That's all...

After sending an email to a Cambodian work colleague offering to make some small changes to improve a training package we had developed I was robustly rejected in an open group email & accused of being the problem as I speak english & need translation.

I sent the following private email to my boss, "If I said the sky was blue do you think he would send an email to everyone saying it was green?"

The response had more than a liberal seasoning of irony & echoed the standard response to any question here, "Yes. But only in Cambodia. You wouldn’t understand, as you haven’t been here long enough :=)" 

There then followed further emails from other people copied into the reply group email - all successfully managing to miss the point of my original message. I received a further email from my boss. "If you mention to X that the sky is blue, he will respond that fish don’t walk."

My time here has left me angry, frustrated but wise, my final word on the matter in reply was, "I have video evidence that some fish can walk but I'm learning to pick my battles!"

In my defence...

For the last two years I have been going to ICU medicine ward most working days in my role as a medical advisor with VSO. Whilst there I have been ignored, shouted at, mocked, told to leave & experienced many hostile exchanges or aggression; I have seen countless patients suffer & die whilst I have stood by seemingly powerless to change the outcome. I've blogged about it, I've talked about it & it has filled me with a slow burning rage that I now can't seem to extinguish. Since finishing my placement with VSO I have not been back there. It's a hateful place that has almost certainly shortened my life expectancy.

Over the last 2 years I have received various feedback from people working in health here; some say that I shouldn't care so much, that I am a bad capacity builder because I judge the health workers, that I should just leave if I don't like it, that I blame others for my own inadequacies, I don't respect cambodian culture, one person even reported that I am "never at work" & ineffective in my job - the list of criticism from people is endless, people are very generous when it comes to criticism.

Interestingly one day last week when I couldn't face the hospital so instead worked from home the head nurse said - Is Esther OK? I miss her. I know that working with Cambodians is very difficult. I hope she is OK.

I have also received some ill informed advice from NGO workers in other sectors. I want to be clear here, although I came to Cambodia as an 'advisor' I tried to only ever advise about things within my remit - I know nothing about education, livelihoods or governance so I refrained from the arrogance of assuming I knew how people in those sectors could do their jobs better.

People who are not here have always given me very positive feedback - but they are not here, so how can they really know whether what I do is any good or even worthwhile?

The result has been that I now doubt my own knowledge, credibility & worth. I've internalised the last 2 years of my failure & inadequacy. I don't go to ICU anymore because I believe it is me that is useless & ineffective because I have failed to effect change.

This week I was away training but J stayed at the hospital. J has been in Cambodia twice as long as me & as I have mentioned countless times in this blog is one of God's better people & someone whose opinion & experience I respect greatly.

J goes to ICU rarely as its not part of her role, but this week she went to audit oral & IV medication administration & vital signs there. This week J had a taste of what I have experienced every working day for the last 2 years. It left her raw & doubting herself also. Although I would never, ever wish ICU on anyone. her experience has helped me to realise that I am not alone. It has strengthened my resolve never to go back to that ward. It has made me realise I need to adapt how I process my experiences here & redirect my energy. It isn't just me & it may even actually be them!

I want to tell J's story as proof that its not just because I am judgemental, absent, useless, over sensitive or any of the other criticisms that are thrown at my feet,  that I have struggled for 2 years on ICU. The reality of this place is that its an extremely difficult environment & to survive it one has to compromise one's self a little with every interaction.

Below is J's recounting of the incident.

"I visited ICU Medicine with L (Esther’s translator) and found a patient who had just been admitted. The patient was a young male prisoner.  He was chained to bed by both of his ankles.  He was on the veranda and had the sun shining on him.  The nurse said he was admitted with a stroke.  The patient was agitated, incontinent and lying face down on the wooden bed with his left arm trapped under his body.  The patient was sweating profusely and had secretions draining from his mouth. His head was getting stuck between the bed head and the side of the bed.  He had removed his IV line and was bleeding from the puncture site; the nurses hadn’t dressed his hand.  He had no caretakers with him, only a young police officer who was guarding him but not able to give him care.

I asked the nurses if they could re-position the patient as he was at risk of strangling himself and obstructing his airway. The trained nurse refused to help so I asked if the students could help me move the patient, again the trained nurse refused.  The trained nurse said the police officer was responsible for the patients care.  The police officer confirmed to me that he was only there to guard the patient.

