Final Demand

My base hospital was dragged into the 21st century by a local business man who when building a cafeteria also suggested they install wifi. 29 months after starting my VSO placement the ER building, my intended workplace, remains under construction, but at least I can check Facebook on my smartphone & have an iced coffee whilst I wait.

The wifi - like most things here - is unreliable & slow. Recently we had no wifi for a week until I cracked & in my pigeon khmer asked the jolly, fat, friendly admin man at the front desk if they had changed the password. An affirmative answer & change of digits fixed that problem. This meant I was then able to smugly gloat to my 2 Cambodian colleagues who hadn't even thought to ask. This is of course because here there is a much higher tolerance of accepting 3rd world problems let alone the insignificant 1st world problem such as slow or absent wifi.

So this week after a big night storm when the wifi had dropped out again, I suggested to L that perhaps it was because of another password change.

She went off to ask the rude, officious admin man about this & was curtly informed there was "a technical problem which was being addressed & she should just wait"

The hospital director was stood right next to PPF as my old VA affectionately called him (Punch Provoking Face) and listened with interest to the conversation.

L was walking back to our office when the Director called out after her & said, a tad sheepishly "Errr, actually we've forgotten to pay the bill so have been cut off"

For some reason this kept me & L amused for the rest of the day.

Check

There has been something of a stalemate at one of the hospitals I work in, they have told me I should be more Cambodian in my character when doing follow up & coaching. From observation & their feedback I think this would involve me;
1) Never disagreeing with any of the doctors - ever
2) Disregarding national guidelines & protocols ratified by the MoH & supported by evidence based medicine
3) Keeping my knowledge, expertise & ideas for solutions to myself as they are worthless & insignificant
4) Score the hospital very highly despite not actually witnessing correct practice.

The head nurse commented to me one morning that the hospital was in trouble, again, after reports of corruption. The NGO I work for was some how implemented in making the complaint. What do you think of this? I queried - testing the waters. Oh - it's entirely fair because the hospital still does have many under the table payments - was his not so unsurprising response. So maybe, I mused, I should tell the doctors that if they pay me $20 I'll write them a really good follow up report?
He wordlessly slapped on the shoulder & he left the room laughing. For those of you that can't read non-verbal Khmer - that's a yes!

So this week with a devil may care attitude I found myself & my assistant walking with a spring in my step to the previously off limits paediatric ward to do coaching & follow up for TB screening. This is an easy thing to do - clinicians simply have to think about TB when seeing a child. By raising awareness they may then think to ask about TB contact, any symptoms suggestive of TB, look for signs of TB & refer if they have suspicions. It seems a simple thing but when the doctors here normally don't take a history or examine patients it becomes slightly more challenging.

It's not like neurosurgery or interventional cardiology where there has to be many expensive resources & extensive training is required, it simply involves a health worker using their brain to ask the right questions.

Last week I cancelled a planned TB follow up because the only doctor on duty was busy with a sick child & OPD was completely empty, later the angry head of department told me that I should just talk to the doctor in his office & go through the follow up form without having to see any patients. He couldn't understand the worth or point of seeing people in their clinical roles. "My staff know it all" - I was told. But we all know that there is a significant gap between knowing & doing - I write this as an obese, unfit, middle aged, ex-smoking Doctor who has recently rediscovered the joys of wine. No one here seems to be able to appreciate that a question & answers session, be it verbal or written, is not the same as on the job coaching & supervision. If checking retention of knowledge was all that was needed & sufficient to initiate behaviour change then post-tests would be the gold standard in vocational training & the medical training programmes in developed world are all completely defunct.

This time, the ward were not expecting us, despite many phone calls to the angry boss man but none the less they shrugged & let us stay anyway. The lovely Chief of ward - who deliberately sent me into the lion's den a month ago where I got my ear chewed off for asking to discuss SAM with angry boss man - smiled warmly at me & even laughed when I told her I would never listen to her advice again. I was set up.

The MA on duty is generally extremely grumpy & rude. She snapped at my assistant "What do you want?" & when L explained she shouted, "well there is no point sitting out there you won't hear anything!"

We went into the OPD room where she saw a child with a history of sore throat & fever for one day. She asked about TB contact & any general symptoms of TB. She went in search of a tongue depressor & even downloaded a torch onto her iPhone in order to look at the child's throat. In short she did a perfect TB screening of the child. L & I stood in the corner stunned. I have never seen the staff do anything completely by the book and to near perfection, she even washed her hands 3 times. Although for a long time I have harboured suspicions that they were capable  of doing the right thing, I had almost lost hope that I would ever live to see it.

Then the chief of ward came in with 2 stools for use to sit - we must have looked like we were about to pass out.

The second child also had a perfect screening & this time there was cause to investigate further for TB due to the child's symptoms, so she explained all this patiently to the grandmother (the parents, like so many, are away working illegally in Thailand) who was then given time to ask questions. When there was no confirmed history of TB contact the MA even asked about adults in the neighbourhood with chronic cough. She checked the child's weight & even though the ward has no growth charts she could comment on the fact that the child had failure to thrive.

I leant back against the wall for support - in an unfamiliar state of happy shock.

After the child had gone with her Grandmother for a chest X-ray I told the MA that I wish I could have filmed her as she had just done two perfect consultations demonstrating how to screen for TB in children. Omitting the part when the child with a sore throat started to cry & the MA told her "If you don't stop crying I will admit you to hospital & give you lots of painful, horrible injections"! Other than that one small 'cultural difference' it was a gold standard consultation.

She looked less grumpy & hostile than normal, which I read as her to be positively beaming.

As we walked back to the office L said - What happened? I have never seen you behave like this with the staff?

