Ethics, emotions, money and mortality.

The universality of nursing experience became apparent to me today. I worked with five of the D ward nurses and an American and a Khmer doctor for three hours trying to keep a patient alive. Despite the language and cultural differences that can often make things so difficult we worked well together, and differences between an Australian hospital and one in Cambodia aside, the arrest was well run. We were organised, we documented, we didn’t get in each other’s way, we were calm and focused.

Unfortunately the patient deteriorated, we couldn’t keep a blood pressure, we defibrillated her heart 6 times but couldn’t keep it in a sinus rhythm, her kidneys weren’t making urine, she was fluid overloaded and eventually she stopped breathing and her heart rate fell. After we decided not to continue I tried to tell the nurses how well they had done. I was having trouble dealing with feeling sad for the family, sad that we couldn’t save her and adrenaline and shock at having expected to save her and having her die. When I said you worked really well together today and you did a good job they said ‘ot sabai jet’ we are not happy because we could not save her. I felt so impressed with the way that had handled the situation, so proud of them integrating new knowledge and skills so well, and still, I know the feeling, of putting in the work to save someone, starting out expecting that we will and then having them pass away. That switch of focus from focusing and concentrating on how to save a person’s life to taking everything off and letting them go and trying to support a grieving family has always been hard for me, I think it is for everyone in that situation. I felt immense respect for our team, and understanding of the fact that you can try your best and still fail to save a life, and yet trying to reassure them I was close to tears myself.

The other difficulty here is that when deciding how much to give the patient and how long to try and save them is that the family (of our medical patients) have to pay for those drugs, and I never know what their financial situation is. It can be an emotionally charged decision to decide to stop trying to save someone, but there is a point where it becomes futile, their heart can no longer beat, no matter what drugs you give or how many times you defibrillate, if they have spent long enough without oxygen going to the brain the chances of surviving with viable brain tissue are reduced. To continue trying last ditch attempts in these situations can make you feel sure that you have done your best, but in cases that are futile can cost the poor and grieving family money that they could have been saved. I have no answers to this dilemma, I wish we could treat everyone, that we could give free care, which we had guaranteed funds and resources but that isn’t the case here.  I am going to try and get the hospital agree that patients and their families don’t have to pay for the cost of care given during life threatening situations. While this might help for the acute situation the reality is that many many people are going without treatment for their medical issues because they cannot afford it.

How to win friends and influence people; A lesson in cake fights and kitchen flood

My first dinner party went off with a literal bang, Jason was the first to arrive and within about 5 mintues he had bumped a pan which fell and knocked the attachment for an old tap of the wall causing a torrent of water to us to start jetting out of the wall, spraying us with water and making the water level in the kitchen quickly rise. He apologised and we laughed and he rode to our local café to ask the guy who works there and who I pay rent to, to come look at the house. Jason came back a little later and took over holding a pot against the flow to try and redirect some of the water into the sink. In the mean time I called Noni and go the phone number of Buff, out local hero and fixer of everything, and also the smiliest guy in Cambodia, and maybe the world.

My phone ran out of credit half way through the conversation and I decided not to bother Buff anymore, and then Yong rocked up and turned the water off (which is way easier to do than I thought). Yong then tried to shove a kitchen sponge in the hole in the wall with a knife and talking about maybe calling someone to fix it tomorrow. I wasn’t convinced about the kitchen sponge, but was happy for the plan to fix it the next day (probably needless to say when Yong turned the water back on the kitchen sponge went flying and the water spout re-started).

After Yong left Buff rocked up (somehow, I don’t know how he found out where I was or what they problem was…) with a bunch of tools and looked at the hole in the wall, then took a few screw drivers to the hole and chipped out the rest of the metal pipe. He turned the old fitting around, put it back in the wall and it was fixed (He really is the coolest dude ever). I offered him a beer or dinner, but he just happily headed off to do whatever it is that Buff does when he’s not fixing all of our problems.

