Some of you have been asking about the work, as if it was all play and no work, so here goes – a typical day in the diary:
5.15 am: The sounds of the plonky xylophone played at 110 decibels through huge aluminium conical loud speakers from the local pagoda penetrates my sleep although it is still dark. I groan and turn over. The floor fan drones on, blowing cool air across my bed and making it almost impossible for mosquitos to fly against and settle on me. The music is playing because a family is celebrating 100 days since the death of a relative, or perhaps the 1st anniversary of the death, or even the 3rd.
5.30 am: Noises in the house reveal that my family is awake and I clamber out tidying the various objects on the other half of the double bed – reading book, torch, iPod, head phones, notebook and biro, mobile phone – and folding the single sheet I use when the fan has cooled me enough to cover up. Turn off the fan. The bathroom light is blinding after the dark bedroom and I shave and then take a cold shower to wake up properly. There is no choice about the shower temperature but it only takes a minute to get used to. Apply deodorant and partially dress.
6.00 am: Already starting to perspire in the heat without the fan. Hand wash underwear, towel and shirts in the wash basin. The mirror falls off the wall and lands on the glass bathroom shelf, fortunately I catch it before it hits the wash basin and neither the shelf nor the mirror is broken. The sounds of the sliding doors on the front of the house being opened are soon followed by engine noise as the car and the motorbike are driven out into the front yard. The house doors are as tall as a factory entrance – metal concertina doors just like an old-fashioned manually operated lift door in a Paris apartment block. It is now light outside.
6.30 am: Finish dressing and hang washing out. Search in the garden borders for a suitable piece of stick to make wall plugs. Various family members take an interest in my search and the younger teenager (Little Sister) produces a bamboo skewer used for cooking fish. Before long, thanks to the knife and screwdriver of my trusty Leatherman, the mirror is back on the wall and shouldn’t fall off so easily next time.
7.15 am: Off to work with laptop, notebook, cap, camera, etc. It’s five minutes across the road to the office. Deposit my shoulder bag, set up laptop and head outside to the parade square for flag break.
7.30 am: The staff are standing in neat in rows before the flag pole in their white uniforms – nurses, midwives, medical students, pharmacists and laboratory staff, while administrators and doctors wear smart clothes – shirt sleeves, dress or sarong. The bell is struck several times, we are called to attention, the national anthem is sung and the flag rises to the top of the pole, its arrival always coinciding perfectly with the end of the song, hopefully to flutter in the breeze, otherwise to hang limply on the hot still days while we all swelter on the ground below. Already it is a relief to walk to the shade of the meeting room for the start-of-day review and briefing.
I sit next to Hueon, my language helper but he isn’t used to simultaneous translation yet and I prompt him frequently to tell me what’s being said. The new admissions over the preceding 24 hours and the current bed state is read aloud in a mixture of Khmer and French from a school note-book with red hearts on the cover by one of the doctors, before being handed to the director or his deputy to lead discussion on difficult or interesting cases, or on any death. I listen out for the French medical terms while asking Hueon for details of the rest. The emergency admissions doctor speaks English reasonably and helpfully turns round to tell me of the maternity cases. Often there is a letter or announcement from the Ministry of Health or Provincial Health Department to read out and this will then become the main discussion topic. Perhaps an exhortation to pay more attention to caring well for patients and not to ask them for extra payment for their treatment. Perhaps a cursory comment on the child who died in the paediatric ward – he was referred too late and there was nothing we could do to save him, or something of that nature.
8.00 am: Ward round in the gynaecology – maternity block, with my language assistant. Usually two doctors are sharing the responsibility, taking one room each with several nurses, midwives and trainees laying out case notes on the beds and collecting them afterwards and following the doctors around to receive instructions about care, discharge, etc. Very few investigations are ordered except for haematocrit (a poor cheap substitute for a haemoglobin test) and perhaps an echo (ultrasound scan) which we do ourselves on the ward. Almost every patient has an iv infusion (drip) and the babies are lying on the beds with the mothers and universally breast-fed. Wounds are prodded on the hysterectomy and Caesarean patients – I have yet to see an infected wound – everyone has a full course of ampicillin after surgery.
8.45 am: Ultrasound scans on a couple of patients. One lady is not passing urine at all and her breathing is noisy through her lips, typical of uraemia. Vaginal examination reveals cervical cancer making the pelvic organs feel as if they are set in concrete. The scan shows both ureters dilated from pelvic level to the kidneys which are also dilated; the right kidney cortex is very thin. The uterus is distended with blood. She has stage 4 carcinoma of cervix with renal failure and is beyond surgery, radiotherapy or any other treatment aside from morphine. It is a long while since I saw such advanced cancer of cervix in the UK – when I was a junior doctor in Liverpool some patients would present themselves very late but cervical smear tests, general awareness of the condition, and latterly papilloma virus (HPV) vaccination in school girls has radically changed the outlook in the Western world. This poor lady will go home to die in a matter of months.
