The first day at Sihanouk Hospital we began rounds as usual
around 9:45. The goal was to start
at 9:00, but times are not rigidly adhered to here and a combination of the
residents finishing their morning examinations of the patients and the time
Kruy Lim needs to deal with her overnight email and ER patients and whatever
personnel issues are looming determines when we actually begin.
Rounds start at Bed 1 and finish at Bed 14; no bed is
visited out of order, except Bed 2, which geographically is next to beds 11 and
12. I write Bed rather than bed
because patients are not identified by their names, but by their bed
numbers. This is useful to the
visiting teacher because it is very unlikely we would either be able to
pronounce the patients’ names so that a Cambodian nurse or doctor would
understand us, or that we would be able to discern among names that are
sometimes nearly identical.
When we stop by the ward from time to time during the day,
the residents give us a quick update—Bed 4’s repeat sodium this morning (96
yesterday) is now 120 . . . the abdominal ultrasound on Bed 2 showed a small
splenic abscess.
It is always a bit of a shock to begin teaching at Sihanouk
Hospital because of the complexity and severity of illness of many of their
patients. Often their problems are unfamiliar to an Oregon
physician. Each year we have cared
for two or three patients with Burkholderia (melioidosis), an infectious
disease that I only barely recognized from my medical school tropical medicine
course and had never diagnosed or cared for. We have already had three patients admitted with miliary
(widely dispersed) tuberculosis.
On day 1 we met two young women with severe advanced lupus—a disease in
which the body develops antibodies against its own cells with resulting
deterioration in virtually every organ.
Left undiagnosed or untreated lupus can lead to early and rapid
death.
The patient in bed 6 was a thin young woman severely short
of breath, breathing at a rate of 40-48 times a minute, a look of desperation
in her eyes, constantly moving as she tried to find a position in which she
would suffocate less. The large group
of us rounding was tightly gathered at the end and side of her bed, listening
to the details of her admission and diagnosis a few days earlier and her lack
of progress. She had not been
previously diagnosed or received treatment for a combination of organ failures
including carditis (inflammation of the blood vessels of her heart) leading to
heart failure and fibrosis and inflammation of her lungs. She had been started on drugs to treat
each of her problems but seemed to be getting worse. Kruy and her residents see many similar patients and among
the visiting teachers there were more questions than suggestions of additional
or different treatment that had not already been considered.
At her bedside day and night was her single family member, a
daughter of 13 who attended to her constantly—helping her squat beside her bed
if she was too exhausted and short of breath to walk the 100 feet to the
toilets, bringing her the little bits of food she would eat from the carts on
the street outside the hospital, massaging her back and arms, cleaning her,
trying to help her find a comfortable position (there were none). We would often find her sleeping beside
her mother, leaning forward to share her mother’s pillow. She was with her night and day for two weeks.
Over the first two days Bed 6 repeatedly appeared close to
dying —frantically struggling to breathe, terror in her eyes, haunting us with
our inability to do anything more.
We gave her small amounts of morphine and she would sleep for an hour or
two, and then again her breathing would accelerate to unsustainable
levels. The work of breathing ate
away her main source of calories, her muscles and whatever fat she had
left.
And then, after two days, treatment of her lupus with prednisone and drugs for her heart failure began to take hold. She began to have periods when she
was calm and breathing perhaps at 30, able to sleep for short periods without
morphine. Although a few hours later she would
be again struggling to breathe, these spells became fewer and shorter. At the end of five days other problems
began to emerge—bleeding from her bladder; inability to urinate, making the use
of diuretics (drugs to move fluid out of her lungs) hard, since if we were to use them she had to be
able to pass urine. Use of a catheter was painful to her and we repeatedly
failed to insert even a small one used in children. A surgeon hovered as we considered putting a catheter
through her abdominal wall directly into her bladder to bypass her obstructed
urethra.
And then even that problem resolved. We saw her every few hours through
those days and gradually she would smile, press her hands together to welcome
and thank us at each visit.
As we were able to think about her leaving the hospital the stark
details of her life emerged. She
had two children, one too young to be at the hospital, now in the care of
someone in her village. She and
her husband had been farmers, growing a little rice. He had disappeared and his parents were dead. Her own father lived far away and was
demented, and her mother was dead.