Then Alexa Noni and Allison arrived with take away Indian Jason swept out most of the small flood,  and I proceeded to be the most unorganised host ever, not having any plates or cutlery or anything, and feeling so happily amused seeing all my bongs in my house J

It was a lovely dinner, and we talked about all the things and teased each other and gave Allison the mug that we got made for her birthday with a picture of Us and all the Kinyei staff on it, and eventually it was time for cake. Khmer cake is an interesting conglomeration of oil slick like puffy cream and spongey cake… It is often thought to be better for throwing than for eating, and so, in a moment that I feel really christened my new home, I took a chunk of it and smooshed it into Noni’s face…  It was Cake-on from then and we quickly deceminated the cake, re-homing it to each others, faces, hair clothes and my entire house, It was one of those moments where you realise your friends are real friends because your can smooth oily cake all over each other and then stand together on the balcony in the rain trying to wash it clean and laughing. Not long after that everyone went home and I bemusedly removed cake from some surprising places, washed it out from behind my earsand went to bed. J

 

Pailin Adventure

On Saturday we rented motorbikes and rode to Pailin. After a 5 minute lesson at the abandoned airport on Alexa’s bike and a trip to Kamping pouy last weekend on an automatic bike I decided to hire a semiautomatic bike (gears, no clutch).

The ride to Pailin is about 2 hours, so after waiting around from 8am to 09:30 for everyone to turn up we got on the road and headed out to Pailin. The landscape changes a fair bit between Battambang and Pailin and it was so beautiful, I kept wanting to stop and take pictures but didn’t want to slow everyone down. We had a few stops on the way down for snacks and flat tyres and just to let our assess get some blood in them, and then we made it to Pailin. The idea was to ride out to the waterfall so we headed down a dirt road that turned into more of a mud puddle than a road. A couple of people fell, and Jason got splashed all over with mud by some amused locals riding by. When we got to the waterfall the bridge was out and we were pretty hungry, so Mark and I jumped in for a quick swim, but we didn’t walk up to the top of the waterfall, and we decided to head out and get some lunch. We rode out to this beautiful spot with a little lake with a swan boat on it and an orchard between these hills but the place was eerily deserted and so we headed off to somewhere else. On the way back from the waterfall Mark slipped out in a particularly muddy area and ended up in the bushes with a 3^rd degree burn on his leg. We didn’t have any cold water so at Untac’s suggestion he covered it in toothpaste J “khmer traditional medicine”. I offered him some codeine I had in my bag but he seemed to want to keep his wits about him while riding so he just toughed it out.

Sitting at the new lunch place in a grass hut I was super hungry and tasted the tasty beef with lime and pepper… so tasty! (sorry cows) then I wanted to eat all the lime and pepper beef, and we ate food there for a few hours and generally talked crap as usual. Afterwards we were going to head to another waterfall but it was getting late and some people wanted to go home, so they headed back and we decided to head back by a back road that had some other waterfall on it, with Untac as our trusty guide we turned around and headed through the most stunning rural areas of Cambodia, I am so desperate to go back and see it all again slower. It was the kind of riding I like where you have to pay a lot of attention because the road is mostly potholes with the odd excited dog or flock of cows. There are lots of plantations out here which I hadn’t seen before and I am so keen to go back and spend some more time out there. Eventually we reached a little gate around a puddle, we followed Untac through it and soon the road disappeared and we were just riding through grass… which quickly gave way to a track which fairly resembeled a mudslide and eventually we had to stop and just walk. As we walked away from the bikes we heard a big thump and turned around to see a monkey pushing over a bike. Mark was concerned that they would steal the keys to the bikes so he went back, armed with a stick, to get the keys, but got ganged up on by a bunch of monkeys and had to turn tail (Untac later informed him that these are all the wrong things to do with monkeys).

When we got down to the waterfall it was beautiful, and we jumped in and it was so amazing, so refreshingly cool and nice and we swam under the waterfall and got waterfall massages. Then tried to drown each other a bit… just for fun J  I could tell people were starting to get antsy about the (at least 2 hour) ride back, so soon enough we started the ride back. Riding in Cambodia at dusk is never fun, it is very hard to see, people often have no lights or the lights don’t work on their vehicles, there are fires everywhere burning off the day’s rubbish, releasing toxic smells and reducing visibility further…  riding on an unknown dirt road full of significant potholes was no easier, luckily for me Jason soon ran out of petrol so I stopped with him and we spent the rest of that dusk time trying to figure out what to do. We decided I should ride off and get petrol and bring it back, by this time it was dark and the visibility for me much easier. I went and bought two coke bottles of petrol (spilt it all over my hands) and rode back with it in a plastic bag… As I rode I noticed an odd thumping happening with my bike and realised I had a completely flat tyre. By this time the rest of the gang had heard what was going on, and when I asked Untac what to do about the tyre they all decided to come back. We rode slowly up the road looking for anyone who could help us (tricky, especially in the countryside). Eventually we found some lovely nine-year olds outside a little wooden shack who replaced my inner tube somehow without removing the wheel and then asked for 50c for their troubles. The rest of the ride back was long, dark, involved getting a lot of bugs in the eye, had a few more stops for petrol etc, and eventually got us into Battambang around 09:30pm.

