It’s Friday, end of week day.
Last night I had a lovely meal in Sisophon with several other volunteers working in education and health, and with nationals working with VSO and Actionaid.
‘Cow on the hill’ consists of a brazier of charcoal set in a hole in the table with a Mexican hat shaped barbecue on top. During the chatter and drinks we placed thin strips of beef marinated in red spicy sauce all around the top of the Mexican hat and as they cooked the juices ran down into the brim of the hat. Prawns and octopus were added to the beef; water added to the brim and with noodles and green leaves a delicious soup was created. Between the 14 of us we had three such ‘barbecue hills’ and on the table, three whole roasted freshwater fish, various dips and the usual boiled rice. It doesn’t compare with Khmer dinner from my landlady of course, that goes without saying…
Meeting others working in health is a chance to talk over some of the events of the week. I had just removed a twisted ovarian cyst in a young woman whose second child was born 5 months ago. The cyst had features which could suggest a malignancy. The staff were bemused at my request for histopathological examination. The operation had cost $90 already and the husband could not afford the $40 to send the specimen to Phnom Penh to be examined. I explained that I have the means to pay – please send the specimen! After a lot of to-ing and fro-ing involving several members of staff, a form was produced and I was asked to complete it, starting with the patient’s name. But I can’t read the patient’s name and I can’t write Khmer! Someone reads the name out, spelling it in western alphabetical characters, while the lady who seems to be dealing with this process writes it down for me. I must write the nature of the specimen – I duly do so – in English. Then I must write the indication for the request – but I wrote all that information already just now. But you must write it down under the heading ‘indication’ (pronounced in French of course). Mais oui! I write the same things all over again. Then the $40 is required. Listen, I am just off to Sisophon for a meal with some friends and my transport will be here any minute, please just put the specimen in formalin preservative and I will deal with it in the morning. After several remonstrations to and fro with this lady including a demand for a receipt on my part and where will I see her tomorrow?, the awfully embarrassing realisation dawns – this is my landlady I’m speaking to…
I wonder whether I’m doing the right thing. When an ovarian cyst undergoes torsion the blood supply gets cut off and usually the ovary dies. It degenerates and that makes it difficult for the pathologist to decide what kind of cyst it was in the first place. Apart from that, I’m not sure the specimen will be going into preservative immediately or whether they will find the formalin at all since this is not what they usually do and therefore it may well deteriorate further before the pathologist gets his hands on it. I don’t what is the quality and reputation of the pathology service in Phnom Penh. And assuming I do get a clear, meaningful report, if the cyst is benign, that’s the end of the story; if the cyst is malignant what chance is there of this family paying for a CT scan, or further surgery, or chemotherapy or attending for 5 years follow-up or whatever seems necessary? Besides the whole ovary has been removed intact and the other ovary looks entirely normal and she has no other signs of a malignant process and 5 months after childbirth a multilocular cyst undergoing torsion could very well be theca lutein, linked to pregnancy, and therefore benign.
I finally conclude that I may have been better to have said nothing, done nothing more and smiled sweetly at her afterwards. Why does she need to be alarmed about what may never happen and about what she has no control or hope of avoiding. Sometimes it’s better not to know. These are the days of the doctor playing God that we once had in the NHS when patients were not told and often didn’t want to know, though in the UK we can never return to those days. The problem is that I have started so I must finish. It has become a different issue. It is now a question of keeping my word in the matter of $40 and providing an answer to an expectant family, and for those reasons alone we must proceed. I am grateful for the sounding board of experienced colleagues around that ‘cow on the hill’ last night.
Just as I leave the Sisophon hotel at 7am for the hospital another guest is checking out. Robyn is a consultant in a pathology laboratory in Phnom Penh! She is from Perth in Western Australia and grew up in Cannington where my grandfather lived and died, and where my cousins live today. She advises me of a hospital and laboratory to which I should send the specimen, whom to contact, and she gives me her card in case of further queries. The encounter confirms me in my decision to go through with the process.
Back at the hospital events seem to have taken a different turn. The specimen has been sent at 6am so I have no control over its destination. I must accept the situation and pay the fee. Further I discover to my horror on my arrival in the ward that the patient in question collapsed last evening with internal haemorrhage and was rescued by Dr Chhaya returning from her prayers at the pagoda and her exercise class to re-operate and ligate the bleeding vessels. The blood in her abdomen is salvaged and re-transfused as there is no other blood available. As you may imagine I go over in my mind in detail the steps in the operation and rehearse the various things that might have avoided this complication. Expressing my gratitude to the doctor who has been my assistant all week but now shows herself a capable and experienced surgeon, I insist that next week the tables be turned and I learn from her and that she teach the medical students too! Then I walk the walk of shame, shuffling from the ward while they all laugh and I find the ability to laugh at myself. Aside from the lessons I am learning, the example of my admission of failings and my acceptance of responsibility and culpability is something the staff here don’t see often. Face saving in this culture makes it very difficult either for a person to display, or for a person to expect of another. So it is rare and therefore I realise afterwards that my mock walk of shame was another lesson for all.
I am so glad the patient seems none the worse for her experience. When I visit at the end of the afternoon, she is asking for her baby as her breasts are full and she is ready to feed him. I am so glad the ‘intensive care’ staff recognised that she was bleeding in time to take decisive action – they must have been checking her vital signs. I move with the young nurses to my other postoperative patients in the ward. They hand me the case records. One patient has transferred today from intensive care after hysterectomy yesterday and no vital signs have been recorded. This is the first thing nurses in the UK will do on receiving a post-op patient on the ward. The next two post-ops I have seen before and so have the nurses. In fact they are ahead of the game: they have already written in the case records the figures for temperature, pulse, blood pressure and respiration rate for the following day! My limited Khmer will not give expression to my feelings at that moment but my facial expression and sign language do. How can you fabricate the vital signs?! Now please go measure them on the hysterectomy lady and do not make them up!
I have only been here a week, I obviously still have a lot to learn …