I wish someone had been there to see this

     Being a visiting nurse is what I did for a long time before I came here, so it feels familiar and comfortable.

     And I like familiar and comfortable, because so often in my life here, I'm not sure of things. I know what I would do back home, or I know what my past experience tells me makes sense, but this isn't back home and often things that make sense there don't make sense here. So even in that familiar role as a visiting nurse, there are countless challenges and moments of confusion and doubt.

     But some things are clear. When a child who has had surgery needs her bandages changed every couple of days, that's pretty straight-forward. There is room for improvisation within the general principles of what should be done, but there are those general principles, and they seem clear and obvious and without need for cultural considerations. Take off the old bandages, clean the wound, put on the new bandages. A simple, technical task.

     Back in in my VNA days, we all entertained ourselves and each other with tales of odd things that would happen in home visits. Everyone had stories of challenging situations, surreal environments, and general WTF moments. I have my share of stories. And now I can add to them. Here was my "only in Cambodia" moment of the week:

     I went with the translator to the home of one of our kids who had surgery last week. The first thing that caught my attention was his announcement that the girl would be at home waiting for us, but her parents wouldn't be there because they were out harvesting their rice crop. Which doesn't sound so odd, except when you realize that this meant she was home alone all day, unable to walk or move around. No neighbor or grandma standing by to take care of her or bring her food and drink or carry her somewhere when she had to pee.

     So we arrived that morning, and there she was, under the stilted house, lying on something that looks sort of like a very rustic dining room table, cobbled together out of random boards and bits of bamboo, with a few stray nails poking out here and there. I was relieved to see that she wasn't exactly alone: there were half a dozen other kids crowded around, admiring her new markers and coloring book from her hospital adventure. The kids all stared at me, as kids here so often do, particularly out in the countryside. A few smiled in response to my greeting, but some just stared open-mouthed.

     Our little patient was looking quite comfortable, but a bit dirtier than than when I had seen her 48 hours earlier. Both of her feet and ankles were still bandaged, but the outer layer, which was once white, was a serious shade of dirt. It was hard to imagine how it got that dirty so fast, especially since she can't move around at all, but then I saw that her legs were resting on a pillow that looked like it had never been washed in all its years of existence. But she actually had a pillow, which is a bit of a luxury item, so all was good.

     I went about setting up the supplies for the dressing change. This means pulling out all the gauze and scissors and tape and irrigating solution and gloves that I might need and laying them out on a clean surface where they were easily accessible. I had brought one of our clean bathroom towels just for this purpose, and in a couple of minutes, everything was arranged and  ready to go. I put on gloves and started to unwrap the bandages from her feet.

     At this point, a scrawny but very energetic chicken appeared from over my left shoulder, flapping and squawking and landing right in the middle of my supplies, sending a flurry of gauze and paper and gloves and saline flying in all directions.

     In my previous life, I learned to make sure that a client's dog or cat wasn't in the room when I did dressing changes. I figured out how to change a C-section dressing while a mother was nursing her newborn. I've worked where the lighting is poor or the room is cramped or a nervous parent was watching. I know how to handle a variety of situations. But nothing in my past experience had suggested I needed to chicken-proof my plan.

     Oh well. All in a day's work.

     I just wish someone who could appreciate the situation had been there to witness it - because, of course, no one who was actually there even batted an eyelash.

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?

Goodbye, my friend

     Sovann's father, Sambath, died yesterday morning in the local government hospital after 12 hours of needless pain and suffering. Many things in this country are broken - the healthcare system, the education system, the government - and now the hearts of his family and friends are broken as well.

     He was my friend, if it's fair to call someone a friend even if you have no common language. I spent time at Sovann's family home several times, and I was always treated as an honored guest. The whole family has been extraordinarily gracious every time I visited, and it has always been a privilege to have a glimpse into their everyday life in the countryside. Sambath and I could only speak with the help of Sovann or his brother-in-law translating for us, and we didn't even know each other's actual names until my last visit in September. He had asked me to call him "brother" and he always called me "sister."

