Working in the office is very attractive. Firstly, in the searing heat it’s the one place with good AC. The other place is the operating theatre but it’s harder to deal with the flies there. Waving one’s arms to chase them away is dangerous when holding a scalpel, besides, they come straight back to the blood on the operating gloves. Second, there is constant supply of refrigerated drinking water. Third, I have English-speaking colleagues (well English and German, which is almost the same thing) so there’s more communication which is very enjoyable.
Most of my office time has been concerned with extracting data from the maternity admissions and deliveries registers of the three hospitals I’m working in. Naturally I have a Khmai colleague as well who is essential for reading the entries in the register although of late I have learned to identify the names of the five referring hospitals and I have a crib sheet for the main diagnoses. Many of the hand written diagnoses are in French so that has made matters easier and any puzzles have been resolved by a quick email to my daughter Cath, in Costa Rica. This data analysis has taught me a huge amount about the pattern of disease, the problems facing the staff and the management of common and serious conditions in Cambodia. Further, the two outlying hospitals have managed to find almost 90% of the patient dossiers which is a minor miracle since they are not filed chronologically, alphabetically or numerically and Thmar Puok had a bonfire of case records last year. I heard that charred pages were fluttering down from the air all over the village. These dossiers have added much to our understanding of the issues in treating severe pre-eclampsia and eclampsia.
You may think the problems of Obstetrics in the developing world are well-known already and you would be right in a general way, but seeing the issues from a local perspective and feeding the data back to those who produced and own it has added a whole new dimension to my understanding and has proved very powerful in the training this week. This is where the time spent in the office is starting to pay back. The teaching sessions in Thmar Puok involving four midwives, half a dozen doctors including the hospital director who is hugely supportive, three VSO volunteers (midwife, manager and me) and a visiting Khmai doctor began with a presentation of their 2010 maternity data. They had 316 mothers deliver and they referred another 33 to Mongkul Borei where I am based. Half of the referrals were severe pre-eclampsia and eclampsia, the high blood pressure and convulsions condition that is so dangerous without proper care, and the other half included haemorrhage (they have no blood transfusion) and obstructed labour (they have no operating theatre yet, though it’s coming). Seven babies died last year mostly stillborn, one of which weighed 5.1 kg and it doesn’t seem they picked up on the likelihood of the mother being diabetic. Small babies (there were 4 under 2kg) probably die at home and are not included in the figures we have.
At 5am on the second day of teaching a premature baby weighing 1.7kg was born which bled from the umbilical cord and was not sucking well. We felt it needed to go to the children’s hospital in Siem Reap but the woman’s father refused saying that they can’t afford the price of food there and he was worried his daughter would come to some harm. Her husband is a soldier and they are very badly paid. The whole family lives in an army camp near the Thai border and will continue to do so until the current troubles settle down, maybe after the Thai elections next month. He has 10 days paternity leave. The hospital director agreed to provide transport and we were able to give enough money for two weeks stay until the baby was stable and gaining weight thanks to the support of friends in the UK, and so the family agreed to go.
There were no maternal deaths last year in this small hospital though we had a profitable discussion about four cases spanning the last five years, one of whom died after transfer to Mongkul Borei – she had been warned by a cardiologist not to get pregnant the third time but a new husband and the lack of education and contraception led to her dangerous pregnancy and to her untimely death in heart failure due to cardiomyopathy. Two others were due to retained placenta with post-partum haemorrhage and the fourth was an eclampsia death. The staff recall these patients well and our discussion led to some good learning points which will continue in our further training next month.
A visit to Thmar Puok is not ‘all work and no play’…
We always eat well at Oly’s house for a start. He somehow manages to create a western food oasis in a Khmai food desert, I’ve no idea how! Lunch consisted of potato salad, lettuce, tomato, cucumber, olive oil, balsamic vinegar and baguettes sliced diagonally. He brings the special commodities from Phnom Penh while the perishables are procured in the little street market round the corner from the house. There is a new bakery in the village too. The evening meal was preceded by aperitifs with Gordon’s gin, tonic and lime, though Oly’s fridge has no ice box. Sweetcorn fritters, rice and a mild pumpkin curry filled us to the brim.
We always take exercise, usually a late afternoon bike ride. This time we saw no snakes but Oly told of the really big one he saw on the road a week or so back, several feet long and as thick as an arm if not more. It struggled to get through the fence at the side of the road it was so big, but then, as Oly confessed, it has probably grown bigger with the telling. As on previous rides it grew dark before we were half way round the circular route. Chugging noises approaching in the dark and a small red light warned of an approaching tractor-trailer driven by a cigarette. A conventional tractor followed us for a considerable way and illuminated the road for us and we pedalled as fast as we could to keep ahead, in his light, but when the road widened and became smoother he overtook and left us in the dark again. I produced my head lamp which was exceeding useful as there were plenty of motos, tractors and some other cycles, many of them without lights and obviously used to riding in the dark. Those with lights would ruin our night vision if we didn’t shade our eyes. I found once my torch was on, shading my eyes just reflected my torch beam and dazzled me further so I learned simply to avert my eyes and concentrate on the road in front and to the right side. As we approached the houses we encountered the many semi-wild dogs which are spooked by strangers in the dark and bark like crazy, coming into the road to shout as we go by. I can’t resist barking or meowing at them and that really gets them excited. We had to peddle like mad to escape on several occasions as they ran after us! Not so easy in the dark and rather worrying with bare legs and feet but it added to the sense of adventure and gave the dogs something to bark about for a while after.
There are always unexpected things to spice up our lives here too. On a late afternoon walk a herd of water buffalo swam across the pond toward us while the owner shouted and gesticulated on the farther side to no avail. They provided some fun photographic opportunities. One of the many two-wheel tractor drivers even allowed me to jump up alongside him and take the controls for a while. I found it was much harder than it looked. They have one lever for two forward gears, neutral and reverse; another lever for engaging and disengaging the clutch and applying the brakes; and one lever in each hand for steering by applying a brake to the right or left wheel according to which direction is intended. Because of the huge torque developed by the diesel engine and flywheel, the steering brake snatches the handles viciously to right or left and threatens to dislocate the shoulder. Applying the brakes in order to stop the forward motion throws the driving handles up into the air and could break the lower jaw of the unwary driver. Discretion quickly led me to relinquish control (if I ever was in control) and I jumped off, leaving the bemused farmer to drive on alone, wondering why on earth the barang had climbed on his tractor in the first place. I would have explained had I acquired the necessary language skills.
So now it is back to normal life in Mongkul Bore and to preparing for a similar exercise of 2010 maternity data feedback and training in Preah Net Preah, the other satellite hospital 45 minutes from here. Never a dull moment!