Over the next few days 8/10 of us also contracted a lovely pink eye conjunctivitis!

All in all I had a great time, I love adventures and being potentially stuck in the countryside, and waterfalls and mud and being a little unsure of what’s going to happen. In fact I think I may have had more fun than anyone else …

The bikes before the monkeys started pushing them over.

Waterfall no. 2 (In Angelina Jolie and Brad Pitts nature reserve place)

Riding through a flock of Cows.

Waiting to get the tyre fixed...

Flood relief clinic

So after the floods in Cambodia some of the doctors who knew people in certain communities around Battambang decided it would be good to do clinics with people who had been displaced from their homes by floodwater. The first of these clinics was in a wat near Phnom Sampov.

We arrived on a Saturday morning and set up desks with nurses taking vital signs and names, then sending the patient to the doctor who would give a diagnosis and prescription and then to the makeshift pharmacy who would fill the prescription and explain to the person what to do with the medication.

I was with the nurses taking vital signs all day, there was a constant stream of people (I think we saw almost 200 that day!) and so I felt I hardly stopped or got to really interact (although my Khmer is so poor I couldn’t have said much anyway). At one point I was presented with a teary baby and realised that apart from the fact that we don’t have any BP cuffs small enough, in my work as an adult nurse I have never had to assess kids or baby’s (not even in english!) so I looked at the now crying baby and tried to get a heart rate or resp rate but wasn’t having much luck… I asked my colleague (and generally awesome dude) Tum if he could help me, he replied ‘sure’ and calmly asked the mother to walk into the shade with the baby and to point up into the sky and watch the leaves from the tree’s above… by doing this he distracted the child and also got it to stretch out it’s abdomen making it easy to count the resp rate, humbled, I said thank’s to Tum and went to see the next patient.

At lunch I saw a big hole in the ground with a web on the inside like an Australian funnel-web but much larger, I assumed something lived in it and thought I should tell people, as the hole was just behind one of our doctors desk’s. I pointed this out to people and asked what it was, thinking that they would tell me what animal it was and sensibly leave it alone….  That was my first mistake… Vichet (one of the doctors) happily told me it was a king spider, (about the size of my outstretched hand, highly poisonous, and apparently quite tasty). He then started pouring water into its hole and poking a stick down trying to make the giant poisonous scary hairy spider come out to kill us all! By this point of course there are a crowd of interested barefoot onlookers crowding round the hole, and I am standing well back having a little whitey conniption about the whole situation. Eventually when everyone had seen the big spider and Vichet had noticed that I was paling a bit, people lost interest and left it alone, went back to seeing patients etc. Meanwhile a pig about the size of four of me wanders out of the jungle and past the nurses desks and off into the camp J

We treated a lot of people for general illnesses, colds, boils, a broken arm that had been wrapped in leaves, dog bite, gastro issues etc, although sometimes I feel the diagnosis and prescription leave a little to be desired… It was an interesting day. Afterwards we went to Kamping Pouy where the people in the camp were from to see what had happened. Kamping pouy is a huge man made dam built by khmer people in atrocious conditions under the khmer rouge. During the flood it had been dangerously full and so the area had been evacuated and the gates opened to let some water out, as the pressure of the water was so high however the water ripped the gates out of the walls of the dam and surged through where the town had been. The damage was scary, I’v never seen water do so much damage, having been to kamping pouy weeks before to go swimming, the changes were drastic and almost unbelievable.

Flooding

So there has been extensive flooding across South East Asia due to typhoon. 80 people have died in Cambodia. Crops and homes have been damaged, and the large amounts of residual dirty floodwater will make it easy for outbreaks of disease to spread (both from infection and mosquito's breeding).

