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 :-(