Sunday, January 30, 2011
Take A Bow
Another hard week of goodbyes. It started with our trip back from Sihanoukville last Sunday. On our way back, Oliver, Jack, and I happened to be on the same bus back to Siem Reap as eight other co-travelers that we met and became friends with. Becky, Jenna, Kelli, and Laura got off the bus in Phnom Penh to go on to Ho Chi Minh, Vietnam. Three of them (England, South Africa, USA) are teachers in South Korea, and the fourth (Australia) is a cousin of one of the others. For better or worse ladies, I will not forget about the human centipede. Or JJ's - awful music but awesome time! In the middle of the week, we said goodbye to Jack and Angela who are going on to Thailand. Angela is a second year internal medicine resident in Boston. Jack is a traveling Brit who's out to see the world. Good luck kids! ;) Jack then goes onto Beijing (which was a plan hatched sometime between Sihanoukville and Siem Reap) just to see what's there. How awesome is that? Mate, have a bloody good time! Then we said goodbye to Susumu, a Japanese photographer who's been traveling around the world for the past year and is going on to Vietnam. STEEL! Muchi muchi! So greaaat, so niiice!! Then on Friday night, Oliver, a med student from London (originally from Toronto) left to go back home. One dollah! How you get so tall? That left Laura, Tim, Austin, and Claudia who were the other four on the bus with us coming back from Sihanoukville. Austin (USA) and Claudia (Canada) are a couple of students doing a one year Chinese immersion program in Xi'an, China. Saturday night, we said goodbye to Austin and Claudia who are moving on to Phnom Penh. Yi lu shun fung. Xie xie ni meng gen wo jiang guo yu. You kong, lai Portland wan. Tonight, we said goodbye to Laura and Tim who go to Battambang for a few days. Laura and Tim are a couple of Kiwis who are on a one-way transit to London and are doing a 3-4 month trip through SE Asia first. Eunuch snowflakes, pop-a-squat, and sphinc-lax (I have learned SO much about Kiwi culture in 7 days). That leaves me with Sylvie, another wild and wacky Kiwi who's volunteering at the orphanage until next week; Peter, yet another Kiwi volunteer at the orphanage; and Martin, an Irish volunteer at another NGO who I have just recently become acquainted with. My friend and soccer teammate Sara gets in tomorrow night. Hopefully, if time allows, we'll be going to Phnom Penh this weekend to meetup with Laura and Tim who will be there by then. To the rest of you, be well, do good, and keep in touch. Until we meet again...
Saturday, January 29, 2011
Photo
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| Once in awhile, you get lucky and capture a photo at just the right moment with just the right light... |
Wednesday, January 26, 2011
A Tale of Two Hospitals
Recently, I was able to go on a tour of two of the hospitals in Siem Reap. One is the Angkor Hospital for Children (AHC) for which Thea's husband, Eugene works at. Several of us volunteers arranged to meet with him for a tour of the place. AHC, if you recall, is the hospital I passed by on my first day here when I was just walking around. The founder of AHC is famed Japanese photographer Kenro Izu who came to Cambodia between 1993 and 1996 to photograph Angkor Wat and the surrounding ruins. Like so many others, during his visit, he was moved by the tragedies that had fallen on the country and in particular on the children. Thus, in 1996 he formed the foundation Friends Without A Border (FWAB) with the goal of building a hospital to treat the children. With the international exposure of his photography, he was able to gather interest and funding from a network of donors and in 1999, AHC was opened.
In short, the hospital was actually much more impressive than I had expected. There is a large waiting area outside where parents wait with their children for the triage station. From there, they are directed to the appropriate departments. Over 400 kids are seen each day and so one might think it would take a long time to get seen. However, we had seen a 12 year old child - Pahl - the day before and we were suspicious of tuberculosis based on a 3 month history of fever and cough with no response to antibiotics. The kid looked emaciated as well. On the morning of our visit, we had ordered a motobike (scooter) to come pick him and his mother up and bring them to the hospital. They were in the waiting area when we arrived. By the time we had finished the tour, he had been seen by the doctor who agreed with the possibility of TB, had received a PPD shot, and was on his way to getting his blood work and chest X-ray done. I was quite impressed with the Cambodian doctor we chatted with as well. The AHC welcomes foreign doctors to come in as volunteers and even hires a few as part of the staff. As part of the deal, they have to see patients with their own Cambodian doctors so that they can receive Western medical training. This Cambodian doctor was sharp enough to also suspect atypical pneumonia (mycoplasma pneumonia, aka "walking pneumonia") - a fair diagnosis to consider. Later in the afternoon, we got the call that they saw the chest x-ray and it was bad enough to be considered diagnostic for active TB, so they were starting him right away on a TB treatment regimen. His entire visit was about 3 hours. The time to diagnosis was another 4 hours. Total time was 7 hours. Not bad at all for a free children's hospital.
In addition, while on tour, we got to visit the microbiology lab. I was shocked to even see a microbiology lab, but also excited at the possibility that I might actually have a place to send kids like Pahl for testing if it's actually needed. At this lab were two Brits, Kate and Chris who were sent here by Oxford University to study the epidemiology of infectious diseases in Cambodia. (By the way, "Oxford University" is SO much fun to say in a British accent. Go on, try it...OXfuhd UniVUHsity. Right??) So anyhow, this is all very fascinating to me because before my trip, I tried to look up some statistics regarding what kinds of infectious diseases to expect here. The usual third world country lists of diseases comes up: HIV, TB, malaria, cholera, dengue fever, etc. The only problem is that nobody really ever has any confirmed statistics as to how prevalent they really are. And I've begun to wonder because Pahl is the first patient I've encountered where I've suspected TB at all. I've only seen one probable case of malaria, one case of cholera, and no known cases of dengue fever. Perhaps it's just the area I'm in, or perhaps it's not the right season. But really, it's just because the diagnostic services here are so poor that no one really knows. No one's actually taken sufficient interest in this region to come in with proper diagnostic testing to confirm the diagnosis of anything so most diagnoses remain as only "suspected". The only thing I can say is wildly rampant here is rhinovirus - the common cold. So anyhow, Kate and Chris were sent here by...Oxfuhd Univuuuhsity...to study the prevalence and distribution of infectious diseases. Need to setup dinner sometime with them to ask them more about their experiences.
It's also worth mentioning that the AHC has an open air kitchen in the "backyard" of the hospital. The guardians or parents of the child patients can go there and pickup a "food basket" from a small supply room. The food basket contains numerous food items such as leafy green vegetables and rice. The parents are then educated on nutrition and what kinds of foods to prepare for their kids at home. They can they cook food for their child in the kitchen and eat with them. Other areas in the hospital are created to allow kids who are healthy enough, to play with coloring books and various toys that they normally don't encounter at home. The notion is that most Cambodian kids don't learn how to play which is a vital part of cognitive development. Thus, a big part of the public health effort by the hospital is to teach them how to engage their minds in their "playing". It's hard to say how much effect it's having on the population, but I like that the hospital has identified factors beyond illness that affect the well-being of a child, and make efforts to address them, or at the very least bring it into the public awareness. So all in all, I was pretty impressed by the AHC. It was free, clean, well-organized, efficient, and staffed by diligent and competent healthcare professionals. Then we went to the Siem Reap Provincial Hospital.
Angela is a second year internal medicine resident who is a volunteer at another program and was working at the SRPH. She was on the tour with us and offered to take us around her hospital to see the contrast. This hospital is where everyone else (e.g. adults) goes when they need medical care. As we walked onto the hospital grounds, the contrast was already obvious. First of all, I couldn't even tell we were in a hospital. It was just a collection of drab decaying buildings with no visible indication that this was a place to come to get healed. We first walked through a long dark hallway (no electrical lighting) into the maternity ward, which was just a narrow room with rows of vinyl covered mattresses on flimsy metal frames. The checkered floor was gray from soot and dirt. Passing by the rudimentary bathrooms, one can detect the pungent smell of old urine wafting out. In fact, it's nearly impossible not to smell it. People, presumably the families of mothers lined the hallway and stared blankly at us as we walked by.
We then went back out to the courtyard and walked to the ICU. On the way we passed by a sign that pointed to our left and said "Laboratory". About 25 meters away was a decrepit yellowish-brown building standing in its own corner of the courtyard. I commented that I'd be interested in seeing the lab, but Angela replied, "Oh, I don't know why that sign is there. I went over there one day and there's nothing in there."
"What do you mean 'nothing'? There's no staff there?"
"No, I mean there's literally nothing in there. It's an empty building."
"@#%&??!!"
So then we arrived at the ICU. I think "hell" would not be an inaccurate term to describe the conditions. Quite frankly I cannot think of single place I'd rather not be at for an eternity. The dirty beds were filled with unwashed and sometimes unclothed patients. I did my best not to look but I'm fairly certain some of them were sitting in their own waste. As soon as you walk through the "door" the filth in this place mounts an all out assault on all five of the senses (not that I dared to lick anything there mind you). The walls behind the bed are lined with old metal pipes that branch off to a valve and pressure gauge above each bed. They were built for oxygen delivery to the beds, and appear to have been built more than 50 years ago. Apparently, 20 years ago was the last time they were actually functioning. Now they just provide a place for patient families to hang up and dry their clothes.