These are some pictures from Battambang.

 'Old Battambang' where I live is in the city and wasn't as badly affected.

From the top of Phnom sampeu - Usually you can see fields of rice paddies from here.

 The highway close to the hospital.

 

 Fishing on the highway.

 The highway towards the hospital.

 So glad the medical centre was built on high ground.

 

So lucky to have these pumps and an awesome team of people helping to keep the hospital functioning and open. Admin and the Dr's were out the front filling sandbags, maintenance made bridges, lifted massive amounts of equipment of the floor, sandbagged the hospital entrances and rigged up pumps, and the nurses and admin staff all came in to work despite most of their homes being flooded.

 

The road on my walk/wade to the hospital.

I love you but your homophobia breaks my heart.

So this post is about two different things. One is about vulnerability, friendship and homophobia, and the other is about what I understand so far of being gay in Cambodia.

The first thing;

This is a feeling I get from time to time, with particular friends or places. Friends I would love to feel wholly comfortable with, but there is something, like an edge, a topic I feel I have to avoid because to talk about it brings up this huge gap between us, and reminds me that there are things that feel to me like a part of the core of me, that my friend cannot understand or does not respect.

This occurs about a few different things, my politics, my views in things like racism and abuse and respect, that are things I don’t feel I can compromise.

 And inevitably it occurs with being queer. I love the people that I love in my life who are queer, trans*, and wonderfully uniquely their brilliant selves. I feel that all of the things I associate with queers can create so much joy and celebration and sparkles and growth and challenge and love. And I know that there is also difficulty and often pain involved in being outside the status quo, In being who you are when people don’t understand it and are threatened, disrespectful, angry or many other reactions. I love the understanding I find with many queers, and I feel love and care for the people who are experiencing difficulty and abuse because of it.

It tears at my heart a little to love something or someone but know that we can’t be friends in the way I wish we could be friends. Because there are differences in our lives and experiences that give us different takes on the world, and trying to explain is gruelling and painful and involves being so vulnerable, sometimes for so little pay off. I sometimes try to explain it all, to help someone understand how my life has shaped me into the person I am, and why comments and ways of treating people that seem fine to them are so hurtful to me… but the process of baring yourself to someone you care about things you deeply believe in and can’t change, and them having them not understand or not care is so painful and demoralising that most often I don’t attempt it.

Cambodia too of course has a certain homophobia, It is not something that really makes me feel personally uncomfortable or threatened. I fit into Cambodia as an expat ‘baraang’. Different expectations and understanding apply to me as opposed to someone who is khmer and was raised here. But for Khmer people who are gay, queer, trans*, I can’t imagine how difficult it would be.

Cambodia is a place I am still getting to know, and as far as I understand (which probably isn’t very far) Homosexuality sort of “dosen’t exist”, It’s understood that people might do a bit of ‘searching’ but that eventually they will settle down and get married. Talking to a distressed Khmer friend the other night I realised how good I have it back home, I can hold another girls hand most places, kiss where I want to, live somewhere where there are lots of other queers, live with my partner and probably have kids if I ever wanted to. Here I think that would be a very hard option if you could do it at all.

I’m aware that I don’t know much about Cambodia, I’v only been here a few months, so maybe this is not the way it is, I don’t have much of an understanding of Khmer culture and I think it differs in the cities and rurally and maybe province to province a bit as well. So this is just what I’v heard (and mostly from other foreigners).

Mainly I feel sad for my friend who is having such a hard time here, and I felt shocked to try and imagine how hard it would be to know I was queer if I was growing up in Cambodia as opposed to how it has been the past few years living in Newtown.

And I feel sad when that point comes as it sometimes does when someone I care for and trust says something out of left field that just makes me feel uncomfortable and shocked, and like I can’t be honest and that they don’t understand me at all.

** Also, I know this sounds a bit whingey and I feel weird writing about myself like this, I am sure I have misunderstood people and made them feel uncomfortable and I feel sorry about that. I also think a lot of people feel like this about differen things so… yea…. Disclaimer ! : )

Questioning our efficacy

So the other day we (the other two young expat nurses and I) started talking about whether we are going the right way about what we are doing here and whether it’s likely to have any lasting effect after we leave.

