I am only one, but still I am one.

     I just spent a week in Phnom Penh. I was supposed to be there for three days, but this is Cambodia after all, and the ability to be flexible is a survival skill. Also, the whole reason for being there was to bring a couple of kids for surgery, and since I may have mentioned already how messed up the medical system is, it shouldn’t be surprising that things took longer than expected.

     Aside from the medical component, a week in Phnom Penh meant that in my free time I had dinner with one friend, went to Cambodia’s only movie theater with another friend, and spent a lot of time on the back of motos criss-crossing the city as I went between my hotel and the hospital.  Arrangements had been made for me to stay at a guesthouse very close to the hospital, but considering that place rents their rooms by the hour, and was lacking a few basic amenities like toilet paper and clean surfaces of any kind, I high-tailed it out of there after the first night. All those moto rides were like a crazy game of chicken – traffic in PP moves much faster, the streets are wider, but the same (lack of) road rules apply. Also, many drivers don’t speak a word of English, so I often had to do my own navigating, clutching my map in one hand and the bike seat with the other, announcing where we had to turn right or left. I especially loved the grizzled old driver who got sick of the traffic jams and just drove right up on the sidewalk.

     The plan had been to bring two Safe Haven children to a hospital in Phnom Penh for orthopedic surgery. They had been seen there in July, and were told to return on October 24 for surgery, which of course got delayed to the 25^th and 27^th. I will say that the children were lucky to have excellent surgeons who were there there visiting from Oxford – a plastic surgeon and a trauma surgeon – and those docs welcomed me and allowed me to spend a lot of time in the OR watching all kinds of surgeries. It was like watching a Discovery Channel medical documentary live and in person, and I circulated between the three operating tables in the one crowded OR. Our kids’ surgeries went well, though they face more in the future, but at least they’re off to a good start.

     After our horrific experience at the local government hospital last week when Sovann’s father died, it was encouraging to see that medical care can look better than that. Visiting surgeons were training the local staff, and the Khmer surgeons looked quite skilled in comparison to any other Khmer doctors I’ve seen in action so far. However, the whole hospital experience is still a far cry from a Western experience.

     As I mentioned, there is one operating room with up to three surgeries happening simultaneously.While crowded, this room looks pretty modern, and sterile technique is observed as it should be. (Heck, there was even running water in the scrub sink, which is more than you can say for the hospital here in Siem Reap!) Outside of the OR is a treatment/recovery room with four gurneys squeezed side by side and absolutely no privacy of any kind. Patients come in here about 15 minutes before surgery to get an IV started and get their clothes removed. They also come into this room to get dressings changed in the days following surgery, and this is also where they come when their surgery is finished so they can be monitored for a few minutes as they come out of anesthesia. So imagine small children, who are already terrified of their impending surgery (as are their parents), coming in here and watching bloody bandages being changed, listening to other children scream and moan, and seeing fresh amputations and burns being unwrapped and re-dressed.

     While it’s a children’s hospital, there were actually plenty of adult patients. One woman has been there for many weeks – she was the victim of an acid attack which burned away most of her face and a good part of the skin on her torso and arms. There were patients with injuries and problems old and new – people with deformities from birth or as the result of traffic or other accidents, children with old untreated burns that left disfiguring and debilitating scars, kids with untreated club feet having their bones cut apart and pinned back together in new configurations, adults with tumors left to grow to the size of watermelons before seeking medical attention. For someone who is squeamish, it would be an absolute nightmare. Luckily, I’m not squeamish, but I still saw people with conditions that are hard to imagine living with. And the fact that there is no privacy for these patients and no attempt to protect other patients – even children – from seeing all of this was almost as hard to take in as the problems themselves.

     Outside of that room is yet another larger room which is the post-surgical ward for those still needing daily attention of some kind. This room had close to 20 beds with barely enough room to walk between or around them, and sometimes more than one patient in a bed. (And by “bed” I mean a frame with a vinyl-covered mattress. No sheets, no privacy curtains, often no pillow, definitely no call bell for a nurse.) Each patient needs a family member present at all times to take them to the bathroom or bring them a bucket, to go out and buy them some food, to hold on to and dispense the medicine that the nurses give out once a day (when they remember.) Family members sit up all night propped against the bed, or if they’re lucky, they find a spot on the dirty floor under the bed in which they can stretch out on the bare concrete. The room smells like blood and sweat and tears and other unidentified body fluids. Children cry and are sometimes scolded by their parents for being too noisy. One man who was trying to sleep offered one of our kids the equivalent of $2 to shut up in the middle of the night when he was crying because he hadn’t had any pain medication in far too long.

     Parents are given medications in a small plastic bag and told how often to give it to their kids. They don’t know what the medicine is for, and they often don’t understand the instructions. Telling someone to give something “every six hours” isn’t very helpful if they can’t tell time and don’t have a watch. No one checks in to see if the parents have given the medicine correctly, but if they figure out that they’ve done it wrong, they’re very quick to chastise them for it. If a parent runs out of medicine, they’re far too scared to ask the staff if they should be given more. Pain control is not a priority, and since my role, in part, was to be an advocate for our kids, I quickly became a thorn in the nurses’ sides, no matter how respectfully and politely I asked questions. One nurse was reasonable and approachable, and the other refused to acknowledge me after the second day, literally ignoring me even when I greeted her in the morning in the most respectful way possible. After day three or four, I gave up and went out and bought the same medicine that the nurses were occasionally dispensing and just gave it to the kids myself.  The nurses never seemed to notice and never dispensed any medicine again once we stopped asking for it.

