The final few days and farewell

We took the Saturday night ferry from Koh Tao to Surat Thani and surprisingly slept very well (perhaps with the help of the travel sickness pills). We then got a bus to Krabi, where we checked into the first hostel we found. We spent the day wandering around Krabi town and exploring the mangroves and caves with a private boat tour.
Krabi seems a very quiet town and perhaps one where backpackers just stop over on their way to islands like Koh Phi Phi. We visited the night market in the evening and had street food for dinner. We were just in Krabi for one day and had a very early start the next morning for our flight to Singapore. Having waited around in Krabi airport all morning (as the shuttle bus runs at silly times), we eventually got on our flight and arrived in Singapore in the afternoon.

Some of my family friends very kindly housed us for our stay in Singapore and introduced us a bit to the city. We spent the whole of the next day at the amazing Singapore zoo.

 In the evening we visited the Marina Bay Sands Hotel bar for drinks on the 57th floor, which overlooks spectacular views of the city. It looked magnificent all lit up at night.

Marina Bay Sands Hotel - three towers with a boat-like structure lying on top!

We both had early starts for our flights home the following day and although I'm sad to finish this amazing adventure, I am so happy to now be on home ground!!

I had a brilliant time travelling and a fantastic dental elective. I really hope to go back to AHC and volunteer as a Dentist in the future. I've learned so much and experienced things I would have never encountered, if I hadn't done this elective. We built up such a good relationship with the staff there and they are also anticipating our return. 

Thanks for following my blog whilst I've been away - I'm sure I'll write more posts soon, reflecting on various aspects as I reminisce.......

Goodbye Koh Tao

This week has gone so fast! Seems like we've only just arrived, and now it's time to leave! Over the past few days we've had a chance to relax on some lovely beaches, do some more snorkelling and re-visit Koh Nuan Yang. 

Thursday was not a pleasant day for me as I got quite ill with what was probably a combination of food poisoning, heat, sun and sea water. (My bets are on food poisoning). So after returning from Aow Leuk bay at 5pm, I could do nothing but lay in bed (and use the bathroom) until the next day :-(

Friday I felt a bit better but still not quite right. In the morning we had breakfast with a couple of Americans who work over here.  Whilst everyone else had big fry-ups, I stuck to one piece of dry toast to try and ease my stomach. 

Jessye and I then revisited Koh Nuan Yang for the rest of the day. This is a collection of three tiny islands linked by a stretch of sand, about 1km off the north west of Koh Tao, easily reachable by a taxi boat (which left us soaked through!). There's an admission fee to get onto the island, and no plastic bottles or cans are permitted. When we arrived, we climbed up to the mountain viewpoint and admired the spectacular scenery. 

<<Hang fire for the photos which are currently still on my camera>>

In the evening we enjoyed another impressive fire show on Koh Tao. 

Saturday! Our last day on the island. After checking out of our bungalow and grabbing some brunch, we treated ourselves to a Thai massage, which was INCREDIBLE! Tonight we leave Koh Tao on the night ferry and take a bus to Krabi, where we'll spend one night before heading on down to Singapore.

Our trip is nearly over!

Into Thailand!

Saturday 27th July

Our time in Cambodia had drawn to a close and an early 5am start welcomed another long haul of travelling. We took a 'minivan' from Siem Reap across the border to Bangkok. The journey wasn't too bad - obviously we set off later than we should have because we were in Cambodia and nothing occurs on time here (one evening we were waiting ages for our drinks to come, AFTER we had finished our main courses - which obviously all arrived at conpletely different times). We were glad to have taken the earlier bus though, as crossing the border was fairly quick and easy. People everywhere always try to get money out of you and we had to wait at a conveniently placed cafe for half an hour whilst we changed buses. The second leg of the journey to Bangkok was also alright and we both managed to catch up on some sleep. 

We arrived in Bangkok mid afternoon - a surreal array of civilisation and multicultural refreshment welcomed us, contrasting from the beautiful rural Cambodia we had just left behind. 