During our visit, I realized we hadn't encountered any doctors. Angela explained that there are no doctors left in the hospital by noon time. They are so poorly paid that they leave after a couple hours in the morning and go to their own clinics somewhere else to earn some more money. I think I may have seen two nurses there the entire time. And the cherry on top of this lovely hospital sundae? The patients actually have to pay to get a bed here. I heard a story from a friend about a brother of some Cambodian he knew who got into a motorbike accident and went to this hospital. He couldn't pay for a bed so he sat on the ground with a head injury from the accident. With the head injury, he couldn't remember where he lived or who his family was, so he sat on the ground for 2 days while medical staffed passed by. He eventually died right there on the filthy hospital floor without receiving the slightest bit of medical care. This, by the way, is a government funded hospital. A government that has obviously decided that there are bigger priorities than a marginally clean hospital in the middle of one of its most visited cities. And to be treated there costs money that many Cambodians don't have. No money, no treatment. Life and death is often very black and white in this part of the world.
In short, the hospital was actually much more impressive than I had expected. There is a large waiting area outside where parents wait with their children for the triage station. From there, they are directed to the appropriate departments. Over 400 kids are seen each day and so one might think it would take a long time to get seen. However, we had seen a 12 year old child - Pahl - the day before and we were suspicious of tuberculosis based on a 3 month history of fever and cough with no response to antibiotics. The kid looked emaciated as well. On the morning of our visit, we had ordered a motobike (scooter) to come pick him and his mother up and bring them to the hospital. They were in the waiting area when we arrived. By the time we had finished the tour, he had been seen by the doctor who agreed with the possibility of TB, had received a PPD shot, and was on his way to getting his blood work and chest X-ray done. I was quite impressed with the Cambodian doctor we chatted with as well. The AHC welcomes foreign doctors to come in as volunteers and even hires a few as part of the staff. As part of the deal, they have to see patients with their own Cambodian doctors so that they can receive Western medical training. This Cambodian doctor was sharp enough to also suspect atypical pneumonia (mycoplasma pneumonia, aka "walking pneumonia") - a fair diagnosis to consider. Later in the afternoon, we got the call that they saw the chest x-ray and it was bad enough to be considered diagnostic for active TB, so they were starting him right away on a TB treatment regimen. His entire visit was about 3 hours. The time to diagnosis was another 4 hours. Total time was 7 hours. Not bad at all for a free children's hospital.
In addition, while on tour, we got to visit the microbiology lab. I was shocked to even see a microbiology lab, but also excited at the possibility that I might actually have a place to send kids like Pahl for testing if it's actually needed. At this lab were two Brits, Kate and Chris who were sent here by Oxford University to study the epidemiology of infectious diseases in Cambodia. (By the way, "Oxford University" is SO much fun to say in a British accent. Go on, try it...OXfuhd UniVUHsity. Right??) So anyhow, this is all very fascinating to me because before my trip, I tried to look up some statistics regarding what kinds of infectious diseases to expect here. The usual third world country lists of diseases comes up: HIV, TB, malaria, cholera, dengue fever, etc. The only problem is that nobody really ever has any confirmed statistics as to how prevalent they really are. And I've begun to wonder because Pahl is the first patient I've encountered where I've suspected TB at all. I've only seen one probable case of malaria, one case of cholera, and no known cases of dengue fever. Perhaps it's just the area I'm in, or perhaps it's not the right season. But really, it's just because the diagnostic services here are so poor that no one really knows. No one's actually taken sufficient interest in this region to come in with proper diagnostic testing to confirm the diagnosis of anything so most diagnoses remain as only "suspected". The only thing I can say is wildly rampant here is rhinovirus - the common cold. So anyhow, Kate and Chris were sent here by...Oxfuhd Univuuuhsity...to study the prevalence and distribution of infectious diseases. Need to setup dinner sometime with them to ask them more about their experiences.
It's also worth mentioning that the AHC has an open air kitchen in the "backyard" of the hospital. The guardians or parents of the child patients can go there and pickup a "food basket" from a small supply room. The food basket contains numerous food items such as leafy green vegetables and rice. The parents are then educated on nutrition and what kinds of foods to prepare for their kids at home. They can they cook food for their child in the kitchen and eat with them. Other areas in the hospital are created to allow kids who are healthy enough, to play with coloring books and various toys that they normally don't encounter at home. The notion is that most Cambodian kids don't learn how to play which is a vital part of cognitive development. Thus, a big part of the public health effort by the hospital is to teach them how to engage their minds in their "playing". It's hard to say how much effect it's having on the population, but I like that the hospital has identified factors beyond illness that affect the well-being of a child, and make efforts to address them, or at the very least bring it into the public awareness. So all in all, I was pretty impressed by the AHC. It was free, clean, well-organized, efficient, and staffed by diligent and competent healthcare professionals. Then we went to the Siem Reap Provincial Hospital.
Angela is a second year internal medicine resident who is a volunteer at another program and was working at the SRPH. She was on the tour with us and offered to take us around her hospital to see the contrast. This hospital is where everyone else (e.g. adults) goes when they need medical care. As we walked onto the hospital grounds, the contrast was already obvious. First of all, I couldn't even tell we were in a hospital. It was just a collection of drab decaying buildings with no visible indication that this was a place to come to get healed. We first walked through a long dark hallway (no electrical lighting) into the maternity ward, which was just a narrow room with rows of vinyl covered mattresses on flimsy metal frames. The checkered floor was gray from soot and dirt. Passing by the rudimentary bathrooms, one can detect the pungent smell of old urine wafting out. In fact, it's nearly impossible not to smell it. People, presumably the families of mothers lined the hallway and stared blankly at us as we walked by.
We then went back out to the courtyard and walked to the ICU. On the way we passed by a sign that pointed to our left and said "Laboratory". About 25 meters away was a decrepit yellowish-brown building standing in its own corner of the courtyard. I commented that I'd be interested in seeing the lab, but Angela replied, "Oh, I don't know why that sign is there. I went over there one day and there's nothing in there."
"What do you mean 'nothing'? There's no staff there?"
"No, I mean there's literally nothing in there. It's an empty building."
"@#%&??!!"
So then we arrived at the ICU. I think "hell" would not be an inaccurate term to describe the conditions. Quite frankly I cannot think of single place I'd rather not be at for an eternity. The dirty beds were filled with unwashed and sometimes unclothed patients. I did my best not to look but I'm fairly certain some of them were sitting in their own waste. As soon as you walk through the "door" the filth in this place mounts an all out assault on all five of the senses (not that I dared to lick anything there mind you). The walls behind the bed are lined with old metal pipes that branch off to a valve and pressure gauge above each bed. They were built for oxygen delivery to the beds, and appear to have been built more than 50 years ago. Apparently, 20 years ago was the last time they were actually functioning. Now they just provide a place for patient families to hang up and dry their clothes.
During our visit, I realized we hadn't encountered any doctors. Angela explained that there are no doctors left in the hospital by noon time. They are so poorly paid that they leave after a couple hours in the morning and go to their own clinics somewhere else to earn some more money. I think I may have seen two nurses there the entire time. And the cherry on top of this lovely hospital sundae? The patients actually have to pay to get a bed here. I heard a story from a friend about a brother of some Cambodian he knew who got into a motorbike accident and went to this hospital. He couldn't pay for a bed so he sat on the ground with a head injury from the accident. With the head injury, he couldn't remember where he lived or who his family was, so he sat on the ground for 2 days while medical staffed passed by. He eventually died right there on the filthy hospital floor without receiving the slightest bit of medical care. This, by the way, is a government funded hospital. A government that has obviously decided that there are bigger priorities than a marginally clean hospital in the middle of one of its most visited cities. And to be treated there costs money that many Cambodians don't have. No money, no treatment. Life and death is often very black and white in this part of the world.
Monday, January 24, 2011
Sihanoukville
Cue the Jimmy Buffet music. I just got back from a weekend in Sihanoukville and had a fantastic time. The bus ride was sort of a fun experience. We took a sleeper bus which is simply a bus with rows and rows of beds. They increase the number of people they can squeeze in by raising the head of the bed and putting the foot of the next bed under it. I'll upload a photo eventually. A sleeper bus is a must since the trip is nearly 11 hours. But it's not all that easy to sleep on the bus. I'll bet you think you could make the trip go faster if you were in a car. But I'll bet you would be wrong. We were FLYING on the road out there. And the thing is, the road kinda sucked. I was always on the bottom bunk so I couldn't see the road (I had about 2 inches of window to peek out of), but from the feel of things, big chunks of it were not paved. That didn't seem the faze the driver in the least. Large segments of our return trip on our Phnom Penh-Siem Reap leg were spent with the wheels not even touching road. This ride scared me more than ANY roller coast I've ever been on. But, I will say that the trip was worth it. It was a much needed change of scenery. Chilled out on a nice beach with a good book, watched a good movie (127 Hours), went on a boat ride to an island, went diving, "sampled" the local cocktails, made some very cool new friends, ate some amazing seafood barbecue, got a haircut (finally), and visited downtown Sihanoukville. Not necessarily in that order. So today I went back to the clinic. The weather has changed and not in a good way. It got hot. And humid. Very humid. I actually got light-headed several times in the clinic today and had to step out for some fresh air. Note to self: buy a fan, winter in Siem Reap is over.
