Wednesday, October 30, 2013
Saturday, October 26, 2013
After the Flood
There has been bad flooding in Cambodia this rainy season which a couple of weeks ago resulted in a Dam near my home being breached to stop the reservoir bursting its banks.
A Khmer blog said that the villagers that had lost their homes had said that "the authority told them that their houses are deliberately flooded because the land in this area has already given as a concession to the company and they company tried to evict them along time ago but the people refused to leave. Now they deliberately flooded their houses in order to evict them from the land."
My friend went last week with a group of people to hand out tarpaulins & rice to the displaced villagers & help make temporary shelters for them. This weekend my assistant wanted to go to see the lake - it felt a little like disaster tourism but as we had lunch at an exorbitant price at least we gave back a little to the local economy. I have never visited the lake before - it is a 1 hour moto journey from my house - therefore I have nothing previous to compare what I saw to but suffice to say you don't need to have visited a place before to recognise devastation.
A Khmer blog said that the villagers that had lost their homes had said that "the authority told them that their houses are deliberately flooded because the land in this area has already given as a concession to the company and they company tried to evict them along time ago but the people refused to leave. Now they deliberately flooded their houses in order to evict them from the land."
My friend went last week with a group of people to hand out tarpaulins & rice to the displaced villagers & help make temporary shelters for them. This weekend my assistant wanted to go to see the lake - it felt a little like disaster tourism but as we had lunch at an exorbitant price at least we gave back a little to the local economy. I have never visited the lake before - it is a 1 hour moto journey from my house - therefore I have nothing previous to compare what I saw to but suffice to say you don't need to have visited a place before to recognise devastation.
 |
| Flooding all the way to the road we travel on once a month to the border hospital |
 |
| Deep enough to necessitate the white 4 x 4 car we go in. |
 |
| The lake still beautiful despite a UK-like grey overcast day & no longer threatening to burst its banks |
 |
| The path the breached water flow took through a village taking with it over 50 dwellings |
 |
| Life after the flood |
 |
| The expensive lake monster we had for lunch - looking at the teeth on it we didn't really fancy a post prandial swim |
Monday, October 21, 2013
Historian
At medical school we were always told that there is no such thing as a patient who is a poor historian just a poor history taker. With this doctrine still ringing in my ears in Cambodia I thought that it was just my extremely poor language skills & things getting lost in translation, which gave me the impression that Cambodian patients are really dreadful historians. I have recently had to revise this opinion.
My khmer teacher, S, who speaks reasonably good english & is an educated woman asked me for some medical advice. In khmer she told me she had a sore throat.
How long for? I enquired.
Since you left for Sampov Luon - came the reply. So this was about 6 days.
Where is it sore exactly?
THROAT! she shouted as me in khmer.
All over, one side, upper, lower???? Could she maybe point to the place? I persisted
Silence & a very blank stare. So I asked again but this time in khmer. Still a blank stare. So I demonstrated pointing to either side of the throat on the outside, then opened my mouth & pointed to my tonsils & finally pointing outside but lower down, by my sternal notch.
THROAT! she yelled at me in khmer again. It is not uncommon for patients to present with unspecified character of pain "choo" all over their entire body so I should perhaps have been grateful we had an area.
What brought the pain on? I asked her, changing tack slightly. Have you had a cough or fever with it? Can you swallow ok?
NO NO NO! she shouted back at me & then disappeared into my bathroom.
She came out a few minutes later & flipped her head back like a cartoon character, opening her mouth in such a way that all could I see was the roof of her mouth & her false teeth.
THROAT - she yelled in khmer at me whilst performing a semi-limbo for me to inspect her dentures. Well at least I could surmise she had an airway, was not hoarse & at 63 years of age was still very nibble.
I felt for swelling or lymph nodes in her neck - she shrugged me off - THROAT! she screamed at me.
Using another favourite history taking trick of mine & the very last of my patience I asked her what she thought the problem was?
"I ate some fish & the next day I had a sore throat, maybe I scratched my throat" she responded in perfect english.
Which side? I asked
She stared at me impassively.
Normally when you get a fish bone stuck or scratch the throat it will be sore in one particular place that people can point to from either in or out side.
THROAT! - she replied......
I have a theory that because in the UK even child birth is medicalised any woman having a baby will have some access to antenatal & prenatal clinics & medical care. Most children are immunised & there are scheduled follow ups for children with community health. Doctors used to go into schools. Dental & optician services used to be provided for free. All of this meant that even if you were a perfectly healthy individual you would still have some contact with free health care services & health surveillance programmes. This meant you became practiced in the questions health workers usually asked. There is health promotion & education in the media, medical dramas & documentaries on the TV all of which provide the language to communicate with health workers. Parents teach their offspring.
Doctors & nurses in the UK talk to patients & depend on their answers to help them make a diagnosis. If you speak to a doctor in my country or ask them a question generally they don't yell at you, tell you to leave there clinic & refuse to treat you again, generally not......
So although I do agree that it is up to a doctor to get a history from their patient there is also something within certain cultures that trains patients to be better historians. Mainly I believe that this is as a result of a decent & robust public health system & professional health workers.
S went to get coined the following day & now feels much better. She is still unable to pin point for me where exactly her pain was but since it has disappeared I thought it was best just to let that one drop.
My khmer teacher, S, who speaks reasonably good english & is an educated woman asked me for some medical advice. In khmer she told me she had a sore throat.
How long for? I enquired.
Since you left for Sampov Luon - came the reply. So this was about 6 days.
Where is it sore exactly?
THROAT! she shouted as me in khmer.
