Teaching Classes

My main purpose for coming to Cambodia and volunteering at Angkor Hospital for Children was to develop, and possibly teach, a curriculum for nurse preceptors. A nurse preceptor is an experienced nurse who directly supervises the orientation to direct patient care of a nurse new to the hospital unit. Like most hospitals in the United States, AHC uses experienced nurses to be preceptors; but they did not have a formal training program for how to be a preceptor. Neither did my hospital when I started as a nurse 14 years ago.

My curriculum ended up being almost a full day of classes. Yesterday and today I taught that class, once in the Satellite hospital and today at the main hospital. I won’t lie – it was a challenge. Overall, though, I think it went very well. The nursing staff at AHC are required to learn English as part of their training and hiring, primarily because all the documentation at AHC is in English. Still, giving my presentation to them in English and having them understand me has been difficult. I suspect part of it may be my accent. But the biggest challenge is lecturing about complex medical topics at a college level to an audience whose English vocabulary may be close to grade-school level. The more experienced the nursing staff here at AHC, the better their English. So, because nurses selected to be preceptors are the more experienced nurses, this group generally were able to pick up most of my lecture. Mr. Vibol, who is the head of nursing education here at AHC, helped me out by translating sections of my lecture throughout the day.

This week was not the first time I gave a lecture at AHC. The beginning of last week I presented a lunch lecture on the management of pain in children. The AHC nursing department has lectures for their nursing staff every Tuesday at lunch time; and they provide a free lunch to everyone who attends. So, naturally, Mr. Vibol asked me to come up with a topic for one of those lectures. I picked pain management because the AHC approach was so different from Western practice.

I somehow had the idea that maybe 10-20 nurses would show up for my talk. But the morning of my presentation the nursing administration secretary showed me the sign-up list, and it went on for two pages!! Afterwards, she told me there were 72 nurses in the audience, including the head of nursing, and several of the nursing unit managers!! That’s a new record for me.

I could tell that I lost a significant portion of the audience within the first five minutes. I’m sure it was because of the language barrier. So I just concentrated on speaking to the managers, and to the more experienced nurses who I had met during my first week at the hospital. Toward the end, Mr. Sophol, the head of nursing, helped me out by fielding some of the questions, and by translating into Khmer some of the more complicated parts of my lecture. And I received some excellent questions at the end of my lecture. So, overall, I was very pleased with the result.

So about the Satellite hospital. About 25 kilometers outside of Siem Reap the Cambodian government has a small country hospital that is part of their national network of rural hospitals. But pediatrics was not their strong suit; so AHC worked out an agreement with them that they would run the pediatric ward if the government would provide the building for it. The result is the AHC Satellite Hospital, an off-shoot of AHC staffed by the same doctors at AHC and by nurses trained and supervised by the AHC nursing department.

Before I go on, I should explain a little bit about the typical work day in Cambodia. My regular schedule has been to arrive at AHC around 8 a.m., which is when the administrative staff normally start their work day. At 11:30 a.m. the AHC staff (and I) go to lunch, and we don’t return to work until 2 p.m. That gives everyone enough time to eat lunch, and then take a good nap. Our work day ends around 5 p.m. On that first day of giving the Preceptor curriculum program presentation, the AHC asked me if I would give that presentation AND my pain management presentation over lunch. That meant that Tuesday was a long day! I spent the morning giving my Preceptor presentation – for the first time. Then, after a 15 minute break to eat the free lunch provided, I gave my one hour pain management lecture to about 35 nurses and doctors. After another short break, I then presented the rest of the Preceptor lectures. Everything went smoothly, though, and we finished up by 4 p.m., and were able to return to AHC and end our day by normal quitting time.

Then Wednesday I gave the same Preceptor curriculum presentation to fifteen more nurses at the main hospital. That was also a long day, even though I was able to take a regular Cambodian lunch break. Again, Mr. Vibol was a great help in translating sections of my lectures into Khmer. It was also nice to spend some more time with some of the nurses that I followed around during my first week here as I tried to get a feel for how nurses practice here at AHC.

So, my work here is done. I am finishing up a report on a variety of topics related to nursing practice. Basically, it will be my recommendations to AHC that I feel would improve nursing practice and improve patient outcomes. This has been the biggest challenge by far as I attempt to navigate the cultural barriers Cambodians have to perceived criticism. So far I’m not sure I’m doing a very good job.

Home Healthcare in Cambodia

I had a wonderful experience today when I was given the opportunity to tag along with a Cambodian Home Health nurse on her morning rounds. We visited three patients all southwest of Siem Reap, two in one household and one in the second household. All three patients and their mothers are HIV positive. HIV is common here, and one of the main reasons children are immune-compromised in Cambodia. But it is not near as big of an epidemic as in African countries.

We started out with the three of us, the home health nurse, myself and the driver (yes, we had our own driver). The first house was about 50 kilometers out of town. We stopped at the Satellite Hospital on the way to pick up the mother (not sure why, except maybe she took a part time job there). Then we went on to their home out in the country.

The two children we saw first were a 9-year-old boy and his 6-year-old sister. They were at school when we arrived so their mother went to get them, and they arrived within five minutes.



Today they were all looking pretty healthy. But I had looked through their charts on the way out; and the kids had had many illnesses and were frequently admitted to AHC. They were a little bashful of me at first, but we gradually became acquainted as the nurse did routine home checks. And by the end of our 45 minute stay, we rolling around on the floor of their home together, playing goofy games with our fingers, and candy wrappers.

It just goes to show you that kids do not need expensive toys to be entertained! The boy did have one toy, which he showed me…



I think the visit by a van from town was probably enough of an excitement for all the neighborhood women and their children by itself, but to have a foreigner along really brought out their curiosity. The neighbors just walked right in through the front door and sat down to stare and smile at me.



One woman had one of her daughters bring me a bag full of local fruit, which I later learned is called chan. To be polite I bit right into it, and got the sour taste of the outer skin. So then the nurse explained to me you didn’t eat the skin, but even then I couldn’t finish it. Apparently Cambodians like the fruit more for the smell they give to your home than the taste!



