Hospital Spot Check!

This has been my best week in Cambodia. And also the worst.

When the Director of the modest provincial hospital at Thmar Pouk asked me and Alison, the VSO nursing advisor, to spend the week with the Head of Nursing assessing the quality of the hospital, we were thrilled. This was our chance to get beyond the polite smiles and find out what care patients get here, and agree ways to make it better. Best of all, we were invited in.

After a breakfast of bananas – unfortunately bread supplies don’t often make it to this village – we step out to learn our first lesson: don’t start the morning after a monsoon, as the dust track becomes a treacherous, slippery mudbath. We should also have avoided the period after two of my translator’s piglets died. But Cambodia has a way helping you find calm and balance, and the happy singing of a little boy minding his grazing cows on the temple island got our visit off to a positive start.

Which was just as well, as I made the mistake of starting the inspection the litter-strewn grounds and deeply unpleasant wash blocks. No visit to the gents should leave you with this mixture of nausea and bafflement:

* Are these toilets clean?” “No they are very dirty” We agree!

* Yes, they are rather - when were they last cleaned?” “They are cleaned every day” “So this colourful crust and interesting aroma developed just this morning?”. Sarcasm doesn’t translate well.

* Ok, how often are they cleaned with bleach and a mop?” “Twice a month” “So when was this particular toilet last cleaned with bleach and a mop?” “Maybe last year?” Logical deduction not a strongpoint either.

* Different tack: “How could we make these toilets cleaner?” “We must teach patients to stop making them dirty”.

* Last try: “Who is responsible for keeping these toilets clean?” “That man sleeping in the hammock under the tamarind tree” “Is he tired from all the cleaning he does?” “No, he runs the hospital fruit and cigarette stall”. Nobody said this was going to be easy.

Things get better – both the hospital wells are broken, but there is hope that someone somewhere might know how to fix them – and even better, we think we know a donor who will pay for it.

Electricity also sparks debate: the hospital supply is unreliable , but it’s not a problem as there isn’t much equipment needing it. But hang on! Maybe the reason we don’t have much electrical kit is that we haven’t secured reliable power. I can’t help thinking that the Khmer language’s lack of a future tense may limit forward thinking.

It’s a baking hot day, and many patients are visibly uncomfortable. Happily all the wards have ceiling fans. Less happily, not a single one is on. All broken? Not at all - it’s just that electricity is “too expensive” (admittedly it does cost three times more here than in the provincial town). So the patients sweat and suffer, and everyone just accepts this, and my blood is coming to the boil...

I have a similar puzzlement when talking with patients - no matter how many times we ask what we can do to improve their experience, the only answer we get is ‘I want to be better so I can get back to my ricefield’. Necessary, of course, but sufficient?

Bless those midwives! Just as I am despairing, the serious matron shows me her spotless, well stocked and immaculately organised delivery suite. And rewards me with a rare smile. What's more, happy days, I have discovered that the hospital has a room with air conditioning!

And whilst the paediatric ward is a little rough round the edges, the bang and clatter outside remind us that a new one is being built. I have no idea why the US Army’s Corps of Engineers Pacific Command agreed to fund this, but we are happily accepting their generosity. I’m confident we are getting better value from their money than some of the usual things on their shopping list.

Outside, cheerful children clamber around the nearby playground – but on closer inspection we had to persuade them to leave, as the equipment was jaw-droppingly dangerous. Think of a slide which is so rusty it resembles a cheese-grater. Another one for our action plan –who might like to donate a new playground?

The medical ward is the busiest in the hospital, yet two of the three staff rostored to work have ‘popped out for a couple of hours’. Unfortunately they are rumbled as our inspection takes longer than that, and the story is modified– they are at a wedding and “may be drunk”. Understatement of the year. Meanwhile my blood pressure mounts again when I uncover old, bloodied swabs in the nursing trolley – and further when the discovery is met with a shrug. Meanwhile Alison finds that patients’ temperature, blood pressure and respiratory rate are neatly recorded for today. And tomorrow. “They can predict them” explained our translator. My esteemed nursing colleague did not concur. At least the drip stands are were not being used to dry fish today – I guess that’s progress?

The final ward has only one patient, a poor, emaciated woman – unbelievably she’s only 27. She knows she has TB, but we’re not sure that she really understands that the red crosses throughout her notes indicate she is also HIV positive. We ask if she is getting enough food, and she tells us she has no relatives to cook for her – only her young son. He’s the happy boy looking after the cows.

At the following day’s morning meeting, the Director harangues staff, who all intently study their flip-flops. We’re not entirely sure what is being said, but the word ‘worry’ is repeated, and we assume some details of our findings have already been shared – oh dear. After a sustained period of finger-wagging the Director fixes me with his gaze and my translator explains the big concern – cleanliness? drug supplies? staffing? financial irregularities? – so much choice. But no! - apparently the real anxiety is that they understand that the poor white man can’t find bread in the market, so they are arranging for the hospital ambulance to deliver me some regular supplies. It’s so sweet, unexpected, surreal, I don’t know what to think...

This week was just the start of course. We’ll now spend the next fortnight with the Head Nurse, discussing what we observed with each ward and department , and agreeing what they will do to make things better – and how we can help. The real crunch will come in August when we do it all over again – and hopefully find that standards are improving. I’m not sure if we’ll have working wells, functioning fans or decent documentation by then – and the poor lady with TB and her happy singing son may no longer be with us – but at least I may be enjoying my daily bread.