• Love Follows Love Follows Love

    Dearest Readers,

    Human history is blighted by periods of disastrous intolerance towards each other, borne out of fear and misunderstanding, resulting in anger, violence and war. Although these intolerances frequently simmer under the skin of our societies, they are often bought to boiling point by powerful rhetoric by those wishing to gain more by dividing people. In current times, these feelings have again been brought to the surface, slowly being fuelled by leaders speaking and tweeting to stoke our insecurities. Animosity currently towards one another is more palpable than I remember, a growing number of the world’s population seeking to be separate from each other, wishing to build walls and recreate borders that were once torn down. The media, too, influences even those of us who do not wish to be influenced by these movements, by altering narratives, by giving misleading information, by giving us doubt when there should be no doubt.

    It was then a strange moment when a visiting surgical team from North Korea organised a visit to our humble surgical centre in Phnom Penh. Information about North Korea, to our eyes and ears, has been limited by an embargo of knowledge, created by years of divisive politics and a Western media representation that is not likely to be wholesomely accurate.

    Our roles, as healthcare professionals is to share, to teach, to exchange knowledge and learn from each other’s experience, for the betterment of our patients. Within these past two weeks, I shared the simple knowledge I had, with the best of my ability, my learnings of orthopaedic surgery.

    I choose love. Love follows love follows love.

    With love always,

  • What Hurts The Most

    Dearest readers,

    Last night I sat alone in a midnight blur. I was surprised to find myself silently crying, somewhat despairing at the thought of a patient I had met earlier in the day. There was a sadness within me I had not felt for the longest time, an inexplicable heartache that I could not ignore. A woman in her fifties, with striking resemblances to my own mother, was wheeled into our clinic in a makeshift wheelchair, pushed lovingly by her husband, followed by a dedicated grandson, no more than six years old. Her hands had the slightest tremor and her facial expression was vacant, her eyes blinking and gaze blanking into the distance.

    Her story was simple. Two years ago the woman fell and hurt her leg but was still able to continue walking as normal, albeit with some residual pain. Her injuries were not too severe. However, to relieve her mild symptoms, she would buy painkillers from her local town’s pharmacy. Over the course of weeks, and then months, and then years, she noticed herself getting weaker, not stronger. She developed muscular aches and lethargy, more pains in her hips, more bruising of her skin, more swelling in her face. Her weakness had progressed so far she could now only get by in a wheelchair. She was now complaining of severe difficulties.

    X-rays were taken of her hips by our centre, showing barely visible bones – the spheres of her hip joints disappearing into darkness. It became clear from just watching her and reviewing her x-rays that she had likely been sold steroids from the pharmacy. And so when I asked to see her medications, her grandson, much like my little nephew, proudly pulled out a neat packet of her medications. The tablets were lovingly (and surprisingly) organised into neat compartments, and when I saw the little white steroid tablet this woman had been taking for years, a deep, unfamiliar stab penetrated my heart. This poor patient, in the hope of relieving her pain, had been slowly and sadly poisoning herself with drugs to the point of life threatening debilitation. This circumstance was only as a result of miseducation, disinformation and a health system that had failed her and her family. This is not an uncommon event in Cambodia, for steroids are truly available by the bucket load, but this particular story, whilst remembering my own mother, hurt me deeper than expected and last night, as I tried to fathom my feelings, I discovered now what hurts the most.

    We all suffer hurt at different and defining moments in our lives, changing us forever in ways we will often never understand. When these moments of pain arrive, we, as beautiful individuals, each palpate our pains differently, reacting to the noxious stimuli in a combination of instinctive and learned ways. From the physical hurt of a fractured bone to the internal pains of a breaking organ, we either cry out in despair or hold back the tears, bite our lips and watch as our wounds develop, forming the scars that appear slowly on the outsides and insides of our skin.

    The grief of emotional trauma often form the longest scars, both visibly opaque and yet clearly invisible within us. The emotional scars run through the entirety of our inner core and outer sphere, dictating which way we turn when challenged, which words we scream out when anguished, how tightly we close our eyes when we are already in darkness and in which moments we decide to let the tears flow past the barricades of our eyes’ resolve.

    As healthcare workers, our pain thresholds often take a specific pattern, for we are continually exposed to the physical and emotional pain of others on a daily, if not hourly basis. It is not surprising our own reactions get numbed, as we are drip fed psychological anaesthesia to move on to the next patient, and the next case, without accumulating the burdens that come from consulting and treating fellow humans in pain.

    As a child, I remember the times I would feel the loneliest, the saddest and the most vulnerable. It was the times when I felt out of control, when events were beyond me, events that I could not influence, that I could not change, that left me so overwhelmed and despondent. From the tragic disasters and sadness in the news, to the passing of loved ones, I would cry at the hopelessness of all that was out of my reach. I still remember sinking into a stupor after reading the diary of Anne Frank when I was eleven years old, so overwhelmed I could not go back in time to prevent this incalculable injustice of my new friend.