Wednesday, January 19, 2011
Reporting In
Yes, I'm alive. My internet connection went from lousy to non-existent two days ago and so I've been unable to post. Things have been incredibly busy at the clinic and we've been working on ways to become more efficient in our workflow. Last weekend I managed to find a day to walk around Siem Reap and just do some people watching which was a welcome break. This week, I also had the opportunity to do a little more teaching while receiving some more Khmer lessons myself.
I think this was the week that I found myself settling into a groove and getting into the routine of daily living. It feels like I've been here a lot longer than I really have. Everything feels familiar and my "real life" back in Portland almost feels like another life I once lived. In fact, it almost feels like I have the memory of someone else's life. Weird. I guess I've never really been away from Portland for more than 2 weeks at a time and perhaps 3 weeks is the time it takes for that sense of familiarity to fade?
In any case, I'll have more to write about soon, but I have to get to breakfast and run some errands before heading out. This morning, I'm meeting up with Oliver and we're going to do a "drug run" for the clinic. And then we're heading over to the Angkor Hospital for Children. There's a child we saw at the clinic yesterday and tuberculosis is high on the differential diagnosis so we're going to meet them at the hospital to make sure he gets in to get a diagnostic workup. We're also going to meeting with Eugene, a retired cardiac surgeon from Texas and who also happens to be Thea's husband. He works at the hospital now as an administrator and he'll be giving us a tour of the hospital.
Tonight, I'm taking off with Jack and Oliver on an overnight bus to Sihanoukville, a town on the west coast of Cambodia. It's about an 11 hour bus ride. I'm told it's a sleeper bus so hopefully, I'll actually be able to get some sleep. Again, I'm uncertain as to what the internet situation is out there, so if it's bad, I won't be able to write again until after the weekend. Until then...
Monday, January 17, 2011
Siem Reap/Savong School Photo Essay
The connection here has been really lousy the last couple of days. But I finally managed to get a few photos uploaded after shrinking them down. In no particular order...
Thursday, January 13, 2011
Good Food, Clean Water
For the first time since I arrived, I haven't had any set plans, and the last few hours have been a much needed break. The clinic isn't open today and I have the morning free, which I chose to use to catch up on some reading. This afternoon, I'll go back to the school so I can get back to teaching a class or two. Time flies when you're keeping busy and it's hard for me to believe I've been here for over two weeks now. I have been settling into work nicely and feel like I have gotten into a groove. The clinic was a little more routine this week and I have had a chance to do a little more thinking about ways to improve the workflow for Thea (Dr. Sokunthea), and about the various public health issues related to the region.
A group of us went out to lunch across the neighboring temples and Dr. Sokunthea joined us for the first time. She took us to a roadside vendor who is a friend of hers. A major perk was that we got a massive discount on the meal in addition to getting generous serving sizes. As I suspected, the locals get charged far less. Fair enough though, I still can't complain about the prices. During our lunch, Oliver, Thea, and I had a discussion about how we could streamline her workload since there are so many patients everyday. We decided a good start would be to put a desk out in front of the clinic where Thea's nurse could collect information on each patient first and we could triage by order of severity of illness/injury. This weekend, I'll be working on creating a form for Thea's nurse to fill out. Creating these forms, obtaining demographic info, and getting vital signs takes up at least 5 minutes per new patient. Given that there are close to 30 patients per day, it adds up to at least two hours of time per day that she could save. There's also some time spent on finding previous information for returning patients because currently the information is just written on a blank piece of paper and placed into a binder in chronologic order which makes finding a returning patient's info difficult and sometimes impossible.
It turns out that we can use English for an organizational system because much of Thea's medical notes are written in English. Unfortunately, it's not quite as easy as alphabetizing the patients since not all have Anglicized names. And for the ones that do, from what I've observed, the "S" binder will probably contain 2/3 of all of the patients if not more. We thought about creating some sort of serial number system and handing out cards, but we're not confident that this is a practical idea given the population we're working with. But perhaps we can refine this idea to make it work.
Public health has been an issue that has been brewing in the back of mind since I've arrived. At the Savong Orphanage center, I actually haven't seen too much evidence of a problem with the water supply. The water is pumped from an underground well water source, and an Australian group has previously donated water filter systems. There is no particulate matter that I can see visible to the naked eye so the filter at least works on that level. I have been unable to see anything under the microscope. I do not believe that infectious agents in the water are a concern since we have only seen occasional cases of diarrhea and none were from the orphanage center. I suspect it is actually a far bigger problem than I have seen, but it may also be a seasonal issue and I would venture to guess that this is less of a problem during the current dry season.
Toxic chemicals are a different matter though since their manifestations may not be as acute or obvious. Several people here and that I've talked to have brought up arsenic which is a valid concern because it is known to occur naturally in underground water sources throughout SE Asia and particularly in certain regions of Cambodia. There is a well established non-profit organization called Resource Development International (RDI) that operates in Cambodia. They work on developing clean water systems and testing the water. I will contact them this weekend to see if they have already tested the water in this region or can provide some help in doing so.
Beyond the common colds that seems to be mini-epidemic right now in Cambodia, the most pressing public health issue for the kids appears to be nutrition. The orphanage kids are actually probably some of the better nourished kids in the region. However, some of the children from local villages though come in looking far smaller than their stated age, having incredibly thin arms, coarse hair, bruise-like lesions on their shins, and protruding bellies. Dorothy had brought over a couple of large bottles of children's multi-vitamins (essentially Flintstone vitamins) from BJ's Wholesale and they have been put to good use. And if any future volunteers are reading this, that would probably be one of the more useful things you could donate and bring if you have room in your bags. Costco or Sam's Club (or whatever your regional equivalent is) would carry the same thing. The smell of grapes, oranges, and cherries have proven to be irresistible to Oliver and Thea as they snuck one for themselves. I'm sure they were just making sure they were safe to give to the kids.
I'm still working on ideas to provide a more sustainable solution for better nutrition to the families in the villages. One was to provide baby chicks and sapling fruit trees or hardy vegetables for them to grow. However, Thea states that lack of education about nutrition is a big part of the problem. She thinks that if we were to do something like that, the villagers would simply sell the chickens when they were big enough and buy rice and fish with the money instead of harvesting the eggs or raising more chickens. Fruits and vegetables are not easy for everyone to grow because not everyone has access to enough water for the plants. I would like to think some more about how we could modify this idea to make this work, but I really need to get out into the community to see how most villagers live and what their notions and priorities about nutrition are.
A group of us went out to lunch across the neighboring temples and Dr. Sokunthea joined us for the first time. She took us to a roadside vendor who is a friend of hers. A major perk was that we got a massive discount on the meal in addition to getting generous serving sizes. As I suspected, the locals get charged far less. Fair enough though, I still can't complain about the prices. During our lunch, Oliver, Thea, and I had a discussion about how we could streamline her workload since there are so many patients everyday. We decided a good start would be to put a desk out in front of the clinic where Thea's nurse could collect information on each patient first and we could triage by order of severity of illness/injury. This weekend, I'll be working on creating a form for Thea's nurse to fill out. Creating these forms, obtaining demographic info, and getting vital signs takes up at least 5 minutes per new patient. Given that there are close to 30 patients per day, it adds up to at least two hours of time per day that she could save. There's also some time spent on finding previous information for returning patients because currently the information is just written on a blank piece of paper and placed into a binder in chronologic order which makes finding a returning patient's info difficult and sometimes impossible.
It turns out that we can use English for an organizational system because much of Thea's medical notes are written in English. Unfortunately, it's not quite as easy as alphabetizing the patients since not all have Anglicized names. And for the ones that do, from what I've observed, the "S" binder will probably contain 2/3 of all of the patients if not more. We thought about creating some sort of serial number system and handing out cards, but we're not confident that this is a practical idea given the population we're working with. But perhaps we can refine this idea to make it work.
Public health has been an issue that has been brewing in the back of mind since I've arrived. At the Savong Orphanage center, I actually haven't seen too much evidence of a problem with the water supply. The water is pumped from an underground well water source, and an Australian group has previously donated water filter systems. There is no particulate matter that I can see visible to the naked eye so the filter at least works on that level. I have been unable to see anything under the microscope. I do not believe that infectious agents in the water are a concern since we have only seen occasional cases of diarrhea and none were from the orphanage center. I suspect it is actually a far bigger problem than I have seen, but it may also be a seasonal issue and I would venture to guess that this is less of a problem during the current dry season.
Toxic chemicals are a different matter though since their manifestations may not be as acute or obvious. Several people here and that I've talked to have brought up arsenic which is a valid concern because it is known to occur naturally in underground water sources throughout SE Asia and particularly in certain regions of Cambodia. There is a well established non-profit organization called Resource Development International (RDI) that operates in Cambodia. They work on developing clean water systems and testing the water. I will contact them this weekend to see if they have already tested the water in this region or can provide some help in doing so.
