Phnom Penh Journal IV

Started Sunday, December 30, 2012
Finished January 11th, 2013

Prelude, Bangkok, and First week 

From seat 41D on the United Airlines flight from San Francisco to Narita-Tokyo and already awake 9 hours into a 33-hour trip, it was easy to question the advisability of my return trip to Phnom Penh. I never leave home (Portland, our Quimby Street house, OHSU) for an extended period of time without developing anticipatory nostalgia (if that isn’t an official DSM 5 diagnosis, it should be). My regret about all of the household or office chores I did not finish quickly wanes and I begin to long for the comfort of my own kitchen table at 5 am, the day’s first cup of tea, toast with marmalade, the New York Times spread in front of me, KQAC classical music quietly playing in the background. I begin to miss the flowers that will blossom and fade before I return and all the coffee shops I won’t visits. Away just hours I already miss the students and residents and friends I have just seen but want to see one more time, sooner than a month from now.

I am not very big, but the space between rows 40 and 41 and seats D and E seemed smaller than a breadbox, and my legs and arms were already complaining about having no space to unfold. United had stuffed the tiny pouch on the back of the seat in front of me with two glossy magazines, ear phones, a seating plan, and a soiled napkin spattered with the previous seat 41D’s occupant’s muffin crumbs. There was no space for my on-board comfort package: a large knapsack stuffed with computer, Bose earphones, two iPods, a novel, two New Yorkers, the stuff for brushing my teeth and blocking out noise and light, a fat wallet full of dollars and yen and baht, a neck pillow, five colors of Precise Micro pens, an 8 x 11 note pad, and a portfolio of itineraries, hotel reservations, visas, and correspondence confirming that a taxi will be sent from my Phnom Penh guest house to the airport to meet my 9:15 AM flight—written in French. My last name, (Noel if you have forgotten), is confusing—especially at this time of year, and especially in Phnom Penh where the French are a substantial component of the non-Khmer population.

Fewer than half the passengers leaving San Francisco were Caucasian--I wasn’t counting, but I am guessing 40%. Most were Asian, and the few I talked with while waiting to board were going to Fukui, Bangkok, Vientiane, Mongolia, Seoul, and Hong Kong. The flight was absolutely full. The flight crew disseminated 900 meals to 300 economy class patients with amazing efficiency—the crew were the workers, the plane was the conveyor belt, and the passengers the product—three hundred delivered bodies all in about the same condition as when they boarded. To my disappointment no babies needed to be delivered, no one had chest pain or sharp lower abdominal pain, there were no asthma attacks—all of which I have cared for on previous flights and which I look forward to as a break in the boredom and a possible free upgrade on a future flight.

I cried over a hopelessly sentimental film from the endless “late works” period of Clint Eastwood, called Trouble with the Curve. Even with Amy Adams and Justin Timberlake doing the best they could with the pathetic script, there was absolutely no excuse for making this film. And yet I cried.

In the Bangkok coffee shop in which I wrote this section, recorded music had just started: “It is beginning to look like Christmas.” Outside it was 95 degrees and it looked nothing like Christmas.

 * * *

Probably the best thing about coming to SE Asia is the reminder of the self-preoccupied condition in which every country spends its days. The USA rated about 10 print inches in the Bangkok Post, most of it about the budget tantrum in Washington and Matsui's retirement from baseball.

* * *

In March Sihanouk Hospital Center of Hope was recovering from a nearly fatal cut in funding in the face of a worldwide recession and then the loss of one major Japanese donor who shifted his support to tsunami recovery. In Cambodia, much that gets done is due to hundreds of non-government organizations like Hope Worldwide or contributions from the governments of other countries. A bridge gets built because of the Chinese, a children’s hospital is set up in a remote part of the country because of contributions from Mr. Honda, and a road to a tourist site is donated by the Japanese. For months SH had to close its medical and surgical inpatient services, the emergency room, and the outpatient clinic for the poor. Much of that had been restored by the time I began in March—and more progress occurred over the summer.

In mid-December, shortly before I left for Phnom Penh, Kruy Lim, the amazing medical director of Sihanouk Hospital, wrote to say that because another donor had withdrawn a million dollar contribution there would be a budget shortfall. She was unsure that those parts of SH that care for those without money would be able to stay open after January first. We agreed that I would come nonetheless and that I would do whatever I could to help care for patients even if teaching had to be severely cut back. 

On my first day, I asked the SH driver Narin how he was. “Not good. Maybe no budget.”

