Same job, different hemisphere.

     How is it that I've found my old job here in this new place?
     Well, wherever you go, there you are. And here I am.

     New Hope is a relatively young organization that has grown rapidly in its few years. It started as a small-scale operation to provide some very basic needs for a few families in a slum on the outskirts of Siem Reap. The village is called Mondul 3 and had once been an army base. If you want to know about New Hope and the area it serves, I highly recommend you visit their website: www.newhopecambodia.com .

     When I was here in March, I visited their clinic and spent a day or two with the Australian nurse volunteer who was here at the time. It seemed like it might be a good fit for me, so I stayed in touch with her and the director. As is always the case, things here shifted and changed during the months since March. Tracey, the nurse, went home to Australia as planned. There is now a string of nurse volunteers who will arrive every month or so. In addition to the Khmer doctor who has been there for a couple of years, there is an amazing British GP who is working there until late October.

     As we were packing up to move, I was told that perhaps New Hope didn’t need me to work as hands-on direct service nurse, but needed some help organizing the ever-changing roster of nurse volunteers. This sounded suspiciously like management and admin work, which was not what I was looking for. (In fact, it was what I was looking to get away from.)

     But after spending a couple of hours there last Tuesday morning, getting a look at the newly expanded health center, meeting with the doctor and the staff, I think I’ve found my place for now. I can still get some hands-on experience if I want to, and I have an opportunity to learn a lot from the doctor. He and I have seem to have very similar ideas about how the clinic could run, if only someone had the time and inclination to put some systems and protocols in place. Attention to staff development, clarification of roles and responsibilities, developing documentation systems, keeping inventory of medications and equipment, ordering supplies, orienting new volunteers as they arrive – those are all things I can tackle. I think I can do this.

     It won’t be easy. The clinic sees dozens and dozens of patients a day, and there are few or no systems in place. The doctors and nurses are all constantly running between the three rooms in the clinic, interrupting each other to find supplies they need. A couple of the translators are great at their job, and a couple of them need some… guidance about their role. (We could start with the idea of showing up every day and not answering personal calls on their cell phones in the middle of seeing patients. As a matter of fact, that's just where we'll start.) A good percentage of the limited equipment available is broken, and the med supplies run out at random times because sometimes there isn’t enough money that week to buy more or because no one knows what’s running low. The bathroom has no towels or paper products, the clocks on the wall have mostly stopped working, and people wander in and out of exam rooms on a constant basis. (The doors are often left open because without any air-conditioning, the rooms quickly become hot and stuffy.) Record-keeping is an enormous challenge, as many of the patients are showing up for the first time ever, and writing Khmer names with the English alphabet is a hit-or-miss crapshoot, so trying to create records is next to impossible. Many of the patients are illiterate, so trying to make sure they understand instructions about medications or treatment is particularly difficult.

The "waiting room."
Just imagine how comfortable it is during a tropical rainstorm... 

     People come with many common complaints, and some not so common. Many present with a litany of vague symptoms. “I have headache and stomach pain, for seven years.” “My child has a runny nose.” “My chest feels hot and my legs are weak.” People show up with high blood pressure and there’s nothing to offer in the way of treatment. They have malaria and typhoid and dengue fever. They have HIV and TB and hepatitis. Two girls came in with mumps on Friday morning. Women report they can’t feed their babies because they don’t make enough milk, probably because the mothers themselves are so malnourished. Kids have diarrheal illnesses and if the clinic is lucky enough to have oral rehydration solution packets in stock to offer, their parents have no clean water supply to mix it with. Today, I spent a good portion of the morning running around the clinic trying to mop up water that was pouring in through the leaky windows when a torrential rainstorm came through. And there were no towels. Would someone please send some of those damn ShamWow things?!?!?

     Some people come in with minor and even imperceptible complaints. A mother reports a rash on her child, and no one can see it. Runny noses are constant, and people want medicine or they feel they haven’t had any help. Other times, people show up with illnesses or injuries that should have been treated weeks ago. They come from the village surrounding the clinic and they come from further afield when they hear there is a clinic that is free. They walk long distances to get there, or they ride bikes. A toothless old woman with a festering foot ulcer was pulled in on a wagon and sat silently while we pulled off the days-old dressing and replaced it with a fresh one, and who knows when she can get back to have it changed again.

     Here in Cambodia, people can go into a pharmacy and buy all kinds of medicines that would be sold only by prescription at home, and the “pharmacists” selling them know very little – or possibly nothing at all – about illnesses or medications. Patients might get three days’ worth of an antibiotic, just enough to cause a nasty rebound infection a week later. Patients tell us that they got an injection at the pharmacy, but they have no idea what it was. It’s frightening, on so many levels. I’ve been told that there are an atrocious number of children here with chronic liver and kidney damage just from toxic doses of inappropriate medications.

     Oh, where to begin? Well, I always start by making lists. I spent my first three days floating around the clinic, watching everyone in action, making lists of questions and trying to understand how things work – or don’t work, as the case may be. There are some pretty simple concrete things we can do quickly to cut down on the chaos and confusion, which will only improve patient care (and staff mental health as well, I think.) The bigger tasks will be developing protocols for diagnosis and treatment, which will be a challenge as the Khmer doctor, who clearly has a good heart, also has a number of ideas that are not quite consistent with Western standards of care. (Kid with a runny nose and cough – how about some Paracetomol  [Tylenol], amoxicillin, and dextromethorphan, all without even listening the the lungs? Oh dear.) Nurses need a better way to triage and screen patients – so we'll work on a form that prompts everyone to ask every patient the same questions and write down all the answers on the triage sheet. Though none of this will fix the fact that patient’s stories change every two minutes:  they tell the nurse they have had nausea for a week and by the time they see the doctor a few minutes later, their chief complaint is headache and dizziness for three months.

     These are desperately poor, malnourished, often traumatized people. They want help, and they think medicine is what they need.  What they really may need is a safe place to sleep, a mosquito net and enough food in their bellies to get through the day. Those problems can’t be solved by the health clinic, though the staff at the Outreach office try to address those issues as best they can. They can get sponsors for some families to pay for a monthly bag of rice or formula for their baby.

     They’re calling me the “Clinic and Outreach Coordinator.” At some point, the hope is that I might improve communication and collaboration between the clinic and the Outreach office. But not this week; first things first. 

     There’s no job description and I don’t yet understand anything about who’s in charge of what within the organization. This will be winging it on a grand scale, but I guess I’ve done that before. And just to be clear, despite all the problems I've mentioned that need addressing, New Hope is full of some amazing people doing amazing work. I just hope my efforts will allow the clinic work to be done even more efficiently and effectively.

     So Monday through Friday, that’s where I’ll be. And Steve will be running between teaching preschool, working in the training restaurant, and doing something not yet defined at the Outreach office – but I’ll let him tell you about that himself.

     And don’t worry – we’re not all work and no play over here. I’ll catch you up on our other activities another day.