Be careful what you wish for...

Recently I blogged in a post festive, peri-new year pensive mood about all the things that I was missing from the UK. As Stephen Sonheim once lyrically put it :-

 Careful the wish you make 
Wishes are childrenCareful the path they takeWishes come true, not freeCareful the spell you castNot just on childrenSometimes the spell may lastPast what you can seeAnd turn against youCareful the tale you tellThat is the spell
So with the soundtrack of 'into the woods' in my head, I find myself seeing my family, wearing my down jacket & knitwear, eating cheese, drinking wine & tap water (the latter really should have been included in the 'missing you already' blog), sleeping under a duvet & orange blankie and had an emotional moment in Waitrose.
This however is because my Grandmother has died & I have come back for the funeral - to try to be a good daughter, sister, grand daughter, Auntie & if time permits friend. 
And because I am contrary I'm now missing Cambodia, Battambang, the hospital and work - there really is no pleasing some people.
So my advice is be careful what you wish for, they might come true past what you can see...

Post Script

As always there is someone who has written on a subject much more succinctly and eloquently than I ever could.

Jon Swain in his book 'River of Time' describes an incident of a bomb injuring a child in Phnom Penh. He went to help the child but couldn't get anyone else to assist on the street or in deed when he took the child to the nearest hospital.

He wrote in the 1990s - "Even today, after years of suffering, the Cambodians do not have a strong sense of caring for their fellow man. Medical staff, negligent and greedy, demand to be paid for drugs provided free of charge by the international aid agencies. Perhaps this is due to the Cambodians fatalistic perception of human life. For many, morality is a luxury to be disowned; survival and money are the ultimate objectives."

Fifteen years on and despite millions of dollars in aid, sadly it seems that this is still very much the case.

I am not quite sure what the cure for compassion fatigue is...

why today my head hurts....

I'm looking for some answers. I would like to know how I can motivate people, how to make them care and how to engender a sense of responsibility? Failing that I'm looking for permission to lapse on my new years resolution.

It's another clinical tale I'm afraid - but often writing it out helps me make sense of it, or at least try to, so sorry if the following bores you.

After the storming success of the PTC course I have started work on the surgical ward, observing trauma management and attempting to encourage the best practice demonstrated in PTC. This required much negotiation with the Director, deputy director and head of service (HS) but was finally agreed, people even signed a piece of paper - there were no photos or banners though.

So the first working day of 2012 I found myself with a man who had fallen from his moto 5 hours earlier. He had a large boggy haematoma on the side of his head, would only open his eyes to voice and was confused (I had to take the Cambodian staffs word for that as my khmer isn't that good yet) and was complaining of a severe headache.

Unfortunately as there is no CT scanner or neurosurgery the plan was just to wait & see. I felt it was probably quite likely that he had a intracranial bleed but in a world of hopeless cases sent home to die, 'no money - no surgery' and no specialist care I wasn't really surprised to not see him the next day. You'd think this case would be the cause of my own headache - not quite.

That same day I ventured on to the Surgical ICU ward - a hybrid of a recovery room (not like any room I'd want to even recover from a bad pedicure in) and a serious cases ward. In there was a young man in a hard neck collar. On further investigation - reading the notes, speaking with the patient and his mother, the staff are 'too busy' -  it became clear he was a construction worker who 4 days previously had fallen 3m onto his head and as a result had a headache, sore neck and couldn't move his arms or legs.

I asked if he had an X-ray taken and his mother produced a solitary AP (front to back) X-ray of his neck. A surgeon popped up to point out to me the crushed 7th cervical vertebrae (its been a while but even I could spot the difference) and when I asked for the other X-rays he just looked at me puzzled and I was told that any other views can not be done here in Cambodia and it wasn't his patient anyway. Now I've learnt a thing or two in my 9 months here and one of them is never, ever question or challenge a doctor directly ESPECIALLY not in front of patients, their relatives (the patient's or the doctor's), nurses, other doctors and occasionally even my own translator (the latter can be a real challenge). So I shrugged, smiled and demurely told the family I'd be back.

I wandered outside to the front of the surgical ward with my VA in tow in search of a surgeon (he gets nervous in these situations.)

I have a new years resolution - I am trying to be good. Note the use of the word 'try' - as long as I am trying it doesn't matter if I am achieving.

Three surgeons were stood outside chatting. I approached them - much arm clasping and slapping (them), hair flicking (me) ensued. In the most non-confrontational & non-threatening way possible I asked if I could ask a question about a patient. All smiles - go ahead, they really are such a friendly bunch as long as you aren't trying to capacity build them. Mind you if I had a personal trainer I would almost certainly react as they did when I asked them who the C7# patient (forgive me but I was conversing with surgeons) was being looked after by?