I showed up at 7:30 AM for my first meeting with the staff and found an empty room. I did not know what that meant—had the hospital shut down? . . . had the staff already seen too much of me in March? One resident had followed me into the room and began making phone calls. I was in the wrong place, but everyone was heading toward the room I was in and in a few minutes there were twenty people and a lovely reunion. They had been in another room meeting with the hospital leaders who told them that they thought there would not have to be any cuts; everyone would have to see more paying patients.

By some kind of magic or good management the hospital’s operations are about where they were last spring—all the inpatient services and clinics and emergency room are open and jammed with patients, and the surgery ward has expanded to 12 beds. Almost all of the doctors I met in March are still here, including the residents, who will not turn over until the end of February.

 * * *

I think I was more grateful than overwhelmed when Kruy said that for three days I would be rounding alone while she attended some meetings. I was not sure if that represented her confidence in me or a really, really bad misjudgment! In two days we had 9 admissions.

On my first day alone with the residents we had a full census, 12 patients, all incredibly sick. There is no such thing as an admission to rule in or out a myocardial infarction; there are no admissions for social problems—everyone in the clinic and emergency room has social problems.

Bed 1—a 60 year old man admitted for sepsis (bacteria in the blood and shock) for the third time. He has a severe anemia, probably from bleeding into his colon—today he developed peritonitis and probably will not survive the night. He is too sick for surgery in our hospital, and no other hospital would have admitted him.

(Afterword: he did die that night—a few hours after his blood culture grew out Burkholderia—melioidosis—for which we were not adequately treating him. At 4 AM his family wanted to return his body to his village, but they had no money and only a motor bike. They sandwiched his upright body, wrapped in a sheet, between his son, the driver, and his daughter, sitting behind. As they were about to leave a nurse spotted them; the night staff scraped together $50 to pay for an ambulance to bring his body home with dignity).

Bed 2—a 23 year old woman presenting for the first time with a vascular inflammatory disease called lupus, with cerebritis and carditis and peritonitis (inflammation of the brain and heart and the abdominal lining). She was admitted in coma a few days ago but the high dose prednisone we are giving her has worked well and today she smiled as I examined her—her abdomen is no longer tender, she probably will recover, at least for a time. She has a seven year old son.

Bed 4—57 year old man the upper half of whose left lung is completely filled with abscesses. We thought this might be an infection of an old tuberculosis cavity, but today his wife brought in his old X-ray images (patients take these with them when they leave) and his lung was clear just a week ago. Our best bet is that he has a severely inflammatory infection with gut organisms. He is desperately ill.

Bed 5—a very old lady admitted with potassium of 8.1 (normal would be less than 5)—who got better overnight and will go home today.

Bed 6—a 51 year old woman with no history of illness who has severe hypertension with a new stroke—she was sent home from a private hospital after five days of treatment because they could not make her better. She came directly to SH and has proved to be very resistant to treatment for us as well. We have just added a fourth drug and we are down to only a few more options. She does not seem to have the usual causes for such severe and stubborn hypertension.

(In two days she improved; when she leaves how will she afford to pay for four medications? even though they are generic and not too expensive, she has no job and her family has no money.) 

Bed 7—A 26 year old man with world-class psoriasis and knees so inflamed that they cannot be flexed.

Bed 13-- another young man with the worst psoriasis I have ever seen-- he is welcome nowhere as he leaves a trail of scales where he stands or sits. He is miserable, with skin that hurts when he moves or breathes or chews. We have found a Dermatology clinic willing to start him on treatment that Sihanouk Hospital cannot afford.

Bed 9—an elderly lady, stone deaf, admitted with profound hypoxia (low oxygen), who was nearly killed in another hospital when they gave her too much oxygen and she stopped breathing entirely. She will go home today.

Bed 10—a 40 year old woman who has pulmonary tuberculosis and kidney failure and heart failure and inability to move the left side of her body. She has not moved from her bed at home in six months. We discovered an infection of her heart valve—she will need weeks of IV antibiotic treatment.

Bed 11—a heart breaking 20 year old woman with appendicitis whose symptoms were ignored or mistreated in four or five clinics and district hospitals. She is grievously ill with a huge abscess in her lower abdomen because of the delayed treatment. We have finally persuaded our surgeon to operate on her, as she has gotten worse with the best antibiotics we have available and she will not recover unless her abscess can be drained. She may not survive her surgery.

Bed 12—a man in isolation because of active tuberculosis involving his lung and pleural cavity (the lining between the lung and the chest wall). He needed a chest tube to drain the fluid, and we have started treatment for tuberculosis. Before he came to SH he saw a surgeon who told him there was nothing wrong with him.

We rounded from 9 AM to noon. By the end of rounds we had found three patients to send home; there were three patients waiting for beds in the emergency room, including a girl with meningitis and continuous seizures. She had also been turned away from two hospitals.