     He was born around 1958, which meant he was a teenager when the Khmer Rouge came into power.  At some point he was shot while trying to cross the Thai border. His life wasn't easy.

     His arms were covered with magic tattoos to protect him.

     He had seven children, five sons and two daughters. He and his wife, Chandy, farmed a piece of land in Battambang Province, growing vegetables and then converting the land into an orange farm. In recent years, they bought a generator and ran a family business charging car batteries for people in their village, where there is no electricity. (Thanks to him, I know now that you can even charge an iPad from a car battery.)

     Sambath was a man of traditional values. He drank a lot of tea and smoked a lot of cigarettes. Though his wife banned alcohol at home, he was known to sneak off and buy a case of beer on important holidays, sharing it with his children and friends behind the house while his wife carefully ignored them all. When Chandy became a traditional spiritual healer a few years ago, he supported her work with enthusiasm. He was known for having long serious talks with his children, who listened attentively and with respect.

      His final hours were difficult and he died less than 24 hours after first feeling ill. His wife and most of his children were at his bedside throughout the ordeal, trying to make him comfortable and trying to get a doctor to help him. Due to the unimaginable inadequacies of the Cambodian medical system, there was no help to be had, nor any compassion or kindness. His family was left to carry his body to a van for the long drive home to Battambang. A day-long funeral ceremony and cremation followed within hours, as is custom.

     Sambath, my brother and friend, you will be missed. Though our language differences meant that our conversations were limited, the language of kindness crosses all barriers, and your kindness to me will never be forgotten.

A selfish post

Greetings, dear blog readers;

     I write to you today, as usual, from Siem Reap, where the sun is shining and the water is just starting to recede a bit from the third (or is the fourth?) flood of the season. We're off on a little adventure to Phnom Penh this weekend to attend TEDx Phnom Penh, which should be interesting. We're all busy with work and school and sweeping and trying to keep our feet dry, and life is generally very good.

     I feel a little awkward about posting this particular entry, but I am motivated by the fact that from time to time, people ask if they can send us something to help out in our various endeavors. Steve knows a few former volunteers from Australia who have generously sent items for his classroom. Last year, in time for Christmas, our friend Miriam and her family sent a box of medical supplies. Our friend Alison and her kids came in February and fulfilled all kinds of wishes from our list at the time. You can't imagine the joy of receiving a box of stuff here - it's better than Christmas ever was, even as a kid! Since our friend Miriam is coming for a long-overdue visit sometime (probably) in December, and has reported that she will have room to bring things in her suitcase, I thought I would put the word out.

     If you have ever thought about wanting to contribute something, but haven't been sure what to send or how to send it, I have created a solution. I spent some time on the Amazon.com website and made a "Wish List of things I can't get in Cambodia." (It totally reminded me of the hours I would spend as a kid pouring over the Miles Kimball catalog, making lists of items I lusted after.) If you want to spend $3 or $10 or $25 or anything at all, you may find something on that list that fits.

     I have no expectations whatsoever here. I don't want anyone to feel any pressure or obligation or anything else unpleasant. This is really meant as an opportunity for those who have expressed interest in "doing something" and nothing more than that.

     There are a number of medical and health-related items on the list, which are my top priorities. These can be used in both of my jobs and also in my "freelance" nursing role here in town. Most prescription drugs are available here cheaply over the counter, but other things are impossible to find or enormously expensive.

I love doctors with "skills."
I once saw a sign for a doctor
who advertised "Using real otoscope."
My best advice: Don't get sick here.

     There are also arts & crafts items on the list that can be used by the girls at the shelter. I don't write about the girls that often, in part out of respect for their privacy, but at any given time there are between 5-20 girls age 5-17 years old who are studying and recovering and getting counselling and preparing for the next stage of their lives, and nothing makes them happier than creating something - and I think it's therapeutic as well.

They make the most amazing things with just colored paper,
but imagine what they could make with other stuff...!

     (I must confess that there are a few selfish items on the list. Feel free to ignore them, but I couldn't resist the urge to include a couple of things we could use around the house. They are lowest on the priority list for sure.)

Sometimes, you just want a little familiar tea for your sore throat.

