A recent medical mission to Cambodia made me remember why I wanted to work in the emergency department, and I realized how much the state of emergency medicine in the United States has deteriorated over the past several years. The differences between my life in the ED in the states and my time spent running an ED as part of a larger volunteer clinic in the mountains of Cambodia were quite stark.
United States: Call 911 to have an ambulance drive you to the ED for a sore throat.
Cambodia: Have family members carry you on their backs, camping outside in the rain, to get to a once-in-a-lifetime clinic three days away.
United States: Expect to be brought straight into a room, regardless of how minor your complaint is, and God forbid someone who arrived after you is brought back before you just for the simple reason they aren't breathing.
Cambodia: After traveling for days to get to the clinic, you are still more than happy to wait in the outdoor waiting area for several hours more. In fact, while waiting you may be called on to act as an interpreter for another patient from your tribal area.
United States: Increasing percentage of patients are “scrollers.” (Patients who have been to the ED so many times that the scroll bar is needed to see all of their visits on the computer screen.)
Cambodia: Nearly every patient has spent his entire life without seeing a medical professional. Ever.
United States: The guy with the arm contusion tells you that Vicodin doesn't work for him, and he will need at least some Percocet.
Cambodia: The guy with the broken arm is happy that we were able to make a better splint for him out of a washcloth, a plastic water bottle, a few sticks, and some Coban. He didn't think he would need the Tylenol we offered him for the pain, but finally agreed to accept it, just in case the pain grew worse again.
United States: My ED has two board certified emergency physicians, five nurses, two techs, and a hospital full of ancillary staff to assist on a moment's notice.
Cambodia: I was the entire emergency department. When I really thought someone was going to die on me, I could go next door and have a doctor consult with me, but all of the procedures, medications, lab draws, and discharge instructions were provided by me.
United States: Half the day is spent doing paperwork and waiting for unneeded diagnostic tests to come back, just to keep the lawyers happy.
Cambodia: No lawyers, no paperwork, no scope of practice. Heaven must be like practicing medicine in the developing world.
United States: Unhappy when a fly is buzzing around the nurses' station.
Cambodia: Happy someone else found the poisonous snake crawling through the clinic and killed it before you got there.
United States: Patients that poop themselves just because they were too tired to get up to the restroom with flush toilets and a sink.
Cambodia: Deathly ill patients who insist on walking the hundred yards to the nearest squatty potty because it would be rude to use a bedpan.
United States: Occasionally have to use an interpreter to go over the finer points of a discharge note.
Cambodia: Need an interpreter to go from Khmer to English, but also hoping there is someone from each village who can translate from their tribal language into Khmer.
United States: Getting hit, kicked, stabbed, choked, spit on, and yelled at for not giving the drug they wanted.
Cambodia: Getting hugged by an old lady who you had to tell that there was no medicine that could reverse her stroke deficits from years ago, but you would pray with her instead.
United States: Multiple drug-resistant strains of bacteria.
Cambodia: Nobody in the area has received antibiotics before, so all of the infections are easier to cure.
United States: Commute to work is about 30 minutes on paved roads, with the radio blasting and four Starbucks on the way.
Cambodia: Commute to work is more than 30 hours in airports or on airplanes, followed by two days of dusty roads breathing in diesel fumes in the back of a truck, but you get to listen to your friends play iPhone karaoke.
United States: Can be a challenge to find an accepting doctor to admit your patients.
Cambodia: Can get your patients admitted to the nearest hospital without too much difficulty provided you reach in your pocket and pay $100 in advance for their care.
United States: Nurses are no longer allowed to hand out home packs of narcotics or even give an aspirin without a written order or standing policy.
Cambodia: Nurses work as primary care providers treating malaria, typhoid, and other exotic diseases, lancing abscesses, and starting IV antibiotics. (We had three physicians we could consult and a pharmacist to help with medication decisions.)
United States: Everything is a one-time-use disposable item.
Cambodia: Had enough needles, but most other items were cleaned and reused among patients because we just didn't have enough ear speculums and the like for 3,000 patients.
United States: Not much to do for dental pain except start antibiotics and maybe give some pain meds when the block wears off, or at least hock them on the streets for something injectable.
Cambodia: Brought our own dentist who was pulling bad teeth like a mad man all day. He kept two staff members hopping to keep the sterilizer cranking out his equipment. By the way, referring to something as difficult by saying it was like “pulling teeth” just doesn't make sense. He was pulling teeth at an incredible rate.
United States: The average weight of an adult patient is well over 200 pounds, and getting heavier every year.
Cambodia: The average patient can be picked up and carried easily by one person.
United States: The typical patient is covered in tattoos, but still states he is afraid of needles.
Cambodia: Typical patient lived through the killing fields' genocide, but still states he is afraid of needles.
United States: You can have a drink at the local bar to unwind after a busy week.
Cambodia: You can visit the thousand-year-old temples of Angkor Wat and get an hour-long massage for $5 after a busy week. Better yet, you can splurge and get the four-hands, hot oil massage for $12.
United States: Anything deep-fried makes a good lunch, including chicken and Twinkies.
Cambodia: Anything deep-fried makes a good lunch, including crickets and tarantulas.
There you have it, a comparison of working the ED in the United States and working an ED on a medical mission in Cambodia. It is true that paying more than $200 a day for the experience doesn't quite pay the bills, but the recharged personal battery I brought back to my regular job was priceless. I highly recommend that everybody steps out of the routine to help people who actually need and appreciate your care.