Beyond the common colds that seems to be mini-epidemic right now in Cambodia, the most pressing public health issue for the kids appears to be nutrition. The orphanage kids are actually probably some of the better nourished kids in the region. However, some of the children from local villages though come in looking far smaller than their stated age, having incredibly thin arms, coarse hair, bruise-like lesions on their shins, and protruding bellies. Dorothy had brought over a couple of large bottles of children's multi-vitamins (essentially Flintstone vitamins) from BJ's Wholesale and they have been put to good use. And if any future volunteers are reading this, that would probably be one of the more useful things you could donate and bring if you have room in your bags. Costco or Sam's Club (or whatever your regional equivalent is) would carry the same thing. The smell of grapes, oranges, and cherries have proven to be irresistible to Oliver and Thea as they snuck one for themselves. I'm sure they were just making sure they were safe to give to the kids.
I'm still working on ideas to provide a more sustainable solution for better nutrition to the families in the villages. One was to provide baby chicks and sapling fruit trees or hardy vegetables for them to grow. However, Thea states that lack of education about nutrition is a big part of the problem. She thinks that if we were to do something like that, the villagers would simply sell the chickens when they were big enough and buy rice and fish with the money instead of harvesting the eggs or raising more chickens. Fruits and vegetables are not easy for everyone to grow because not everyone has access to enough water for the plants. I would like to think some more about how we could modify this idea to make this work, but I really need to get out into the community to see how most villagers live and what their notions and priorities about nutrition are.
Wednesday, January 12, 2011
USA! USA! USA!
It feels good to be back in Siem Reap and going back to the clinic. Yesterday was another busy day at the clinic with a variety of geriatric and pediatric cases. A young med student from London named Oliver has found me through a friend of his, Dominic at a volunteer organization they were both at. I had met Dominic earlier at a New Year's Eve dinner. Oliver had become dissatisfied with their setup and so he asked to come see the clinic. It's a bit crowded now, but at least it will free me up to do some more teaching, which I would very much like.
At night, Kuro and I joined Oliver, Dominic and other volunteers from their other organization for dinner. They included three other guys from the UK, and a couple from Holland. When I first introduced myself, a groan went up from the table. "Oh, you're an Amerrrricaaan. We don't see very many of you around. Fortunately.", joked one of the UK guys. At least I think he was joking. You could tell this was going to be one of THOSE dinners.
We made the usual small talk, but things got lively when the Dutch guy, Jasper somehow brought up Sarah Palin. I was in the middle of talking to one of the UK guys, Ed, when I heard the name. They all then looked at me and Jasper says, "Yah, you Americans love Sarah Palin!" I laughed and shrugged my shoulders, "Hey, I voted for Obama and I have no idea why she's so popular. In fact, why do you all know who she is as well?? Why would you care about someone like her?" Davi, the Dutch girl replied that it was because they were starting to get some extreme right wingers in their government who were now imitating SP's fear mongering tactics. And, she went on, unfortunately it has had the result of polarizing the country and the fringe groups now have enough power to really bog down the government when it comes to legislation. Not at all unlike the USA I suppose.
As it turns out, the Europeans follow a lot of the same media that we in the US do - they know about FoxNews and Glenn Beck, they watch The Daily Show with Jon Stewart. However, I was told by the Dutch couple in no uncertain terms that liberals in the US would be considered the far right in Holland. Okaaay. I'm totally feeling the love at this point. Jasper was obviously quite politically informed with equally strong opinions.
After the dinner, Kuro and I came across another traveler from Switzerland, Phillipe and joined him for a few drinks. Phillipe is a chef now splitting his time between Zurich and Singapore. I only got to chat with him for a bit, but he's a great guy, and has a fascinating backstory I'll get into later. He's going to join a group of us for dinner later tonight. At some point in our chat, we started talking about the largest cities in the world. He was convinced that it was Tokyo. Kuro of course agreed, but his opinion didn't count since it was obviously biased. Phillipe claimed to be a geography geek and an avid reader of The Economist. Tokyo was apparently said to be the world's largest city from some article he read. Well, I happened to have had this discussion just this past summer back in Portland with a couple of friends and remember looking it up online. However, I conveniently forgot to mention this little piece of information. I stated with confidence that it was Shanghai. Phillipe insisted there was absolutely no way and he was quite sure it was Tokyo. I insisted that he was wrong and that Tokyo wasn't even in the Top 10. Phillipe then laughs and says, "Ahh, but you're an American!" Okay, NOW it's on. "Yes, but I'm an American who's going to prove your Swiss ass wrong." Phillipe suggested a friendly bet of one beer and we could check by internet by tonight's dinner. Wikipedia's info was agreed upon as the definitive answer. And so to be sure, I just looked it up and reconfirmed. Woohoo, in one hour, I'm going to have a delicious FREE beer with my dinner. Who's your daddy now, Switzerland?
At night, Kuro and I joined Oliver, Dominic and other volunteers from their other organization for dinner. They included three other guys from the UK, and a couple from Holland. When I first introduced myself, a groan went up from the table. "Oh, you're an Amerrrricaaan. We don't see very many of you around. Fortunately.", joked one of the UK guys. At least I think he was joking. You could tell this was going to be one of THOSE dinners.
We made the usual small talk, but things got lively when the Dutch guy, Jasper somehow brought up Sarah Palin. I was in the middle of talking to one of the UK guys, Ed, when I heard the name. They all then looked at me and Jasper says, "Yah, you Americans love Sarah Palin!" I laughed and shrugged my shoulders, "Hey, I voted for Obama and I have no idea why she's so popular. In fact, why do you all know who she is as well?? Why would you care about someone like her?" Davi, the Dutch girl replied that it was because they were starting to get some extreme right wingers in their government who were now imitating SP's fear mongering tactics. And, she went on, unfortunately it has had the result of polarizing the country and the fringe groups now have enough power to really bog down the government when it comes to legislation. Not at all unlike the USA I suppose.
As it turns out, the Europeans follow a lot of the same media that we in the US do - they know about FoxNews and Glenn Beck, they watch The Daily Show with Jon Stewart. However, I was told by the Dutch couple in no uncertain terms that liberals in the US would be considered the far right in Holland. Okaaay. I'm totally feeling the love at this point. Jasper was obviously quite politically informed with equally strong opinions.
After the dinner, Kuro and I came across another traveler from Switzerland, Phillipe and joined him for a few drinks. Phillipe is a chef now splitting his time between Zurich and Singapore. I only got to chat with him for a bit, but he's a great guy, and has a fascinating backstory I'll get into later. He's going to join a group of us for dinner later tonight. At some point in our chat, we started talking about the largest cities in the world. He was convinced that it was Tokyo. Kuro of course agreed, but his opinion didn't count since it was obviously biased. Phillipe claimed to be a geography geek and an avid reader of The Economist. Tokyo was apparently said to be the world's largest city from some article he read. Well, I happened to have had this discussion just this past summer back in Portland with a couple of friends and remember looking it up online. However, I conveniently forgot to mention this little piece of information. I stated with confidence that it was Shanghai. Phillipe insisted there was absolutely no way and he was quite sure it was Tokyo. I insisted that he was wrong and that Tokyo wasn't even in the Top 10. Phillipe then laughs and says, "Ahh, but you're an American!" Okay, NOW it's on. "Yes, but I'm an American who's going to prove your Swiss ass wrong." Phillipe suggested a friendly bet of one beer and we could check by internet by tonight's dinner. Wikipedia's info was agreed upon as the definitive answer. And so to be sure, I just looked it up and reconfirmed. Woohoo, in one hour, I'm going to have a delicious FREE beer with my dinner. Who's your daddy now, Switzerland?
Tuesday, January 11, 2011
Culinary Adventures Part 2: Crispy Critters
Before I left Battambang, I decided to take the exotic foods sampling up a notch. Our tour guide Kim took us to a roadside stand that was selling stir fried crickets. And barbecued rats. I was surprised by the crickets. They were actually extraordinarily tasty and I'm being 100% sincere. I wouldn't have be totally starving to eat them. In fact, I intend to have more before I leave. I hear they're quite good with beer. I think it helped that they were stir fried in some delicious seasoning. Once you ignore the fact you're chewing on an insect - yum, quite delicious. Ch'ng an. And the rat? We were assured that the rats were not city rats but were caught out in the rice fields so their only diet is rice. That was reassuring. Rat was actually pretty easy. As Kuro commented, "Rike chiggen". Yup. Even the Japanese think everything tastes like chicken.