     So if you're interested in "doing something," take a look at the list at this link. You will be able to see my comments and priorities on the right side of the page. You can sort by price or by priority. You can have the items sent directly to my friend Miriam's address, avoiding any troublesome logistics. Many of the items listed are just examples of things needed and you can easily substitute something else bought locally - or better yet, if you happen to have something already lying around the house unused, send that. I guess that idea works better for some things than others - a used blood glucose monitor is a fine idea, but maybe used rubber gloves are not...

     Have questions? Ask me. Have something else in mind that you want to send along? Just ask me to make sure it's a good use of Miriam's suitcase space - you can never predict what is and isn't available here, and some things are dirt cheap. And if there's something you'd like from Cambodia, I bet Miriam will have suitcase space on the way back too. Just ask me!

     I'm sorry I can't offer you a tax deduction for any contribution you make, but I promise that anything sent will go to the best possible use and I'll be able to tell you all about how amazingly helpful it is.

     In the meantime, I am missing my friends and family and Vermont foliage, but feel honored to be able to be here trying to do my small part in the world. Perhaps our next trip home to Vermont will be for yet another wedding, as Skyler has just proposed to his wonderful girlfriend Jenny and there is another wedding in this family's future!

With heartfelt gratitude and warmest regards,
Jess

 

The weather, and other topics

The past few weeks have been full of things to write about, and yet my general sense of inertia has prevented me from sharing it here. Today I will make an effort to catch up a bit, though as one experience after another leaves an impression in my mind, I fear that the older impressions get fuzzier and fuzzier...

Despite its reputation as a meaningless topic of conversation, the weather has been pretty remarkable here lately. Though we are getting closer to the end of rainy season, it shows no sign of  letting up, and there have been tremendous floods all over, including right here in Siem Reap town.  The Siem Reap River, which normally ambles through town as a slow-moving ribbon of brown water (they try to trap all the garbage in a big net just before the river hits the touristy part of town) rose dramatically to the edge of its grassy green banks, and then quickly spilled over into the streets. Our house was not affected, for which we were very grateful, but the main streets were hip-deep in some places, and lots of people had to vacate their homes when the water came inside or the roads became impassable. Getting from one place to another became a huge wet adventure. I learned that as long as my muffler didn’t end up underwater, I could drive my motorbike through the flooded streets, but the problem was that sometimes the water was only shin-deep in one spot, and then quickly became much deeper, leaving little opportunity to turn around and go back. The roads themselves weren’t visible through the filthy water, and it became impossible to see the pot holes and broken pavement. As cars and truck ands tuktuks made the same valiant attempts to move around town, they created wakes and currents and shoulder-high splashes, which meant that going anywhere, even when it wasn’t raining, resulted in getting soaked. People were kayaking down Pub Street, the main drag of restaurants where all the tourists usually for dinner. 

Driving on dirt roads was even more of a challenge than driving on paved streets – the roads were washing away bit by bit, exposing unseen boulders, or the mud was ankle-deep slippery clay, providing a fish-tailing experience similar to driving on an icy Vermont road in January. The roads to both my office and the shelter were flooded, and the shelter itself ended up partly underwater. One day, I saw fish swimming in the driveway as the poor barefoot security guard slogged through the water to open the gate. Kids swam in the streets and jumped off the bridges into the fast-moving river. Stories abounded about crocodiles that had escaped from the crocodile farm right here in town and were swimming in the streets – making me worry a bit about those kids dog-paddling down Sivatha Boulevard!

Allegedly an escapee from the crocodile farm

The first time the river overflowed, it was pretty impressive and the whole thing was a bit of a fun adventure. When it receded after a few days, everyone breathed a sigh of relief and set about drying out their belongings and mopping up the mess. When the rains started again a few days later and the river came up faster and deeper than the first time, it wasn’t nearly as amusing. Even more Cambodian villages were flooded, a group of tourists had to be air-lifted by helicopter out of one of the temples when the water came up suddenly, and the news was filled with photos of people clinging to trees and roofs and escaping their homes by boat. Many people couldn’t get home for the big Pchum Ben holidays. The last figures I heard say that more than 150 people have died in flooding in Cambodia, with hundreds of homes, businesses, pagodas, schools, roads, and hospitals damaged or destroyed, not to mention vast areas of ruined rice crops. While we whined about the inconvenience, that’s all it was for us, but for many people here this is devastating, and of course there is no safety net.