All over, one side, upper, lower???? Could she maybe point to the place? I persisted
Silence & a very blank stare. So I asked again but this time in khmer. Still a blank stare. So I demonstrated pointing to either side of the throat on the outside, then opened my mouth & pointed to my tonsils & finally pointing outside but lower down, by my sternal notch.
THROAT! she yelled at me in khmer again. It is not uncommon for patients to present with unspecified character of pain "choo" all over their entire body so I should perhaps have been grateful we had an area.
What brought the pain on? I asked her, changing tack slightly. Have you had a cough or fever with it? Can you swallow ok?
NO NO NO! she shouted back at me & then disappeared into my bathroom.
She came out a few minutes later & flipped her head back like a cartoon character, opening her mouth in such a way that all could I see was the roof of her mouth & her false teeth.
THROAT - she yelled in khmer at me whilst performing a semi-limbo for me to inspect her dentures. Well at least I could surmise she had an airway, was not hoarse & at 63 years of age was still very nibble.
I felt for swelling or lymph nodes in her neck - she shrugged me off - THROAT! she screamed at me.
Using another favourite history taking trick of mine & the very last of my patience I asked her what she thought the problem was?
"I ate some fish & the next day I had a sore throat, maybe I scratched my throat" she responded in perfect english.
Which side? I asked
She stared at me impassively.
Normally when you get a fish bone stuck or scratch the throat it will be sore in one particular place that people can point to from either in or out side.
THROAT! - she replied......
I have a theory that because in the UK even child birth is medicalised any woman having a baby will have some access to antenatal & prenatal clinics & medical care. Most children are immunised & there are scheduled follow ups for children with community health. Doctors used to go into schools. Dental & optician services used to be provided for free. All of this meant that even if you were a perfectly healthy individual you would still have some contact with free health care services & health surveillance programmes. This meant you became practiced in the questions health workers usually asked. There is health promotion & education in the media, medical dramas & documentaries on the TV all of which provide the language to communicate with health workers. Parents teach their offspring.
Doctors & nurses in the UK talk to patients & depend on their answers to help them make a diagnosis. If you speak to a doctor in my country or ask them a question generally they don't yell at you, tell you to leave there clinic & refuse to treat you again, generally not......
So although I do agree that it is up to a doctor to get a history from their patient there is also something within certain cultures that trains patients to be better historians. Mainly I believe that this is as a result of a decent & robust public health system & professional health workers.
S went to get coined the following day & now feels much better. She is still unable to pin point for me where exactly her pain was but since it has disappeared I thought it was best just to let that one drop.
Sunday, October 20, 2013
Saving face
In Asia saving face is culturally pretty big. I am told that it is a form of respect towards others & helps keep the peace. Personally I have only ever experienced it as a method to lie, cheat & avoid responsibility and my face has certainly never been saved as a result of it.
It seems the phrases "I do not know", "I am wrong", "I did not do", "That was my fault" & "I am sorry" are not synonymous in cultures that 'save face'.
I will give you a very small, non-medical example of this phenomena.
7 am - I call the water man to deliver a new container of water.
9 am - My khmer teacher is concerned that maybe the water man did not understand my request (it has after all only been 30 months that he has been receiving calls from me), so she calls him to check that he is coming - 'in a minute' she is told.
5 pm - I call my teacher to ask her how long is "in a minute" and she says she will call the water man to see if he has forgotten about me.
5 05pm - She calls me back to say that he delivered the water this morning. I tell her maybe he is confusing me with another house as I still have an empty container of water with the money waiting for replacement. She seems pretty certain that he has delivered to my address. I am also pretty certain, being that I am actually AT my address that he hasn't. She says she will re-check with him. I tell her it is not a problem if he has forgotten but it would be good if he could deliver this evening as I have no water in my house.
5 10pm - Second call from my khmer teacher telling me I am mistaken as he has told her he has definitely been to my house & delivered a new container of water already. HE DID IT HIMSELF. She is quite insistent that I must be wrong as he has said he has definitely done it already earlier today.
Slowly & patiently I explain that I am at my house with an empty water container & the money for a replacement one. It is sitting in the same spot that I left it over 10 hours ago. It is fine if he has forgotten to deliver it but if he is insisting on 2 separate phone calls that he has done it already then he is just a liar.
Please wait until 6pm & I will call again my khmer teacher urges.
5 15pm - silently the water man furtively comes up the steps to my house & replaces my empty water container with a new one. I watch through my screen door as he creeps away trying to mute the rustling plastic of the empty container.
I think he is a lying, incompetent idiot who can't even admit to forgetting my delivery & have the decency to admit it or say sorry. Not really sure how this saving face thing is meant to work but it is really not working for me.
|
Saturday, October 19, 2013
The quest to sleep
In an attempt to get some sleep - dogs, monks, karaoke, night time storms, mice have all been conspiring to rob me of my 6 hours recently - I have taken to some desperate measures. These have included moving out of my house - the noise unfortunately just followed me. And purchasing some strong sedatives to see if I could sleep for more than a couple of hours in one night.
The result is that I have slept well enough but I am now externally blunted. By this I mean I am still, expressionless, muted, move slowly, forget what I was going to say, don't express any anger or irritation. From the outside I look calm if still a little tired - I have dark circles under my eyes as well as multiple bags & wrinkles.
Inside however is a different story - I am beside myself with sleep deprivation, frustration & agitatation, anxious & negative about my future. My heart feels like it is physically breaking into tiny little pieces every time I think about leaving Cambodia. This internal turmoil causes chest pains, hyperventilation & water to leak out of my disconnected eyes.