     The uncomfortable thing about this was that besides our two kids, there were those other 20 or so patients in that post-op ward. (Sometimes there was more than one patient in a bed, if the patients were small enough.)  They saw me as “staff” and sometimes asked for help, and there was little I could do but lead them to the nursing staff and say, “I think this patient needs to talk to you.” There was nothing for patients to do but lie there and stare at the ceiling. Occasionally, a small TV mounted in a cage on the wall was turned on and people could watch karaoke videos or wrestling, if they were lucky enough to be able to see the screen through the chaos. We brought paper and markers and coloring books and a few toys for our kids, and found things to prop them up with, and encouraged their parents to get them drinks and food. At one point, in sheer desperation, I pulled out my iPad and let them watch a few Pixar short movies as a distraction, and soon their shared bed had a crowd of other patients and family members watching as well, laughing and pointing and enjoying the show.

     One of our kids was born with club feet, a not-so-uncommon deformity that can usually be easily remedied as an infant by wearing a series of casts for a few months. This girl had had some casts put on as a baby, but when her parents had no money to return to the hospital in Siem Reap (this means they lacked $1.50 for moto fare), the treatment ended. Now eight years old, this girl has been walking on the outer edge of her feet and ankles her whole life, and she’s only one of thousands in this country in this condition – maybe tens of thousands? So for lack of a few dollars in moto fare and lack of understanding about what this would mean long-term, this girl now faces multiple painful orthopedic surgeries. – and she’s one of the lucky ones who will actually get help. Thankfully, the treatment at this hospital is free, but the cost to bring the family here and coordinate the care and do the follow-up visits so that she heals appropriately isn’t cheap – just the transportations costs alone run in the hundreds of dollars.

     As with any organization, communication is a challenge. As I already said, the visiting surgeons were great at what they do, but they’re busy in the OR all day and the communication with the local staff was difficult even for them. Because I was talking with the surgeons often, I knew what they intended to have happen in terms of frequency of dressing changes and timing for a cast to be put on, and I often had to run interference when the Khmer staff attempted to do something completely different than was asked. (I guess this explains why I was not so popular with them at times.) Discharge and follow-up plans changed hour-by-hour depending on who I talked to, and I finally asked the visiting docs exactly what they wanted and then stopped caring what the local staff thought of me and relayed the plan to them as an “order.” If I hadn’t, I think we would still be there, wondering what was happening and going to happen, listening to kids crying in pain and fear, and sitting in that awful ward sweating and being pissed off. And that’s exactly what some patients are still doing right now, and that pains me to think about.  

     Eventually, our kids were discharged from the hospital and we brought them back to Siem Reap to stay in a guest house for a couple of days. They both live outside of town and it’s easier (and cheaper) to keep them close by for a little while rather than have me spend all day driving to go see them at home.  They looked so much happier and so much more comfortable, stretched out on beds with sheets and pillows, watching TV. (Not that they have beds or sheets or pillows or TV at home...) They were getting appropriate pain medications every 4-5 hours, thanks to my wonderful Khmer project manager who was calling the parents every time they needed to give the kids their next dose, and I could change the dressings for the girl who needed it without her wailing and grimacing in agony. I am in my element, being a visiting nurse, and this makes me feel useful at least to these children.

     But what about the others? What about the ones who never get any medical attention? Or the ones who do, but who don’t have someone in their corner advocating for pain control and appropriate follow-up? What about those who don’t have an NGO with a nurse and a PT who will provide what they need after they go home, if they are even lucky enough to get the care they need in that terrifying environment?  How does one effect change in a broken system of care...?

     And who am I to think I know what can work better? People here are doing the best they can, and the constant dilemma is this: What is good enough? What are culturally appropriate expectations? How do you help a country in which most of the adults have some degree of PTSD to understand that it’s not OK to "joke" with a 7-year-old kid that the remedy for their completely treatable foot  abscess is cut off their leg? (Haha-fucking-ha.) I’ve seen this exact scenario more than once, even among Khmer staff who have had a lot of training from Western doctors.

     Some things are cultural differences that deserve respect and understanding. Some things are just wrong. Telling a kid you need to cut off their leg when you don’t need to do any such thing is just wrong. How do you change that? How do I make myself useful in those conditions? Is it good enough that I might help a small handful of kids have a slightly better experience than they would have had without my intervention?

     These are the same questions I asked myself over the years working in Maternal Child Health at the VNA. I console myself with this Helen Keller quote:

“I am only one, but still I am one.

I cannot do everything, but still I can do something;

and because I cannot do everything, 

I will not refuse to do the something that I can do.”

     All I know how to do is to be my little tiny drop in the bucket. I can make sure two kids have reasonable post-op pain control. I can bring them something to distract them from their distress. I can tell their parents that they are doing a good job when that is true, and I can help them to do better when that’s possible. I can tell doctors not to scare children with jokes about amputation.

     There are a few things I can do - I can help someone pay for their education, or finance for their father’s funeral, or practice their English. But I can't do everything. I am only one, but I cannot refuse to do the something I can do. Because as much as I support the current cultural upheaval in our Western world, I am still part of the 1% as far as the big picture goes. What can I do?

     What can you do?