Katie en Laurent bij de Khmer: Hedgehogs, ducklings and sardonic smiles

31.3.11
Today was considerably calmer than yesterday. We even had the late afternoon off! The temperature is steadily rising to the familiar 40°C, and rising, undoubtedly, to a climactic thunderstorm this weekend. For some reason the afternoon surgery was ground to a halt; and I found myself with dr Rithy, dr Vaun and dr Lemsokong discussing the upcoming jour de fête. Similar to our all soul's day, it is a to remember the dead. Dr Rithy explained that having a family tomb is much more advantageous; financially speaking. From death the discussion soon treaded on the sensitive subject of the "bayl Pol Pot" the era of Pol Pot. As dr Vaun recounted this period saw the abolishment of religion and destruction of many tombs. As he puts it "pour la construction des routes". When the discussion dwelled upon catacombs and such, Tuol Sleng was mentioned. After reading the biography of Saloth Sar (by Chandler) I was familiar with the name of the most feared place in the country at that time. The dreaded interrogation centre from where nobody returned. Where thousands were tortured and executed. Dr Rithy broke the somewhat solemn silence that followed and narrated that it was there that he went to get a few skeletons to study his anatomy in his student years. He also swore to be telling the truth when he convinced me that of all the remains in Tuol Sleng only left limbs can be found, and nobody knows where the right ones are. I must investigate this when we visit...

Then our conversation was interrupted by a patient being wheeled passed us on a stretcher. I noticed his cramped spastic leg and arm but couldn't quite make out why he was smiling in that very odd way. Just as I might have guessed it, Dr Rithy diagnosed the patient with Tetanus. Lockjaw, spastic attacks and the famous Risus Sardonicus... I remembered something about a differential with Rabies so I looked it up later that day in the holy Oxford Handbook of Clinical Medicine. On opening the exotic infections page my eyes fell onto a page which confirmed the britishness of this book. In a humorous way it suggested that the history of a patient could reveal important clues as to the exotic disease. "Are your carps well?" is the key question in diagnosing Mycobacterium Marinum and "Did a stray pig hide under your house during the monsoon season?" points to Japanese Encephalitis, "Has your hedgehog been unwell lately?" .. etc etc.

We rounded off the day at the open air restaurant square where our favourite stall holdster welcomed us for dinner. As a treat (we get on very well together) she offered to bring us something "extra", something typically cambodian! But when she dropped by to show it to us before preparing it, it looked just like a plain hard boiled white egg. Slightly disappointed we waited for the dish to arrive, and when a brown and yellow boiled egg (without shell) was served with peppersauce and some herbs our smiling hostess exclaimed "baby egg!". My jaw dropped; the book had warned us about it; the khmer favourite: duck fetus. Drenched in pepper sauce I very carefully ate it, very much fearing the moment when I would feel the fetal beak crunch between my teeth... but nothing happened; slightly abhorred by the idea and very mindful not to look too closely at what was obviously a yolk-imbedded-unborn-duckling but otherwise fine... we got on with the meal! Another adventureous day in Cambodja!

1/4/11
Today's ward round was as entertaining as ever. The first patient presented with a nasty fracture of the shinbone and when I asked whether he was riding a motorcycle at the time he answered that it was his wife who did it to him. I was sure I misunderstood, the file clearly said "AC" or "Accident de Circulation". But he insisted that his wife was responsible for the broken bone. On further inquiry he added that his wife was angry with him because he had been seeing another woman. She had apparently uttered her discontentment ... by way of machete! Now, I may be naive but no machete could break a bone in that way, so I got help and eventually it was cleared up that it was not the knife attack but the chase that had caused him to fall down the stairs and break his leg... Glad we had that cleared up! Next!
Next came a young man with superficial abrasions and cuts whose file said "plaies multiples, desorienté". With the help of Sok Chea I found out that he had been misbehaving at a wedding party. His drunken behaviour had eventually gotten the police involved, which in turn led to the administration of a couple of thousands of volts by way of Taser Gun. Enough for anyone to forget their name and age... Next!
By this time the wards were crowding with white coats; a new delivery of nurse interns were having their very first introduction to clinical nursing. Unfortunately one girl had to attend the dressing changing of a particularly nasty wound which had obviously caused her to faint. Her friends carried her away to a nearby nursing room but I followed them in a minute later to see if everything was fine. On entering I saw that the helpful friends were trying their best to keep her on her feet... which made things even worse. I tried explaining we should lift put her in the bed and hold her legs up but they looked at me with a look of complete helplessness so I just grabbed her and lifted her 40kg on the high bed and held up her legs, she soon came by.

Then it was time for OR, first an external fixator with dr Rada. Then dr Vuthy helped me pulling a metal pin out of a collar bone and to finish of I assisted dr Rada on an abdominal wall mass... under local aneasthesia. This soon turned to disaster. Unlike we had expected (on the grounds of likeliness and echography) the mass had all aspects of malignity. There we were cutting much to deeply, even opening the peritoneum, under local ... It was all a bit much for the patient and I suggested giving her an IV with diazepam or something. Eventually we got the horrible tumor out but since we started without even wearing sterile aprons or using a sterile cloth to mark off the territory (this was supposed to be 15min works; but turned out to be a 1.5h operation with perforation of the peritoneum); we hope for the best. Dr Rada insisted on pathological analysis of the specimen. The patient was terribly young and the mass very very nasty-looking.
After that came a hernia for me, an appendicitis for Katie, and I got to insert another thorax drain under the auspices of dr Rithy and the close watch of about half the OR staff. But everything went smoothly and mr Pich mumbled something to dr Rithy who translated for me "Mon personnel dit que vous être très fort..." It easy to look strong when everybody around you is 30cm shorter.

Well, tomorrow dr Lemsokong is kidnapping us to his home town for the weekend. Very exciting!

Some of this week's photos,

L.