The doctor arrived on the ward and asked the nurse to dress the patients hand as he was bleeding (the nurse ignored this request).  The doctor did not examine the patient but observed him as he walked past.  When I persisted in asking the nurse to help the patient he refused and said the doctor would see him.  The doctor wrote in a patient’s notes and then left the ward without seeing the patient.

I asked the nurse for some gloves so I could re-position the patient to maintain his airway; he refused to give me any gloves and told us to leave the ward and not to interfere with the patient.  When we went back to the patient he was cheyne stoking and died.  We informed the nurse but he didn’t go to see the patient, so there was no attempt at resuscitation.  L and I put the screens around the patient as no nursing staff went out to check him.

The nurse was rude and hostile to us and told us to leave the ward on more than one occasion.

As it was a public holiday there was no senior medical or nursing staff on duty to call for assistance." 

 J's story of this excludes some salient points. Firstly she had taken photographic evidence of the state of the patient to show the staff before confronting them. Next when the nurses refused to give her gloves she had told them "I am worried that if someone sees this patient in this state - there are two English doctors visiting the hospital today taking publicity shots for a fund raising video - they may take these photos to the press & then there would be serious trouble." This veiled threat provoked further aggression & hostility but unsurprisingly did not motivate the nurses to get off their seats where they were sat watching TV. J was worried about this but I later reassured her that at least she hadn't grabbed a doctor's lapel & called him a murderer - one of my less fine moments where the accusation of judgemental & poor impulse control could be fairly levelled at me. In my case it did however result in the patient getting the correct care & her Mother bringing in a box of bananas to thank me.

Finally J was walking back to her office to get gloves to move the patient by herself when she discovered he had died. She can't shake the feeling that there was more that she should have done & she is some how responsible. As I have told her since - this patient was in a living hell that he has now been thankfully released from, we however are still living in our living hell!

When I returned later that same day to the hospital I found J sat with L having an iced coffee - my very own diazepam alternative frequently taken after my attempts to intervene with patient care on ICU. J was angry, shaken, upset & funnily enough I not once felt it was appropriate to tell her she was being judgemental or over sensitive or if she didn't like it could just go home.

That afternoon we had our monthly meeting & J discussed this case & showed the photos to a group of male Cambodian NGO Doctors & Nurses. Dr H - the Bong - who has the best poker face I have ever seen - looked opening shocked & appalled. If expressing emotion was on a scale with latino at one end Cambodians would definitely be at the other end of the scale. Smiling & laughing is the set response in any situation here. I have never seen Dr H visibly effected like he was on hearing the story & seeing the photos. That in itself was quite powerful. He started taking photos of the photos off J's computer screen & when J offered to email them to him he quickly said not to. It was at this point I advised J to tell Dr H about her threat to the ICU staff about going to the press. Dr H's poker face returned.

"What should I have done?" J implored - strange for me to hear as I am a big WWJD? advocate & this is the question I am always asking her.

Dr H said she had done the right thing & he would discuss this case with the hospital director. 

One of my favourite Cambodians said this about the whole sickening affair. Even if the patient had murdered someone it can't be morally any worse than what the staff failed to do for him - their job - resulting in his death. The worse thing is that this happens every day here. 

Facing these morally bankrupt people is it any wonder that J & I are incensed into calling them murderers or threatening to go to the press - this place can make good people mad.   

I'm not saying this represents all of Cambodian health care, I'm not even saying it represents all staff on ICU, it's just this is the part of Cambodian health care I am unfortunately very familiar with. And writing it out, trying to make sense of it, sharing it with who ever wants to read about it - that's my therapy.

This -  without cigarettes & alcohol due to my post dengue abstinence - is the only thing that is currently keeping me sane, this is my defence mechanism.

Its not a matter of life & death, its more important than that!

Cambodian Doctor (CD) - Esther these cases you wrote for TB training are not right.

Me - Oh really - how so?

CD - You have written about percentiles on a growth chart but here in Cambodia we use standard deviations instead.

Me - Oh I see, its not a problem though as we can just remove it. I was told by Dr C (Cambodian doctor with NGO) that health workers are more familiar with colour coding of weight anyway. (Green normal, Orange minus 2 SD & Red minus 3 SD) So we can just leave in the text what colour the child plots on the chart.