Their home was quite larger than I expected, but generally vacant of decoration, as you can see. The two major decorations were the Buddhist altar, and the photos from the rafters that included portraits of their revered King Sihanouk, and the Queen Mother (the kids had a school holiday on Monday because it was her birthday).



Their house is about 10 feet off the ground on stilts, like most houses around this swampy land, and the ladder that goes up to their front door was very steep. All stairs in this country are very steep, just like in all the ancient temples. The Khmer do not seem to mind, but I keep looking for the handrail every time I go up or down!!

The mom is divorced and really struggles to make ends meet. For awhile she was trying to run a little store for the neighbors out of her house, but she was only making about 5000-10,000 reils a day, which is only $1.25-2.50. She could have made more, but just did not have enough money to get sufficient inventory. Her mother lives close by and used to help her, but now the grandmother has grown too feeble to be much help anymore.

At the second house there was a little girl about 5 years old who lived with her mother, grandmother and siblings. The little girl was very shy, and definitely not looking as healthy as the kids at the first house, just not hospital sick. From the charts I noticed that the home health staff often did not find this family at home. Often the mother was away doing opportunistic jobs – usually working in the rice fields - and the girl was either left at home with relatives or neighbors who did not know her medical care, or the little girl went with her mom. Today they were at home.

The home health nurse does a quick exam of the children, and asks a few questions about how things are going. Her main purpose is just to be sure the patients are receiving their anti-viral medications to treat their HIV infection. So they count all their pills, calculate to make sure they have taken enough, then make sure they have enough until next time. The program is funded by an outside NGO (non-governmental organizations) I think based in Germany.

Past Weekend in Siem Reap

At the end of last week I was ready for some rest and relaxation. I had just completed a marathon week developing two presentations for the nursing staff at AHC. And even though I was getting plenty of great exercise walking almost everywhere around Siem Reap, I was missing the adrenal rush of my previously almost daily triathalon training.

So first thing Saturday morning, after a vigorous breakfast of pancakes and honey, I packed my backpack and walked into downtown Siem Reap to find a bike shop. The bike I had the weekend before was okay, I guess, but this time I wanted something a little sturdier – and faster!! Green Cycles had pretty close to what I was looking for – a Giant brand mountain bike.


The tires needed a little air, but that ended up being an asset later as I occasionally needed to negotiate some tough terrain to get where I wanted to go.

Now I do have a history of getting lost, and then feel too foolish to ask for directions. And Saturday was no exception. I took the wrong road out to Angkor Wat, and ended up at the wrong park entrance. I needed to be at a different entrance which was the only place you can buy passes for visiting all of the MAIN temples around Siem Reap, including Angkor Wat itself. I realized it right away, but the young lady at the wrong entrance felt the need to remind, “I think you lost,” and point out that I had to backtrack about five kilometers. She then offered to arrange a ride for me to the correct entrance (for a small fee, of course). But what she didn’t get was that I relished the idea of adding another quick 10 kilometers to my morning ride!! So back toward town I went.

Okay. So it’s the rainy season here, right? I had assumed that meant it was going to be raining half the time I was here, and that I was going to have to adapt to both being hot and wet all the time. But it doesn’t really work that way. It does rain every day or every other day or so, but it’s usually limited to a quick shower sometime in the mid to late afternoon. And there’s usually plenty of warning. The sky may not show it, but a little breeze picks up, then you hear an occasional thunder clap, and 10-20 minutes later it rains for about 20 minutes. Sometimes the sun comes right back out and by dinnertime you can’t even tell it had rained. This past weekend didn’t really follow that pattern, though. On Saturday early afternoon the sky was the darkest I had seen yet. I had the awesome luck of arriving at the temple of Phnom Bakheng, which is built on the highest summit in the area. So I enjoyed some absolutely amazing vista views just as this tropical thunderstorm showed up.



I could see the rain a couple of kilometers away, but, ironically, I didn’t get rained on until an hour or so later. And then it was a torrential rain. I followed the example of the tuk-tuk drivers I saw along the road, and just hung our under a tree for awhile with my raincoat on.



That night it rained and rained and rained. And then Sunday it just sprinkled all day long. It made for some more reasonably cool days to biking.

So Saturday I took in the obligatory visit to Angkor Wat, the Elephant Terrace (where they used to have elephant races, I’m told), and Ta Phrom – the temple with all the giant trees growing in it. Sunday I went out of town the other direction and visited a trio of Hindu-era temples. The last temple, Lorlei (sp), now also had a Buddhist monastery right by it. I thought it was very appropriate that one of the buildings there had some wonderful painting showing an Indian-looking man finding enlighten from the Buddha.


There are still plenty of sights to see in the area. Always more temples. The king (Cambodia is, after all, a Kingdom) has a summer palace in town walking distance from here. There are also some historical museums. And I still have a hundred or so restaurants I haven’t tried yet. Tonight I found the other mall where all the teens dress just like their American counterparts and where I could go for a good old American type burger and fries!

Making Progress at AHC

I must admit that after yesterday, the first day of my third week at Angkor, I was beginning to doubt whether I was actually going to do anything worthwhile during my volunteer time here. Last Friday, and yesterday (Monday) the staff at AHC were just too busy to spend any one-on-one time with me to work on my projects. But I was pretty much finished with everything they asked me to work on so far. This included a new curriculum for their nursing preceptor program (which I had expanded into a whole day training event), and then a lecture on pain management in children. I was hoping for some constructive feedback about either presentation, but so far had only received just some minimum editing suggestions. Otherwise, the staff almost seemed uninterested in what I had prepared.

But today was a different story. I gave my lecture on pain management at lunch today. I was expecting possibly 4-6 nurses to attend. Instead, 72 nurses were there, most coming in on their day off!! Of course, it probably helped that they all received a free lunch out of the deal. And I deeply suspect that for the majority of the audience my English was either too over their ability or too hard to understand. But, based on some of the questions I received (and with a little help from AHC’s head of nursing) I really think many of the nurses got something worthwhile from what I had to say.