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| Down the hatch... |
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| Kim gets things rolling... |
Monday, January 10, 2011
Battambang Photo Essay
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| View of Battambang from the rooftop of our hotel |
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| Streets of Battambang |
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| Wat Banan - otherwise known as "mini-Angkor Wat". It took 359 very steep steps to get up to this temple. |
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| Kim shows us one of the home granaries used to store rice. It is built from the leftover rice plant after the rice seeds have been removed, and mud mixed with cow dung. You can see from the build date on the left that they are actually quite sturdy, especially when you realize they also have to survive the monsoon season. |
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| A gas station outside of the city |
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| Eggs at the Psar Nath Market. Either they have 50 lb chickens or some of these are not chicken eggs. |
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| Ta Dambong sits at the edge of the city |
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| 5 headed Naga. This particular commemorative piece of artwork is built out of AK47's that were collected after the fall of the Khmer Rouge. Blow it up to its original size to see the guns. |
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| Butcher at the Psar Nath Market. No refrigeration. Thus, animals are killed in the morning and are sold that same day or not at all. |
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| View from Phnom Sampeau, site of the Killing Caves |
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| During the brutal reign of the Khmer Rouge, thousands fell to their deaths when they were pushed from the top of the caves, about 20 meters (~65 feet) up. |
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| Groundskeeper at the bottom of the Killing Caves |
All Aboard The Bamboo Express
Rough day yesterday. I've been careful, but somehow ate something on Sat that put me in bed for most of the day on Sun. Azithromycin is not the usual drug for stomach bugs, but there is a high rate of ciprofloxacin resistance in SE Asia. I can now fully vouch for its effectiveness. Two pills and two hours later, my fever broke. Another 15 hours of sleep and I was back on my feet, with only a raging headache as any evidence that I was sick. I'm on 48 hours of almost no food and my appetite has finally returned. Before I got knocked out by bug, I managed to squeeze in a full day of touring around Battambang. I'll leave most of it to the photos in the next post, but one of the activities deserves a bit more narrative.
The highlight of the day was the ride on the Bamboo Train. Also called "nori" in Khmer, the Bamboo train is a bit of ingenious retro-engineering created out of necessity. The train tracks were built years ago, and in the 50's and 60's, the Cambodian railroads were bustling with activity. However, civil wars and sabotage by the Khmer Rouge in the 70's took a toll and the railways fell into disrepair. It is now rare to see any train go on it at all. However, the locals being the ingenious folks that they are, saw all that unused railway and said to themselves, "Hmmm, this might be useful...". And thus, was born the Bamboo Train. Basically, it is a lightweight rectangular platform made of bamboo that is placed on top of two axles with wheels that were salvaged from junked tanks. It is powered by a lightweight motorcycle motor that is then coupled to an axle by a transmission belt. The locals use it to transport goods to the market, travel to work, or buy things like medicine that they can't get in their own village/town. We barang use it for a fun teeth chattering, butt shaking ride. It's like Disneyland, but without all (any) of the safety features. It travels up to 40 kph (25 mph), which is quite fast when you're only sitting 2 ft above the tracks.
I say tracks, but I mean track because there's only one. So this brings up the problem of what to do when two "trains" meet. They have that worked out as well. Local rules of the rail dictate that whichever train has the lighter load has to get off the tracks. The driver of the "winning" train has to help the driver of the other train disassemble their train. The engine comes off, the platform lifts up, and then the wheels/axles are removed from the tracks. The other train is pushed through about 20 feet and then the first train is reassembled on the other side. Meanwhile, we (better nourished) foreigners watch on in fascination and snap our photos.
Our final destination was only a few kilometers away at a brick factory. After exploring the brick factory, we sat in the shade for some drinks sold by an old man and his family. I whipped out my Khmer dictionary and tried out a few phrases with him. And for the next half hour, I got Khmer lessons for the cost of one soda ($0.50). Now that's a great deal. The man seemed extraordinarily happy anytime we foreigners pronounced something correctly, flashing an enormous toothless grin. And in that hour, I think I came away with a better grasp of something that is so fundamental to human nature - our desire and need to connect.
The highlight of the day was the ride on the Bamboo Train. Also called "nori" in Khmer, the Bamboo train is a bit of ingenious retro-engineering created out of necessity. The train tracks were built years ago, and in the 50's and 60's, the Cambodian railroads were bustling with activity. However, civil wars and sabotage by the Khmer Rouge in the 70's took a toll and the railways fell into disrepair. It is now rare to see any train go on it at all. However, the locals being the ingenious folks that they are, saw all that unused railway and said to themselves, "Hmmm, this might be useful...". And thus, was born the Bamboo Train. Basically, it is a lightweight rectangular platform made of bamboo that is placed on top of two axles with wheels that were salvaged from junked tanks. It is powered by a lightweight motorcycle motor that is then coupled to an axle by a transmission belt. The locals use it to transport goods to the market, travel to work, or buy things like medicine that they can't get in their own village/town. We barang use it for a fun teeth chattering, butt shaking ride. It's like Disneyland, but without all (any) of the safety features. It travels up to 40 kph (25 mph), which is quite fast when you're only sitting 2 ft above the tracks.
I say tracks, but I mean track because there's only one. So this brings up the problem of what to do when two "trains" meet. They have that worked out as well. Local rules of the rail dictate that whichever train has the lighter load has to get off the tracks. The driver of the "winning" train has to help the driver of the other train disassemble their train. The engine comes off, the platform lifts up, and then the wheels/axles are removed from the tracks. The other train is pushed through about 20 feet and then the first train is reassembled on the other side. Meanwhile, we (better nourished) foreigners watch on in fascination and snap our photos.
Our final destination was only a few kilometers away at a brick factory. After exploring the brick factory, we sat in the shade for some drinks sold by an old man and his family. I whipped out my Khmer dictionary and tried out a few phrases with him. And for the next half hour, I got Khmer lessons for the cost of one soda ($0.50). Now that's a great deal. The man seemed extraordinarily happy anytime we foreigners pronounced something correctly, flashing an enormous toothless grin. And in that hour, I think I came away with a better grasp of something that is so fundamental to human nature - our desire and need to connect.
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| Kim, our tour guide extraordinaire. |
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| The ride was NOT as smooth as might appear. |
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| We had the bigger load, but there were 8 other trains behind this one, so we got off the tracks. |
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| At the brick factory, rice husks are used as fuel for the kilns. |
Saturday, January 8, 2011
Disappearing Stick
We arrived in Battambang yesterday just before noon. What a ride. I think we managed to find the fastest driver in all of Cambodia. If you Google travel times between Siem Reap and Battambang you will find that most sites estimate the trip will take between 3 and 5 hours. We completed the trip in less than 2.5 hours. Imagine driving 120 kph (75 mph) down a 2-lane highway while passing hundreds of scooters, bicycles, and pedestrians. I think we spent about 1/4 of our trip in the left lane. Arriving at our hotel, Kuro looked at his watch and let out a breath. "Oh. Bewwy hwastuh." Very fast. I nodded, "Yes. Like Bullet Train."
We arrived in Battambang with no real idea of where to go or what to see. Dorothy and Gordon have been here, but they took the boat and we had no idea what time they were going to arrive. After we checked into our hotel, we found out we had a rooftop with a large terrace and at 6 stories, it is the second tallest rooftop in all of Battambang. The view was breathtaking. Battambang was a much bigger city than I had anticipated. Tired from the trip, we sat in the comfortable rattan lounge chairs to enjoy the cool breeze. After an hour, a couple of barang showed up to check out the view - Carrianne and Kate, both from the UK. Carrianne had been working in rural village 2 hours west of Battambang for the last 5 months and Kate was a new arrival who will be working at the same location for the next 3 months. They had spotted the terrace from another shorter rooftop and came by just to check it out. They were on their way to a cafe and invited us to join them. Having lived here for the past 5 months, Carrianne kindly gave us the lowdown on Battambang, with things to do and sights to see.
The name of the city - Battambang - is actually a mangling of proper proununciation and westernized spelling, "Bat Dambong". "Dambong" means 'stick' and "Bat" means 'to disappear'. The story goes, there was once a young shepherd boy who found a wood stick. He found that the stick was magical and had the power to control his cattle. But as we all know, power corrupts and the boy soon became unsatisfied with merely controlling cattle. So one day, he used the stick to overthrow the king and take the title for himself. The king's son had to flee into the forest where he became a monk. While meditating, he became incredibly ill and nearly died. Sometime later, the new king, Ta Dambong had a dream that his rule would only last 7 years, 7 months, and 7 days. In his dream, his rule was ended when he is defeated by a monk on a flying white horse. So he called a meeting of all holy men in the kingdom with the intention of killing them all. The prince, now a monk but still in ill health, started the long journey off to the palace to attend. But on the way there, a hermit stopped him and asked him to take care of his white horse while he went off to see the king. The white horse turned out to be a magical horse and cured the monk of his illness. One of its magical powers also happened to be flying. So off the prince went into the sky to go to the palace. Upon seeing him descend upon the white horse, Ta Dambong realized that his vision was about to come true. He tried to fight anyhow using his magic stick, but the gods protected the prince and Ta Dambong ran away in defeat. The magic stick disappeared, never to be found again. Legend has it that it will appear again one day.
Battambang is interesting for its contrast to Siem Reap. In Siem Reap, everything seems to center around tourism, which is only natural because of the number of foreign visitors they get. However, in Battambang, there are far fewer tourists and so I think most people don't come to depend on tourism for their daily living. Thus, when walking through the city, you can see many stores such as hardware stores, appliance stores, electronic stores, regular clothing stores (that don't have "I Heart Battambang" written on them), bakeries, etc. What you don't get are shoulder to shoulder bars and restaurants with big signs in English trying to entice you to come in. Souvenir shops are a little bit more difficult to find. However, my sampling of Siem Reap has been somewhat limited to more touristy areas. When I get back, I will have to try and get out to explore other areas and see how they compare.