After a very long conversation it was established that none of the 3 surgeons I was talking to were responsible for this young quadriplegic man's care. They then commandeered my VA and chewed his ear off for another 10 minutes about operation lists, the nurses not doing what they are told, how I had only been here 9 months imagine how they feel and if I had a problem I should speak to HS, he is responsible for all patients as head of service. At this point I had only asked who I could talk to about the patients management - I can only assume that they knew he had been mismanaged and this explained their defensive behaviour. That or their new years resolution was to be as obstructive and rude as possible - damn, I should have picked that one to, much more achievable.

When I smiled (as a good person would) and said I only wanted to log roll him (not documented as done on admission) to check he hadn't any further injuries (if you have one spinal fracture it significantly increases your chances of another) and I just wanted permission from his attending surgeon, then there was a queue to grant me consent.

The next challenge was to find people able to log roll him. Its not brain surgery (which is a good job because we can't do that here) but a log roll does require 4 people who know what they are all doing. There was a student nurse (always good log rolling fodder), a nurse who had been on the PTC course (reinforcing transportation workshop) and B from URC to take the head but we needed one more person. B and my VA being polite, respectful Cambodians didn't want to disturb the nurse writing her monthly report. I'm not Cambodian and thought it would be polite & respectful to the patient for him   to have a proper log roll so called out for "Kroo Peit moie tiet!" - another nurse came.

We log rolled him, he had no other spinal tenderness but a sacral pressure sore of a size and depth that you would expect of a newly quadriplegic man who had laid on a metal bed with no mattress for 4 days without being turned.

I'm trying to be a good person so I pointed out to the nurses what HS had written in the notes that morning about 2 hourly turns, checked that they knew now how to log roll and left.

I went in search of  HS, he unlike the rest of the department - who were still stood outside watching the construction of a restaurant (yes they can build a staff canteen but not complete the sodding ER building!) - was scrubbed in theatre all day.

The following day I checked on the patient - he hadn't been turned since we had done it last (a long 2 hours). I  caught up with HS - he wasn't in good humour. Staying up half the night doing a laparotomy will do that to you. I suggested perhaps I could come back another day - I knew where this encounter was heading, we've been here before. Despite my best smiling & trying to be a 'good person' and even after me saying "please don't get defensive I just want to talk generally about improving trauma care" - it all went a bit defensive.

Apparently HS was not responsible for the patient with the C7#, couldn't tell the nurses what to do and certainly wasn't responsible as the head surgeon for any of the other surgeons. He thought I should not work in the surgical ward and it would be best if I waited for the ER to open (or failing that the new hospital restaurant). I may have said some things I shouldn't - maybe not quite in keeping with my new years resolution. In khmer I know how to say 'lazy', 'arrogant' and 'closed minded' but he started it off by saying all the staff here were 'blind' and I just ran with it. None of this was a problem, as these are practically the only 3 words in khmer I use in work, he has heard it all before (sticks & stones) but when I told him (in english) that I thought the staff here didn't care - that appeared to hit home.

The staff in ICU pretended they couldn't understand what I was asking when I went without my VA to see if we could turn the patient and so that afternoon when I returned with my VA there was a student nurse and some tumble weed. HS had suggested the family log roll him, when this idea was mooted with the patient he said he would prefer people who knew what they were doing. I bit my tongue - I am trying!

URC staff log rolled the patient that afternoon.

Today after lunch I went to check up on C7#, we passed HS on the way who decided to give me the cold shoulder - this was an excellent opportunity for my VA to learn another idiom and also revealed that maybe staff do care, about what remains to be seen.

No surprises that the patient had not been turned since the last time we were there. We corralled a posse of log rollers and as I observed worsening bed sores and paralysis the futility of it all suddenly hit me. What was I doing? It certainly isn't sustainable. What was best for this 24 year old man anyway? Why the hell doesn't any of the staff care about his pressure areas, potential pneumonia and progressive neurological deficit?

I went in search of a surgeon who could tell me a plan so I could believe that someone had one and did actually care. I failed but in fairness did remain 'good' throughout. Even when a surgeon I hadn't even known was in the building came up to me whilst I was deep in conversation with the duty surgeon and shouted "I am busy and don't want to talk to you" - cue serene good person's smile.

None of the staff will take responsibility for, is motivated or seems to care about this (or any) patient. I don't know how to capacity build from this starting point.