I thought we would have plenty of time to casually wonder the streets and see a little bit of Bangkok at a leisurely pace. But as we left the hotel where we dumped our bags, a torrential downpour hit the city and we got soaking wet, desperate to find the Lomprayah  office to book our bus and ferry ticket.  

Nothing is ever simple and I ended up having some trouble with my debit card, which got blocked after I tried withdrawing cash. However, having hardly used my phone for a few weeks I didn't think to check if my bank had tried calling. And sure enough they had...a missed call, text message and answer phone message about checking fraud; leaving me to call them back. Great. Another expensive phone bill to treat myself to. So after stressing all afternoon, turns out it may be safer not to use that bank card at all - off I went to an Internet cafe to transfer money to my other card. 

So in the end I didn't really get to see a lot of Bangkok, but I did get the gist of things whilst rushing around trying to sort everything out.

We took the night bus at 9pm from Bangkok down to Chumphon - a wobbly double decker, in which we moved seats three times - Jessye thought she would fall out the seat and down the stairs at one point!

Sunday 28th July 

Arriving at Chumphon, just gone 5am, we had a couple of hours until the ferry departed, so were able to watch the 'sunrise' over the bay (I didn't actually see the SUN, it just kind of got lighter...)

One ferry journey later and we finally arrived on the island of Koh Tao!! 

This island is a little slice of paradise! 

Although the main port and high street is home to many taxi drivers trying to offer you a ride, our beach is a bit quieter and we can generally wonder about without being too hassled. 

We were glad to have booked accommodation for the first night, as everywhere was full when we looked around! But we were tucked up in a mountain view room, so aimed to find a beach bungalow for another night.

After sorting ourselves out, we had dinner in a beachfront restaurant with spectacular views. Then a bit of cultural entertainment in the evening with the 'queen cabaret' (lady boy) show. 

Monday 29th July

We took a snorkelling day trip around the island and stopped off at 5 bays. The waters are crystal clear here and we saw so many beautiful corals and tropical fish, sometimes completely surrounding you - it was incredible! I really wish I had an underwater camera, it was unbelievable and we definitely want to re-visit a couple of the spots before we leave. 

On return, we found parts of our bodies red raw with sunburn - my back is the pattern of the life jacket I wore and our legs denote where our bikini bottoms were. We thought we reapplied sun cream enough times, but obviously not :-( I am VERY sore indeed.)

In the evening we headed out to an Auzzy bar for live music and 241 alcohol buckets. It was a nice atmosphere, and a couple of hours later, the bar crawl crowd arrived. Conclusion - there seem to be a lot of Irish people on Koh Tao!

We moved on to a couple more bars, saw lots of fire shows, and danced the night away. 

Tuesday 30th July

After a painful nights sleep on my stinging sunburnt back, we had to check out of our accommodation in attempt to find our bungalow. We managed to get one a short walk from the beach :-) 

.......and........relax! Finally - time to just lie on the beach and read (or fall asleep due to the late night before...) so serene. 

The final week

Tuesday 23rd July

I had great expectations for today: I challenged myself not to make a kid cry. Well that was an unrealistic aim. I'm sure we're yanking out some of these children's teeth when they're not completely numb!  However you can never really tell - children are unreliable as it is when it comes to distinguishing pain from pressure, now add in the fact they're thrashing about all over the place and won't even open their mouth.......you cannot get a decent answer out of them when asking if it hurts. And you certainly can't be Mr nice guy and wait half an hour for them to calm down (they never do). You just have to go for it, whip out the tooth so they only feel it for a couple of seconds, rather than prolonging the traumatic experience by tentatively attempting and re-attempting a painless extraction.
I got bitten again today - kids have quite strong jaws you know! The patient was crying hysterically and I was in the middle of extracting a tooth when his jaws clamped down on my finger. I literally couldn't move it for about 5 seconds (which is a pretty long time to have your finger locked between a set of nashers) and I let out a bit of a yelp (more like an 'AHHRGH!') I had to prise open his mouth to release myself. Our whole chair (nurse, parent, child, me) were all shouting one way or another (mainly telling the child to open his mouth wider throughout the whole procedure).