She had no cousins or aunts, no brothers or sisters. She was utterly alone to feed and
clothe and shelter her daughters.
Beyond her small crop of rice, her only income was pushing a cart around
her village to gather cans and bottles—a chore hard to imagine her
resuming.
Through our resident Kosal I asked if she had money. She
has none. Do you have money to
buy your food here at the hospital?
She had a little left from what she brought, about 10,000 real or two
and a half US dollars. I asked if
she would allow me to give her money—about ten dollars—so that her daughter
would have enough to buy food for them for the rest of her stay. She squeezed her eyes shut, bowing her
head, raising her hands again to express gratitide. She says now we
can have more food. An hour
later her daughter appeared with several plastic bags of food and two iced drinks! They had been eating rice gruel.
A few days later she was ready to go home. I asked Kruy if it would be
possible to visit her in her village. The patient said the tuk tuk could only go part way to
her village, and then the road was blocked. Someone would have to take her on a motor bike the rest of
the way. Kruy said you cannot go, it is not safe.
Every year at least one patient breaks my heart. Bed 6 broke many of our hearts. A neurology resident visiting
from the Mayo Clinic was worried about what would happen to her daughters if
she died—they would be orphans and the plight of orphans in Cambodia is
sometimes unspeakable. He said he
would like to find a way to pay for the daughters to go to a residential
private school if she could not care for them or died.
She would need follow-up care soon after discharge. The trip would cost her $10 each way
and without the clinic’s help she could not afford her medications. An
arrangement was made to pay for her clinic care in a week. I gave her money for the trip and for a
month of food. More money
accumulated from others—I don’t know exactly who gave what or when it will run
out. Life is often measured in
dollars at Sihanouk Hospital.
A few days ago, while seeing another patient on rounds I
noticed that bed 6 had become empty, stripped of its sheets. Bed 6 had walked out of the hospital
with her daughter. Had she not
been admitted two weeks before, had there been no available bed, she would have
died.
The Patient in Bed 6 and her Daughter
________________________________________________________________________
I arrived from Chiangmai through Bangkok on a Friday
afternoon. The flight to Bangkok
at 10 AM took 75 minutes; flying at 1:00 to Phnom Penh took 90 minutes. On each flight an entire meal was served,
a cold breakfast on the first, a hot lunch on the second. The meals and drinks are served
efficiently and quickly, in full planes.
I would not fly to Phnom Penh just for the lunch, but it is phenomenal
how Asian airlines have preserved a level of gracious service and decent meals
for economy passengers, on flights barely long enough to warrant water and
juice service in the US.
In Phnom Penh the road traffic and dust are intense, but the
people are soft and welcoming. A
taxi from my guest house met me.
At le Safran, where I stayed last year, I felt like a friend arriving
for a visit and not a customer.
Thira, the young woman who lugged my suitcase up the stairs (I swear,
she insisted) would have fit inside and weighed at most 40 lbs more than it
did.
When I walk by the reception desk, the several staff members
stand up and pay full attention to anyone, guest or visitor. I am so unused to this kind of service
that on the first day I almost saluted and barked “at ease” (I did this exactly once in my military
career, to astounding effect, but I am saving that for another journal, A
Montana Naïf in a Major’s Uniform).
The rooms at le Safran are beautifully spare, decorated with
modern paintings and interesting lighting and simple furniture—just enough
shelves and hanging space, immaculately clean, always fully made up within
minutes of my leaving. Last
year I rattled around in a huge “deluxe” room with a long balcony overlooking
the pool and enough space to play badminton. At $55 that seemed unnecessary and my $38 room this year
seems like a bargain given the breakfast, comprehensive service, furnishings,
and warmth of the staff. About
half the guests are French, the rest a mixture of visitors from the English-speaking
diaspora.
I am up before dawn here as at home. Walking outside at 4 AM, the streets
and guest house are quiet except for bird songs, the small grounds smelling of
the trees in flower. The tuk
tuk and moto drivers and some of the staff sleep on the cushioned benches
around the terrace and outside dining room because their homes are too far away.