Many events around town were cancelled, lots of expats took the opportunity to get out of town and go to Bangkok for a few days, and our shopping and eating expeditions were limited to places closer to home than usual. As of two days ago, the water has receded yet again – though just as it was starting to go down, we received emergency emails and text messages from the US Embassy warning of us of impending floods in the next few days. Either they’re a little late getting their warnings out, or there is more to come. Time will tell.

In the meantime, I sneak looks at people’s Facebook photos of Vermont foliage and feel quite homesick. I'm sure I will feel differently when I start seeing people post about freezing temperatures and snowstorms, but for now, I truly do miss the crisp fall air and the blaze of color and freshly-picked apples. I would love to be sitting in front of our fireplace with a glass of red wine, smelling a pot roast simmering in the oven, and hanging out with my friends and family. I’m not sure why we feel this so strongly right now (Steve and I are on the same page at the moment); maybe there’s something about having been gone for a full year and missing things for the second time around that make it more difficult. Rest assured, Vermonters – we miss you!

In other odd tidbits, there have been the usual moments of serendipity and surprise. A couple of weeks ago, I got an email from an American woman who had just arrived in town and confessed to being a blog reader. She was kind enough to have looked at our “wish list” on the blog and generously brought me two boxes of my favorite cereal. I have savored every mouthful of Frosted Mini Wheats and Cracklin’ Oat Bran. Ah, the kindness and generosity of strangers!

While we can’t enjoy those freshly-picked Vermont MacIntosh apples, we do continue to enjoy the huge variety of fruit available here. There is always a lot to choose from, but as things come into season, they get ever more delicious and cheaper. I paid 75 cents per kilo for rambutan the other day (about 35 cents/lb) and shuddered to think about the time back home in Vermont that I splurged and bought some past-their-prime rambutan at the Asian market for $8/lb. (My advice is don't bother.) Having found lox in the freezer section of the local supermarket, I have finally learned to make bagels since none of the bagel options in town measure up. Steve made the most excellent pasta sauce last week and we ate that for two nights in a row with no complaints because it was so delicious. Sovann has just started his full-time studies at Ecole Paul Dubrule, the Cambodian equivalent of New England Culinary Institute, and I assume that his repertoire in the kitchen will soon expand and we’ll enjoy the benefits here at home.

    

We celebrated Steve’s 60^th birthday this past weekend in grand style. He and I spent Friday night at the big fancy hotel where he has a tennis membership, since his membership fee included a free night’s stay. I so rarely venture into these big hotels that I forget how foreign they can seem. We had a beautiful room overlooking the free-form pool and lush gardens, and it felt like we could have been in Orlando for all we knew. We had a real bathtub (a true luxury here), took advantage of the breakfast buffet and even had a complimentary massage that was vastly better than what one can get at the $6/hour places around downtown. It felt quite decadent. 

After coming home on Saturday, we got ready for Steve’s birthday party. Having invited all our local friends to stop by any time over the afternoon or evening to have a drink, we weren't sure how many to expect, but they showed up in large numbers! As usual, it was an lively mix of Cambodians and Westerners, and it was a lot of fun. I finally met some of Steve’s tennis partners , one of our Cambodian friends brought his extended family, and our driveway was packed with tuktuks, motos, and cars. (We know people here who have cars!!!) It was interesting to see how our varied our social circles are here; a few expats met each other for the first time. Leave it to Steve to know how to put together a good mix of guests, as always, and if the number of empty beer cans waiting to be cleaned up in the morning were any indication, it seems that everyone had a good time.

In between all the flooding and parties and day-to-day details of life, I had a bit of an adventure in Battambang province with Sovann’s family, which I think I will save for another entry. I only hope I can do the experience justice, because there is a story to be told if I can find the right words. 