I am not naive enough to believe what happened represents any major change in their practice or a personal achievement for me. In fact I  assume that the staff had been told to do the business & deliver what ever we were following up on. I have no doubt that the moment we left the MA went back to monosyllabic history taking & minimal touching of patients, not giving TB a second thought. But for the time we had observed her she had shown me that she could, if she wanted or instructed to, screen children for TB perfectly well. So they do know it & my job is meant to be to help & encourage them to actually do it.

L however seemed to imply that perhaps it was actually me who has had a change in character. Maybe its just temporary change in me as a result of Pchum Ben induced sleep deprivation, maybe I had subconsciously taken the previous weeks advice from my male Cambodian work colleague or as my best Cambodian friend texted me on an completely unrelated matter - But sometime a place can also change people? Can't it? ;-)

Coffee break conversation

L - Cambodian men are really bad!

Me - They aren't all bad, that one (pointing to the cafeteria waiter) he seems like a good person. I think  he's a good man.

L - How can you say that? What's your evidence???

Me - Errrr, I don't have any evidence (Thinking - damn that Proof Blog, she's really taken that one to heart) but my intuition tells me he seems like he is not a bad man. I like him.

L - Intuition??? Like my Teacher (The one who sexually harassed her to the point that she had to change schools) told us in his Psychology class, women are only good at 2 things; having good intuition & multi-tasking.

Me - Ok, you're right. All men are complete arseholes. Can you pass me the tea pot whilst you're deconstructing my argument?!

My work here is done.........

Barriers to good health

Its not just the rotten, corrupt, health system or the health workers in it that are a barrier to change & good health here, another big barrier is the general population's attitude to health & health care. There is a fatalism that extends beyond the frequently occurring scenario of a doctor sending home a potentially curable patient as "a hopeless case" to die. The people themselves also often display the same hopelessness & a learnt helplessness which surely comes from years of having such an ineffective health care system.

I have countless examples of patients just seemingly accepting their lot, which can often be more infuriating than the health workers attitudes. Patients are scared to ask for decent health care, they lack a sense of entitlement for it. This lack results from a complexed combination of history, resources, belief systems, heirachy, patronage, religion & of course culture.

M - the 17 year old girl with WPW syndrome - spent a week in an SVT of over 200/min waiting for me to get back from my holiday because she wouldn't go to the hospital if I wasn't there. She blindly hoped it would just get better by itself despite my advice that she should always go to seek help if she develops symptoms. This was frustrating when she finally came to hospital jaundiced & swollen from her multi-organ disfunction but not unsurprising considering how she had been treated on her first admission. Now I am left worrying about what she will do when the inevitable happens, her drugs run out or are lost before her next appointment & she has another run of SVT but no money to get to the NGO hospital. Will she just sit & wait patiently for karma to do its thing. Here the poor will often just shrug & think health care is too expensive for them. This is their fate, their karma from a previous life, their 'rice has run out', its their time to go. Small children die needlessly for the want of an antibiotic, immunisation or nutritious food and people shrug & say a spirit - the mother from a previous life -  has taken the child back. Every one knows that only one twin will ever survive - that's just the way it is. One in twenty children not making it to their 5th Birthday is considered Karma.

My old VA contacted me about a health problem & I advised that he go to the local NGO clinic because it is both cheaper than any of the exorbitant private clinics here & inarguable provides a much better standard of medical care. Instead he chose to go to one of the many private clinics where they charged $450 for treatment which was most likely either inappropriate or completely unnecessary. Medicine is primarily about making money here & secondarily for curing patients. The fact that he, like every other Cambodian, refused to listen to my medical advice just meant that I felt significantly less obliged to pick up his over inflated medical bill.

Two of my friends have eye problems which I am worried about so want them to get checked out but both are resistant for similar reasons. They don't trust the eye doctor to know what is wrong with them & to do the right thing. They can't go back or ask for a second opinion without the doctor getting angry with them. They certainly can't ask for only a consultation because they will be 'forced' into purchasing  unnecessary & expensive medication. One friend went & was operated on immediately without being given time to consider the options for her non-urgent eye complaint. If they ask any questions about their problem or the medications they have been given (all the labels will be removed so they can't buy them outside the clinic) the doctor will "shout & get angry". Why? I ask - because the Doctor is a very important person who knows everything & his patients are very low status & should not question him. I am inclined to believe from my experience with Cambodian doctors that the anger actually comes from ignorance - no one likes to be asked questions they don't, but should, know the answers to. I loitered outside the hospital eye ward for 20 minutes recently waiting for the doctor to leave so my friend & I could slip in & ask the nice nurse to use the slit lamp, me going along to a consultation with a doctor for either of them is absolutely out of the question. I think my friend would rather go blind than do that. That in itself is a damning indictment of the Cambodian health care system. The nurse however was extremely compassionate & kind - she should open her own clinic, maybe she already has.

There also seems to be a general ignorance when it comes to health in Cambodia, which surely must stem from the incredibly poor education & health systems, the poor governance hence minimal public health policies, plus of course genocide eradicating a whole generation of wisdom, knowledge & common sense. The median age in Cambodia now is 22.9 years old. This probably explains why the great Cambodian public think IV glucose is necessary for every condition & gives you 'energy', spitting in wounds is helpful not in fact an infection risk, massaging a fracture is healing rather than agonising, pulling a trauma victim around like a rag doll is spine friendly or rubbing someone repeatedly with a tiger balm lid until they are black & blue is a panacea for all ails. The general public's health ignorance results in my friend's family mocking his eye problem when in actual fact what he has is a common cause of blindness that their treatment of spitting, breast milk & steroid cream have all been shown to be wholly ineffective against.

