Phnom Penh Journal

Saturday, 17 March, 2012
Phnom Penh, Cambodia


When I read about visiting Cambodia after accepting the invitation to teach at the Sihanouk Hospital Center of Hope, in a left brain way that led to no action whatsoever I wondered whether this was one of my bright ideas that I should have ignored. There certainly have been some, many not so long ago.

Frommer’s Cambodia & Lao was seeded with warnings about poverty, banditry, and danger to those who wander out of the usual tourist areas. There are about 2,000,000 mines yet unexploded, left from the long period of the French-and-then-American war against Ho Chi Minh, the subsequent atrocities committed by the Khmer Rouge and Pol Pot against their own people, and then, in a final act, the swift and effective removal of the Khmer Rouge by the Vietnamese.

And yet in spite of their many cautionary remarks, Frommer’s and Lonely Planet each publish over 300 pages of destinations and adventures and histories of an ancient civilization as dramatically advanced as those of Mexico, Central and South America.

Whatever. I had already bought my plane ticket.


* * *

Sihanouk Hospital is located near what is called the Olympic Stadium, in the northeast quadrant of central PNH. I am picked up every morning at 7:10 by Sarin, who drives a Hyundai van to transport hospital workers to several mobile and satellite clinics. Every block along the route is a new demographic—much of the central area was never affluent, and skimpy structures and fractured roads have simply endured 40 years of war and outright murder of much of the population by the Khmer Rouge. Some blocks have embassies or NGO’s, others are low, cobbled-together structures in which working and living occur in the same space. The road in front of the buildings are an extension of the living space; where there are sidewalks, they are usually full of parked motorbikes and cars.

People, cars, tuk tuks, motorbikes, pedicycles, bicycles, trucks, and pushcarts all are mixed together in the brisk traffic. I have seen one traffic light. When a motorbike or tuk tuk wants to park on the left, it simply heads right into the oncoming traffic angling toward the far bank . There is very little honking, and although I understand that the orthopedists say that accidents are frequent and their business brisk, I have not seen even a sudden swerve or precipitous stop.

Business rush hour is also school rush hour: children are driven by mothers or older sisters or fathers, three or four or five to a motorbike. At the Central Market today I saw three children under 5 pressed like peas in a pod between the driver-mother and the grandmother, only a fraction of whose rear had a seat under it They were unconcerned as they weaved through hundreds of workers and shoppers and four acres of vegetables and fruit and what yesterday had been pigs and cows and chickens.

On my second night here I went to Majid’s restaurant Saffron. Majid is Pakistani; with his Australian wife Yvette, he owns both my guest house, Circa 51, and a small restaurant on a block with twenty or thirty small restaurants on a road with perhaps a hundred small restaurants. If a Circa51 guest eats at Saffron, they call a tuk tuk for you if they doubt your navigational skills or safety in vehicular avalanches. There was no tuk tuk immediately available, so I was chauffeured on a motor bike. What are the stages of anticipating death? First I concentrated on blocks, left turns, right turns so I could walk—not ride back (denial). I quickly reached the negotiation stage when we crossed the main east-west road and I wondered whether I should stay with the bike if we crashed or simply jump on the hood of the impaling car. Then resignation: no longer counting blocks and abandoning an escape from the bike, I settled for thinking about the most wonderful moments of my life so that I would have pleasant thoughts as I entered . . .

And then we stopped at Saffron.

I have declined further generous offers of motorbike taxis, although a walking Caucasian attracts 30 tuk tuk or motorbike taxi ride invitations a minute. “Tuk tuk sir?” Apparently there is a strong cultural belief that no Caucasian truly wants to walk.

None of this is exaggerated.

* * *

Since my third year of medical school, when I began a long life of caring for patients, I have experienced grief many times—all doctors and nurses do. Patients die unexpectedly. Patients reveal the circumstances of lives that will never again have hope or pleasure or comfort. Even patients whose death is expected and not premature have punched a hole in my heart when they finally went.