    And yet now into the middle of life, those feelings of sadness and despair when faced with a situation out of my control have largely disappeared. Perhaps it is our growing experiences in life that help put perspective on our pain, for I did not feel such personal hurt during my work in Haiti, when in the blink of an earthquake, thousands lost their lives and millions lost their loved ones. And in Pakistan, I did not personally feel the hurt of those displaced millions, losing their homes to the rivers of floods that swept down the nation. Or in Cambodia, and Myanmar, interacting with those bright eyed people that were soon to lose their lives to cancer did not open scars that had not already formed within me.

    Now I have realised what truly hurts the most. It is not horrendous outcomes of situations where we out of control, like an earthquake, or a flood, or a rare diagnosis of cancer – but situations when injustices occur to people where we are in control, when mistakes could be minimised, when man-made disasters could and should have been avoided. As healthcare professionals, we take an even deeper burden of this responsibility, to ensure we do no harm, at all times, at all events, for all of our patients. This patient, so reminiscent of my mother, so dedicated to the medicines prescribed to her, should not have been to the point where her life is at risk, simply by getting poor medical advice.

    Similarly, in our small surgical centre, often providing life changing operations, we should uphold the enormous burden to prevent easily avoidable mistakes in our own practice, to minimise the complications we may encounter, to eliminate any harm we may cause. In the short period of time I am here in Cambodia, I can only hope to implement safer practices to our surgery, in an attempt to gain back control in seemingly uncontrollable environments, to ensure at least our standards are robust, even if there are pitfalls elsewhere. Most human errors can be curtailed with an open heart, good communication and a willingness to improve – a mantra I explain to my colleagues each day – that talking to each other is free of charge, performing safer surgery costs no extra to plan and prepare in advance. I truly want to ensure we are doing the best with the free tools we have, to ensure that we do not hurt our patients and the people of this country, to not replicate mistakes made by others, and deep down, not hurt each other in the process, for I do no want to feel this pain each night in Cambodia.

    With love always,

  • The Temple of Surgery and The Checklist Prayer

    Dearest readers,

    Pchum Ben is a national religious festival in Cambodia – a time when families pay their respects to their dearly departed – those relatives that walked the earth before us, those who lived, laughed, cried and prayed in an era when we were not necessarily present. The ceremony involves the offering of food from the living to the dead, as the ghosts of bygone relatives temporarily waken from their perceived existence in the magical worlds beyond ours. Food is prepared and transferred via monks, acting as intermediaries between the donor and recipient in the confines of the temples and pagodas, the religious houses of worship in the community.

    Pagodas are architecturally quaint – a tiered tower with numerous eaves and hanging rooftops. They are often used to store sacred relics and scriptures of Buddhism and are revered locations where people gather, pray and find their peace. And like all religious houses, from mosques to churches and from synagogues to gudwaras, pagodas exude calmness and cleanliness, whilst simultaneously adhering to strict cultural rituals, rules and codes of conduct.

    Our hospital closes every year for a week in respect of the Pchum Ben festival, allowing staff an opportunity to spend time with their loved ones, near, far or further distant still. And during this year’s closure, with some personal energy, the hospital funded a refurbishment too of its most sacred room – the operating theatre. Surgery too, I believe is a metaphorical form of religion, with a worldwide cult following and a mixed mantra of ancient and modern scriptures combining science, art and hope.

    The operating room, like all religious houses, must follow a strict guide of practice. From dress code to the opening and closing of doors, from cleaning schedules to the correct positioning of vital equipment, every facet must be adhered to with fastidious, delicate care, like they too were sacred relics.

    The operating room staff, from surgeons, anaesthetists, nurses, technicians and maintenance staff must too treat the room like a temple, assigned guardianship of this hallowed room in which they are the monks that navigate and guide worshipers safely in and out of this temple.

    And the patients, often in Cambodia with little understanding of their own complex ailments let alone the science around surgical treatment, will come to this small surgical centre, in hope and prayer that their suffering can be alleviated. They are the true worshippers of this religion of surgery, believing there maybe cure within the temple of the surgeon. Their faith in surgery is the most enshrined of all trusts between humans, willingly becoming anaesthetised and powerless, whilst asking another human to help them.

    The World Health Organisation recently published a safe surgery checklist – a list of important safety measures that a surgical team should comply with, prior to and after performing every operation. It’s adoption was sluggish even in many developed countries but has now been recognised as an essential aspect of performing surgery and most surgical teams in the UK would feel naked without it. It’s uptake in low and middle and income countries has been equally difficult where other complicated factors often mean the safe surgery checklist is neglected or only paid with unwilling lip service. However, in this comparison with surgery as a religion, the checklist too is the dedicated prayer, the harmonious coming together of the theatre practitioners before and after surgery, to repeat and recycle the ascribed phrases and sentences, to ensure the patient has a safe passage through their procedure.

    With the new operating room completed, in its bright and shining glow, I have been urging all hospital staff to treat the room like the sanctuary of a pagoda, to be it’s guardian, to maintain its protocols and standards, and to ensure safety of our patients at all times, paying the same respect to them as they pay in faith to us.

    With love always,

    The new operating room in development, brighter, lighter and calmer: