Final notes from Cambodia

This morning we met with the nursing leaders of the hospital for a wrap up. I was hoping to get feedback on our talks but it was mostly a thank you fest. Don’t get me wrong, it is nice to be thanked but I work harder at home. The challenge for this mission was trying to teach within the cultural context as well as within the limits of their supplies and technology. I think we did pretty well and at this point I can’t think of what I would do differently. I had read that it would be good to bring some small gifts so we were able to give them thank you cards and a small gift when we went out tonight. Manila, the head of nursing education and Salay who works with her, took us to a Vietnamese restaurant for a farewell dinner. We had a nice time and we learned that Manila’s husband is an Obama nut. She expressed surprise that Barb and I like Obama since he is black so I guess it will take a long time for that stigma about the US to go away.
Traveling and living with someone you only know slightly can be a challenge. Barb and I were acquaintances although now that we have been inseparable for 2 weeks I guess we are friends. Last night she did not like her meal that much so we just traded. Things like that have been easy. We eat the same way, have kept the same sleeping hours and have done well sharing the bathroom in terms of showers. I guess we have both been conscious of being considerate. We are about the same age and have similar family structures. Thank God neither of us are major snorers!
There are things I will miss about Cambodia; deliciously ripe fruit served to me in the morning (the pineapple is cut beautifully so it has frills) the walk to the hospital (it is dusty but it is nice to be able to walk to work) The beautiful children that stare and giggle because I am pale and have round, blue eyes and silver hair. There is a little boy that jumps up and down saying “hello, hello, hello” when I see him. I have attached Mr. Hello’s picture. I think I will miss that green mango salad but maybe I can figure out how to make it. One of the more amusing sights is that many children and women wear pajamas all day. I think for them it is a cool outfit as opposed to something to sleep in. I like the fact that the parents cook the food for themselves and their children at the hospital and that they harvest directly from the garden. I like the simplicity of the life and the curiosity of the Cambodian nurses about us, our culture, our profession. I will miss many things but not enough to stay. I will be glad to get home. Which reminds me, Paul, please do not forget to bring my coat when you come to pick me up. I am facing a 50 degree or more temperature change! IT is Saturday am around 10:45 and already about 90 and humid. I look forward to arrivng home but the 24 hours worth of airplane travel will be tedius.

Last full day

This afternoon we gave our final lecture. We had a smaller group and they were not as talkative so much more work for us. We had spent the morning writing test questions and reviewing the new information that had been presented during journal club. I had mentioned that in my practice, we use a weak (10%) bleach solution for some types of skin disinfectants thinking that because it is inexpensive, it might be useful in this setting. This was a bit of a radical idea and as I reflected on it, I was not sure I should have talked about this. To my surprise, Sophal (the director of Nursing) found a reference to using this in the WHO manual. This legitimized the idea so we discussed possible uses. The other new piece of information related to a type of bacteria that can grow in a commonly used antiseptic. I was able to locate a reference for this to reinforce that information (go Google!) which allows them to think about changing practice. Barbara and I have been reflecting on exactly what we have accomplished with this trip and I think it is these little nuggets of incidental information as much as the lectures that have made a contribution. Anytime you can give information that changes nursing practice to make it safer, you have contributed something worthwhile. Many of the more useful pieces of information we have talked about were not part of formal lectures but examples we used to clarify concepts. Interesting how that works.
The dress code at the hospital is different. All nurses and administrators wear the same light blue cotton uniforms but shoes can be anything so we see flip flops and cute shoes with heels. In the US we only wear closed toed shoes for safety reasons so this looks pretty weird. I brought closed toe shoes to wear at the hospital but I need not have bothered.
Because of the heat, we chose to go to the closest restaurant for lunch. It is an American style coffee shop with pretty good food. For the first week we ate only Khmer food which is quite good, although they tend to leave the heads on the fish. It is somewhere between Vietnamese and Thai which makes sense since Cambodia is between those countries. My personal favorite is Green Mango salad which I intend to have one more time before we go. We have eaten French, Indian, Vietnamese, Scandinavian and pseudo-American while we are here. I think eating at home sounds really good. As does cool weather but I won’t be saying that next week. I have seen how cold it is at home.

Update

Just a short note to say that the baby I saw rescusitated last week has left the ICU and moved to the medical unit. He is well enough to nurse again. The second one is also doing very well. His mother is quite relieved.