I have never been as sad as watching Kruy explain to an exhausted mother—and then an hour later, to a handsome older brother—that their beautiful, doll-like child and sister would soon die. Kruy is the head of the department of medicine at Sihanouk Hospital. Perhaps forty, single, living with three sisters and a brother in a small house, all caring for their 85-year old father who is one of the few men of his generation not to be murdered by Pol Pot, she has been an internist at SH since it opened in 1996. Every day at 9 we round on the 12 inpatients for about two hours, and then we go down one floor to the emergency room where there are eight or twelve patients on cots being evaluated. On the first morning, on the fifth ER cot, was Reung. About two months ago she was diagnosed somewhere else with meningitis. In Cambodia, there is a 50:50 chance that meningitis is caused by tuberculosis. We have no idea whether the diagnosis of non-tuberculous meningitis was correct—but she was treated at home with IV antibiotics. When her fever and headaches and lethargy did not get better, she was taken time after time to the doctor who first saw her. At some point her doctor added prednisone.

After two more weeks she was worse and her mother brought her to SH. The trainees who evaluated her thought she still had meningitis, but when I examined her she clearly had something else—she had hyperactive reflexes, uncontrollable tremors of her arms, dilated pupils. She looked at me with a uncomprehending gaze. She had a high temperature. Within a few hours we were able to do a CT of the brain—thinking we would find evidence of increased pressure, swelling of the brain. It wasn’t present. Then Kruy performed a spinal tap. The pressure was normal, there were no abnormal cells. She did not have meningitis.

We admitted her directly upstairs. She was “bed 7.” We stopped all of her medications, thinking she had encephalitis, an inflammation of the brain—and we thought if this were a viral encephalitis, she would gradually get better. The next morning additional laboratory tests returned revealing unexpected severe destruction of her liver. We looked for viruses that could affect both the brain and liver, or perhaps vasculitis (an inflammation of the blood vessels and surrounding tissues). None of those tests were positive.

Only about ten percent of Cambodians can pay for modern health care, the rest get very little. Some are lucky enough to be admitted to one of the 12 beds at SH. All of the care is given by family members, and at every bed at every hour, there is someone from the family or extended family. Reung was attended by her mother constantly (her father had been killed in the wars) and by shifts of young women who were friends or cousins or sisters. For four days they held her limp body up and gave her food bought outside the hospital gate by spoon—the family provides food. They constantly sponged her with wet towels. They helped her toilet, they changed her clothes—all in an open room with eleven other patients, all gently, all lovingly. At every moment she was clean, touched, watched over by. The nurses give medications, start iv’s, check vital signs. Everything else is done by family.

Many times we asked her mother if they had given her traditional medications—many of which have unknown and toxic ingredients. The mother said they had given her only what her doctor had prescribed. We asked her to bring in everything. Among the medications was a common drug—acetaminophen—given to her to suppress her fever. They had been given bottles of acetaminophen intended for intravenous use, 1000mg in a bottle, and they had given it to her intravenously three times a day—3000 mg of iv acetaminophen a day.

Yesterday it was clear that her neurological symptoms were the sequelae of her original encephalitis. Perhaps they would have cleared in time. But the acetaminophen which she had received in toxic doses had destroyed her liver. And yesterday her family was given the news. Kruy talked to her for ten minutes—there were six or seven of us at the foot of Reung’s bed—trainees, nurses, Kruy. Family members of adjacent patients made up a second row of audience to a mother so stricken with the news that she slowly crumpled to the floor. Three times during the remainder of rounds she returned to Kruy: they had no money but they would do anything, sell anything, there must be something that could be done.

She—Reung—when she spoke at all, had cried out to go home for four days. We were doing nothing but watching and hoping, and I had let my heart go soft—each day I saw her first thing in the morning, last thing when I left, hoping for evidence that she was getting better—good, she had a slightly lower temperature overnight, good, maybe she was a little more comprehending when we talked with her.

An hour after our rounds had finished, , I was crushed— Reung’s family had taken her home. Bed 7 was empty, being aired out. In an hour another patient took up her bed. In a week she will be dead, from taking a drug that we use every day for mild pain and fever. It has this terrible effect when taken in toxic doses. When the liver is destroyed, it does not recover. There are no liver transplants in Cambodia.

I have cried for the hour I spent writing this.

