Crumbs from the table of joy

"Sometimes a crumb falls

From the tables of joy

Sometimes a bone

Is flung

To some people

Love is given

To others

Only heaven."

Every once in a while here I am thrown a crumb of hope. Some weeks I have even been known to get two.

Before I went back to the UK I attended a hospital clinical case review (CCR) that was chaired by the deputy director, ON - my only friend at the hospital, or as he would put it "not just her friend but her psychiatrist too!" He is of course correct.

I was moved to write to my boss to tell her about it because ON did such a great job that it gave me hope. He picked a case that was an excellent example of common system errors with possible action points that could be achievable & realistic. He went through the notes before asking to talk to me about it, he had picked out already all the points for improvement I would have done too. He asked for a template powerpoint so I gave him a sample presentation I had developed for CCR training, which he went on to use.

The CCR case was a pregnant woman who had initially been seen by the surgeons before being passed on to the obstetricians,who finally turfed her to ICU medicine, where after further neglect she eventually died. There had been no collaboration between specialities, there was late recognition of sepsis, no blood cultures had been taken, inadequate fluid resuscitation was used & there was inappropriate use of antibiotics & inotropes in this case. Just another normal day in my Cambodian hospital workplace.

ON asked me to attend the meeting, I went despite having no translator so just sat quietly at the back, out of the way, but the hospital director came to sit right next to me. The staff got angry & animated at certain points but ON chaired the meeting really well, allowing everyone to have their say whilst making sure the salient points were communicated. At one point the hospital director got up & shouted at them all for never listening to anyone, ignoring others training & advice. Not exactly in keeping with the CCR philosophy but I could hardly blame him for it - I often feel like doing the same but as a mere visitor & low status female I am prohibited.

After the CCR meeting I wanted to feedback to ON how well I thought it had gone, to ask him for translation & summary of the meeting, to make sure I had followed the important themes & to give some suggestions on how to take the CCR to the next step by developing action points that individuals are responsible & accountable for with actual deadlines. However there was a pre-election CCP meeting directly after the CCR meeting so I was ushered out & then didn't see ON for the next month.

When we finally had a chance to meet up it was after I had been banned from the paediatric ward. Mr S ,the head nurse, was particularly delighted by all my trouble making with the doctors. He enjoys someone else, other than him, being on the receiving end of their normal foul behaviour - especially when that person is a bolshy barang.

ON was less delighted by my collaborative working fail, more resigned that I would never be able to endure his colleagues poor behaviour towards me. He told me to just stop going to the wards & only work with him because he wanted & needed me. What did it matter if all the other doctors hate me, he wanted me!? Crumb number one.

He went on to tell me that USAID on a recent visit had interviewed him & asked him what would he prefer to have, equipment for the hospital or an overseas expert. He told them he would rather have me. I really do think he was being completely sincere. Crumb two.

I finally had the opportunity to feed back to him about the CCR he had chaired & it turned out I had understood most of what was said plus ON realised they had not formulated any action plans but we both recognised how hard accountability is to practice here.

Then he threw me an unprecedented third crumb. Earlier in the month whilst I had been at the border hospital he had contacted me asking if I could help him with a patient. I had to explain that I was away from the hospital & wouldn't be back for 3 days, which I absolutely hated doing because if people ask for help I want to give it & here if you fail to give the help they have requested then they can hold it against you forever. I have learnt this bitter lesson on numerous occasions, failing to meet people's unrealistic expectations here is a common occurrence for me.

ON got out his smart phone to show me a photo.

He explained that whilst I had been away a trauma patient had been transferred from Thailand who still required ventilation. He had called me because he wanted help to set up a high care area on the surgical ward.

For the last 2 & a half years I have been advocating for a high care area in the hospital (whilst patiently waiting for the ER to open) this advice has of course been persistently ignored.

On ON's request I had managed to find a portable ventilator which was donated by an NGO for the ER, which as it is not yet opened ON had used in this newly created high care area. There was a monitor & bed from a donation from France, but for me the most exciting thing was a drip stand. This photo surpassed my wildest dreams of what a high care area could look like in this hospital during the time I have been here.

I was so happy that ON had the same vision as me that I posted this photo on facebook & to my dismay people congratulated me for this, I was horrified to think that they all thought I was just blowing my own trumpet. In fact I wasn't in anyway feeling self congratulatory, the reason I was happy was for ON's success in changing the system. I genuinely don't believe I can take any, even a small amount, of credit for this. If any thing I have failed to capacity build or inspire change during my time here but ON and a small handful of Cambodians I know have shown me their huge potential & capacity for change and I have just tried to help them in what ever way I can.

I don't believe for one minute that having a high care area with donated equipment will automatically mean that patients will suddenly get much better nursing & medical care here, but I am happy that it is a step in the right direction & it was a step made by the hospital, on their own innovation.

I think the moment I actually start believing that I have personally or singlehandedly changed another person or situation is probably the same moment that my ego has overtaken good sense or reason, humility has been lost & I have started to fling bones at people instead of looking for the crumbs.