Wednesday 24th July
Frustration really began to kick in today...sometimes I feel like I'm losing my patience with the communication barrier: it would be hard enough to get a good history from kids in the UK, who may understand you, but here it's sometimes impossible. Some of the nurses aren't that great at English and I'm not sure they actually translate what I want to say. Some tend to answer 'yes' to everything: "which side is painful?" "yes"; "no WHICH side?" "Yes"; "where...left or right?" "Yes", even pointing at left then right doesn't help! They could be a bit more helpful sometimes. I do feel slightly guilty though, because they speak more English than I speak Khmer!
This experience has made me realise how important communication and language is in Dentistry - especially if you want any chance of having a cooperative patient. Even other communication means such as tone of voice and actions doesn't help if the kid doesn't understand your language. I definitely take that for granted in the UK.
I occasionally feel like just giving up and getting the child to come back another time, because how am I supposed to treat the problem when I don't even know what the problem is?! And there's an uncooperative child in the chair!? After feeling like this a few times today, I tried to stop being so selfish and actually imagine what's it's like to be that child.......Here you are, in an unfamiliar place for the first time, with a scary weird looking foreign person, trying to speak to you in your language, and now they want to peer into your mouth and fiddle about with your teeth.....of course you're not going to answer them when they say "choo moy na?" (where does it hurt?).
This experience has taught me to learn to be patient with everyone, to put myself in the patient's place and understand they're probably terrified and don't care that we have a tight schedule. I do however think I've learned a great deal about communicating in an unfamiliar language - which was one of our elective project aims.

On another note, we donated blood today! It felt good, especially as I didn't faint like last time <in the UK> (then got banned for a year for causing so much hassle as they couldn't find a vein or get much blood out...) The hospital here were very grateful, and gave us a goody bag containing a t-shirt, can of coke, box of crackers and pack of multivitamins.

Thursday 25th July
Today was our last day at the surgery as tomorrow, we'll be on a whole day of outreach at a  rural health centre 80km away.

Disceitful Cambodians...

Everywhere you go in Siem reap, you are greeted by friendy tuk-tuk drivers: "you want tuk-tuk lady?" And in the markets, hundreds of 'friendly' Cambodians trying to sell you whatever they can. I had a rather disheartening experience today when I was looking around the old market for a dress to wear on the beach. I thought they'd probably try selling it to me for about $8 and would hope I could bargain it down to at least $5. However this one lady insisted that she always sold them for $15 and could offer me a "very good price" of $14. Hmm EVERY SINGLE market seller tells you they'll do you a 'special price'...anyway I tried it on and after the woman gave me copius amounts of over-the-top compliments, I managed to bargain it down to $8. This was all very well and good, if she had then just let me leave. But no, she HAD to attempt to force another dress upon me (for "such a good price"), she even shoved it in my bag and tried convincing me she had no change so I had to buy two. Well I didn't want it and although she almost made me buy it, I ended up waking away with just the one that I wanted. After the stand off, she turned very sour and started complaining that it was "such a good deal" blah blah blah and when I thanked her and left, she just ignored me. So I guess all the sweet taking beforehand was all lies! I've had a couple of these encounters, where someone starts talking to you but quickly turns nasty once they realise you're not going to give them money. It makes me wonder how many Cambodians are genuinely friendly and interested, and how many are just trying to get your money.

Friday 26th July
I CANNOT believe it's our last day today!
We set off for outreach at 8am this morning (a nice late start compared to the normal 7.30 kick off). We went to a health centre in a rural village about 80km away. Rural Cambodia is so beautiful, I love all the colours: red dirt tracks lined by wooden houses on stilts and bright green rice fields interrupted by tall tropical trees. It was such a hot day today and this village had no electricity as it's too expensive so we couldn't make use of the fans which had been installed in the health centre. Patients come here if they're in pain or have a medical problem, however they don't receive any treatment here - they would have to be referred to a hospital in the city. It was the first time dental outreach had come here and they'll start coming every two months. We saw 28 patients today 23 in the morning and only 5 this afternoon. It was a lovely way to end our elective, not too stressful, just a couple dozen extractions back to back for both of us.

