Phnom Penh Journal III

Friday 30 March, 2012


Phnom Penh Journal III

My last morning in Phnom Penh. At 11:30 I will leave Circa51 for the airport; by the end of the afternoon I’ll be at the Rex Hotel in Ho Chi Minh City.

I couldn’t face packing last night—by the last hour of my last day at Sihanouk Hospital the final wisps of emotional energy had ebbed. I was a balloon with all the air wheezed out, useless.

What words to describe these three weeks? –intense, exhausting, endlessly fascinating, at times incredibly sad, scary, confusing. Rich at the limits of my ability to put words to what I have experienced.

Yesterday, many people asked if I would come back. Two weeks ago I would not have bet on it. Leaving the patients, the residents, the staff, the secretaries yesterday, driving back to the guesthouse through the after-school traffic, I was unable to imagine not coming back. (Yes, a subtle double negative. As Miss Fink, would never acknowledge, sometimes a double negative makes a more powerful affirmation than a single positive. “I was able to imagine coming back” is something very different.)

* * *

At the end of the 7:30 whiteboard talk everyone for the first time was very positive and engaged. “We hope you want to come back.” “Please have dinner with us again next time.” “We thank you professor for teaching us.”

It was strange—I never think of myself as “professor.” It would be like a friend whose shrubs I had helped reshape saying “thank you gardener for showing us how to prune.” I think that doctors practicing general internal medicine spend their lives explaining—at some point, explaining to patients, to students, to each other is how we spend our lives, almost as unconscious as asking patients the questions we call a history or seeing the pattern that transforms the puzzle of a patient’s symptoms into a diagnosed illness.

Later, I had lunch with two of the women doctors and a resident. I am guessing both women are in their forties, each has had a short period of specialty training—a few months of diabetes for one, gastroenterology for the other.

Rin, the gastroenterologist drives a motorbike to work. I asked if she rides fast. “Very fast. I have a car but there is too much traffic. With a motor bike I can go around and through.”

Yes. And sometimes up on the sidewalks. All space is potential thoroughfare. There is no time for afterthought in Phnom’s Penh’s surging traffic.

She and Lim both went to medical school in Moscow, as did the resident. The countries that have been most supportive of training the Cambodians after the Khmer Rouges’ execution of most of the professional class have been Vietnam and Russian. Only a few of the residents training at Sihanouk Hospital went to medical school in Cambodia. Most of the non-Cambodians living in Phnom Penh are with governments or organizations that are helping Cambodia recreate a civic structure and a workable economic model.

The academic year starts in the spring here, as in Japan. The new first year residents work at the level of a beginning US third year student at best. Our current intern after two weeks is still unable to organize his admission history chronologically without including this morning’s laboratory results and yesterday’s emergency room treatment in the chief complaint. He doesn’t understand the medicines his patients are receiving or the difference between a bacterial and parasitic infection. Kruy is direct—“you don’t understand what you are doing. You need to read about every drug. You cannot read an ECG. I want you to give me your reading of every new ECG”. Yesterday, at bed 12, in exasperation she put him on probation: in his workup and presentation he said a patient paralyzed on his left side had normal strength in all extremities; there had been a dozen other errors already. There was no committee meeting or discussion with a lawyer to insure due process. All of those would have been impediments: he is not ready to do this work and either gets better or leaves. There are too many sick patients and after two weeks there is no more time to lead him step by step.

The best of the senior residents are working at about the level of our finishing interns. The junior staff are more experienced but prone to ignoring details. A patient admitted two days ago with a serum sodium of 90 (135-145 are the usual values in healthy people) had been seen in clinic five or six times with serum sodiums less than 120 without comment or intervention in the progress note or intervention—the last time the sodium was 100 and the plan was “return to clinic in two months”. Kruy points all of this out to the admitting residents—“this is your work. You have to check everything and stay until you have an answer and a plan. You can’t just ignore it.” In 16 years she has trained hundreds of residents. There are patients as sick as these in every hospital in Cambodia. The residents come to Sihanouk because of the lectures given by the volunteer faculty and because of Kruy. She works without a back up, takes a day off a week, rarely takes a holiday. Her salary is less than a third of what our residents are paid.

If setting back the clock were possible, I prefer their training model: once it was ours, when I began training in the early sixties. All the patients are in a single room, the residents and nurses and secretary sit in the center, the nurses circle with us on rounds, the families are always present, the notes are hand written, xrays and outpatient records are on a rack in the room. We finish examining a patient and then walk to a light box to review the images. Sometimes the radiologists are wrong—Kruy is more reliable. Kruy sees every patient who will be admitted in the ER and manages them there until they are stable. When she rounds in the morning, she has already been involved with diagnosis and treatment from the first few hours. She reads the orders as we round, corrects them, writes new orders, points out mistakes. Most patients go home days before we would release them. For the sickist patients we see the natural history of tuberculous meningitis and hemopneumothorax , gram-negative sepsis and ST-elevation myocardial infarction—patients stay for days only when therapy at home is impossible—and impossible for them is a very tough standard.