Pain management at AHC (and in most of SE Asia, from what I’ve read) is drastically different than what we do in the United States. Granted, there are some cultural differences such that the Western focus on attempting complete pain control would not work so well here. I am not saying that Cambodian children do not have much pain. I suspect, though, their culture and history gives them internal resources which may help them cope with pain better than American children. That said, I personally think their pain is undertreated here. But instead of using this lecture to tell the staff at AHC what they are doing it wrong, I took the approach, “This is how we do it in the United States.” Then they can take what parts they feel applies to their hospital. And based on some of the questions and feedback I received from senior nurses and unit managers today, I suspect there will be some changes down the road.

I did learn a wonderful new phrase today. As I was talking about chronic pain in certain patients, one of the lead nurses brought out the term, “douleurs sans frontières,” which is a French term that means Pain Without Frontiers. I think that is a wonderfully useful way to describe the type of pain some of our patients sometimes feel.

The rest of today I spent talking with the nurse overseeing infection control at AHC. She is one of only two women in the upper ranks of nursing at AHC (the other is the critical care unit manager). First off, is it very difficult to compare how we practice infection control issues in the United States with our somewhat unlimited resources to what is available and practical here in Cambodia. I have read through a ton of information that I received from some associates I work with in Indianapolis, plus what I’ve researched on my own; and I feel like I’ve just touch the surface. What I can see is that AHC has truly made some incredible strides and used innovative ideas really dig themselves up out of the Dark Ages of what used to be the status quo in Cambodia!! AHC started a hand hygiene program just 18 months ago, and in that short time their compliance numbers went from 20% to over 70%! I know we have much higher numbers than that in the United States, but I’m pretty sure it took much longer than 18 months to get there.

But the infection control nurse still has her work cut out for her. She has no real authority to enforce the standards she has learned and knows need to be implemented to bring infection control up to the next level. If she approaches a staff about wearing gowns in isolation rooms, she has no recourse to enforce it if they refuse because they are “too hot” (which it really can be!) Her dedication keeps her going so far, though. Next month she will be going down to the capital of Cambodia (Phnom Pehn) to be part of a consortium of health care personal working toward a national program on infection control. The World Health Organization has put together a set of guidelines to help third world countries to create national programs. Cambodia’s neighbors, Thailand north and Vietnam south, both have national programs.

Week 2 at Angkor Hospital for Children

It’s starting to become a routine around here. I wake up at 6:30am, eat breakfast down by one of the four swimming pools here at the Golden Banana, then catch a tuk-tuk to the hospital to arrive by 8 am. By then there is already a large mob of Cambodian families waiting to be seen outside the outpatient area. I go to work with the nursing education staff (mostly Vibol) on our current projects until around 11:30am. Then the staff goes to lunch, and doesn’t return until 2pm. The work day ends at 5pm. Of course, the nursing staff is a little different. They only take an hour for lunch. Half of them leave the unit at 12pm; the second group takes their lunch break right afterwards. Everyone makes sure they get a good nap in over lunch, including me…. (In the United States, nurses are lucky to get 30 minutes for lunch; and usually they’re still answering call lights in between bites of food.)

I still walk almost everywhere. There are lots of foreigners here – Koreans, Japanese, Indian, Australians, Europeans, who knows. I bet there’s at least a thousand new tourists go through this town every day, and this is the slow part of the season. I walk by them on the streets, but very few of them even make eye contact with me. The locals, on the other hand, are very friendly. Everyone says hello; even the toddlers say “hello” in English to me, with or without their pants on (diapers seem to be limited only to infants). Of course, many of them want me to buy something or take me somewhere on their motorcycle or tuk-tuk. And they’ve figured out what I’m about, probably after I walked back and forth to the hospital all last week in scrubs, because now many of them greet me with, “Hello, doctor.”

This week I’m finally starting to do some of the things I actually came here to do. I’ve spent most of this week putting together the details of a preceptor program for the AHC nursing staff. Before I leave, I will be presenting two all-day classes to experienced AHC nurses on how to be a nursing preceptor.

I also started today working on a class about pain management in children. This actually may be where I can make the biggest immediate impact on nursing care here at AHC. While the nursing staff at AHC are compassionate and caring nurses, they have no clearly defined methods for evaluating and treating pain for their patients. This has become a standard of care in the United States; certainly at my hospital in Indianapolis.



Of course, I can see there may be significant cultural differences here about pain. I have not seen any patient at AHC who were unduly suffering from untreated pain. In fact, on the day I spend in the post surgical unit, one of the nurses took me around to every patient on the unit that morning and we evaluated together the level of their post-operative pain. They all appeared to be without significant pain, including two patients with burns, and one patient recovering from an infection in his leg bone (which can be VERY painful).

So we have plans for me to give two short talks on evaluating and treating pain in children, one to the staff at AHC, and a second lecture to be presented to one of the satellite hospitals I plan to visit the week after next. This particular satellite hospital is a small rural hospital mostly run by the Cambodian government; but it has started to coordinate with AHC to improve their care of pediatric patients there.

I just had to finish out this post with a photo of some beach graffiti I took at West Baray, which is a gigantic lake created several centuries ago ago during the Angkor Empire. Today it is a beach resort frequented by the locals. The mystery is who posted this little love note on this uniquely Cambodian landscape, but in English.

Nursing at AHC, Part 2

I have spent one whole week now at the Angkor Hospital for Children. I’ve been trying to put my thoughts around some why to summarize the experience, and the best I can come up with so far is: Nursing care is surprisingly similar to the way we practice in the United States; yet I was constantly noticing subtle differences between how they do things and how American nurses practice. Many of the differences in techniques I think my nurses buddies would just find jaw-dropping. For example, most blood draws are done with just a syringe and the needle it comes packaged with!!


AHC Inpatient Unit

One example of how things are the same…. Hand hygiene is a huge push at AHC, and they are measuring compliance just like we do in the U.S. They have staff go around the hospital and observe whether staff, nurses versus doctors, do hand hygiene each time they are suppose to. And they report the results to the staff just like we do.



There are squirt bottles containing alcohol gel hanging on the walls almost everywhere, and signs with hospital honchos demonstrating the correct way to use them. Family members are even encouraged to watch the hospital staff to make sure they use the gel.