Quick after-lunch snooze in the hammock

It's the elections this weekend!

Cambodian road outside the health centre

Entrance to the health centre

Waiting to be seen in the dental clinic

Enhance to the health centre

'Clarking' patients (which tooth hurts....)

House on stilts

 These three weeks have flown by so fast, and we both feel sad to leave. This elective has been an unforgettable, enjoyable and challenging experience - I feel truly blessed to have been a part of AHC dental team and extremely grateful for this incredible opportunity. I don't think I'd have ever witnessed or experienced some of the things I have, if I hadn't done my dental elective here in Cambodia. I feel so much more confident in everything I've practised here. I had never extracted a child's tooth before coming here, but within the first hour of being in AHC dental clinic, I had already lost count of how many I had done. From the ones I recorded throughout the three weeks, I did about 160 extractions and saw about 145 patients (not including those at outreach).
I have also got used to all the screams and cries and tantrums and painfully ear piercing shrieks of children thrashing about on the dental chair. Going back to England will be a bit weird: the children will not be restrained and forced to have their teeth extracted (most go under GA if they need a lot out), there will be spitoons for patients to actually use and not just for holding cotton wool pledgets, we will have to speak in English and not Khmer, we will have time to: check for haemostasis (blood clotting) after an extraction, acclimatise the patient before embarking on treatment, gain a decent and accurate pain history, take radiographs (!).....the list goes on.

So after a full on three weeks of Dentistry, we're off on our travels tomorrow at the crack of dawn (think I'll have to set the alarm for 5am) we travel to Bangkok and then down to ko tao for what we hope will be a relaxing break from all our hard work!

The long one

After not posting for a week, I've had to combine everything into one post, so I apologise for the lengthy read.

I'll start with a few challenges that I've had to find a way around.

---Communication. This is a big one, I don't speak a lot of Khmer so have to rely on the dentist/nurse to talk to the child. I have picked up a few phrases, and tend to say "Ha. Ha mot. Ha mot thom!" a lot, which means "Open. Open mouth. Open mouth wide!" Other common phrases that I use are "sus day" (hello), "bet mot" (close mouth), "cam" (bite), "aw na" (well done), "chooa" (pain), "choo moy na" (where is the pain). Both dentists have actually commented that my pronounciation is very good and they've never known a volunteer to speak so much Khmer!
 I also try to communicate with the child with the tone of my voice and actions such as pointing to the ceiling to get them to look up, and demonstrating the use of dental instruments on their finger so they know what to expect in their mouth-no need to describe it if you can show it! Kind of skips out the first stage of 'tell-show-do' but I do say some English, or make weird sounds to attempt to describe things. Eg "pokey pokey" for the dental probe whilst tapping their finger nail, "shh sh shh" to try and calm them down etc etc. It is incredibly difficult to get a decent pain history out of the patient and I've had to simplify things by asking very closed simple questions such as "can they sleep", "is it hurting now". Diagnosis is a bit dubious as you just have to base assumptions on the dodgy pain history and the unreliable special tests. Eg if the child cannot sleep because of the pain, the assumption is irreversible pulpitis. If the tooth is tender to percussion, you assume an acute periapical periodontitis. If the tooth only hurts when they eat, you might assume a reversible pulpitis. But at the end of the day, the child has come to the dentist for a reason and I have to trust the supervisor to translate accurately for me. So really, a definitive diagnosis doesn't really matter, if the treatment is going to get them out of pain.

---Knowing whether or not the child is in pain during treatment. This was hard to begin with because any sort of crying or distress from the child immediately assumes pain, thus an indication to stop treatment and reassess. However I've come to realise this is not always the case and most children come into the surgery already crying and having a tantrum. There is also no time to try and completely calm the child down, so I find myself being pressured by the dentist to get the extraction/filling done as quickly as possible, so all the children can be seen. Thus lies the question: is it better to treat one child perfectly, with no pain or fear, or treat lots of children quickly and efficiently but instilling fear and causing some pain? The dental clinic here aims to treat all the presenting patients, and succeeds to do so. Thus the most number of children can be seen within the time frame available. However, I do feel that they cut some corners to allow this to happen, for example: They don't check haemostasis after an extraction, unless they think there will be excess bleeding. Most of the time the child is sent home biting a piece of cotton wool. Radiographs are rarely taken, only for root canal treatment or oral medicine queries (eg pyogenic granulomas) and we're not sure if the dentists really understand the principles of radiography in great detail.