I think it is probably fair to question the wisdom of a population that bruises, burns & puts inert poultices on the head's of their children yet doesn't know the dose of Paracetamol to give their child if they are in pain or have a fever. I often dream of producing a series of different dramas - the Cambodian equivalent to Casualty, Holby city, ER, Dr Martin etc. - which based on the philosophical foundation of public service broadcasting would inform, educate & entertain the masses. I would have to include one character; a pissed off English NGO doctor that no one ever listens to but who stubbornly stays regardless. I am sure Cambodians would enjoy watching her unravel whilst her closest Cambodian work colleagues learn to swear like dockers & become blind militant feminists. It has got to be better than the crap Korean soap operas we are currently subjected to here.

In the past the patient only paid the healer, whether that was monk, traditional or western doctor, at the end of a successful course of treatment, like in China, hence a doctor who was good at their job got paid more. Paying the doctor first removes this incentive & in a country where everything is about the money maybe this would be the best way to re-motivate doctors to do their job properly, keep up to date with & follow treatment guidelines. I suggested this to one hospital director & he laughed, agreeing with me. He then reflected that it was better when it was the 'old way', doctors had a better relationship with their patients. There was trust then, which currently is completely lacking.

Another huge issue & barrier is the levels of mental illness & psychological problems in the population that prevent access to healthcare but also affects the expression & presentation of illness. I was recently asked to see a relative of a staff member who was being treated for Hepatitis C with interferon. She was experiencing what sounded to me like anxiety attacks but they were tightly enmeshed with her hepatitis symptoms & the side effects of interferon. We had a long conversation about what her fears were & unlike her family who were looking for a physical cause & cure she too thought it was psychological. She was in her late 50s & lives in an area which had active violent civil war right up to the elections of 1993 & sees many consequences of the war to this day with mines & unexploded ordnance.

I talked about how people aren't just physical symptoms or purely expressions of their psychology. She has both physical & psychological elements to her - like we all do. She agreed with this but her Doctor relative also nodded sagely & told me - every patient that we see here in Cambodia we have to ask ourselves how much is a psychological manifestation & what is physical.

Although Cambodia has more than its fair share of mental health problems this country has very few psychologists or psychiatrists so any problems are mainly left untreated. Unless of course you can get to the Pagoda or traditional healer to exorcise the bad spirits.

Once my assistant asked me once to see a man who was withdrawing from alcohol because he believed he was possessed by evil spirits & wanted to show me - the skeptic - that spirits did really exist. Unfortunately having a translator who doesn't believe in alcohol withdrawal made it hard to convince the staff or relatives that the patient needed Diazepam. Luckily the patient himself needed less persuading to break his 48 hours abstinence from 2 litres of palm wine a day & promptly self discharged to self medicated.

And who can blame him? When I think about all the barriers to good health in Cambodia I find myself heading towards my emergency bottle of red wine too.

Sense of smell too

Seeking solace in my spiritual home - a local boutique hotel - I saw some english writing belonging to one of the bar staff. I asked her if I could see it & embarrassed she immediately hid it under the bar.

What was the writing for? I pursued. It was a homework piece for English class I was told coyly.

Then I found out where she studied & I told her my friend went to the same school & had just gone up to the level above her. As I have become an English homework specialist I asked which one she was doing. "About smell" she informed me.

I know this one I exclaimed - you have to write about a smell & what memory it is linked to. What are you writing about? I probed to her increasing discomfort. "Jasmine fragrance & my childhood garden"

Oh... I was stopped in my tracks.

Was there something the matter? She enquired.

How old are you? I asked for clarification.

20.

My friend is 15 years older than you, when he did this same homework he wrote about the smell of blood & a mine explosion.

She smiled politely & asked me if I would like another beer.

Taking the crunchy with the smooth

The Cambodian space project played at my friends wedding so it was with much excitement & anticipation I awaited their performance one Friday night recently when they came to play at a guest house & bar just around the corner from my house.

I enrolled my assistant, J & her visiting daughter, my work colleague's wife Sb & a kiwi nurse from the local university to come along with me.

It was a slightly complicated affair for my assistant as her father initially gave consent but later said he would lock her out of the house at 9pm & she could not use either of the families motos to get in from her village to town. Being a flexible & adaptable ex-VSO volunteer I made up my spare bedroom & arranged lifts for her instead.

The set started at 9pm so beforehand we all met up at my friends cafe & had a meal consisting of such delicacies as goat's cheese & hummus. There were mixed reactions from the Cambodians.

My assistant who is a good khmer 'girl' was persuaded to have a Pina colada & eventually succumbed to a can of beer too. If you can't capacity build them then corrupt them - is my new development mantra.

Sb's family are wedding entertainers so after the intermission she got up on stage & sang a song with the band. She, like her whole village, had viral conjunctivitis hence the shades giving her a slight hint of gangster. I loved that she could just get up & sing with no preparation or rehearsal on a dare from us all. We were all very proud to be her friend & as her husband texted me the next day - "S told me that she had a big blast with you last night that she's never had the great day like this since she was born."
Below is a video of her performance.

We all had a big blast - L & I staggered home just before 1am which may seem modest by western standards but is ridiculous late in Cambodian culture.

The follow morning I woke up with the monks banging the drum & despite the lack of sleep & moderate hangover I was still feeling on a high from the 'blast' the night before.

Whilst I was outside on my veranda hanging out my washing my landlady looked up & told me bluntly "The dog is dead", L heard & came out to find out what was going on. We discovered that Scabby dog had been hit by a moto 3 days prior & had been bleeding for a day & had just died that morning. No one had told me she was hurt & the morning before I had wondered why she had sat mournfully under my hammock just letting her puppies eat the food I was offering her also.