Then there are the differences. The gel is made within the hospital based on a formula developed by the World Health Organization. Purchasing Purell would just be too expensive. And they use the gel for almost everything. Instead of alcohol swabs/pads, they just take cut-up pieces of gauze and squirt the gel on them before using them to “sterilize” surfaces (such as skin). I saw the same thing used in the operating room when the anesthesiologist simply cleaned off the bag mask between surgery patients!! The bottom line, though, is that these may all be reasonable differences when you factor in the limited resources they have at AHC.

As I mentioned in a previous blog entry, teaching is a huge task at AHC. Many of the “rural” patients that come to AHC have a poor or misguided understanding of health practices. For example, many Cambodians worry that meat is a high infection risk (which most Americans would not doubt after they observe how most meat is sold in the open markets!). So when their children are not healthy, they often avoid giving them meat products; and that leads to a dietary deficiency called Kwashiokor. The day I was in the inpatient nursing unit, I saw two patients suffering from that.

AHC has a special kitchen just outside the hospital where they teach families how to cook healthy, well-balanced meals. There are posters everywhere demonstrating the main food groups (using Cambodian staple foods as examples), and how to include all of them in meals. And the big screen TVs frequently show videos demonstrating proper diets and food preparation.

Speaking of videos…. I was really impressed with the quality of the teaching videos I watched on the various TV sets. One great example was a video about disease transmission by coughing. A beautiful woman walks past a group of young Cambodian men, and one of the men’s eyes pop out of his head like a Roger Rabbit cartoon. But when she has cough, suddenly all the guys turn away in disgust. Other videos had great animation, or contained catchy little tunes. One of the nurses, though, told me he didn’t think the patients or their families really paid attention to education videos; and only watched the TVs when there were Hollywood animation movies on. If you look at the TV on the photo above over the inpatient unit, the TV is showing Ice Age 3.

I am impressed with the dedication of the nurses at AHC. Most of them could make more money at other hospitals in the area, or for private clinics. They chose to stay at AHC because they believe that is where patients get the best care. They are eager to learn new, improved ways to do things. And they work together well. Whenever a nurse needed to start a new IV, draw blood or had a new patient arrive, there were always at least 2-3 other nurses right there to help them.

The nursing managers are the same way, but in a more encompassing way. One manager asked me about measuring pain; so I downloaded and printed out a variety of pain scales (the only place they use pain scales at AHC is in critical care!!!). The director of nursing has stopped me a couple of times to ask me some questions about nursing research. Yesterday he showed me an upper-management book on nursing, and asked me to explain to him about Nursing Theory (for those of you that are not a nurse, this is something of an inside joke!). They are all hungry for the type of education they could get with a bachelor degree in nursing; but right now the only nursing degree offered in Cambodia is a three-year diploma nurse degree (which I am told is equivalent to an associate/RN degree in the West).

Siem Reap

My room at the Golden Banana is nice enough, but it does not have a kitchenette. So that means I pretty much have to eat out for all my meals. The Golden Banana actually has a café/bar and a sort-of restaurant within the compound (free breakfast, but I’m starting to tire of eggs and fruit every day). Otherwise I must walk to a reputable eating establishment. Luckily, downtown Siem Reap is less than six blocks from here. But within that block I’ll pass (and usually be harangued by) several tuk-tuk (rickshaws pulled by a motorbike) drivers, food vendors and farmers selling fresh produce I’ve never seen before, all at their pre-determined locations.

One of my favorite places to eat so far has been The Warehouse. My son Logan will remember we went there late one night last November for beers and some pool with our travelling companions. It’s a favorite hangout for tourists, but I like it because they offer a great variety of good food, and they play great background music – anything from Velvet Underground to Amy Winehouse.

I found the Siem Reap Mall a few days ago, also close by. It has a department store, and a couple of upscale, very Western restaurants, including a pizza place and ice cream. Upstairs is a video arcade; and that’s where the local kids hang out after school. There’s also a movie theater I’ll have to check out later.

Across the street from the Warehouse is a city block that on the outside just looks like a bunch of trinket shops in small buildings. I would not have known any different until one day I was walking by and I noticed a strong fish smell. So I turned in, and after passing a few dozen more trinket shops I found a complete food market just like the one my son and I visited in Phnom Pehn. There was all the fresh fish, shrimp, meat, produce and spices you could ever want just sitting out on tables! Turns out the entire block is just one big, open building with several hundred vendors inside, each in their small little cubicle. It’s called the Old Market. Angry Birds is big here. All the cool kids have the t-shirts. Even one of the doctors at the hospital wore a pair of Angry Birds sandals. So, of course, I had to get a pair. I managed to talk one of the Old Market vendors down to $3, but I’m guessing a local would have gotten them for $1. This was confirmed when I had a local phone store place $10 on the temporary (local) cell phone I’m using, and the store gave me another set of sandals as a promotional gift!! But I can’t wait to wear them at the Jordan Y pool later this summer!

One thing Cambodians were jealous of was my iPhone. They are very expensive here. $400-450 for an iPhone and $650 for an iPad. One of the recovery unit nurses suggested I should buy a few iPads before I come next time, and then sell them here for a $100 profit each. I could pay for my next trip!! It does seem a little ironic that iPads are made just north of here in China, yet cost so much more here. Since the nurses at AHC make at most $50/day, I suspect I won’t be selling them any iPads in the near future.

Nursing at AHC

So this is where I tell you just how impressed I am with the staff of Angkor Hospital for Children! I have just spent the last two days following around the nursing staff of AHC, and observing just how nursing can be in third world countries with the best resources that can be found in third world countries. Yesterday I spent the day observing the outpatient clinic, and today I spent the day on the IPD, or inpatient department.

First the outpatient clinic…. I remember how impressed we used to be when the ER I worked at several years ago managed to see over 100 patients in one day! Now imagine that times five, and that’s your typical day in the AHC clinic! Some days the count goes over 800! In fact, many of the patients, some who travel long distances for the chance to be seen at AHC, do not get make the cut, and have to spend the night waiting/sleeping in the AHC courtyard. Of course, the AHC outpatient staff are on the look-out for any patients in the crowd who are too sick to wait; and they are brought back right away. Most patients seen first by three very busy triage nurses. After that, there are as many as seven pediatricians waiting to see those patients who make the cut past the triage processes.