Tuesday 16th July

Despite my initial impression of Dr N; her little patience with the kids and my slow working, she has definitely become more lenient towards us. Maybe she's starting to warm to us and it was nice she was so eager to join us going to the children's village last weekend. I've also become a lot quicker at extractions over the past week, and was able to see a patient about every five minutes at outreach today.

Outreach take two

After a long bumpy drive (I lost count of the number of times I hit my head on the window whilst asleep) to a school about an hour away, we arrived in the pouring rain and set up the dental clinic in a classroom. Due to the bumpy ride, a box of equipment had fallen off the seat and all the alcohol gel had leaked out (our only method of cleaning hands between patients).....luckily I had a small bottle in my rucksack.

Setting up the dental clinic

One of our nurses gave a quick oral hygiene lesson to the children before the ones in pain came through to have their teeth pulled. There were only 10 today because a lot of children miss school when the holidays are approaching. Again, all the children on outreach seem much happier and willing to receive treatment than the kids at the hospital, probably because nobody had brought them along and they themselves are keen to have the tooth out. The kids are really friendly, it's easy to approach them and let them practise their English: "hello...how are you...I'm fine thank you" is about as far as it goes.

Free toothpaste!

Wednesday 17th July
We got the opportunity to do some extensive treatment planning this afternoon, as the clinic was pretty empty, with only one patient! But we spent the whole four hours on her! She had very crowded anterior teeth one of which had a uncomplicated crown fracture and carious pulpal involvement, ectopic canines, retained deciduous canines, extensive caries.....and she couldn't afford ortho treatment. So the dentists asked for our opinion and we needed to come up with a treatment plan...after a long afternoon of pulp extirpation, caries removal, radiographs (some of which didn't work due to glitches in the digital scanner!), and temporary fillings...we came up with a plan and were the last ones to leave the surgery.....so tired!!!

Thursday and Friday 18th and 19th July
I saw a flurry of patients on Thursday morning and did loads of extractions, I feel like I've become much quicker at everything over the past week :-)
Friday was a manic day, Jessye and I have a lecture and discussion on child management - the similarities and differences between our countries. This was very last minute as Dr Bora is away next week, so this was the only available day. It went alright though, considering the lack of preparation, and the hospital provided lunch for us all which was nice. In the evening, Jessye and I treated the dental staff to a meal, as a way of saying thank you for all they've done. We went to a traditional Khmer BBQ, which is like a buffet of raw food that you cook yourself on a little BBQ at your table. Very tasty!

Khmer BBQ

Motorbike ride

We then hitched a ride on the dentist's motorbikes to a music themed pub quiz, to join some other people from our guesthouse. Our team came fourth which wasn't too bad!