We arrived in Battambang with no real idea of where to go or what to see. Dorothy and Gordon have been here, but they took the boat and we had no idea what time they were going to arrive. After we checked into our hotel, we found out we had a rooftop with a large terrace and at 6 stories, it is the second tallest rooftop in all of Battambang. The view was breathtaking. Battambang was a much bigger city than I had anticipated. Tired from the trip, we sat in the comfortable rattan lounge chairs to enjoy the cool breeze. After an hour, a couple of barang showed up to check out the view - Carrianne and Kate, both from the UK. Carrianne had been working in rural village 2 hours west of Battambang for the last 5 months and Kate was a new arrival who will be working at the same location for the next 3 months. They had spotted the terrace from another shorter rooftop and came by just to check it out. They were on their way to a cafe and invited us to join them. Having lived here for the past 5 months, Carrianne kindly gave us the lowdown on Battambang, with things to do and sights to see.
The name of the city - Battambang - is actually a mangling of proper proununciation and westernized spelling, "Bat Dambong". "Dambong" means 'stick' and "Bat" means 'to disappear'. The story goes, there was once a young shepherd boy who found a wood stick. He found that the stick was magical and had the power to control his cattle. But as we all know, power corrupts and the boy soon became unsatisfied with merely controlling cattle. So one day, he used the stick to overthrow the king and take the title for himself. The king's son had to flee into the forest where he became a monk. While meditating, he became incredibly ill and nearly died. Sometime later, the new king, Ta Dambong had a dream that his rule would only last 7 years, 7 months, and 7 days. In his dream, his rule was ended when he is defeated by a monk on a flying white horse. So he called a meeting of all holy men in the kingdom with the intention of killing them all. The prince, now a monk but still in ill health, started the long journey off to the palace to attend. But on the way there, a hermit stopped him and asked him to take care of his white horse while he went off to see the king. The white horse turned out to be a magical horse and cured the monk of his illness. One of its magical powers also happened to be flying. So off the prince went into the sky to go to the palace. Upon seeing him descend upon the white horse, Ta Dambong realized that his vision was about to come true. He tried to fight anyhow using his magic stick, but the gods protected the prince and Ta Dambong ran away in defeat. The magic stick disappeared, never to be found again. Legend has it that it will appear again one day.
Battambang is interesting for its contrast to Siem Reap. In Siem Reap, everything seems to center around tourism, which is only natural because of the number of foreign visitors they get. However, in Battambang, there are far fewer tourists and so I think most people don't come to depend on tourism for their daily living. Thus, when walking through the city, you can see many stores such as hardware stores, appliance stores, electronic stores, regular clothing stores (that don't have "I Heart Battambang" written on them), bakeries, etc. What you don't get are shoulder to shoulder bars and restaurants with big signs in English trying to entice you to come in. Souvenir shops are a little bit more difficult to find. However, my sampling of Siem Reap has been somewhat limited to more touristy areas. When I get back, I will have to try and get out to explore other areas and see how they compare.
Thursday, January 6, 2011
Battambang or Bust
Tomorrow morning, Dorothy and Gordon, volunteers from Canada are headed to Battambang by boat. Kuro and I are also going, but we decided on the taxi option. The boat ride is supposed to be anywhere between 5 and 8 hours depending on if the boat gets stranded - the risk increases as we get further into the dry season - and costs $20. The taxi ride takes 3 hours and costs $35 ($17.50 for each of us). Dorothy and Gordon rave about the scenery from the boat ride (they have taken it before), but Kuro and I chatted today and we decided that we wanted to get there as fast as possible so we could just chill out there. Plus, the boat ride starts at 6 AM, which is a deal breaker after the week I've had. So tomorrow, it's off to Battambang. I'm bringing my computer but I don't know if we'll have internet or not. If not, I won't be able to write until I get back on Monday.
Lost In Translation
Yesterday was somewhat bittersweet. All good things come to an end and I had to say goodbye to a couple of fellow travelers and volunteers who were leaving town. On the plus side, there are new volunteers coming through in the next week, and Kuro is still here. Kuro is a Japanese university student from Tokyo and is studying to become a teacher. Yesterday, he and I shared a tuk-tuk out to the school and had a really fun conversation. You wouldn't think it likely because Kuro's English is quite limited. He said to me later that he encounters a particular language problem with Westerners that I found really interesting because I've noticed it as well. You can see it happening everywhere here in Cambodia - us Westerners, or barang in Khmer, talking to the Cambodians way too quickly and using big words. And then repeating ourselves if we're not understood by saying the same thing, but louder. As if the problem was volume. The Cambodians often just bow, smile, and say "Yes, yes, okay". And we Westerners often have no idea that we might as well have been talking to the wall.
But there is a way to increase your odds of being understood if they at least know a few words - Broken English. Having grown up in Saudi Arabia and having non-native speaking parents, I've become fairly fluent in it. The idea is to minimize the number of words in a sentence, keep the vocab simple, and violate grammar rules with wild abandon (i.e. drop adverbs, no verb conjugation or verb tenses). In short, talk like them. It's not taken as an insult unless they're fluent in English. It's actually a relief because then they have a shot at understanding you. Throw in a little miming and it's sometimes quite amazing how far you can get. Especially when communicating with someone as bright as Kuro. So anyhow, our ride passed rather quickly as I tried to chat all things Japanese with him. We talked about the popularity of the iPhone in Japan, the Bullet Train, Kyoto's Shinto temples, Mt. Fuji monkeys, the most popular cars in Japan (in order from top to bottom: Toyota, Nissan, Honda/Suzuki), and of course my favorite Japanese topic - sushi. Kuro continues to apologize for his English, but as I keep telling him, it's far better than my Japanese, which at the time of this writing, consists only of the ability to list a lot of Japanese electronic/automotive goods and sushi dishes. And only because I'm a big consumer of both.
Nearby the school, there are three temples that are not as famous as Angkor Wat, but still pretty spectacular to see: Bakong, Preah Ko, and Lolei. The temples comprise the Roluos (a nearby modern town) group of temples that are the remains of the first capital of the Angkor period - Hariharalaya. Thus they are the oldest temples of the Khmer empire and date back to the early ninth century. At lunchtime, Kuro, Michelle (volunteer from Holland), and I borrowed a couple of bikes from the orphanage center and rode a few kilometers up the road to go check out the temples. We got there and found two guards there who wouldn't let us through without a temple pass which none of us had and had to be bought at the main temple ticket office, which was 16 km away near Angkor Wat. Not going to happen. Undeterred, Kuro tried to change their minds with a barrage of Broken English. It was quite the scene to watch the back and forth between them. "Ret us go. Shree minots. We not tell anyone." Let us go in for three minutes. We won't tell anyone. "No. Me no wor. Boss watch me." No, I can't. I'll lose my job. My boss is watching me. "No, you not loose job. We not teh yo boss. We bewwy quiet. Nobody know." You get the point. After a few more exchanges the guard still held his ground and Kuro sighed in defeat. But then a lightbulb apparently went off in his head. He took one step at a time towards the temple, gesturing at the ground while asking the guard, "Where is line? Is here?" One more step forward. "Or here?" Another step. "Or here?" The guard laughed and shook a finger at him. "You no good." Kuro shrugged his shoulders, snapped a quick photo, and walked back to where Michelle and I were watching in amusement. As we sat on the stone brick ruins in front of the guard table and under the shade to cool off, the guards turned to us and invited us to have lunch with them. Michelle and I politely declined while Kuro instantly whipped out a spoon, took off his backpack and crossing his legs, sat down *on* their table to join them. And that is the way of Cambodians. As far as they are concerned, all are welcome to join in their meals even if it means less food for them. And the way of Kuro? What can I say, the kid has moxie.
But there is a way to increase your odds of being understood if they at least know a few words - Broken English. Having grown up in Saudi Arabia and having non-native speaking parents, I've become fairly fluent in it. The idea is to minimize the number of words in a sentence, keep the vocab simple, and violate grammar rules with wild abandon (i.e. drop adverbs, no verb conjugation or verb tenses). In short, talk like them. It's not taken as an insult unless they're fluent in English. It's actually a relief because then they have a shot at understanding you. Throw in a little miming and it's sometimes quite amazing how far you can get. Especially when communicating with someone as bright as Kuro. So anyhow, our ride passed rather quickly as I tried to chat all things Japanese with him. We talked about the popularity of the iPhone in Japan, the Bullet Train, Kyoto's Shinto temples, Mt. Fuji monkeys, the most popular cars in Japan (in order from top to bottom: Toyota, Nissan, Honda/Suzuki), and of course my favorite Japanese topic - sushi. Kuro continues to apologize for his English, but as I keep telling him, it's far better than my Japanese, which at the time of this writing, consists only of the ability to list a lot of Japanese electronic/automotive goods and sushi dishes. And only because I'm a big consumer of both.