Alternative garbage disposal

Last night we ate at an Indian restaurant, The Kamasutra (no kidding). Our table was next to an Indian couple who heard me say as I ordered a glass of wine, “I am celebrating”. When asked what, the answer was President Obama and the Indian man turned to us and said that he was celebrating also. He and his wife were eating quickly to get back and watch CNN and he told us how proud he is of the US. We stayed up to watch the festivities on the small TV in our room. For us, the speech did not start until after midnight but we stayed up to watch, counting ourselves among the “thousands from around the world’. The excitement translated through the screen and the crowd scenes were amazing. The comment I heard was it is cool to be an American again. I feel so very proud.
We had to get up early to go with the Home Care team again. This time we went 81 km west to see a child with malnutrition. How they find these homes is beyond me but through a series of turns down rutted, red dirt roads we found ourselves in the middle of nowhere. The home was typically small, up on stilts and one room for the parents and 7 children. It was swept clean and had no mess as they have virtually no possessions. We were quickly surrounded by the extended family that lives in adjacent homes and there were a lot of kids as you can see in the picture. The child had been admitted for severe malnutrition and had been tube fed, then bottle fed with formula. Although they live on a farm, they have only 2 chickens which do not produce enough eggs for their family. Their big issue is lack of protein although lack of calories is an issue as well. By entering the hospital, this family gained access to seeds, a water filter, food delivery every 2 weeks with the home care visit, clothes and teaching about nutrition, hygiene and general health. The nutrition display was divided into starches, proteins and fruits/vegetables. The protein category includes chicken, fish, frogs, snakes etc. The community really benefits since once we arrived, the whole group came and listened to the nurse teach. While we were there, she also treated one of the siblings with a bad runny nose, and a young woman came in with her baby who had diarrhea so she was given oral rehydration solution along with instructions on how to prepare it. We saw a woman with a huge goiter and an aunt had what looked like a herpes lesion on her lip so she was given gentian violet for that (I will have to look that up). Lucky is the community with a child that can make it to Angkor Children’s Hospital with malnutrition.
The painful part was watching the food being given to the patient while all the other children looked on hungrily. The mother had the fruit washed and then shared it with the other children. This was “longan” which has a peel and fruit resembling a grape around a large black seed. She would pick off a bit of peel and then pass it to the baby. The peelings and the seeds would be pushed through a hole in the floor where the pigs rooted under the house. Thus the alternative garbage disposal.

In the hospital

We finally have hot weather- the kind where you stay damp and everything sticks to you. The kind where you take off your shirt and can’t believe your collar is that color because you did bathe in the morning. I do not expect sympathy because I am sure that would feel really good to you about now.
It was a pretty good day today. The hospital had a population explosion over the weekend and in the surgical unit, they have added beds in the center where they did the physical therapy last week. The child I saw resuscitated last week has improved enough to get off the ventilator and today I saw a repeat of that scenario with a new baby brought in with sepsis. We did rounds in the surgical unit and saw children with chronic osteomyelitis ( a recurrent infection in the bone) who were brought in because of a visiting orthopedic surgeon. This surgeon grafted bone from the child into the place where healing has not occurred which is a pretty sophisticated surgery. So we saw a lot of casts and a child with oeteogenesis imperfect which is a horrible condition- it is sometimes known as “glass bones” because the bones break so easily. As long as the orthopedist is here he should see the child I saw in the clinic today with six fingers on her left hand. Often the extra digit doesn’t move but she could move all 6. In some cultures that is considered lucky but I am not about how it is perceived here.
I was asked many questions about our politics and how Obama, as a black man, was elected instead of Hillary a white woman. They also asked me why John McCain chose Sarah Palin. I did a bit of “tap dancing“ on this.
We did our second journal club today- this time on infection. The article was review but we did generate a lot of discussion and even got them thinking about a possible research project they could do. We were to have 2 more talks but we have had to cancel the kidney talk due to a staffing shortage. There just are not enough nurses to staff the hospital, have time off and attend lectures. We will deliver the nursing process talk again on Thursday afternoon but tomorrow we go with home care again. And tonight we will see as much of the inauguration as possible.