Yesterday a 16 year old boy came to the emergency room with a swollen face and right arm, and a mass in his neck . A chest xray showed a huge mediastinal mass (under the breast bone). The most probable diagnoses are Hodgkin’s disease (or lymphoma) or metastatic testicular cancer. These are both potentially curable, but he was turned away because there are neither radiotherapy nor chemotherapy available for a patient without money in Cambodia. Because possibly he has tuberculosis, for which there is money for treatment, I am going to try to see if we can biopsy the neck mass, but none of the necessary specialized tests to characterize a lymphoma or cancer can be done at SH. The argument that a teaching hospital might admit him because he would be a very good patient for students and residents to care for carries no weight—there are thousands of such patients in Cambodia.

* * *

Kruy Lim invited me to meet her father—who she invariably refers to as “my lovely father”—and her sisters. At the end of the day yesterday we went by tuk tuk through Phnom Penh’s intense traffic to their home near the Russian Market. The tuk tuk driver knows the way and the tactics—he spent half of his time driving on the sidewalk when there was more room there than on the roadway. There is no eye contract between drivers, one simply turns swiftly in front of oncoming cars and motos and tuk tuks and trusts that they will slow down. It seems to work.

After the Khmer Rouge were driven out by the Vietnamese army, Kruy’s father and family had lost everything. They returned to Phnom Penh from the rural areas in which they had been sent to work on farms; they started with a simple street stand selling fruits and vegetables, Kruy and her sisters and brother going to school and working when not in school. In a year or two they opened a little shop at the Russian Market selling soda and beer and cigarettes and whatever small things people might need; today along every road and street there are still hundreds of such shops, each making just a little money: supermarkets are still uncommon. Then they opened a second shop selling bricks—much had to be rebuilt in Phnom Penh—and in time they added separate businesses selling concrete and then structural iron.

Their house is larger than I had expected—three tall stories connected by steep stairs. There are hundreds of plants, squeezed into every space with a little light—doors are thrown open to the outside, as is the whole top floor, which has only a roof but is open on all sides. They live with comfortable clutter in a place they have occupied for 30 years now—Kruy was 10 when they moved there. She lives with her father and two other sisters; countless cousins and nieces and nephews come and go—they never know who will be there for dinner--and visiting occurs all day long without forewarning. Each day her father, now 85, goes with the oldest daughter to the iron business, where she manages and he spends the day talking with customers and friends. He is always with some family member. A second sister—Ngor--works for the Ministry of Education and is the main chef. They own two cars, but Kruy herself isn’t considered to be safe driving—her own assessment.

Half the main floor was full of perhaps 50 beautiful plates of fruit and flowers being prepared for a family wedding the next day— it is plain that they frequently do this work together for ceremonies and celebrations and temple visits—they do not entrust it to markets or florists.

We sat at a small round aluminum table surrounded by stools set up each evening in the central room. Only Kruy’s father sat in a wooden chair with a back, and when he started to eat, we all did. The dishes were a half dozen Cambodian river fish steamed with dried Chinese mushrooms and ginger and unknown spices; river lobsters prepared in two different ways, as sweet as any Maine lobster but much more flavorful because of the broths in which they had been cooked; rice-straw mushrooms that had been steamed in another broth; rice; and five kinds of fruit. There was little conversation—only Kruy and one sister speak English—and over the course of the meal other family members joined, a child arrived to spend the night, bed preparations began (as many as five or six people sleeping in two rooms). There was no plan for my visit other than simply adding me as yet another member of the family. I was sent home with bags of small and large oranges and other fruits the names of which I may never know.

* * *

This is my first day to relax. Once again I am in a Brown’s Coffee Shop to write—but a different one. It is packed with young, well-dressed Khmer. A few westerners share a long library table with me, all but one of us welded to our Apple computers (does the simile “like fetuses attached to their placentas” seem gross or merely weird? Think about it). iPhones ring everywhere, there are no empty seats, morning coffee has now drifted into lunchtime, there is a pleasant incomprehensible chatter. The first week has been very different than anything I experienced in March: I have spent every evening and all last weekend with Khmer friends or with Kruy and her family. The intensity of sickness at the hospital is less overwhelming. I am out to dinner three times next week. The weather is cooler than last year, no more than 80 or 85 during the day. The Cambodians are complaining that it is too cold.

I have figured out a way to make myself a pot of tea at 5 each morning to have with a bit of yesterday’s baguette and marmalade, and I can listen to KQAC streaming along with the New York Times on my computer as I read the overnight emails from all those I miss.