Lorazepam would not be my first drug of choice for agitation perhaps NICE should look into the evidence base for a nice cup of tea, a big hug & some sympathy. Can't seem to get any of these in Cambodia however. So I will to find a way to get some sleep via an alternative method which doesn't leave me so brain dead whilst my heart tries to escape from my chest, unrestrained by reason because it's in the hot tub with the lorazepam.
The result is that I have slept well enough but I am now externally blunted. By this I mean I am still, expressionless, muted, move slowly, forget what I was going to say, don't express any anger or irritation. From the outside I look calm if still a little tired - I have dark circles under my eyes as well as multiple bags & wrinkles.
Inside however is a different story - I am beside myself with sleep deprivation, frustration & agitatation, anxious & negative about my future. My heart feels like it is physically breaking into tiny little pieces every time I think about leaving Cambodia. This internal turmoil causes chest pains, hyperventilation & water to leak out of my disconnected eyes.
Lorazepam would not be my first drug of choice for agitation perhaps NICE should look into the evidence base for a nice cup of tea, a big hug & some sympathy. Can't seem to get any of these in Cambodia however. So I will to find a way to get some sleep via an alternative method which doesn't leave me so brain dead whilst my heart tries to escape from my chest, unrestrained by reason because it's in the hot tub with the lorazepam.
Thursday, October 17, 2013
More by accident than design
J & I have got into rather a bad habit of having to have ice cream after going to the Chinese noodle shop.
Today whilst I tucked into my newly discovered delight of a $2 banana split, which as it is with fruit you can count as one of your 5 a day - I noticed something that made me look twice.
There was a man walking towards us, the khmer restaurant that we go to is a hot spot for glue sniffing street kids & beggars to harass tourists, but the ice cream is great so its worth it! The man walking towards me had an above knee amputation with an artificial leg, which in these parts is not so unusual what with all the mines still being cleared here, but what was notable was his use of a single crutch.
In between mouthfuls of melting ice cream I mentioned to J that it was unusal to see anyone, let alone a Cambodian, using a single stick or crutch correctly but this man actually was - he was holding the single crutch for support in his left arm. Normally people, despite being told by health workers, will hold the stick the same side as the leg with the problem, when in actual fact they should hold it the opposite side for better stability when walking.
I was really impressed by this. My physio friend would also be I thought to myself.
As he walked past our table he then came into view for J to observe his gait.
"Esther" - J dead panned - "He doesn't have a right arm to hold a stick with."
And that is pretty much how it goes here, if you see something that is right it will often be quite literally more by accident than design.
Today whilst I tucked into my newly discovered delight of a $2 banana split, which as it is with fruit you can count as one of your 5 a day - I noticed something that made me look twice.
There was a man walking towards us, the khmer restaurant that we go to is a hot spot for glue sniffing street kids & beggars to harass tourists, but the ice cream is great so its worth it! The man walking towards me had an above knee amputation with an artificial leg, which in these parts is not so unusual what with all the mines still being cleared here, but what was notable was his use of a single crutch.
In between mouthfuls of melting ice cream I mentioned to J that it was unusal to see anyone, let alone a Cambodian, using a single stick or crutch correctly but this man actually was - he was holding the single crutch for support in his left arm. Normally people, despite being told by health workers, will hold the stick the same side as the leg with the problem, when in actual fact they should hold it the opposite side for better stability when walking.
I was really impressed by this. My physio friend would also be I thought to myself.
As he walked past our table he then came into view for J to observe his gait.
"Esther" - J dead panned - "He doesn't have a right arm to hold a stick with."
And that is pretty much how it goes here, if you see something that is right it will often be quite literally more by accident than design.
Tuesday, October 15, 2013
KL
This Pchum Ben holiday I took my lovely assistant to KL. I wanted to thank her for all her support & good work. I also wanted her to see what somewhere other than Cambodia is like. She would like to find a scholarship to study overseas but I wanted her to know what overseas was like first.
We flew from Siem Reap so we also had an opportunity the day before to visit Angkor Wat. For me it was my 7th visit there. For L it was her first as an adult, she had been once before as a small child. It absolutely poured with rain - Pchum Ben is traditionally the wettest time of year - like a UK August bank holiday!
That evening I traumatised L by ordering spring rolls that had pork & not shrimp the advertised in them - she is vegetarian. Then an american tourist knocked my drink all over me by swiping our table with her bag. She then proceeded to deny any responsibility. Truth was I was pretty wet already from the saturated temple visit.
 |
| Umbrellas brightening up the grey & acting as lightening rods! |
 |
| Angkor Wat |
As for Malaysia I think I will just leave it to L for the words & I will just provide some photos....
"After I visited Kula Lumpur in
Malaysia for several days on Pchum Ben day, I found out there are some
similarities and differences from my own country, Cambodia. Malaysia is much
different from Cambodia. It is really
modern city. It has a lot of high standard buildings. There are trees around
the city and buildings. There are also many restaurants and shops for us to go
for eating and shopping. Varieties of foods and clothes are offered, such as
Indian, Chinese, Western, etc. Moreover, the public transportation is very good
and well-organized. It is easy to find the bus, taxi, and train. They are fast.
And, the roads are really good and clean. On the sidewalks, there are shelters for
passengers to relax. Over the driving roads, there are roads with the roof for
walking. So even it is raining, you can walk easily without getting wet. The
environment in the city is good. It is clean and has light all days even it is
at night. Beside the modern infrastructures and public transportations along
with clean, good environment, however, people there are not really friendly.