Cultural Commentary

Someone must have donated a large number of shirts with the "playboy" logo to this country. You see them on everyone, adults and children, and I think they must think it is a cute rabbit. They are interviewing new nurses to day to select staff for the most prestigious pediatric hospital in Cambodia and one of the applicants, a pretty young girl, is wearing a shirt with this logo. Sometimes context does not translate.
There is a much air pollution and water pollution which is a big problem for develping coutries. Most people drive motos or bicycles but there are a few Hummers and Mecedes. I have been told that the rich people are Cambodians who own hotels or else they are from somewhere else. Many people travel by pck up truck- they pack 16 people in the back of the truck to take them to town or wherever they are headed. They wear the traditional headscarves to protect themselves from the sun.
The Cambodians remove their shoes before enterng anyplace with a roof. We see endless sweeping and mopping in an effort to keep down the dust. We see people weaaring surgical masks everywhere but not for infection prevention but to avoid inhaling dust and dirt from the road. Some of the masks are cloth and home made and others are from the store or stalls.
I love going to the markets area and yesterday our guide told me the names of some of the fruits and vegetables that are unfamiliar to us. Since they have no power and therefore no refrigeration at home, they shop daily. Cambodians eat a rice porridge for breakfast and usually eat at the market. Early morning is there social time and since we now have hot weather now, I understand why they go out in the morning.
We are both a bit sad to miss inauguration day at home. We cannot feel the exciement from here, but have been watching CNN when we can and see how cold it is at home. We can only get snippets of the speeches and yearn for more. We plan to stay up tonight to see as much as we can live but the actual ceremony will start at 11pm here and we have to be at the hospital at 7:30 am. This is the one factor in our timehere we would want to change but it cannot be helped.

Thank you

This is to say thank you. We needed another article for journal club on Tuesday and were not happy with what we had. My friend Christine had emailed and offered to do anything we needed so I asked her to get us an article on surgical infection. Well, she sent 4 and now we can select the one that is most appropriate for this setting. Thanks Christine!
Tonight we watched a movie on Pol Pot and the slant was it was all Richard Nixon’s fault. Now I am not a big fan of Nixon but I think that is a stretch, so I need to read a more historical view point from someone unbiased if it exists. But it was a terrible episode in the history of this country and its impact will continue to be felt for a long time. The Cambodian people have been wonderful to us and tonight when we went to the hospital to use their wireless internet, we saw a nurse we had worked with who wanted to make sure we had everything we need. Then Peng the computer genius was on the campus delivering a huge bag of clothing that had been donated (it is Sunday evening). He paused to make sure my computer was operating properly. This hospital seems to be a true vocation and the employees are dedicated in a way I have not seen in the states. They seem to really believe in the mission. It is amazing/impressive.
One thing that we have talked about over and over is that there are so many men in Nursing here. They are wonderful with the children as are the female nurses, but we come from a setting that is so completely female dominant that this is surprising. We asked if nurses were respected here and the answer was no but I think we need to explore exactly what that means. I have enormous respect for these nurses. Any of them have multiple degrees in areas like IT and business. As I said, they are impressive people.
We ended tonight on a humorous note with me getting my feet groomed by fish. Totally bizarre and a once in a lifetime experience as the nibbling of “dead skin” was just too weird as far as I am concerned.

Tourist vs real Siem Reap

Today we went to the national museum, a beautiful building which was built recently. It is nicely laid out and after reading all the history from 600=1300 AD I have a better sense of Angkor Wat and what all this means. What is still missing is the history of the last 50 years since this museum is ancient history only. Tonight we plan to go to a movie at the Angkor night market to fill in the gaps for recent history. I anticipate being depressed.
On the way back we accidently found the local market which is a bit different from the tourist markets. The fish are unrefrigerated and aromatic and I think I saw clothes we donated to one of those yellow boxes in Falls Church. Being a total freak about clean food, I am sorry to say that I prefer the tourists markets and its sanitation. I love looking at the fruit and vegetable displays although it would be better if I knew what I was admiring and how it tastes, and how to cook it. We also saw a large net stretched across the river upstream from the major tourist area. This net had captured a large quantity of debris to keep it from visually contaminating the more sanitized and profitable parts of the city. From there we saw a market outside an active Pagoda. The wares included lotus blossoms and incense as well as other offerings to be made in the religious ceremony. I have a picture of the market stalls but did not feel comfortable photographing the pagoda in full religious celebration.
Barbara and I both have colds but after 3 days with a wicked and unimproved sore throat, I bought some Amoxicillen. 5 days worth cost me $1.20 which says a great deal about the US pharmaceutical industry but that is a diatribe for another day. I anticipate feeling much better tomorrow, just in time to work on the journal club for Tuesday and the kidney talk for Wednesday. Just like home, you are sick on the weekend to get better to go back to work. I hope to get to the hospital tonight so we can post and check email. It is but a 10 minute walk from the hotel where we are the only Americans. Lots of Aussies and French and a few Germans. I guess that is what you get when you stay in a hotel with a French name- The Auberge Mont Royale.