So unless you have any answers to my original question can you please give me permission to lapse - the trying to be good is most definitely the hardest part.....

Seasons Greetings!

Today I wished the head doctor (Dr L) of ICU medicine a Happy Christmas!

He growled back that he was Buddhist.

I smiled sweetly and told him that never mind - I'm an atheist but I still celebrate Christmas.

Tomorrow I will celebrate New Years Eve.

January 23rd I'll celebrate Chinese New Year (year of the Dragon).

April 13th-16th I'll be celebrating Khmer New Year.

I like to keep my options open.

Perhaps I should be agnostic...

Missing you already...

Saying goodbye to another set of visitors set me thinking about how lucky I am but also how much I miss from home.

I miss people of course. 

My wonderful family & friends whose support keeps me here especially on the days that I really think I can't do it anymore. Having my sister, brother-in-law & 2 gorgeous nieces for 10 days over Christmas now means that I miss them even more acutely than before. Skype is great but you can't choreograph a synchronized swimming routine over Skype. Whatsapp is instant and you can share photos & videos but not a G&T or a dirty hot chocolate. When all else fails & its bad news there is always my Cambodian mobile but the reception is not so good which led me to believe the other day that it was my sister and not in fact my Grandmother who was gravely ill. 

I miss not being able to be an irritating medical relative. 

I miss being a good daughter, sister, grand daughter, auntie & friend (although my parents, sisters, grandmother, nieces & friends may argue I never have been).

I miss money. I miss not having to think about whether I can afford stuff. This can be something as small as a cinnamon roll or a decent cup of coffee.

I miss my camera - it was stolen on Christmas Eve. I miss not just being able to replace it and I miss all the photos on the memory card I will never get back.

I miss cheese - I REALLY MISS CHEESE. In all the lovely 5 star hotels my family stayed in over Christmas there was REAL cheese for breakfast. My continental breakfast feasts became the stuff of legend. Grace procured some swiss cheese, smuggled out in a napkin which I enjoyed last night with crackers but no red wine. Now I miss cheese....A LOT. (and WINE!).

I miss hugs.

I miss HUI.

I miss Waitrose - truth be told this should really be a lot nearer to the top of this list, in reality a half degree below people, is that wrong? Right or wrong I miss a middle class, overpriced, semi-ethical, elitist supermarket. There I've said it.

I miss duvets and down jackets - I miss layers, and knitwear and socks and all things snug & cosy. As the temperature here plummets to the low 20˚Cs I have worn socks once and added a blanket to my bed and on occasions even worn a fleece but it is hardly the winter that the UK had last year with an average temperature of -1˚C.

I miss baths (& Bath!).

I miss working in team (or working in a team where everyone can speak the same language - preferably my mother tongue).

I miss real clinical work. Talking to patients, putting them at ease, building rapport. The conversations you have with patients as you perform intimate or painful procedures on them are simply always lost in translation.

I will miss my computer when the heat, humidity & dust finally kills it.

If you are reading this - I miss not telling you this is how I am feeling right now, face to face.

I won't miss 2011 because I have 2012 and all that it has to bring just around the corner.....

Happy New Year!

A Christmas Quiz...

Merry Christmas everybody - where ever you are, what ever you are doing and who ever you are with - I hope you have a safe and festive time.

I am back to work - 'capacity building' in the tropics.

I have a little Christmas quiz for you, its guess the age of the group of people I am describing;

They are a group of 15 people who are coming to a training day. They are coming because they have been told to come and will get a $4 per diem if they attend the whole day.

The invitation says the start time is 8 am - 10 out of the 15 arrive after 8 30 am.

The first session is setting the ground rules - the first rule is that they want change the morning session end time from 12 to 11 am, this gives them a 3 hour instead of 2 hour lunch break. When the facilitator tries to negotiate that as they mostly arrived over half an hour late for the start of the session that perhaps they could compromise and stay until 11 30 am (their usual lunch break start time) - this suggestion is rejected.

The second ground rule to be set is that there should be no use of mobile phones - they reject this but say they will switch to silent-mode. The next 2 hours is a cacophony of various mobile phone ring tones and loud intrusive phone conversations.

When asked after a lecture if there is any questions one person asks why he doesn't have a free pen and only a free pencil in his free folder, this is the only question.

The snacks arrive, there is a stampede to the table even before the teaching session is over. The first people to arrive take plastic carrier bags and fill them up to the brim with snacks for themselves and then leave the teaching. The remaining people have a bottle of water and a small piece of fruit if they are quick enough.