An ounce of prevention (or would that be a gram?)

     On Friday I taught a “First Aid” workshop at my new job. Let me just say that teaching first aid skills in a developing country is a bit different than teaching it at home – not that I've actually taught ”first aid” at home, but I once was  a certified CPR instructor many years ago, for what that’s worth.

     In fact, we didn’t learn CPR at all on Friday. For one, I know of no CPR dummies available here, and it’s the kind of thing you really want to do some hands-on practice with. But even if there were any, I would still be reluctant to think that teaching CPR is the best use of time. Last I knew, when I was still getting re-certified every year, CPR doesn’t often work so well, and when it does, it’s because the EMTs with the defibrillator arrive within minutes – after all, the first thing you do is call 911. But here, there is no 911 to call. There is no number of any kind to call, because there aren’t any EMTs or real ambulances or defibrillators or well-equipped hospital ERs to resuscitate those whose hearts have stopped for whatever reason. There are lots of people who live miles and miles and miles from any healthcare facility of any kind, and the small government clinics they might be able to access after a long bumpy motobike ride (assuming they have access to a motorbike and the roads aren’t flooded) are little more than dispensaries for paracetomol (Tylenol) and amoxicillin. (Interestingly, the standard protocol at the village clinics for paracetomol seems to be to take twice the recommended dose only half as often. Not really so useful.)

     It seemed to be a more productive use of time to talk about the real health problems that people are likely to have here that we can potentially have some impact on. So while we skipped CPR, we did learn and practice the Heimlich Manuever.  We also talked a lot about cuts and bleeding and burns – and we talked a LOT about fainting. People in Cambodia report a lot of “fainting.” Everyone has a story about having fainted, or someone in their family having fainted, or a stranger on the road fainting. I can’t begin to tell you why it’s so common, though I suspect that general poor health and nutrition, un-diagnosed diabetes, chronic dehydration, and stress/anxiety/hyperventilation often play a role. Recently there have been mass faintings at garment factories in Cambodia, and while poor ventilation or chemical fumes have been blamed, no has been able to pinpoint the cause for sure. And considering that in one report, even the security guards outside the factory ended up fainting as well, I suspect that there is at least in small part a bit of mass hysteria that played a part in 300+ people keeling over at a time in different locations on different days. I hope that doesn’t sound insensitive – I don’t mean to imply that people were faking, just that people here have a lot worries and misunderstandings about their health, which leads to a lot of anxiety, and one or two people fainting could easily scare many others into a fit of hyperventilation.

     One of the Khmer staff had a story to share about how he has helped people in the past who have fainted. Twice he has been able to “revive” someone by biting them. On the heel. He swears that it worked, and they woke up. While commending him for caring enough to take action, I suggested  that he could probably skip the heel-biting in the future.

     Everyone around the table had stories to share, which made for lively conversation and all kinds of new learning opportunities for me. When talking about dealing with cuts and bleeding, I learned that people use both spider webs and cigarette ashes in wounds to help stop bleeding. Headaches are often cured by applying burning incense to the scalp and pulling the hair. Children’s stomach troubles may be treated by applying hot coals to their belly. Some of those methods are a bit concerning, and I tried to address them in culturally respectful ways. Other traditional healing methods are widespread but relatively safe, and I wouldn’t begin to tell someone that getting coined (rubbed repeatedly with the edge of a coin until bruises appear) is not useful. People believe that it releases “bad wind” from the body, and it used as a cure for everything from fever to fatigue to body aches – and if you believe something will help, it probably will, either because of the placebo effect or because the pain of being coined causes endorphin release so that you actually feel better for a while. (Or because the pain of being coined takes your mind off the original problem.) In any case, it is amazingly common, and I’m not going to get anywhere telling people that it doesn’t work. If people in the west want to use crystals or feng shui or chicken soup and claim to feel better, I’m not going to argue with them either. I’ll only draw the line at burning children with hot coals...

     Many of the staff had good questions, such as “If you live with someone who has diabetes, can you get it too?” When we talked about burns and why cool water is better than ice to apply to a burn, I ended up talking about the damage that ice can do by explaining what frostbite is – no one had ever heard of such a thing, and now I think they assume I come from a very dangerous country if my toes can potentially freeze off in the winter.