9.30 am: To the office to continue extracting data from the 2010 maternity register to try to get an overall impression of the demographics and problems here. Hueon is meticulous and so helpful as he translates and checks data with me on place of residence, number of past births, type of delivery and complications, length of stay and so on.
There were 800 mothers delivered in the hospital last year. Fifty four percent of all mothers live within 20km of the hospital, 7.5% in Mongkul Borei commune itself and 12% live over 50km away. Just over 50% were having their first child, 5-6% having their 5th or more. Seven percent are teenagers and a similar number over age 40. Seventy percent have normal births and the rest are equally divided between Caesarean and vacuum delivery – the ventouse or vacuum extractor replacing the obstetrics forceps here and in many parts of the world these days, being a safer instrument in most hands. Between 6 and 7% have a seizure due to toxaemia (high blood pressure and fluid retention) and a similar number have a haemorrhage either before or after the birth – 125 units of blood were used in the year, about 10% of the 1200 or so units of blood donated in the hospital being consumed by maternity. Road traffic accidents and general surgery use much of the rest, as well as some severely anaemic medical cases. Less than 5% are Rhesus negative here, compared with 15% in the UK. Right now we have no Rhesus negative units in the blood bank. 1 in 38 pregnancies are twins, 1 in 36 babies is still-born or dies at birth, 1 in 15 weighs less than 2.5kg and there were 7 maternal deaths last year, that’s 1 mother dying in every 114 giving birth in the hospital (compare that with 1 in 24,400 in the UK 2006-8).
10.00 am: Teach the medical students until lunchtime. The discussion usually goes on until the next commitment calls a halt. The topic today is Hydatidiform Mole or Molar Pregnancy. These abnormal pregnancies with no baby growing, just a large aggressive placenta with a risk of severe haemorrhage, toxaemia, thyroid enlargement, ovarian cysts and worst of all, a significant risk of a form of cancer (which is almost 100% curable in the West but only because we follow-up well and catch it early) are very much more common here, occurring 1 in 150 compared with 1 in 1,500 in UK, and they present themselves very much later.
11.30 am: Lunchtime! Everyone goes for lunch followed by a siesta until 2.00pm. The duty staff set up their folding beds and mattresses, the patients snooze, the relatives and carers sleep on the floor or in their hammocks, everything is quite during the hottest part of the day. I usually stay in the office and reply to emails or write my blog as I am today. The office is air-conditioned.
Midday: Phone call from Tarak the tuk tuk driver. He’s waiting at my house to give me a Khmai lesson. I padlock the office door, cross the road to buy two green coconuts with straws to share. Coconut milk is refreshing even though it’s not chilled and it never carries bacteria. Twenty meters down the street the tuk tuk is waiting and I climb into the back for my lesson. I have a list of English sentences I want to say in Khmai ready for my weekend trip, things to say to the family, and we are working our way through the Khmai alphabet with it’s 33 consonants and 20 or so vowels. We generally have a laugh over something and he learns as much English as I do Kmai. All the same I pay him – for his fuel costs from Sisophon and for the teaching. $3 each teaching session aside from fuel but I’ll have to stop when my language learning allowance is used up.
1.30 pm: Back at the office I continue my emails and blog. By 2pm Hueon has just returned from eating rice. Unfortunately he has nowhere to sleep but he may catnap during the afternoon with his head on his arms on the desk.
2.30 pm: Operating theatre. The staff are playing games on the computer. Today we have another hysterectomy for fibroids in a patient who is bleeding and has finished with childbearing. As usual the lady doctor will not operate in the presence of an older, male, white doctor who must for those reasons alone be better and more experienced than she. Not necessarily so, but I realise that she wants to learn from assisting and watching me, and of course I enjoy the surgery very much so there’s not much point in protesting. The medical students and nurses also crowd into the theatre to watch, especially interested in the method of closing the skin with no stitches showing. Very often my landlady is giving the anaesthetic. It’s not that we can’t find anyone else to do it – that’s her job!
4.00 pm: One of the students helps me write the notes and fill the register. I can’t write the names in Khmer script – that’s the problem. I write the operation notes in English with a smattering of French medical terms. The operating theatre staff who weren’t involved in our case are still playing games on the computer.