CD - No we need to have the SD as well.

Me - OK but do you know what SD means so you can explain it to participants when they ask?

CD - *silence*

Me - Lets just delete percentiles & keep the colours hey? Keep it simple.

Cambodian Nurse - But Esther the problem with that is the yellow card which is used in Cambodia doesn't have green for normal, it has yellow! And it doesn't mention percentiles or standard deviations.

Me - Oh - perhaps we should just say normal or say that the colour for normal can be either green or yellow depending on what chart is being used.

CD - No we MUST say green & SD!

CN - But that may confuse people because the yellow card (growth chart & also used to record immunisations - like a red book in the UK) which is used from birth to 5 years old has yellow as normal weight.

CD - No it doesn't - you are wrong.

CN - (producing his daughter's yellow card) Bong (respectful term of address) but look here is an example of a Cambodian yellow card.

Long protracted conversation in khmer - Cambodian doctor shouting at submissive Cambodian nurse - I understand only weight, yellow & green.

CD goes to get his laptop & does a google search of weight charts.

CD - (triumphantly) See, here is a photo of a chart with green not yellow as normal.

Me - Yes, very good, I can see that. Is that the charts you use here in Cambodia though?

CD - (said immediately with no thought) YES!

Me - (heavy sarcasm) Oh I see so what CN has just showed us is not a Cambodian weight chart, but what you find on the internet is?

CN kicks me under the table

Me - (smiling through gritted teeth) OK so I will delete the percentile & keep the colours - green, orange & red.

CD walks off with chest puffed out. CN & I lock eyes & simultaneously roll them.

This is how small & petty my life has become, its painful.....

Twiglet wisdom

This blog is dedicated to my fellow ex-VSO-er – Claire, as promised….

Finishing your placement with VSO can be very difficult because “When life offers you a dream so far beyond any of your expectations, it’s not reasonable to grieve when it comes to an end.” When we started with VSO some one should have told us  “I hope you enjoy disappointment.” I perhaps should have known how my placement would go, “Good luck tended to avoid me.” But “Hasn’t anyone ever told you? Life isn’t fair.”

Initially when the placement ended “It was nice to be alone, not to have to smile and look pleased; a relief to stare dejectedly out the window at the sheeting rain and let just a few tears escape.” Rainy season had come early this year!

There are many coping strategies to deal with this sense of loss & grieving, “I do a good job of blocking painful, unnecessary things from my memory.” Such as watching teenage Vampire movies or graduating on to True Blood – vampire porn. Sometimes the sense of relief & liberation was euphoric “You know, your mood swings are kind of giving me whiplash.”

These last two years “I wondered if I was seeing the same things through my eyes that the rest of the world was seeing through theirs. Maybe there was a glitch in my brain.” Sometimes I would get so angry with people in my placement “My palms tingled — I wanted so badly to hit something. I was surprised at myself. I was usually a nonviolent person.”

Working in the health sector has been challenging & frustrating, “Death is peaceful, easy. Life is harder.”

Here be leprechauns

Developing training material, getting it approved by the MoH, training trainers & delivering the training is alway an epic feat here. The training for screening & treatment of Severe Acute Malnutrition (SAM) has been no exception. The tribulation has resulted in a heightened state of hysteria which means that I found myself trying to laugh rather than cry.

Having introduced the screening of SAM by showing a video to a group of health workers from four different hospitals we then walked them through the process & practised examples in small group work in the morning. In the afternoon we all went to the hospital to measure the height & weight of some real children. Beforehand there was a short session on common mistakes when measuring children plus any questions for clarification before going to the ward.

It is quite common here for participants to miss the salient points of a training & instead focus on one very, small, irrelevant, uncommon or ridiculous point.

WHO height-weight charts depend on measuring the height of the child & reading what column the weight of the child fits below - this can be one of four results - median, - 1SD, -2SD or -3SD. The charts are for use with children from 6 months to 5 years, the height starts at 52.5cm.

If a child is older than 6 months old but weighs less than 4kg this in itself is a diagnosis of SAM, if a child is 6 months to 5 years & less than 3 standard deviations (SD) they have SAM, if a child is under 6 months with visible wasting they have SAM, and a child of any age has bilateral pitting oedema this is SAM.

