Thma Puok is one of 4 outlying hospitals which refer complicated cases to us in Mongkul Borei. Three of them are on tarmac roads but not this one. The rumour is that the people of Thma Puok are not big supporters of the Cambodian Peoples Party and something of the history of the Khmer Rouge, I’m not sure what exactly, makes those in the corridors of power slow to develop this area by putting in a metalled road. Consequently travel by ambulance, or any vehicle for that matter, is rough to say the least, and travel in the rains becomes extremely difficult.
This week I’m heading up there for a couple of days training on the subject of stabilisation and safe transfer of pregnant patients suffering from eclampsia – that’s convulsions caused by severe toxaemia of pregnancy, one of the five main causes of death in association with pregnancy in resource-poor countries. We will include the ambulance driver in the training of course, as he is a key figure and often gets left out of teaching sessions like this.
The teaching is based on data on this serious complication extracted from Thma Puok hospital’s records from 2010 which included various bits of random information such as: 20% of the pregnant patients are teenagers, the age of marriage of girls is predominantly 15-19 years and the main occupation (70%) is farming. This is a rural community in a nation which exists because of basic subsistence activities; farming and fishing being the most important.
This weekend saw the grand ceremony of Royal Ploughing Day, yet another national holiday, when the king officially initiates the season of preparation for rice planting in readiness for the rainy season which has already begun in fits and starts. So has the ploughing, as the farmers cannot wait on state ceremony to prepare the ground for rice-growing, and the water which has already fallen is making life difficult for some of them.
I watched a man harrowing his field which was largely under a few feet of water with his Japanese two-wheeled tractor creating a bow wave ahead of him and he walking knee-deep behind, cheerfully waving at my camera. These two-wheeled tractors are everywhere. The weight of the engine and gear train is set squarely above the driving wheels; long handles with clutch, gear lever and accelerator attached allow the driver to walk behind the plough or harrow, or to ride on a small seat towed behind, mounted on its own set of wheels of the type seen in horse-drawn implements in our grandparent’s day. On the road the driving wheels have pneumatic tyres and the tractor draws a trailer to create a stable four-wheeled vehicle. In the field the wheels are replaced by metal paddles with a much broader tread and the ability to grip in the soil and mud while drawing the plough.
Steering is done by swinging the handles of the tractor to right or left and the turning circle is determined by the reach of the driver. The articulation of the engine and the trailer allows the tractor to turn but tight turns are not possible and sometimes the driver has to leap from the vehicle into the roadway to turn as sharply as possible and then considerable agility is needed. Needless to say they do not travel very fast or jumping off would be more hazardous.
The momentum of a flywheel on the side keeps the two-stroke engine turning over and also carries the pulley for the drive belt (which acts as a clutch) and also allows other implements to be driven when the tractor is stationary. In the dry season the commonest activity in the fields appears to be the use of the tractor to drive a water pump for irrigation using one of the many ponds or the canals and ditches that criss-cross the landscape.
These water sources are also teeming with fish. “Have water, have fish” is a Kmai saying and I see children and adults fishing in every river, stream, ditch and pond, no matter what the size. It’s towards the end of the season now so the yield is not so good until the annual flooding carries fresh stocks of fish from the major rivers across the face of the flat earth and leaves them trapped in every body of water – and there are countless fish ponds, almost every house in the rural areas has its own.
One of the mismanagement problems in eclampsia here is the over use of intravenous fluids. It is a condition where too much fluid has leaked from the circulation causing swelling of the legs, hands and face known as oedema; the same happens to the brain and is responsible for the convulsions, and pulmonary oedema is one of the causes of death in these women. They seem to pour fluids into the intravenous drips as enthusiastically as they pump water into their fields, and that is just one of the practices that we need to address in our workshop this week.
So visiting Thma Puok will provide another opportunity for me to watch in fascination the simple lives of ordinary people in this pleasant, beautiful land. And an opportunity to interact with the staff in the little hospital there and learn from them of their problems and challenges, and to impart something of our modern medical know-how in the hope of improving the safety and survival of these hard-working farming folk.