I was very, very upset.

The landladies son buried scabby dog by the banana plants at the side of my house.

The landladies daughters cried all day.

I had plans to go to the Pagoda to offer the monks a meal with my Cambodia mother (S), J & L so I went as planned, lit a candle, burnt some incense, offered a lotus flower & sat through a lot of buddhist chanting whilst my lower back went into spasm & my legs grew totally numb.

At one point S offered a plate with money on it, J & I were instructed to touch her whilst everyone chanted. With my lower body in spasm & excruciating discomfort & my right palm placed firmly on the small of S's back I suddenly felt overwhelmed by loss & as they say here the "tears dropped down".

Life is suffering, this too shall pass, everything is temporary.

S was delighted & beaming to be at the Pagoda offering the monks food & money. Her joy made me feel even more bereft. How could I ever leave here? I thought as I felt S's solid presence against my hand - joy & people both have a limited time span.

When I went back home the 3 remaining scabby puppies were laying on my porch waiting to be fed. The next day R helped me give the 2 more approachable ones their anti-parasite injections. After scabby puppy girl squealed, yelped & struggled through her jab, R looked me steadily in the eye & said "So Esther, now you will feed, inject & love these puppies until they get hit by a moto & die prematurely also? Is that your plan?"

Yes Mr R - ask your 3 year old daughter who cried at the Disney film I gave her - its called the circle of life!

Or as Billy Bragg would say - in life you have to take the crunchy with the smooth. 

Re-skilling

Last week I went to another town to do some training & arranged to have lunch with a health volunteer there. I went to meet him in his office in the local emergency department & to marvel at an emergency nurse volunteer actually placed in an real Emergency department. My ER remains mid construction - 31 months now & still counting.

Jm had dengue recently & as a result has started smoking so wanted to sneak outside for a quick fag before going out to lunch with my boss who for some reason he didn't want her to know that he smokes. As we walked through his department - which has an odd lay out so all patient care is delivered in the main corridor because the rooms have all been renovated & are hence too nice to put patients in - we couldn't help notice an unconscious man being given chest compressions by his relative in the middle of the entrance to the ER.

A man, who I assumed to be the head nurse because he asked Jm to intubate the man, was ventilating the man with a bag valve mask whilst the relative delivered reasonably effective chest compressions. Jm explained he couldn't but perhaps I could. So I found myself at the head end asking for suction & some gloves with my scarf posing its own infection control hazard.

Jm disappeared briefly to return with an automatic defibrillator, he has singlehandedly by donations equipped his ER to the level of a 1980s NHS casualty department. It's really quite impressive, the staff with emergency skills is still a work in progress.

So whilst he attached the pads I intubated the patient & started doing one of my favorite things - running a cardiac arrest in a second langauge, and when I say second there's a hell of a long drop off from my first one.

The AED revealed that the man was in a non-shockable rhythm so off Jm trotted to get an ECG monitor. I was very impressed by the Hewitt Packard monitor - it's been a while since I've seen one in use. It not only showed that the man was in asystole but that our attempts at CPR had produced an oxygen saturation above 95%. Or it could have been the limb massaging that that family were performing.

We discussed with the nurses & family that the history - he had cardiac arrested 20 minutes before arriving at the ER & the rhythm meant we should withdraw resuscitation & with their agreement we stopped.

I washed my hands & removed my by this time contaminated scarf then thanked the head nurse for letting me help to resuscitate this patient. It turns out he was a senior doctor, so although I had failed to capacity build him I had however successfully convinced myself I haven't de-skilled as I often fear I may.

Once again it was demonstrated to me that what staff here need in an emergency is someone confident enough to lead them but few have these skills. My job has been to try & capacity build these skills but there are two common outcomes. The first is they just refuse to listen to me & ignore my advice completely or the second, like this instance, is that they step back & disengage to save face. There simply isn't the organisational culture in government hospitals for on the job training which is consequently seen as demeaning & belittling to the 'highly qualified' doctors here.

In the UK the general public are well aware that doctors train on the job & there is a system of supervision & seniority. Here in Cambodia doctors train in medical school for 7 years & then are fully qualified. Referring to a text book, guidelines & protocols or doing an internet search are all seen as weaknesses. Doctors are all knowing but can not be questioned, especially by their patients.

A few years ago there was a paper published about doctors use of google. Radio 4's Today programme interviewed the author & was particularly sniffy & derisive that doctors should already know 'everything' & it was 'shocking' that they had to use google - what did they do at medical school? the interviewer scoffed.

I personally would prefer to see a doctor that can say - I don't know- & who asks for help beyond their training & skill set. I am a generalist so have always been comfortable referring on to 'experts'. If you prefer to be treated by doctors with the blind arrogance that they know everything & need not ask for help or refer to the literature than I suggest one seeks out medical advice in Cambodia.

Meanwhile I patiently wait to be asked for help & listened to whilst Jm the next day went outside for a sneaky cigarette & inadvertently bumped in to my boss.

That's life.

Change of character

It was fed back to me this week, by a male colleague I work with, that one of the doctors in the hospital had told him that one of his many problems with me was I should "Change your character a bit to fit with Khmer culture" Initially I wasn't sure if this doctor meant I should be more like a Cambodian doctor - only care about money, status symbols, be closed minded & not interested in improving patient care. I am of course being facetious - this doctor meant I should be more like how he expects a Cambodian woman to behave - silent, respectful, not challenging him, agreeing with him even when he is dangerously wrong and certainly I should drop being so passionate about patient care & the right to health for everyone including poor people who cannot afford bribes.

