Emergency Care Course, Cambodia

Its great to be back in Cambodia again. This is my third trip here, and I think I have more fun every time I come as I get to know more and more people. When I arrived back in Battambang, I immediately was able to reconnect with friends and pick up where I left off.








Monday and Tuesday were part of Chinese new year, and although Cambodians are not Chinese, its provides a good excuse to now show up for work... because after all, China is close to Cambodia - so why not? I worked in the office and prepared teaching sessions on chest pain, ECG review, and how to use an AED. There is now a video on you tube detailing how to use a defibrillator in Khmer... the only one I know of. 

The hospital was relatively quiet, but we had a few interesting cases. There is still a reluctance to engage on the part of the Cambodian doctors. It becomes a game to get them interested in bedside learning without having it appear that you are actually teaching them. There is a huge fear here of looking like you don't know what you are doing; so much in fact that people will actually leave the hospital on the premise of some same excuse to avoid having to deal with a difficult patient. I am seeing some improvements, however, and people are starting to use things from prior lessons. 

 Last time I was at Battambang hospital, I had 3 doctors and a room full of nurses show up to my lectures. This time I had 23 physicians, almost all of them in the hospital. I was thrilled with the turnout.


In contrast to India, it has been very difficult to find "sick" snakebite cases in Cambodia. This is because most patients go to traditional healers and get a salad mashed up and put on their skin instead of antivenom. The sick ones die, and the ones that eventually go to the hospital are going to survive regardless of what you do for them. This poor 19 yo man stepped on an unsuspecting cobra and got bit in the foot. He had a very mild local reaction and didn't require antivenom. In a severe case, he would start having hypersalivation, intense stomach cramps, and progressive muscle weakness and paralasis requiring intubation and mechanical ventilation. There are many of these cases every year in Cambodia... but again, most of them die before they make it to a proper hospital. 

 I am now back in Phnom Penh with the rest of my team - 5 in total with about 25 local staff. We are putting on 4 day emergency care course with workshops for some 65 doctors. In the past we had a mixed group of doctors and nurses, but due to cultural peculiarities, this didn't work out because doctors refuse to ask questions and participate in front of nurses, likely because many of the nurses know more than they do and they are afraid to look stupid.

One of the work stations will be chest tube insertion. They make special mannequins for this, but they cost thousands of dollars. Instead I went to a 9 local hardware windows to collect various baskets, tubing, hose, tape, etc to try to construct an artificial chest wall with foam padding over the top. We'll see how it works. Hopefully better than nothing. 

 We met with the local nurses and doctors that will help us translate and facilitate small groups. This is a staff of about 20. We didn't have the chest tube mannequins made yet, so we had them practice on cardboard boxed. Kind of ghetto, but it got the point across. They had lots of fun stabbing the boxes and acting out the part of sick patients. 

 One the key skills we are teaching them is how to deal with femur fractures in trauma patients. We wanted to see what they had been using for traction splints, and to no great surprise, they had not been splinting them at all! Rather than showing them some expensive piece of equipment we use in the U.S., I made a traction splint out of PVC pipe, rope, hose, cloth, and some fittings. It has a pulley system in it, and it actually works as well as any expensive device I've ever used in the US!

 We went out for dinner at the Foreign Correspondents Club (FCC) last night, which is about as much of a tourist joint as you can get. It was used by reporters to send reports back to the U.S. and U.K. during the Vietnam war. I now displays many awesome B&W photographs from the war on the walls... and has cheap beer. On our way home, the tuk tuk driver asked if we wanted to go dancing. One of our team, a perpetually dancing individual, said, "sure, why not?" We were then, to our surprise, taken to one of the coolest night clubs I had seen! This was in a back alley, in the middle of no where. The stage lighting alone would have paid to build an entire emergency department! There is a very small subset (<1%) of ministers, building owners, and people who made out very well after the Khmer Rouge stepped down after peace negotiations with the Vietnamese, that had tremendous wealth despite this being a relatively poor country. I'm guessing they keep this club open, along with the local Range Rover, Mercedes, and Cadillac dealer. Curious.

DEL->BANG->HYD->DEL

 The end of October brings Halloween, the rain, less daylight, and my second trip to India. I few via Hong Kong to Delhi and was greeted with the bright sounds, sweat smells, and hurried commotion that is India. While at first I was unsettled by the apparent lack of organization, lines, and typical courtesies found in the United States, I quickly adapted again and found liberation in the flow of things. My first stop after arriving in India would be the cooler climates of Bangalore. This developing tech city, often called the 'silicone valley' of India was, and is still a popular retirement site for wealthy Indians. The price per square foot in the city for land rivals that of popular locations in the U.S. 