At 11 01 everyone looks at the watches, starts to mumble and leaves; despite the fact there is a demonstration on how to deliver effective CPR still in progress.

They have in fairness been quite well behaved today so far.

Those of you who have children or work with children have an unfair advantage as you should be able to gauge which age-group demonstrate these types of behaviour.

A.The average age of this group of Doctors & Nurses is 40 years old.

PTC - an epic tale

It has been a while since I have properly put finger tips to keyboard. There are a multitude of reasons for this but PTC (primary trauma care) lends itself to a blog all to itself - it is an epic tale. It is a story of what I do here and of why so often this blog (to quote my friends husband) becomes a 'litany of despair' but it is also I hope a story of the reality of capacity building and the hard slog towards positive change.

It all started in May of this year when Sz an anaesthetist from Australia came to BTB to run an airway course. We got talking and before long she had recruited me to instruct on a PTC course she was planning in Siem Reap in September.

For the uninitiated, PTC is the developing worlds version of ATLS (Advanced Trauma Life Support) which in turn was created in the States after an orthopaedic surgeon crashed his plane with all his family in it and realized standards of care for trauma patients could probably bear some robust improvements. Cambodia's deaths due to trauma are double that of any other country in South East Asia so there is a strong argument for introducing PTC here.

The Course in Siem Reap was the first of its kind in Cambodia & the first 2 day course was instructed by Sz, me, another Australian Anaesthetist and a Filopino trauma surgeon. Then after a 1 day training the trainers course the second ever course was run by Cambodians - doctors and nurses that all work for the brilliant NGO hospital Angkor Hospital for Children and had been participants of the first course.

For a movement such as PTC to be incorporated into the medical culture it is important (I believe) for there to be ownership of the course my government hospital staff and to have their commitment - they after all will be treating the trauma patients, 17.8 per 10000 vehicles of which currently die. Because of this I asked if HS - the head surgeon of BTB Hospital; previously worked in NGO hospital and trained for 2 years as an orthopaedic surgeon in France - would be able to come on the Siem Reap course and then train as a trainer. This you would think would be an unremarkable feat - well I thought so, how wrong a girl can be.

So HS said he would come, he even at one point promised he would come. But I later learnt that a Cambodian promise is not quite the same thing as a european promise, actually I learnt this at 6 am whilst in PNH for my second language training. When I was told that Cambodia has an early culture I assumed it meant they came early for appointments (nothing could be further from the truth!), in fact it just means they are all just very early risers so phoning you, playing really loud music, banging very loud drums and delivering a huge bunch of bananas can all happen here before 6 am. HS in fairness to him only did the very former of this list of early morning activities, calling me with various excuses - one of which if I remember rightly was something to do with the dog eating his homework - for why he couldn't come to Siem Reap.

Having secured funding from URC for him to attend the PTC course to say I was mildly disappointed with him would be an understatement. In fact when I got back to BTB there was a 20 minute conversation with him which started with us eye to eye and ended with him slumped on his Moto dejected as I did a very good impersonation of a mother of a teenager. "I am very disappointed"  was mentioned, "you've let me down, the hospital down but most of all yourself down" may have been a sentiment expressed by me also. All the NGO doctors and nurses had told me that government staff would not engage in training, they had bet me that HS would not attend the course. I told him so and that he had proved them all right, I believed he had potential to be a great instructor and improve trauma care in Cambodia but was lacking any proof.

HS delegated Dr V to go in his place but only for the first course as a candidate and then the training the trainers course. This would all work out fine because Dr V would have to be an 'instructor candidate' on one course and we could plan for that course to be here next time in BTB.

Three days before the course started in Siem Reap Dr H from the URC office called me - he had concerns about Dr V going on the course, as he holds the URC purse strings I needed his approval before Dr V could go. Dr H's case was that Dr V already taught with another trauma organization and perhaps it would be better for HS to go seeming as he was an orthopaedic surgeon and head of service - like I hadn't thought of that!

Dr V loved the PTC course, he was engaged with the subject matter and the style of teaching was novel, so completely different from previous methods he'd been exposed to, he could see its worth and regretted not being able to stay to teach on the 2nd ever Cambodian PTC. He was motivated and excited to deliver the course as an instructor candidate in BTB so we set a date for 4 months time - the end of the year - we wanted to keep the momentum going.

I picked the one week in December that Dr V was available to teach, I requested URC to financially support the training (VSO don't pay per diem & BTB staff won't get out of bed for anything less - that's a whole other blog!) and put it into the work-plan. I tried to book a room at the hospital but was told it was too early (forward planning isn't big in Cambodia). I confirmed with the directors that this week would be a good time for the hospital and that they supported the principle of PTC. I confirmed that Sz, Drs Ch & P, N (see favourite Cambodians list) from AHC were available to teach. I double checked that the timing was good for the hospital, I triple checked and then I emailed Sz confirming the second week in December as a date for the third PTC course in Cambodia.