* * *

Kruy told me on Monday that the young woman with encephalitis and liver destruction, Reung, died the day after her family took her home.

In three weeks I have regained the instinct of recognizing imminent death in the very young. Tuesday a 24-year old woman was admitted with floridly contagious tuberculosis—every breath rattled with wet secretions. She was delirious. Her symptoms had been ignored for months by various traditional doctors who gave her unknown treatments. A few hours after she was admitted we rounded on her. There was nothing left of her but bones and skin, no muscles. An hour later she told her mother she was sleepy, and in a few minutes she stopped breathing. This disease—the disease that killed Keats and the Brontes, Alexander Pope and Guy de Maupassant and Kafka --was called “consumption” in the 19th century. She had used up every accessible calorie in her body and her fire simply went out. Her mother begged us for hours to try to revive her body. She left behind a five-year-old son. He had been exposed to her for months, but no one will check.

* * *

On my last drive to the hospital the driver took me by a different route. We passed a nice dress shop where the young clerk was sweeping the sidewalk in front while her perhaps-two-year-old-daughter played jump the broom. The little girl will spend the day in the shop with her mother. On the sidewalk next to the shop a young woman weaves brooms from cane, her feet inches from the motor traffic. Next to her an old woman with a few plastic bags of food prepares breakfast over charcoal for two men sitting on low plastic stools. Students stream by on the way to the adjacent high school. Boys ride motor bikes; if girls are passengers, they side with their legs over the left side; girls driving themselves mostly are on scooters. Uniforms are simple: white shirts or blouses, blue pants or skirts. Only black hair. No ornaments. Most will not be able to attend university—there are few scholarships for those without money.

Leaving in the afternoon, we passed by perhaps a thousand used industrial sewing machines in a stretch of a dozen shops in 50 meters. Clothing manufacture always moves to the least expensive labor markets and Phnom Penh is now where much of the world’s mass-produced clothing is pieced together. It had been Thailand and Vietnam, but those countries have become too expensive as labor has shifted to electronics and heavy manufacturing and their labor practices have attracted attention forcing better wages and shorter hours.

* * *

On my last night, Daroth had prepared a Cambodian meal in her Pakistani restaurant. She asked me to come at 5, before most people dine. There were six dishes—deep fried prawns, the kind we call coconut shrimp in US Thai restaurants; a chicken curry; green papaya salad with shrimp; another prawn dish with vermicelli and something like vinegar; rice. Too much food. Our conversation is limited—she does all the conversational work, doing the best she can with a limited English vocabulary. A Khmer-English dictionary and my laptop tuned to the internet are our dinner table partners. A cousin’s cousin’s four-year-old daughter had been left for the day—Daroth fed her bits and I found Grover--the Groucho Marks of this generation’s children-- on You Tube. She sang the ABC song forty times. A twelve-year old boy who stops by Saffron every night on his restaurant sales rounds translated for us—he goes to the local school and speaks excellent English. He asked me to be his Facebook friend. He wanted to see pictures of George Obama.

By seven I was worn out and excused myself. Daroth asked why I was leaving: Why? There are no customers in Saffron yet, you have no more lectures to write.

In Cambodia, families spend time together without plans or TV or structure or lists or a desire to be someplace else. There is no concept of “personal time.” Why was I leaving to be alone in my guesthouse, why wouldn’t I want to stay for the rest of the evening?

Today she and her sister Pich and the little girl were waiting for me at Circa when I came back from the coffee shop, an hour before my departure time. A SUV from the hospital took us to the airport. Only passengers are allowed inside the terminal. After I checked in I came back out to say goodbye. We sat for a while, the little girl played with a balloon, Pich told me which western young men entering the airport she wanted to marry. They would have an hour-long tuk tuk ride back to central Phnom Penh. They had spent three hours with me already. I thought they must be tired, eager to go back. They were not. I was humbled by their complete contentment just being with a friend.

* * *

Everything came together on Wednesday. Kruy had a meeting; I rounded with the residents by myself, twelve patients, bed to bed. We examined each patient, reviewed the data. I asked questions about plans, there were a dozen things to do after rounds.

The rounds were not much different than I make at home, absent the computers and the team room. Except--they were conducted half in English, half in Khmer; the next-door patients’ family participated actively in the presentations and stood up to watch me do examinations. A patient with diarrhea took care of the matter squatting over a pan on the floor next to her bed. Half of the patients had active tuberculosis, two more had less than a third of a normal cardiac output, another three had gram negative infections. A man brain damaged as a child seized with the regularity of a clock, every ten minutes, as he had for two days.

That morning’s conference worked better than most of the earlier ones—we talked about preventive medicine and screening. When we got to exercise and eating, questions became highly personal as I estimated the calories in the most frequent foods in their diets. They were surprised by how few calories are consumed by casual exercise (300 for a 3 mile run at a moderate pace), how many by a man laboring all day shoveling (4000) and the implications for feeding him.

And then the universal question—it never fails: how many calories for sex. Everyone laughed. I said, it depends on who is doing what. They laughed again and wanted details. I said, next year when I come back. More laughter: sooner please.