Even you say hello, they seldom smile and talk back to you. They do not care
about you. But there are also similarities to Cambodia. It seems everything is
more expensive for the tourists. People seem overcharge for us. For example,
when we looked for the taxi, the taxi driver gave us high price which is not
usual price. It is the same in Cambodia. And the men are the same. Most of them
are arrogant and look down to women. When I walked on the roads, men blink and
do some bad signs to me. They do not respect women. All of these are some
similarities and differences between Malaysia and Cambodia."
What she has omitted to write about is;
She suffered terrible travel sickness that resulted in an incident with a plastic bag with a hole in it just minutes from arriving at our hotel in the shuttle bus.
Every thing was cooked in coconut oil & the rice in Malaysia is no where near as good as Cambodian rice.
I lost the ability to navigate or read a map & we got horribly lost.
We nearly missed our flight back due to a combination of taxi related human & mechanical error.
On returning to Cambodia L's house was under flood water.
She sent me this in a text shortly after - "This is Cambodia - dirty country"
What have I started?
What she has omitted to write about is;
She suffered terrible travel sickness that resulted in an incident with a plastic bag with a hole in it just minutes from arriving at our hotel in the shuttle bus.
Every thing was cooked in coconut oil & the rice in Malaysia is no where near as good as Cambodian rice.
I lost the ability to navigate or read a map & we got horribly lost.
We nearly missed our flight back due to a combination of taxi related human & mechanical error.
On returning to Cambodia L's house was under flood water.
She sent me this in a text shortly after - "This is Cambodia - dirty country"
What have I started?
 |
Sunday, October 13, 2013
When you believe in things you don't understand
Last week I read a story from my grade 4 khmer text book & from what I can gather this is the plot (bearing in mind my khmer is still extremely grade 1 but S, my khmer teacher, keeps dragging me onwards & upwards regardless); A father & son are travelling in a boat & the son asked the father where did the rivers & mountains come from. The father told his son this story about a boy going to get a girl from another empire where the king of the monkeys had abducted her (I think). For some reason the king of the monkeys uses a sacred sword to make 2 furrows in the ground or maybe he gets the boy to do it, these become two rivers. But they need to make a causeway across to the sea so the monkey king ties clumps of earth to his leg hair & flies but meets a rain storm & the strong winds shake off the earth from his leg hair & they fall on the ground to form mountains. I think the boy gets the girl.
There was an exercise after the story with 4 questions.
1) The son asks the father about what?
2) The rivers & mountains were made how?
3) The king of the monkeys orders the boy to do what?
4) This story is true or not true? Why?
When we got to question 4) I laughed & said clearly it is not true. S looked at me sideways with an expression that I have grown very accustomed from all Cambodians, which wordlessly says "I do not believe or trust you." She said to me - No, you are wrong, I think this is a true story.
Have you ever tried to explain plate tectonics & geology in another language which you have barely 200 words of? Thankfully S has a world map, speaks at least 2 out of the 3 languages we both share with much more proficiency than me; plus her english is infinitely better than my khmer & I struck lucky with volcano in khmer being Phnom Pleung very early on in the explanation/debate/persuasion.
The larva & volcano break through got her thinking I may actually be on to something, the explanation of the boxing day tsunami was further evidence. I could see the was giving it serious consideration - so the story was fiction right? - I reasserted.
She screwed up her face & told me she still wasn't sure.
A monkey king flies in the sky & earth the size of mountains falls from his leg hair - Do we really think this is based on a real life event?
Apparently one of us still did.
Then inspiration struck, a few months ago I had purchased the grade 4 answer book, anticipating exactly this kind of situation. So I leapt up, retrieved the book & asked S to check the answer of question 4 in it.
She read out that it was indeed not a true story. The second part of the question, why? because it didn't mention the exact date that it happened.
Giant monkey king flying & dropping from his leg hair clods of earth the size of mountains apparently entirely probable but what was really wanting was a precise date when this very realistic event actually occurred.
I really am not exaggerating.
This episode not unsurprisingly inspired the superstition blog.
There was an exercise after the story with 4 questions.
1) The son asks the father about what?
2) The rivers & mountains were made how?
3) The king of the monkeys orders the boy to do what?
4) This story is true or not true? Why?
When we got to question 4) I laughed & said clearly it is not true. S looked at me sideways with an expression that I have grown very accustomed from all Cambodians, which wordlessly says "I do not believe or trust you." She said to me - No, you are wrong, I think this is a true story.
Have you ever tried to explain plate tectonics & geology in another language which you have barely 200 words of? Thankfully S has a world map, speaks at least 2 out of the 3 languages we both share with much more proficiency than me; plus her english is infinitely better than my khmer & I struck lucky with volcano in khmer being Phnom Pleung very early on in the explanation/debate/persuasion.
The larva & volcano break through got her thinking I may actually be on to something, the explanation of the boxing day tsunami was further evidence. I could see the was giving it serious consideration - so the story was fiction right? - I reasserted.
She screwed up her face & told me she still wasn't sure.
A monkey king flies in the sky & earth the size of mountains falls from his leg hair - Do we really think this is based on a real life event?
Apparently one of us still did.
Then inspiration struck, a few months ago I had purchased the grade 4 answer book, anticipating exactly this kind of situation. So I leapt up, retrieved the book & asked S to check the answer of question 4 in it.
She read out that it was indeed not a true story. The second part of the question, why? because it didn't mention the exact date that it happened.
Giant monkey king flying & dropping from his leg hair clods of earth the size of mountains apparently entirely probable but what was really wanting was a precise date when this very realistic event actually occurred.
I really am not exaggerating.
This episode not unsurprisingly inspired the superstition blog.
Saturday, October 12, 2013
Very superstitious, nothing more to say
Cambodians are a superstitious lot.