These are a sample of the questions the participants focused on during this training;

1) When a child is difficult to weigh you can weigh the child with mother & then just the mother to get the child's weight. The child needs to be weighed without clothes or nappy. SO does the Mother have to take off her clothes also?

It sounds like a saucy joke but this was asked in all seriousness. After a long protracted discussion one of the Cambodian trainers stood up, we thought to clarify that it didn't matter as obviously the mothers weight would be subtracted anyway. This is what he said - "If the Mother has many thick, heavy layers of clothing on you should remove some of them first!" - IN ALL SERIOUSNESS!!!

2) What if a child over 6 months old weighs 3.9kg but by the time they have been transferred to a SAM treatment Hospital they weigh 4.4kg because they have fed?

Again we asked if this has ever happened to anyone - no, but what if?!

We tried to explain that a weight gain of half a kilo in a 3.9kg child was both highly unlikely & more likely to represent a discrepancy in weighing scales than actual weight gain. Participants remained unconvinced. Clearly daily weighing on small children & the patterns of weight gain are unfamiliar to them as they have NEVER done it.

3) What happens if there is a child over 6 months old whose height is less than 52.5cm?

This question clearly demonstrates that they never measure children's height because if they did they would know that the average length on a new born baby is around 50cm & by 6 months of age even the lowest percentile is still way above 52.5cm.

We tried to explain this - they were insistent that this could happen. I asked them for an example of a child they have seen who was older than 6 months, shorter than 52.5cm & heavier than 4kg. They couldn't but they still wouldn't accept the explanation that even if it was possible for a child to be shorter than the lowest height on the chart after 6 month they would almost certainly weigh less than 4kg.

They really couldn't see this. One nurse from my hospital said she had seen a case of a child you was 51cm but sure enough they had also weighed less than 4kg. This still failed to convince the participants.

Jn - my boss - suggested perhaps they were talking about leprechauns. Maybe a human baby had been swapped at birth with a leprechaun, this would make sense. A teeny, tiny leprechaun child that didn't have SAM was just normal size for a leprechaun. Then I suggested that perhaps in fairy land there was an enormous, giant of a human child towering over their leprechaun adopted parents, hysteria kicked in - Jn & I started crying with laughter.

It is estimated that between 50 - 80, 0000 children in Cambodia have SAM but in 2011 only 1226 children were treated for SAM. Cambodian health workers need to stop worrying about impossible clinical anomalies of the WHO height-weight charts & instead concentrate on identifying, treating & saving the lives of the hidden 79,000 Cambodian children who are quite literally starving to death.

Don't make me angry - you won't like me when I am angry......

When I was 7 years old my favourite pyjamas were an incredible hulk pair - I wore them to rags. This week it would seem that like Bruce Banner I too am dangerous when provoked.

I have been sitting at 8 on the VAS for anger, with occasional rapid cycling to 10 for a while now and one incident of 9 at the weekend. There are a lot of contributing factors for this but as discussed in the previous blog other people's attitudes is very high on the list.

One such person, a khmer doctor, accused me of doing something which I wasn't even responsible for but told me in no uncertain, rude terms that I was wrong - its important here to blame someone. I tried to explain that what he was referring to occurred after I had been involved with what we were discussing. The national guidelines had been changed & the training material, what we were discussing, had been edited to match these changes but they had forgotten to align one small section of the training with the new guidelines. Of course he was not at all convinced with my explanation & made it clear he thought I was the idiot.

I was fuming - no day that starts without electricity & witnessing a moto versus dog accident can turn out well.

Did I argue my point, assert my qualifications & experience or make a big scene? This is what another  expat had recently told me I do, in work. In actual fact I did what I always seem to do with Cambodia health workers which is calmly say my piece, leave the room, internalise it all, feel useless & crap, if I've really had it I will then cry. This expat has never seen me in work & their opinion of me may well be coloured by all the 50 cent draft beer & 25 cent cigarettes they consume. They got a 9 out of me.

I was at the end of my tether where being treated rudely & disrespected was concerned, especially by misogynists. I was carrying quite a lot of suppressed anger & rage.

The next day the training was delivered & the same doctor was due to teach the session I had originally prepared - before the discussed edit.