________________________________________________________________________
I timed my arrival to be able to go to Kruy’s father’s 87th
birthday party. Claire Zeigler, a chief resident at OHSU who also has come to
teach at Sihanouk Hospital, joined me at the party, although she had just
arrived after a very long and mostly sleepless flight a few hours before. Our tuk tuk trip to Kruy’s house was
serpentine—beyond the Russian market the houses and streets are more heavily
residential, with less of the office building construction happening in many
other sectors. Our path was broken
several times by construction that closed streets, and by weddings in tents set
up in the middle of the street. Once on the right street, we had trouble spotting the house: the numbering of houses is quixotic, perhaps reflecting the order in
which houses were built rather than progressive from one end of the street to
the other. We finally spotted the
lush gardens overflowing the terraces of the upper house and an aunt or two
waiting for us. Immediately we
were awash in introductions and hugs.
I believe some of the people who hugged Claire and me had no idea who we
were but recognized that there was a fuss going on: there just aren’t that many tall blonde young women
accompanied by diminutive antique professors in that part of Phnom Penh.
Inside the main floor--already full of furniture and many
years’ accumulation of the apparatus and keepsakes of long lives—was crowded
with 160 people, at least half of them children. We were introduced as we made our way under Kruy’s guidance,
to a round table thoughtfully filled with English speaking cousins and nephews
and nieces. Kruy and her sisters
had been cooking for several day; all the Chinese dishes for eleven of the
twelve courses had been prepared by them and arrived one by one at our and the
dozen other tables in bowls from which portions were ladled into our smaller
bowls by neighborhood girls brought in to serve and clean up. Each dish had a name that wished a long
and happy life. Probably the shark
fin soup had been prepared from real sharks, but fortunately the dish named
Dolphin was topped with pickles shaped like dolphins and no real dolphin had
been invited to participate.
There were dozens of children sitting at and passing by our
table; almost all, if not too shy, spoke perfect English inflected with
Americanisms that were startling coming out of small Khmer mouths. Many seemed to be attending the
International School, taught half in English and half in Khmer, with a curriculum
comparable to western schools. I
got started in a back and forth teasing conversation with the most outspoken of
the children, a seventh grader. She was scolded by her aunt and told
bluntly to be more respectful. I
confessed that it was all my fault but the aunt was unrelenting—there could be
no excuse for disrespect of an elder.
I had thought this was a special birthday party. Kruy said they started the birthday
party many, many years ago to bring the family and all of their friends and her
father’s business associates and their families together. The menu was exactly the same every
year. Those attending asked that everything be kept the same. Kruy and her sisters knew
everyone in the room and every child by name and history, and they all knew
each other.
Several hours into the party there were three pink birthday
cakes flashing light sticks. To keep the children interested, there was a lottery. Every guest got a
number and a gift: Claire got a
helicopter (not real) and a dress for a one-year-old girl. I got a pot to heat a lunch dish.
________________________________________________________________________
My friend Daroth has given up her tumultuous and stressful
job managing a Pakistani restaurant.
After a year of trying to quit and then being talked into coming back,
she finally succeeded in walking away. Daroth has
a large family for whom, as the oldest child, she is responsible. Her sister Srey Pich has ended an
unsuccessful marriage to a Korean who came to Cambodia to find a bride. Now with her mother she has a shop in a small market on the
fringe of Phnom Penh doing hair and make up. Daroth has joined them. She now earns a fraction of her manager’s salary; at the
restaurant she also got her meals and slept upstairs with two country girls who
worked for her. Now she commutes to
and from home on rough roads to her house far beyond Phnom Penh with her mother
and Srey Pich, squeezed together on a small and deteriorating motor bike. From home to the market is an hour; to central Phnom Penh,
two hours. There have been many
crashes over the years.
I have written about Daroth and her family in the earlier Journals. There has never been enough money. Daroth has loans to pay for the
completion of her house for which the monthly payments leave very little from
their three salaries and what her father sends home. Her computer has now-outdated software and has become extinct; she has
no internet.
Daroth’s sister Dany has attended a Catholic boarding school
for girls; boys come for classes but do not live there. Daroth told me that the school charges
her $18 a month for board, room, and schooling. When I first saw Daroth she said she had not been able to
pay in December or January. I gave
her enough to bring her up to date.
Her mother drove two hours to pay the bill the next day.