Angkor Wat

This was our sightseeing day. We hired a guide and a tuk tuk to take us to Angkor Wat and some other temples since that is the main reason people come here. Our guide, Bebe, met us at 6:30 and off we went. Bebe is from Siem Reap and grew up behind Angkor Wat. He used to play hide and seek at the temple as a child so he knows it well. His English is very good. He has only one brother because his other 2 brothers died during the Khmer Rouge genocide. One of his brothers died of starvation, both of his parents died. Bebe and his brother went to live at the Pagoda with the monks and they were educated by them. It sounds as though the monks took in a lot of children during this time and to this day, they are the educators of the poor. While school is mandatory and free, you must buy your books and pens and uniforms and you must pay the teacher which continues to put education out of reach for many. One of the hospital nurses told us that he went to nursing school far from his family and for the first year he camped out in the Pagoda and the Monks fed him. Literally camped out- after that year he worked for room and board in a clinic.
Angkor Wat is massive and impressive and it was great to have a guide to tell us the significance of carvings and the history behind them. We also went to Bayon and the Elephant terraces and a temple built of brick in the 10th century. The crazy thing is that it was bricks without mortar. Instead they made a glue from tree sap and built it 5 levels and then carved on the brick. It is not in great shape but it is pretty old so I guess that is expected. On the way back from the temples (including Tomb Raider Temple ala Angelina Jolie) we stopped at a monument near a former rice paddy/killing field. The monument has a glass case of bones gathered from the fields and you can clearly see the skulls. It is horrible.
Both Barb and I have colds that are slowing us down. I rarely get sick but I guess I have no immunity to these Asian viruses. We napped and then went to dinner and afterwards had our first ice cream of the trip. It tasted great. We may go to Battambong tomorrow if we feel up to it or maybe hang around this town some more. We agree we have seen enough temples and it would be nice to see something else. The only way I can post to the blog is to go to the hospital so I will have to see how that works out.

Success

Our talk went very well. My part was the most boring topic possible in nursing second only to nursing theory. I was very glad there was no audible snoring. Seriously, a lecture on nursing process is difficult to make interesting but the feedback was positive in that I used examples from their hospital and spoke slowly and clearly enough to understand. And I was told my explanations used simple language and so Manila, the nursing director, was happy. Barbara continued the lecture with physical assessment (the application of my part) which they were interested in and then we did psychosocial assessment which seemed to be somewhat new territory. They were very interested in this portion and although Barb did the presentation, we did very well bouncing off each other for examples and explanations. We were so relieved that to celebrate we stopped at a spa on the way back to the hotel and got facials. For $22 they soak and massage your feet and during the facial, they massage your hands and legs. They also give you tea to sip for the foot massage portion and a lovely drink after the facial. We plan to return. Maybe often.
This morning we were in the ICU which has 4 beds. It is connected to the emergency room and they share staff which makes sense in many ways. The ER has 4 bays and while I was there, an infant arrived in shock. The resuscitation effort was fast and the child was stabilized and on the ventilator (respirator) within 15-20 minutes. The poor Mom was young and really scared. I have never wished more that I had words of comfort but all I could do was gently pat her back and make a sympathetic face. Most of what I saw was consistent with what we would do at home given the same patient scenario. The ICU was filled with infants- all 4 beds including the one who came in while we were there.
At lunch time we went to a conference where a case is presented and then everyone discusses what went well, what did not and what are the lessons learned to improve care for next time. Again this is very much like we do at home and I was impressed with the discussion. These are bright, competent doctors. We worked on our talks for next week after that and I left a bit early to nurse my iffy stomach. Must have been something I ate or drink but I have been very careful.
We have arranged for a guide to take us to Angkor at tomorrow so that we can understand what we are looking at. I will have to figure out how to post this since my computer only connects at the hospital.
I love getting comments and emails so keep them coming!