They generally believe in ghosts, spirits, fortune tellers, karma, traditional (harmful) remedies & practices, dream prophesy, a magic log for predicting lottery numbers to name just a few. It is easy to mistakenly think that these superstitions are only really limited to rural, uneducated people but the truth is that I haven't met many Cambodians that aren't significantly superstitious.
There also seems to a general lack of skepticism, unless its regarding something a foreigner says, which results in people readily believing propaganda, gossip & rumour. With the recent flooding this rainy season the conspiracy theory circulating was that the government had caused the floods by letting Thailand open flood gates, whilst protecting themselves in Phnom Penh. Support for this theory was that only the northern provinces were flooded & the southern capitol was not. Phnom Penh was in fact knee deep in water but when I tried to explain this, I have friends who live there & post regularly on Facebook, my counter argument was immediately dismissed. Reason & evidence are not very powerful tools when used in a debate here, as they might well be elsewhere in the world.
Doctors here will have coining when they get a headache. My assistant's father believes that a certain sort of moth gives you TB. My land lady 'disappeared' half of scabby dog's puppies because 6 is an 'unlucky' number & 3 is 'lucky'. My khmer teacher believes I have had a love spell cast in me - not as a metaphor but as a real-life spell that requires numerous ceremonies to break it. A friend's baby will grow up 'retarded' because she didn't wear a hat.
My friend was in a foul mood in work this week. Turns out a fortune teller had told him he would lose a limb in an accident this year so he must urgently do a ceremony which will cost $30. When I suggested that he save his money & not do the ceremony so he can feed his family for a week I was met with scorn. So I asked him did the fortune teller ever tell him good things - not often he admitted but he didn't believe the good things anyway, just the bad. Better to spend money to prevent an accident than have to pay expensive medical fees was his reasoning.
He also believes in ghosts & along with 14 million other people here. One nurse I used to work with was one of the few Cambodians I've met who actually doesn't believe in spirits. His mother became ill soon after her mother died & was convinced that she had been possessed by the spirit of her mother. He asked my advice about how he could manage what sounded to me to be anxiety & a normal grief response. Even though he didn't believe in ghosts or share his mother's 'traditional' beliefs, I suggested he should do as his mother wanted, which was to go to the Pagoda & be exorcised by a monk. He was skeptical but did it & it worked.
Beyond understand the culture of a country & the health belief systems imbedded in it you would think none of this should effect me very much but this superstition & associated lack of critical thinking extends to health workers, which means they don't believe a word I say. I am not mocking Cambodians for being so superstitious rather highlighting it as one of the many barriers to effective capacity building here.
I asked R when he was head nurse & J was a VSO volunteer in his hospital did he disregard her advice & ideas the same as the staff we currently work with do. Turns out not, which is why he has been working with J for 5 years. He may be superstitious but he is also open minded & adaptable.
So did you accept everything J told you? - I probed.
Of course not! - he snapped (he has the limb loss thing hanging over him remember) - I would listen, think about it, see if it made sense & if she could prove she was right & her way was better I would do - he explained to me.
100% of the time?
No maybe 95% of the time.
And the other 5% - why didn't you follow that advice?
Not because I didn't believe the evidence - he assured me - but because it was difficult to do in the current situation like doing 15 minutely vital signs on an emergency patient for example.
I conceded that in the UK we had an automated machine that would monitor a patient in resus & then the nurse could retrospectively fill in the observation from the machine's memory if they were too busy giving drugs, taking bloods etc. at the time.
So what do me & J do that you find odd or strange? - I was curious to know.
Silence.
What do we believe that you don't understand? - I persisted
Nothing - he eventually shrugged.
Now this answer could be due to one of two reasons;
1) J & I are devoid of any cultural opposing beliefs or behaviours (very unlikely)
or
2) R is too self absorbed to even consider any one other than himself......
Realistically I know I can't change superstition here but I can try to understand it so as to work better within the healthcare system to help improve it; working with open minded, if some what superstitious, health workers such as R.
They generally believe in ghosts, spirits, fortune tellers, karma, traditional (harmful) remedies & practices, dream prophesy, a magic log for predicting lottery numbers to name just a few. It is easy to mistakenly think that these superstitions are only really limited to rural, uneducated people but the truth is that I haven't met many Cambodians that aren't significantly superstitious.
There also seems to a general lack of skepticism, unless its regarding something a foreigner says, which results in people readily believing propaganda, gossip & rumour. With the recent flooding this rainy season the conspiracy theory circulating was that the government had caused the floods by letting Thailand open flood gates, whilst protecting themselves in Phnom Penh. Support for this theory was that only the northern provinces were flooded & the southern capitol was not. Phnom Penh was in fact knee deep in water but when I tried to explain this, I have friends who live there & post regularly on Facebook, my counter argument was immediately dismissed. Reason & evidence are not very powerful tools when used in a debate here, as they might well be elsewhere in the world.
Doctors here will have coining when they get a headache. My assistant's father believes that a certain sort of moth gives you TB. My land lady 'disappeared' half of scabby dog's puppies because 6 is an 'unlucky' number & 3 is 'lucky'. My khmer teacher believes I have had a love spell cast in me - not as a metaphor but as a real-life spell that requires numerous ceremonies to break it. A friend's baby will grow up 'retarded' because she didn't wear a hat.
My friend was in a foul mood in work this week. Turns out a fortune teller had told him he would lose a limb in an accident this year so he must urgently do a ceremony which will cost $30. When I suggested that he save his money & not do the ceremony so he can feed his family for a week I was met with scorn. So I asked him did the fortune teller ever tell him good things - not often he admitted but he didn't believe the good things anyway, just the bad. Better to spend money to prevent an accident than have to pay expensive medical fees was his reasoning.