Nearby the school, there are three temples that are not as famous as Angkor Wat, but still pretty spectacular to see: Bakong, Preah Ko, and Lolei. The temples comprise the Roluos (a nearby modern town) group of temples that are the remains of the first capital of the Angkor period - Hariharalaya. Thus they are the oldest temples of the Khmer empire and date back to the early ninth century. At lunchtime, Kuro, Michelle (volunteer from Holland), and I borrowed a couple of bikes from the orphanage center and rode a few kilometers up the road to go check out the temples. We got there and found two guards there who wouldn't let us through without a temple pass which none of us had and had to be bought at the main temple ticket office, which was 16 km away near Angkor Wat. Not going to happen. Undeterred, Kuro tried to change their minds with a barrage of Broken English. It was quite the scene to watch the back and forth between them. "Ret us go. Shree minots. We not tell anyone." Let us go in for three minutes. We won't tell anyone. "No. Me no wor. Boss watch me." No, I can't. I'll lose my job. My boss is watching me. "No, you not loose job. We not teh yo boss. We bewwy quiet. Nobody know." You get the point. After a few more exchanges the guard still held his ground and Kuro sighed in defeat. But then a lightbulb apparently went off in his head. He took one step at a time towards the temple, gesturing at the ground while asking the guard, "Where is line? Is here?" One more step forward. "Or here?" Another step. "Or here?" The guard laughed and shook a finger at him. "You no good." Kuro shrugged his shoulders, snapped a quick photo, and walked back to where Michelle and I were watching in amusement. As we sat on the stone brick ruins in front of the guard table and under the shade to cool off, the guards turned to us and invited us to have lunch with them. Michelle and I politely declined while Kuro instantly whipped out a spoon, took off his backpack and crossing his legs, sat down *on* their table to join them. And that is the way of Cambodians. As far as they are concerned, all are welcome to join in their meals even if it means less food for them. And the way of Kuro? What can I say, the kid has moxie.
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| One of the guards at Praeh Ko. And his ferocious guard dog. |
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| Cambodian watermelon. The entire thing. |
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| Fresh fruit for lunch. For less than a buck. A lot less. |
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| The best toilets in a 15 km radius. No really. Before we saw the sign, we thought it was a modern temple. |
Tuesday, January 4, 2011
Happy "Hour"
On a lighter note (and for those of you with no interest in medicine or unpleasant-looking skin lesions), here are a few random photos from the last couple of days:
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| A liberal use of the word "hour". |
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| One of the orphanage kids. |
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| A Cambodian wedding that started more than 24 hours ago. Weddings here go for two days straight. |
Warning, Not For The Squeamish
Yesterday was another busy day at the medical clinic. I'll keep this one short. The cases included asthma, depression, anxiety attacks, bronchitis, urinary tract infection, tonsillitis, and the assortment of colds in the little ones. Sehar came by for his dressing change. His wounds look a little better, and so far, no fevers. The day was mostly typical general medical cases, though incredibly varied. However, there was one jawdropper case.
34 year old woman came in with a couple of skin lesions that are difficult to describe. I believe this is a case when a couple of pictures are worth a thousand words. If you lose your appetite easily, you might think about not clicking the photos for the larger versions.
The interesting thing about this case is that this woman has had these lesions for ten years. She reported that it has not ever gotten better and has only been slowly growing over this time. I can only come up with one potential diagnosis: lepromatous leprosy. Leprosy is one of those diseases that has attained near mythical status from its long documentation throughout human history. I could hardly believe I was potentially seeing a real live case right in front of me. We're going to try her on a course of anti-fungal cream for a week to see if there's any change, but I doubt it's fungal given the history. I'll have to do some more research on this, but if you can think of anything else it might be, let me know.
34 year old woman came in with a couple of skin lesions that are difficult to describe. I believe this is a case when a couple of pictures are worth a thousand words. If you lose your appetite easily, you might think about not clicking the photos for the larger versions.
Monday, January 3, 2011
Medical Day...
I spent the entire day out at the medical clinic yesterday. It was an exhausting but fascinating day. Most of the kids and infants who are brought in by their parents just have the common cold. They've become pretty easy to spot. Slight runny nose, mild fatigue, mild fever and cough. Questioning confirms that all the kids in the family have the same problem. There seems to be a mini-epidemic of common cold in SE Asia right now, as I've come across many adults who have been complaining of a cold too. But things got interesting just before noon.
At about 11:30, Dr. Sokunthea went on her lunch break somewhere back in Siem Reap. As I was packing up my bag to go find someplace to eat as well, a young man shyly shuffled into the room. I looked up and his problem was immediately obvious. The skin of his left arm was about 50% rubbed off. Another large abrasion above his mouth on the left side. And a huge 6 cm gaping wound above his mouth on the right side. The wounds were purulent and covered in the red colored dirt that is everywhere here. Holy crap. "Umm...Docta Hahn...you wememba me?" Until he asked, I hadn't. But then I realized this was one of the three kids that caught a short ride with me in the tuk tuk back to the orphanage on Friday as I headed out from the school. Sehar was his name. Sehar went on to explain that he got into a scooter accident on Friday night at about 11:30 pm. He came to the clinic, but Dr. Sokunthea's assistant was the only person around. He pointed to some small bottles of clear fluid in the cabinet. That was what she had handed to him. I looked at the label, but it was written in Vietnamese and there was only one English word I recognized - "OXY". Hydrogen peroxide, maybe??? So there we were, on Monday morning, and his wounds were still pretty much untouched from Friday night. Luckily, I had brought two big bottles of saline with me. Dorothy a volunteer from Canada, came in to help me. The next hour and and a half went by as I washed all the wounds, applied antibiotic cream, covered them with a non-stick gauze pads. Let me just say for the record that this kid's tolerance for pain was superhuman. There was no lidocaine to be found in the cabinets. Tears streamed down his face as I cleaned the wounds, but he kept insisting that he was okay. Then Dorothy raised a good question - "Do you think the inside of his mouth okay?" Lifting up his upper lip, there it was - a small puncture oozing a little pus, just opposite the large gaping wound on the outside. Did I say holy crap before? Holy crap. Rolling up some gauze with a little antibiotic ointment, I packed it into area. Not ideal, but the best I could do. He's coming back today to see me so I can check over everything. On the plus side, it has been 3 days and I couldn't see any signs of infection. I found out later what had happened. He and his buddies were out and had a few beers. As he was driving his scooter home with his two friends on the back, he came across a pothole but couldn't react in time. I'm guessing the gaping wound was a result of his face hitting some part of the scooter. The other two friends got away with minor cuts and bruises.
In the afternoon, an older man came in. Complaint was abdominal pain - right upper quadrant - that came on after eating. No swollen belly, soft liver, but *really* enlarged spleen. Yellow eyes. Possible gallstones? Confirmed that he had spiking fevers for the last 3 days. Also has a history of malaria - P. vivax. I did a finger prick for some blood. When I put the blood drop hit the slide, it spread out quickly like blood tinged water. Clear sign of anemia. His urine dipstick was positive for urobilinogen and bilirubin. It all added up to some kind of hemolytic anemia. Given his history of malaria, I am highly suspicious for it, but could not confirm it by microscopic exam. Not leukemia or lymphoma, but I can't rule out other causes for hemolysis. Autoimmune? Hereditary? As good as the microscope is, I couldn't make out the red blood cells very well. It may be due to poor prep technique which I will have to try to improve. Won't be able to do anything about the gallstones and surgery is just not an option unless there's some way to get him free treatment. But my priority is to treat the cause of the anemia which is pretty severe given the thinness of his blood. Did some research last night and will treat him today presumptively with anti-malarials. For those of you interested in medicine, check out Artemisinin. Not available in the U.S. but widely used effectively everywhere else in the world.
The other patients in the afternoon included a possible pellagra case (Vitamin B3 deficiency) presenting with white patchy skin spots on sun exposed areas, and a congestive heart failure case presenting with dyspnea alleviated by lying down. Amazing first full day in the clinic. I was so tired last night, I finally got my first night of more than five hours of sleep. Let's see what's in store for today...
At about 11:30, Dr. Sokunthea went on her lunch break somewhere back in Siem Reap. As I was packing up my bag to go find someplace to eat as well, a young man shyly shuffled into the room. I looked up and his problem was immediately obvious. The skin of his left arm was about 50% rubbed off. Another large abrasion above his mouth on the left side. And a huge 6 cm gaping wound above his mouth on the right side. The wounds were purulent and covered in the red colored dirt that is everywhere here. Holy crap. "Umm...Docta Hahn...you wememba me?" Until he asked, I hadn't. But then I realized this was one of the three kids that caught a short ride with me in the tuk tuk back to the orphanage on Friday as I headed out from the school. Sehar was his name. Sehar went on to explain that he got into a scooter accident on Friday night at about 11:30 pm. He came to the clinic, but Dr. Sokunthea's assistant was the only person around. He pointed to some small bottles of clear fluid in the cabinet. That was what she had handed to him. I looked at the label, but it was written in Vietnamese and there was only one English word I recognized - "OXY". Hydrogen peroxide, maybe??? So there we were, on Monday morning, and his wounds were still pretty much untouched from Friday night. Luckily, I had brought two big bottles of saline with me. Dorothy a volunteer from Canada, came in to help me. The next hour and and a half went by as I washed all the wounds, applied antibiotic cream, covered them with a non-stick gauze pads. Let me just say for the record that this kid's tolerance for pain was superhuman. There was no lidocaine to be found in the cabinets. Tears streamed down his face as I cleaned the wounds, but he kept insisting that he was okay. Then Dorothy raised a good question - "Do you think the inside of his mouth okay?" Lifting up his upper lip, there it was - a small puncture oozing a little pus, just opposite the large gaping wound on the outside. Did I say holy crap before? Holy crap. Rolling up some gauze with a little antibiotic ointment, I packed it into area. Not ideal, but the best I could do. He's coming back today to see me so I can check over everything. On the plus side, it has been 3 days and I couldn't see any signs of infection. I found out later what had happened. He and his buddies were out and had a few beers. As he was driving his scooter home with his two friends on the back, he came across a pothole but couldn't react in time. I'm guessing the gaping wound was a result of his face hitting some part of the scooter. The other two friends got away with minor cuts and bruises.