     While we talked about lots of things to do in response to injuries or illness, I talked even more about prevention. In a world littered with plastic bags, where children use sharp implements from a very early age, where gasoline is sold in soda bottles, where child-proof caps are completely unheard of, and where “the kitchen” is an open fire on the ground outside your house, there are unlimited possibilities for  poisoning, burns, and injuries. In a place where few people ever get a tetanus vaccine and even fewer dogs get a rabies vaccine, the potential for serious consequences of otherwise relatively minor problems is huge. And in a world where many people have no clean water or soap, even simple advice like keeping a wound clean is far more complicated than you might imagine.

     The clean water thing is huge. In my first weeks on this job, I came to realize that many of the families we visit have no clean water. They may be drinking what they scoop from the river, and often don’t even boil it. When you ask if they know that boiling the water makes it safer, they often say that they know, but they’re “too lazy” to do it. They tell us, “No one in this village boils the water.” Lazy sounds harsh; I suppose that when you’re living hand-to-mouth, possibly malnourished and probably depressed, boiling all your water does seem like a daunting task. And there is no obvious immediate effect from not boiling the water – sure, people get sick, but it’s not always clear that the filthy water is the culprit. Maybe they can’t spare the fuel for the fire to boil all the water they would need. Maybe they don’t have a big enough pot. Maybe there are the factors in play that I know nothing about. In any case, it has become part of my mission as the person responsible for health concerns for these families to address the water issue, and the director is on board after our email discussions. She’s working on raising the money to provide the ceramic and plastic water filters to all of our 47 families. This will present its own set of logistical challenges – while the filters only cost about $15, they are big and difficult to carry on a moto to deliver to all these far-flung families. They will require some washing and maintenance in order to remain effective. And lots of evidence shows that people are far less likely to be invested in using and caring for it properly when they have been given the filter for free rather than having to pay even a small amount. So figuring out how to deliver all these filters, train people to use them well, and monitor their use will be one more thing for the staff to take on. I’ll let you know how it goes.

     The best resource I’ve got here when doing any sort of health teaching is the book “Where There Is No Doctor.” It’s an amazing resource that I may have mentioned before. The English version can be downloaded completely free, and it was recently translated into Khmer by friends of ours who have lived here for a few years. It’s full of good advice appropriate for developing countries and places with limited resources, and I photocopy the Khmer pages back to back with the English pages so everyone can look at particular sections in their first language and have the same information. Given the limited literacy of many rural Khmer people, it’s not so useful for them (and also a BIG book, so sometimes a bit daunting to find what you’re looking for) but it’s great to use for staff trainings. I will be forever grateful to those who took on the task of getting it translated, and to the Hesperian Foundation, which makes English versions of all their many useful resources available for free download.

     So my job as a “visiting nurse” in Cambodia is in some ways not so different than my job was at home – focused on education and prevention wherever possible. The next big task is to arrange for some of the kids I visit to be seen at the local children’s hospital and get some actual diagnoses and treatment, if possible, for the varying and vague symptoms that some of them have. “Seizures” abound among these kids, but the histories and descriptions are so vague and confusing that nothing is clear. I saw a girl last week whose grandmother’s chief worry was the girl has a “hot body” all the time. “Hot body” may or may not mean fever, and no one has a thermometer anyway. She looked pretty fine the day I saw her, other than the infected toe from stepping on a thorn and then probably running through the cow dung in the yard. I am quite sure she will not be happy to see me again after we dealt with that on my first visit.

     So, the next time you cut yourself, be thankful for the soap and clean water and Bandaids and Neosporin you have available any time you need them. No need to look for a spider web or cigarette ashes to apply – just stay out of the cow dung.  And if you’d care to contribute to the water filter fund, let me know and I’ll send you the link. In the meantime, I’ll be here NOT boiling my water (because I can afford to buy it) but doing other stupid shit that I know isn’t necessarily good for me.