The weekend!
I was so relieved that we didn't have to get up early on Saturday! The first PROPER lie in since....I can't even remember when! So after a late start, I finally curbed my craving for a good swim and cycled to a swimming pool at a nice hotel, at which I was the only one in the pool (perfect!) Jessye and I then spent most of the afternoon looking for accommodation on koh tao, we finally booked somewhere for the first night, which will give us a chance to look around the island and decide which beach we'd like to stay on. Saturday night we hit the town, going between the two main clubs on pub street ('Angkor what?' And 'Temple') they are just opposite each other, so the blaring music gets churned up as you swap from one to the other. We also experienced a total blackout in the city as we were having drinks at a bar beforehand, which was interesting......
Sunday saw another nice lie in, deserved from the night before and getting in at 3.30am. After brunch, I took the opportunity to fulfil the 'alscott5' tradition of an obligatory bike ride on holiday. I wanted to head for Angkor Wat and just sit outside the temple, enjoying the view. However, when I passed the check point, I was told I needed a ticket to cycle around the temples (anywhere in the Apsara authority I think). Having only $6 cash on me, I had to turn back. So now I had no idea where to go and decided to just cycle straight, following the river through Siem Reap. I rode through some rural villages, next to rice fields and beautiful
countryside. I didn't feel like stopping so just kept pedalling, occasionally stopping to take the odd photo. I saw a mountain in the distance and decided to make that my end point, at which I'd turn around, but when I arrived, there seemed to be lots of tuk-tuks and tour buses passing by, so I was curious to find out where they were going. It turned out to be lake chong kneas, home to some floating villages which were interesting to see. There were boats departing from the little port, taking people on tours of Tonle Sap (the big lake running through Cambodia). Satisfied that I had cycled far enough (about 20km) I had a quick rest and raced back to Siem Reap <I find the return journey on bike rides is always faster, and I managed to get back to Siem Reap in less than half the time...no photo stops or scenery gazing, I even overtook a few motorbikes (they drive quite slowly over here)> . Suitably drenched with sweat and utterly disgusting, I went straight to the pool and cooled off. In the evening we all went to the circus!! It was amazing! It was a mixture of dance, music, contortion, gymnastics and acrobatics. The performers were all so enthusiastic and it was a great show!

Phare, the Cambodian circus

Excellent end to the week, cannot believe we're into our last week at the hospital tomorrow :-(

Flying through the trees

After a late-ish night out at pub street and pacing the streets of siem reap trying to find an ATM which doesn't charge to withdraw cash (I doubt they exist here), we woke up early again to go zip lining through the jungle! We went with a company called 'flight of the Gibbon', who have centres set up in Bangkok, Chiang-mai and now Siem reap. The one here is the only high ropes/zip wire course to be set up in a world heritage site. It only opened a month ago, and is placed within the rainforest surrounding the Angkor temples (they had to ensure that no temples could be seen though). They also managed to fix it up without attaching a single bolt into a tree - it's all attached by friction. 

After lunch, we headed on to 'Honour Village Cambodia', a foster home for children. I couldn't believe it had only been set up three years ago! All the children are so friendly and welcoming, and speak such good English. We delivered some boxes of toothpaste and toothbrushes. Everyone seemed like one big tight-knit family. Today they had a big leaving party for a couple of volunteers who had been there for a year, so there were loud speakers and party games and lots of excited children. 

I cannot believe we've been here for a whole week already! It's gone so quickly and I feel sad that we only have two more weeks left. What's more, we still need to sort out our travel plans and book a flight from somewhere(!) to Singapore, so we can get home!! 

Oh well, must get prepared for another hard working week of screaming children and dentistry......

Temples

I had a nice 'lie in' today, so woke up at 7am to visit the Angkor temples! Our guesthouse provided my very own tuk-tuk driver for a set day price, who drove me to the temples I wanted to see. 

The first temple we stopped at was the famous Angkor Wat, the world's largest religious complex. Seen as I was on my own, it took me a little while to actually get into the temple; finding someone to take my photo, then having to stand next to them for their photo(?!), trying to turn away pester-ers who wanted to give me a private tour/sell me stuff etc. eventually I reached the architectural wonder and quietly took myself around the bas-relief corridors and ancient ruins.

Angkor Wat

Bas Relief

I decided to just take myself around the temples rather than get a tour guide, and that's probably how I managed to see them so quickly. I aimed to see my three main ones (Angkor Wat, Angkor Thom and Ta Prohm) in a morning so I could relax by the pool after a loooonnng week of non-stop dentistry. But to be honest I was more interested in keeping moving and seeing the beautiful awe inspiring sights, rather than  having a proper tour. 

It was a scorching hot day today but at least that meant no toilet stops during sightseeing, as I sweated out all the water I drank! 

Next stop was Angkor Thom ('large capital'). Bayon was my favourite temple amongst these, as it looked like the original structures had been untouched - reminded me of something out of the jungle book, and I had '...now I'm the king of the swingers....I wanna be like you oo ooo....' Stuck in my head, whilst clambering around the derelict fantasy. There were elephants giving rides and monkeys grooming each other on the road between the temples. Bayon is surrounded by hundreds of sculpted faces, four on each tower to represent four different qualities of the king.