I spent today on the inpatient unit. There are just over 40 beds. 24 beds are in the main room on cots two feet apart, 6 more in a small room with isolettes for neonatal patients, and the last 12 patients in beds in the hallway. Each nurse has around six patients. The worse case I saw was a patient with tuberculosis meningitis. Below is one of the patients in the hallway. She is suffering from some type of dietary deficiency related to poor carbohydrate intake that turns her skin so pale.



About half of the nursing staff at AHC is male. I was told today that is mostly because many young men go to nursing school because they have no other job prospects. In the past most nurses were male, so that is changing, and AHC expects to hire more women to be nurses as they feel women are more devoted to the job. The staff I followed were all very efficient and engaging with their patients and families, and most of them have been male. In fact, most of the upper managers in nursing at AHC are men; and all of them have impressed me with their dedication to providing the best nursing care at AHC, and toward the nursing profession in Cambodia overal.

I found more similarities than differences between the AHC and pediatric nursing in the U.S. Their charts look amazingly similar to how we charted before the hospital implemented computerized documentation. They use similar techniques for starting IVs, placing feeding tubes and administrating medications. The doctors and nurses work closely together, and frequently joke around with each other and their patients.

Educating patients and their families at AHC is HUGE!! They have a special cooking school where parents are taught how to prepare nutritious meals for their children. They even have an herb garden, and offer free plants to anyone to start their own gardens. The courtyard, the cooking school area and the inpatient main room all have big screen TVs where they continuously show professionally prepared public service videos on diet, cooking, and good hand-washing. That is, until mid afternoon when they show a children’s movie. Today it was Ice Age 3, and most of the kids were “glued” to watching, even though the sound was inaudible!!

We have No Smoking signs all around our hospital, but AHC has a different concern outside their hospital:

First Day and Dengue Fever

I start my second day at Angkor Hospital for Children (AHC) today. Yesterday was primarily a check-in and register with the hospital. There were five of us in the check-in group, all of us from the U.S. The couple from the west Japanese-American doctors from Fresno --- he’s a pediatric orthopedic surgeon, and she’s a radiologist. The couple from NYC included a Chinese-American doctor (just graduated from med school) and her Cambodian-American husband. We are all now officially displayed in the lobby of the Friends Center, which is the only place at the hospital where the general public can visit without a pass.


My Official Pass

I will be spending today in the outpatient clinic following a nurse there, then spend the rest of the week following nursing on some of the other nursing units – inpatient tomorrow, critical care on Thursday and OR/surgery on Friday. At least half of the nurses here are male, including the head of nursing and the head of nursing education. This week I will be learning instead of teaching, I think. I hope to have pictures tonight, but so far I haven’t filled out the paperwork that allows me to take photographs at the hospital.

I will also be sure to put on the bug spray today. There is a slight Dengue fever epidemic going on here right now with about a fourth of the patients listed on the ER board yesterday as having “DF”. And today I will be amongst all of the cases coming in from the area. Dengue fever is, of course, transmitted by mosquitoes, and there was no immunization against it.

The Golden Banana

I arrived at the Golden Banana in Siem Reap just after midnight Thursday night safe and sound. When Sivpheng picked me up at the airport, he offered that I could start up at the hospital at 8am the next morning, or we could wait if I wanted to recover from jetlag. I thought recovery mode was a good idea, and took that option. Then I realized that it would then be the weekend, and I would have three full days to myself. So my trip has started out with a whimper so far. But that’s okay.

The Golden Banana has been a great place to stay so far. Free breakfast, fairly decent WiFi, a stocked mini-bar; and the setting is absolutely gorgeous – at least three swimming pools (one by the café/bar), jungle all around me, and two (2) balconies off my room, one overlooking the second pool. I’m five minutes walk from the nightlife of Siem Reap (which can be very lively), and ten minutes from AHC. I’m also just a block from one Khmer temple, Wat Damnak, which I visited this morning. It appears to be a monastery now (example photo below). And I’m also just next door to several Cambodia family homes, who’s backyards I see from my balcony.

I’m beginning to think getting any work-outs done here may be a challenge. I was told that I could rent a bike for $1-2 a day, but those bikes are the kind I would have been embarrassed to ride when I was a kid back in the 60’s, let alone do any decent aerobic work-outs in! The one bike shop suggested to me that had “decent” bikes was going to charge me $13 a day!! Running may be an option, but only early, early in the day – at least until I get acclimated more. I need some confidence in getting around town first, too, before I go too far off on my own. I’ve managed to get myself lost twice already – then committing the ultimate tourist no-no of walking through a marginal neighborhood looking confused at my map! I managed to get back safely, though, and ignored all the men asking me if I was interested in “bam-bam” as they demonstrated by running their pointer finger through two other fingers…..

Air conditioning has been essential as I try to slowly acclimate to this heat and humidity. It cooled off to maybe 80 last night after a little rain, but it’s been in the 90’s by noon every day so far. I checked out all the other people on the street as I walk by, and I can’t figure out why they’re not sweating like I am. :)

My new culture shock today was pink toilet paper! It was white up until today, but for some reason when the cleaning staff cleaned they switched even the spare rolls all to pink!!! Still works the same.

Tomorrow is my first big day!! Pictures to follow….

Ready to Go!

Saturday afternoon I was starting to get a little nervous. I was scheduled to work 12-hour shifts at the hospital Sun/Mon/Tue, and then fly out Wednesday morning!! Somehow I would need to finish organizing my stuff, and pack it all up by Saturday night!! To complicate things, I had three boxes of medical supplies I had agreed to try to pack in with my personal stuff. I soon realized my own personal luggage was not going to work. So I made a few calls and quickly found friends and relatives with larger suitcases I could borrow for a month. So now everything fits, but the new concern will be are suitcases over the 50 pound limit!!?