Last weekend her friend Vannak, a tuk tuk driver who
stationed himself outside of Daroth’s restaurant for years, drove us to Dany’s
school, where I talked to one of the senior nuns, Sister Ched. I was impressed with the care the
school takes for each of its students, the comprehensive curriculum, and the
number of students who, like Dany, have no money. Dany is a very good student and happy at the school.
Dany, Sister Ched, and Daroth
The Seventh Grade
Don Bosco School
I asked if I could pay for Dany’s school for a year; Sister
Ched wrote out what it would cost.
I was doubly shocked to see that the full cost of schooling was $35 a
month, and room and board another $35.
Shocked because $70 a month was so much higher than the $18 I had been
planning, and shocked because in reality $70 a month is just a tiny percent of
the charges for a boarding school in the United States. I asked Sister Ched--if I send you what
Daroth’s family is paying will they have no further obligation? She said the family would have no charge; the nuns would try to find another sponsor for Dany to pay the rest. Many other girls have sponsors and they
are always grateful when a new one appears.
Coming from a poor family, Dany’s hope for the future
depends on education. Even
English-speaking young women who graduate with a bachelor’s degree in business
earn only a few hundred dollars a month as secretaries or accountants. For the next year I will pay beyond
what Daroth’s family have been paying; if she continues to get good grades I
will continue for a while, but the stretch through high school and college will
require others to invest in her as well.
Neither Daroth nor Srey Pich finished college—they began
work at 20 to support their
family. Daroth was lucky to have a
benevolent friend hire her at a good wage with food and a room for seven years. Now she cannot find a similar job. To work or study in Phnom Penh she would need her own motor
bike (she could not afford a room in the city). To improve her ability to
care for herself and her family, she needs to study more English, become facile
with the use of the internet (surprisingly few are), and then learn skills that
thousands of others do not have.
Her dream is to go the United States. Neither her experience nor skill ratings
as a restaurant manager or hair stylist qualify her to enter the green card
lottery.
Daroth often asks me if I can find her a husband, a good man
with a good heart, not a Cambodian man, but an English or Australian or New
Zealand or Canadian, or US man. I
laugh and tell her I am not in that business. “No problem,” she says. I have no idea what that means.
________________________________________________________________________
A few days ago I was able to change my flight back to the US
at the end of this week. My
original booking required that I go back to Bangkok to catch a United Airlines
flight to Portland, with a two day layover in Bangkok to be a tourist. Since leaving Chiangmai two weeks ago the
conflict between those protesting and those supporting the government has
spiraled into bombings and shooting.
The protestors blocked early voting last week and one was killed. Yesterday an open running gunfight
broke out in the airport’s district between the two factions. Voting is today, but there have already
been massive blockades of polling places all over the country, especially in
the south, which heavily supports the protestors.
From the New York Times Today
The protestors hope that with many districts not able to
vote, the Election Commission will declare the election null. They hope that the caretaker government
of Yingluck Shinawatra will then be unseated by a military coup.
Civil war seems possible if not inevitable.
Thailand goes through political upheaval and coups every few years,
and always it recovers quickly. But
many think the differences are now so vast that public institutions such as respect for the royal family and courts are crumbling. The vast royal family itself is torn
into factions before and against Yingluck and her party. There is now talk of two Thailands, Bangkok
and the south permanently separated from the north, as it was in the 1800’s and
for centuries before that.
We are in the middle of the Lunar New Year. Every year tens of thousands of Chinese
come to Thailand for the five-day holiday. Travel agents in Hong Kong and Shanghai and Beijing have
reported that this year there were no bookings at all. Flights into Bangkok are half empty
when usually they are full.
My friend Tom Cooney helped me master changing flights among
the various Asian airlines affiliated with United. I am bringing back bottles of Angkor Beer to thank him. I was going to add a small packet of
deep fried tarantulas to eat with the beer and then remembered that he is now a
vegan and so doesn’t eat arachnids.
What a shame.
Bathrooms in good restaurants and hotels in Phnom Penh have
spray hoses next to the toilet.
The person ahead of me in Brown Coffee’s men's room appears to have taken a shower with the
spray: the floor was pooled with
water, the toilet paper sodden. A
small fish flopped out the door as I entered.
Now I am prepared for anything.
No comments:
Post a Comment