This is the kitchen As you can see the cooking over an open flame in a house made of dried plant materials. In the winter, they see many burns from families sleeping close to the fires for warmth. I am surprised more homes don't burn down. They are flammable and there are no smoke detectors. Come to think of it there are no fire departments.

Home visits

This morning we went to AHC early to meet with the director of Home Care so that we could go on a home visit, an hour’s drive out of the city in a very rural area. It is so rural that instead of an address, the family must draw a map to the home when they are set up for home care. The house was on stilts as they all are, so that when the rains come, you have some hope of staying dry. This first house was home to a 3 y/o and her mother, both HIV positive and on therapy. The child had been hospitalized for 6 months when first diagnosed and was quite ill as you can tell from her tracheostomy scar. She is small for her age with thin hair, but she hugs her teddy bear and rocks it- a sure sign that she is loved and cuddled. The nurse is the sweetest man. He takes time to play with the child before he examines her, and he is gentle, professional and very kind. I was close to tears when he opened a new package of pajamas and with great tenderness, dressed the little girl. The child has been home for 6 months with monthly home care visits and during this time she has not required hospitalization despite less than desirable blood work. Before we left, he gave the family a bag of food, standard care for home visits. The food included fresh fruit, vegetables, dried fish (a staple), eggs and rice. A different group delivers large bags of rice to each of these families monthly and the hospital provides seeds so that the families can grow some fresh greens.
Our second stop was closer to Siem Reap The little girl came out to meet the nurse and was clearly happy to see him. This child has been on treatment for two years and is a nice size with shining hair and a great smile (except for the cavities). She appears much healthier than the first child and is very pretty. She also got new pajamas but was clearly waiting for the food bag. When it was opened, she grabbed the bag of fruit, and then took the sausage bag as well. I do not know the name of this fruit but it is reportedly quite sweet and she seemed very excited about it.
The homes are on platforms and consist of one room. The floors are slats with gaps so dirt and trash fall through. Chickens abound and walk into the houses (think bird flu) and there are wells. Trust me when I tell you the water does not smell nice. They lay mats on the floor to sit and sleep and the kitchen, well – it is one of the pictures since I can’t describe it. On hot days they sleep in hammocks under the house and there are hammocks upstairs as well.
This organization does very good work. The standard of care in the hospital is high and the quality of care is good. This home care program is working and I was delighted to learn that the medications for the HIV patients come from USAID. One funny note- at lunch one day we were accosted as usual by children trying to sell us stuff which we declined to buy. In an effort to change our minds the young girl started to recite facts about the US- the capital, the population, the upcoming president’s name and the current president’s name. The other, younger girl pipes up- “and nobody likes George Bush”. She must have been about 9 years old- we cracked up.

Preparing Talks

We have been working very hard on our talks. We gave a journal club (read the article and discuss it) with the group on Tuesday and it went well. The subject was documentation, specifically how abbreviations and shortening of words can be misunderstood or have 2 meanings, and how this leads to confusion or even errors. We had looked through several patient charts so we had an idea of where and how things could be improved as well as specific examples from their patient records. I thought that took some effort but compared to the hours we have put in on the Nursing Process talk, it was nothing.
This morning we go with the home care director to the countryside to see patients in their home setting. I am looking forward to this as I think it will give us a better picture of the real Cambodia. Siem Reap is the least poor province due to tourist dollars so is not reflective of the remainder of the country.
In the afternoon, we give a lecture for 3 hours which is to contain how to plan care for your patients using critical thinking skills, physical assessment and psychosocial assessment. Putting that together in a way that respects the culture as well as is reflective of their culture has been daunting. That is why I find myself up at 5 going through the slides again, changing words to make it more understandable and rearranging the order yet again. I will be very glad when this is over although we repeat this lecture next week. It then becomes part of their required curriculum and will be given by the nursing education team here after we have gone home. Yesterday they asked us to write test questions derived from the lecture as part of that package. We can do that after we see how this lecture goes and we modify it as I am sure we will learn many things as we attempt to do this.
It is winter here so it is a bit cool in the mornings (55 or 60) and the locals are complaining bitterly. This is the coldest winter they have had in years but I think it is great and days in the high 70”s seem perfect to me. It is very dusty and a fine red film coves everything and I am coughing quite a bit. To keep the dust down, they water the streets so then there is the mud. All in all it is quite pleasant although I don’t think I will get used to using toilet paper for everything from napkins to cleaning thermometers between patients!