Our partners in India, GVK-EMRI (Emergency Management and Research Institute) is an amazing organization. They are the largest call center and EMS agency in the world, literally serving millions of people every day, and answering each call on average on the first ring! We have partnered with them since 2006, and are now focusing mainly on physician training programs, trying to elevate the quality of emergency care in rural areas by traditionally non-emergency trained doctors. Our latest program is the Pediatric District Hospital Physicians Training program. We have been working on this for the past 3 months. 

 Our first run was at the Advanced Learning Center in Bangalore. This facility blew our expectations away! With multimedia conference rooms, cadaver labs, and high-fidelity simulation labs comparable to Stanford Medical School, we barely knew what to do without having to work between power outages and marginal equipment. The participants were eager to learn, diverse, and really enjoyed the program.

 We conducted hands-on workshops on advanced airway management, BLS, IV/IO access. The hands-on stations are by far the most popular. It is also astounding how much opportunity there is to teach everyone.... even senior consultants. This is also my favorite time because you get to interact with the participants one on one.

We have adapted our teaching style from pure lecture to 1/2 content small group workshops. This allows more questions and critical thinking.

 Bangalore itself is a well laid out city with lots of shopping malls and restaurants. I of course found the closest thing to an American coffee shop, Coffee Day. This bar, sky bar, is at the top of a shopping mall owned by the same man that owns King Fisher beer / airlines. It has all the comfort of home... and an amazing view.






We then flew to Hyderabad to the main EMRI campus and conducted the course again. This time we videotaped the lectures with all the speakers in front of a green screen. We then used video editing software to make layered videos for the participants, presenting all the slides with the speakers superimposed on them. This will eventually be the lecture format, with participants reviewing the lectures from home and then later coming to the campus for hands on training and small group sessions.

On return to Hyderabad, we revisited the Charminar. This historic monument is mostly visited by Muslim Indians. This popular bazaar is a constant commotion of humans, standing room only. Carts and shops sell hand-made clothing, handicrafts, bangals, jewelry, and just about anything you could want.  

 For some unknown reason, security was on high alert at the Charminar. The blue-clad army was fashioned with their machine guns and human beating sticks... fortunately looking bored.

 After leaving the comforts of our amazing hotel in Hyderabad, the Taj Deccan, we loaded up our van with tons of luggage, 6 people, and headed to the airport on time India style (30 minutes late)

I am now writing in Delhi, looking at the milk colored sky through my window. The air quality here is akin to a dirty fish tank. The humidity, pollution, and constant burning for cooking and heating make the air sour and thick. Tonight we kick off the EMCON conference in Delhi with a faculty dinner. Over the next 3 days I will be lecturing and moderating sessions for India's premier Emergency Medicine conference.

Cambodian People

I won't lie... the food here takes a little getting used to, and I love foreign foods. No, what Cambodia really has going for it is it's people. I was talking with a bloke from Ausy in a hotel pool who has been traveling around the world for the past year, and he appropriately observed that the Cambodians are some of the kindest people in the world. By their very nature they avoid confrontation, they are always polite.

For the most part, Cambodian children are playful, healthy, obedient to their parents, and polite to strangers. They learn to play with practically nothing, and have the biggest smiles across their faces. They lack the unattractive commercialism and sense of entitlement that many western kids have. Many of them start working around the age of 6 to help support their families.








The land here is lush, hot, humid and currently rainy. Much of the forest was removed during the Khmer Rouge to develop rice fields. Hungry and tired people rarely have time to think of opposition, only starvation and fatigue. Small pockets of jungle remain.

As usual, I have made a favorite friend while abroad. The name brown was already taken, and I though this dog looks a little like a Chiwawa, so I just call her my little friend. She joins our table every day in hopes of getting leftovers. Funny, just like my golden retriever at home. 

I'm noticing a funny trend across developing countries. As a generalization, and certainly not a rule, many doctors and nurses already know everything. I'm quite amazed, because despite my western education and recognition of the vast and endless sea of medical information that I will never fully understand, somehow they are able to master it all. As a result, there is a hesitancy to be open to learning. Now of course I'm being a little sarcastic, but I'm finding out from local doctors that on paper people will be really open in order to receive the funding, equipment and affiliation. But if given the change, the cold shoulder is often given when it comes down to bedside teaching and didactic lectures. This is not specific to any country. I wonder how I would feel if someone from... say France... came to my hospital, followed me around for a month, and pointed out all my inadequacies. I'm sure I'd be less than excited too.