I attempted to mend my broken capacity building relationship with HS.

Nearer the time I tried to book the large hospital meeting room for training again and this time was told by the admin man that I could not have the room for 2 days as there may be more important meetings which have not been arranged yet BUT could be arranged.

I lost it.

I went to the deputy directors office and lost it with them. I spelt out to them that PTC was an internationally recognized trauma course, they had the first ever Cambodian government staff instructor candidate on their staff, he had gone to Siem Reap on their approval so he could train the rest of BTB staff, all the equipment for the course would be provided by URC & AHC, instructors had already bought their tickets from Australia (Sz and her trauma surgeon mate Sp - they were coming in their own time and at their own expense). Despite not having to travel anywhere, stay overnight away from home or even leave their workplace they were still getting a per diem (this is a whole other topic for discussion - don't get me started) and ALL that I was asking for was one room. It would seem that this was just too much.

They were perturbed - they had seen frustrated Esther quite a lot already - but never incandescent with rage Esther, so they rang the Director at home. He said - give her a room!

I had a meeting with the hospital (they were rejecting my work-plan but again that is another story and don't get me started) - the issue of staff attending training was raised. It was suggested that perhaps if the management team attended courses this would improve 'discipline'. Another suggestion floated was training should be held in hotels. I calmly countered this with the argument that I am VSO and don't have money for a hotel room and more importantly clinical teaching is best delivered in a clinical environment. I said I would ask URC about getting a hotel room (it sounds so sordid) for PTC but I already knew the answer. Jn (Hospital Improvement Team Leader URC) didn't dignify my email with a reply.

When I told them the answer was no (or technically silence) the hospital seemed to take it pretty well. They told me that there was a meeting planned for the second week in December but as it was later in the week it wouldn't affect my PTC plans.

Three weeks to D-day and I was away in Anlong Veng when I received a phone call from my VA - he sounded very worried. "Try to keep calm boss" he implored me. The hospital in their wisdom had booked a meeting during the course so we had no venue now for training. I remained calm - it was after all not my VA's problem although as he sagely told me "your problem becomes my problem boss!".

I was having my own 'issues' in Anlong Veng (another story for another time) so rang J (URC BTB hospital co-ordinator) who went with Jn to speak with the deputy director. They seemed to think it was a genuine mistake rather than my cynical interpretation that was just a device for getting a hotel room. Thankfully URC came to the rescue and we changed the course venue to the meeting room at the BTB URC office - I believe thats what is called a compromise.

The next hurdle was obtaining a list from the hospital of 20 participants. I met with HS and asked if he could provide a list - he gave me 3 names. What followed was a 1 hour negotiation to increase that number to 10 staff from the surgical ward, at this point I was beginning to think PTC was NEVER going to happen. Once again URC provided one third of the solution by placing 6 of their staff on the course so they could then train as instructors. I applied VSO's volunteer dimensions and problem solved by being flexible - I invited OPD staff and the deputy directors. HS's name was not on the list but I invited him anyway.

I organized all the equipment needed for the course. This is a very short sentence that fails to convey the enormity of that task.

I spoke again with HS - I explained I had invited him because I needed his support. He promised me he would come, I pointed out that I had previous experience of what his promise means. I reset my expectation to 'none'.

Monday evening before the PTC course on the Tuesday I felt immense anticipation and a little bit of dread.

HS came, I owed all the faculty a drink as I had lost my bet that he wouldn't attend. The hospital staff surpassed my expectations which I suppose as I had 'none' is not that hard. They were engaged, they supported each other, their post-test scores were double the pre-test and although HS is still not instructor potential material the head nurse was good & has now done the instructor training with 7 other potential instructors from URC.

Dr V was a star.

The highlight for me was playing the role of a pregnant trauma patient and being log rolled. The surgical nurse doing the scenario tried to do a rectal exam on me, when I moved my head to object the person holding it clamped down on it like vice to protect my c-spine. It was all very real for them (& me!) and that is why scenario teaching is such a powerful teaching method!

Obviously I was a useless co-ordinator, I didn't get the certificates right, I hadn't bought gifts for everyone and I wasn't to be trusted with even the simplest task - but hey this is Cambodia and feedback is always only of the negative variety. They just haven't had the 'how to give feedback lecture' yet...