In the afternoon, an older man came in. Complaint was abdominal pain - right upper quadrant - that came on after eating. No swollen belly, soft liver, but *really* enlarged spleen. Yellow eyes. Possible gallstones? Confirmed that he had spiking fevers for the last 3 days. Also has a history of malaria - P. vivax. I did a finger prick for some blood. When I put the blood drop hit the slide, it spread out quickly like blood tinged water. Clear sign of anemia. His urine dipstick was positive for urobilinogen and bilirubin. It all added up to some kind of hemolytic anemia. Given his history of malaria, I am highly suspicious for it, but could not confirm it by microscopic exam. Not leukemia or lymphoma, but I can't rule out other causes for hemolysis. Autoimmune? Hereditary? As good as the microscope is, I couldn't make out the red blood cells very well. It may be due to poor prep technique which I will have to try to improve. Won't be able to do anything about the gallstones and surgery is just not an option unless there's some way to get him free treatment. But my priority is to treat the cause of the anemia which is pretty severe given the thinness of his blood. Did some research last night and will treat him today presumptively with anti-malarials. For those of you interested in medicine, check out Artemisinin. Not available in the U.S. but widely used effectively everywhere else in the world.
The other patients in the afternoon included a possible pellagra case (Vitamin B3 deficiency) presenting with white patchy skin spots on sun exposed areas, and a congestive heart failure case presenting with dyspnea alleviated by lying down. Amazing first full day in the clinic. I was so tired last night, I finally got my first night of more than five hours of sleep. Let's see what's in store for today...
Sunday, January 2, 2011
Culinary Adventures Part 1
Last night I had dinner with a group of fellow travelers. Somehow, we all agreed to try something a little different. So we ended up at a Cambodian BBQ place on Pub Street. Cambodian BBQ usually involves a big bowl with a central raised dome that has slits in it. This goes over a gas powered stove that sits right on your table in front you. As the dome heats up, they pour water into the rim area. Then they bring vegetables, noodles, and meat. The vegetables and noodles go into the water. The meat goes on the dome and the juices slowly drip into the water making a delicious veggie noodle soup to eat with the meat. What was different about this meal was the meat. Among the usual meats that most foreigners know and love, the dinner menu also included: crocodile, kangaroo, ostrich, frog legs, and goat. We got the ostrich, frog legs, and goat. The rest of the table liked the beef the most, but I have to say, I REALLY liked the ostrich. It tasted like a cross between pork and chicken. The goat was pretty good too. I will be back again eventually to try the rest of the meats. It's hard to describe the setup, so the camera will definitely be with me next time. There are other food items that are a lot less tame than these things. I'll get around to them eventually...
Saturday, January 1, 2011
Happy New Year
Spent New Year's Eve out on the town with a group of new friends from all over the world - Spain, France, Switzerland, Indonesia, China, Taiwan, India, Canada, and USA. To friends old and new, to family here and departed, I wish you all the best in 2011. Happy New Year!!!
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| Recent litter of puppies at the school |
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| Dirt road leading to Savong's School |
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| 2011 in Siem Reap |
Day Two: Into The Deep End
Yesterday the medical clinic was closed since Dr. Sokunthea doesn't work there Fridays and was off in Phnom Penh for an ultrasound class, so I went to the school. At 4 o'clock, one of the Cambodian teachers asked if I'd like to teach her class. I had intended to teach just the one hour class and be done. But as I am starting to realize, intentions are frequently a pointless endeavor in Cambodia.
I had arrived early in the afternoon so I first spent some time chatting with the staff, one of whom decided to put me to work by handing me a stack of about fifty test papers to mark and correct. This ate up time VERY quickly. While I was reviewing them, several staff members sat with me and scrutinized each of my corrections to try and pick up more English themselves. The task given to the students was to list the letters of the alphabet up to "O" (no idea why they didn't go to "Z") and follow each letter with a word that started with that letter. Some were pretty amazing with perfect spelling and often better handwriting than my own (though that is not that difficult). Some had a mixture of English and Khmer letters. And some were just random lines and dots. The misspellings resulted in some funny moments. "Ice cream" was a very popular choice. But one of them had slightly misspelled it - "Lice cream". As I marked it and laughed, the staff gave me puzzled looks. So I drew a louse on a piece of paper. One of the staff pointed and said, "Yes, spider!". I shook my head. "Lice". I pointed to my head and started scratching. "LICE", I repeated. They chuckled a little, but most likely just because I probably looked ridiculous scratching my head. But after a few seconds one of them let out a big "AHHH" of recognition. He turned around and excitedly explained to the others in Khmer which caused them all to double over in laughter. Apparently, irony translates rather well.
The first class was made up of about 15 older students, pretty similar in age and it seemed like their English was decent across the board. The Cambodian English teacher (I really need to learn the staff names) handed me a lesson book which all the kids had, and showed me where they were. So off we went. The lesson covered possessives (***'s vs ***s') and articles ("a" vs "an" vs "some"). I diverged a few times during the hour when I found that they were missing some basic understanding about things like vowels and consonants that, as I mentioned previously were critical to understanding some parts of the lesson ("a" vs "an"). I also diverged a few times to work on pronunciation. "V", "F", "R" and "TH"sounds appear to be particularly problematic for them. On the plus side, they seemed to take tremendous delight in echoing me while I chanted "vuh vuh vuh, fuh fuh fuh, ruh ruh ruh". Fun with phonetics.
The second class was filled with about 60 kids. That is not a typo. This class was filled with 4-8 yr olds who streamed in almost endlessly and seemingly out of nowhere because they weren't even on the school grounds just 10 minutes earlier. These kids were in Cambodian school during most of the day, but they don't learn English there so they come here after their regular school. We started with numbers first for which they were pretty good. They knew the game of BINGO so we played that (note to self: with a class size of 60, earplugs are recommended). Then we did giant flashcards with photos of various animals. They had clearly gone over these before because they at least knew the general sounds of the animal names. But again, the same pronunciation issues came up so I worked on emphasizing certain sounds that they likely don't encounter in Khmer. During this class, I discovered that the kids would learn a lot faster if I could compare an English word to a Khmer word. For example they had initially had trouble with raccoon which came out sounding like wack or wahco. So then it occurred to me that raccoon sounds a lot like one of the few phrases I know in Khmer - au kuhn, which means thank you. When it finally dawned on them that I was saying something to them in Khmer, they caught on really quickly and the result sounded *much* better. I suppose this means I should learn some more Khmer words.
As a side note, a total of about thirty students introduced themselves to me yesterday. I tried my best to remember their names, but it's hopeless as I realized something. Not a single one of them had the same name. I *thought* I had a repeat name when one student introduced himself as what sounded to me like Savong. "Ah! Savong! Like the school!", I said. But he and several of his buddies all shook their heads in unison, so I had them spell it for me. "S-A-V-O-R-N". Sigh. From what I've seen, Cambodian names are pretty unique. I have yet to come across the equivalent of John or David. I'd like to be able to address them individually, but I don't think that's likely to happen. Maybe I can find a stack of "Hello. My name is..." labels and have them all write their names on it and stick it on their shirts. Kidding...hmm, maybe that's not such a bad idea actually.
The third class was a very mixed group. They seemed to range from 13 all the way up into the 20's. They also had the most difficult grammar lesson. I tried, but I don't think more than one or two students, if even that, really understood it. For sure, the younger ones were completely lost from the very first minute. More to the point, I wondered how relevant it was and whether we were putting the cart before the horse. Should I be trying to explain what a present continuous form of a verb is when their vocabulary and pronunciation still need a lot of work? Maybe this is fine, I don't know. Comments from those of you with experience in this?
On the medical front, I also picked up my first patient yesterday. One of the older students (20-something) heard that I was a doctor so he came over just before my third class to ask me about a skin rash. His English was really quite good. Good enough that I was able to get a short history from him before the class began. Very itchy bumpy rash present for a week with no remission. First appeared on his right forearm. But now present on various parts of his trunk and legs. I only looked at the rash on his right arm. It was raised with some coalescence. It didn't look red but his skin was pretty dark and the lighting in the classroom was poor. No pustules or ulcers. No fevers, no loss of appetite, no pain, no GI changes. Never had this before in his life. Nobody else around him has it. The next class was starting so I told him to come see me in the clinic on Monday so I can get a better look, but I thought I'd throw this out there for you medical people. I know you're dying to give me a differential so let's hear it, eh? I'm going to try to figure out a way to get a tissue sample on Monday and try out the microscope.
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