In the clinic

Today we spent the morning in the outpatient department. We arrived at 7:30 and there were a lot of families already waiting. I sat with one of the triage nurses and observed him with a family of 4. The first and youngest of these 4 boys had a mild cold, the next one had a cold with wheezing on one side. The next son had a severe abscess on his ankle so was set up to see the surgeon and the last brother was having a significant asthma attack. Mom related that there was a 5th child in school. 2 of those children really needed medical help but I wonder if we would have seen this family if only one was ill. It is an effort for most families to get to the hospital although care is free, transportation is not and the average family in Cambodia lives on 1 dollar a day. The hospital has funds to help the families get back home, as well as clothing, and everything is donated.
For the short time I was observing, I saw a few colds, a terrible infection under the eye in an adolescent girl (periorbital cellulitis) a tiny child with “crossed eyes” whose health card read congenital heart disease and a toddler who was seen urgently for a dog bite. There are a lot of dogs in Cambodia and lots of mother dogs with pups. Spaying and Neutering is expensive and uncommon so the result is a lot of dog bites. One of the children who came in for a cold was missing a small piece of his nose from a bite.
Cambodians have large families and 50% of the population is under 15. Remember that much of the population of the country was wiped out during Pol Pot’s reign and he died only 10 years ago. An appalling statistic is that of the 4,000 physicians in Cambodia, there were on 40 left after the fall of the Khmer Rouge. Some escaped and emigrated but many were killed. This also wiped out the nurses and other health care providers which is why this mission of ACH to train pediatric nurse is so important.
The children are fascinated by these white people with round blue eyes and love to have their picture taken. This little girl was pretty funny- she hammed it up and laughed for the camera. She was pretty healthy but skinny as they tend to be.

Orientation

It seems the only way I can post is to do it first thing in the am. It is 5:30 and I am awake so here we go.
Yesterday was very long and busy. The free time is officially over. We met at the hospital at 8 am, toured, talked etc. It is an amazing place and they are doing good work. It is the only non-government hospital in Cambodia and therefore can do things in a less regimented way. This has given them the freedom to be innovative and to set the standard for pediatric care in Cambodia, however the Ministry of Health still has oversight and the administrative structure comes from them. That is another story.
The director of Nursing, Manila Prak, spent a lot of time going over the hospital mission and their goals for pediatric care in Cambodia. They teach Nursing students- all 5 nursing schools send their students to Angkor on a 2 weeks rotation which is lecture as well as bedside nursing. The hospital’s Nursing staff gets ongoing education from visiting volunteers as well as the hospital’s own staff educators. The nurses are required to take English classes, provided at the hospital, and their charting (record keeping) is in English. I asked to review a chart yesterday so I could have a better idea of our focus on when we do a journal club on documentation. I was trying to understand what one note meant and the other nurses could not tell me. That is the concern when your documentation is not in your native language.
After lunch, I spent a couple of hours on the surgical unit whose primary diagnosis was osteomyelitis. This is an infection in the bone. The children stay in the hospital for 2 weeks of IV antibiotic therapy and then 4 weeks of oral antibiotics at home. I observed a physical therapist working with a child on weight bearing on the injured leg. He was most unhappy but she was very good and persistent and turned it into a game with the other children. I was included in the games which was fun for me. The ward is open, there are no sheets on the beds and no privacy curtains. Parents and siblings are there in the ward, and one parent sleeps in the bed with the child. The parent does the toileting, bathing and feeding of their child and uses the family kitchen which is supplied with nutritious ingredients. They do have play therapy, 2 of them, which is unique in Cambodia.
The last thing we did at the hospital was to review my talk on critical thinking which is to be given Thursday. They wanted many changes, mostly to align the language with what is in their education packets, and we worked on that for a long time last night to incorporate their suggestions. They do not want to offend and we want our teaching to meet their needs so this is how we will approach all of our talks. By the time we finished, we were exhausted but at least we could do this at the hotel. The only working plug in our room is in the bathroom so the set up that works is I am in a chair just outside the bathroom with the computer on my lap, and Barb is on the bed by the only light so we can review the talk together. Not ideal but it works.
I will attempt to send pictures from the hospital wireless connection later this am.

Peng is a genius!

We are now connected via my lap top at Angkor children's hospital. The diretor of volunteers and IT manager and former ICU nurse has reconfigured my laptop so we can now transmit directly. I will try to give an ovrview of our introduction this am.