He also believes in ghosts & along with 14 million other people here. One nurse I used to work with was one of the few Cambodians I've met who actually doesn't believe in spirits. His mother became ill soon after her mother died & was convinced that she had been possessed by the spirit of her mother. He asked my advice about how he could manage what sounded to me to be anxiety & a normal grief response. Even though he didn't believe in ghosts or share his mother's 'traditional' beliefs, I suggested he should do as his mother wanted, which was to go to the Pagoda & be exorcised by a monk. He was skeptical but did it & it worked.
Beyond understand the culture of a country & the health belief systems imbedded in it you would think none of this should effect me very much but this superstition & associated lack of critical thinking extends to health workers, which means they don't believe a word I say. I am not mocking Cambodians for being so superstitious rather highlighting it as one of the many barriers to effective capacity building here.
I asked R when he was head nurse & J was a VSO volunteer in his hospital did he disregard her advice & ideas the same as the staff we currently work with do. Turns out not, which is why he has been working with J for 5 years. He may be superstitious but he is also open minded & adaptable.
So did you accept everything J told you? - I probed.
Of course not! - he snapped (he has the limb loss thing hanging over him remember) - I would listen, think about it, see if it made sense & if she could prove she was right & her way was better I would do - he explained to me.
100% of the time?
No maybe 95% of the time.
And the other 5% - why didn't you follow that advice?
Not because I didn't believe the evidence - he assured me - but because it was difficult to do in the current situation like doing 15 minutely vital signs on an emergency patient for example.
I conceded that in the UK we had an automated machine that would monitor a patient in resus & then the nurse could retrospectively fill in the observation from the machine's memory if they were too busy giving drugs, taking bloods etc. at the time.
So what do me & J do that you find odd or strange? - I was curious to know.
Silence.
What do we believe that you don't understand? - I persisted
Nothing - he eventually shrugged.
Now this answer could be due to one of two reasons;
1) J & I are devoid of any cultural opposing beliefs or behaviours (very unlikely)
or
2) R is too self absorbed to even consider any one other than himself......
Realistically I know I can't change superstition here but I can try to understand it so as to work better within the healthcare system to help improve it; working with open minded, if some what superstitious, health workers such as R.
But as Stevie Wonder would sing - "When you believe in things that you don't understand.Then you suffer. Superstition ain't the way"
Friday, October 11, 2013
How things go
This is generally how things go.
Arrive at hospital to find a patient in the ER, initially came in shocked & was resuscitated with IV fluids & transferred to the ward. 2 days later became unwell with shock again so was transferred back to the ER. In the UK this would be seen as retrograde step in the patient pathway, which would never happen or be tolerated but as the ER is the only place in the hospital with oxygen cylinders, suction machine, airway equipment, nebuliser machine (donated by URC), ventilator (new from MoH) & cardiac monitor (new from donor) this was actually the best move for this patient.
In my experience if I get involved too early in patient care the medical staff will get really defensive & aggressive or just ignore my advice. I have learnt to let them run their clinical course, reach a diagnosis or management dead end & then they might ask me for help. They are pretty stubborn & proud so this can sometimes be days. DO you have any idea how hard this can be when a patient is really sick but you know if you do something or try to help if will just make the situation worse as they may deliberately do the opposite of what you suggest?
This time it took 2 days.
Early on the second morning I found her in the ER with no one observing her so I took this opportunity to take a history & examine her myself.
These were my findings - she had a 2 week history of total body pain which all started with a painful & swollen left leg. She had then developed breathlessness & pleuritic chest pain. When she first presented to the hospital her blood pressure was unrecordable & she had collapsed at home. Her heart rate had been a persistent sinus tachycardia of 120/minute for the last 3 days.
I had bought some ECG dots for the hospital (I buy great presents!) & used her the day before to demonstrate how to use the monitor, she was happily throwing off atrial ectopics & having runs of atrial bigeminy. I tried to show the medical staff this but as they don't fully understand what a p wave is yet this was a bit of a struggle. They looked at the monitor with the same intensity as parents in PICU. I have often thought it would be good to have a TV playing behind the vital sign wave forms on these monitors so at least people would understand something that was on the screen.
She had a raised JVP & a parasternal heave. Her oxygen saturations were 89% on room air.
All of the evidence was pointing towards her having a pulmonary embolism - PE.
Just as I had finished my examination one of the more amenable MAs came in & I relayed to him my findings & my differential diagnosis - or as my nurse friend likes to call it "best guess"!
He agreed & wanted her to be transferred to the referral hospital but said the other MAs did not agree so could I help him. We went to the hospital morning meeting together & afterwards I went through my history, examination & investigation findings with all the medical staff. I explained that the patient's initial treatment with oxygen & fluids was excellent but she needed a 12 lead ECG & ECHO, which were not available at this hospital. Like all chest pain she should receive aspirin but also needed heparin, which was not available at this hospital either. Her current treatment of IV dextrose & vitamins was probably not going to be very affective for treating her sinus tachycardia.
Rather than agree to transfer her or ask questions about the signs & symptoms of PE the deputy director attacked me. "All patients are liars, they are poor & stupid, they do not tell the truth, you can't believe them that is why we only exam them & make are decisions with out bothering to talk to them, you know nothing about Cambodia etc etc etc"
When he had finally finished his tirade - he is a verbose man. I smiled sweetly & calmly explained that this is why objective data is so important. The patient had been shocked - cardiovascular collapse is a symptom of massive PE, the patient was hypoxic - PE, the patient was in a sinus tachycardia with runs of atrial bigeminy - PE, she had a parasternal heave - PE, respiratory rate of 38/minute - PE, left calf swelling & tenderness - PE......