But then I got called off early at work Sunday, and for the whole day today (Monday). That gave me plenty of time to pack and make any last minute arrangements. So now I feel – Ready to Go!

I fly out from Indianapolis Wednesday, May 30th, at 10 a.m., and arrive 10:30 p.m. Thursday night at Siem Reap, Cambodia (via Atlanta and Seoul, Korea). The staff at Angkor Hospital will pick me up at the airport and deliver me to the Hotel/B&B they arranged for me to stay at during my visit. I am told everything will be within walking distance. I also plan on renting a halfway decent bicycle while I’m there to get places, and for exercise (the RAIN Ride – all 160 miles – in July 21st). I have received all kinds of great advise from several doctors and nurses in the U.S. who have volunteered their time before me, including an ophthalmologist from Riley Hospital. While it is still not entirely clear how exactly I will be spending my time at AHC next month, there are a few projects I expect to spend most of my time working on. The biggest project is to work with the head of nursing education at AHC to help him develop a Preceptor Program for their newly hired nurses. Some other projects might be: teaching basic pediatric oncology (to nurses and doctors), helping nurses start small research projects, and infection control. Of course, I also hope to be able to spend time with patients at the hospital, and possibly visit some of the remote clinics in the countryside operated in conjunction with AHC.

Thanks to several of my friends at work I have a sizable discretionary fund to spend on gifts and toys for the children at AHC. I had originally planned to buy the toys here in Indianapolis and have them shipped to Siem Reap; but the staff at AHC informed me I would be able to buy all the toys I want right there in town (and probably at much cheaper prices). See you in Cambodia!!

Scott Neeson - Cambodian Children's Fund

In an earlier post I mentioned that I was originally going to Cambodia to spend time at an orphanage in Phnom Pehn. The organization responsible for it is called Cambodian Children's Fund, and it was started by a guy who truly inspires me, Scott Neeson.

I visited CCF for a short time while I was in Cambodia last Fall. I felt a little conflicted making the visit, though. It's a busy place, and someone from there had to take time away from their busy schedule to take me on a tour. Plus there are billboards all over Cambodia discouraging tourists from visiting orphanages. For Cambodians such visits can be exploitative as the tourists visits are like a trip to the zoo, and do nothing to help (in fact may hinder) the work the orphanages are trying to do for the children.

In the end I was glad I went. It is truly an impressive place, and I plan to continue to support CCF financially as one of the best ways to help make a difference for children in Cambodia. CCF is not a typical orphanage; in fact most of the children have parents they live with at the garbage dump - Steung Meanchey. CCF provides the children a place to stay while their parents salvage a living at the dump. While at CCF the children can attend school, learn a trade, and get a proper meal. The young man who showed me around the CCF building I visited had himself been "rescued" by CCF, and ended up going to the local university. He now works at CCF as an accountant.

Cambodian Children's Fund Website

Below is the biography of Scott Neeson stolen directly from the Cambodian Children's Fund website.

Scott was born in Edinburgh, Scotland. At age 5, he emigrated with his family to Australia.

Scott grew up in Adelaide, South Australia and started what was to be a long, successful career in the film business when he joined a company that operated local and rural drive-in theatres. He moved to Sydney in 1983 to further his film career by joining the Greater Union cinema chain. Soon thereafter, he was chosen to head Hoyts Theatres film programming and purchasing, and then became General Manager of a joint venture in film releasing between 20th Century Fox, Columbia/TriStar and Hoyt's local film productions.

By 1993, he had relocated to Los Angeles to join 20th Century Fox as head of international marketing. In 2000, Scott became President of 20th Century Fox International, overseeing the release and marketing of several of the top films of all time – including 'Braveheart,' 'Titanic,' 'Star Wars' and 'X-men' – and managing gross revenues in excess of $1.5 billion dollars. In 2003, Scott left Fox to head Sony Pictures International's marketing operations.

In the five weeks between new positions, he took a mini-sabbatical through Asia, but a two-day stop-over in Phnom Penh became a four week mission that started him on the path to establishing the Cambodian Children's Fund.

Several early attempts at assisting the most impoverished children failed. Parents often removed their children from the schools where Scott had placed them, preferring that they be earning money instead. The gifts of clothing, shoes and books that he left them were usually sold within days.

Scott left Cambodia in September of 2003 to start his new role at Sony Pictures, but the impact of his experiences in Cambodia stayed with him, and it became increasingly apparent that incorporating a senior film industry position with his philanthropic mission was not an option. In the following year, as he laid the first tenuous plans for a permanent facility in Cambodia, he made the commute from Los Angeles to Phnom Penh eleven times.

While still maintaining personal ties with respected media industry leaders like Rupert Murdoch and Sumner M. Redstone, in 2004 Scott resigned from his 26-year film career and began the process of the long-term move to Cambodia, selling his home, car, boat and other assets. All initial costs for the establishment and operation of the CCF1 facility were covered by Scott, who now acts as the organization's full-time Executive Director.

In 2007, Scott was awarded the inaugural Harvard School of Public Health "Q Prize" in recognition of his extraordinary leadership in advocacy for children. In the same year, the CCF received the Rex Foundation Bill Graham award for creating a safe haven for Cambodian children to thrive, learn and grow.

Today, Scott divides his time between the CCF administrative offices and field work in Steung Meanchey and the rural provinces of Cambodia. He knows all 700 children in his care, their names, histories, personalities and aspirations. Having successfully established CCF1 – CCF6, as well as the CCF Community Centre and Daycare Program, Scott's future goals include the expansion of the CCF External Education Program.

Angkor Hospital for Children

Angkor Hospital for Children is a charitable hospital located in Siem Reap, Cambodia, that has treated over 900,000 children since 1999. Cambodia is one of the least developed countries in the world. With an average income of about $21 USD per month, very few families can afford to pay for health care. Services at AHC are provided to children free of charge. The hospital offers outpatient, inpatient, acute, emergency, surgical, low-acuity, dental and ophthalmologic care, as well as education and outreach programs.