In the courtyard of the hospital is a garden which is the sustainable agrculture project. In addition to growing some food for patients, they use this to teach about sustainable agriculture and nutrition. Many families come a great distance to seek health care so they ahve a group of people ready and willing to be educated ina variety of ways who just stay here for days or even weeks. They sleep in a covered aarea where they are given mosquito nets and masks if they stay over night.
I am now going to meet with the nursing director so I can post more later.

sunday morning

Thank you for all the email messages of support. The sad news is that I cannot post via my laptop and therefore cannot send pictures. I would need a global PC modem bought and installed and I am cheap and chicken to test my computer in that way. So it is back to the hotel internet with it's weird keyboard.
Last night we wandered around Siem Reap and ate Cambodian food. Lots of lemon grass, basil and coconut. We crashed early and decided to go to the lake this am. Tonle Sap is about 20 minutes away by tuktuk which is a cart towed by a motor scooter. What we did not count on was how chilled we would get in our summer clothes. On the boat we were wearing the life vests to provide warmth. The floating village is boats that line the river and then move to the lake during the dry season when the river gets too low. they live on these boats and fish and then sell the fish at market. They have floating schools and 2 floating basketball courts, the old ladies with boats full of produce sell door to door, or boat to boat, there are markets of junk food. It is a simple way of life but contaminated by tourism as wehad a planned stop at the crocodile farm - an enticement to purchase stuff- and the store for school supplies where we declined to spend 5 dollars for 10 pencils. Our guide was very disappointed in us. He did remember when the Khmer Rouge came through his village and wiped out 300 people overnight. This is recent and painful history for these people.
Among the more amusing sights are the gas stations- they line the road and sell gasoline from old whiskey bottles. Johnnie Walker, both red and black, are very popular flavors of gasoline.
Tomorrow we start our real purpose and will put aside the sightseeing until next weekend. We are both anxious to get started on our assigned tasks and to see how we can be of the most use.
Thank you again for all the support.
Deb

Beng Melea

after a bit of wandering we decided to go to Beng Melea which is a 12th century wat (temple( that has seen better days. Our hotel arranged the driver and we went about an hour east. Lots of traffic and dust but I am amused to see whole pigs -large porkers- strapped to the back of "motos" they were deceased and on their way to market. No cello wrappings on the meats here. we also saw young boys fishing in the ponds and lots of water flowers, lilies and such. Cows, water buffalo, goats , pigs and lots of dogs are plentiful as you get farther from the city. They do not eat dogs here but everything else is for sustenance.
The temple is amazing as it is in ruins in the jungle with trees growing through everything. YOu wander through the debris, climbing over the rocks and fallen arches, carved stones etc. It is a real Indiana Jones experience. A nice young man showed us around and we saw more than we would have on our own. about 25 times more than we would have done as he helped us scale everything and gave us perspective on where the entrances were and pointed out the carvings. It was worth the dollars we gave him.
The country is very poor and carries 3-4 people on a scooter, often small children and even infants in their mothers arms. No booster seats for kids under 60 lbs here!
tomorrow we are going to Ton Le Sap to see the floating villages. Monday we start at the hospital so we are getting in the sightseeing pieces while we can.

finally here

It went well. Paul dropped me off just before Korean air opened its stations- all the uniformed folks were lined up, crisp and ready to go, hands behind their backs and the bell dinged! Think precision as in the Chinese Olympics when the crowd surged forward to check in.
My very heavy bag of medicines did not require over weight payment *a miracle*
The flight was very long, I watched 4 movies in succession and then could not do any more/ 14 hours and 45 minutes and then we changed planes in Seoul for an additional 5 hours to Siem Reap.
We were told to expect heat but it is pleasant and our hotel is adequate. Nice room, shower, air conditioning and ceiling fan. It is surprisingly quiet.
Breakfast had good strong coffee and wonderful fruit including something called dragon fruit which has a red peel and soft white fruit with little black seeds-think poppy seeds. Subtle flavor.
So Barb and I will wander around and get our bearing this morning. No glitches other than blowing the computer surge protector when I stuck it in the socket. The good news is that it was not connected to anything. Tonight I will find some smart person who can help me connect to the internet so I can use my laptop whose keys are more traditional than this computer. The cost for 30 min internet service at our hotel is 1$.
Much more to come.