I am sure if I tried I could behave like this but then I probably wouldn't be able to do a very good job of capacity building health workers. As I have said numerous times before if they aren't shouting at you then you are probably doing something wrong. When a system is so rotten, broken & terrible, trying to suggest politely even very small changes can provoke an aggressive, defensive back lash & is certainly doesn't win you many friends. The Pinner/Arkill genes in me hold me steadfast & stubborn on this particular point. I won't be bullied by these people to stop challenging them and I certainly can't stop believing that things need to change & improve for Cambodian people to access decent & acceptable healthcare. 

It is hard sometimes, especially when you are being told to change your character & that everyone hates you not to take it personally. At times this week I have felt like it must be all my fault & what a terrible person I am, when this happens I have reminded myself of something that happened a fortnight ago & also meditated on these words "This too shall pass"

The MoH had come to deliver haematology training a few months ago but no doctors had attended, even after the director attempted an emergency whip round in the afternoon there was only 4 doctors who showed up. Understandably the MoH were not very impressed by this so had organised a second training day where attendance was mandatory. When I heard about it I asked if I could go along as I have previously tried to train on blood tests interpretation & safe blood transfusion, I wondered whether I was in line with MoH thinking. "Why not?" replied my Deputy director. 

The first session was a typical Cambodian trainer - a 'Professor' from Cambodia, powerpoint presentation in English obviously written by an international expert, very high level, lots of talking, talking, talking with no pause for breath, never checking to see if the participants understood, in fact there was no participation so we could call them an audience of the Professors enormous ability to talk very importantly on a subject so that no one could actually understand it. 

This is what Cambodians are used to. If you teach at a basic level that explains first principles, is understandable, ask lots questions, allow lots of questions & involve the participants this is generally seen as a poor educational method. Use of a lesson plan I was told recently, "may be ok for Barangs but for a Cambodian it means you are weak & do not know the subject."

When I think of the hours I have spent writing lesson plans that will never be used because it is better to look 'clever' & 'strong' rather than actually deliver good quality, consistent training, 

Even when the professor talked there were still roughly half the audience on their mobile phones talking loudly behind a hand covering their mouth (this is not an effective sound barrier, I'm not sure they realise this) or watching youtube videos or playing candy crush on their smart devices. I have seen pre-school children with more of an attention span & respect of a learning environment.

The next session was run by a NGO doctor who I have worked with before. He may not be a professor from a Phnom Penh Hospital but he has trained for the last 10 years with international experts & probably has a much better medical education as a result. Because he has been exposed to barangs his teaching style was different - he was more informal, didn't talk incessantly but asked questions, prompted the participants for their ideas or experience, explained things from evidence base & not just his anecdotal experience. 

Hence he was giving quite a good lecture that I was actually engaged with & following despite it being in my very second language when something not unusual here happened, it was surprising however because I previously thought it only ever happened to me.

One of the surgeons (these are the same surgeons that didn't know how much blood was in a human body) stood up & interrupted the speaker - "Stop talking now, you are not good, you have bad attitude & are disrespectful, you ask us questions because you don't know anything, it seems to me you have no knowledge. I will not listen to you any more, I will only take information from the Professor. You are just a NGO doctor. Sit down now"

The NGO doctor smiled & sat down (I was taking notes at this point as I am sure this is what I too am expected to do in these situations) and then the Professor started talking very quietly. The room was silent, people put away their mobile phones & actually listened. Very calmly the Professor continued the lecture reiterating everything that the NGO Dr had said. Never saying openly that the NGO doctor was right nor showing he thought the surgeon was rude or condemning his behaviour.

I was stunned - I had always assumed it was because I was a female foreigner but apparently 'low status' male Cambodians can be treated the same way.

Afterwards I spoke with Dr ON the deputy director - he couldn't see what the problem was. I had to explain that in my country what the Surgeon would have been extremely rude, disrespectful & offensive. ON shrugged - But the speaker was an NGO doctor, we don't respects NGO doctors here! - I was told in no uncertain terms.

So when a poorly educated, ignorant but rich, high status doctor is rude & dismissive of a higher trained, professional  NGO doctor who he considers "lower status" to him, the correct response apparently is to just smile & sit down silently. And there it is, thats the part of my character which it would appear is in need of an urgent change.

I have an opinion about what they can do with this part of khmer culture but unfortunately it would probably go against the personal development advice I was given earlier this week.

Polypharmacy

Regulation of pharmaceuticals is not something that has reached Cambodia yet & if you know what drugs you want or need, then you can pretty much buy any medication over the counter.

My Cambodian friend had a fever & cold symptoms so came around to my house asking for my advice about what medication to take, as well as subsequently passing it on to me - as I type I am experiencing both rigours & chills. She produced the above pick & mix bag of drugs that her local 'pharmacy' had given her & wanted to know what, if any, she should take.

This little bag was all she was given. No explanation of what drugs they are or what they are for and lets not worry about allergies, adverse effects & contraindications. Most importantly she was only given one dose of each type of drug, as that is all she had asked for. No need to wonder why there is 70% amoxicillin resistance in streptococcus bacteria here.

