Servicing the giant revolving door

I had hoped to spend my elective in some busy general hospital, seeing terrifying things and learning a lot. It hasn’t really turned out that way, but my time at the river clinic is showing me something else instead.

This is ‘GP land’, as they say at home, but with little capacity to do anything beyond the basics. No friendly ambulance a phone call away; few diagnostic tests. GP land in extremis. Sitting at the doctor’s table in our one-roomed floating clinic, I watch the local villagers as they come in – often barefoot, mums breastfeeding, stooped old ladies, kids staring wide eyed at the strange white doctor. Some are really sick; others are here for their weekly health check, taking advantage of the free clinic and its medicines.

Often the doctor and I have three sets of notes at once as a young mum presents her runny-nosed toddler, her feverish baby and her own painful abdomen all at the same time. We see lots of common things – a boy with bacterial conjunctivitis, an elderly woman with a painful hip, a small child with a chest infection. Our tools are a stethoscope, auroscope, pen torch and The Oxford Handbook of Tropical Medicine. The contents of the drugs box have been selected carefully for the setting – metronidazole, ciprofloxacin, albendazole, paracetamol, oral rehydration salts.

I can see how useful the clinic is, in this location so far from any other formal health care, but from a medical perspective I find it quite frustrating. Perhaps I’m too inexperienced in primary care. I wonder how many people here have HIV and other STIs, and realise that probably nobody knows.

A young woman presents with vaginal discharge, and the doctor asks me what I think we should give her. “Well…what colour is the discharge? Is it itchy?” I can’t speak Khmer, so the doctor is translating the histories for my benefit. “She says it’s clear, and a bit itchy. What do you think?” I’m not feeling great about this. Even if I wasn’t just a medical student, I’m pretty sure I’d still be reluctant to make a diagnosis based on three words: ‘clear’, ‘itchy’ and ‘discharge’. “Can we have a look at it?” I ask. “She doesn’t want to show us”. I’m not really surprised. Anyway, the team dentist is seeing another patient behind the curtain. “Can we ask about sexual partners?” “Well she’s married”. “Is her husband likely to have other sexual partners?” “Sure. But we can’t ask her that.”

In the end the girl goes away with metronidazole and clotrimazole to cover all bases, and I’m left with a sense of futility. Without knowledge about STIs, and without her husband’s co-operation, she’ll be back again and again and again. I realise that, without good public health and education, doctors are simply footmen servicing a giant revolving door. In a way it’s why I like general practice so much – through patient education, primary care doctors get to prevent illness, or at least treat it before it gets bad. It’s frustrating to see a situation where there are so many obstacles to health.



In which the author overcomes hurdles and ends up somewhere unfeasibly hot

I travelled more than 6000 miles to do an elective in Phnom Penh. And, y’know, defied probable death and stuff. So when I arrive to find the hospital empty except for maybe one post-op patient and one receptionist (asleep), I can’t help feeling a bit let down. Ok, so perhaps medical electives are basically a glorified jolly for privileged white kids, but I’m here now, I flew a long way and I want to see something.


A busy elective

Ok, fine. Smile. Operation audacity.

A few emails and a long bus ride later, the elective fates have deposited me in Siem Reap, possibly the hottest place on earth. Google says it’s 37 degrees. My headache says 57. It’s a welcoming town though, all golden pagodas and motorised tuk-tuks, and women selling fruit I’ve never seen before by the roadside.

My destination: The Lake Clinic. Run by an ex-American nurse and staffed by local doctors, nurses, dentists and midwives, it’s a small organisation that provides basic health care to remote communities. They don’t officially take medical students, so I’m feeling pretty fortunate and happy to be here.


Siem Reap. Heat not shown.

TLC consists of two teams who travel to remote locations each week – one on a lake, one on a river – and set up pop-up floating clinics for three days at a time. People living here are some of the poorest in Cambodia, and getting to the nearest health centre or hospital is usually too far and too expensive. So TLC brings basic free health care to the communities, as well as providing health education and making referrals.

I’m joining the river team. We meet at 6am and load the minibus – waterproof boxes of drugs and medical equipment, mosquito nets, food and loads of bottled water. It’s a three-hour drive to the river, then a boat. The last hour is mostly dirt track – bumpy and narrow, winding between rice paddies,  and mango trees, with chickens strutting beneath houses on stilts. I can see why we’re here – I wouldn’t want to get sick here – it’s an hour at least to the nearest health centre, and it’s… how can I say this… SO. HOT.

Eventually we stop on the river bank and transfer to the TLC boat for the next leg. Presumably this river was once shaded by lush rainforest, with birds and monkeys in the trees. Sadly we’re a hundred years too late. Most trees have gone to make way for farming, and the riverbanks are lined with noisy diesel motors pumping water up onto nearby fields. I’m reminded of a line from my Oxford Handbook (page 389 this time). “The world moves on, tarnished, tawdry and trashed”.


Start of the mission

The clinic is a large floating hut moored to the opposite bank. We’ve been travelling since 6.30am but there’s a morning clinic scheduled, so everyone sets to work hanging curtains, setting up folding tables and arranging the ‘pharmacy’. The whole thing is amazingly well designed, and within minutes I’m standing in a fully functioning, one-roomed, floating health centre.



I’ll be assisting the team doctor. Our ‘doctor’s box’ contains a BNF, stethoscope, auroscope/pen torch, thermometer, electronic BP machine, tongue depressors, a pulse oximeter, the Oxford Handbook of Tropical Medicine, and some documents outlining local prescribing guidelines. Most of the things you’d expect for a doctor in a primary health clinic… except with no hospital nearby, no easy referral.

We take a seat, the doctor and I, and await our first patient. And luckily we have a fan. Did I mention that it’s hot?

Pteromerhanophobia to Phnom Penh

Something about me: I’m afraid of flying. Really afraid. Nights before a flight I’ll lie in bed made breathless by the certainty of an imminent, terrifying death. Plane crashes are statistically highly unlikely, you say? They happen, I say. Who’d you think is on that plane that vanishes or tumbles out of the sky in the dead of night? It has to be someone – why not any one of us – why not me?

At the same time though, flying fascinates me. Ascending, taking off, watching as your home your country becomes the whole world. Flying changes your perspective on everything. The way back gardens become snow-ridged mountains. The lives and loves and wars played out across hundreds of cultures below as you eat your pseudo middle-eastern sandwich from the Doha section of the airplane meals dept and watch reruns of Friends. It’s another dimension. Marco Polo took 24 years over this journey.

Anyway, there’s a huge world out there; sometimes you have to balance risk of death against the probable gains. And I’m off on medical elective – two months in which we’re let loose to do anything we like (related to medicine), anywhere we like in the world. How on earth do you make a choice like that? I chose a small surgical hospital in Phnom Penh, Cambodia, specialising in cleft lip and palate repairs, burns reconstruction, trauma surgery and cataract surgery. Phnom Penh! It’s almost worth it for the name alone.