In addition to providing healthcare, a mission of the hospital is to increase the self-sufficiency of the Cambodian people. It serves as a teaching hospital for Cambodian doctors and nurses, and as a training site for the WHO-developed Integrated Management of Childhood Illnesses (IMCI) training program. After the devastation of the country's resources by the Khmer Rouge, only approximately 270 doctors remained in the country. As of 2010, there are approximately 2200 doctors and 374 dentists for the Cambodian population of 13.6 million people. There is a critical need for more fully trained doctors.

Angkor Hospital for Children is partially funded by Friends Without A Border, which has branches in the United States, Japan, and France and though direct contributions Angkor Hospital for Children . FWAB is a registered 501(c)(3) in the United States, which qualifies donations as tax deductible.

Friends Without A Border was founded by Kenro Izu of Japan. He saw the plight of Cambodian children while on a photography trip in Cambodia, and has dedicated his life to improving the lives of Cambodian children.

From Wikipedia, the free encyclopedia

Angkor Hospital for Children (AHC) is located in Siem Reap, Cambodia, home of the famous Angkor monuments, relics of the Khmer Empire which lasted from the ninth to fifteenth centuries.

The vast majority of children who come to AHC suffer from preventable and treatable illness. In Cambodia it is not uncommon for a child to die from complications of untreated respiratory infections, diarrhea, or illnesses virtually eradicated in the more-developed world. AHC is child and family focused, using a patient’s time at the hospital as an educational opportunity. The hospital provides vaccinations and multivitamins in addition to extensive education on nutrition, wellness, and illness prevention.

AHC also reaches far beyond the hospital doors to provide care to some of its most fragile patients. The HIV/ Homecare Program delivers follow-up treatment and checkups to children who suffer from debilitating illness, including HIV/AIDS, meningitis, cerebral palsy, epilepsy, and other chronic conditions. The HIV Homecare program was the first and remains the largest such program outside the capital, Phnom Penh.

AHC is also the largest facility outside of Phnom Penh which offers antiretroviral treatment to pediatric HIV/AIDS patients and currently administers this life-prolonging medication to hundreds of children.

Why Cambodia (Good Reason 3) - Tonlé Sap

Tonlé Sap

Geographically, Cambodia is a very wet and hot country, making it very conducive for fishing and rice farming. In the center of the country between the cities of Phnom Penh and Siem Reap is a gigantic lake called the Tonlé Sap. The Tonlé Sap River, which flows southward from the lake, is a tributary of the Mekong. Cambodia’s weather is punctuated by two major seasons, the wet season and the dry season. It rains so much during the wet season that the depth of the Tonlé Sap increases by dozens of feet each year. There is so much water that the Tonlé Sap River actually reverses flow backwards into the Tonlé Sap by the end of the rainy season. This gigantic shift in water levels brings a huge amount of nutrients in the lake, and is the reason Tonlé Sap is one of the most productive fishing lake in the world.

Tonlé Sap

Logan and I had the opportunity to take a long boat ride of Tonlé Sap when we were in Cambodia last Fall. The river culture of the Cambodians who live on Tonlé Sap is amazing! Some of their homes are built on stilts several stories tall, while others are simply anchored houseboats. During the dry season their small communities are on dry land. But by the end of the rainy season the Tonlé Sap rises up to the bottom of the stilts. We saw several children barely old enough to walk piloting small boats (or simply large buckets) with paddles all by themselves! In many instances, the families even had pet dogs, and floating cages of pigs next to their houses.

It was the end of the rainy season when Logan and I visited last November. It fact, it was one of the worst monsoons in the area in recent history; and several parts of Cambodia (and Thailand) were damaged by flooding last year. When I go back to Cambodia in June it will be toward the end of the dry season. So I should see a very different version of the country this time.

Why Cambodia (Good reason 2) - Prince Sihanouk

King of Cambodia

Perhaps the most fascinating and most revered individual in Cambodia is the head of their royal family, Prince Norodom Sihanouk. Up until the early 1950’s, Cambodia was a colony of France. Sihanouk, a grandson of the previous king, was a jet-setting young playboy in his youth. When the king of Cambodia died in 1941, the French placed Sihanouk on the throne over the true heir, thinking Sihanouk would be easy to control.

Instead, Sihanouk help lead the Cambodian people to eventually gain independence from France in 1953. Sihanouk has been the consummate survivor ever since. Over the years he has used his charm and finesse to remain a powerbroker in his country. Even the Khmer Rouge dared not harm him when they took over the country. Many other members of the Cambodian royal family did not do so well in April, 1975. Sihanouk played the French, the US, China and the UN over the years to broker influence for himself and his country. Although he turned over his official royal duties to his son many years ago, Prince Nordom Sihanouk is still universally adored and revered in the country. Gigantic photographs and memorials of him and his number one wife can be found throughout Phnom Pehn and the Cambodian countryside.

Prince Norodom Sihanouk

Sihanouk is also a true renaissance man. He lives in a sprawling palace in the center of Phnom Pehn full of Buddhist temples and memorials. He maintains homes both in France and China, and is famous for his fine tastes in food and beverages. He is also a connoisseur of the culture and art of his country. He has even written and directed several films over the years.

You can read more about Sihanouk at Wikipedia.

Why Cambodia (Good reason 1) - Angkor Wat

Despite how the history of the Khmer Rouge in Cambodia as come to represent a negative aspect of the human condition to me, I have come to appreciate Cambodia for several interesting and exotic positive things.

There is the history of the ancient Khmer Empire. From the 12th to the 15th Century, the Khmer people, the ethnic majority of Cambodia, ruled over a vast empire that included most of Southeast Asia. It was a powerful kingdom with a rich culture as evidenced by the extensive temple systems that still scatter the countryside of northern and central Cambodia. Logan and I were able to spend two full days exploring many of the temple ruins, including the famous Angkor Wat temple, which was the centerpiece of the Khmer Empire.

Angkor Wat

Several movies, including Raiders of the Lost Ark, and Tomb Raider, were filmed on location of some of these fascinating temple ruins.

Spong Tree at the Ta Prohm temple

Why Cambodia (The Bad Part)

So why Cambodia? Why does a country on the opposite side of the world provide such a fascination for me?