In her bag of tricks was;

• Big yellow round sealed tablet - Known by J & me as "yay's little helpers", contains Paracetamol 500mg, Phenylpropanolamine 25mg & Chlorpheniramine 2mg. Basically the Cambodian version of night nurse. Generally accepted as useful for cold & flu symptoms but the dose is 2 tablets taken up to 4 times a day.
• Red & yellow capsule - Amoxcillin 500mg. One dose is about as much use as a ashtray on a motorbike or a Cambodian pharmacist's advice. Have I mentioned drug resistant bacteria & over use of antibiotics here before?!
• White round tablet - according to pill identification wizard its Lorazepam - a sedative or sleeping tablet
• Large yellow oval tablet - multivitamin, although there is no evidence that it shortens cold symptoms it remains a common cold remedy, so I will give them this one.
• Yellow small tablet - either Ranitidine for excess stomach acid or Clarithromycin an antibiotic. Neither are indicated
• Pink small tablet - Dexamethasone. Because here you get a steroid for everything even if its been shown by evidence based medicine to increase mortality rates e.g. EV71 

One common theme is if you go to a private clinic or pharmacy without knowing what it is exactly you want you will always leave with 6 different types of medication - its the rule. I have been told that in Cambodian culture odd numbers, particularly 3 is lucky - not so when it come to making money out of sick people it would appear. 

Another friend (English) asked for my advice about his infected burn on his leg. He had attended the 'best' private clinic in town & had told them his concern about having an infection. He too received a booty bag, but of 3 days worth of medication, when after this his leg just was worse he then asked for my advice.

In his bag of wonders were;

• Enzyme tablets - for digestion
• Paracetamol
• Cox-2 Inhibitor - an anti-inflammatory drug
• Omeprazole - for excess acid in the stomach
• Multivitamins
• Antihistamine

When I informed him that no where in his smorgasbord of medications was there even one antibiotic he was genuinely surprised and understandably a little annoyed. After all why in a country where antibiotics are over used would you not get given antibiotics when suffering with an obviously bacterial infection of a large burn & resulting cellulitis of your entire lower leg. 

After 30 months working in & witnessing the Cambodian health care system it takes an awful lot more than this to surprise or shock me now.

Foot note to proof

Checking some English homework today I stumbled across this classic question & answer exercise. To give it more context the writer is my work colleague, a very good nurse & my best Cambodian friend, apart from a study tour across the border in Thailand he has never been out of Cambodia.

1. What are you dying to do?
I am dying to be a specialist doctor

2. What are you sick of doing?
I am sick of giving new information to the others but they don't accept it.

3. What would you like to have the opportunity to do?
I would like to have an opportunity to take an examination to study abroad 

So its not just me then!

Proof

One of the things that I really struggle with here is not being believed, taken seriously or even listened to, ever. People have told me (including Cambodians themselves) that Cambodians, generally speaking, will reject anything new immediately out of hand - its a force of habit. But what annoys me isn't skepticism, which I actually encourage, nor stubbornness, which I too am afflicted with, but rather the complete lack of an enquiring mind this is a symptom of.

If someone tells me something which I haven't heard about before or is different from what I believe to be true e.g. my cambodian male work colleague who has 'eye disease' told me that breast milk can cure viral conjunctivitis; I will ask - Why? How do you know that? Show me the evidence? Where is your proof? For this example I thought maybe it as something to do with IgA in breast milk & a google search revealed many mother & baby websites that confirmed this old wives tale, less so when I did a proper literature search.

Here when I say something contrary to popularly held Cambodia opinion the standard response is "NO! That is not right, you are wrong, that won't work - this is Cambodia!" often even before I have finished my sentence or its been translated into khmer.

This closed mindedness, this narrowness of vision, this lack of curiosity or acceptance of new ideas or conflicting opinions literally drives me to tears, despite knowing & appreciating the roots of it - a poor education system, civil war, PTSD, an oppressive regime to name but a few.

It used to be only in clinical environments when people were suffering or dying as a result of my advice being ignored that I would be crying tears of frustration but recently I have found that the chronic exposure to rejection of my statements without any question is actually shortening my life expectancy significantly.

One recent weekend I had bought some bread & went to put it in the freezer (I was going away but my friend was arriving to stay at mine the next day) when my khmer teacher screamed at me "NOOOOOOOO!" I thought maybe there was a deadly snake or scorpion I was about to step on but apparently it was just to stop me putting the bread in my freezer. Now maybe there is new research that shows that frozen food causes cancer but my khmer teacher didn't use this in her argument, she just repeatedly told me "No, you can not do". Eventually, brandishing reason & rational argument, which is always a little tricky here, I asked her had she ever owed or used a freezer. Silence then a muted "no"  - So I challenged her on what evidence was she telling me I couldn't put bread in the freezer. Turns out there was absolutely none whats so ever, she just had never seen it done before & therefore felt in a position to tell me what to do, despite having no prior knowledge, exposure or experience of freezers & bread.

This happens A LOT to me here.

A beautiful Pagoda moment was spoilt by me casually saying to my Cambodian friend, who was playing with a lotus flower - pulling on a thread from the stem -  that in Burma they use the lotus flower stem to make silk. "NOOOOOOOO" came the response in stereo from her & my Cambodian mother - This was wrong - I did not know what I was talking about. It took me 24 hours to calm down enough to show them both my holiday photos before they would believe me. They didn't ask for this proof, it was forced upon them.

It worries me that even the brightest & the best here still have a tendency to reject things initially but if you spend time to show them the evidence or proof they will eventually - often weeks later - concede you may have a point.

Rarely in work am I asked why do you think/say that? what is your proof? Yet if I am asked it is usually used as a delaying tactic, if I show proof it too is often rejected without even being considered. The biggest problem of this lazy thinking clinically is that if a patient doesn't die it is believed that treatment that was used is correct, it is very hard to persuade health workers using critical or evidence based thinking.

Snakebites are a really good example of this. 70% of people bitten by a snake won't actually be envenomated & hence what ever you do to them they will survive. So 70 times out of a hundred if you go to a traditional healer & they spit on the bite or cut it out or put a poultice on it or say a prayer or throw some bones you will still survive & would have survived even without all the spit & incantations.