The hardest thing is culture change. Because emergency medicine is very new in many countries, we are trying very hard to prevent bad habits from forming from the beginning. We are often greeted with, "Well in my country, emergency medicine is like this." The irony is that we are in the process of bringing emergency medicine to the country and it doesn't exist yet. True, however, that each country and province has unique needs. Local motivators, however, are rarely best patient care practices and usually more along the lines of power, money and influence.

If at first you don't succeed, just give up. This shoe was found stuck in a crack on a walk way... somewhere there is a very lazy one shoe man.

Although most people live in absolute poverty, religious and cultural monuments are spectacular. This collection of Apsaras ornaments a roundabout just outside my hotel. I often see small children running around them, pretending to be dancing with them. People will sometimes give them food, as though they were real people.

Foreign Aid Worker's Prayer

[Borrowed from Molly (who blogs at Molly In Monrovia) and Alex]

Dear Lord,
Today, aid me in my otherwise mundane tasks, that they shall not
result in gangrene or identity theft.
By Your grace, cancel the flight of our donor, so that I might have 24
more hours to shiny up our anecdotal success stories with pictures of
children
May the M&E consultant be amenable to case studies, or at least
receptive to my sexual advances
May the Internet, like Your mercy, flow abundantly, so that I might
watch that new Rihanna video on Youtube.
Please Lord, give me the serenity to accept the dangers of salads
the courage to eat the unidentifiable bits of meat
and the wisdom to know the difference between the proper course of
self-medication for the results of each
Fill me with Your glorious knowledge of the nationality of the person
that I am greeting, and how many cheek kisses are required; because
otherwise, Lord, it is always kind of awkward.
Grant me the patience to sit through yet another tale of Central Asia
in the early ‘90s, that lo this elderly consultant may one day, acting
in Your name, offer me a job, for only You know when the funding for my
current position may dry up
Lord, may the DJ always play Toto, for I am drunk, and THAT IS MY JAM
Forgive me for saying I was “working from home” the morning after karaoke,
as I forgive the still unsubmitted financial reports of our local partners.
And in Thy wisdom, let today be a public holiday in honor of a former
dictator’s birthday
But failing that, may I not receive too many marriage proposals on my
walk to work, for it shall make me indignant (…but just a couple would
not hurt).
And lead us not into open sewer pits, but deliver us to air
conditioned offices in white land rovers.
AMEN

Battambang

 Battambang is one of the larger cities in Cambodia, boasting the 4th most popular tourist city. It has a combination of temples, vistas and architecture that make it a "cant miss." There are several resident artist, including this modern art display over street 1 1/2 just off the riverside.

 As in most cities in Cambodia, each building has a small spirit house, a place to keep one's ancestors and good spirits. Incense help cover the ever-present smell of putrefaction in the streets. Its very similar to the French and body odor covered with perfume - eventually its normal.

 Speaking of the French, this is one of the last places in Cambodia where the residual French colonial architecture has been preserved. This bank building demonstrates what it must have looked like prior to the Khmer Rouge. Now only a few buildings remain, closed off to the public with metal fencing. The remainder of the architecture is in classic Cambodian (and most of Southeast Asian) style with concrete construction, tiled floors, and open fronts.

 Battambang provincial hospital is a sprawling campus with several open buildings. Each ward has its own purpose; ICU, medical, pediatrics, surgical and obstetrics, and tuberculosis. A separate building houses radiology and laboratory. They can perform basic x-ray, basic ultrasound, and basic labs including a CBC, creatinine, malaria smear, and at times chemistry (although not routinely). They can also do cultures and gram stains. 

 Battambang has a combination of both Buddhist and Hindu symbology. This intersection roundabout houses a classic Khmer-style roof with a series of dancing apsaras in the middle (not well seen). Apsaras are a mythical nymph that hangs around the temples, seen hundreds of times carved into the side of Angkor Wat. 

Durian fruit, when compared to vomit, stale eggs and milk, and old gym shoes with dog poo on it, takes first place. Despite this, Durian is a SE Asian delicacy often found on street carts. The fruit is so smelly, my hotel actually bans people from bringing it inside, and charging them a fine if they do. I have yet to try this rotting-flesh smelling fruit. I'll stick to mango and pineapple.

Back in Cambodia

Well, I'm back in Cambodia. This time the rice fields are lush and green, and the air humid. The rain brings down the temperature to a manageable degree. It was nice to overlap a day with my colleague Lusana to share notes before heading out on the 6 hour bus ride to Battambang today. 

Sorry I didn't post anything from our India trip. I posted things mainly on Facebook, but as I found out, it ends up being a lot of posts and filling people's inbox... so I'm back to the blog. Here is a map of our trip in Cambodia.

View Cambodia in a larger map

SRI LANKA 2009

LINK TO SRI LANKA 2009