By the way, Cambodia is a small country in Southeast Asia just west of Vietnam and south of Thailand. It is one of the poorest nations in that area, though recently it has begun to make a resurgence through foreign investments and economic advances, and a thriving tourism trade.

I was a senior in high school when the Vietnam War came to an end in April of 1975. At the time, I was not a fan of our military involvement in the region. But the US still had a military draft, and I was soon to come of age to be eligible for possible involuntary recruitment and service into the US military. It was heavy on my mind what I would do if I should ever be drafted. Other young Americans who had been drafted had refused to serve (sometimes as a “contentious objector”), or went to Canada to avoid the draft. The draft was a lottery then, and many of my classmates had their draft numbers come up. But I was lucky, and the draft was stopped just a couple of months before I turned 18.

During the Vietnam War, Cambodia had become a major chess piece in the conflict, subject to partial occupation by Vietnamese communist troops followed by extensive bombings of the Cambodian countryside by American aircraft pursing those troops. American financial and military support in Cambodia during the waning years of the war helped keep in place a corrupt military government that further suppressed the Cambodian population. Eventually this gave rise to a new insurgent group called the Khmer Rouge. The Khmer Rouge quickly gained strength, and by April 1975 they controlled major portions of Cambodia. Within days of the last American troops leaving Vietnam, the Khmer Rouge marched into the Cambodian capital of Phnom Phen to take complete control of the country.

What happened next in Cambodia is partially chronicled in the Oscar-winning film, The Killing Fields. Immediately after taking control, the Khmer Rouge emptied all of the major cities, and forced the entire population into rural work camps. The stated purpose was to turn the country into an agrarian utopia based on the communist revolutionary model. They turned Cambodian society upside-down by placing the poor, working class farmers who made up the bulk of the Khmer Rouge army in charge, and branded anyone else as “enemies of the revolution” until proven otherwise. The killings began immediately. During the four years the Khmer Rouge controlled Cambodia two million people were killed (one third of the population), many outright by the leaders, but also through starvation, disease and war.

The Khmer Rouge was in power during the same time I was a college student at South Dakota State University. The truth about the Khmer Rouge came out while I continued my education at Purdue University through 1982. This was a formative time for me. One intellectual curiosity I had was trying to understand the human capacity to inflict pain and suffering upon their fellow man. I had already read about Hitler and the Nazis, and everything I could find on serial killers. The history of the Khmer Rouge became, to me, a story of how an entire country was turned into a bunch of serial killers.

The Khmer Rouge Leadership

The Khmer Rouge was supervised by a small band of communist counter-revolutionaries who, at first, remained hidden both inside and outside of the country. As a result, few people outside of Cambodia had any idea of what was going on inside. The leaders referred to themselves as Angkar, the omnipotent overseer of the Khmer revolution. The decisions and judgments of Angkar were considered always wise and perfect, and, therefore, never to be questioned. Eventually the leaders did reveal themselves; but even then, the Khmer Rouge’s top leader, Brother Number 1, Pol Pot, was not revealed until much later.

Pol Pot

This disconnect between the leadership and their decisions quickly caught up with them. Their attempts to convert Cambodia into the “rice basket” of Asia through highly productive rice farming was an abysmal failure. The leaders blamed the failures on enemies within, and became increasingly paranoid. They also started to pick fights with their larger and much stronger neighbor, Vietnam. Eventually Vietnam invaded Cambodia in 1979, and installed a puppet government. But the Khmer Rouge remained a powerful force in Cambodia for decades afterward. Some of the top Khmer Rouge leaders who are still alive today are finally being prosecuted in a War Crimes Tribunal.

Introduction

During the month of June 2012, I will be taking a leave of absence from my job at a local children’s hospital in Indianapolis to volunteer at the Angkor Hospital for Children in Siem Reap, Cambodia. This blog will be a place where I plan to share this adventure with my friends.

Last November (2011), my son, Logan, and I took a vacation together to a little country in Southeast Asia called Cambodia. The trip was my second attempt to visit a country that has long held a special place in my heart (which I’ll explain in the next few blog entries). Our trip last year was a true vacation under the guidance of a reputable travel agency and a tour guide. My son and I were safely escorted through the country as tourists. Cambodia today (along with much of Southeast Asia) has become a popular vacation destination for Westerners, and is a safe and exotic place to visit. But this was not always so.

In fact, during the late 1970’s, Cambodia was possibly the most dangerous place to be on the planet!

A couple of years ago I came upon an opportunity to go on a medical mission trip to Cambodia. As a registered nurse, I had already been on several medical mission trips to Latin America through a wonderful Indianapolis organization called the Timmy Foundation, now called Timmy Global Health (http://www.timmyglobalhealth.org/). But I was ready to try something new. The trip to Cambodia was organized around doing some support work for a relatively new orphanage mission called the Cambodian Children’s Fund (http://www.cambodianchildrensfund.org/).

Unfortunately, the organization in Indianapolis planning the trip took a bad turn (to put it nicely). After canceling the trip twice, they tried to keep the money I had paid in full for the trip. Over a year later after several legal maneuvers and with the wonderful help of an attorney friend of mine I eventually got the money back. After that, I decided to plan a new trip to Cambodia, and invited my son to come along.

My trip to Cambodia with Logan was a wonderful experience! We were able to see all the of the places in Cambodia I had been reading about for the past twenty years. I even was able to make a short, but satisfying visit to the Cambodian Children’s Fund orphanage site during one of my free afternoons. It was also a great chance to have some quality adult bonding time with my now grown-up son.

But I left the country dissatisfied.

While we were in Siem Reap, I noticed there was a children’s hospital there called Angkor Hospital for Children. When I returned to the US, I went online and found the hospital’s website. I discovered that they welcomed volunteers to their hospital (as long as they paid their own way). And I found out that their theme for the second quarter of 2012 was hematology/oncology (I work on a hematology/oncology floor)! So I sent them an email along with my resume, and a couple of days later I received an email back inviting me come visit and help train their medical and nursing staff!!

One thing I have learned since becoming a nurse several years ago is to take these opportunities as gifts. It's just plain rude not to accept them in the spirit they are given!