The room was silent then the deputy director triumphantly said - but her white cells are elevated.....PE came my response.
DO you think they listened to me? DO you think they believed me? DO you think they followed my treatment plan? DO you think she was transferred the referral hospital to get further investigations & heparin? DO you have any frigging idea how frustrating it is that the answer to these questions is always & relentlessly NO?
Later that same morning I was in OPD trying to do TB follow up without a translator whilst also doing some informal triage & SAM follow up coaching. The nurses are warm, friendly & open to learning - it was just I was a little limited in my explanations in khmer back to them.
A 9 month old boy came in grunting away giving himself auto-PEEP & with signs of severe respiratory distress. All the other patients & relatives stepped back to let him be seen by the triage nurse first, self triage, murmuring in awe "breathless" (only in khmer, which is "Hot")
He triaged red, which means he needed to be seen immediately because his pulse was 180/min, his respiratory rate was 60/minute & his oxygen saturations were 81%. The triage nurse looked to me for reassurance as she ticked the box - yes I nodded that's correct, he really is sick, she beamed back at me. Nurses are so much easier to work with than doctors. I walked over with the nurse, mum - in floods of tears & the head bobbing little boy, to the ER.
I contacted my work colleague on the ward to tell him I needed his help in ER - it was 9 15.
At 9 25 the ER nurse finally managed to get oxygen on the child at an enthusiastic 6 l/min through nasal specs. I have seen glass creep faster than the speed this ER nurse worked but as my work colleague & translator was no where to be seen I was making do with my limited khmer to reassure the crying mother, take a basic history & coach the nurse how to not blow away the poor babies nostrils.
9 30 the male nurse called the doctor to tell him about the category red child in the ER.
9 50 my work colleague rocked up, shrugged when I asked him if he could help me with translation, telling me "you can manage without me, you seem to be able to understand most things anyway"
I had to go for a little walk at this point - the child was stable & waiting for a doctor & I was in danger of killing my work colleague. The grounds of this hospital are very picturesque with views of mountains & surrounding fields. It is a little brighter than before as they have just cut down two large trees. The blossom is beautiful. There was a cool breeze. Breath.
When I came back at 10 10 the 2 ER nurses were having a long protracted conversation about nursing documentation with my colleague whilst the mother clung to her baby crying as no one (except me who doesn't count because she couldn't understand me & another relative had to translate my khmer for her) had explained what was going on with her child who lay limply in her arms, grunting, head bobbing, recessing & generally working very hard to breath.
Where's the doctor I asked?
Don't ask me, how should I know? my work colleague shrugged. It had actually been a request for translation - I snapped - but clearly nursing documentation is far more important than actually nursing a hypoxic & distressed child. Credit to the cluelessness of Cambodians my work colleague still failed to detect any anger or sarcasm in this statement & continued to coach on observation charts for another 10 minutes.
The child was doing much better on the oxygen but was still quite wheezy & even though less than 1 years old could probably justify a nebuliser if I could find a doctor to prescribe it. I am not allowed to prescribe drugs because I went to a proper medical school & have had extensive post-graduation professional training instead of being a khmer rouge medical assistant for 30 years, so clearly I know nothing.
We had to leave at 10 30 at which time a doctor still hadn't arrived to see the child.
In the car my work colleague asked me if I was angry with him - at least he worked this out in a shorter period of time than it took to Doctor to come to see a category red patient in the ER.
When I first started going to this hospital the nurses wouldn't have started treatment, including oxygen, until the doctor arrived. Wheezy children were all given IV antibiotics & they didn't even consider giving a nebuliser delivered via the new machine.
On my request my work colleague called the hospital to follow up on the child. The doctor had finally arrived at 11 am - he prescribed a nebuliser but no antibiotics. The child was breathing better when we called. This is how things go.
As an emergency physician I find the pace here & rate of change deeply soul destroying.
Arrive at hospital to find a patient in the ER, initially came in shocked & was resuscitated with IV fluids & transferred to the ward. 2 days later became unwell with shock again so was transferred back to the ER. In the UK this would be seen as retrograde step in the patient pathway, which would never happen or be tolerated but as the ER is the only place in the hospital with oxygen cylinders, suction machine, airway equipment, nebuliser machine (donated by URC), ventilator (new from MoH) & cardiac monitor (new from donor) this was actually the best move for this patient.
In my experience if I get involved too early in patient care the medical staff will get really defensive & aggressive or just ignore my advice. I have learnt to let them run their clinical course, reach a diagnosis or management dead end & then they might ask me for help. They are pretty stubborn & proud so this can sometimes be days. DO you have any idea how hard this can be when a patient is really sick but you know if you do something or try to help if will just make the situation worse as they may deliberately do the opposite of what you suggest?
This time it took 2 days.
Early on the second morning I found her in the ER with no one observing her so I took this opportunity to take a history & examine her myself.
These were my findings - she had a 2 week history of total body pain which all started with a painful & swollen left leg. She had then developed breathlessness & pleuritic chest pain. When she first presented to the hospital her blood pressure was unrecordable & she had collapsed at home. Her heart rate had been a persistent sinus tachycardia of 120/minute for the last 3 days.
I had bought some ECG dots for the hospital (I buy great presents!) & used her the day before to demonstrate how to use the monitor, she was happily throwing off atrial ectopics & having runs of atrial bigeminy. I tried to show the medical staff this but as they don't fully understand what a p wave is yet this was a bit of a struggle. They looked at the monitor with the same intensity as parents in PICU. I have often thought it would be good to have a TV playing behind the vital sign wave forms on these monitors so at least people would understand something that was on the screen.