Bayon

My favourite temple of them all was Ta Prohm - the tomb raider temple. This was magical, the temple walls are caressed by intertwining branches of nature's trees, engulfing the 'jungular' housing with beautiful shapes and textures. It was also a relief to be shaded by the jungle, and it gave me a chance to cool off a bit.

Ta Prohm

Templed-out, I spent the rest of the day by the pool to cool down and get some R+R from the busy week. Now revitalised, we're off to dinner and tomorrow will be taking a zip wire through the Cambodian jungle, with 'flight of the Gibbon'.

Ear piercing screams to finish the week

Friday 12th July

After running late all day yesterday, and feeling like I was doing a rubbish rushed job of drilling and filling, today has been more productive. However, Dr Naren still thinks I'm incredibly boring because I take too long to do a filling (even though I am so much faster than I am at uni) she's not really interested in checking stuff thoroughly, she seems to know when there are still caries present just by looking, like she's got superhuman, tactile vision! I like that though, gives you more control and responsibility if you don't have everything checked every other second.

So this afternoon I stayed on clinic whilst Jessye went on outreach. All I did all afternoon was extractions, which was good because I didn't have much luck with my extractions yesterday, not being able to do some of them due to difficult teeth. But today I have been more confident and able to do all of them. One child was totally petrified and shrieked so loud, my ears were ringing afterwards. I've found you just have to be confident and forceful, and do it as quickly as possible, whilst trying to ignore the screams. I have to rely on the nurse, or supervisor (who speak Khmer) to tell me whether the child feels only pressure, or if they actually feel pain...but during that particular extraction, I was surprised such screams could indicate the feeling of pushing and fear....nevertheless I managed to whip the teeth out swiftly and the child resorted back to just whimpering.

This week has gone so quickly! And we have done so much dentistry (and so little sightseeing/touristy things - getting up at 6.30am and not getting back until 5.30/6pm leaves very little time to do anything other than grab dinner and wind down).....so I'm hoping to visit the temples tomorrow morning and then chill out for a bit in the afternoon as I am pretty exhausted from this busy week!

I think I came here with the expectation of gaining a lot of experience and learning, which has proved to be true, but one thing I've found is that we're not just here for our own good but for the good of the patients. It's not like England where you can take time discussing different treatment options with the patient, and persuade them to go for the most expensive option or whatever. Here it's all about getting the child out of pain, treating their illnesses, and giving them a better chance...there's no time to write up fancy notes like what bur you used etc, or even the batch number of the LA cartridge. You've just got to write the essentials and move onto the next patient.

So after a great week, I'm glad it's the weekend, and hope to find time to relax and do some touristy things.....

Tropical rainstorms.....

Thursday 11th July

Yet another downpour of rain today, they only last a few minutes but the heavens truly open and forcefully throw down buckets of water, flooding parts of the road but leaving the street slightly cooler than the sweltering heat that builds up throughout the day.

Anyway, the last couple of days have been choka-blocked with dentistry......
Something I have found is that the dentists here seem a lot less concerned about continual patient care such as thorough charting and special inestigations (X-rays, pulp vitality testing etc) - they are more concerned about the presenting complaint eg pain. In effect, they are a pain clinic. I had one patient who needed an extraction, and when I asked to do a full dental chart (to find out if any other teeth needed fillings, extractions etc), the supervisor just took a quick glance in the mouth and said "yes yes everything fine, now extract tooth" hmmm I'm sure there were some small carious lesions in there, but I guess they don't have time for that here. They just need to deal with the presenting complaint - even if it does mean having tunnel vision to everything else in the mouth. I try to do a quick intraoral examination, just so I can reassure myself there's nothing sinister going on. Today I felt like I was being rushed by the dentist, I feel bad either way: there are so many children to see in a day and I do need to speed up, but I just feel like I'm doing a botch job when I'm against the clock........can't win :-(

