explained he didn't know of any other celebrities to write about, only me & Janice.

It's all nonsense of course but as I'm in the process of writing the final report for my placement which includes me also having to write my own bloody reference e.g. Esther was told by her deputy director, via her Khmer teacher because he was too scared to tell her directly, that she needs to be less angry! Do you think I could use this as my reference for the last 26 months with VSO instead?

Secondly - if I really am a celebrity a) where's my prize? and b) GET ME OUT OF HERE!

Cambodian Christmas

Ho Ho Ho!

This blog is a little belated.

I am not a stranger to spending Christmas away from home or working all through the holiday, but this year Christmas took on new, more surreal, dimension.

I spent Christmas this year in a dusty, dirty border town in north west Cambodia with 3 of my favourite people in Cambodia. J & me to our credit put in some effort to be festive in the face of sun, heat, dust & an absence of Christmas spirit. R to give him his due & with no previous experience also entered into the festive spirit & unlike my Father even made a concerted effort to be cheerful on Christmas day. Mr T - our driver - hadn't a clue what was going on but embraced the concept of eating lots of good food.

We travelled on Christmas eve - a 3 hour journey that J & I filled singing Christmas Carols & listening to cheesy Christmas songs. There was something remotely vengeful about it - pay back for all the hours of karaoke we have had to endure. R said the only one he liked was jingle bells.

In the evening we wanted to go somewhere special but the first place had washing hanging out to dry so was considered not appropriate. The second place had no washing so we were able to stay & enjoy a feast of fish, duck & beef. Pushing the boat out as far as it would go J, R & I shared a bottle of beer between us. J had bought hats, balloons & party poppers. You could see the owners of the restaurant were more than a little bemused by our behaviour but obligingly took the above photo.

Christmas morning I was awoken not out of excitement or due to the sound of sleigh bells rather the early morning run of trucks of cassava to the commercial border crossing - trucks with heavy loads & poor suspension on unsealed roads. It wasn't a white Christmas but it was a dusty beige.

J & I had made stockings & forced R to open his gifts in front of us. In Cambodia people don't open gifts in front of the giver - its consider rude or inappropriate. I think we can safely say we converted him to the consumerism of Christmas.

For breakfast we had khmer coffee & a mince pie that lovely Katie had sent in a Christmas care package to me. R was less convinced by this Christmas tradition.

I spent the working day training advanced airway.

For lunch R ordered my favourite khmer dishes & we ate rice.

In the afternoon we saw patients in the new ER - this is another blog entitled "just call me the grim reaper".

That evening we went for soup at the forest. The forest is an eating place near the border with Thailand - ironically named but maybe not intentionally - due to its situation in a decimated deforested area.

Soup involves a communal pot of broth with various vegetables & animals parts - tendons, brain, intestine etc. added in a DIY fashion. Its delicious but as J is a Vegetarian she stuck to rice.

We then went back to the hotel & watched 'Its a wonderful life' & I skyped my family.

I was feeling pretty homesick & sad after my alternative 25th December, but the following day instead of the traditional bubble & squeak with cold cuts & pickles we went for the best Bor Bor - rice porridge & then khmer dessert and I had the epiphany that Christmas is traditionally about being with people you love & remembering the absent ones, giving to people (which can be your time & not necessarily socks & smellies!) & feasting (but again this doesn't necessarily have to be your Mum's roast dinner & homemade pudding).

We did all that in SLN successfully & we even introduced jingle bells into the khmer psyche. However I may be insisting on a Christmas day in July when I return to the UK.

Alternative Christmas pudding

Bubble & Squeak Cambodian style

Random acts of kindness

Today it was very busy in ICU medicine. Lots of sick & dying patients. A patient in the corridor who had a stroke and was in a coma happened to be the father of someone my assistant knows. One of the relatives had put a spoon into his mouth to stop him biting his tongue.

I tried to explain that this was dangerous & could potential damage & cause aspiration of his teeth - I was (as usual) ignored.

My WPW patient is back - that's another blog - and the staff were being at best obstructive. For example the one good nurse was preparing the drug infusion to give to her & I needed help getting oxygen and the 3 nurses sat watching TV in the staff room shouted aggressively that they were too busy to help. I have grown accustomed to this hostile/lazy/uncaring attitude so shrugged & struggled on myself until the chief of ward - too scared to manage his staff helped me.

In an attempt to save my patient the deputy director (my friend & psychiatrist) suggested we see if any of the defibs the hospital has had been fixed. This involved an anaesthetic nurse showing me where they were locked up. We went via ICU so I could check on my patient & he noticed the man in the corridor with the now broken teeth & partially obstructed airway. I explained to him I had tried to stop them using a spoon. What about a OPA (oral pharyngeal airway)? he naively asked - only available in the operating theatre I explained, not on the wards.

We went to see the defibs - all were not working.

I went back to check on my WPW patient & as I was leaving the ward I found the anaesthetic nurse was with the stroke patient in the corridor putting in a OPA and explaining to his family to nurse him on his side to let secretions drain. He looked a bit sheepish when he realised I had seen him.