I went into the training room to see his presentation but he hadn't yet begun. In actual fact he was stood by the door with his finger resting through a metal loop meant for a padlock. One loop was on the door frame & the other loop was on the door. Me opening the door partially amputated the tip of his finger. There was blood everywhere. I had a huge adrenaline surge, had all that pent up rage been converted into an unconscious act of violence towards him, I hadn't seen him at all when I opened the door.

Emergency Physician Esther kicked in so I guided him to a tap to clean the wound - he refused to listen to my advice. Even in an emergency the bastards won't listen to a word I say. I forced his hand under the tap & then led him to sit down as he was looking rather grey & sweaty.

I got gauze & told him to apply firm pressure & elevate his hand - he continued to ignore me so that now my initial guilt transformed in a cold heartedness - if he wouldn't listen to my advice screw him.

It was only after cleaning the wound & starting to close it with steristrips that I asked him "Do you know what job I did before I came to Cambodia?" - him & another male Cambodian doctor were both saying the he needed stitches. My question was prompted after I heard them say in khmer that I didn't know what I was doing. He looked at me sheepishly & then shrugged - he had no idea whether I was even a nurse or a doctor. I told him what I was - his attitude then changed a little.

I dressed the wound as best I could & gave him 2 paracetamol. He declined going to get an X-ray - I was feeling sick with guilt again - I can't maintain heartless bitch for too long. He did concede to take a course of prophylactic antibiotics but whether he believes me when I told him not amoxicillin as the resistance rates are very high here I don't know.

He then went on to stoically deliver the training.

I skipped lunch as I couldn't shift the guilty, sick to the pit of my stomach, feeling. My boss asked me to remind her never to make me angry,

Could my anger have manifested itself in this act of unconscious violent revenge? What next - ripped shirts, green tinge to my skin, Anger management classes?

My Cambodian victim said it was clearly an accident & if anyone was at fault it is him for standing with his finger wrapped through the padlock metal loop of the door to the entrance of the training room.

I, however, am still not convinced it wasn't bad karma or my budding telekinesis skills. And next time it won't just be a finger....

Doubt

In my medical school interview I was asked if I had self doubt. Of course I do - I am human. But then I met many doctors who seem to live free of this particular affliction. I still believe that self doubt makes you a better & safer clinician but I can also concede the point others make, that you don't want your surgeon to have doubt when they are cutting you.

As an emergency physician I got very used to every one else doubting me, especially doctors I was referring patients to. My last clinical shift in the NHS the on call surgical F2 told my locum SHO that the Emergency consultant's clinical judgment "wasn't worth a lot" - as I said in the subsequent email to his college tutor, my last act as an NHS consultant - it may well be the case that my clinical judgment is worthless but that's not really the point, the GMC code of conduct is pretty clear on this, there is a whole paragraph pertaining to respecting colleagues & not defaming them. I was quite cross about it at the time - it was 12 30 am on a Sunday night & it had been a long weekend on call. When the F2 came into the resus room to try to tell me that he had accepted the locum's referral so what was my problem, the patient I was then seeing - a man who had jumped from a bridge - was more concerned at my robust request that the F2 left my resus room than he was his bilateral smashed ankles & hips.

Of course although frequent - episodes such as the arrogant F2 would happen on a daily basis when I worked as an Emergency Consultant - nothing could have prepared me for the doubt shown towards me & my credibility here in Cambodia. It is not so much a daily experience but one that taints every single interaction I ever have in work with Cambodian health workers. I have blogged about it many times, it fuels my deep seated anger & frustration with this place & this week I may have just reached my limit.

Cambodian doctors & medical assistants (MA) - especially male - I have grown to expect this doubt from & can brace myself against their scorn. This week one MA got through my defences by flapping his hand in my face & laughing when I suggested a patent could have an iron deficiency anaemia - what a fool I was because apparently the man's daughter was rich! As I had been referring to occult bleeding causing the Hb of 4.7 I was a little confused as to why the daughter being rich had anything to do with the patient's current condition. This only served to make me look even more stupid because I was told iron deficiency anaemia never occurs in rich people. I tried to explain what occult bleeding was & how common iron deficiency anaemia was in high income countries but the hand went up again to silence me & I was told he wasn't bleeding, the MA could see no bleeding - how stupid was I?  I didn't really get a chance to define 'occult bleeding' - I knew I wasn't going to get anywhere with this particular ignorant MA so I made my excuses & left the ward. Before I could stop them tears of frustration were running down my face. R was surprised that what is a daily occurrence for me had suddenly made me cry, he tried to console me, telling me I shouldn't mind the MA, he was the stupid one. I tried to explain to R why I appeared upset but was actually very frustrated. This frustration comes not from personal insult - such as the anger I felt with the case of the surgical F2 - but from an immense feeling of failure, failure to advocate for a patient & get them the best care, failure as a doctor.