Equally if you go to a hospital in Cambodia many doctors including the NGO ones I work with believe that Chinese herbal tablets are effective for snake bite. When you try to explain the odds of envenomation & why it would appear that they work when evidence shows they are useless they shake their heads & say - you are wrong, I have seen them work, this is Cambodia. It is a little like homeopathy but if you have actually been envenomated by a king cobra you tend to die, pretty quickly.

A health NGO worker (not a clinician) once told me that he "couldn't see the harm in the traditional snake healer" in his village - as he wasn't a clinician he obviously hadn't seen one of the 30% that die, like the 7 year old girl who was bitten in her mosquito net & was taken by her parents to the traditional healer first so was already in respiratory arrest when they arrived at hospital. DOA - No harm done hey? Lazy thinking like this I have come to tolerate from Cambodians but it is unforgivable coming from a barang.

There are in fact 2 polyvalent anti-venoms for use in Cambodia & distributed by the MoH. One is for snakes that cause clotting problems "heamo" such as the green pit viper & the other is for snakes - like cobras - that cause neurological problems "neuro". Staff have had training on this.

We arrived at the border hospital this week to find a 18 year old boy who had stepped on & been bitten by a cobra - it had been killed & brought in with him. The staff had decided to give him antivenom after demonstrating that although his blood clotted he had a pulse of 52/minute & felt sleepy, which they felt represented a problem due to the cobra venom. Now this decision is debatable as he had no other neurology but as I wasn't there when they made it I have to accept their clinical decision.

However I did feel I could question their decision to give the 'haemo' antivenom for a boy who was confirmed to be bitten by a cobra - a neurotoxic snake & who had no symptoms of a coagulation problem. But when I broached this I was told that there was only one antivenom for all snake bites in Cambodia.

The antivenom comes from Thailand & the instructions are in Thai & English. I showed them the bottle that clearly stated it was 'Haemo' antivenom & the instructions which clearly talked about 2 different kinds of antivenom but at this point even my work colleague wouldn't believe me. I showed them the powerpoint presentation & video produced by an american university that works with my NGO in Cambodia - rejected as foreign & therefore not respectful or knowledgeable of the Cambodian context.

I showed them a WHO document about snakebite in Cambodia which states that doctors have poor knowledge & are known to not use the 2 antivenoms appropriately. There is only one antivenom in Cambodia I was repeatedly told. YOU ARE WRONG.

I started to doubt myself - this is also very common. I think maybe 20 years ago perhaps there was only one type of antivenom available.

Luckily the boy was fine, ambulatory, asymptomatic & as he was fit & healthy his pulse of 52/minute was just a normal sinus bradycardia for him. I decided that as the boy seemed not to be envenomated & had no adverse effects from the antivenom - such as anaphylaxis or death - best just to drop it. Life here has really taught me how to pick my battles.

The next day he was discharged, "See!" my work colleague beamed, "the antivenom was the right type & now he is cured. "

He was deliberately goading me of course but equally he was reflecting the thought processes of the MoH hospital staff here. The boy survived so they were right & I am wrong.

If I DC shock a 17 year old girl out of her life threatening SVT this inarguably provides immediate proof that my clinical knowledge & skills are correct but often the changes needed to improve medical practice here, such as something as simple as washing hands between patients, can take time to prove & if people don't want to see that proof, well then they just won't see it.

Meanwhile I continue to make self doubt a fine art......

The truth

I am having a spot of bother with one of the hospitals I work in. It would appear to be an issue of differing expectations. 

I expect them to do the very basics of nursing & medical care for all their patients within the realms of their ability & resources available, with support & advice from my NGO colleagues & myself.

They expect me to only praise their work & to never point out areas for improvement of try to discuss methods for improving care. They think that they "know it all" - this is an actual verbatim quote - I wish I could say the same with such confidence (another blog on this particular affliction will follow shortly), therefore whether they actually do it correctly or not is irrelevant to them.  

Previously - whilst in the midst of a civil war - they had MSF doctors that did their job for them. I have tried to explain that now it is their turn to 'do' & I am here to share my knowledge & skills with them; to capacity build them. They would prefer that I just did all the work, gave them lots of equipment/money & shut up.

One particular doctor has a problem with my NGO following up on MoH guideline & training of severe acute malnutrition (SAM) on his ward. He asserts that he is a very important man & as a mere female NGO doctor, who am I to comment on his wards performance or coach them how to improve? A few weeks ago he completely lost the plot with me in a clinical area - yelling & throwing personal insults - after I had asked if we could meet to discuss SAM follow up. Everyone it seemed, including my male Cambodian NGO colleagues, thought I must have some how been responsible for his behaviour. I have never been spoken to by another 'professional' in such a manner before - which as an emergency physician is saying something. I didn't think that I had said or done anything to particularly provoke him - but perhaps he can read my thoughts. My assistant was with me & she confirmed it was indeed unprovoked & completely inappropriate.

Since that incident he has been given the follow up report, which I had been trying to give him when he physically removed me from his ward. Now he claims all his problems with me & the NGO I work for are due to this report which had been written to reflect feedback & coaching done with staff on his ward last month. The report he hadn't even seen or read when he behaved like a complete misogynist **** towards me & my assistant. 

A meeting was called by the hospital to discuss this. 

I have been told that I must surely exaggerate events for dramatic effect for this blog. I am a little bit fed up that people don't believe my stories about health care in Cambodia, despite other people - foreigners & Cambodians - who witness these events or similar, concurring with me. I am tired of people thinking that it must only be me that has a problem. I admit that I am frustrated that I can not seem to help towards realising the goal of better health care for the Cambodian people. Since starting this blog I have always tried to give a relatively balanced re-telling of any events portrayed, which I would be happy for all characters involved to read, hence the blog being in the public domain. I hope that when I report my feelings about things that happen in my work place here that they are read as just that; my feelings, my view of my reality & my version of the truth. 