As he left the ward I intercepted him. I had goosebumps from seeing this rare random act of kindness.
"Thank you" I told him, "Today you give me hope. You have shown compassion & cared for a patient. I see that so rarely I sometimes lose faith that things will ever change here. So thank you for showing me I am wrong"

He shrugged, smiled, patted me on the arm & walked back to theatres.

Bleeding to death

I recently conducted some training on shock. It was repetition from a course that was held here last year & has already been reinforced with various workshops since then but as I am in my dying throes of volunteerism I am conducting an emergency medicine training curriculum for the still uncompleted ER.

In my lesson plan were four cases of the different classifications of shock - all real life patients I've seen here, in an attempt to prevent the "but this is Cambodia..." chestnut. I didn't get past the first patient - a 23 year old with an ectopic pregnancy - why this was the case will become clear below.

I presented the case step by step, asking questions about assessment & management. The main learning points that I wanted to highlight were as follow;

1) Insert 2 large IV cannula in the ACF of a bleeding patient

This was largely debated & rejected despite me explaining the physics of a wider, shorter tube in a larger vein being better than a small IV in someone's little finger. Also I citing ATLS/PTC - the latter of which there has been a course at BTB. Eventually ON piped up he had seen this practice in Thailand & Singapore. My point was begrudgingly then accepted.

2) Give fluid boluses in shock

I was told that giving lots of IV fluid causes pulmonary oedema. I tried to explain that in this young, previously well woman the reason she later went into pulmonary oedema was not due to excess IV fluids but because she had been inadequately fluid resuscitated and had hence gone into renal failure. My one surgical ally afterwards took me to one side to explain that the doctors in the room did not have the basic science knowledge to understand even my simple explanation. This was self evident - see below.

3) Reassess after an intervention

At this point of the training - when I explained that after giving one bolus we should reassess the patients clinical condition - I got shouted out. I was told that this patient should go immediately to theatre as it was obvious she had an ectopic pregnancy - reassessment was pointless & unnecessary. When I tried to explain that we were now only 10 - 15 minutes into the patients admission and we had only just started giving the first fluid bolus, I was called a liar, told I didn't know what I was talking about & I was trying to cover up my mistakes & stupidity.

J was shocked at this point that I didn't just walk out. I am nothing but a trier - or perhaps just very obstinate.

I had to tell them all to "shut up & listen to me" - they were all shouting & pointing aggressively & poor L wasn't being given a chance to translate my response to their initial questions & then their subsequent abuse. Afterwards my one surgical ally bought me lunch & said I should consider losing my temper with them more often. He was thrilled after 2 years I had finally stood up for myself instead of trying to be culturally sensitive - he has been wanting to tell them all to shut up & just listen for the last 10 years. The saving face culture only seems to count if its their face they are saving - clearly disrespecting me is allowed under this misogynistic culture.

I calmly explained that if you have a bottle with a hole in it how do you know that it is still leaking unless you first fill it to see if the water stays in or not, i.e. unless you replace volume & see if vital signs improve or not how do you know you have an unstable patient? Patients can tamponade & stop bleeding so although initially shocked after adequate fluid resuscitation will improve & may not need emergent surgery, if at all.

They weren't getting it. See above re; lacking basic knowledge. So I tried another tack. How much blood does a person have to lose?

Silence.

I asked again - how much blood does this 45kg woman have to lose?

Silence.

Feeling very vindictive after my verbal assault I suggested that as surgeons who cut patients open &  make them bleed every day it was probably their responsibility to find out how much blood was in a human body.

Silence.

I told them - they all wrote it down in silence.

4) Give bleeding patients blood if they are unstable or their Hb is below 7

5) Take unstable patients to theatre to stop bleeding

Points 4 & 5 were never made as it was 11 30 am by now & they all went to lunch.

I can cope with being shouted at, insulted, ignored & disrespected.

But what I really can't cope with is another 23 year old dying due medical mismanaged. I am very weary now. I can feel the last bit of hope & resolve haemorrhaging away. One could say that I am in need of some serious resuscitation - but will the Cambodians notice, let alone see the need to reassess me?!

Gender - a conversation

This international women's day I'll keep it simple.

Me: Gender is such a big issue here in Cambodia

White older male NGO worker: No it isn't - there are no gender issues in Cambodia

Me: Errrrr - I think you'll find there are plenty. I often think it would be much easier if I was a male  when working with Cambodian doctors.

White older male: You're more likely to have a problem with the doctors listening to you because you are a nurse rather than because you are female

Me: *speechless*

Or another of my favorites.

Me: I try to support Cambodian women I'm friends with & keep gender issue open for discussion with them. Only they can make the change here.

Another old white male - NGO worker: Esther - Cambodian women are like someone who has been born blind. They know no different & you shouldn't be discussing gender issues with them, it will give them silly ideas which are dangerous, If their husbands beat them it will be all your fault. Leave them in the kitchen having babies - that's all they can & should be doing.

Me: *speechless*

And I wonder why I feel permanently incensed here!


Oh & to my favorite middle sister - Happy Internationsl women's-Birth-day!