I am a failure because I fail to convince people that I am credible & have any knowledge or skills. I am frustrated because this failing means that patients don't get the right care & health workers continue to have poor practice. This unremitting lack of credibility & respect has resulted in my self doubt reaching a new all time high. This soul destroying frustration will be the reason I leave - soon.

If I could apportion this doubt to only Cambodian health care workers it maybe would help to restore my faith in myself but unfortunately the expats here share the same behaviour. Although my medical opinion is frequently sought it is very often second guessed or dismissed.

The same day as the anaemia incident an expat - who I have never met before - emailed me for some medical advice. I gave them the diagnosis, probable cause & treatment (none). In their response they told me they had checked the internet & sent me the link to a chat forum to show me what the diagnosis was. They then explained to me how it could have been caused. I was left wondering if they had read my response to them. Did they thank me for my help - no, "Thank god for the internet!" was their parting shot.

Its days like these that make me question why I am even here & why I should bother to persist in trying. Its days like these that make me doubt myself.

Night call

My Khmer teacher is definitely one of my top three Cambodians. She is like a mother to me & does a lot more than teach me to read & write khmer. I really do love her - an awful lot.

Last Friday she called me at 1 am to tell me she couldn't move. I slept through her first call because I haven't been sleeping well recently & was utterly exhausted, but I must have been partially woken because I was woken up by J texting me to tell me that S had also called her husband - G - to say she needed me. G was dressed & getting ready to pick me up on his moto.

When I went to my bathroom to ablute, the biggest cockroach I have ever seen in my life was walking around the bucket of water I have for showering (I still don't have a reliable water supply) - I saw this as a sign of ill portent. I am not sure whether it was being woken from a very deep sleep, the early hour or the monster cockroach but the surrealness gave a certain edge to my anxiety.

Scabby dog was pleased to see me, as always & Tony started his usual aggressive barking & growling assault on me for just walking out of my house. I sat on the stone bench outside my gate, by the little pharmacy shop, pondering on how many people were still up & about at this hour of the morning in Battambang & wondering what the hell I would do if S was seriously ill or died. I tried to focus on the prostitutes & drug dealers still going about their business, this was the more cheerful line of thought.

By the time G arrived I had dealt with almost every possible outcome the evening could bring & vowed never to cycle alone this late at night - there was too many undesirables about. I had also given up trying to get scabby dog back into the compound  before I locked the gate - she is pregnant already so not much more damage could be done to her reputation.

S lives in an old french colonial corner house in the town centre & rents most of the rooms to other people. One of the women that rents a room & owns a shop in front of her house heard us arrive & came down to open the metal roll shutter door to let us in. I rushed up stairs to the room where I have my daily khmer lesson after work.

We sit at her table & talk about life, death, love, family, sex, illness, happiness, khmer rouge, loss & occasionally we even learn some language - S English much more than me Khmer. But that evening the room was empty, S was laying on her bed in the little windowless bedroom off this room with another of her tenants holding a boiled kettle on her feet & the tenant's daughter massaging her arms & legs frantically.

When I was 18 years old I sat with my Grandfather - who had a massive stroke & subsequently died -  & my grandmother waiting for the GP & then the ambulance. Years later when my grandmother was dying of cancer I spent a weekend with her talking about a lot of things including that day & how even when I was a teenager she could see then the doctor that I would later go on to become. There's an intimacy in care giving which is a lot less stressful, I have recently learnt, when you can be sure of access to a good, free, health care system.

I felt very alone as I knelt down by S's bed, kissed her on the shoulder & asked her what was wrong, it was the loneliness of someone who is medically trained yet knows there is no decent health care facilities for 1000s of km.