So for those of you who doubt this, my assistant - to practice her English - wrote her perception of the meeting we had with the hospital, maybe you will believe her truth, even though she is young, female, & not rich. 

"One day, J, Esther, R, and I had a meeting to solve difficulties in follow up with staffs in pediatric ward under facilitating of two deputy directors, Dr. ON and Dr. H. When the meeting started, Dr. H told us there are some feed backs in the follow up are contradicted to what the pediatric staff has done. They disagree and do not accept those. Then he asked us to explain what the follow up is , what the objectives of the follow up are , what the advantages we will get from those follow up, and what the follow up will be used for. J gave the general information of the follow up. Then he asked what tool comes from. “It came from NNP and MOH. They worked with us to make this follow up tool” J said. When she finished the explanation, we began to talk about the problems we have with the staffs. Dr. CP asked is it true that tool gets from the MOH and NP. Mr. R said” yes, it is.” He continued to ask,” why you scored us in low when we have tried to do. Why you cannot give us 4.” He never kept time for us to answers at all. He always shouted and asked aggressively. I felt so angry, but I could not say anything as I am not either a nurse or NGO staff. Just keep silent. The whole one hour of meeting was just for Dr. CP to talk and show who he is. We already knew who he is and what his ward has done. At end of meeting, we asked him whether we can do SAM follow up next time. He said wait until he make sure that it came from NNP and MOH .Esther asked him about the TB screening follow up whether we can do it next Friday. He did not listen at all. He just said that if the child is suspected have TB, we send him/her to TB service. Esther replied quickly “no, we just asked about the screening, about what the doctor thinking about TB when screening the child”. Even she talked clearly, but Dr.CP just turned deaf ear to her. No matter how we try to explain in short time, he did not take a look at us. I wonder if he take breathe or not for an hour talking. After this meeting, I realized that there is a cultural problem, mainly saving face culture which I do hate. It is not about the translation errors. In Cambodian, even if you are either a professional doctor or nurse from other countries, you cannot criticize truly from what you see to Cambodian male doctors.  If you tell them like that, they will think that you hate or accuse them. Also, if you are a good nurse comparing to them, but you are low status-not rich as them, you cannot criticize also. Even you criticize them, you should say please……..like begging them to change as I have noticed from what has been told by Dr. CP.  And if you can put them the high score, then you can criticize things. So i think the person who can observe them is only people in high government position. I know that the culture problem is hard to be sorted out. It can be solved if the doctor wants to be changed. Therefore, the meeting is just saving face problem for doctor as he cannot accept the reality. For the follow up next time as just in case he approves us to do more, it is more likely that the only the higher Cambodian people can do it."

Seven Qualities

My assistant & I often end up having girly talks, which generally involve discussing what misogynist gits most men seem to be here, strangely enough we rarely talk about clothes, makeup or shopping. 

She is, unfortunately for her, very beautiful as well as intelligent, resilient & compassionate, which has resulted in the unsolicited attention of various foreigners, some three times her age or equally inappropriate. She also has lots of male friends from uni & school, who although she denies are anything but friends, one recently declared his love for her. She has since had to re-think the assumed platonic nature of these relationships. 

Worried that my cynicism was infecting her, after she declared she hated "all men", I asked her why she wasn't interested in her good male friend who obviously liked her very much. Well - she told me - I gave him a list of 7 qualities I needed in a husband & he said he couldn't guarantee the first one which I think is the most important. So he can not be my husband. 

Could I see that list? - I requested.

Below is her written response - an 'essential' requirements list for the job of her husband to be. 

Her female friends have told her that such a man doesn't exist anywhere in the world. I can't decide if this is just a damning indictment of half the world's population or related more to the exceptionally low expectations for equality & respect that most Cambodian women seem to possess. 

After all people, regardless of their gender, will only behave how you allow or expect them to behave. Equality doesn't just come from those with power giving it up, the disempowered also need to take it.

Seven Qualities to Be My Husband

Marriage is very importance in our life. We need to think carefully about it. We have to see which quality of men that you can live after your wedding. For me, a man whom I would like to marry needs to have these seven qualities.

            First, he has to be honest man. He only loves me. He is not allowed to cheat me at all. He does not play around with other girls. He needs to tell me everything that he has done or did even it is a bad thing. For example, he should have to tell where he goes and who he is with. He shares what he think and what he has problems. He should have to tell what is in his mind. So it is easy for me to help and share the problems with him. That can build our trust with each other. This honesty is the most essential requirement for my perspective man.

            Second, he has to be respectful. He needs to respect me and every people. He needs to treat everybody respectfully. He is good to all the people. He never either speaks or does badly to everybody, especially to women. So we have to respect each other.

            Also, he is empathy person. He understand how people feeling and cares about people around him. He can share the feeling with them. He thinks about how people feel if he does that. He tries to put himself in another person situation. So he is not selfish man.

And he is kind. He likes to help people. He is generous to poor people or other people. He tries to assist them as much as he can.

            Besides that, he is sensible person. He knows what he is doing. He has a specific plan in his life. When he does something, he is able to set plan ahead. Therefore, he set a plan ahead before he does something.

One more thing is being independent. He can do things himself. He does not rely on somebody at all. He is capable to decide something by his own. He is confidence to make his own decision.

            Finally, he is educated person. At least, he has graduated from university. He has a good background in studying.

In short, I would like to marry only someone who has those qualities.