 * * * * * * * * * * * * * * * * * * * * 

     To avoid posting a text-only blog entry, here are some photos that demonstrate the current status of water in the town of Siem Reap. The river has overflowed its banks and getting around town is interesting:

365 days; 4,637 questions

     Back in December, soon after I left my first job at the clinic, I posted a blog entry that included the following quote:

"...I beg you... to have patience with everything unresolved in your heart and to try to love the questions themselves as if they were locked rooms or books written in a very foreign language. Don't search for the answers, which could not be given to you now, because you would not be able to live them. And the point is to live everything. Live the questions now. Perhaps then, someday far in the future, you will gradually, without even noticing it, live your way into the answer."
                                                                                          Rainer Maria Rilke, 1903
                                                                                          in Letters to a Young Poet

     Today marks one year since we arrived in Siem Reap. I am living the questions, as hard as I can, and there are more questions than ever.

     I had every intention of writing an entertaining retrospective of the last twelve months, but this just isn't one of those days; all feeble attempts to write have been quickly deleted. Steve and I thought that perhaps we should treat ourselves to a nice dinner out to celebrate, and then we were invited to a party to celebrate two birthdays and a farewell, so instead we'll go hang out with an interesting bunch of young expats and we'll toast to birthdays and farewells and anniversaries.

     And I'll keep trying to live the questions, which come fast and furious. There are plenty of new questions since this time last year, and some of the same old ones continue to provide fodder for endless mulling and theorizing. Now I understand why Cambodia advertises itself as the "Kingdom of Wonder" - it leaves me wondering about so many things every day.

      So, lacking profound things to say about our first year in Cambodia, I will instead leave you with a peek at my notebook collection. Some of you who know me well may remember that I love notebooks: the symbol of a fresh start, of learning something new and promising myself I will only write neatly this time, a repository for lists and random thoughts and notes from dinner parties. One of the good things about Siem Reap is that there are a number of shops that sell notebooks, and I've amassed a nice little collection, each chosen for their interesting cover art or captions.

"Whispers of love
Love is good for your heart
My love for you will never end"
"HEART TO HEART ENVELOPE SET
Love and friendship"
"Enjoy your writing with MengFeiEr products"

"WOOO is super ecological building material"
"WORK SHOP"

"I lost you.

This is in the world,  each persons have the person who wants

look for, once missed will not come back."

"very good"
"so love"
"pain past is pleasure"
"of all...papo terie r"

"notebook"

"best"

"story"

"beanfield"

"No. 1
STRONG
Good quality worthy of trust
Be the best oneself"

"FLOWER
Happy time
together we spend
exciting every day"

"That's incredible!"
"Sim Sim!"
"happy"

"What's up in your Fashion?
Precious things are very few
That must be why there's just one for you"

"Lattice emotion
Because earlier results in the past (the first due to consequences)
is one of the characteristics of the causal link, but the causes and consequences
must be contact with the inevitable, that the relationship between
...pace...home...step up...nest...cell...shack...
...cage....bleach...coop...fossa...
the two is the relationship between
cause and be caused"

"I promise that I'll be able to recover all my memories of you
she said all of a sudden as we were walking along...
We've se enten so together. Ever nery In rla I would fee your traces. Newborn babies.
the pntt on the plate that you can see under a paper-thin slice of sashimi:
fireworks of one summer. The moon hidden by clouds over the scene at nig...
When I'm sitting down inadvertently stei on toes nnd have to apol
when someone I've dropped..."

"Eternal Forever Hot Thailand Summer Chili"

"Silent is a silent movie

only images of early film, film itself is silent, only the background music. 

Dramatis personae through the movements, facial expressions

so the that audience understand the plot, a bit like a pantomime. When necessary,

would be to insert some subtitles to help viewers

understand what people say."

(The even smaller writing in the upper right makes even less sense.)

This one is valued for the caption printed on every page:

"Take up your pen and open your note book right now. Note down what you thought,

what you felt. Return to the writing age. After many years,

when you open the notebooks, you will find something

different about yourself. You will feel that everything is on its way to somewhere."

   
     As a matter of fact, I do feel like everything is on its way to somewhere...