She had a raised JVP & a parasternal heave. Her oxygen saturations were 89% on room air.
All of the evidence was pointing towards her having a pulmonary embolism - PE.
Just as I had finished my examination one of the more amenable MAs came in & I relayed to him my findings & my differential diagnosis - or as my nurse friend likes to call it "best guess"!
He agreed & wanted her to be transferred to the referral hospital but said the other MAs did not agree so could I help him. We went to the hospital morning meeting together & afterwards I went through my history, examination & investigation findings with all the medical staff. I explained that the patient's initial treatment with oxygen & fluids was excellent but she needed a 12 lead ECG & ECHO, which were not available at this hospital. Like all chest pain she should receive aspirin but also needed heparin, which was not available at this hospital either. Her current treatment of IV dextrose & vitamins was probably not going to be very affective for treating her sinus tachycardia.
Rather than agree to transfer her or ask questions about the signs & symptoms of PE the deputy director attacked me. "All patients are liars, they are poor & stupid, they do not tell the truth, you can't believe them that is why we only exam them & make are decisions with out bothering to talk to them, you know nothing about Cambodia etc etc etc"
When he had finally finished his tirade - he is a verbose man. I smiled sweetly & calmly explained that this is why objective data is so important. The patient had been shocked - cardiovascular collapse is a symptom of massive PE, the patient was hypoxic - PE, the patient was in a sinus tachycardia with runs of atrial bigeminy - PE, she had a parasternal heave - PE, respiratory rate of 38/minute - PE, left calf swelling & tenderness - PE......
The room was silent then the deputy director triumphantly said - but her white cells are elevated.....PE came my response.
DO you think they listened to me? DO you think they believed me? DO you think they followed my treatment plan? DO you think she was transferred the referral hospital to get further investigations & heparin? DO you have any frigging idea how frustrating it is that the answer to these questions is always & relentlessly NO?
Later that same morning I was in OPD trying to do TB follow up without a translator whilst also doing some informal triage & SAM follow up coaching. The nurses are warm, friendly & open to learning - it was just I was a little limited in my explanations in khmer back to them.
A 9 month old boy came in grunting away giving himself auto-PEEP & with signs of severe respiratory distress. All the other patients & relatives stepped back to let him be seen by the triage nurse first, self triage, murmuring in awe "breathless" (only in khmer, which is "Hot")
He triaged red, which means he needed to be seen immediately because his pulse was 180/min, his respiratory rate was 60/minute & his oxygen saturations were 81%. The triage nurse looked to me for reassurance as she ticked the box - yes I nodded that's correct, he really is sick, she beamed back at me. Nurses are so much easier to work with than doctors. I walked over with the nurse, mum - in floods of tears & the head bobbing little boy, to the ER.
I contacted my work colleague on the ward to tell him I needed his help in ER - it was 9 15.
At 9 25 the ER nurse finally managed to get oxygen on the child at an enthusiastic 6 l/min through nasal specs. I have seen glass creep faster than the speed this ER nurse worked but as my work colleague & translator was no where to be seen I was making do with my limited khmer to reassure the crying mother, take a basic history & coach the nurse how to not blow away the poor babies nostrils.
9 30 the male nurse called the doctor to tell him about the category red child in the ER.
9 50 my work colleague rocked up, shrugged when I asked him if he could help me with translation, telling me "you can manage without me, you seem to be able to understand most things anyway"
I had to go for a little walk at this point - the child was stable & waiting for a doctor & I was in danger of killing my work colleague. The grounds of this hospital are very picturesque with views of mountains & surrounding fields. It is a little brighter than before as they have just cut down two large trees. The blossom is beautiful. There was a cool breeze. Breath.
When I came back at 10 10 the 2 ER nurses were having a long protracted conversation about nursing documentation with my colleague whilst the mother clung to her baby crying as no one (except me who doesn't count because she couldn't understand me & another relative had to translate my khmer for her) had explained what was going on with her child who lay limply in her arms, grunting, head bobbing, recessing & generally working very hard to breath.
Where's the doctor I asked?
Don't ask me, how should I know? my work colleague shrugged. It had actually been a request for translation - I snapped - but clearly nursing documentation is far more important than actually nursing a hypoxic & distressed child. Credit to the cluelessness of Cambodians my work colleague still failed to detect any anger or sarcasm in this statement & continued to coach on observation charts for another 10 minutes.
The child was doing much better on the oxygen but was still quite wheezy & even though less than 1 years old could probably justify a nebuliser if I could find a doctor to prescribe it. I am not allowed to prescribe drugs because I went to a proper medical school & have had extensive post-graduation professional training instead of being a khmer rouge medical assistant for 30 years, so clearly I know nothing.
We had to leave at 10 30 at which time a doctor still hadn't arrived to see the child.
In the car my work colleague asked me if I was angry with him - at least he worked this out in a shorter period of time than it took to Doctor to come to see a category red patient in the ER.
When I first started going to this hospital the nurses wouldn't have started treatment, including oxygen, until the doctor arrived. Wheezy children were all given IV antibiotics & they didn't even consider giving a nebuliser delivered via the new machine.
On my request my work colleague called the hospital to follow up on the child. The doctor had finally arrived at 11 am - he prescribed a nebuliser but no antibiotics. The child was breathing better when we called. This is how things go.
As an emergency physician I find the pace here & rate of change deeply soul destroying.
Subscribe to:
Posts (Atom)