G waited outside & was shocked to hear me being gentle, kind & reassuring - I guess my bed side manner hasn't been exercised much in the last 2 years. And then because in serious situations I always tend to be a little flippant or humorous I asked S if she needed to be coined - she smiled weakly & declined. G was relieved to hear the real Dr Esther was still in there.

She told me she was numb around her mouth & the right side of her body- this took some time to establish as I had not brought my dictionary & the word was not in hers. I now know that ស្ពឹក is numb. I have since pointed out to her that if she was a better khmer teacher & I a better student I probably would have known that by now but during a medical emergency & in the early hours of the morning was probably not the best learning environment.

Her blood pressure was very high, she couldn't stand & she felt weak and had already self medicated with an antihypertensive tablet, one of the many dangers of living in a country with unregulated pharmaceuticals.

At a loss to do anything in a country with no decent medical interventions & an absence of anything close to nursing care I gave her a big hug & we sat there like that for a long time slowly rocking with her chanting, like a mantra, "you are here now". This seemed to calm her down & after a while she got up, used the chamber pot & told me I must now stay at her house over night.

Since I started having my lessons at her house every week day, for the last year S has been conspiring to get me to sleep at her house, when I had Dengue she even tried to sleep at mine & now she had orchestrated a TIA (mini stroke) to obtain her goal. G was dismissed.

The boiled kettle was transferred to her abdomen & we all bedded down on various hard wooden day beds & benches - me & S on the day bed with a thin mattress, the owner of the shop downstairs on the day bed with no mattress & the neighbour on the cushion-less wooden sofa. I got the best deal but I couldn't sleep.

My mind was racing - had she had a posterior TIA? Was it a bleed? Would she go on to have a massive stroke? What would I do if she did? Where would I take her? How does anyone ever sleep on these really hard beds?

I came up with a few conclusions.

Firstly its a lot more stressful if someone you care about gets sick in a country where there is no available universal, free, good quality health care. My other experiences of sickness or loss in people I love have always been in an environment where I have believed & trusted that everything possible will be done for them. I realised that my anxiety & fearfulness could be so much worse without this security blanket.

Secondly if S dies I will really lose my shit with this place & have to leave Cambodia - I can't cope with all they premature death, suffering & injustice - I have nearly had my fill of it.

Thirdly I am miles away from my family & friends who I care about very much but this place has a strange hold over me that I can't articulate.

Finally I can never leave Cambodia as long as there are people that I love - as surrogate family, friends or some even a tad inappropriately - are living here, who can't access decent healthcare. Why should people born in one place be exposed to poor health & no medical care whereas others can afford good health without even appreciating what they have? I came here to capacity build the health care system & I really as a finisher completer I shouldn't leave until I have finished & completed this task....it was about 4 am by the time I reached this final conclusion, I was delirious with sleep deprivation & anxiety.

I must have finally fallen asleep because when I woke at first light the neighbours had left & S had gone back to her comfortable bed. She got up looking a little shaky & drawn. We drank ovaltine & talked now she was calmer & more coherent. I am sure she had been coherent before when speaking in khmer, its just I couldn't understand anything of what she was saying.

She had thought that she was dying in the night, she told me that she didn't know what she would do if I wasn't here - I suggested maybe never go to the government hospital EVER, under any circumstances. She agreed. I explained what I thought had happened, a TIA & what tests I would like to do (CT, ECG) and what medications she should start. We took our blood pressures - mine was a lot higher than hers now.

When she said again how afraid & scared she was that she may die I told her I would prefer her not to that. She then said that really what was so much worse than dying would be disabled & unable to be independent here in Cambodia - I agreed & offered to put a pillow over her face if it came to that. We talked about her going to France to be with her sister & her son but the cold & damp makes her joints ache & Cambodia is her home, where her ancestors bones are, where she wants to die & where her bones will also be.

G came early on his moto to take me home so I could go back with aspirin & antihypertensive medication to S's. She asked lots of questions about what the medication did & why the dose & for how long she needed to take it all for. Something that in the last 2 plus years I have never seen from any patient in the MoH hospitals. The thought of a stroke scared her but she understood that the tablets would reduce the risk of last night happening again.