4.15 pm: Office. The director is present. I inform him of my intention to visit Thmar Puok at the weekend and may not be back in work until the Monday afternoon. I will be looking at the hospital there as well as having weekend off visiting the ancient temples at Banteay Chhmar. He likes to be kept informed of what’s going on and it is bad politics for him to hear something from another source that he didn’t already know from me. He’s perfectly happy about my plans and for a visit to teach in Stung Treng hospital next month.
4.30 pm: Hueon and I work another hour on the register. We have almost done. Should be finished by New Year – that’s national holiday from Wednesday 13th April returning to work Tuesday 19th. It’s going to be a ghost town here – the hospital I mean, like the Marie Celeste, but Mongkul Borei town will be very much alive. Everyone goes to their family home, some two days journey away while many will return to this area from Phnom Penh or wherever. After Hueon leaves for Sisophon on his moto I check for final emails. This is the time of day when family and friends are awake in the UK and may be sending a message to me. You are 6 hours behind in the summer time. Are you having any summer yet? I certainly am!
5.45 pm: Finish work and go for a bike ride with my camera around the town, each time exploring further and further afield, the various pagodas, river bridges, back streets, etc. Firstly I visit the cycle repair man and have some more air put in my back tyre at no cost. He finds a spare dust cap and screws it onto my tyre valve. All the kids shout ‘Barang!’ and ‘Hello!’ and laugh and smile. I smile and laugh back at them and sometimes shout ‘Kmai’ or ‘Goodbye!’ – I get loads of smiles, it’s the smiliest place I’ve ever been in. By dusk I’m on the way home watching the great red orb of the sun descending through the grey haze into the trees and behind the buildings while the sounds and smells of cooking the evening meal hang in the still air, thankfully a little cooler than an hour ago. The light in the evening is beautiful but so short-lived as the sun goes down so rapidly.
6.30 pm: It’s dark and I’m parking my bike in the yard for Little Sister to put away in the kitchen round the back. The Lexus is lined up ready to drive into the house and the children are watching TV. Raiman rushes out to greet me with a cuddle round the knees. I remove my sandals at the threshold and walk inside barefoot, into my room and the shower to wash off the perspiration and dust of another day.
7.00pm : I’m dressed in shorts and T-shirt when the knock on the bedroom door announces the arrival of my dinner tray. Little Sister carries it in to my table and then returns with a bottle of chilled water. She bows her head in respect as she walks past me and I thank her in the same way as I do every night and she responds with ‘Cha! – Yes!’ which does for any response to a comment or question. I gratefully pour myself a glass of the water – I gave up adding sterilizing tablets to it last week. The tray of food has a decent size plate of boiled white rice; a bowl of soup full of greens and meat maybe fish, chicken or pork, but generally fishy in flavour; a plate of fried meat (if I’m lucky), or a roasted whole fish full of bones, or an omelette; a small bowl of soya sauce and a plate of prepared fruit, often mango – it’s the mango season – banana, pineapple or something exotic I couldn’t name.
I put on my headphones to drown the sound of the imported Khmai-dubbed Chinese Imperial Soap Opera the family are watching in the next room (it is very popular!) and set my computer to show the next episode of the Long Way Round. Ewan McGregor and Charlie Boorman are pushing their BMW motorbikes through waist high rivers in Siberia heading for Magadan and the flight to Alaska. My meal lasts throughout the programme as I slowly munch and generally enjoy both food and film and the relaxation at the end of another busy day without breakfast or lunch – just lots of cold water and ginger tea.
7.45 pm: I emerge from my room and hand over the empty tray demonstrating my appreciation of Khmai food as well as expressing my thanks again. The family is still glued to the soap opera and I sit with them for 15 minutes while the children show me the toys they are playing with or get me to lie on the floor and draw animals and cars on a sheet of paper. When the children head for bed so do I as there is no point gazing at a soap opera stars whose mouths move totally out of phase with a language I don’t understand and the only adult interacting with me is Grandma, bless her, still chatting to the barang who can’t make head nor tail of her story, although we both try!
8.00 pm: I write my diary, check what I’ve spent during the day – usually about 75 cents, clean my teeth with bottled water and get ready for bed. The fan goes on, the lights out and I read my book by torchlight swatting the odd fly attracted to the light. If it’s a mossie I reach for the fly spray…
By 9.00 I’m falling asleep or I may do so to the sound of some relaxing music on the iPod, or maybe the Lord of the Rings narration. After all, I’ll be up again at 5 tomorrow…