Another difference between the dentists here and at BDH (bristol dental hospital) is the level of confidence, or maybe carefree laid back nature......for example, when extracting a tooth at BDH, if you're concerned some root has fractured or is left behind in the socket, you would thoroughly check in the socket for any root remnants by cleaning, irrigating, suction-ing etc.....but yesterday after I extracted a primary molar, and thought I felt the root crack, on delivery one root was half the size of the other...now, because this was a primary (baby) tooth, it may have been due to root resorption, but at BDH you would still double check in the socket, which is what I did, but I don't know if I was feeling the root or the permanent successor. When asking the dentist if she wanted to check, she just replied "no no I am 100% certain that is root resorption. I know this. I know." Haha well that is confidence!

It was quite nice to have a cooperative patient the same age as the one in the horror experience I had the other day (4yrs). This time, I was able to inject him and extract his tooth without him crying or screaming or wriggling. And afterwards he was giving me high-fives :-)

We have been asking a lot of questions to the dentists and nurses about dentistry in Cambodia, and also their training etc. they don't seem to read any evidence based literature such as journals or papers. So they don't really know the best evidence based treatment options. And when asked how they learn/get their teaching, we found out they mostly get lectures from volunteers.....so here was a surprise, we are expected to give them a lecture!! On any topic, so we've been asking what they'd like us to cover. With one patient, we showed them how to fit a stainless steel crown which they were grateful for, probably because it took us a while to trim down the crown and get the perfect fit. So we might cover the hall technique, as it would make treatment much quicker and less painful for the kids if they didn't have to give injections and drill away caries.......

The stainless steel crown we fitted.

They would also like us to lead a discussion on child management, and the behaviour management techniques we use in our country...they were quite surprised to hear that we aren't allowed to restrain the child during dental treatment...

In other news, we went to an aspara dance and buffet the other evening - a type of traditional Cambodian dancing, very slow beautiful movements and controlled balancing....great bit of Cambodian culture dipping.

Outreach Clinics

I can't believe it's only the second day! This morning we were both at the hospital clinic, I did a few fillings and the beginning of a root canal treatment to start with, and Jessye had all the extractions. I was then trying to help Bora decide what dose of diazepam should be used for oral sedation in children, as he had never used it before....so after introducing him to the bnf online, which said diazepam should not be used for Dental treatment on kids, we decided another drug should be used. I find it interesting that they are so confident using materials and drugs that they have never/rarely used. As the dentists here say: 'no choice' - they have to use what they've got to help the kids.

I had the most horrific experience with my next patient: a scared little four year old boy. He was whimpering as he got put in the chair, but I really felt like the bad guy in a horror movie when giving him local anaesthetic...he shrieked and screamed and balled his eyes out, thrashing his body about like he was in pain, but it was just because he didn't want the treatment. It was horrible. I almost cried. But the tooth just needed to come out as quickly as possible. And after it did, he was fine (although probably traumatised for life) A LOT of the children at the hospital are like that every day :-(

The afternoon was more pleasant, I went on outreach to a school about an hours drive away from the hospital. It was exactly what I had imagined a third world outreach programme to be like- the dental team (Dr Naren, two dental nurses and me) set up a clinic in a dark dingy classroom. We had one portable dental chair which Dr Naren and I used, and the nurses used a couple of school desks for their makeshift dental unit. (Dental nurses do everything the dentists do here.) There were no lights in the classroom, so a handheld torch provided our tiny glimmer of light. They do have enough clean instruments to use for each patient which was good to see!
School children who are in pain come to the outreach clinic, the nurse then quickly examines them and confirms which teeth need extracting, we then rattled through the patients (18 altogether today) within an hour. I feel much more confident with extractions from outreach alone. These kids are much more cooperative than at the hospital and don't cry so much, because they actually want the treatment, to get out of pain. In fact when the last patient was told to get up and leave because they were being uncooperative and not accepting an injection, they immediately lay back down and opened their mouth as they really wanted the teeth out.

They are then all given a toothbrush and toothpaste. The kids were all really sweet and liked having their photos taken....watch this space  for uploaded photos coming soon...