J & I met for breakfast to discuss how to get a CT scan for S. We went to a private clinic where patients from the hospital J worked in with R, when she was a VSO volunteer, were sent if they needed a CT & could afford it. We were surprised to find the price was the same for us as Cambodians - $100 - we had expected a price hike. The private clinic is just around the corner from S's house so we went to find her but she had already been to check prices so had decided she would take her chances with just taking aspirin.

A long imploring conversation ensued which resulted in her taking $100 from her purse - not our intention - and agreeing to go with us to have a head scan.

At the clinic 3 people acknowledged me as a doctor from the provincial hospital which made me smile considering the doctors there don't even recognise my qualifications. It meant however that S went straight in for her BP check, ECG & CT scan of her head. She was quaking & afterwards showed all the signs of claustrophobia - thank god there aren't many MRI scanners in Cambodia.

The doctor called her through with the results & wanted to know why I wanted a scan if she hadn't had a head injury or a headache. I explained she had transient neurological symptoms & I was worried about a bleed or an infarct. Whilst we went in J paid the medical bill - as previously & repeatedly stated in this blog, J is one of God's better people. Unable to fully accept J's kindness & generosity S (J's landlady as well as khmer teacher) later bought a washing machine for J's house whilst we were working away from Battambang - Karma.

S has got it into her head that she has to do gymnastics to prevent further episodes - I am sure something I said has been very lost in translation. She also will take the aspirin & was amazed I could answer all her questions about it's mode of action & dose. I had to remind her that I am a doctor or at least I was one once. The kettle of boiled water on the feet is apparently a well known Khmer remedy for reducing blood pressure & coining is only for headache & fever - the fact that I didn't know this already is probably the reason S can't believe I am really a doctor.

The whole experience has left me a little raw - anxiously waiting for the next call in the night, dreading what the future may bring, fearful of the loss of the things I love the most.

After all isn't it the case that you can never truly appreciate something until you have lived without it. 

Flappy hands

One of my pet hates is the dismissive hand flapping that is endemic in Cambodia. My favourite flappy hand experience, that I may have mentioned before, involved a flat tyre on my bicycle (precipitated by the first incompetent bicycle repair man destroying my valve), a very hot 'hot season' morning & four bicycle repair people flapping their hands at me dismissively as I walked for one hour just trying to get it repaired.

When ever I have brought up the hand flapping with Cambodians they generally don't see it as rude at all, they just stare at me impassively wondering what the problem could be. This is Cambodia - flapping your hand in someones face is apparently neither disrespectful or rude. Mind the culture gap.

However the other day I had a flat tyre - also endemic in Cambodia - the wheel had not been put back onto my bike correctly after the repair, which I only noticed after my evening Khmer lesson. My teacher & Cambodian mother, S, insisted on coming with me to facilitate fixing it. Like a true translator she not only navigated the linguistic waters but also helped with some of the cultural eddies as well.

At the first repair place, near her house, we got the flappy hand from the man - he only did motos, not bicycles, I was reliably informed.

The second place looked promising as he was in the process of fixing a child's bicycle but he too flapped his hand in our general direction & then I saw something previously unprecedented by a cambodian - S also got offended by his flappy hand. She asked him why he was dismissing us & he told us he was busy. This is as far as I have ever got with this particular scenario - keep walking until you find someone who doesn't flap their hand in your face even if that takes an hour.

Both my Grandmothers have died but when they were alive one of their favourite pastimes was telling random strangers what my occupation was. One time the gas meter man was told I was a doctor as he dutifully read my Grandmothers meter, whilst I quietly died of embarrassment in the kitchen. My Grandfathers I'm sure would have been equally proud, its just they had both died by the time I had qualified.

S - channeling the ghosts of my Grandmothers -  pulled herself up on her 4 foot 11 inch frame & looking the bicycle repair man square in the eye, assertively told him that I was a doctor working at the hospital & he WOULD fix my bicycle, we would wait.

I am so used to the flappy hands at the hospital I wasn't aware that announcing my credentials would have such a positive effect.

5 minutes later the wheel was central, S was the first Cambodian to understand the flappy hand from a barang perspective & I even got a smile out of the repair man.

From a woman that gesticulates so much herself I wonder why it is that I find the flappy hands so offensive. But this is Cambodia - Kingdom of Wonders......