* * *

In bed 11 there is a young mother of two who was treated for tuberculosis about ten years ago. She was admitted with an infection in the cavity created by the earlier tuberculosis. A chest xray confirmed a pneumonia; she had staphylococcus in her blood. She was wan, listless, coughing yellow sputum and blood, gradually losing what little muscle she has left. In four days she was no better. A chest CT showed five—maybe six or seven lung abscesses-- too many to drain. There is no chest surgeon at SH. Surgery would probably require removal of most or all of the right lung. Antibiotics alone will not cure this. She will go home in a day or two but she will die at 34.

* * *

Sometimes there is no money for a CT: the doctors chip in to pay for it. A CT is about $90.

The trainees receive no income. The staff doctors are paid about $700-900 a month. Sometimes Kruy just pays from her own pocket.

A junior policeman or someone working in a restaurant six days a week earns about $50 a month. Neither will have health insurance.

* * *

Patient census day 2, by bed—four patients waiting for admission in the ER

1. 48 year old hypertensive man with a large right-sided stroke. Home on day three unable to walk. Family trained to give him care at home.
2. 80 year old man with urinary sepsis, serium sodium 90. Home on day four with a sodium of 130.
3. 40 year old woman with lupus admitted with angioedema (swollen all over) after taking a traditional remedy. Home in two days.
4. Woman with chronic hepatitis B and encephalopathy. Better with lactulose and discharged home on day 2.
5. 20 year old man with tuberculous empyema and pneumo-hemothorax, new diagnosis of tuberculosis. Kruy and trainee put in the chest tube. Home on day four with oral antibiotics.
6. 20 year farmer with type I diabetes admitted with massive staphylococcal infection of right hand requiring debridement. Still in the hospital. The surgeons gladly transferred him to their ward.
7. Reung, encephalitis
8. 50 year old woman with fever and hepatic encephalopathy. Had been taking prednisone but stopped and she also had adrenal insufficiency
9. 20 year old boy with nephrotic syndrome on steroids admitted with peritonitis due to tuberculosis, strongyloides, or typhoid
10. 80 year old man with liver failure and pancytopenia (low white cell and platelet counts, very anemic) probably due to sepsis. Died with serum HCO3 of 4 and lactic acidosis shortly after admission
11. 34 year old woman with multiple lung abscesses
12. 50 year old woman with tetanus with moderate symptoms. Treated with equine tetanus antitoxin and massive doses of valium

By the end of rounds Kruy had chosen the four patients to be sent home so that four new patients could be admitted from the ER.

Five of these patients had mitral stenosis. Several more also had active pulmonary tuberculosis.


* * *


The day I arrived Majid asked it I would see the manager of his restaurant. I saw her at Circa51 with her sister and several of the Circa staff helping to translate. It was a long and interesting conversation about her work and her family. She has the kind of shoulder and neck pain that is common in anyone who does lifting and carrying all day long. I suggested a program of relaxation and strengthening exercises and a new mattress.

The next day she and her sister prepared a meal for me at Circa to say thanks, and today she took me along at 7 AM when she shopped for the restaurant at a large market near the royal palace and river. She bought leafy vegetables at five different places, fruits and vegetables at two places, and pork and beef ribs at two places. In the end she had about fifty pounds of food which ordinarily she would have carried sitting on the back of a motor bike.

I had been told to weld my money to my body, but there was nothing particularly different at the market than I have experienced in Bangkok or Vietnam. I saw thousands of people, women outnumbering men five to one, and lots of little children making their day care with their mom and sisters where they were set up. I was the loan westerner and the only person with a camera.

In three or four “shops” large river fish had heaved themselves out of shallow basins and were flapping toward mounds of fruit or piles of ribs. No one but me noticed or cared.

Darosh says Central Market is cheap—and everything is certainly fresh. Meat is uncured. In a large tray of eggs one had been opened to show the live near-hatchling inside. Whole chicken intestines were draped around hooks like pearls in a Tiffany window. An old man with his legs blown off just below the knees did his work scooting around on his butt—life goes on.


* * *

In Japan in 2001 my default quick response to being spoken to in Japanese was to answer in Spanish. Poorly, but in Spanish.

In Spain last fall, I had trouble not responding in Japanese

The reflex persists: I am continually surprised when my afternoon greeting—konichiwa--or I understand—wakarimashita—result in a blank stare. In the coffee shop in which I am writing this, the girl who served me was puzzled when I said arigato gozaimasu—thank you. “You cannot speak English?” she asked.

The look of pity is universal.