None of us really have experience in this kind of work which is sort of looking at the hospital and then making projects to try and improve it – trying to increase patient safety and reduce rates of infection, and to introduce idea’s of leadership, self regulation of the ward and trouble shooting and critical thinking and self/hospital improvement to the Nurse unit managers. Also trying to create a culture where everyone feels that they have a say and promotions etc. are given out on merit not bribery.

Culturally we are very different, and I don’t think any of us understand much about Khmer culture, it is easy to put something down to someone’s culture, but I don’t know how much of that is assumption and how much is accurate. There are also big differences between khmer culture in city’s and out in rural provinces and among people who have had more jobs and more contact with westerners and those who haven’t and I’d say probably it differs with class as well. So a blanket statement about something being ‘their culture’ is maybe just going to be inaccurate anyway. Our lives have definitely been very different up to this point.

 There are so many assumptions that you just can’t make, and so many inherent misunderstandings that occur and we are learning as we go. Things like talking about medication errors, because it has been so ingrained into us what they are and that they are bad, when we introduced the new medication charts I think we forgot to explicitly say that if you haven’t signed for having given the medication, that is an error, even if you gave it correctly, you still need to document it, there’s no rule like at home that ‘if you didn’t document it you didn’t do it’ because there aren’t the regulating bodies and authorities here to do anything about it.

And we gave the NUM’s calenders to fill out the other day to help us all stay on the same page with what’s going on and when they were sort of looking a bit confused I asked has anyone used a calender before? And only one person out of eight had. Sometimes you just have to go ok, and go back a few steps. It’s a bit of an eye opener about just how ingrained our culture is and how much we assume.  The NUM’s are great and try really hard, I have such respect and appreciation for them working with us and our crazy ways. We have started meeting briefly everyday to keep up with introducing all of the things we want to introduce and trying to keep up with following everything up etc. It’s also hard to know how much is just doing what we say because we are white as well, and whether they feel comfortable really telling us their opinions, but a few times recently they have told us problems they see in our plans which is really heartening.

So back to the question of whether it is effective, there are a few reasons that perhaps these changes won’t stay in place when we go; one is that we don’t know much about the culture and if we aren’t doing these things in a way that fits in with the culture here, it will probably just go back to the old way when we leave, (although we are making some changes to the culture of the hospital as well, and I will be interested to know if they will stay). Also we are introducing many changes,  we have so so many things we want to introduce and I think we need to calm down a little and pick some focus area’s to work on that are the most important perhaps and do really good follow through with our projects, I might only be here for another four or five months, (or maybe a little longer) and The others might only be there for a further eight months (unless they get further funding) so we need to be a bit realistic about what we can achieve in that timeframe…

We are trying to do a lot of things right now, we have changed the medication charts and vital sign charts in the hospital, opened a medical ward, introduced a crash cart, started Nurse Unit Manager meetings, started portfolio’s for staff and writing policies and procedures, started writing a pharmacy book as a reference for all the drugs, started teaching anatomy and physiology and pathophysiology, we are about to try and introduce a new way of documenting, make a system so that patients have unique medical record numbers and introduce medication error reporting forms, trying to get the policies that we have written part of hospital culture and self regulating checking of those things, (trying to convince the hospital board that the cost of paper towels to dry hands is worth the reduce in infection rates that proper handwashing is shown to have). And I’m sure I’m forgetting things, so within all of that I’m sure that some of those will not get followed through, or fall by the wayside..

It can be disheartening trying to make changes, but I think some of that is just wanting things to happen to fast or misunderstanding why it’s not working. The time I usually end up frustrated is in the middle of a nightshift when there is someone very sick and I can’t communicate well and the standard of care that I’m used to for a patient, and things that I take for granted as basic don’t get done, but I just try to remember that this hospital has been running for a long time without us and yes some people probably have died from aspiration pneumonia etc, but also the hospital has saved a whole lot of people who would have died otherwise.

It's a very funny situation to be in helping a hospital that was set up as a war hospital to start accepting medical patients, and to be trying to bring the standards of care and the idea of responsibility for your patients to be more like a western hospital, and still being constrained by resources and budget and trying to make the best of the material we are donated. I think its sort of a unique situation in that, and I am hopeful that we can help the hospital to become a little safer and the nurses hopefully to develop more knowledge and pride and responsibility in their work.

We'll see, but its 02:30am, so goodnight for now!